Rheumatology

Question 1

Osteoarthritis treatment

Answer 1

NSAIDs (use topical gel if any renal impairment)
paracetamol
Movement
Education
CBT / mindfulness

Question 2

mechanical vs inflammatory arthritis - how to specifiy

Answer 2

Better or worse w movement
Morning stiffness - if so how long does it last (inflammatory is hours)
Symmetrical or asymmetrical

Question 3

DIP joint involvement - what type of arthritis

Answer 3

osteoarthritis
psoriatic (nail involvement)

SLE and RA SPARE the DIPJ

Question 4

Lots of different joints (large/small) suddenly involved

Answer 4

Reactive arthritis
- Gastro bugs
- STI (reiters syndrome: cant see/pee/climb a tree)

Question 5

What hand signs do you get in OA

Answer 5

Bocuhards (PIPJ)
Heberdens (DIPJ)

Question 6

What hand signs do you see in RA

Answer 6

MCP swelling, ulnar subluxation and deviation
Sparing of DIPJ

Question 7

What can a positive RF be from

Answer 7

RF (50-60% specificity)
Hep B and C
some malignancies

anti-CCP has 95% specificity for

Question 8

What types of psoriasis are highest risk for developing psoriatic arthritis

Answer 8

Scalp and nail psoriasis

Question 9

What are the features of psoriatic arthritis

Answer 9

can look like rheumatoid (symmetrical, multiple joints)
or asymmetrical with one joint

Often has dactylitis

Question 10

What is normal ankylosing spondylitis

Answer 10

Seronegative inflammatory arthritis (related to HLAB27)
* symmetrical
* Sacroilitis joints most commonly involved
* Tx: NSAIDs, TNF alpha therapy

• asymmetric oligoarthritis (≤4 joints)
• Enthesitis (Achilles tendinitis, plantar fasciitis and intercostal enthesitis)
• M>F, <45yrs
• Extra axial manifestations (due to overlap with HLA B27): iritis, IBD

5% of population has HLAB27, 5% of these have related pathology

Question 11

Why does ank spondylitis primarily affect the sacroiliac joints

Answer 11

Ethesitis (where tendons/ligaments connect) of the spine, SI joints have the most of this
This inflammation can stimulate secondary bone formation

Question 12

Extra articular features of SLE

Answer 12

• butterfly malar rash (sparing of nasolabial folds)
• Raynauds
• ulcers / nose ulcers
• Patchy alopecia
• Serositis (linings, pleurisy, peritonitis, pericarditis)
• lupus nephritis

Always do MSU + ACR looking for blood/protein

Question 13

Bloods for SLE

Answer 13

• ANA
• ENA
• Double stranded DNA
• Low complement
• ESR (high), CRP normal

high ESR and low CRP indicates high disease activity

Question 14

Monitoring for DMARDs

Answer 14

3 monthly bloods
FBC, UEs, LFTs

MTX, leflunomide, hydroxychloroquine, salazopyrin
* tetratogenic

Question 15

key thing to remember with biologic tocilizumab

Answer 15

inhibitis production of CRP, even when unwell

Question 16

What should you consider if someone is unwell and on a biologic

adalimumab, entanercept, inliximab, rituximab, tocilizumab

Answer 16

they wont mount an immune response, can quickly deteriorate

Treat immediately, if unwell can WH biologic until well

Question 17

Why is probenecid second line to allopurinol

Answer 17

because it pushes /drains lots of urate out of the kidneys and can increase risk of kidney stones

Whereas allopurinol is a xanthine oxidase inhibitor blocks purines formi

Question 18

How does starting allopurinol cause a flare

Answer 18

Lower serum urate concentration means urate moves out of the joint down the concentration gradient.

The moving of the urate out (and in) to the joint triggers a flare

Question 19

What are your urate targets

Answer 19

<0.30 with tophi
<0.36 without tophi

Question 20

What are purines

Answer 20

From DNA, therefore anything living has purines in it. things like animal products have a higher purine load

Purine gets broken. down into urate

Question 21

Age cutoff for GCA

Answer 21

> 50’s

Question 22

What are the additional features of ankylosing spondylitis

Answer 22

the ‘A’s;
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis

Question 23

Signs on exam of ‘tennis elbow’

Answer 23

Lateral epicondylitis
Pain on resisteed wrist extension
pain and tenderness localised to the lateral epicondyle

self resolves within 12 months, PT is first line
RF: repetitive movement >2hrs

Question 24

What are the features of PMR

Answer 24

AI mediated inflammation of the bursa/tendons
Causes pain and stiffness without muscle weakness
Shoulder, neck, hips
>50yrs, peaks 70-75
W>M

• Pain starts on one side but then becomes bilateral
• worse w rest (night and mornings for 45mins), better w movement
• Muscles are actually spared, but tendons/bursa get inflammed causing referred pain
• Strongly linked w GCA

Question 25

Tests for PMR

Treatment

Answer 25

high ESR/CRP
Normal CK as muscles are spared (unlike polymyositis)

15-20mg PO OD until symptoms controlled, with a very slow wean
50% of patients relapse

Age >50yrs

Question 26

What is GCA

Answer 26

Vasculitis of large and small IC vessels causing thickening
Strongly associated with PMR

Although it is often termed temporal arteritis, it does not just affect the temporal artery

Question 27

Symptoms of GCA

Answer 27

Fever, anorexia
New onset or new type of headache
Temporal artery or scalp tenderness
Jaw or tongue claudication
Sudden visual impairment, e.g. diplopia, reduced acuity, vision loss
Thickened temporal artery
Unexplained elevated levels of CRP +/- ESR

High ESR/CRP, low Hb

Question 28

features of dermatomyositis

Answer 28

Gottrons papules (erythematous papules over the knuckles) - itchy/painful/photosensitive
symmetrical proximal muscle weakness /pain/tenderness
mainly larger muscle groups (shoulder and hip)
dysphagia
Heliotrope rash
Malar rash

This condition is strongly linked to malignancy, with 25% of patients having an undiagnosed malignancy at the time of diagnosis of dermatomyositis.

Question 29

What is dermatomyositis

Answer 29

Inflammatory disorder of skin and muscle (from destruction of blood vessels)

Strongly linked to HLA gene, can be triggered by coxsackie virus or tumours