Rheumatology

Question 1

Peripheral nerve sensory distribution hand

Answer 1

Ulnar nerve - little finger and half of ring finger dorsal and palmar side
Median nerve - 1st 3.5 fingers palmar side and tips of dorsal side
Radial nerve - 1st 3.5 fingers dorsal side (except the tips)

Question 2

Where are Heberden’s nodes and Bouchard’s nodes found

Answer 2

Bouchard - PIP

Heberden’s - DIP

Question 3

Signs of median nerve pathology

Answer 3

Wasting of the thenar eminence, weakness of thumb abduction, sensory loss over the palmar side of the 1st 3.5 fingers

Question 4

Signs of ulnar nerve pathology

Answer 4

Wasting of the hypothenar eminence
Weakness of finger abduction
Sensory loss over the palmar and dorsal side of the 5th and half of 4th finger

Question 5

Signs of radial nerve pathology

Answer 5

Wrist drop
Weak wrist and MCP extension
Sensory changes over the dorsal side of the 1st 3.5 fingers (but no the finger tips)

Question 6

What are the extra-articular manifestations of RA?

Answer 6

Eyes - scleritis, episcelritis, dry eyes
Anaemia 
Lungs - fibrosis, effusions 
Heart - pericarditis 
Skin - pyoderma gangrenosum 
Abdomen - Felty's with splenomegaly 
Kidneys - nephrotic syndrome 
Nervous - mononeuritis multiplex

Question 7

What is the treatment for rheumatoid arthritis ?

Answer 7

1. DMARDs
2. Steroids if active flare
3. Biologics - TNF alpha inh, IL1 antagonists

Question 8

What are the systemic manifestations of psoriasis?

Answer 8

Gout - PA is associated with hyperuricaemia 
Eyes - uveitis
Resp - apical fibrosis 
Heart - aortic regurgitation, aortitis
Enthesitis

Question 9

What are the patterns of joint involvement of psoriatic arthritis?

Answer 9

1. Asymmetric oligoarthropathy - mainly affecting DIPs, can get dactylitis
2. Bilateral deforming polyarthropathy resembling RA
3. DIP arthropathy
4. Mutilans - aggressive and deforming
5. Spondylitis +/- sacroiliitis

Question 10

Apart from the skin changes what else might differentiate psoriatic arthritis from rheumatoid arthritis clinically?

Answer 10

Dactylitis
Enthesitis
Spinal involvement - spondylitis/sacroiliitis
Apical fibrosis

Question 11

X-ray features of RA?

Answer 11

Decreased joint space
Deformity - ulnar deviation, Volar subluxation, swan neck, Boutonniere’s
Erosions
Periarticular osteopaenia

Question 12

X-ray features of psoriatic arthritis?

Answer 12

Pencil in cup 
Telescoping 
Fluffy periostitis 
Osteolysis 
Periarticular proliferation

Question 13

What is meant by enthesitis? which condition is it seen in? where?

Answer 13

Inflammation of tendons, ligaments etc at the insertion into the bone. Seen in psoriatic arthritis and ank spon. Especially Achillies and Plantar Fasciitis

Question 14

What is meant by dactylitis? which condition is it seen in?

Answer 14

Inflammation of the tendon sheath and soft tissue causing swelling of the finger - “sausage digit”

Question 15

How do you treat psoriatic arthritis?

Answer 15

Analgaesic and NSAIDs
AVOID STEROIDS - can flare psoriasis
Conventional DMARDs - not when axial involvement
Biologics - anti-TNF agents

Question 16

What are the nail changes in psoriasis called?

Answer 16

Onycholysis, subungual hyperkeratosis, transverse ridging, pitting

Question 17

What are the systemic manifestations of ank spon (the As + others )?

Answer 17

Anterior Uveitis 
Apical fibrosis 
Aortic Regurg 
AV conduction problems 
Achilles tendonitis (enthesitis)
Atlanto-axial subluxation 
Amyloid 
Inflammatory bowel disease

Question 18

What are the seronegative arthropathies?

Answer 18

Psoriatic Arthritis
Ankylosing Spondylitis
Enteropathic arthritis
Reactive Arthritis

Question 19

What is the treatment for ankylosing spondylitis?

Answer 19

Analgesia and NSAIDs
Steroids - no real role
DMARDs - may help for peripheral disease but not axial
Biologics - anti-TNF alpha, IL 17 inhibitors

Question 20

X-ray findings in ankylosing spondylitis

Answer 20

Sacroiliitis - subchondral erosions, sclerosis and proliferation on the iliac side of the SIJ
Spondylitis - Small erosions at the corners of the vertebral bodies, vertebral body squaring, syndesmophytic ankylosis - bamboo spine, dagger spine - fusion of the posterior longitudinal ligament

Question 21

X-ray changes in the different arthropathies

Answer 21

RA - marginal erosions
Gout - juxtarticular punched out erosions, tophi
OA - osteophytes, subchondral sclerosis, decreased joint space, subchondral cysts
Psoriatic - fluffy periostitis, pencil in cup deformity

Question 22

Difference between rheumatoid nodule and gouty tophi?

Answer 22

Age and sex - if young female gout less likely

Joint involvement - if DIP involvement then not RA

Question 23

What are the seronegative spondyloarthropathies?

Answer 23

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis