Rheumatology

Question 1

4 seronegative arthropathies

Answer 1

psoriatic arthritis
AS
reactive arthritis
enteropathic arthritis

Question 2

what processes occur in OA

Answer 2

localised loss of cartilage
remodelling of adjacent bone and formation of osteophytes
mild synovitis

but the repair processes don’t fully compensate for the joint damage and symptoms of pain and stiffness

Question 3

morning stiffness in OA

Answer 3

no morning stiffness

or morning stiffness lasting no longer than 30 minutes

Question 4

joints of the hand affected by OA

Answer 4

typically the first CMC joint, PIP and DIP

MCP joints are spared

Question 5

investigations for OA

Answer 5

HISTORY
establish if it has an effect on daily activities including work and sleep
any psychosocial impact

EXAMINE the joint
calculate BMI

routine X ray of the affected joint is not usually needed to confirm the diagnosis but may be considered

blood tests like CRP/ESR + FBC to rule out inflammation
can also be useful to check baseline U+Es + creatinine before starting patients on NSAIDs

Question 6

signs of OA on Xray

Answer 6

narrowing of joint space
subchorndral sclerosis
osteophytes
subchondral cysts

Question 7

management of OA

Answer 7

PATIENT EDUCATION
CONSERVATIVE
weight loss
muscle strengthening exercises
footwear
TENS
offer support to help with the psychosocial impact of the disease
occupational health assessment - e.g. workplace modifications if needed
MEDICAL
paracetamol - advise on regular use rather than as needed
can add NSAIDs
opioids - codeine or topical capsaicin as alternative
arrange to regularly review
intra-articualr steroids
SURGICAL
when significnat impact on life and are refractory to non-surgical treatmnet

Question 8

surgical options for OA

Answer 8

arthroscopy + debridement
osteotomy
partial joint replacement
total joint replacement

arthrodesis is an option for base of thumb OA

Question 9

referral to MDT in OA

Answer 9

• Physiotherapy — for advice on exercise, provision of protective joint supports
• Occupational therapy — for advice on assistive devices for daily activities.
• Podiatry — for possible biomechanical assessment and advice on appropriate footwear and insoles.
• Orthopaedic surgery — for consideration of joint surgery.
• Pain clinic — for specialist pain management.
• Psychological services — for specialist management of co-morbid anxiety and depression.

Question 10

complications of OA

Answer 10

• Joint deformity
• Due to bony nodules on the dorsum of the finer next to the DIP (Heberden’s) and PIP (Bouchard’s nodes)
• As the disease progresses, there may be ulnar or radial deviation at affected joints
• Functional impairment
• Psychosocial impact
• Occupational impact
• Falls

Question 11

genetic component in RA

Answer 11

HLA DR4

Question 12

pathophysiology of RA

Answer 12

inflammatory infiltraion of the synovial membrane
leading to synovial cell proliferation and synovial villi hypertrophy –> pannus

pannus = an abnormal layer of fibrovascular tissue

Question 13

later deformities in RA

Answer 13

ulnar deviation of the fingers

dorsal wrist subluxation

Question 14

later deformities in RA

Answer 14

ulnar deviation of the fingers 
radial deviation of the wrist
dorsal wrist subluxation 
swan neck deformity
Boutonniere deformity 
Z thumb
subluxation of MCP joints
extensor tendon rupture

Question 15

extra articular manifestations of RA

Answer 15

cutaneous - nodules, nailfold infarcts + splinter haemorrhages, vasculitis rashes
pulmonary - pleural thickening, pleural effusions (exudative), fibrosing alveolitis, pulmonary fibrosis
neurological - peripheral neuropathy
haematological - ACD, Felty’s syndrome, thrombocytosis
ocular - epislceritis, sclertitis
renal - drug toxicity, amyloid
cardiac - pericarditis, CAD, mitral valve disease

Question 16

investigations for RA

Answer 16

examine
RF
anti-CCP
X ray of the joints - help with diagnosis and determination of disease severity
consider the following to act as a baseline prior to treatment - FBC, renal, LFTs (and FBC may show ACD, raised platelets and rasied WCC)
CRP or ESR - usually but not always evelated

can also consider US or MRI depending on local policy and availability

Remember that patients have to be referred to a rheumatologist for confirmation of diagnosis and before starting DMARD treatment

Question 17

disease activity monitoring score for RA

Answer 17

DAS 28

Question 18

rheumatoid factor

Answer 18

antibodies that are directed against the Fc component of IgG

found in 60-70%

Question 19

anti-CCP

Answer 19

associated with erosive disease

found in 80%

Question 20

conservative measures for RA

Answer 20

stopping smoking, and drinking only sensible amounts of alcohol, to reduce the risk of cardiovascular disease

Question 21

how do you know when to refer a patient with suspected RA to a rheumatologist

Answer 21

Refer urgently, within 3 working days of presentation (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if there are any of the following:
o Small joints of the hands or feet are affected.
o More than one joint is affected.
o There has been a delay of 3 months or longer between the onset of symptoms and the person seeking medical advice.

consider offering an NSAID while patient is awaiting appointment