Rheumatology

Question 1

Arthralgia

Answer 1

Pain in a joint

Question 2

Arthritis

Answer 2

Inflammation in a joint

Question 3

Arthropathy

Answer 3

disease in a joint

Question 4

Non-inflammatory arthritis

Answer 4

Osteoarthritis

Question 5

Seronegative arthritis

Answer 5

Ankylosing spondylitis
Enteric Arthritis
Reactive arthritis
Psoriatic Arthritis

Question 6

Seropositive Arthritis

Answer 6

RA
SLE
sjogren's 
systemic sclerosis 
vasculitis

Question 7

What do the seronegative arthritis conditions have in common?

Answer 7

Strong predisposition with HLA -B27 gene

Question 8

What do the seropositive conditions all have in common?

Answer 8

auto-antibody production

Question 9

Potential triggers for RA

Answer 9

Smoking
stress
infection

Question 10

Genetics and RA

Answer 10

HLA DR4 genetic predisposition. also associated with increased severity.

Question 11

Pathophysiology of RA

Answer 11

Inflamed synovium and tenosynovium. Formation of locally invasive synovial fluid is characteristic and causes RA erosions. Osteoclasts stimulated.

Question 12

Link between RA and Osteoarthritis

Answer 12

RA can cause cartilage cells to be destroyed and not rebuilt so can stimulate osteoarthritis.

Question 13

Presentation of RA

Answer 13

Symmetrical, swollen, painful, stiff SMALL joints for >6 weeks. Morning stiffness >1 hour that gets better as the day goes on.

Question 14

3 joints most commonly affected by RA

Answer 14

1) metacarpophalangeal
2) proximal interphalangeal
3) metatarsophalangeal

Question 15

less common joints in RA

Answer 15

C1 and c2 of spine (only ones from spine that can be affected)
wrists, elbows, ankles

Question 16

Most specific test for RA

Answer 16

anti-ccp antibody

Question 17

Tests done in RA

Answer 17

Anti-CCP
RF
Anaemia of chronic disease
X-ray: erosions (cannot detect early disease)
Ultrasound and MRI more sensitive

Question 18

1st line management of RA

Answer 18

Methotrexate +NSAIDS

methotrexate takes a while to work so may need steroid to bridge gap

Question 19

Use of steroids in RA

Answer 19

Flare-ups and bridge gap between starting DMARD and DMARD being effective

Question 20

Treatment pathway in RA

Answer 20

1) Methotrexate
2) Methotrexate +Sulfasalazine
3) Methotrexate +Sulfasalazine +hydroxychloroquine
4) Biological agents

Question 21

When can Biological agents be used?

Answer 21

If DAS 28 > 5.1 despite 2 DMARDs and methotrexate must be 1 of the 2 in combination e.g.
methotrexate and sulfasalazine used in combo and DAS 28>5.1 then qualify for biologics

Question 22

Categories of DAS 28

Answer 22

<2.6: remission
2.6-3.2 low disease activity
3.3-5.1: moderate disease activity
>5.1: high disease activity… BIOLOGICS

Question 23

Causes/Risk factors of osteoarthritis

Answer 23

Risk factors:
Inc age
Obesity
Triggers:
previous trauma
RA
crystal deposition

Question 24

Pathophysiology of Osteoarthritis

Answer 24

loss of cartilage due to homeostatic imbalance between cartilage synthesis and degradation.
wear and tear.

Question 25

Presentation of Osteoarthritis

Answer 25

mechanical pain, especially of weight bearing joints/joints used excessively (thumb, cervical/lumbar spine, knee and hip). Morning stiffness <30 mins.

Question 26

Signs of Osteoarthritis

Answer 26

``` crepitus joint swelling bony enlargement squaring of the hands Heberdens nodes Bouchards nodes ```

Question 27

Difference between heberdens nodes and Bouchards nodes

Answer 27

``` Heberdens nodes (DIP) Bouchards nodes (PIP) ```

Question 28

Diagnosis of Osteoarthritis

Answer 28

Loss of joint space Osteophytes Subchondral cysts Subarticular sclerosis

Question 29

Management of Osteoarthritis

Answer 29

``` Surgery is the only definitive management (joint replacement) Exercise analgesia: paracetamol + topical NSAID topical capsican Amitriptyline: nerve pain Gabapentin: muscle relaxant ```

Question 30

what do you need to be before starting biologics?

Answer 30

TB, HIV, Hep C and Hep B risk of reactivation of TB IGRA blood test checks for latent or active TB.

Question 31

Features of RA on X-ray

Answer 31

erosions, osteopaenia Does not show early disease. joint space narrowing

Question 32

Features of RA on ultrasound

Answer 32

shows its the synovium inflamed not the bone. The synovium is hypervascularized etc.

Question 33

If a patient is pregnant and on methotrexate what happens?

Answer 33

methotrexate goes to sulfasalazine. cannot conceive within 3 months of stopping methotrexate. Cannot breastfeed while on methotrexate.

Question 34

What is methotrexate co-prescribed with and why?

Answer 34

Folic acid, because methotrexate is a folic antagonist. Low folic causes nausea, mouth ulcers and hair to fall out.