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Year 4: MSK > Questions (Rheum) > Flashcards

Questions (Rheum) Flashcards

1
Q

Describe what is meant by drug-induced lupus erythematosus [4] - include which antibodies are commonly found [2]

Which drugs most commonly cause this? [2]

A

Most common causes
* procainamide (antiarrhythmic)
* hydralazine (antihypertensive agent)

Features:
* arthralgia
* myalgia
* skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
* ANA positive in 100%, dsDNA negative
* anti-histone antibodies are found in 80-90%
* anti-Ro, anti-Smith positive in around 5%

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2
Q

Name [1] and describe a severe form of PsA [3]

A

Arthritis mutilans is a severe and destructive form of psoriatic arthritis
* It is characterised by progressive joint damage, leading to bone and cartilage loss, deformity, and disability.
* This condition is relatively rare but can profoundly impact an individual’s quality of life.
* Arthritis mutilans typically affect the small joints of the hands and feet, causing a telescoping or ‘pencil-in-cup’ deformity. Early diagnosis and aggressive treatment are crucial to help manage symptoms, preserve joint function, and improve long-term outcomes.

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3
Q

What would the histological findings be of a RA nodule? [1]

A

The histological composition of subcutaneous nodules is areas of fibrinoid necrosis surrounded by palisading epithelioid cells.

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4
Q

What are the pulmonary manifestations of RA?

A

Pulmonary conditions that patients with rheumatoid arthritis are at increased risk of developing include interstitial lung disease and pulmonary fibrosis (lower lobes), bronchiectasis, pleural effusions, lung nodule

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5
Q

Felty’s Syndrome:
- Treatment of choice is initially with []

A

Treatment of choice is initially with the **disease-modifying anti-rheumatic drug methotrexate. **

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6
Q
A
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7
Q

In younger adults, particularly females, disseminated gonococcal infection may cause [hand condition]

A

In younger adults, particularly females, disseminated gonococcal infection may cause acute migratory tenosynovitis

e.g.
On examination, the affected finger is markedly swollen and erythematous, with tenderness to touch – especially along the flexor aspect of the finger. The patient is holding the finger in slight flexion; attempts at straightening the finger passively cause the patient extreme pain.

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8
Q

Which disease / infection can cause false positive results for antiphospholipid antibodies? [1]

A

Syphilis

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9
Q

A patient is diagnosed with AS.

What should you screen them for every 2 years according to NICE? [1]

A

Patients with AS are at increased of osteoporosis, likely due to chronic inflammation, and as a result are more prone to fragility fractures, and should be offered screening for osteoporosis every 2 years, as per NICE guidance

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10
Q
A
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11
Q

What is most commonly associated with rheumatoid arthritis?

Shrinking lung syndrome
Pulmonary hypertension
Apical fibrosis
Bronchiectasis
Yellow nail syndrome

A

Bronchiectasis

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12
Q

Which symptoms seperate GCA from PMR? [4]

A
  • headache, fever, malaise, and scalp tenderness
  • tender & thickened arteries
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13
Q

Which of the following tissues is the most common site of calcium pyrophosphate crystal deposition in patients with pseudogout?

Synovium
Ligaments
Cartilage
Tendons
Bursae

A

Synovium

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14
Q
A
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15
Q

Acromegaly increases the liklihood of:
- Gout
- Pseudogout

A

A swollen and painful joint in a patient with a past medical history of acromegaly and no prior history of gout is likely to be caused by pseudogout

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16
Q

How do you differentiate between septic arthritis and RA from fluid aspiration?

With regards to:
- colour [1]
- WBC [1]
- neutrophil % [1]
- gram stain [1]

A

Septc arthritis:
* Colour: yellow/green
* WBC: >50 000 cells/mm3
* Neutrophils: >75 %
* Gram stain: often positive

RA:
* Colour: turbid, yellow
* WBC: 2 - 50, 000/mm³ cells/mm3
* Neutrophils: >70%
* Gram stain: negative

NB: septic arthritis would have WBC > 50k. RA has WBC between 2k and 50k.

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17
Q

Hydroxychloroquine - may result in a which important side effect? [1]

A

Hydroxychloroquine - may result in a severe and permanent retinopathy

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18
Q

A person is taking a medication that increases that chance of an atypical fracture.

What is this medication? [1]

A

Bisphosphonates are associated with an increased risk of atypical stress fractures

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19
Q

Describe the primary [1] and secondary thromboprophylaxis (initial VTE [1]; recurrent VTEs [2]; arterial thrombosis [1]) used for anti-phospholipid syndrome

A

Management - based on EULAR guidelines
primary thromboprophylaxis
* low-dose aspirin

secondary thromboprophylaxis
* initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
* recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
* arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

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20
Q

What is the difference in pathophysiology of Marfans and Ehler-Danlos? [2]

A

Marfans- Mutation to fibrillin 1
Ehler-Danlos mutation to Collagen (most common subtype is III)

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21
Q

What is the most common presenting pattern of psoriatic arthritis?

Arthritis mutilans

Asymmetrical oligoarthritis

Distal interphalangeal joint arthritis

Proximal interphalangeal joint arthritis

Spondylitis

A

Asymmetrical oligoarthritis

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22
Q

Sjogrens patients are most likely to develop which cancer? [1]

A

mucosa-associated lymphoid tissue (MALT) lymphoma.

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23
Q

What side effect does colchicine give at high dose? [1]

A

Causes diarrhoea when given at high doses

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24
Q

Describe the change seen in this x-ray? [1]
What does it indicate? [1]

A

Squaring of the thumb:
- indicates OA

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25
Q

Describe what is meant by Löfgren syndrome

A
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26
Q

Which of GPA / eGPA is more associated with sinusitis? [1]

A

GPA - cANCA

Saddle nose x

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27
Q

Describe the difference between presentation of PMR and dermatomyositis [1]

A

PMR = pain
DM = weakness

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28
Q

Dermatomyositis is strongly associated with which pathology? [1]

A

With malignancies - especially lung cancer

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29
Q

Describe how you manage long term bisphosphinate treatment [1]

A

After a five year period for oral bisphosphonates (three years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan.

This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true:
* Age >75
* Glucocorticoid therapy
* Previous hip/vertebral fractures
* Further fractures on treatment
* High risk on FRAX scoring
* T score <-2.5 after treatment

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30
Q

This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true [6]

A
  • Age >75
  • Glucocorticoid therapy
  • Previous hip/vertebral fractures
  • Further fractures on treatment
  • High risk on FRAX scoring
  • T score <-2.5 after treatment
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31
Q

Alendronate can cause atypical stress fractures of which bone? [1]

A

atypical stress fractures of the proximal femoral shaft
- they reduce bone remodelling since they inhibit osteoclasts, which means micro fractures can’t be healed as well.

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32
Q

Describe the acute phase response of bisphosphinate initiation [3]

A

acute phase response: fever, myalgia and arthralgia may occur following administration

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33
Q

What change in Ca levels would occur with bisphosphinate tx? [1]

A

hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant

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34
Q

What are RA x-ray changes? [5]

A

loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation

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35
Q

How do you differentiate gout from pseudogout on x-ray? [1]

A

Chondrocalcinosis helps to distinguish pseudogout from gout

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36
Q

Name two drug classes that cause erythema nodosum [2]

A

penicillins; sulphonamides

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37
Q

Felty’s syndrome is a triad of []

A

Felty’s syndrome is a triad of rheumatoid arthritis, splenomegaly and neutropenia (low white cell count).

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38
Q
A
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39
Q

Pneumonic for remembering causes of erythema nodosum? [+]

A

NO : idiopathic
D : drugs → penicillin sulphonamides
O : oral contraceptives / pregnancy
S : sarcoidosis / TB
U : ulcerative colitis / Crohn’s disease / Behçet’s disease
M : micro → strep, mycoplasma, EBV and more

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40
Q

The concurrent use of [] and [] containing antibiotics may cause bone marrow suppression and severe or fatal pancytopaenia

A

The concurrent use of methotrexate and trimethoprim containing antibiotics may cause bone marrow suppression and severe or fatal pancytopaenia

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41
Q

What would indicate that Raynaud’s is primary and not a secondary cause? [1]

A

Raynaud’s disease typically presents in young women (e.g. 30 years old) with bilateral symptoms.

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42
Q

What is the difference in treatment betwen mild and moderate fungal nail infections in terms of:
- presenting features [1]
- treatment [1]

A

Mild:
- < 2 nails impacted
- Topical amorolfine

Moderate:
- > 2 nails impacted
- Oral itraconazole

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43
Q

[] score is a useful tool to assess hypermobility.

A

Beighton score is a useful tool to assess hypermobility.

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44
Q

A patient has gout, which they are given long term treatment for.

He comes in with an acute exercabation of another illness he has.

A FBC reveals pancytopenia.

The interaction of which medications is likely to have caused this? [2]

A

Azathioprine and allopurinol have a severe in teraction causing bone marrow suppression

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45
Q

What is the difference in underlying pathologies causing:

Low calcium, raised phosphate, raised ALP, raised PTH
versus
Low calcium, low phosphate, raised ALP, raised PTH

A

Low calcium, raised phosphate, raised ALP, raised PTH = kidney failure

Low calcium, low phosphate, raised ALP, raised PTH = osteomalacia

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46
Q

What is the immediate plan for a patient who has a fragility fracture and is over 75? [1]

A

Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan
- the most likely diagnosis is osteoporosis

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47
Q

Which two key parts of a question indicate a patient is suffering from polymalgia rheumatica? [2]

A

Shoulder Girdle pain x raised ESR

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48
Q

A 57-year-old female has noticed that the skin on her hands has become very tight and that her fingers sometimes turn blue. She has also had difficulty swallowing both solids and liquids. What autoantibody is most associated with these symptoms?

Anti-centromere
Anti-topoisomerase (anti-Scl-70)
Anti-double-stranded DNA (anti-dsDNA)
Anti-cyclic citrullinated peptide (anti-CCP)
Anti-mitochondrial (AMA)

A

A 57-year-old female has noticed that the skin on her hands has become very tight and that her fingers sometimes turn blue. She has also had difficulty swallowing both solids and liquids. What autoantibody is most associated with these symptoms?

Anti-centromere - patient has limited cutaneous systemic sclerosis

Anti-topoisomerase (anti-Scl-70) - for diffuse systemic sclerosis

anti-centromere –>’mere’ and ‘limited’ are synonyms

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49
Q

[RA drug] - may result in a severe and permanent retinopathy

A

Hydroxychloroquine - may result in a severe and permanent retinopathy

Donald trump loves hydroxychloroquine- wouldn’t stop going on about it
He is orange (skin pigmentation), he is nightmarish (nightmares), always looks like he’s squinting (reduced visual acuity- bullseye retinopathy), and his brother died from alcoholism (liver toxicity)

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50
Q

Schober’s test < [] cm is suggestive of ankylosing spondylitis.

A

Schober’s test < 5 cm is suggestive of ankylosing spondylitis.

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51
Q

Which of the following antibodies is most specific for diffuse cutaneous systemic sclerosis?

Anti-nuclear factor
Anti-centromere antibodies
Anti-Scl-70 antibodies
Rheumatoid factor
Anti-Jo 1antiobodies

A

Which of the following antibodies is most specific for diffuse cutaneous systemic sclerosis?

Anti-nuclear factor
Anti-centromere antibodies
Anti-Scl-70 antibodies
Rheumatoid factor
Anti-Jo 1antiobodies

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52
Q

‘[]’ and ‘[]’ deformity are typical x-ray features in psoriatic arthritis

A

‘Plantar spur’ and ‘pencil and cup’ deformity are typical x-ray features in psoriatic arthritis

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53
Q

Ankylosing spondylitis - x-ray findings: [3]

A

Ankylosing spondylitis - x-ray findings: subchondral erosions, sclerosis
and squaring of lumbar vertebrae

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54
Q

A positive Schirmer’s test would indicate which antibodies to be present? [2]

A

Positive Schirmer’s test are suggestive of Sjogren’s syndrome. Positive anti-Ro and anti-La antibodies

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55
Q

Co-trimoxazole contains trimethoprim and therefore should never be prescribed with []

A

Co-trimoxazole contains trimethoprim and therefore should never be prescribed with methotrexate

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56
Q

Which SLE drug is safe in pregnancy? [1]

A

Aziothropine

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57
Q

Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of []

Name another common symptom associated with this condition [1]

A

Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of psoriatic arthritis

Commonly presents with Onycholysis

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58
Q

A patient is diagnosed with dermatomyositis.

What is the initial investigation and why? [2]

A

Dermatomyositis is commonly a paraneoplastic phenomenon - therefore perform a CT chest/abdomen/pelvis

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59
Q

Patients with suspected visual loss secondary to temporal arteritis are usually given [] initially

A

Patients with suspected visual loss secondary to temporal arteritis are usually given IV methylprednisolone initially

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60
Q

Which complication are people with Marfan’s most likely to suffer from? [1]

A

Pneumothorax

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61
Q

When does NICE recommend NOT giving bisphosphinates to patients with osteoporosis? [1]

What should you give instead? [1]

A

bisphosphinates:
- contraindicated if the eGFR is less than 35

Denosumab: used as 2nd linea after bisphosphinates

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62
Q

A patient has RA.

Which medication is causing this condition? [1]

A

Hydroxychloroquine:
- ‘bull’s eye maculopathy’

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63
Q

Fibromyalgia typically presents in which patient aged population? [1]

Polymyalgia rheumatica (PMR) typically presents in which patient aged population? [1]

Describe the difference in presentation between them [2]

A

Polymyalgia rheumatica (PMR) typically presents in older adults with bilateral aching and stiffness in the shoulder and hip girdle muscles, often with morning stiffness lasting more than an hour.

Fibromyalgia typically affects younger individuals and presents with chronic widespread pain, tenderness at specific points, fatigue, and sleep disturbances.

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64
Q

[] is a pharmacological option for Raynaud’s phenomenon

A

Nifedipine is a pharmacological option for Raynaud’s phenomenon
- causes vasodilation

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65
Q

Describe the basic pathophysiology of osteogenesis imperfecta (more commonly known as brittle bone disease) [1]

A
  • autosomal dominant
  • abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
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66
Q

TOM TIP: The key feature that often appears in exams that should make you think about osteogenesis imperfecta is the []

This is a unique feature that examiners love to drop in. The exam patient may be a young child with unusual and recurrent fractures that would normally make you consider safeguarding, however “you notice a blue discolouration to the sclera”.

A

TOM TIP: The key feature that often appears in exams that should make you think about osteogenesis imperfecta is the blue sclera.

This is a unique feature that examiners love to drop in.

The exam patient may be a young child with unusual and recurrent fractures that would normally make you consider safeguarding, however “you notice a blue discolouration to the sclera”.

67
Q

Tx for osteogenesis imperfecta? [2]

A

The underlying genetic condition cannot be cured. Medical treatments include:

  • Bisphosphates to increase bone density
  • Vitamin D supplementation to prevent deficiency
68
Q

What blood results would you see in osteogenesis imperfecta? [1]

A

**Adjusted calcium, PTH, ALP and PO4 results **are usually NORMAL in osteogenesis imperfecta

Osteogenesis Imperfecta…but PERFECT blood results.

69
Q

Drug induced lupus can be indicated by which antibodies being present? [1]

A

anti-histone antibodies

Drug induced lupus: The answer is in their HISTory (drugs) –> anti-HISTone

70
Q

In which cases of osteoporosis do you manage immediately (i.e. before a DEXA scan) ? [2]

A

A postmenopausal woman, or a man age ≥50 has a symptomatic osteoporotic vertebral fracture

71
Q

How can you differentiate between septic and reactive arthritis with regards to time frame of previous infection? [2]

A

Septic arthritis:
- Usually around 1 week

Reactive arthritis:
- Precedes 2-4 weeks prior

72
Q

Pneumonic for remembering which drugs cause / trigger psoriasis [7]

A

BALI TAN ‘I got a tan in Bali’

B blockers, Antimalarials/ACEi, Lithium, Indomethacin/Inflimab
Trauma Alcohol NSAID

73
Q

Describe the pathophysiological cause of ocular complications in temporal arteritis [1]

A

Anterior ischemic optic neuropathy accounts for the majority of ocular complications in temporal arteritis

74
Q

If a patient is having renal complications of systemic sclerosis - which drug should you give? [1]

A

Renal complications of systemic sclerosis - ACE-inhibitors

75
Q

How do you treat temporal arteritis when there is suspected visual impairment? [1]

A

Urgent IV methylprednisolone and admit to ophthalmology

76
Q

How do you adapt osteoporosis management plans if a patient is on a long term steroid?

A
  • aged > 65 no need DEXA
  • aged < 65 do DEXA first
  • if T score less than 1.5 -> give alendronate
  • If T score more than 1.5 ->repeat scan 1-3 yearly
77
Q

What is important to note before prescribing bisphosphinates? [1]

A

Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates

78
Q

Low levels of which one of the following types of complement are associated with the development of systemic lupus erythematous?

C4
C5
C6
C7
C8

A

SLE: complement levels (C3, C4) are usually low during active disease - may be used to monitor flares

79
Q

A patient has anterior ischaemic optic neuropathy (AION) secondary to temporal arteritis.

What is the most likely finding on fundoscopy? [1]

A

swollen pale disc and blurred margins

80
Q

Should oral bisphosphonates be taken with / without food? [1]

A

Oral bisphosphonates should be swallowed with plenty of water while sitting or standing on an empty stomach at least 30 minutes before breakfast

81
Q

A patient has gout and RA.

Which two medications would you avoid co-prescribing because of the risk of bone marrow suppression? [2]

A

Azathioprine and allopurinol have a severe interaction causing bone marrow suppression

82
Q
A
83
Q

Treatment for fibromyalgia? [4]

A
  • explanation
  • aerobic exercise: has the strongest evidence base
  • cognitive behavioural therapy
  • medication: pregabalin, duloxetine, amitriptyline
84
Q

AS presents with reduction of which movements in clinical examination? [3]

A
  • reduced lateral flexion
  • reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
  • reduced chest expansion
85
Q

When do you give oral prednisolone vs IV methylpredinisolone for temporal arteritis? [1]

A

Oral pred:
- no visual changes or other ischaemic organ damage

IV methylprednisolone:
- patients with visual changes

86
Q

[] antibodies are associated with drug-induced lupus

A

Antihistone antibodies are associated with drug-induced lupus

87
Q
A
88
Q

Which tests should you order when investigating secondary causes of osteoporosis? [6]

A
  • full blood count
  • urea and electrolytes
  • liver function tests
  • bone profile
  • CRP
  • thyroid function tests
89
Q

State investigation findings of AS [4]

Which would you see first? [1]

A
  1. Syndesmophytes (ossification of outer fibres of annulus fibrosus)
  2. A bamboo spine on plain x-ray is a late sign which is rarely seen in clinical practice.
  3. sacroiliitis: subchondral erosions, sclerosis
  4. squaring of lumbar vertebrae
90
Q

How do you interpret a T-score > -1? [1]

A

Osteopenia or osteoporosis detected in one measurement site means there is generalised osteopenia or osteoporosis; it is a systemic process and cannot be localised to only one region.

91
Q

NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to [] or []

A

NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to risedronate or etidronate

92
Q

A positive [] antibody can assist in making the diagnosis of dermatomyositis [1]

A

anti-Jo1 antibody

93
Q

Renal complications of systemic sclerosis - use [1]

A

ACE-inhibitors

94
Q

Mnemonic for remembering the manifestations of diffuse sclerosis? [8]

A

CREST CPR (more serious than limisten
C- CAD and HTN (both systemic and pulmonary)
P- Pulmonary Fibrosis
R- Renal crisis (AKA Scleroderma renal crisis)- anuria, organ failure

95
Q
A
96
Q

What does prescribing folate alongside MTX specifically reduce the risk of? [1]

A

Prescribing folate with methotrexate reduces the risk of myelosuppression
- Methotrexate inhibits dihydrofolate reductase, an enzyme required for DNA synthesis, which lowers folate levels and impairs blood cell production. This can result in low counts of white blood cells, red blood cells, and platelets, increasing the risks of infection, anaemia, and bleeding

97
Q

Describe the typical joint aspirate in a person with RA [3]

A

Joint aspirate in rheumatoid arthritis shows a high WBC count, predominantly PMNs. Appearance is typically yellow and cloudy with absence of crystals

98
Q

What type of neuropathy (eye) does PMR x CGA cause? [1]

How does this present in a fundoscope [1]

A

Anterior ischemic optic neuropathy - fundoscopy typically shows a swollen pale disc and blurred margins

99
Q

APS causes what finding in a clotting study? [1]

A

prolonged APTT.

100
Q

Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take []

A

Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take sulfasalazine

101
Q

What is a skin manifestation of APS? [1]

A

livedo reticularis

Livedo reticularis can also be caused by many other conditions, it is not exclusively a sign of APS.

102
Q

Patients with Sjogren’s syndrome have an increased risk of [] malignancies

A

Patients with Sjogren’s syndrome have an increased risk of lymphoid malignancies

103
Q

What is the gold standard diagnostic test for AS? [1]

A

Magnetic resonance imaging of the sacroiliac joints

104
Q

haemochromatosis is a risk factor for

RA
Septic Arthritis
Acute gout
Pseudogout
OA

A

haemochromatosis is a risk factor for

RA
Septic Arthritis
Acute gout
Pseudogout
OA

105
Q

Anti Jo-1 is associated with []

A

Anti Jo-1 is associated with polymyositis

106
Q

Which form of vasculitis is associated w hepatitis B infection? [1]

A

Takayasu’s arteritis

107
Q

Which of the following patterns of inheritance best describe Marfan’s Syndrome?

Autosomal Dominant

Mitochondrial

X-Linked Dominant

X- Linked Recessive

Autosomal Recessive

A

Which of the following patterns of inheritance best describe Marfan’s Syndrome?

Autosomal Dominant

Mitochondrial

X-Linked Dominant

X- Linked Recessive

Autosomal Recessive

108
Q

Describe a clinical test you would perfom for a ? lumbar disk herniation [1]

A

The straight leg raise is a test used for diagnosing herniated discs, with a sensitivity of approximately 90% and specificity of 25%.
- On performing the straight leg raise, the patient complains of back pain

109
Q

Aneurysms x constitutional symptoms with a purpuric rash can suggest the diagnosis of []

A

Aneurysms and constitutional symptoms with a purpuric rash can suggest the diagnosis of Polyarteritis nodosa.

110
Q

Adult-onset Still’s disease is a diagnosis of exclusion and can only be diagnosed if rheumatoid factor and anti-nuclear antibody are negative

What presentation would help to suggest this pathology? [5]

A

The triad of joint pain, spiking fevers, and a pink bumpy rash is very characteristic of adult-onset Still’s disease.

Additionally, it is also associated with high serum ferritin and leucocytosis.

111
Q

How do you manage clotting risk in APS patients who have not had a thrombosis before? [1]

A

Patients with anti-phospholipid syndrome who haven’t had a thrombosis previously are generally on low-dose aspirin

112
Q

An X-ray shows erosions in the centre of the right distal interphalangeal joints, which are described as having a pencil in cup appearance.

What is the most likely diagnosis?

Osteoarthritis
Psoriatic arthritis
Rheumatoid arthritis
Gout
Systemic lupus erythematosus (SLE)

A

Psoriatic arthritis

113
Q

Patients who are allergic to aspirin may also react to []

A

Patients who are allergic to aspirin may also react to sulfasalazine

114
Q

A 33-year-old man has been diagnosed with ankylosing spondylitis. Unfortunately, it is not well controlled, and his rheumatologist thinks he should start on a new medication.

How many different non-steroidal anti-inflammatory drugs must this patient have failed to respond to before he can be started on anti-TNF alpha inhibitors, in someone with predominantly axial disease?

1
2
3
4
5

A

Anti-TNF alpha inhibitors should be used in axial ankylosing spondylitis that has failed on 2 different NSAIDS and meets criteria for active disease on 2 occasions 12 weeks apart

115
Q

eGPA and microscopic polyangiitis both can present with positive p-ANCA.

How would you distinguish between them through their symptoms? [2]

A

Microscopic polyangiitis:
- respiratory (alveolar haemorrhage; haemoptysis, renal (necrotising glomerulonephritits) and generalised symptoms (fever; weight loss; malaise

eGPA:
- Asthma
- Rhinosinusistis
- Muscle or joint pain

116
Q

What treatment would you give for symptomatic ocular manifestations of Sjogren’s disease? [1]

A

Hypromellose:
- Management of Sjogren’s syndrome is mainly topical and targeted towards symptomatic relief. Hypromellose act as artifical tears and are applied as eye drops to soothe eyes

117
Q

Why should you Cover with NSAIDS or Colchicine for the first few months of initiating ULT? [1]

A

Starting urate lowering therapy can cause an acute flare, hence it is advisable to cover with anti-inflammatory agents such as NSAIDS or Colchicine until effective dose is achieved.

NB: Allopurinol given when flare is over.
Colchicine can be given during flare.

118
Q

Iloprost is a medication that can be used for Raynauds.

When is it specifically indicated? [1]

A

Can be given when a patient has evidence of tissue loss

119
Q

Myeloperoxidase antibodies (MPO) aka? [1]

A

pANCA

120
Q

Which drugs can cause drug induced lupus? [1]

What antibody does this cause to be positive? [1]

A

Positive anti-histone antibody

Drugs that are known to cause DIL include:
* sulfadiazine
* hydralazine
* procainamide
* isoniazid
* methyldopa
* quinidine
* minocycline
* chlorpromazine

121
Q

What antibody associations are associated with discoid lupus? [1]

A

Usually negative for ANA

122
Q

When do you give oral pred vs IV methylpred for CGA? [2]

A

Methylpred: ocular or neurological involvement

Pred: None of above

123
Q

How do you distinguish between polymyositis from polymyalgia? [1]

A

(both cause weakness of proximal muscles) is that polymyalgia is associated with stiffness and polymyositis is associated with pain (in 1/3 of cases)

124
Q

(both cause weakness of proximal muscles) is that polymyalgia is associated with stiffness and polymyositis is associated with pain (in 1/3 of cases)

What drug is used in initial management

A

ACE inhibitors is first-line in scleroderma renal crisis as it significantly reduces blood pressure for many patients
- It is usually recommended to start a short acting ACE inhibitor such as Captopril before moving on to a longer acting agent such as Ramipril once the patient is stabilised.

125
Q

[] are an ophthalmological issue which may be caused by corticosteroids.

A

Cataracts

126
Q

Which biomarkers are raised in dermato- and polymyositis? [4]

A

CK
LDH
Aldolase
ALT
AST

DM & P turn muscles into CLAAA

127
Q

What is the first and second line treatment for discoid lupus? [2]

A
  1. topical steroid
  2. hydroxychloroquine
128
Q

What hearing defects may occur in Pagets [2] and why? [1]

A

Tinnitis and hearing loss
- Cochlea damage due to ankylosis of ossicles and narrowing of internal auditory meatus

129
Q

Pagets dx with a sudden worsening of pain could indicate…? [1]

A

Osteosarcoma

130
Q

How long do you treat septic arthritis for? [1]

A

Abx for 4-6 weeks

131
Q

Tx for PAN? [1]

A

IV steroids and pulse cyclophosphamide

132
Q

Which drug should MTX not be prescribed alongside? [1]

A

Trimethoprim

133
Q

You suspect a patient has gout. You take a serum sample of their uric acid levels.

What level would indicate gout? [1]
What would you do if the level if below^ [1]

A
  • > 360 indicates gout
  • < 360 - repeat in 2 weeks
134
Q

How do you manage acute gout in someone in CKD? [1] Why? [1]

A

Use steroids - colchicine is CI in CKD

135
Q

Describe a way of remembering different types of strengh of steroids [4]

A

Hydrocortisone; Eumovate; Betamethasone; Declomethasone

Help every budding dermatologist

136
Q

What are important AEs of CGA need to consider? [3]

A

Blindess
Stroke
Thoracic AA

137
Q

How does eGPA specifically impact the kidney? [1]

A

Granulomas in kidneys

138
Q

What do you check BEFORE [1] and DURING [1] aziothropine use?

A

Before: TPMT
During: risk of myelosuppresion - check markers etc

139
Q

Describe how you start allopurinol [1]
What advice do you give? [1]

A
  • Cover with colchicine for 6 months
  • Describe that can cause an initial flare of gout but will settle and help to eradicate uric acid
140
Q

Which antihypertensives are best suited for gout patients? [2]

A

Amlodopine
Losartan

141
Q

What do you need to check if you dx osteoporosis in young men? [1]

A

Testosterone levels:
* Low testosterone levels can cause rapid bone turnover

142
Q

Describe how you specifically diagnose APS [1]

A

two positive anticardiolipin tests 12 weeks apart
- can get an acute rise in infection

143
Q

Why need to do MRI of C-spine prior to surgery for RA patients? [1]

A

Risk of atlanto-axial subluxation

144
Q

Felty’s syndrome consists of a triad of..?[3]

A

Ra
Splenomegaly
Neutropaenia

145
Q

CGA has a 17x increased risk of … [1]

A

thoracic aortic aneurysm

146
Q

Suspected systemic sclerosis in a patient.

Initiate what test? [1]
Why? [1]

A

Renal function - check for renal cisis

147
Q

Describe the rash on the face in dermatomyositis [1]

A

reddish-purple rash (heliotrope rash) on the upper eyelid or across the cheeks and bridge of the nose in a “butterfly” distribution and on the forehead and scalp.
- NB: Lupus doesn’t generally appear in the area below the nose and above the lips, while dermatomyositis does

148
Q

What sign on US would suggest CGA? [1]

A

Halo sign

149
Q

Anky spond. has a decrease in which three movements? [3]

A

Forward flexion
Chest expansion
Lateral flexion

150
Q

Tx for lupus nephritis? [2]

A

Pred and cyclophosphamide

151
Q

Name 6 different causes of dactylitis [6]

A

PsA; ReA
SCA
TB; Sarcoidosis; Syphilis

152
Q

When do you initiate ULT in gout? [4]

A
  • 2/3 attacks in a year
  • Chronic tophaceaous gout
  • X-ray changes
  • Severe disabling attacks
153
Q

Hep B is associated with which vasculitis? [1]

A

PAN

154
Q

What prophylatic screening should you conduct every 2 years for AS patients? [1]

A

Osteoporosis

155
Q

Long term OA - most optimal treatment? [1]

A

Celecoxib - reduced impact of peptic ulceration

156
Q

An important differential for abdominal pain is which vasculitis? [1]

A

Polyarteritis Nodosa (PAN)
- due to vasculitis of medium-sized mesenteric arteries

157
Q

APS causes which change in clotting markers? [1]

A

APTT

158
Q

What change might you see in FBC if on MTX tx? [1]

A

Macrocytic anaemia due to folate deficiency

159
Q

APS treatment and INR aim for multiple thrombotic events? [1]

APS treatment and INR aim for recurrent thrombosis (despite previous tx) ? [1]

A

Multiple thrombotic events: Warfarin with INR of 2-3

Recurrent thrombosis: Warfarin and INR of 3-4

160
Q

What are the different DAS-28 scores and their associated classifications of disease severity in RA? [4]

A

< 2.6 = Disease remission
2.6 - 3.1 = low severity
3.2 - 5.1 = medium severity
> 5.1 = high severity

161
Q

All SLE patients need which test? [1]

A

Urine dip - test for lupus nephritis

162
Q
A
163
Q

In which of the following conditions can tendinitis/tenosynovitis present without being swollen and tender?

Systemic sclerosis
Gout
Rheumatoid arthritis
Disseminated gonococcal infection
Reactive arthritis

A

In which of the following conditions can tendinitis/tenosynovitis present without being swollen and tender?

Systemic sclerosis
Gout
Rheumatoid arthritis
Disseminated gonococcal infection
Reactive arthritis

Year 4: MSK (40 decks)

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