MSK (Hands)

Question 1

What investigations would you order for Rheumatoid Arthritis?

Answer 1

Bedsides: General OBS and MSK examination of adjacent joints

Bloods: FBC (anaemia, WCC), CRP & ESR, U&Es (baselines or renal involvement) and LFTS (DMARDS)
- Auto-antibodies: Anti-CCP and Rheumatoid Factor

Imaging: Hand X-ray
- Loss of joint spaces, erosions, soft tissue swelling, soft bones (osteopenia)
Chest Xray to exclude lung involvement

Question 2

What scoring system can you use to monitor severity of Rheumatoid Arthritis and determine when to use DMARD?

2.6 - 3.2 - 5.1

Answer 2

DAS 28:

• number of joints involved and size (small vs big)
• CRP and ESR
• AntiCCP and Rheumatoid Factor
• Duration of symptoms (> 6 months)
• Subjective opinion on wellbeing

Question 3

How would you manage Rheumatoid Arthritis?\

conservative
analgesia
anti-inflammatories

conventional dmards
biological dmards
surgical

Answer 3

Conservative: Physiotherapy and exercise with rest during exacerbation

Pharmacology:

1) Analgesia = Paracetamol & weak opioids
2) Anti-inflammatories = NSAIDs and glucocorticoids (IM, PO and intra-articular)

3a) Conventional DMARDs - methotrexate, sulfasalazine, hydroxychloroquine and leflunomide (all PO)
3b) Biological DMARDs - AntiTNFalpha (infliximab), rituximab, abatacept, toclizumab

conventional DMARD with glucocorticoid –> Methotrexate with another conventional DMARD –> Methotrexate and biological DMARDs

Surgical:
Joint replacement, arthrodesis and osteotomy

Question 4

What are the side-effects of Methotrexate, its mechanism and monitoring needed?

Answer 4

SE: Pulmonary fibrosis, immunosuppression, N&V and diarrhoea, sore mouth and deranged LFTs and cirrhosis

Anti-folate

• Stop 3 months before trying to get pregnant.
• Be careful with trimethoprim

Monitor LFT FBC UEs weekly until stabilised then 3-monthly. Do baseline CXR and lung function tests.

Question 5

Side-effects of Sulfasalazine & Mesalazine & monitoring?

Answer 5

Hypersensitivity: Rash & urticaria, SJS

Renal impairment: Interstitial nephritis, nephrotic syndrome

Question 6

For gout what is the acute management & management for renal impairment?

Answer 6

Acute management: NSAID & Colchicine

If renal impairment (cant use NSAID and Colchicine) so use normal steroids

Question 7

What are examples of seronegative spondyloarthropathies?

Answer 7

1) Ankylosing Spondylitis
2) Psoriatic Arthritis
3) Reactive Arthritis
4) Enteropathic Arthritis

Question 8

What are extra-articular features of Seronegative Spondyloarthropathies?

Answer 8

Axial + sacroiliitis
Asymmetrical large joint
Dactylitis (digits inflamed -> sausage)
Enthesitis: inflammation at tendon, ligament and joint capsule
Iritis + Psoriatic Rashes + IBD and Oral ulcers

Question 9

What is felty syndrome?

Answer 9

Rheumatoid Arthritis
Splenomegaly
Neutropenia (low white cells in blood)

Question 10

Rheumatoid Arthritis markers?

Answer 10

Anti-CCP (best)

Rheumatoid factor

Question 11

Sjogren’s Syndrome markers?

Answer 11

Anti RO & LA
Rheumatoid Factor
ANA

Question 12

Systemic Lupus Erythematous markers?

Answer 12

Most specific: anti-dsDNA (not sensitive)
Sensi = ANA
others: anti-RO + LA +SM + RNP

Question 13

Systemic Sclerosis markers?

i) Limited
ii) Diffuse

Answer 13

Limited = anti-centromere

Diffuse = scl 70/topoisomerase & RNA POL 123

Question 14

Anti-phospholipid syndrome markers?

Answer 14

anti-cardiolipin

Question 15

What is anti-phospholipid?

management?

Answer 15

Clots: Venous (thrombosis), arterial (stroke)
Coagulation defect: Prolonged APTT
Livido reticularis
Obstetric complications: miscarriage at 1st trimester
Thrombocytopenia

MX: aspirin or warfarin (if recurrent thrombosis)

Question 16

Polymyositis & Dermatomyositis markers?

Answer 16

Anti-Jo1

Question 17

Clinical features of SLE?

Answer 17

Arthritis

Renal: Increased BP and proteinuria
ANA +
Serositis: Pericarditis, Pleuritis
Haem = autoimmune haemolytic anaemia, low white cell counts and low platelets.

Photosensitivity
Oral ulcers
Immune phenomenon: anti-dsDNA, anti-phospholipid
Neuro: seizures and psychosis

MALAR rash = facial erythema sparing the nasolabial folds
DISCOID rash = face and chest pigmented hyperkeratotic

Question 18

Clinical features of systemic sclerosis?

• Limited 5x
• Diffuse

Answer 18

Limited:

• Calcinosis (calcium deposition)
• Raynaud’s
• Eosophagus & gut dysmotility ~ GORD
• Sclerodactyly = thickening & tightening of skin
• Telangiectasia

and also beak nose and microstomia

Diffuse: Mainly organ fibrosis

• heart: conduction defect + arrhythmias
• lung: fibrosis and pulmonary hypertension
• gut: GORD, aspiration, dysphagia and incontinence
• renal: acute hypertensive crisis

Question 19

Clinical features of polymyositis & dermatomyositis?

Answer 19

Polymyositis = symmetrical proximal muscle weakness + pelvic girdle and shoulder wasting + dysphagia, dysphonia and respiratory weakness
associated with paraneoplastic (lung, breast, pancreas, ovarian, bowel)

Dermatomyositis: 
- Heliotrope rash (eyelid + oedema)
- Macular rash (shawl sign) 
- Nailfold erythema
- Gottron papules (knuckle)
and also = mechanic hands (rough skin, retinopathy (haemorrhage and cotton wool spots), subcutaneous calcification

Question 20

Causes of drug-induced lupus?

Marker or drug-induced lupus?

Answer 20

Hydralazine,
Isoniazid,
Procainamide
Phenytoin
Chlorpromazine 
Sulfasalazine
Quinidine
tetracycline abx i.e. lymecycline, minocycline, doxycycline

Marker = anti-histone