Year 5 – Ortem – Rheumatology 2

Front 1

Name 2 large vessels, 2 medium vessels, 2 small vessels (ANCA positive), and 2 small vessels (ANCA negative) vasculitides.

Back 1

Large

Giant cell arteritis

Takayasu arteritis

Medium

Polyarteritis nodosa

Kawasaki disease

Small ANCA+

Granulomatous polyangiitis

Microscopic polyarteritis

Small ANCA-

Hypersensitivity

Henoch-Schonlein purpura

Churg-Strauss

Cryoglobulinaemia

Infections

Neoplasms

Autoimmune

Front 2

What is Wegener's granulomatosis

Back 2

The past name of granulomatous polyangiitis

Front 3

What vessels are affected by GCA?

Back 3

Largest in the body (eg aorta and carotids)

Front 4

Name one condition with a significant overlap with GCA

Back 4

Polymyalgia rheumatica (50% patients with GCA have PMR and 20% patients with PMR have GCA)

Front 5

3 main symptoms of GCA

Back 5

Headache

Scalp tenderness (pain when combing)

Jaw claudication (chewing fatigue)

Visual disturbance (central or amaurosis fugax)

Front 6

Two investigations in GCA

Back 6

CRP/ESR

Temporal artery biopsy

Front 7

Treatment of GCA (including dose)

Back 7

Steroids (high dose – 1mg/kg/day up to a max of 60mg/kg/day)

Bone protection (alendronate, Vit D, Ca)

Gastroprotection

Front 8

Demographic most affected by Takayasu arteritis

Back 8

Young Japanese women

Front 9

How does Takayasu arteritis present?

Back 9

Signs, symptoms and complications of vascular blockage

Absence of pulses

Bruits

Claudication

Loss of vision

Stroke

as well as dramatic weight loss and constitutional upset

Front 10

Treatment of Takayasu arteritis

Back 10

Steroids and cyclophosphamide (think of it as even more dramatic than GCA and therefore requiring even more potent treatment)

(like PAN, granulomatous polyangiitis and microscopic polyangiitis)

Front 11

P/C

Malaise

Weight loss

Cough productive of blood-stained sputum

Acute renal failure

History

Never smoked

TB unlikely

CXR

Cavitating lesions in both upper lobes

Likely diagnosis and first test for investigation?

Back 11

Granulomatous polyangiitis ⇒ Test for ANCA

Front 12

Name of the sign and potential cause

Back 12

Coin lesion

Granulomatous polyangiitis

Front 13

Which vasculitis may present with positive Hep B antigen or antibody?

Back 13

Polyarteritis nodosa

Front 14

Patient presents with nephritic syndrome (oliguria, hypertension). Serum blood test is positive for ANCA. Likely cause?

Back 14

Vasculitis

Granulomatous polyangiitis

Microscopic polyangiitis (mPA)

Front 15

Patient presents with nephritic syndrome (oliguria, hypertension). Serum blood test is positive for ANA. Likely cause?

Back 15

SLE

Front 16

What tissues are mostly affected by polyarteritis nodosa (5)?

Back 16

Nerves

Intestinal tract

Kidney

Skin

Joints

Front 17

Name of the sign and disease where it occurs

Back 17

Rosary sign (chain of aneurysm – here in coronary vessels)

Polyarteritis nodosa

Front 18

What nerve disease occurs in polyarteritis nodosa?

Back 18

Mononeuritis mutliplex

Simultaneous or sequential involvement of noncontiguous nerve trunks, evolving over days to years and typically presenting with acute or subacute loss of sensory and motor function of individual nerves.

Front 19

Investigations in polyarteritis nodosa (3)

Back 19

ESR

Hep B positive

Angiography (microaneurysm and occlusions)

Biopsy

All serology is negative !

Front 20

Treatment of polyarteritis nodosa

Back 20

Steroids

Cyclophosphamide

(like Takayasu, granulomatous polyangiitis and microscopic polyangiitis)

Front 21

T/F: PAN presents with positive ANCA

Back 21

False (ANCA is a feature of some small vessel vasculitis, not medium vessels)

Front 22

What demographic is affected by Kawasaki disease?

Back 22

Children

Front 23

Name of the sign and disease where it occurs

Back 23

Strawberry tongue

Kawasaki disease (think of children who like strawberries)

Note also the fissuring lips that is another sign of Kawasaki disease

Front 24

Most feared complication of Kawasaki disease

Back 24

Coronary arteritis

Front 25

What organs are typically affected by Kawasaki disease?

Back 25

All

Front 26

Treatment of Kawasaki disease (2)?

Back 26

Aspirin

IV Ig

Front 27

5 clinical features of Kawasaki disease

Back 27

Strawberry tongue

Fissuring/Crusting lips

Fever

Conjunctivitis

Lymphadenopathy

Palmar erythema and dry hands

Front 28

Significance of raised ANCA?

Back 28

Small vessel vasculitis, mostly

Granulomatous polyangiitis

Microscopic polyangiitis

Front 29

What does ANCA stand for?

Back 29

Anti-neutrophil cytoplasmic antibody

Front 30

Name two types of ANCA and their significance in diagnosis of small vessel vasculitis

Back 30

cANCA – Granulomatous Polyangiitis

pANCA – Microscopic Polyangiitis

(think of proximity of letters in the alphabet)

Front 31

How does granulomatous polyangiitis present?

Back 31

Classic triad

Upper airway – sinusitis/otitis media unresponsive to treatment

Lower airway – pulmonary haemorrhage

Renal disease – Glomerulonephritis

Front 32

What investigations would you consider in a patient with granulomatous polyangiitis (4)?

Back 32

ESR/CRP

cANCA

CXR

CT sinuses

Front 33

What marker correlates with activity of disease in granulomatous polyangiitis?

Back 33

cANCA

Front 34

Treatment of granulomatous polyangiitis

Back 34

Steroids

Cyclophosphamide

(like Takayasu, PAN and microscopic polyangiitis)

Front 35

Treatment of microscopic polyangiitis

Back 35

Steroids

Cyclophosphamide

(like Takayasu, PAN and granulomatous polyangiitis)

Front 36

Treatment of the following vasculitides:

GCA

Takayasu

PAN

Kawasaki

Granulomatous polyangiitis (gPA)

Microscopic polyangiitis (mPA)

ANCA negative small vessel vasculitides

Back 36

GCA

Steroids

Takayasu, PAN, gPA, mPA

Steroids

Cyclophosphamide

Kawasaki (think kids)

Aspirin

IV Ig

ANCA negative

Consider steroids

Front 37

Besides the classic triad, what other organ may be affected by granulomatous polyangiitis?

Back 37

Skin (gange

Joints

Neuro

Front 38

How does microscopic polyangiitis present?

Back 38

Renal disease

Pulmonary haemorrhage

Gangrene

Stroke and MI

Bowel infarcts

Front 39

Compare gPA and mPA in terms of their impact on lungs, URT, kidneys, joints, skin, histology, CV, GI

Back 39

Front 40

Demographics most affected by Henoch-Schonlein purpura

Back 40

Children

Front 41

3 main symptoms of Henoch-Schonlein purpura and main complication

Back 41

Symptoms

Purpura

Arthralgia

Abdominal pain

Main complication

Renal failure

Front 42

What class of antibodies causes Henoch-Schonlein?

Back 42

IgA

Front 43

Pathogenesis of Henoch-Schonlein?

Back 43

Immune complexes deposition containing IgA

Front 44

Pathogenesis of cryoglobulinaemia

Back 44

Cryoglobulins are proteins that precipitate at low temperatures blocking blood vessels

Front 45

How does cryoglobulinaemia present? What other disease presents similarly? How do they differ?

Back 45

Purpura, Arthralgia, Glomerulonephritis

Similar to Henoch-Schonlein purpura but

1) CG mostly affects adults while HSP mostly affects kids

2) CG does not present with abdo pain

3) CG is often caused by Hep C

Front 46

What causes cryoglobulinaemia?

Back 46

Usually Hep C

Front 47

A patient presents with vasculitis and asthma and eosinophilia. Diagnosis?

Back 47

Churg-Strauss sydnrome

Front 48

Which vasculitis can be caused by Hep C?

Back 48

Cryoglobulinaemia

Front 49

Which vasculitis is associated with asthma?

Back 49

Churg-Strauss syndrome

Front 50

Which vasculitis occurs in children and associated with abdo pain?

Back 50

Henoch-Schonlein purpura

Front 51

RF for gout (7)

Back 51

Unmodifiable

Male

Family history

Production ➚

Alcohol

Polycytaemia rubra vera

Haemolysis

Surgery

Rich diet (red meat)

Chemotherapy

Excretion ➘

Alcohol

Renal failure

Diuretics (thiazide)

Dehydration

Front 52

3 clinical features of gout

Back 52

Monoarthropathy (acute)

Renal impairment (uric acid stones and Calcium oxalate stones)

Skin tophi

Front 53

Where do skin tophi occur in gout (2)?

Back 53

Extensor tendons and tip of ear

Front 54

Investigation in gout (1)

Back 54

Joint aspirate

Needle shaped crystals with negative birefringement

Front 55

Treatment of gout:

Acute – 1st, 2nd and 3rd line

Long-term

Back 55

Acute

NSAIDs

Colchicine

Steroids (local or systemic)

Long-term

Allopurinol

Front 56

What should we be careful about when giving allopurinol?

Back 56

It may initially precipitate symptoms so give with colchicine or NSAIDs for first 6 weeks

Front 57

Characterise and distinguish the presentations of polymyositis and dermatomyositis

Back 57

Polymyositis

Proximal muscle weakness

Dermatomyositis

Polymyositis + Rash

Front 58

Pathogenesis of polymyositis and dermatomyositis

Back 58

Polymyositis

T–cell infiltration in muscles

Dermatomyositis

T–cell infiltration in muscles

Antibody and complement deposition in the skin

Front 59

Investigation of polymyositis and dermatomyositis and how these relate to pathogenesis (3)

Back 59

CRP/ESR ➚

Creatine kinase ➚ (due to muscle damage)

ANA +ve (in 50% of patients)

Anti–Jo1 +ve (if lung involvement)

Muscle biopsy

Front 60

3 rashes in dermatomyositis

Back 60

Shawl-like rash

Lilac-coloured rash (mostly around eyes)

Gottron's papules (raised erythema over MCP and PIP)

Linear erythema on fingers

Front 61

Besides the rash, what do patients with dermatomyositis complain of?

Back 61

Profound proximal weakness with little pain

Examples: difficulty putting up laundry, combing hair, getting out of chair, going up the stairs

Front 62

Treatment of dermatomyositis

Back 62

Steroids (IV if severe)

Front 63

How does polymyalgia present?

Back 63

A bit like fibromyalgia but more focal and with low-grade fever and anaemia

Front 64

T/F: The diagnosis of osteoporosis is based on a z-score < -2.5

Back 64

False: the diagnosis is based on difference with bone mass density at peak age (t-score) rather than at similar age (z-score)

Front 65

BMD on DXA shows a t-score of -2.2. Diagnosis?

Back 65

Osteopenia

Anything between -1.0 and -2.5

Front 66

Disease

Back 66

Scleroderma

Front 67

What is definitely affected in scleroderma? What is variably affected?

Back 67

Definitely – Skin (Thickening and fibrosis)

Variably – Internal organ

Exception: scleroderma sine scleroderma (only organs)

Front 68

Incidence of scleroderma

Back 68

Very rare (20/1,000,000/year)

Front 69

Distinguish limited and diffuse scleroderma in terms of:

Skin involvement

Raynaud's phenomenon onset

Pulmonary fibrosis

Pulmonary hypertension

Renal crisis

Antibody present

Back 69

Front 70

Name the 3 organ most commonly affected by limited and diffuse scleroderma alike

Back 70

Hands, Raynaud's phenomenon (95%)

Skin (90%)

Oesophagus (80%)

Front 71

First symptom of scleroderma

Back 71

Raynaud's phenomenon

Front 72

Sequence of colour change in Raynaud's

Back 72

White, Blue, Red

Front 73

4 triggers of Raynaud's phenomenon

Back 73

Cold

Change in temperature

Stress

Vibration

Front 74

Back 74

Raynaud's phenomenon

Front 75

Characterise the skin disease in scleroderma (distribution, initial presentation, later presentation)

Back 75

Symmetrical

Initially: oedema

Later: fibrosis with subcutaneous atrophy

Front 76

Name two skin complications of scleroderma

Back 76

Ulcers at end of fingers (very painful)

Depigmentation

Front 77

Back 77

Facial scleroderma

Front 78

Name 5 clinical features of scleroderma

Back 78

CREST

Calcinosis (deposition of Ca in the skin)

Raynaud's
Esophegeal dysfunction
Sclerodactyly (skin thickening in fingers)
Telangiectasia

Front 79

Why is calcinosis concerning in scleroderma?

Back 79

Because it may damage a nerve

Front 80

What might you hear on auscultation of the lungs in scleroderma?

Back 80

Bibasal inspiratory 'Velcro' crepitations

indicating pulmonary fibrosis (hence more likely in diffuse scleroderma)

Front 81

What might you see on pulmonary function test in scleroderma?

Back 81

FVC ➘➘

FEV1 ➘

FEV1/FVC > 0.8

Diffusion capacity ➘

Front 82

What oesophageal symptoms occur in scleroderma?

Back 82

Dysphagia and dyspepsia

Front 83

Besides oesophagus, what GI disease occur in scleroderma (3)

Back 83

Delayed motility

Fibrosis ⟹ Decreased colonic flexibility ⟹ diverticula

Anorectal dysfunction ⟹ Faecal incontinence

Front 84

Why might a patient with scleroderma have malignant hypertension? What is the prevalence of this condition?

Back 84

Renal crisis (20% of patients with scleroderma)

Front 85

Strategy for the management of scleroderma

Back 85

Symptomatic and aim to treat complications

(Immunosuppression has no effect)

Front 86

T/F: Immunosuppression is effective in scleroderma

Back 86

False

Front 87

Treatment of Raynaud's phenomenon (4 steps)

Back 87

1) Cold avoidance (gloves & hat)

2) Oral vasodilator

a) CCB (Amlodipine or nifedipine)

b) ACEI

3) IV vasodilator

4) Sympathectomy

Front 88

Treatment of pulmonary fibrosis in scleroderma

Back 88

IV cyclophosphamide

Front 89

Treatment of renal crisis in scleroderma

Back 89

ACEI

Renal replacement therapy if necessary

Front 90

Patient has dry eyes and dry mouth. He has a PMH of SLE. What is the likely diagnosis?

Back 90

Sjögren's syndrome

Front 91

Pathogenesis of Sjögren's syndrome

Back 91

Lymphocytic infiltration of glandular organs

Front 92

Demographics most affected by Sjögren's

Back 92

50 yo female

Front 93

Serology of Sjögren's

Back 93

ANA +ve ➙ Anti Ro/La

Front 94

Particular severe complication of Sjögren's

Back 94

Lymphoma (x 40)

Lifetime risk 8%

Front 95

Treatment of Sjögren's

Back 95

Lubricants (eg eye drops)

NSAIDs

HCQ

Front 96

Serology in scleroderma

Back 96

Anti-Scl70 (diffuse)

Anti-centromere (limited)

Front 97

Clinical sign of pulmonary hypertension (as useful in limited scleroderma)

Back 97

Raised JVP with cannon a-waves

Front 98

Besides examination and LFT, what other investigation may you organise for a patient with scleroderma and respiratory symptoms?

Back 98

Echocardiogram to check for right-sided heart failure

Front 99

Significance of positive RNP in lupus

Back 99

Worse prognosis

Front 100

Significance of anti-histone antibodies in lupus

Back 100

Likely drug-induced lupus

Front 101

One possible sign of GCA on ophthalmoscopy

Back 101

Pale retina due to ischaemia

Front 102

What do you examine for in suspected GCA

Back 102

Temporal artery tenderness

Facial artery tenderness (1/3 on mandibular edge from ear)

Front 103

72 year old lady had headache and pain when combing. On further questioning she tells you that she also has muscle fatigue when chewing. Bloods reveal raised CRP. Temporal artery biopsy is negative. Likely diagnosis?

Back 103

GCA – Negative biopsy may be due to skip lesions

Front 104

Pattern recognition

Claudication in a young (20s-30s)

Back 104

Takayasu

Front 105

Pattern recognition

Pulseless

Back 105

Takayasu

Front 106

One sensitive sign of Takayasu

Back 106

Subclavian bruit

Front 107

Distinguish appearance of Takayasu and atheroma on angiogram

Back 107

Much neater and symmetrical over a cross section of the artery than atheroma and with lots of collateral vessels because patients are otherwise young and healthy

Front 108

T/F: PAN may present with synovitis

Back 108

False, only arthritis

Front 109

Patient is not cold. Name the sign and 2 differentials

Back 109

Livedo reticularis

SLE (antiphospholipid syndrome)

PAN

Front 110

Impact of PAN on:

Muscle

Joints

Skin

Nerve

Lung

Kidney

GI

GU

Back 110

Muscle – Myalgia (but not myositis)

Joints – Arthritis (but no synovitis)

Skin – Livedo reticularis

Nerve – Mononeuritis Multiplex

Lung – None

Kidney – Failure

GI – Mesenteric ischaemia

GU – Orchitis (sterile)

Front 111

How does Mesenteric ischaemia present?

Back 111

Pain after meal

Front 112

What does cANCA and pANCA refer to?

Back 112

Cytoplasmic ANCA

Perinuclear ANCA

The difference can be visualised on microscope.

Front 113

What part of the body is best at distinguishing granulomatous polyangiitis from microscopic polyangiitis? How?

Back 113

Nose – Affected only in GPA

Epistaxis, nasal crusting, discharge, collapsed nose septum

Front 114

3 ΔΔ for collapsed nose septum

Back 114

GPA

Cocaine use

Congenital syphilis

Front 115

Why may patients with granulomatous polyangiitis have deafness?

Back 115

Conductive – Upper airway disease

Sensory – Mononeuritis multiplex

Front 116

Pattern recognition

Adult onset asthma

Back 116

Churg-Strauss

Front 117

Pattern recognition

Palpable purpura, sky high Rheumatoid factor

Back 117

Cryoglobulinaemia (RF is even higher than in RA)

Front 118

Name of the sign. In what disease does it occur?

Back 118

Hyperaemic nail bed

Dermatomyositis

Front 119

Besides the rash and muscle weakness, what other two features may be present in dermatomyositis

Back 119

GI

Dysphagia (indicates a bulbar involvement and may cause aspiration)

Lung

Diaphragmatic weakness causing orthopnoea

Interstitial lung disease (if ANA +ve – Anti-Jo1) ➙ Very poor prognosis

Front 120

3 investigations and their results in dermatomyositis

Back 120

ESR/CRP ➚

CK ➚

ANA +ve (Jo-1)

Front 121

Most common rheumatological disease in kids

Back 121

Juvenile idiopathic arthritis

Front 122

At what ages does juvenile idiopathic arthritis (JIA) develop?

Back 122

Before 16

Front 123

Outline the ILAR classification of JIA (6). Which is most common?

Back 123

◾ Systemic onset JIA (SOJIA)

◾ Oligoarticular (persistent or extended) – Most common

◾ Polyarticular (RF + or -)

◾ Psoriatic

◾ Enthesitis related

◾ Undifferentiated

Front 124

Define diagnosis of systemic JIA

Back 124

Arthritis with or preceded by a fever and accompanied one or more of:

◾ Evanescent rash (ie transient)

◾ Lymphadenopathy

◾ Hepatosplenomegaly

◾ Serositis

Front 125

What defines oligoarticular JIA?

Back 125

≤ 4 joints affected for the first 6/12 regardless of the number of joints eventually affected

Front 126

3 year old girl has arthritis in the left ankle, right knee and left hip which has been symptomatic for 2/12. Likely diagnosis (as precise as possible)

Back 126

Oligoarticular JIA

Front 127

4 year old girl has had arthritis in the left ankle, right knee and left hip which has been symptomatic for 2/12 last year. She now presents with a 1/12 history of arthritis in most joints. Likely diagnosis (as precise as possible)

Back 127

Extended oligoarticular JIA

(It is still oligoarticular JIA since what matters is the first 6/12 but is called extended because more joints are now affected)

Front 128

Serology of JIA

Back 128

Oligoarticular

ANA + or -

Polyarticular

RF + or -

Front 129

3 RF for chronic anterior uveitis in oligoarticular JIA

Back 129

ANA +ve

Girls

< 8 years

Front 130

3 complications of anterior uveitis

Back 130

Cataract

Glaucoma

Cystoid macular oedema

Front 131

4 year old girl has had arthritis in most joints of the lower limbs for 2/12 . Likely diagnosis (as precise as possible)

Back 131

Polyarticular JIA

Front 132

Which joints are affected in polyarticular JIA and how does age influence this?

Back 132

Younger ⟹ Large joints

Older ⟹ Small joints

Front 133

3 year old girl has arthritis in the left ankle, right knee and left hip which has been symptomatic for 2/12. Her mother has psoriasis. Likely diagnosis (as precise as possible)

Back 133

Oligoarticular JIA

Front 134

3 year old girl has arthritis in the left ankle, right knee and left hip which has been symptomatic for 2/12. O/E, there is nail pitting. Her mother has psoriasis. Likely diagnosis (as precise as possible)

Back 134

Psoriatic JIA

Front 135

Define the diagnosis of psoriatic JIA

Back 135

A) Arthritis with psoriasis

B) Arthritis and ≥ 2 of:

◾ Dactylitis

◾ Nail pitting/Onycholysis

◾ Psoriasis in first degree relative

Front 136

T/F Psoriatic JIA involves that the patient has psoriasis

Back 136

F: patient can also have ≥2 of dactylitis, nail pitting/onycholysis, psoriasis in first degree relative

Front 137

Define the diagnosis of enthesitis related JIA

Back 137

A) Arthritis with enthesitis

B) Arthritis with ≥ 2 of:

◾ HLA B27

◾ First degree relative HLA B27

◾ Sacro-iliac joint tenderness or inflammatory spinal pain

◾ Anterior uveitis

◾ Boy > 8

Front 138

In what JIA can anterior uveitis occur?

Back 138

Oligoarticular JIA

Enthesitis-related JIA

Front 139

Main complication of JIA

Back 139

Leg length discrepancy

Front 140

3 causes of acute joint swelling in a child

Back 140

Trauma

Sepsis

ReA

Front 141

5 causes of chronic joint swelling in a child

Back 141

JIA

Other inflammation (sarcoid, SLE...)

Malignancy

TB

Haemophilia

Front 142

What is the key in the management of JIA to achieve good outcome?

Back 142

Diagnose early

Front 143

Medication ladder for JIA

Back 143

NSAIDs

Corticosteroids (injection or oral)

MTX and other DMARDs

Biologics

Front 144

Indications for MTX in JIA

Back 144

Either of:

Recurrent joint injections

Polyarticular JIA

Uncontrolled eye disease

Front 145

What biologics would you use in JIA

Back 145

Anti-TNF (Etanercept or adalimumab)

Anti-IL6 (Tocilizumab) for SOJIA

Front 146

How is uveitis diagnosed and managed in JIA?

Back 146

Screen every 3/12 (as it may be asymptomatic)

Managed with topical steroids and MTX

Multi-disciplinary team

Front 147

Name 6 polyarticular disease that may occasionally present as monoarthritis

Back 147

PsA

IBD

ReA

RA

JIA

Viral arthritis

Front 148

What organisms causing septic arthritis are most aggressive?

Back 148

Gram positive bacteria (eg staph, strep)

Front 149

Seven questions to ask in history of monoarticular disease and their significance

Back 149

A) HPC

Onset of pain?

◾ Sec - Min: trauma

◾ Hrs-Days: infection, crystal, inflammatory conditions, palindromic RA

◾ Days-Wks: mycobacteria, fungi, OA, tumour

Joint damage/overuse?

Other symptoms: rash, low back pain, diarrhoea, urethral discharge, conjunctivitis, mouth sores? (ReA, PsA, IBD)

Risk of infections (eg IVDU)?

B) PMH

History of similar episode in other joints?(crystals, inflammatory joint syndromes)

History of bleeding? Use of anticoagulants? (Haemarthrosis)

C) DH

Prolonged steroid use? (infection or osteonecrosis)

Front 150

T/F: fever with monoarthritis means septic arthritis

Back 150

No, many inflammation of the joint can present with fever and septic arthritis may present without

Front 151

Pattern recognition

Polyarticular migratory arthritis that then settles into one joint

Back 151

Gonococcal septic arthritis

Front 152

Pattern recognition

Monoarthritis with tender pustular lesions on an erythematus base and haemorrhagic papules

Back 152

Gonococcal septic arthritis

Front 153

Single most useful diagnostic study in the initial evaluation of monoarthritis

Back 153

Synovial fluid analysis

Front 154

4 reasons to do synovial fluid analysis in a patient with monoarthritis

Back 154

1) Confirm diagnosis of septic arthritis and identify organism

2) Confirm and treat crystal arthritis

3) Confirm haemarthrosis

4) Distinguish inflammatory from non-inflammatory arthritis

Front 155

What is arthrocentesis?

Back 155

Joint aspiration

Front 156

T/F: The following presentation rules out septic arthritis: patient presents with monoarthritis and joint aspirate reveals many negatively birefringent crystals.

Back 156

False: gout may coexist with infection

Front 157

Besides synovial fluid analysis, name 2 investigations that are almost always indicated in monoarthritis

Back 157

1) Radiograph of the joint
2) FBC (mostly for WCC)

Front 158

T/F: serum uric acid level is a relatively good marker of gout

Back 158

False: it is notoriously useless

Front 159

You suspect septic arthritis in a patient but you could not confirm it clinically. You have just sent blood and synovial fluid for cultutre. What do you do now?

Back 159

Start treating as if it was septic arthritis until culture results come back

Front 160

Name 5 chronic monoarticular arthritis (4 inflammatory and 1 non-inflammatory)

Back 160

Inflammatory

TB

Fungal

Spondyloarthropathies

RA (monoarticular presentation)

Non-inflammatory

OA

Front 161

Synovial fluid analysis in OA

Back 161

Normal (non-inflammatory)

Front 162

Besides adult onset asthma, name one symptom of Churg Strauss

Back 162

Nasal polyp

Front 163

Painful hands and knees with morning stiffness and history of miscarriages

Back 163

SLE

Front 164

What defines antiphospholipid syndrome?

Back 164

Antiphospholipid antibody positive and symptoms (DVT, PE)

Front 165

Impact of MTX on the lung. When can it occur?

Back 165

Pneumonitis (inflammation of the walls of the alveoli)

Present with: very dry cough, terrible exercise tolerance (Sats fall to 50% when walking for 200m), very rapid onset

Can occur at any stage of the course of MTX

Front 166

Two most specific features of RA on Xray

Back 166

Erosion

Periarticular osteopenia

Front 167

What part of LFT are you interested in when patients are on MTX?

Back 167

ALT and AST (both can go up)

Front 168

How are DMARDs most commonly administered

Back 168

Subcut

Front 169

T/F: When biologics are started, DMARDs can be stopped.

Back 169

False: DMARDs protect the biologic agent and so should be taken alongside. If DMARD was not tolerated (a valid reason to start biologics), then keep them at a low dose (10mg) just to keep the biologic protected.

Front 170

In which disease is HCQ not indicated?

Back 170

PsA as it causes more skin problems

Front 171

First question to ask in acute monoarthritis?

Back 171

Are you otherwise well (to investigate septic arthritis)

Front 172

When is "Rash? Bowel? Eyes?" most useful?

Back 172

In seronegative arthritis

Front 173

What is important to ask about the diet in gout?

Back 173

Red meat
Shellfish

Front 174

Three drugs to ask about in history of gout

Back 174

Aspirin

Thiazide diuretics

Chemo

Front 175

Management of septic arthritis

Back 175

Theatre, wash out, broad-spectrum ABx

Front 176

First question to ask in a patient in whom you suspect AS

Back 176

Family history

Front 177

Four extra-articular features of ankylosing spondylitis

Back 177

Aortic Regurgitation

Apical Scarring (fibrosis)

Achilles Tendinitis

Anterior Uveitis

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One investigation of choice in AS

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T2w MRI

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T/F: DMARD are useless for axial disease (eg AS)

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True

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What might you see in the hands of a patient with dermatomyositis (3)?

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Gottron's papules (raised erythema over MCP and PIP)

Linear erythema on fingers

Mechanical hands

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Sausage-like fingers

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RA – Rheumatoi nodules

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RA (Early stage) – Active synovitis

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Psoriatic arthritis – Sausage-like fingers and destroyed nails

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Scleroderma

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Why might a patient with dermatomyositis be SOB?

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Aspiration (oesophageal involvement)

Diaphragmatic paralysis

Interstitial lung disease (if anti-Jo-1 positive)

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Besides blood tests, name 2 tests that you might consider in dermatomyositis

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T2w MRI of the most affected part and biopsy

EMG (outdated but still in textbooks)

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What separates diffuse from limited scleroderma in terms of skin involvement

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Above the elbow ⟹ Diffuse

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pGALS: 3 screening questions to ask

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Do you have any pain or difficulty in moving your arms, legs, neck or back?

When you get dressed, are you able to do this yourself without any help?

Can you walk up and down the stairs without any problems?

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pGALS: what is the 3 fingers in the mouth test used for?

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Temporomandibular joint disease

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5 broad causes of limping and how they can be differentiated clinically

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LIMPS

Leg length discrepancy

Equal time spent on each limp

Incoordinated

Abnormal rhythm and controlled falls

Muscle weakness

Hip - Trenderlenberg's sign

Knee – Weak quads

Ankle – Lifts foot high in the air to avoid tripping

Pain

Shorter time spent on painful limb

Stiffness

Hip – Sway back and fort and hoist pelvis up

Knee – Swing leg out to the side

Ankle – Foot rocks forward from heel to toe