Rheumatology

Question 1

Polymyalgia Rheumatica

Answer 1

Generalised ache, tenderness, morning stiffness in shoulders/proximal limbs, mild poly arthritis, tenosynovitis, carpal tunnel, fatigue, weight loss, depression
Ix: CRP, ESR, plasma viscosity
Tx: pred 10-15mg -dramatic respond in 4days, reduce dose + gastric and bone protection for long term steroid use

Question 2

Causes of monoarthritis

Answer 2

Septic arthritis
Gout/pesudogout
OA
Trauma eg haemarthrosis

Question 3

Symmetrical polyarthropathies

Answer 3

RA
OA
viral

Question 4

Asymmetrical polyarthropathies

Answer 4

Reactive arthritis

Psoriatic arthritis

Question 5

X-RAY features of OA

Answer 5

LOSS
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

Question 6

X-RAY features of RA

Answer 6

Justa-articular osteopaenia
Soft tissue swelling
Joint deformity
Loss of joint space

Question 7

X-RAY features of gout

Answer 7

Peri articular erosions
Normal joint space
Soft tissue swelling

Question 8

Features of OA

Answer 8

Affects larger joint eg hip, knee
Crepitus, worse and end of day
Stiffness after rest, joint instability
Pain at rest

Question 9

Features of OA hand

Answer 9

Heberedens nodes at DIP
Bouchards nodes at PIP
Mainly affected DIP

Question 10

OA management

Answer 10

Exercise and weight loss
Paracetamol and topical NSAIDS
Oral NSAID/ codeine +PPI
Topical capsaicin 
Intra articular steroids/hylauronic acid injections
Heat/cold patches, TENS
Joint replacement

Question 11

Septic arthritis

Answer 11

Acute inflamed joint
Often in pre-existing joint disease eg OA, or DM, immunosupressed
Needs urgent synovial fluid microscopy and culture
Start empirical ABx after aspiration
Commonly staph
If v bad may have to refer to ortho for lava get and debridement

Question 12

Features of RA

Answer 12

Symmetrical
Swollen, stiff, painful small joints, worse in morning 
MCP/MTP, PIP, wrist
Tenosynovitis or bursitis 
Atlanta-axial subluxation

Question 13

Features of RA hand

Answer 13

Ulnar deviation 
Dorsal wrist subluxation
Boutonnière and swan neck deformity
Z thumb
Extensor tendon rupture

Question 14

Extra articular features of RA

Answer 14

Nodule - lungs and elbows
Lymphadenopathy
Vasculitis
Lungs: fibrosising alveolitis, obliterative bronchiolitis, pleural/pericardial effusion
Raynauds/carpal tunnel
Peripheral neuropathy
Splenomegaly
(Epi)scleritis
Keratocnojunctivitis Wicca 
Osteoporosis

Question 15

RA Ix

Answer 15

RF - higher title=worse disease
ACPA/antiCCP
Anaemia of chronic diseas
X-RAY 
USS/MRI

Question 16

RA treatment

Answer 16

Calculate DAS28

early DMARDS/biologicals

Question 17

Gout presentation and features

Answer 17

Acute monoarthropathy
MTP of big toe, ankle, foot, hand, wrist, elbow
Monosodium urate crystals
Precipitated by trauma, starvation, infection, duirecfics
Ax with renal disease

Question 18

Causes of gout

Answer 18

Diabetes
Diuretics
Leukemia
Chemo
Dietary routines
Alcohol excess

Question 19

Gout Ix

Answer 19

Microscopy of synovial fluid - negatively bifringent urate crystals
Raised serum urate but can be normal

Question 20

Treatment of acute gout

Answer 20

High dose NSAID eg diclofenac
If CI Cochicine
Steroids

Question 21

Gout prevention

Answer 21

Address lifestyle

Start prophylaxis if >1 attack/year or tophi, renal stones
Allopurinol at least 3w after acute episode. Titration against plasma urate
Cover with 6w NSAID or 6m colchicine when starting
Don’t stop in acute gout attack
Febuxosta is alternative

Question 22

Pesudogout

Answer 22

Calcium pyrophosphate 
Tends to be larger joints than gout
Usually self limiting
Ax w/ hyperparathyroidism, haemochromatosis
Microscopy - positive bifringent 
Rest, NSAIDs or steroids

Question 23

Ankylosing Spondyltiis

Answer 23

30yr old man
Low back pain, morning stiffness, worse at night, better with exercise
Radiates to hips/buttocks
Loss of spinal movement
Question mark spine - neck hyperextension+kyphosis

Question 24

Extra articular features of ank spond

Answer 24

Enthusiastic eg Achilles tendonitis, plantar fasciitis 
Acute iritis
Osteoporosis
Aortic valve incompetence
Pulmonary fibrosis

Question 25

Ankylosing spondylitis Ix

Answer 25

``` Clinical diagnosis X-ray - sacroilitis, bamboo spine Normocytic anaemia Raised ESR, CRP HLA B27 ```

Question 26

Ankylosing Spondylitis Tx

Answer 26

``` Exercise Physic NSAIDS TNF alpha blockers Steroid injection Bisphosphonates ```

Question 27

Psoriatic arthritis

Answer 27

DIP, spinal (like AS) X-RAY - erosive pencil in cup Synovial sand nail changes Can present before skin psoriasis

Question 28

Reactive arthritis

Answer 28

Sterile arthritis Lower limbs 1-4weeks after chlamdyia, campylobacter, shigella +- iritis, keratoderma, brown patches on soles and palms, balanitis, mouth ulcers, enethesis No specific treatment, just manage joints and treat cause

Question 29

CREST syndrome/ limited cutaneous systemic sclerosis

Answer 29

Limited to face, hands and feet ACA (anti centromere) Pulmonary hypertension ACE, cyclophosphamide

Question 30

Diffuse cutaneous systemic sclerosis

Answer 30

``` All skin Organ fibrosis Scl70 antibodies/anti RNA Needs regular echo and spirometeery Terrible prognosis ``` ACE, cyclophosphamide

Question 31

Polymyositis/dermatomyositis

Answer 31

``` Proximal muscle weakness and striated muscle inflammation Myalgia and arthralgia Dysphagia, dysphonia Autoimmune but can be paraneoplastic Purple rash on eyelids (heliotrope) Macular 'shawl' rash Test muscle enzymes Prednisolone ```

Question 32

SLE

Answer 32

``` Anti ANA, anti dsDNA Low C3, C4 Lymphadenopathy Fatigue Malagia Fever Rash - discoid/malar ``` Cyclophosphamide, prednisolone

Question 33

Anti phospholipid syndrome

Answer 33

Ax with SLE CLOTS: coagulation, livedo recticularis, obstetric, thrombocytopenia Give low dose aspirin/warfarin

Question 34

Polyarteritis nodosa

Answer 34

Necrotising vasculitis causes aneurysms and thrombosis Ulcers and rash Causes significant renal impairment Cyclophosphamide