Rheumatology Long Case

Question 1

SLE (History)

Answer 1

1. Presenting symptom & organ involvement
   (Systemic, skin, sicca, pleurisy, renal, haem, miscarriages, vasculitis, Neuro)
2. RF (FHx, drugs - TNFi)
3. Ix (antibodies, complement, ESR, FBE, urine red cell cast/ PCR, kidney bx)
4. Progress and management
   - current disease activity
   - pregnancy
5. Complications from immunosuppression
6. Cardiovascular risk factors
7. Impact
8. Understanding of prognosis

Question 2

Ankylosing Spondylitis (History)

Answer 2

1. Presentation
   - age at diagnosis (<45)
   - inflammatory lower back pain
   - peripheral joints
   - enthesitis
   - extra-articular manifestations - uveitis, aortic regurgitation, pulmonary fibrosis
   - alternative diagnoses - reactive, psoriasis, IBD
2. Investigations
   - XRAY sacroiliac joints
   - MRI sacroiliac joints
   - HLAB27
3. Management
   - NSAIDs
   - exercise program
   - anti-TNF monoclonal antibody/IL-17
   - helpful?
   - response in markers of disease activity
   - joint surgery
4. Complications
5. Impact
   - on work
   - exercise
   - ADLs
   - limitations

Question 3

Ankylosing Spondylitis (Examination)

Answer 3

1. Inspection
   - kyphosis and loss of lumbar lordosis
2. Palpation
   - tenderness/spasm
   - ASIS spring - activity
   - Achilles’ tendinitis
   - Plantar fasciitis
   - Large joints
3. Function
   - Finger-nose distance
   - Lateral flexion, extension
   - Schober’s test
   - Occiput to wall distance
4. Extra-articular manifestations
   - chest expansion
   - AR, MVP
   - uveitis
   - IBD
   - psoriasis

Question 4

Rheumatoid arthritis (History)

Answer 4

1. Diagnosis
2. Risk factors
   - age
   - female
   - smoking
   - family history
   - autoimmune diseases
3. Presentation
   - oligo/symmetrical joint pain, stiffness
   - fatigue/anorexia
   - extra-articular manifestations (skin, ILD, cricoaryteroid, scleritis/sicca, pericarditis, renal, peripheral neuropathy, anaemia/Felty’s, vasculitic)
4. Investigations
   - FBE (anaemia)
   - RF titre
   - anti-CCP
   - ESR, CRP
   - XRAY of affected joints (erosion, juxta-articular osteopenia, narrowing, oedema)
5. Management
   - induce remission
   - smoking cessation
   - physiotherapy/splinting
   - DMARDs (MTX, sulfasalazine, HCQ, leflunomide, azathioprine)
   - biologics (TNF, tocilizumab, tofacinitib, rituximab)
   - steroids (bridge)
   - surgery (joint replacement)
6. Complications
   - complications of DMARDs - ulcers, CKD, hepatic, cytopenias, infection, pulmonary
   - complications of biologics - TB, hepatitis, infusion reaction, infection
7. Outlook
   - function
   - pain
   - fine-motor, mobility, work, ADLs
   - current disease activity (number of joints, active synovitis, duration/severeity of morning stiffness, function, systemic symptoms)

Question 5

RA (monitoring)

Answer 5

1. Education - review/symptoms
2. DAS28 score
3. FBE, CRP, ESR
4. Yearly XRAY
5. Bone health - Vit D, DEXA
6. Monitor for extra-articular
7. Monitor drug side effects
8. CV risk reduction
9. Infection risk reduction
   - vaccinations, prophylaxis, education

Question 6

RA (non-pharmacological & pharmacological)

Answer 6

1. Weight loss
2. Smoking cessation
3. Exercise programs
4. Splinting, OT
5. Rest
6. NSAIDs/steroids in acute
7. MTX + second DMARD
8. Add biologic to MTX (after 6months)

Question 7

Vasculitis (History)

Answer 7

1. Diagnosis
   - GCA
   - GPA
   - EGPA
   - MPA
   - PAN
2. Aetiology
3. Presentation
   - systemic symptoms
   - sinusitis
   - pulmonary
   - renal
   - neurological
   - cardiovascular
   - skin
   - haematological
4. Investigations
   - FBE
   - ESR
   - ANCA
   - UEC + urinalysis
   - LFT
   - CXR/HRCT
   - Biopsy
5. Management
   - steroids
   - cyclophosphamide
   - rituximab
   - azathioprine/MTX
   - PLEX
6. Complications
   - medication side effects
   - CVD
   - HTN
   - diabetes
   - infections
   - osteoporosis
   - malignancy
7. Outlook

Question 8

Complications of cyclophosphamide

Answer 8

1. Cytopenia
2. Infection
3. Infertility
4. Teratogenic
5. Haemorrhagic cystitis
6. Malignancy, bladder cancer
7. Hair loss

Question 9

Complications of steroid use

Answer 9

1. Diabetes mellitus
2. Infections
3. Osteoporosis
4. Neuro/psychiatric
5. Cataracts/glaucoma
6. Weight gain
7. Cushing’s
8. NASH
9. Skin changes

Question 10

Osteoarthritis

Answer 10

1. Diagnosis
2. Risk factors
   - age, female, family history
   - weight
   - occupation
   - joint injury
3. Presentation
   - pain, stiffness, functional limitation
   - erosive
   - weight bearing/generalized
4. Investigations
   - rule out RA
   - XRAY (LOSS)
5. Management
   - identify contributing factors
   - weight loss
   - exercise program
   - gait aids/splints/assistive devices
   - maximise function
   - topical analgesia
   - multimodal analgesia
   - surgical

Question 11

Antiphospholipid syndrome

Answer 11

1. Diagnosis
   - recurrent miscarriages
   - arterial or venous thromboses
   - antibodies
2. Risk factors
   - primary
   - secondary ?SLE related
3. Investigations
   - lupus anticoagulant
   - anti-cardiolipin
   - anti-B2 glycoprotein
   - autoimmune serology
   - imaging for thromboses
4. Management
   - anticoagulation (warfarin)
   - pregnancy counselling (clexane, aspirin, psychological)
5. Complications
   - bleeding
6. Outlook

Question 12

SLE

Answer 12

1. Diagnosis
2. Risk factors
   - young female, family history
   - TNF, procainamide, hydralazine
3. Presentation
   - malar rash
   - photosensitivity rash
   - cytopenias
   - lupus nephritis
   - neuropsychiatric
   - cardiac
   - respiratory
   - oral ulcers
   - APLS
   - miscarriages/pregnancy related issues
4. Investigations
   - FBE
   - CRP/ESR
   - DsDNA, Smith, ANA
   - C3, C4 levels
   - UEC
   - LFT
   - haemolysis screen
   - APLS screen
   - urinalysis
5. Management
   - education
   - aim for remission
   - sun screen, sun avoidance
   - Vit D, calcium
   - close monitoring
   - NSAIDs
   - steroids if severe
   - HCQ for all
   - azathioprine, MTX
   - cyclophosphamide
   - rituximab
   - warfarin for APLS
   - nifedipine for Raynaud’s
6. Complications
   - bull’s eye retinopathy (HCQ)
   - steroid complications
   - immunosuppression complications
7. Outlook
   - pregnancy
   - function
   - QOL

Question 13

SLE (Examination)

Answer 13

1. General - Cushing’s, mental state
2. Hands - vasculitis, rash, arthropathy
3. Arms - lived reticularis, purport, proximal myopathy, blood pressure
4. Head - alopecia, scleritis, ulcers, malaria rash
5. Cardiovascular
6. Respiratory
7. Hepatosplenomegaly
8. Synovitis/hip - aseptic necrosis
9. Ataxia
10. Urinalysis

Question 14

Scleroderma (History)

Answer 14

1. Diagnosis
   - limited or diffuse
2. Risk factors
   - medication induced sclerodactyly
3. Presentation
   - CREST
   - arthritis
   - renal crisis/CKD/hypertension
   - ILD/pulmonary hypertension
   - pericarditis/cardiomyopathy
   - dysphagia/SIBO/GORD
4. Investigations
   - FBE
   - ESR
   - anti SCL-70 diffuse
   - anti-centromere CREST
   - anti RNA polymerase renal crisis
   - IgG, ANA, RF
   - gastroscopy/manometry
   - HRCT, PFT
   - TTE/RHC/6MWT
5. Management
   - Raynaud’s - stop smoking, stop B blockers, avoid cold weather, nifedipine, prazosin, iloprost, methyldopa
   - arthritis - NSAIDs
   - GORD - PPI
   - SIBO - antibiotics
   - sicca - eye drops
   - lung dx - cyclophosphamide
   - early ILD/pericarditis/myositis - teroids
   - pulmonary hypertension treatment
   - captopril for renal crisis
6. Complications
   - side effects
7. Outlook
   - fine motor function
   - ADLs, work, pain

Question 15

Scleroderma (Exam)

Answer 15

1. CREST
2. Function/myopathy
3. Fixed flexion deformities/ arthropathy/ulcers/vasculitis
4. Blood pressure
5. ILD
6. Pulmonary hypertension
7. Cardiac failure
8. GI - cachexia
9. Urinalysis