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FRACP clinical exam > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Which joints are never/rarely involved in RA?

A
  1. Lumbar spine

2. DIPJ

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2
Q

10 extra articular features of RA

A
  1. Skin - raynauds phenomenon, leg ulcers
  2. Eyes - scleritis, sjogrens syndrome, cataracts secondary to steroids
  3. Cricoarytenoid joint disease (sore throat, hoarse voice, neck pain), recurrent headaches at the base of the skull or arm tingling from C1-2 subluxation
  4. Lungs - ILD, pleural effusion, pleuritis
  5. Heart - pericarditis, valve disease due to rheuamtoid nodules, ACS
  6. Renal - drug use, amyloid (all rare)
  7. Nervous system - peripheral neuropathy, entrapment neuropathy, mononeuritis multiplex
  8. Blood - ACD, felty’s syndrome
  9. Systemic - fevers, weight loss, fatigue
  10. vasculitis - digital arteritis, ulcers, pyoderma gangrenosum
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3
Q

4 side effects of MTX

A
  1. Hepatic toxicity
  2. Pulmonary fibrosis
  3. Thrombocytopenia
  4. Leukopenia
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4
Q

3 side effects of leflunomide

A
  1. Diarrhoea
  2. Alopecia
  3. Liver toxicity
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5
Q

3 side effects of HCQ

A
  1. Nausea
  2. Pigmentation
  3. Retinopathy - needs regular ophthalmological review
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6
Q

5 side effects of sulfasalazine

A
  1. Rash
  2. Nausea
  3. Haematological abnormalities
  4. LFT derangements
  5. Reversible oligospermia
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7
Q

5 differential diagnosis of deforming, symmetrical, chronic polyarthropathy

A
  1. Rheumatoid arthritis
  2. Psoriatic arthropathy or other seronegative arthropathies
  3. Chronic tophaceous gout (rarely symmetrical)
  4. Primary generalized osteoarthritis
  5. SLE - usually but not always non-deforming
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8
Q

4 causes of arthritis and nodules

A
  1. SEROPOSITIVE RA
  2. SLE - rare
  3. Rheumatic fever - very rarely
  4. Amyloid arthropathy in conjunction with myeloma
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9
Q

4 criteria for diagnosis of RA according to 2010 ACR/EULAR RA criteria

A
  1. Number of joints involved
  2. Serology (RF, ACPA)
  3. Acute phase reactant (CRP, ESR)
  4. Duration of symptoms - <6 weeks or >6 weeks
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10
Q

Anti-CCP antibodies

A

More specific at 97%

Associated with more severe disease course and erosive disease

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11
Q

Rheumatoid factor

A

70% of patients are seropositive

Positive especially if they have rheumatoid nodules or associated vasculitis

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12
Q

Xray changes to look for in RA

A
  1. Soft tissue swelling
  2. Symmetrical joint space narrowing - in OA the narrowing are asymmetrical
  3. Juxtaarticular osteoporosis
  4. Marginal joint erosions
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13
Q

Action of leflunomide

A

Pyrimidine antagonist which inhibits the proliferation of T cells

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14
Q

2 major poor prognostic markers in RA

A

Large number of joints involved at the outset

Significant abnormalities in the inflammatory markers

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15
Q

Causes of drug induced SLE

A
  1. Procainamide
  2. Hydralazine
  3. Isoniazid
  4. Methyldopa
  5. Penicillamine

For both procainamide and hydralazine, most patients are ANA positive within 1 year.

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16
Q

5 clinical features of GPA

A
  1. Nasal congestion
  2. Rhinorrhoea
  3. Bloody ansal discahrge
  4. Cough with haemoptysis
  5. Breathlessness
17
Q

Disease association with polyarteritis nodosa

A

Hepatitis B - 1/3 of cases

18
Q

5 clinical features of EGPA

A
  1. Asthma
  2. Allergic rhinitis, nasal polyps, saddle nose
  3. Eczema
  4. Cough and breathlessness
  5. PNS disease such as symemtrical peripheral neuropathy or mononeuritis multiplex

Asthma occurs before peripheral eosinophilia

19
Q

4 features of mixed essential cryoglobulinaemia

A
  1. Palpable purpura of the extremities
  2. Raynauds disease
  3. Arthritis
  4. Neuropathy

Concurrent Hep C is common

20
Q

Differential diagnosis of livedo reticularis

A
  1. ANCA vasculitis
  2. Cholesterol atheroembolism after vascular procedure
  3. APLS
21
Q

5 year survival rate for scleroderma

A

70%

22
Q

Which patient group have higher incidence of diffuse disease and of ILD?

A

Asian patients

23
Q

Manifestations of scleroderma:

Dermatological:
Arthritis:
GI:
Renal:
Respiratory:
Cardiac:
Others:
A

Dermatological: Raynauds (commonly the first symptom), tight skin, sclerodactyly
Arthritis: arthropathy in rheumatoid distribution, carpal tunnel syndrome
GI: dysphagia, heart burn (oesophagitis), diarrhoea causing malabsorption
Renal: HTN, CKD
Respiratory: ILD, pleurisy, PTHN
Cardiac: Pericarditis, arrhythmias, dilated cardiomyopathy
Others: Erectile dysfunction, hypothyroidism, non-melanoma skin cancers

24
Q

Differential diagnosis to manifestations of scleroderma

A
  1. Eosinophilic fasciitis
  2. Diabetic cheiroarthropathy
  3. Nephrogenic systemic fibrosis
25
Q

Screening for ILD and pulmonary hypertension

A
  1. Lung function test
  2. HRCT
  3. Echocardiogram to check for PHTN
  4. If high suspicion for PHTN, R heart catheterization and 6MWT.
26
Q

2 rules for use of biological agents in treatment of RA

A
  1. Failure of at least 6 months of treatment with traditional DMARD
  2. Treatment must include MTX and combination of HCQ, LEF, or sulfasalazine
27
Q

What is the role of nailfold capillaroscopy?

A

Presence of dilated tortuous nailfold capillaries with drop outs are suggestive of underlying connective tissue disease and can help to distinguish between primary raynauds vs secondary raynauds phenomena

28
Q

Poor prognostic factors in scleroderma

Good prognostic factors?

A
  1. Asian patients - more ILD and diffuse disease
  2. Men
  3. Renal manifestations
  4. Late onset disease

Good prognostic factors include those with skin/gut involvement without other organ disease

29
Q

Management of scleroderma

A

Symptomatic treatment - avoid vasospasm by stopping smoking, beta blockers, cold weather

Aggressive treatment of reflux with PPIs to prevent oesophageal stricture

Nifedipine, prazosin or methldopa for raynauds phenomena

Artificial tears for dry eyes

Malabsorption - suspect and treat bacterial overgrowth with antibiotics

D-penicillamine for skin disease may be helpful (immunosuppressant which interferes with collagen cross linking)

Cyclophosphamide for 9 months if progressive lung disease

Treat pulmonary hypertension with ERA, PDE5 inhibitors, IV prostaglandins.

ACEI for preventing hypertensive renal crisis.

30
Q

What to expect when asked to examine the hands in the introductory stem…

A
  1. Arthropathy
  2. Acromegaly
  3. Peripheral nerve lesion
  4. Myopathy
  5. Neuropathy

FRACP clinical exam (8 decks)

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