Rheumatology and diagnostics

Question 1

All possible bloods for rheumatology

Answer 1

FBC 
Urea+ Electrolytes
Liver function tests
bone profile
Erythrocyte sedimentation rate
C-reactive protein

Question 2

FBC results for inflammatory arthritis

Answer 2

Hb - anaemia or normal
Normal MCV
Usually normal WCC
normal/increased platelet count

Question 3

FBC results - osteoarthritis

Answer 3

all normal

Question 4

FBC results - septic arthritis

Answer 4

Haemoglobin normal (too acute)
Normal MCV
Leukocytosis (neutrophilia)
Platelet count normal or raised (if with intense inflammation)

Question 5

When is U+E useful for rheumatological diagnosis?

Answer 5

Multi-system rheum diseases can affect kidneys, e.g. SLE vasculitis, poorly controlled inflammatory disease
NSAIDs may cause kidney impairment (osteo)

Question 6

how may poorly controlled inflammatory diseases affect the kidneys?

Answer 6

High levels of serum amyloid-A protein
SAA deposits in organs
AA amyloidosis

Question 7

What are LFTs used for in rheumatology?

Answer 7

DMARDs can cause liver damage - patients on methotrexate need regular blood tests (8 weeks)
Low albumin can reflect leak from kidney e.g. SLE nephritis

Question 8

What is included in bone profile?

Answer 8

Calcium
Phosphate
Alkaline Phosphatase (ALP- also in LFTs)

Question 9

Name diseases identified through bone profile

Answer 9

Paget’s disease
Osteomalacia
Osteoporosis

Question 10

Bone profile results - Paget’s disease

Answer 10

Very high ALP due to the disease being caused by abnormality of high bone turnover

Question 11

Osteomalacia - bone profile results

Answer 11

ALP normal or raised

Ca and PO4 normal or low

Question 12

Osteoporosis bone profile results

Answer 12

Calcium, PO4 and ALP normal

Question 13

Non-pathological reason for raised ESR

Answer 13

Elevated immunoglobulin level
paraprotein
anaemia
tends to rise with age

Question 14

Rule of thumb for SLE ESR/CRP

Answer 14

ESR high, CRP normal

except significant synovitis or inflammatory pleural or pericardial effusion

Question 15

Auto antibodies indicated in rheumatoid arthritis

Answer 15

1. Rheumatoid factor - nonspecific (hep C Sjorgen’s syndrome)
2. Cyclic citrullinated peptides antibodies - specific, associated with worse prognosis
3. ANAs

Question 16

When to test for Antinuclear antibodies

Answer 16

in combination with correct clinical features of auto-immune connective tissue diseases
Due to false positives

Question 17

Interpretation of ANA results

Answer 17

Negative test rules out SLE

Positive test does not discriminate for SLE, only suggestive is other clinical and lab features support diagnosis

Question 18

If ANA positive, other tests to order for auto-immune connective tissue disorders

Answer 18

ENA (extractable nuclear antigens)
incl Ro, La, RNP, Smith, Jo-1
dsDNA antibodies - highly specific for Lupus

Question 19

Features of Sjorgen’s syndrome

Answer 19

Dry eyes
dry mouth (due to destruction of salivarian and lacrimal glands)
Extra acticular features

Question 20

SLE clinical features

Answer 20

Arthritis
Skin rash (butterfly sunlight)
mouth ulcers
kidney disease
haematological
pleural effusion
pericardial effusion

Question 21

Polymyositis clinical features

Answer 21

Muscle imflammation
weakness
high creatine kinase (CK)

Question 22

Scleroderma clinical features

Answer 22

vasculopathy (especially Raynaud’s)
skin thickening
organ fibrosis

Question 23

Indications for joint aspiration

Answer 23

1. Diagnostic

2. Theraputic

Question 24

Synovial fluid analysis use in diagnosis

Answer 24

septic arthritis - gold standard, send for MC&S, identify organism and guide antibiotic choice
crystal arthritis - birefringence of crystals

Question 25

Gout vs pseudo-gout joint aspiration findings

Answer 25

Gout - needle-shaped negative birefringence

Pseudo-gout - rhomboid-shaped crystals with Positive birefringence

Question 26

Reactive arthritis vs septic arthritis

Answer 26

reactive - sterile fluid culture, no antibiotic therapy or joint lavage
septic - positive fluid culture, antibiotic therapy, joint lavage

Question 27

Imaging modalities - rheumatology

Answer 27

X-ray first line
CT
MRI - soft tissues, spinal
ultrasound smaller joints, soft tissues

Question 28

Osteoarthritis X-ray findings

Answer 28

joint space narrowing
subchondral bony sclerosis
Osteophytes
Subchondral cysts

Question 29

Rheumatoid arthritis imaging

Answer 29

X-ray for soft tissue swelling, peri-articular osteopenia, bony erosions,
Ultrasound - for synovitis (synovial hypertrophy, increased blood flow)
MRI

Question 30

gout features on x ray

Answer 30

rat bite erosions

Question 31

rheumatoid arthritis vs osteoarthritis X ray differences

Answer 31

joint space narrowing - RA OA
subchondral sclerosis - OA
osteophytes - OA
osteopenia - RA
bony erosions - RA

Question 32

what are bouchards nodes

Answer 32

osteophytes at proximal inter-phalangeal joints (OA)

Question 33

what are Heberdens nodes?

Answer 33

osteophytes at distal interphalangeal joints (OA)