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MDEMO - Rheumatology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

autoimmune?

more common in?

seen in which age group?

commonly affects which joints?

strong RF for RA?

A

yes

females

all ages - most commonly 30-50

MCP, PIP joints (DIPS are rarely affected)

smoking

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2
Q

features?

deviation of fingers to which side?

A

Morning stiffness, improves with use
Bilateral symptoms
Systemic upset

ulnar deviation

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3
Q

how many are rheumatoid factor +ve?

how many are rheumatoid factor +ve after 10 yr progression?

difference in features?

A

40%

80%

Rhf +ve are more likely to have extra-articular manifestations

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4
Q

which gene makes you 60% more susceptible to RA?

A

HLA-DR4

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5
Q

which joints are usually affected?

A
  • Stiff, swollen symmetrical distal joints in hand and feet – worse in morning and improves during the day.
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6
Q
  • Boutonniere and swan neck deformities of digits are due to ?
A

PIP joint synovitis

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7
Q

why do you get radial deviation of wrist ?

A

to compensate for ulnar deviation of fingers.

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8
Q
  • Only get rheumatoid nodules in ?
A

RhF +VE

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9
Q

Extra-articular features of RA

synovitis can cause median nerve compression - what condition is this?

often found in patients who test positive for rheumatoid factor. ?

– predom in seropositive for rheumatoid factor – features include leg ulcers and peripheral neuropathy?

Felty’s syndrome triad?

1/3 of RA patients will have?

bowel associations?

A
  • Carpal tunnel syndrome – synovitis can cause median nerve compression – very common.
  • Rheumatoid nodules in elbow, Achilles tendon and hand – often found in patients who test positive for rheumatoid factor.

Vasculitis

Triad of RA with splenomegaly and neutropenia.

– 1/3 of RA patients will have lung disease (fibrosis, nodules, effusion).

IBS associations

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10
Q

What are all raised in presence of synovitis?

A

increase in CRP, ESR, plasma viscosity (raised platelets)

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11
Q

which test is highly specific for RA (98% specificity)?

A
  • Anti-CCP serological test – highly specific for RA (98% specificity).
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12
Q
  • X-ray shows:

L
E
S
S

A

Loss of joint space narrowing
erosions
soft tissue swelling
soft bones (osteopenia)

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13
Q

what % of RA patients are ANA +ve?

A

30%

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14
Q

diagnosis of RA - how many out of 7 do you need for ARA criteria to be diagnosed ?

A

4 / 7

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15
Q

what is DAS28 score?

what score means:

  • high disease activity?
  • moderate disease activity?
  • low disease activity?

a decrease in DAS28 score by what means a poor response to tx?

a decrease in DAS28 score by what means a good response to tx?

A

assess tenderness and swelling at 28 joints to calculate disease score

high = >5.1
moderate = 3.2-5.1
low <3.2

<0.6 = poor 
>1.2 = good
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16
Q

Tx of RA

conservative?

medical?

  • Waiting to be referred from GP to rheumatologist?
  • NICE recommend what within 3 months of first onset of symptoms as first line?
  • what can you give alongside MTX?
  • when do you administer biologics?
  • what do you give for flares?
A

conservative

  • exercise
  • physiotherapy
  • stop smoking

administer NSAID.

  • NICE: 1st line within 3 months: combination of MTX + another DMARD + short term glucocorticoid
  • folic acid to help with nausea
  • failure of 2 DMARDs (using DAS28 score)
  • Steroids rapidly reduce symptoms and inflame but have no effect on disease progresison – useful for when disease flares, administer methylprednisolone (intra-articular) or prednisolone (oral).
17
Q

A 61-year-old female is reviewed in the rheumatology clinic with increasing shortness of breath. She has been on long-term drug therapy to control her rheumatoid arthritis. Her oxygen saturations on room air are on 89%. Investigations reveal the following:

Chest x-ray Bilateral interstitial shadowing

Which drug is most likely to be responsible for her symptoms?

infliximab
hydroxychloroquine
sulphasalazine
methotrexate

A

methotrexate

complications of drug therapy e.g. methotrexate pneumonitis

18
Q

A 40-year-old woman is newly diagnosed with rheumatoid arthritis after a 6-month history of persistent wrist and hand pain. She also experiences stiffness each morning which takes 2 hours to fully resolve.

Her blood tests show a raised C-reactive protein and rheumatoid factor.

Which is of the following findings is most likely to be found on examination of the patient’s hands?

swollen DIP joints
swan neck deformity
boutonniere deformity
wrist tenderness

A

wrist tenderness

Swan neck and boutonnière deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient

Whilst the swan-neck, boutonniere and Z-thumb deformities are all textbook hand findings of RA, they are secondary to joint and tendon changes caused by years of chronic synovitis and so would be unlikely in a newly diagnosed patient

19
Q

A 45-year-old lady, with a past medical history of rheumatoid arthritis, is scheduled to have a laparoscopic cholecystectomy. What imaging should be performed pre-operatively?

anteroposterior and lateral cervical spine radiographs

CT cervical spine

hand radiographs

anteroposterior cervical spine radiographs

A

anteroposterior and lateral cervical spine radiographs

Atlantoaxial subluxation is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression. Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication, ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation.

20
Q

What is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression?

what is a preoperative screen?

A

Atlantoaxial subluxation

Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication, ensuring the patient goes to surgery in a C-spine collar

21
Q

A 36-year-old female attends your GP clinic following her outpatient appointment with the rheumatologist. She has been informed of the complications of her rheumatoid arthritis, and is most concerned over the visual complications mentioned.

What can you inform her is the most common ophthalmic complication of her disease?

acute angle glaucoma
keratoconjunctivitis sicca
dry macular degeneration
anterior iritis

A

Most common eye complication of rheumatoid arthritis: keratoconjunctivitis sicca

22
Q

Most common eye complication of rheumatoid arthritis?

A

keratoconjunctivitis sicca

23
Q

An 82-year-old woman with long-standing rheumatoid arthritis presents with a history of recurrent chest infections over the past 6 months. On examination she is found to have splenomegaly. Her current medications include methotrexate and sulphasalazine.

What is the most likely cause of the neutropenia?

hodgkin's disease 
felty's syndrome 
non-hodgkin's disease 
CLL
MTX use
A

felty’s syndrome

24
Q

A 64-year-old female is referred to rheumatology out-patients by her GP with a history of arthritis in both hands. Which one of the following x-ray findings would most favour a diagnosis of rheumatoid arthritis over other possible causes?

loss of joint space
juxta-articular osteoporosis
subchondral cysts
subchondral sclerosis

A

juxta-articular osteoporosis

25
Q

Which of the following is associated with a good prognosis in rheumatoid arthritis?

Rhf -ve
Anti-CCP
HLA DR4
rheumatoid nodules

A

Rhf -ve

26
Q

A 28-year-old woman who has rheumatoid arthritis is to be started on etanercept injections after failing to respond to methotrexate and sulfsalazine. Which one of the following adverse effects is associated with the use of TNF-alpha inhibitor - etanercept?

tendonitis
cardiomyopathy
reactivation of TB

A

reactivation of TB

TNF-α inhibitors may reactivate TB

27
Q

You refer a 24-year-old female to rheumatology with intermittent pain and swelling of the metacarpal phalangeal joints for the past 3 months. An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid factor is positive and a diagnosis of rheumatoid arthritis is made. What initial management is she most likely to be given to help slow disease progression?

infliximab

MTX

sulfasalazine

MTX + sulfasalazine + short course prednisolone

diclofenac

A

MTX + sulfasalazine + short course prednisolone

The 2009 NICE guidelines recommend that patients with newly diagnosed active RA start a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids).

28
Q

You are doing the annual review of a 50-year-old woman who has rheumatoid arthritis. Which one of the following complications is most likely to occur as a result of her disease?

CLL
HTN 
Colon cancer 
T2DM 
IHD
A

IHD

Rheumatoid arthritis: patients have an increased risk of IHD

29
Q

Rheumatoid arthritis: patients have an increased risk of?

A

IHD due to increase in atherosclerosis

30
Q

For each one of the following side effects please select the drug that is most characteristically associated with it . Each options may be used once, more than once or not at all.

Proteinuria?

Oligospermia?

Reactivation of TB?

A.	Methotrexate
B.	Gold
C.	Infliximab
D.	Azathioprine
E.	Prednisolone
F.	Ciclosporin
G.	Sulfasalazine
H.	Hydroxychloroquine
A

Proteinuria = gold

Oligospermia = sulfasalazine

Reactivation of TB = infliximab

31
Q

A 36-year-old female presents with stiff and swollen joints. She says that the joints are particularly stiff in the morning for the first few hours of the day. She has a strong family history of rheumatoid arthritis (RA) affecting her mother and sister. On examination she has a symmetrical polyarthritis affecting the small joints of the hand. Rheumatoid factor antibody, anti-nuclear antibody and anti-ds DNA are all negative.

What is the most appropriate test from the options below?

Anti-CCP
Serum uric acid levels
Anti-Ro
ANCA

A

Anti-CCP

MDEMO - Rheumatology (11 decks)

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