Rheumatology

Question 1

Rheumatoid Hand Signs

Answer 1

• MCP/PIP inflammation
• Swan neck deformity
• Boutonniere’s deformity
• Ulnar deviation/subluxation
• Wrist subluxation

Question 2

Suspect if 3 joint areas involved, MCPJs/MTPJs, early morning stiffness > 30 minutes and symmetrical joint involvement with duration of >6 weeks

Answer 2

Rheumatoid Arthritis

Question 3

Diagnosis of Rheumatoid Arthritis

Answer 3

Clinical diagnosis using ACR criteria
- Need 6/10 features
- Clinical and biochemical features assessed

Question 4

Investigations for Rheumatoid Arthritis

Answer 4

Bloods: CRP/ESR, RF, anti-CCP, ANA, ANCA, Ig, complement
Imaging: XR, MRI, US
Joint Aspirate: Inflammatory

Renal: Urine dip + PCR
Cardiac: ECG, echo
Resp: CXR, HRCT

Question 5

XR features in RA

Answer 5

• Periarticular osteopenia
• Symmetrical joint space loss
• Deformities
• Erosions
• Nodules
• Soft tissue swelling

Question 6

Management of RA

Answer 6

CONSERVATIVE
- PT/OT/psych
- Smoking cessation
- Peer support groups
- Monitor disease activity (DAS 28)

MEDICAL
- Treat to target (ie remission)
- Steroids short term to induce remission
- MTX + alternative DMARD (hydroxychloroquine/sulfasalazine)
- Biologics if 2x DMARDs fail (anti-TNF, anti-IL6, anti-CD20, JAK inhibitors)
- Bone/gastroprotection

SURGICAL
- Joint replacement
- Joint fusion

Question 7

Complications of Ankylosing Spondylitis

Answer 7

6 As:
- Anterior uveitis
- Aortitis/Aortic regurgitation/AV node block
- Apical fibrosis (rare)
- Amyloidosis
- Atlanto-axial dislocation (cord compression)
- IgA nephropathy

Question 8

Ank Spond scoring system

Answer 8

Bath ankylosing spondylitis disease activity index

Question 9

Ank Spond Examination

Answer 9

• Hands
• Eyes
• Heart
• Lungs
• Back (range of movement)
• Shober’s test (back) - 5cm below + 10cm above dimples of venus

Question 10

Ank Spond Investigations

Answer 10

Bloods: CRP, U+E, HLA B27 gene
Imaging: XR lumbar spine, ?MRI
Renal: Urine dip/PCR
Cardio: Echo, ECG
Resp: CXR, HRCT, spirometry

Question 11

Management of Ankylosing Spondylitis

Answer 11

CONSERVATIVE:
- Exercise
- PT/OT
- Smoking cessation

MEDICAL
- Analgesia (NSAIDS) + PPI
- Bone protection
- MTX for peripheral joint problems
- Biologics if fails 2x NSAIDs (anti-TNF)

SURGICAL
- Joint replacement
- Valve replacement

Question 12

Asymmetrical deforming polyarthropathy with DIPJ involvement, nail changes, dactylitis and enthesitis

Answer 12

Psoriatic arthritis

Question 13

Diagnosis of Psoriatic arthritis

Answer 13

CASPAR criteria (minimum 3/5)
- Psoriasis/FHx of
- Psoriatic nail changes
- RF negative
- Dactylitis
- Juxta-articular bone on XR

Question 14

Extra-articular features of PsA

Answer 14

Skin - psoriasis
Nails - pitting, onycholysis
Eyes - Iritis, conjunctivitis

Question 15

Investigations for PsA

Answer 15

Bloods: CRP, ANA, RF, anti-CCP
Imaging: XR
Joint aspirate: High WCC, no crystals

Question 16

Management of PsA

Answer 16

CONSERVATIVE
- PT/OT
- Lifestyle advice (smoking cessation, weight loss, exercise)

MEDICAL
- Steroid injections
- NSAIDs
- DMARDs if NSAIDs fail/high PASI score
- Biologics (anti-TNF, Ustekinumab)
- Management of psoriasis

SURGICAL
- Joint replacement

Question 17

A connective tissue disease characterised by autoimmunity, vasculopathy and fibrosis

Answer 17

Systemic Sclerosis

Question 18

What are the 2 types of Systemic Sclerosis

Answer 18

Limited cutaneous/CREST - affecting face, neck, skin below elbows and knees

Diffuse cutaneous - affecting skin proximal to elbows and knees and trunk

Question 19

Antibody associated with CREST syndrome

Answer 19

Anticentromere antibody

Question 20

Antibody associated with Diffuse Sclerosis

Answer 20

Anti-Scl70

Question 21

Clinical features in Systemic Sclerosis

Answer 21

• Calcinosis
• Raynauds
• Oesophageal dysmotility
• Sclerodactyly
• Telangectasia
• Pulmonary fibrosis
• Renal crisis
• Pulmonary HTN

Question 22

Investigations for Systemic Sclerosis

Answer 22

Bloods: ANA, anti-centromere, anti-Scl70
Skin: Nailfold capillaroscopy
Lungs: HRCT, spirometry
Heart: ECG, echo
Kidneys: Urine dip, PCR, US renal tract
GI: Endoscopy, barium swallow

Question 23

Management of Systemic Sclerosis

Answer 23

CONSERVATIVE
- PT/OT/specialist nurses/MDT
- SLT/dieticians
- Patient education/support groups

MEDICAL
- Immunosuppression eg AZA/MMF/MTX for skin
- Treatment of pulm HTN (PDE5 inhibitors)
- ACE inhibitors for renal crisis

Question 24

Management of SLE

Answer 24

CONSERVATIVE
- Patient education
- Advice re pregnancy
- Smoking cessation
- Sunscreen

MEDICAL
- Mild//mod: hydroxychloroquine, MTX, pred
- Severe: MMF, cyclophosphamide, rituximab
- Manage CV risk factors
- ACEI for proteinuria

SURGERY
- Renal transplant

Question 25

Clinical Features of SLE

Answer 25

Skin: Discoid lupus, malar rash, alopecia Joints: Synovitis, Jaccoud arthropathy Serositis: Pleuritis, pericarditis Renal: Lupus nephritis Neuro: Seizures, confusion, psychosis, mononeuritis multiplex Haem: Haemolytic anaemia

Question 26

Investigations for SLE

Answer 26

ANA Anti-dsDNA Anti-smith Low complement Antiphospholipid antibodies

Question 27

Management of anti-phospholipid syndrome

Answer 27

- Avoid OCP - Prophylactic aspirin - Warfarin if thrombosis

Question 28

Clinical features of anti-phospholipid syndrome

Answer 28

- Arterial thrombus/unprovoked venous thrombus <50yrs - Recurrent thrombosis - Unusual site for thrombosis - Foetal loss/recurrent miscarriages

Question 29

Treatment of GCA

Answer 29

- 40mg prednisone if no visual symptoms/jaw claudication - 60mg prednisone if visual symptoms/claudication - IV methylpred if visual loss/amaurosis fugax - PPI/bone protection - Consider low dose aspirin

Question 30

Diagnosis of GCA

Answer 30

ACR criteria = 3/5: - Age over 50 - New headache - Raised ESR - Abnormal temporal artery on imaging - Abnormal temporal artery on biopsy