Tutorial 1

Question 1

Arthralgia vs arthritis

Answer 1

Arthralgia = pain in the absence of swelling
Arthritis - swelling

Question 2

Four pain differentials

Answer 2

Osteoarthritis - middle aged
RA - can present at any time, F
Spondyloarthritis - younger males, hx of psoriasis
Crystal arthritis - gout - mono sodium urate crystals in middle aged men, CPPD - no longer called pseudogout - calcium pyrophosphate crystals

Question 3

Hx taking for joint problems

Answer 3

Affected joints - small vs large, axial vs peripheral
Symptoms
Severity of pain
Preceding infection or event
Exacerbating and relieving factors
Response to analgesics or NSAIDs
Constitutional symptoms
FH for HLA B27 disease
SH - occupation, smoking, alcohol
Sexual history - reactive arthritis
Travel hx - Lyme disease or TB
DRUGS

Question 4

Inflammatory vs mechanical cause - how would you differentiate with symptoms

Answer 4

Inflammatory:
Worse in morning
Better with activity

Mechanical:
Opposite to above

Question 5

Systems review questions

Answer 5

Systems symptoms - fever or sweats
Malaise and fatigue
B symptoms and weight loss
Symptoms suggestive of connective tissue disease

Question 6

Key PMH

Answer 6

Psoriasis, iritis, IBD - HLA 27
Other autoimmune or auto inflammatory diseases - DM, thyroid
Hep c - poly arthritis nodosa
HIV - Arthralgias

Question 7

Which drugs could impact rheum conditions

Answer 7

Diuretics - risk of gout
Anticoagulation - risk of haemarthrosis
Immunosuppression - septic arthritis
Steroids - risk of septic arthritis
Statins - myalgias
Anti-oestrogen treatment

Question 8

Vasculitis

Answer 8

Takayasu arteritis - younger women - hands above head, pain
Lupus - younger women

Systemic sclerosis - middle aged women
Sjogren’s - middle aged women

GCA - over 50s

Answer 9

Send for immunofluoresence

Question 10

Lupus symptoms

Answer 10

Joint symptoms
Photosensitive rash - a rash on sun exposed areas
Raynauds
Hair fall - when you wake up in the morning and the pillow has had a hair transplant
Mouth ulcers and genital ulcers

Question 11

Behçet’s disease

Answer 11

Perianal ulcers

Question 12

Crest - anti-centromere
Systemic - anti-scl70
Limited
Diffuse

Answer 12

Limited - raynaulds for a long time

Systemic sclerosis
Skin features - tightening, telangiectasia, calcinosis, reduced mouth opening
Raynaulds, finger

Question 13

Sjogren’s

Answer 13

Dry eyes
Dry mouth
Overwhelming fatigue
Gum disease
Poor dentition
Swelling of glands
Joint symptoms

Anti-Ro, anti-La

Question 14

If Sjogren’s serology is negative, what is the most likely condition for these symptoms

Answer 14

Keratoconjunctival sicca

Question 15

Idiopathic immune myosotis

Answer 15

Weakness rather than pain - different from PMR

Muscle pain and weakness, proximal > distal,

Myositis

Muscle
Lung
Skin

Dermatomyositis -

Answer 16

Inclusion body myositis - cancer

Question 17

GCA - large vessel arthritis

Answer 17

Temporal headache
Jaw claudication - pain after chewing

Pain during chewing = tMJ dysfunction

Visual symptoms
Polymyalgic features

Question 18

Polymyalgia rheumatic a

Answer 18

Stiffness and pain more than weakness
Shoulder and hip pain and stiffness
Difficulty dressing

Question 19

Small vessel vasculitis

Answer 19

Purpuric rash
Upper airway involvement - see below
Respiratory symptoms
Haemturia/frothy urine
Ankle swelling
Mononeuritis multiplex

Granulomatosis - upper airway, epistaxis, sinusitis

EGPA - lower resp - untreatable asthma

Same risk of renal disease

Question 20

Key question for connective tissue disease

Answer 20

Multiple pregnancy losses

Answer 21

RA
Thyroid disease
IBD
T1DM
Endocrine disorders
SpA

Question 22

Gynaecology questions for osteoporosis

Answer 22

Menarche - over 16 years
Menopause - under 48
Periods of amenorrhoea - pregnancy or anorexia

Question 23

Drugs predisposing for osteoporosis

Answer 23

Steroids
Antidepressants
Anticonvulsants
ARTs
Gonadotropin therapy - men, prostate cancer
Anti oestrogens

Question 24

FH questions for osteoporosis

Answer 24

Parental hip feature
Any FH

Question 25

Osteoporosis life style questions

Answer 25

Calcium intake
Vit D
Exercise - weight bearing, high impact fast walking
Smoking
Alcohol

Question 26

Key drugs to ask about in osteoporosis

Answer 26

Any swallowing problems or any GI problems - not good for alendronic acid as it can erode through the oesophagus if not swallowed properly

Renal problems

Question 27

Antibodies

Answer 27

Super high RA - Sjogren’s
Hx of lupus, high crp and low esr - infection
Low crp high esr - lupus flare