Rheumatology

Question 1

What age group are most likely to be affected by temporal arteritis?

Answer 1

70-79 y/o (rarely before 50)

Question 2

What are the clinical symptoms of temporal atreritis?

Answer 2

Unilateral headache - usually temporal
Scalp pain - difficulty brushing hair
Jaw and tongue claudication
Visual symptoms: Diplopia, blurring and temporary monocular blindness
Fever, weight loss, fatigue
Polymyalgia symptoms

Question 3

What are the clinical signs of temporal arteritis?

Answer 3

Abnormal temporal artery: typically thickened, tender with reduced or absent pulse
Scalp tenderness on palpation
Transient or permanent visual loss
Visual field defects
Optic disc changes: pale, swollen optic disc (anterior ischaemic optic neuritis)
Retinal changes: pale retina with cherry red spot (central retinal artery occlusion)
Other: cranial nerve palsies, asymmetrical pulses (if large vessel involvement - subclavian)

Question 4

What is the principle investigation for temporal arteritis?

Answer 4

Temporal artery biopsy

Question 5

How is temporal arteritis treated?

Answer 5

With visual symptoms: 60-100 mg one off dose prednisolone until further ophthalmic assessment (same day).
Alternatively, intravenous methylprednisolone 500-1000 mg for three consecutive days, then oral prednisolone (~60 mg daily).

Without visual symptoms: 40-60 mg prednisolone daily (minimum 0.75 mg/kg).

Question 6

What precautions should be taken for long term prescription of steroids?

Answer 6

Bone protection (e.g. bisphosphonates and vitamin D supplementation)
Gastric protection (e.g. proton pump inhibitors)
Monitoring blood sugar (at risk of steroid-induced diabetes or worsening of glycemic control in known diabetics)

Question 7

The following clinical features are characteristic of which rheumatological disease?

Swollen, painful joints in hands and feet
Stiffening worse in morning
Ulnar deviation
Swan neck deformity
Boutonniere deformity
PIP and MCP swelling, DIP sparing

Answer 7

Rheumatoid arthritis

Question 8

The following features on xray is indicative of which disease:

Loss of joint space
Soft – tissue swelling
Subluxation
Periarticular erosions

Answer 8

Rheumatoid arthritis

Question 9

How is rheumatoid arthritis managed?

Answer 9

DMARDs: Monotherapy +/- prednisolone
Methotrexate, Sulfasalazine, Leflunomide

TNF inhibitors – if there is no response to 2 DMARDs:
Etanercept, infliximab, Rituximab

Monitor using CRP and DAS28
Flare ups - corticosteroids

Question 10

What clinical features are seen on xray for a patient with osteoarthritis? (LOSS)

Answer 10

X-Ray Features - LOSS

Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis

Question 11

The following clinical features are seen in which rheumatological disease?

Pain worse on movement and towards end of day
Pain improves with rest
Morning stiffness not prolonged
Decreased range of movement
Muscle wasting
Nodules: PIP (Bouchard’s) and DIP (Heberden’s)

Answer 11

Osteoarthritis

Question 12

How is osteoarthritis managed?

Answer 12

If increased BMI – weight loss + muscle strengthening exercise

Analgesia
1st line NSAIDs and paracetamol
2nd line - NSAIDs and COX -2 inhibitor. PPI needed.

Joint replacement
Psychosocial aid