Rheumatology

Question 1

What type of symptoms can you have in SLE?

1. Mucocutaneous
2. Musculoskeletal
3. Cardiorespiratory
4. Renal
5. Neuropsychiatric
6. Haematology
7. Immunology
8. Obstetric

Answer 1

1. Oral ulcers, photosensitive rash
2. Arthralgia, myalgia
3. Pleuritis, pericarditis
4. Proteinuria, cellular casts
5. Seizures, psychosis
6. Haemolytic anaemia, lymphopenia, leukopenia, thrombocytopenia
7. Anti DNA, Anti Sm
8. Recurrent miscarriage, IUGR, neonatal lupus, prematurity, stillbirth

Question 2

What are the first-line management options for SLE? (3)

Answer 2

Avoid sunexposure and wear suncream
Hydroxychloroquine
NSAIDs for pain

Question 3

What antibodies are present in:

1. Sjogren’s
2. Polymyositis/dermatomyositis
3. Systemic sclerosis
4. Limited sclerosis
5. Antiphospholipid

Answer 3

1. Anti Ro and Anti La
2. Anti Jo-1
3. Anti Scl 70
4. Anti centromere
5. Anti cardiolipin

Question 4

What is the general presentation for:

1. Granulomatosis with polyangiitis
2. Eosinophilic granulomatosis with polyangiitis
3. Microscopic polyangiitis

Answer 4

1. Nasal crusting and deformity, conductive deafness, haemoptysis, cough, dysnpnoea, glomerulonephritis
2. Severe asthma which worsens with Monelukast, haemoptysis, skin nodules and papules, eosinophilia
3. Haematuria, proteinuria, RBC casts, alveolar haemorrhage

Question 5

What is polyarteritis nodosa?

What infection is commonly associated?

Answer 5

Necrotising arteritis involving visceral arteries

Hepatitis B

Question 6

Which cardiovascular symptoms are associated with Takayasu’s arteritis?

Answer 6

Aortic regurgitation
BP difference >10mmHg in both arms
Jaw and arm claudication

Question 7

What is the differential diagnosis for vasculitis? (5)

Answer 7

Subactuve bacterial endocarditis
Cocaine abuse (nasal deformity)
Atrial myxoma 
Antiphospholipid antibody syndrome (livedo reticularis)
Cholesterol embolism (livedo reticularis in digits)

Question 8

What intial tests should be ordered when investigating vasculitis?

Answer 8

FBC, LFTs, antibodies (RF, anti-CCP, ANA, ANCA, PR3 (pANCA))

Urine dip and ACR

Question 9

What symptoms are most common in fibromyalgia? (4)

Answer 9

Widespread muscular pain
Generalised stiffness
Persistent fatigue
Non-refreshing sleep

Question 10

What are some conditions that are associated with fibromyalgia? (8)

Answer 10

Rheumatoid arthritis
SLE
IBS and irritable bladder
TPJ dysfunction
Dysmennorhoea 
Raynaud's phenomenon
Restless legs

Question 11

What are the differentials for fibromyalgia? (6 categories)

Answer 11

Inflammatory: PMR, SLE, connective tissue disorder
Endocrine: hypothyroidism
Metabolic: vitamin deficiencies, anaemia
Malignancy
Infection: Lyme disease
Myopathy

Question 12

What are the management options for fibromyalgia?

1. Pharmacological
2. Non-pharmacological

Answer 12

1. Pain killers, antidepressants (amitryptiline, SSRIs, duloxetine)
2. Exercise programmes, CBT, relaxation therapies and hydrotherapy, mindfulness, acupuncture

Question 13

What are some systemic manifestations of rheumatoid arthritis?
What is Felty’s syndrome?

Answer 13

Sjogren's, scleritis and episcleritis
Ulcers, rashes, nail fold infarcts
Nodules
Polyneuropathy
Cardiac and respiratory involvement
Hepatomegaly and abnormal LFTs

RA with anaemia, leukopenia and splenomegaly

Question 14

What is the general management of RA?

Answer 14

Involvement of the MDT
NSAIDs
Steroids and DMARDs

Question 15

Which medication is used for an acute flare of RA?

Answer 15

Intra-articular methylprednisolone

Question 16

What are some risk factors for gout?

1. Medication
2. Medical conditions
3. Lifestyle

Answer 16

Medication e.g. diuretics, chemotherapy
Obesity, CHD, diabetes, CKD
Meat, seafood, alcohol

Question 17

What are the differentials for acute gout? (5)

Answer 17

Septic arthritis
Reactive arthritis
Psoriatic arthritis
Pseudogout
Haemarthrosis

Question 18

What microscopy tests should you order for a red, hot and swollen joint?

Answer 18

Joint aspiration and synovial fluid analysis (culture and polarising microscopy)

Question 19

What is the treatment for acute gout? (3)

Answer 19

NSAID + PPI or colcichine
Intra-articular steroids if above not effective
Oral steroids

Question 20

What is the prophylactic treatment for gout?
What is second line?

What blood tests are required before starting/during treatment?

Answer 20

Allopurinol after acute attack has resolved - measure uric acid and U&Es every 4 weeks until <300; given lifelong

Febuxostat - must measure LFTs before starting

Question 21

What are the risk factors for pseudogout? (6)

Answer 21

Haemochromatosis
Wilson's disease
Hypothyroidism
Hyperparathyroidism 
Acromegaly
Low magnesium and phosphate

Question 22

What will you see in joint aspiration for pseudogout?

What will you see on joint x-ray?

Answer 22

Weakly positive birefringent rhomboid shaped crystals

Chondrocalcinosis

Question 23

What x-ray changes will you see in OA?

Answer 23

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

Question 24

When should you suspect secondary OA? (2)

What are some of the causes?

Answer 24

<40, atypical distribution

Gout, Wilson's, acromegaly, haemochromatosis
Collagen disorders
Trauma 
Congenital disorders e.g. SUPE
Diabetes

Question 25

What are the management options for OA?

1. Conservative
2. Surgical

Answer 25

1. Pain relief, weight loss, strengthening exercise, psychological support, OT assessment
2. Arhtroscopy, joint replacement