Rheumatology workbook

Question 1

Which features support a diagnosis of RA

Answer 1

MCPs/PIPs, symmetrical, FH, (bully in a playground)

Question 2

Can you see gout on x ray

Answer 2

No

Question 3

Which joint is usually spared in RA and more indicated in OA

Answer 3

CMC spared (thumb)

Question 4

Which joints apart from hands are routinely affected in RA

Answer 4

Feet - MTP
Wrist
Elbows
(Knees and shoulders less common)

Question 5

Classical examination findings in RA

Answer 5

Ulnar deviation, soft tissue swelling and tenderness

Rheumatoid nodules, swan neck and boutonnière deformity,

Question 6

Multisystem problems in RA

Answer 6

CAPS
Carpel tunnel syndrome
Anaemia/amyloidosis/Atlanta-axial involvement
Pleurisy/pleural effusion/pulmonary nodules/fibrosis/progressive broncholitis obliterans
Sjogren’s syndrome

Question 7

Which investigations would further help with RA diagnosis

Answer 7

Rheumatoid factor anti-CCP
USS/MRI

Question 8

Radiological features of RA vs OA

Answer 8

RA:
Loss of joint space
Erosions (Periarticular)
Soft tissue swelling
Subluxation/see through bones

OA:
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 9

Treatment options for RA

Answer 9

DMARD monotherapy
TNF inhibitors (infliximab)
CD20 inhibitors (Rituximab)
JAK inhibitors/CTLA inhibitors

Steroids (prednisolone) and symptoms control with NSAIDS

Question 10

Which monitoring is required when using RA treatments long term

Answer 10

Check FBC for anaemia, and liver function tests

EGFR

Question 11

Which features distinguish RA from other arthritidies

Answer 11

Stiffness in the morning for over 30 minutes
Systemic symptoms
Symmetrical
FH strong

(Starts in small joints, insidious onset, better with NSAIDs)

Question 12

Pattern of stiffness in OA

Answer 12

Less than 5 mins

Question 13

Acronym for lupus

Answer 13

Question 14

Investigations for lupus

Answer 14

Raised ESR, ANA positive (ro or la), C3 and C4 fall, urinalysis, skin biopsy, thrombocytopenia FBC

Question 15

Treatment options for SLE

Answer 15

Short courses of prednisolone for flare ups
Hydroxychloroquine for rash and arthalgia

Mycophenolate mofetil, Rituximab, and cyclophosphamide induces remission

Azathioprine

Question 16

What type of disease is ankylosing spondylitis

Answer 16

Seronegative spondyloarthropathy

(RF negative)

Question 17

Pattern of back pain in ankylosing spondylitis

Answer 17

Inflammatory back pain (worse at rest)

Question 18

SPINE ACHE what is it

Answer 18

Pneumonic for seronegative spondyloarthropathy

Question 19

What does SPINE ACHE stand for

Answer 19

Sausage digits (dactilytis)
Psoriasis
Iritis
NSAIDs help
Enthesitis (inflammation where ligaments join bone)

Arthralgia
Crohns
H
Elevated inflammatory markers

Question 20

Why do you get reduced chest expansion in ankylosing spondylitis

Answer 20

Costochondritis

Question 21

Typical presentation and examination of ankylosing spondylitis

Answer 21

Mid thirties male, loss of lumbar lordosis, reduced chest expansion

Positive Schober’s test

Question 22

What is Schobers test

Answer 22

Draw a horizontal line 10cm above and 5cm below PSIS

Measures degree of lumbar forward flexion as you bend forward and is positive if limited motion (distance increase over 20cm)

Question 23

Types of SS

Answer 23

SPEAR

Spondyloarthropathy in juveniles
Psoriatic arthritis
Enteropathogenic arthritis
Ank spond
Reactive arthritis

Question 24

Reactive arthritis features

Answer 24

Cant see, can’t pee, can’t climb a tree

uveitis, urethritis, arthritis

Question 25

Examination findings in SS

Answer 25

reduced neck movement Positive FABERs

Question 26

What is FABERs

Answer 26

Tests for flexion, abduction and external rotation

Question 27

What investigations would further help with diagnosing Ankylosing Spondylitis

Answer 27

MRI spine and sacroiliac joints X-ray of sacroiliac joints (check for pelvic narrowing)

Question 28

Genetics with ankylosing spondylitis

Answer 28

HLA-B27 gene variant

Question 29

Complications of ankylosing spondylitis

Answer 29

Anterior uveitis/(apical fibrosis/aortic incompetence)/abdominal colitis/Atlanta-axial involvement 1/2 patients have substantial colitis (IBD) Spine fusion causing kyphosis, joint damage and reduced flexibility, osteoporosis and spinal fractures Heart disease and stroke Psoriasis

Question 30

What treatments are available for Ankylosing spondylitis

Answer 30

NSAIDs first line for pain management Physiotherapy to improve mobility TNF inhibitors and IL-17 inhibitors JAK inhibitors

Question 31

What features support a diagnosis of gout

Answer 31

Male over 40, pain, redness

Question 32

Clinical findings in gout

Answer 32

Fever, joint swelling/warmth/redness, tophi, ocular findings include MSU crystal deposition,

Question 33

Common causes and associations of gout

Answer 33

Increased purine uptake/alcohol/high fructose intake/energy drinks Obesity/congestive heart failure/coronary artery disease/smoking/DM/diuretics

Question 34

Key points in gout

Answer 34

Question 35

Which investigations help with making a diagnosis of gout

Answer 35

MSU crystals found in synovial fluid aspirate Blood test to measure uric acid levels X-ray to exclude other things

Question 36

Which treatment options are available for patients with gout

Answer 36

Acute: NSAIDs, steroids, colchicine Chronic: ULT (allopurinol and febuxostat)(xanthine oxidase inhibitors)

Question 37

Joint pain schematic

Answer 37