rheumatology

Question 1

Most common optic complication in temporal arteritis, and findings?

Answer 1

anterior ischaemic optic neuropathy

Pale, swollen optic disc on fundoscopy.

Occlusion of posterior ciliary artery

Question 2

Osteoarthritis x-ray findings:

Answer 2

LOSS
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

Question 3

Ocular involvement in temporal arteritis:

Answer 3

Anterior ischaemic optic neuropathy

Amaurosis fugaux

Permanent visual loss

Diplopia due to compression of oculomotor system e.g. cranial nerves.

Question 4

Describe the features of ankylosing spondylitis back pain:

Answer 4

Improves with exercise

Reduced lateral flexion

Reduced forward flexion (Schober’s test)

Reduced chest expansion

Question 5

‘A’s’ of ankylosing spondylitis (extra features, 8):

Answer 5

Anterior uveitis
Apical fibrosis
Amyloidosis
Aortic regurgitation
Achilles tendonitis
AV node block
And cauda equina and peripheral arthritis.

Question 6

Differentials of polymyalgia rheumatica:

Answer 6

Rheumatoid arthritis
Dermatomyositis
Polymyositis
Hypothyroidism

Question 7

What 3 things define Felty’s syndrome?

Answer 7

Rheumatoid arthritis
Splenomegaly
Low white cell count

Question 8

Most useful investigation in ankylosing spondylitis?

Answer 8

Pelvic x-ray, showing sacroilits.

Other late changes can include squaring of lumbar vertebrae, bamboo spine, syndesmophytes.

CXR could show apical fibrosis.

If pelvic x-ray is negative for sacroiliac joint involvement, do an MRI.

Question 9

Episcleritis vs scleritis:

Answer 9

Scleritis is painful, episcleritis is not.

Both present with erythema.

Question 10

Investigations for secondary causes of osteoporosis:

Answer 10

History and physical exam
Bloods, inc ESR and CRP, serum calcium, LFTs etc.
TFTs
DXA

Question 11

Medications that may worsen osteoporosis:

Answer 11

Glucocorticoids
SSRIs
Antiepileptics
PPIs
Glitazones
Long term heparin
Aromatase inhibitors e.g. anastrozole

Question 12

Most important risk factors for osteoporosis:

Answer 12

Steroid use
RA
Alcohol excess
Hx of parental hip fracture
Low BMI
Smoking (current)

+ CKD, MM, lymphoma, hyperthyroid and parathyroid etc.

Question 13

Management of acute flare of RA?

Answer 13

IM methylprednisolone or oral steroids
Refer to rheumatology

Question 14

Choices for initial DMARD monotherapy:

Answer 14

Methotrexate +/- bridging prednisolone. Must monitor LFTs (liver cirrhosis) and FBC (myelosuppression.)

Sulfasalazine
Leflunomide

Hydroxychloroquine, only if mild.

Question 15

How should you assess response to treatment in RA?

Answer 15

CRP + disease activity, measured with DAS28 score e.g.

Question 16

Conditions that present with positive RF:

Answer 16

RA
General population (5%)
Sjogren’s syndrome
Infective endocarditis
SLE
Systemic sclerosis

Question 17

Risk factors for pseudogout:

Answer 17

Increased age
Haemochromatosis
Wilson’s Disease
Acromegaly
Hyperparathyroidism
Low mg, low phos

Question 18

What is a T score diagnostic of osteoporosis?

Answer 18

< -2.5

Question 19

A young man presents with a fracture secondary to osteoporosis; what is the most important thing to test?

Answer 19

Testosterone

Question 20

Classic x-ray appearance of psoriatic arthritis:

Answer 20

‘Pencil in cup’ due to periarticular erosions and bone resorption

Question 21

Signs of psoriatic arthropathy:

Answer 21

Dactylitis
Enthesitis - inflammation at site of tendon and ligament insertion.
Tenosynovitis
Nail changes e.g. pitting, onycholysis
Psoriatic skin lesions

Question 22

In which condition are Gottron’s papules most likely seen?

Answer 22

Dermatomyositis.
This could present alongside a heliotrope facial rash (predominantly eyelids).

Question 23

Differential diagnoses for thenar wasting:

Answer 23

Carpal tunnel most likely

Median nerve trauma, RA, mononeuritis multiplex.

Question 24

When and where are Herbeden’s nodes likely to be seen?

Answer 24

Osteoarthritis

DIP joints

Question 25

Which nerve is most likely to be damaged in TKR surgery?

Answer 25

Common peroneal

Question 26

Which joints are most likely to be involved in osteoarthritis of the hand?

Answer 26

CMC and DIP

Question 27

Poor prognostic features in RA:

Answer 27

RF positive
Anti-CCP antibodies
Poor functional status at presentation
X-ray with early erosions, <2yrs
Extra-articular features e.g. nodules
HLA DR4
Insidious onset

Question 28

Features of reactive arthritis:

Answer 28

Sterile joint aspirate
No fever
More chronic presentation

Can be caused by chlamydia

Question 29

Management of septic arthritis:

Answer 29

Synovial fluid sampling
Blood cultures
Joint imaging

1. Native joint: IV flucloxacillin, if allergic then IV vancomycin, 4-6 WEEKS
2. If considered to be at high risk of g-ve organism e.g. immunocompromised, lots of UTIs, sickle cell disease ADD IV GENT.
3. If prosthetic, then IV vancomycin + gentamicin.

Question 30

Components of the Z score:

Answer 30

Age, gender, ethnicity

Question 31

Triad of symptoms for reactive arthritis:

Answer 31

Arthritis
Conjunctivitis
Urethritis

Question 32

Skin features of dermatomyositis:

Answer 32

Heliotrope rash
Macular rash over back and shoulders
Gottron’s papules
Dry, scaly hands
Photosensitivity

Question 33

Non-cutaneous features of dermatomyositis:

Answer 33

Proximal muscle weakness and pain
Raynaud’s
Respiratory muscle weakness
Interstitial lung disease
Dysphagia or dysphonia

Question 34

Risk factors for SLE

Answer 34

HLA B8, DR2,3
Females
Afro-Caribbeans and Asians

Question 35

Features of Sjogren’s:

Answer 35

Dry eyes, mouth, vagina
Arthralgia
Raynauds, myalgia
Sensory polyneuropathy
Recurrent episodes of parotitis

Anti-Ro is most specific antibody.
C4 is low.
Schirmer’s test +ve.