Rheumatology

Question 1

Antibodies in RA?

Answer 1

RF
Anti-CCP

Question 2

X-ray appearance of RA?

Answer 2

Loss of joint space
Juxta articular osteoporosis
Soft tissue swelling
Peri-ariticular erosions / subluxation

Question 3

Poor prognostic factors RA?

Answer 3

RF +ve
CCP +ve
Poor functional status
Extra articular features
HLA DR4, Insidious onset

Question 4

What score monitors response in RA?

Answer 4

DAS28 score

Question 5

What RA drug exacerbates MG?

Answer 5

Penicillamine

Question 6

What RA drug causes demyelination / TB reactivation

Answer 6

Etanercept (anti-TNF)

Question 7

SE of Sulfasalzine?

Answer 7

Rash
Oligospermia
ILD
Heinz body anaemia

Question 8

SE hydroxychloroquine?

Answer 8

Retinopathy

Question 9

SE methotrexate?

Answer 9

Pneumonitis / Myelosuppresion

Question 10

X-ray appearance of psoriatic arthritis?

Answer 10

Pencil in cup

Erosive changes and new bone formation

BETTER prognosis than RA

Question 11

What is reactive arthritis

Answer 11

HLAB27 assoc seronegative spondyloarthropathy

Triad = urethritis, conjunctivitis, arthritis

Usually develops 4 WEEKS after Ix and last 4-6months

It is an asymmetrical oligoarthritis of lower limbs

Question 12

Antibodies in SLE?

Answer 12

ANA (99% +ve)

anti-dsDNA (more specific, less sensitive)

anti-smith, RF

Question 13

Monitoring of SLE?

Answer 13

ESR. CRP usually normal.

Question 14

Complement in Lupus

Answer 14

It is low during active disease?

Question 15

1st line DMARD for SLE?

Answer 15

Hydroxychloroquine

Question 16

Drug induced lupus antibodies?

Answer 16

ANA +ve 100%
Anti ds DNA -ve

Anti-histone antibodies (80-90%)

Question 17

Most common causes of drug induced lupus?

Answer 17

procainamide
hydralazine

Question 18

Antibodies for polymyositis / dermatomyositis

Answer 18

ANA +ve 80%
Anti JO 1

Symmetrical proximal weakness and skin lesions (HELIOTROPE RASH)

Question 19

PMR Ix

Answer 19

Raised inflammation markers.

EMG + CK N.

Typically morning stiffness NOT weakness.

Rapidly responds to steroids.

Question 20

Antibodes for Sjogrens

Answer 20

Anti-ro and Anti La

Question 21

Antibodies for systemic sclerosis ?

Answer 21

Limited = CREST
Anti-centromere

Diffuse = anti-scl70abs
Most common cause of death is ILD

Question 22

Crystals in gout?

Answer 22

Needle shaped negatively birefringent

Question 23

When to start allopurinol after acute attack?

Answer 23

2 weeks after

If already on = continue

Question 24

What is 2nd line to allopurinol?

Answer 24

Febuxostat

Question 25

Crystals in pseudogout?

Answer 25

+ve birrefringent rhomboid crystals Calcium pyrophosphate crystals

Question 26

Most common organism in septic arthritis?

Answer 26

S Aureus

Question 27

Most common organism in young adults with septic arthritis

Answer 27

Gonorrhoea

Question 28

Risk factors for osteoporosis?

Answer 28

Increasing age Female Steroid use RA Alchohol Excess Low BMI Smoking Premature menopause Hyperthyrtoid / CKD IBD Liber disease

Question 29

When to start bisphosphate?

Answer 29

If T score -2.5 SD or less start bisphosphonate, Ca and vit D

Question 30

Bisphosphonates

Answer 30

oral bisphosphonates such as alendronate and risedronate are typically first-line. These are often taken weekly are need taking in a particular way to minimise the risk of oesophageal side-effects however, the NOGG recommend IV zoledronate as the first-line treatment following a hip fracture. This is given yearly

Question 31

Bisphosphate clinical scenario

Answer 31

Postmenopausal women, and men age ≥50, who are treated with oral glucocorticoids: if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months, start bone protective treatment at the same time general osteoporosis management as above don't wait for a DEXA scan before starting treatment oral bisphosphonates are used first-line e.g. alendronate or risedronate

Question 32

Bisphosophonate clinical scenario

Answer 32

A postmenopausal woman, or a man age ≥50 has a symptomatic osteoporotic vertebral fracture: general osteoporosis management as above start treatment straight away - oral bisphosphonates are used first-line e.g. alendronate or risedronate

Question 33

Hip fractures in older adults

Answer 33

in older adults a hip fracture is a manifestation of osteoporosis following a fragility fracture in women ≥ 75 years, a DEXA scan is not necessary to diagnose osteoporosis and hence commence a bisphosphonate BMD should be measured, but this acts as a baseline rather than determining whether treatment should be given bisphosphonates should be given first-line NOGG recommends IV zoledronate but local guidelines may vary and oral bisphosphonates are often use

Question 34

Calcium phosphate ALP and PTH in osteoporosis?

Answer 34

ALL NORMAL

Question 35

Pagets Disease:

Answer 35

Normal calcium, PTH and phosphate, HIGH ALP Think old man with bone pain and normal everything except ALPO

Question 36

drug causes gout?

Answer 36

diuretics: thiazides, furosemide ciclosporin alcohol cytotoxic agents pyrazinamide aspirin: it was previously thought that only high-dose aspirin could precipitate gout. However, a systematic review (see link) showed that low-dose (e.g. 75mg) also increases the risk of gout attacks. This obviously needs to be balanced against the cardiovascular benefits of aspirin and the study showed patients coprescribed allopurinol were not at an increased risk

Question 37

After a five year period for oral bisphosphonates (three years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan. This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true: Age >75 Glucocorticoid therapy Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score <-2.5 after treatment If any of the high risk criteria apply, treatment should be continued indefinitely, or until the criteria no longer apply. If they are in the low risk group however, treatment may be discontinued and re-assessed after two years, or if a further fracture occurs. In the case of this patient, she has no risk factors which put her into the high risk group, but we do not have a recent DEXA scan. The best option would therefore be to re-scan her now, and consider a two year break if her T score is >-2.5

Question 38

If patient suffers significant GI upset from alendronate what do u do?

Answer 38

Change to risedronate

Question 39

why never Rx methotrexate and co-trim?

Answer 39

Co trim contains trimethoprim, that + methotrexate causes severe myelosuppression

Question 40

Onion skin appearance on X-ray

Answer 40

Ewings sarcoma small round blue cell tumour seen mainly in children and adolescents occurs most frequently in the pelvis and long bones. Tends to cause severe pain associated with t(11;22) translocation which results in an EWS-FLI1 gene product

Question 41

osteosarcoma facts

Answer 41

osteosarcoma, this is the most common primary malignant bone tumour in children and adolescents which commonly affects the metaphyseal region of long bones. Radiographs classically show Codman triangle (a triangular area of new subperiosteal bone) with an associated sunburst appearance. The family history is significant as osteosarcoma is associated with the retinoblastoma gene.

Question 42

Blood tests in antiphospholipid?

Answer 42

Prolonged APTT and low platelets

Question 43

Bloods tests in protein C deficiency ?

Answer 43

Normal Ptr and APTT

Question 44

Osteomalacia bloods

Answer 44

Low calcium, Low phosphate, High ALP Translucent bands on X-rays

Question 45

Skin disorder assoc with antiphospholipid

Answer 45

Livido reticularis

Question 46

patchy uptake on iodine scan + hyperthyroid

Answer 46

toxic multi nodular goitre