Rheumatology

Question 1

What are classic nail signs in psoriatic arthritis?

Answer 1

Pitting
Ridging 
Onycholysis
Hyperkeratosis
Discolouration / oil-spots

Question 2

What are clinical indications of activity in inflammatory arthritis?

Answer 2

• joint line tenderness
• bogginess
• effusion
• erythema and heat may be present, but less likely

Question 3

What are DDx for rheumatoid nodules?

How to differentiate?

Answer 3

• Gouty tophi
• Calcinosis cutis
• Ganglion

Distribution:

• Rheumatoid nodules are at extensor surfaces/pressure points
• Tophi typically originate at the joint margin, can be in ears

They will be firm, non-tender, subcutaneous lesions Rheumatoid nodules may be fixed or movable, whereas tophi fixed

Appearance of tophi will be whitish with chalk-like texture. They can also leak and ulcerate, become infected

Question 4

XR changes in OA?

Answer 4

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

Question 5

XR changes in rheumatoid arthritis?

Answer 5

Periarticular swelling
Periarticular osteopaenia
Marginal erosions
Joint space narrowing
Deformities

Question 6

XR changes in gout?

Answer 6

Erosions with overhanging edges / punched out
Calcified tophi
Preserved joint space and no osteopenia

Question 7

XR changes in psoriatic arthritis?

Answer 7

“Rat bite” erosions with periarticular joint erosions, pencil in cup deformity
Soft tissue swelling and sausage digits

Question 8

Extra-articular manifestations of RA?

Answer 8

Face - anaemia, eyes for scleritis/episcleritis
Chest - fibrosis, rubs
Abdomen - splenomegaly 
Legs - pyoderma 
*screen other joints too

Question 9

Extra-articular manifestations of spondyloarthropathiess?

Answer 9

Face - anaemia, uveitis
Abdomen - stoma, resection
Back - axial disease
Feet - enthesitis

Question 10

Extra-articular manifestations of gout?

Answer 10

Tophi in ears / rest of body 
Underlying cause 
- metabolic syndrome
- BP
- ETOH 
- fluid overload
- CKD

Question 11

What is difference between limited and diffuse systemic sclerosis?

Answer 11

Pattern of skin involvement
- if sclerosis in upper arms/chest then is diffuse

*note limited can involve face

Question 12

DDx for Raynauds

Answer 12

Primary

Secondary

• Scleroderma
• Systemic lupus erythematosus
• Polymyositis/dermatomyositis
• Sjögren’s syndrome
• MCTD

Cryoglobulinemia

Hypothyroidism

Vasculitis

Drugs (sympathomimetics)

Question 13

After hands, what to look for in systemic sclerosis?

Answer 13

BLOOD PRESSURE

Body habitus (malnutrition)

Face

• alopecia
• bird-like facies / mouth opening restriction
• anaemia
• telangectasia

Chest

• Pulm HTN
• Rubs
• fibrosis
• heart failure

Question 14

Dermatomyositis - hand signs?

Answer 14

Gottron's papules 
Mechanic's hands (rough cracked)
Nailfold capillary changes = 
- abnormal capillary nailbed loops 
- periungual erythema
- cuticular hypertrophy

Question 15

Dermatomyositis - after hands, what signs will you look for?

Answer 15

Skin

• heliotrope rash
• shawl sign

Neuro
- proximal myopathy

Resp exam
- interstitial fibrosis

Question 16

DDx for widespread skin thickening?

Answer 16

Systemic sclerosis 
Nephrogenic systemic fibrosis
Endocrine 
- Diabetes
- hypothyroidism
Amyloidosis
Chronic GVHD
Drugs (chemotherapy)

Question 17

What are the possible patterns of presentation of psoriatic arthritis?

Answer 17

• Distal arthritis, characterized by involvement of the DIP joints
• Asymmetric oligoarthritis, in which less than five small and/or large joints are affected in an asymmetric distribution
• Symmetric polyarthritis, similar to and, at times, indistinguishable from rheumatoid arthritis
• Arthritis mutilans, characterized by deforming and destructive arthritis
• Axial disease

Question 18

Classic arthropathy of haemachromatosis?

Extra-articular manifestations to look for?

Answer 18

2nd / 3rd MCP predominant involvement

Other manifestations

• bronze skin
• hepatomegaly
• signs of diabetes
• dilated cardiomyopathy

Question 19

DDx for symmetrical deforming polyarthropathy of hands?

Answer 19

Rheumatoid arthritis
SLE (deformities passively reversible)

Psoriatic arthritis

Question 20

Manifestations of Cushing’s / evidence of steroid complications on exam?

Answer 20

Body habitus

HTN
Hyperlipidaemia
Diabetes

Bruising / skin atrophy
Proximal myopathy
Oral thrush
Cataracts

Question 21

What antibodies would you check in suspected systemic sclerosis?

Answer 21

ANA titre and pattern

Limited -> anti-centromere (associated with pulmonary hypertension)

Diffuse

• > RNA-polymerase III (associated with renal manifestations)
• > Scl-70 (associated with ILD)

Can also review U1-RNP for DDx of MCTD

Question 22

What other investigations (aside from antibodies) would you want to review in SSc?

Answer 22

To look for specific organ involvement

• HRCT to look for ILD
• PFTs to look for ILD
• TTE to explore pulmonary HTN
• Can consider looking for GI involvement with upper endoscopy +/- oesophageal manometry

Question 23

Where in the lungs is SSc - related ILD most affected?

Answer 23

Bases