Rheumatology Conditions A

Question 1

Osteoarthritis - Description

Answer 1

mechanical degeneration of synovial joint articular cartilage

Question 2

Osteoarthritis - Risk Factors (9)

Answer 2

1) >50 years old
2) female
3) genetic (50%)
4) obesity
5) diabetes mellitus
6) inflammatory arthritis
7) trauma
8) occupation
9) joint hypermobilility

Question 3

Osteoarthritis - Pathophysiology (6)

Answer 3

1) progressive articular cartilage degradation (many causes)
2) exposed underlying bones damage
3) increased osteoblast bone synthesis (repair mechanism)
4) subarticular sclerosis (bone overgrowth around articular surface)
5) osteophytes (calcified bone overgrowth at joint margins)

Question 4

Osteoarthritis - Symptoms (5)

Answer 4

1) progressive joint pain (esp. after activity)
2) joint stiffness (esp. after rest, <30 mins in morning)
3) limited joint movement
4) crepitus (crunching sensation when moving joint)
5) tenderness around joint

Question 5

Osteoarthritis - Signs (4)

Answer 5

1) Bouchard’s nodes (PIPJ bone swelling)
2) Herberden’s nodes (DIPJ bone swelling)
3) joint effusion (increased intra-articular fluid)
4) surrounding muscle wasting

Question 6

Osteoarthritis - Investigations (2/3)

Answer 6

initial
1) joint x-ray (LOSS, loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis)
2) normal CRP + ESR (exclude RA)
consider
1) joint MRI
2) rheumatoid factor (negative, exclude RA)
3) anti-CCP (negative, exclude RA)

Question 7

Osteoarthritis - Management (6/1/3)

Answer 7

conservative
1) regular exercise
2) weight loss
3) hot/cold packs
4) joint braces
5) joint supports
6) insoles
medical
1) analgesia
surgery
1) joint replacement (hip, knee)
2) osteotomy (change bone shape)
3) arthrodesis (joint immobilisation) (unmanageable pain)

Question 8

Osteoarthritis - Management (Analgesia) (4)

Answer 8

1) paracetamol ± TOP NSAID
2) NSAID + PPI
3) codeine
4) IA corticosteroid (short term severe symptoms)

Question 9

Rheumatoid Arthritis - Description

Answer 9

chronic systemic autoimmune inflammation that affects joints (synovium)

Question 10

Rheumatoid Arthritis - Risk Factors (6)

Answer 10

1) 40-55 years old
2) female (2:1)
3) family history
4) genetic (HLA-DR1, HLA-DR4)
5) infection (e.g. gingivitis)
6) smoking

Question 11

Rheumatoid Arthritis - Pathophysiology (9)

Answer 11

1) environmental trigger (e.g. smoking)
2) citrullination (arginine —> citrulline) of proteins (e.g. type 2 collagen)
3) genetic susceptibility (e.g. HLA-DR1)
4) citrullinated proteins no longer recognised as self-antigens
5) autoimmune reaction to citrullinated proteins (anti-CCP)
6) overproduction of inflammatory cytokines in joints
7) synovium proliferates forming pannus (thick swollen synovial membrane with granulation tissue)
8) articular cartilage degeneration due to pannus
9) underlying bones are exposed and damage (bony erosions)

Question 12

Rheumatoid Arthritis - Symptoms (9)

Answer 12

1) joint pain (esp. MCP, PIP, MTP
2) joint stiffness (esp. in cold, >1 hour in morning)
3) joint tenderness (esp. MCP, PIP, MTP)
4) joint swelling (esp. MCP, PIP, MTP)
5) joint erythema (esp. MCP, PIP, MTP)
6) joint warmth (esp. MCP, PIP, MTP)
systemic
1) fatigue
2) fever
3) weight loss

Question 13

Rheumatoid Arthritis - Signs (6)

Answer 13

1) ulnar deviation (swelling of MCPJ causes fingers to drift towards little finger)
2) Z thumb deformity (MCPJ hyperextension, PIPJ flexion)
3) swan neck deformity (PIPJ hyperextension, DIPJ flexion)
4) Boutonniere’s deformity (PIPJ flexion, DIPJ hyperextension)
5) rheumatoid nodules (esp. elbows)
6) surrounding muscle wasting

Question 14

Rheumatoid Arthritis - Complications (9)

Answer 14

1) frozen shoulder
2) neuropathies (e.g. carpal tunnel syndrome)
3) tenosynovitis
4) pleural disease (inc. pleural effusion)
5) pericarditis
6) ischaemic heart disease
7) vasculitis
8) scleritis
9) osteopenia—>osteoporosis

Question 15

Rheumatoid Arthritis - Investigations (5/2)

Answer 15

initial
1) joint x-ray (periarticular erosions: early—>soft tissue, late—>joint space loss, later—>bone)
2) high CRP + ESR*
3) rheumatoid factor* (70% positive)
4) anti-CCP* (70% positive)
5) FBC (anaemia, leucocytosis)
consider
1) joint MRI
2) joint ultrasound

Question 16

Rheumatoid Arthritis - Diagnosis (5/3/2/2)

Answer 16

≥6 = diagnosis
joints
1) 1 large joint = 0
2) 2-10 large joints = 1
3) 1-3 small joints = 2
4) 4-10 small joints = 3
5) >10 small joints = 4
serology
1) negative RF + anti-CCP = 0
2) low positive RF or anti-CCP = 2
3) high positive RF or anti-CCP = 3
inflammation
1) normal CRP + ESR = 0
2) high CRP or ESR = 1
duration
1) <6 weeks = 0
2) >6 weeks = 1

Question 17

Rheumatoid Arthritis - Management (4/4/2)

Answer 17

conservative
1) regular exercise
2) weight loss
3) smoking cessation
4) physiotherapy
medical
1) DMARDs (e.g. methotrexate*, sulfasalazine)
2) IM, PO, IA corticosteroids (short term symptomatic flares)
3) NSAID
4) biological agent (e.g. TNF-αi infliximab)
surgery
1) synovectomy (reduce inflamed tissue bulk)
2) arthroplasty (severely affect joints)

Question 18

Gout - Description

Answer 18

inflammatory arthritis due to intra-articular monosodium urate crystals

Question 19

Gout - Causes (1)

Answer 19

1) hyperuricaemia

Question 20

Gout - Risk Factors (Decreased Urate Excretion) (8)

Answer 20

90%

1) elderly
2) male (4:1)
3) post-menopausal
4) diabetes mellitus
5) hypertension
6) kidney disease
7) thiazide diuretic
8) aspirin

Question 21

Gout - Risk Factors (Increased Urate Production) (5)

Answer 21

10%

1) alcohol (esp. beer)
2) purine rich foods (e.g. red meat)
3) sweeteners
4) lymphoproliferative disorders (e.g. ALL)
5) myeloproliferative disorders (e.g. CML)

Question 22

Gout - Precipitants (5)

Answer 22

1) heavy meal
2) heavy drinking
3) cold
4) trauma
5) infection

Question 23

Gout - Symptoms (5)

Answer 23

1) rapid onset severe joint pain (esp. 1st MTP, big toe >50%)
2) joint tenderness
3) joint swelling
4) joint erythema
5) joint warmth

Question 24

Gout - Signs (2)

Answer 24

1) tophi (aggregates of monosodium urate crystals that form nodules in joints, esp. elbows, knees)
2) few joints affected (usually <4)

Question 25

Gout - Complications (3)

Answer 25

1) osteoarthritis 2) nephrolithiasis 3) kidney disease

Question 26

Gout - Investigations (1/3)

Answer 26

initial 1) joint fluid aspiration + microscopy (negatively bifringent crystals) consider 1) serum uric acid (high, 2 weeks after attack) 2) joint x-ray (punched-out periarticular erosions) 3) joint ultrasound

Question 27

Gout - Management (4/5/0)

Answer 27

``` conservative 1) dietary advice (avoid purine rich foods, eat dairy) 2) weight loss 3) alcohol control 4) monitor RFT medical 1) NSAID (high dose) + PPI 2) colchicine (NSAID intolerant) 3) IM, PO, IA corticosteroids 4) allopurinol (3 weeks after attack) 5) replace thiazide diuretics with ARBs ```

Question 28

Pseudogout - Description

Answer 28

inflammatory arthritis due to intra-articular calcium pyrophosphate crystals

Question 29

Pseudogout - Risk Factors (7)

Answer 29

1) old age 2) female 3) hyperparathyroidism 4) haemochromatosis 5) diabetes mellitus 6) oestoarthritis 7) joint trauma

Question 30

Pseudogout - Symptoms (6)

Answer 30

1) rapid onset severe joint pain (esp. wrist, knee) 2) joint tenderness 3) joint swelling 4) joint erythema 5) joint warmth 6) fever

Question 31

Pseudogout - Investigations (2/4)

Answer 31

initial 1) joint fluid aspiration + microscopy* (positively birefringent crystals) 2) joint fluid aspiration + culture (exclude septic arthritis) consider 1) joint x-ray (chondrocalcinosis - linear calcification parallel to articular surfaces) 2) FBC (leucocytosis) 3) UnE (exclude hyperparathyroidism) 4) iron studies (exclude haemochromatosis)

Question 32

Pseudogout - Management (0/4/2)

Answer 32

``` medical 1) NSAID (high dose) + PPI 2) colchicine (NSAID intolerant) 3) IM, PO, IA corticosteroid 4) paracetamol surgery 1) joint fluid aspiration 2) joint replacement ```

Question 33

Osteoporosis - Description

Answer 33

decreased bone density

Question 34

Osteoporosis - Risk Factors (10)

Answer 34

1) >50 years old (female) 2) >65 years old (male) 3) female 4) family history 5) Caucasian 6) Asian 7) smoking 8) alcohol 9) steroids 10) low BMI (<19)

Question 35

Osteoporosis - Symptoms (2)

Answer 35

1) vertebral pain | 2) vertebral tenderness

Question 36

Osteoporosis - Signs (1)

Answer 36

1) increased kyphosis (abnormally outwardly curved thoracic spine)

Question 37

Osteoporosis - Complications (1)

Answer 37

1) fracture (wrist, spine, hip)

Question 38

Osteoporosis - Investigations (5/0)

Answer 38

initial 1) x-ray (fracture, not osteopenia) 2) dual absorption x-ray absorptiometry (DEXA) scan* (T score<2.5) 3) serum Ca2+ (normal) 4) serum PO43- (normal) 5) serum ALP (normal)

Question 39

Osteoporosis - Management (6/3/0)

Answer 39

conservative 1) dietary advice (high dietary calcium, vitamin D intake) 2) weight bearing exercise 3) balance exercise 4) home fall prevention (inc. home visits) 5) smoking cessation 6) alcohol control medical 1) bisphosphonates (1st line) 2) calcium supplement (e.g. calcium carbonate) 3) vitamin D supplement (e.g. ergocalciferol)

Question 40

Ankylosing Spondylitis - Description

Answer 40

spine and sacroiliac joint sclerosis and immobility due to new bone formation caused by chronic inflammation

Question 41

Ankylosing Spondylitis - Risk Factors (5)

Answer 41

1) 15-30 years old 2) male (more severe) 3) HLA-B27 4) Native American 5) Klebsiella pneumoniae

Question 42

Ankylosing Spondylitis - Pathophysiology (3)

Answer 42

1) inflammation of enthesis (site of ligament attachment to bone) 2) enthesitis heals with sclerosis and new bone formation (syndesmophytes) 3) fusion of vertebral bodies

Question 43

Ankylosing Spondylitis - Symptoms (7)

Answer 43

1) sacroiliac joint pain (radiates to hips/buttocks, better at night) 2) progressive lower spinal pain (worse at night, relieved by exercise) 3) progressive spinal stiffness (relieved by exercise) 4) progressive limited spinal movement (frontal, sagittal) 5) sleep disturbances 6) fatigue 7) dyspnoea (kyphotic or costochondral joint)

Question 44

Ankylosing Spondylitis - Signs (4)

Answer 44

1) decreased thoracic expansion 2) decreased lordosis (abnormally straight cervical and lumbar spine) 3) increased kyphosis (abnormally outwardly curved thoracic spine) 4) Schober’s test

Question 45

Ankylosing Spondylitis - Complications (5)

Answer 45

1) enthesitis (e.g. Achilles tendonitis, plantar fasciitis) 2) iritis/uveitis 3) aortitis —> aortic regurgitation 4) osteoporosis 5) anaemia

Question 46

Ankylosing Spondylitis - Investigations (3/3)

Answer 46

initial 1) MRI (sacroiliitis, bone marrow oedema) 2) pelvic x-ray (sacroiliitis, sacroiliac joint margin erosion/sclerosis) 3) cervical, thoracic, lumbar x-ray (bamboo spine, sacroiliac joint margin erosion/sclerosis, syndesmophytes) consider 1) FBC (normocytic anaemia) 2) high CRP + ESR 3) rheumatoid factor (negative)

Question 47

Ankylosing Spondylitis - Management (3/4/2)

Answer 47

``` conservative 1) regular exercise 2) good posture 3) physiotherapy medical 1) NSAID 2) analgesia (e.g. paracetamol, codeine) 3) IA corticosteroid (short term severe symptoms) 4) TNF-αi (refractory, severe) surgery 1) hip replacement 2) spinal osteotomy ```

Question 48

Psoriatic Arthritis - Description

Answer 48

chronic autoimmune inflammatory joint disease associated with psoriasis

Question 49

Psoriatic Arthritis - Risk Factors (3)

Answer 49

1) psoriasis 2) HLA-B27 3) family history

Question 50

Psoriatic Arthritis - Patterns (5)

Answer 50

1) asymmetrical oligoarticular - <5 joints (esp. weight bearing) 2) symmetrical polyarticular - >5 joints (esp. small joints) (RA like) 3) spondylarthritis - sacroiliac joints and cervical spine (AS like) 4) distal interphalangeal predominate - DIP joints 5) arthritis mutilans - DIP joints (severe)

Question 51

Psoriatic Arthritis - Symptoms (5)

Answer 51

1) joint pain 2) joint swelling 3) joint stiffness 4) joint erythema 5) joint warmth

Question 52

Psoriatic Arthritis - Signs (3)

Answer 52

1) dactylitis (DIP, AM) 2) nail abnormalities (e.g. ringing, pitting) (DIP, AM) 3) telescoping fingers (bone resorption collapses finger soft tissue) (AM)

Question 53

Psoriatic Arthritis - Complications (1)

Answer 53

1) cardiovascular conditions

Question 54

Psoriatic Arthritis - Investigations (6/0)

Answer 54

initial 1) joint x-ray* (erosion) (AO, SP) 2) pelvic, spinal x-ray (sacroiliitis, syndesmophytes) (SA) 3) hand, feet x-ray (DIP ‘pencil in cup’ erosion) (DIP, AM) 4) normal CRP + ESR 5) rheumatoid factor (negative) 6) anti-CCP (negative)

Question 55

Psoriatic Arthritis - Management (1/4/2)

Answer 55

conservative 1) physiotherapy medical 1) DMARD (e.g. methotrexate, sulfasalazine) 2) NSAID 3) IA corticosteroid (short term severe symptoms) 4) TNF-αi (e.g. infliximab) (refractory, severe) surgery 1) hip replacement 2) joint replacement

Question 56

Reactive Arthritis - Description

Answer 56

acute inflammatory arthritis post GI or GU infection

Question 57

Reactive Arthritis - Causes (5)

Answer 57

``` GI 1) Salmonella 2) Shigella 3) Campylobacter GU 4) Gonorrhoea 5) Chlamydia ```

Question 58

Reactive Arthritis - Risk Factors (3)

Answer 58

1) 20-40 years old 2) male 3) HLA-B27

Question 59

Reactive Arthritis - Symptoms (8)

Answer 59

``` large joints asymmetrical (esp. sacroiliac, knees, ankles) 1) joint pain 2) joint swelling 3) joint stiffness 4) joint erythema 5) joint warmth systemic 1) fever 2) fatigue 3) weight loss ```

Question 60

Reactive Arthritis - Signs (1)

Answer 60

1) dactylitis

Question 61

Reactive Arthritis - Complications (6)

Answer 61

1) conjunctivitis 2) uveitis 3) urethritis 4) cervicitis 5) enthesitis 6) secondary osteoarthritis

Question 62

Reactive Arthritis - Investigations (6/0)

Answer 62

initial 1) stool culture (gen. negative unless tested very early) 2) urine culture (gen. negative unless tested very early) 3) high CRP + ESR 4) rheumatoid factor (negative) 5) anti-CCP (negative) 6) x-ray (chronic - sacroiliitis, enthesitis)

Question 63

Reactive Arthritis - Management (3/4/0)

Answer 63

``` conservative 1) screen sexual partners 2) rest 3) splint medical 1) antibiotics 2) NSAID 3) IA corticosteroid (short term severe symptoms) 4) DMARD (chronic, >6 months) ```

Question 64

Septic Arthritis - Description

Answer 64

acute inflammatory arthritis due to joint infection (medical emergency)

Question 65

Septic Arthritis - Causes (5)

Answer 65

1) Staphylococcus aureus 2) Streptococci 3) Neisseria gonorrhoea 4) Haemophilus influenzae 5) Escherichia coli

Question 66

Septic Arthritis - Risk Factors (7)

Answer 66

1) osteoarthritis 2) rheumatoid arthritis 3) prosthetic joint 4) IA corticosteroid 5) IV drug abuse 6) diabetes mellitus 7) alcohol

Question 67

Septic Arthritis - Symptoms (7)

Answer 67

1) joint pain (agonising in young, muted in old) 2) joint swelling 3) joint tenderness 4) joint erythema 5) joint warmth 6) loss of joint function 7) fever

Question 68

Septic Arthritis - Complications (2)

Answer 68

1) joint destruction | 2) osteomyelitis

Question 69

Septic Arthritis - Investigations (4)

Answer 69

initial 1) blood culture (identify bacteria) 2) joint fluid aspiration + stain, culture (identify bacteria) 3) joint fluid aspiration + microscopy (exclude gout/pseudogout) 4) high CRP + ESR (CRP may be normal)

Question 70

Septic Arthritis - Management (3/4/1)

Answer 70

``` conservative 1) monitor CRP + ESR 2) joint immobilisation 3) physiotherapy medical 1) stop DMARDs + TNFαi 2) double corticosteroid dose 3) IV antibiotics (2 weeks) (after fluid aspiration) 4) NSAID surgery 1) joint drainage ```

Question 71

Osteomyelitis - Description

Answer 71

infection of bone and/or bone marrow

Question 72

Osteomyelitis - Causes (5)

Answer 72

1) Staphylococcus aureus (90%) 2) Streptococci 3) Pseudomonas 4) Escherichia coli

Question 73

Osteomyelitis - Risk Factors (5)

Answer 73

1) trauma (penetrating) 2) surgery (contamination) 3) IV drug abuser 4) diabetes mellitus 5) peripheral vascular disease

Question 74

Osteomyelitis - Routes (3)

Answer 74

1) direct (e.g. trauma, surgery) - common 2) contiguous (e.g. DM, PVD) 3) haematogenous (skin—>blood—>bone) - rare

Question 75

Osteomyelitis - Symptoms (9)

Answer 75

1) dull pain at infection site 2) infection site swelling 3) infection site tenderness 4) infection site erythema 5) infection site warmth 6) fever 7) fatigue 8) malaise 9) draining sinus tracts (chronic)

Question 76

Osteomyelitis - Complications (3)

Answer 76

1) septic arthritis 2) fracture 3) growth retardation

Question 77

Osteomyelitis - Investigations (3/3)

Answer 77

``` initial 1) FBC (leucocytosis - acute) 2) high CRP + ESR 3) x-ray (osteopenia) consider 1) bone MRI (marrow oedema) 2) bone marrow biopsy* 3) bone marrow culture* ```

Question 78

Osteomyelitis - Management (2/1/1)

Answer 78

``` conservative 1) monitor CRP + ESR 2) limb immobilisation medical 1) antibiotics (high dose) surgery 1) surgical debridement ```

Question 79

Systemic Lupus Erythematosus - Description

Answer 79

multisystemic inflammatory autoimmune disorder

Question 80

Systemic Lupus Erythematosus - Risk Factors (7)

Answer 80

1) 20-40 years old 2) female 3) family history 4) African/Asian descent in West 5) genetics 6) drugs (e.g. hydralazine, penicillamine) 7) smoking

Question 81

Systemic Lupus Erythematosus - Pathophysiology (7)

Answer 81

1) inefficient phagocytise removal of apoptotic cellular remnant bless 2) blebs transferred to lymphoid tissue 3) normally hidden nuclear antigens are recognised as foreign 4) antigens stimulate production of autoantibodies 5) autoantibodies either circulate or deposit in tissues 6) autoantibodies actuate complement system and neutrophil influx 7) multisystem inflammatory autoimmune disorder

Question 82

Systemic Lupus Erythematosus - Symptoms (8)

Answer 82

1) arthralgia (RA like) 2) seizures 3) psychosis systemic 4) fever 5) fatigue 6) weight loss 7) malaise 8) myalgia

Question 83

Systemic Lupus Erythematosus - Signs (7)

Answer 83

1) butterfly erythema 2) photosensitive rash 3) discoid rash 4) oral ulcers 5) alopecia 6) vasculitic lesions 7) Raynaud’s pheno (digit colour change to red—>white—>blue due to artery spasm)

Question 84

Systemic Lupus Erythematosus - Complications (7)

Answer 84

1) anaemia (chronic haemolytic) 2) pericarditis/myocarditis/endocarditis 3) cardiovascular disease 4) pleuritis/pleural effusion 5) nephritis 6) vasculitis 7) depression

Question 85

Systemic Lupus Erythematosus - Investigations (7/1)

Answer 85

initial 1) anti-nuclear antibodies (95% positive) 2) anti-dsDNA antibodies (60% positive, highly specific) (confirmation) 3) anti-Smith antibodies (confirmation) 4) FBC (anaemia, leucopenia, thrombocytopenia) 5) normal CRP 6) high ESR 7) UnE (high urea, creatine) consider 1) any test that confirms complications

Question 86

Systemic Lupus Erythematosus - Monitoring (3)

Answer 86

1) anti-dsDNA antibodies 2) C3 + C4 levels 3) ESR

Question 87

Systemic Lupus Erythematosus - Management (4/6/0)

Answer 87

conservative 1) monitor 2) high factor sunscreen 3) weight loss (CVD risk) 4) smoking cessation (CVD risk) medical 1) hydroxychloroquine (arthralgia, fatigue, skin disease) 2) NSAID (arthralgia, fever) 3) PO/IM corticosteroid (arthralgia, serositis) 4) TOP corticosteroid (rash) 5) immunosuppressant (e.g. methotrexate, azarthioprine) 6) cyclophosphamide (neuropsychotic symptoms, nephritis)