A: Finals: Rheumatology

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Mike2556
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260871
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A: Finals: Rheumatology
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2014-02-08 22:21:39
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rheumatology orthopaedics
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Rheumatology and orthopaedics
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  1. Give 5 features of a typical presentation of rheumatoid arthritis
    • Found in DIP/PIP and MCP joints
    • Symmetrical
    • Pain and swelling
    • Early morning stiffness
    • Rheumatoid nodules
  2. Describe 5 hand deformities seen in rheumatoid arthritis
    • Subluxation: MCPs drawn out of sockets, usually radial-dorsal
    • Ulnar deviation: MCP deviation
    • Boutonniere: PIP flexion and DIP hyperextension
    • Swan neck: DIP hyperextension and PIP flexion
    • Z-thumb: Fixed flexion and subluxation of MCP, hyperextension of IP
  3. What 5 features may been seen in a hand x-ray in R.A?
    • Loss of joint space
    • Subluxation
    • Juxta-articular osteopenia
    • Bony erosions
    • Soft tissue swelling
  4. Give 4 other systems affected by R.A. and specific manifestations
    • Respiratory: Pulmonary fibrosis
    • Haematological: Anaemia
    • Cardiovascular: MI/CVA risk increased
    • Skin: Rheumatoid nodules
  5. Give a brief description of the diagnostic criteria in R.A
    • Number of small joints: 3/4 = 2/3 points
    • Number of large joints: 2 = 1 point
    • Low/high RF or ACPA = 2/3 points
    • 6 weeks or longer = 1 point
    • High ESR or CRP = 1 point
    • 6 or more means definite R.A
  6. Give 4 investigations useful in diagnosing rheumatoid arthritis
    • Bloods: ESR, CRP and Hb
    • Serology: Anti-CCP (80%), RF (70%) and ANA (30%)
    • Imaging: X-ray for baseline
    • Aspiration: Effusion and rule-out septic arthritis
  7. Give 6 considerations in the management of R.A
    • Analegesia: NSAIDs
    • Acute: Intra-articular corticosteroids
    • Long term: DMARDs to avoid corticosteroids
    • Physiotherapy: Maintain joint movement and muscle stiffness
    • Occupational therapy: Help with ADL
    • Restoration: Surgical reconstruction
  8. What are the differential diagnoses for acute joint pain and swelling? Give 5
    • Septic arthritis until proven otherwise
    • Osteoarthritis
    • Reactive arthritis
    • Gout
    • Pseudogout
  9. Give 5 risk factors for oestoarthritis
    • Obesity
    • Female
    • Hypermobility
    • Trauma
    • Occupation
  10. Give 5 red flags in back pain
    • <16 or >50 new onset pain
    • Neurological features (anal tone, urinary retention etc)
    • Worse at rest
    • Malignancy Hx
    • Steroid use
  11. What investigations are available in low back pain?
    • Only required if red-flags present or atypical presentation
    • Imaging
    • Bloods: FBC, ESR, bone profile for underlying condition
  12. Give 4 radiological features seen in oesteoarthritis
    • Narrowing of joint space
    • Osteophytes
    • Sub-chondral sclerosis
    • Sub-chondral cysts
  13. Give 4 signs and 4 symptoms of osteoarthritis
    • Signs:
    • - Crepitus
    • - Reduced range
    • - Effusion
    • - Muscle wasting

    • Symptoms:
    • - Pain
    • - Stiffness
    • - Instability
    • - Loss of function
  14. Give 4 considerations in the management of osteoarthritis
    • Analgesia: NSAIDs
    • Lifestyle change: Weight loss
    • Physiotherapy: Muscle strength and stability/walking aids
    • End-stage: Arthroplasty
  15. OSTEOARTHRITIS SURGERY
  16. Give 4 investigations used in suspected septic arthritis
    • Aspirate: Urgent microscopy, stain and culture
    • Blood cultures
    • Swab
    • Bloods: FBC and inflammatory markers to monitor improvement
  17. What is the acute management for septic arthritis?
    • General resuscitation
    • IV flucloxacillin and fucidin (erythro in allergy)
    • Analgesia
    • Drainage of joint/washout
  18. What is 'pseudogout'? How is it treated?
    • Calcium pyrophosphaste crystals are deposited in joints or extra-articular tissues
    • Crystals are rhomboid, unlike gout crystal
    • Treated similarly to gout
  19. What x-ray feature is seen in avascular necrosis of the femoral head?
    Well demarcated area of increased bone density in upper pole of femoral head
  20. Give 5 features of a typical gout presentation
    • Sudden onset
    • Agonizing pain
    • Swelling and redness
    • First MTP in 75%
    • Precipitated by excess food, alcohol or dehydration
  21. What investigations should be performed in suspected gout?
    • Aspirate: Joint fluid microscopy for crystals (and cultures for DDx)
    • Bloods: Serum uric acid, U+Es
  22. Give 4 medications which may be used in the management of gout
    • NSAIDs: Naproxen, diclofenac
    • Colchicine: Anti-inflammatory
    • Corticosteroids: IM injection
    • Allopurinol: Reduce urea
  23. What is a "seronegative spondyloarthropathy"? Give 3
    • An arthropathy without the production of RF
    • Ankylosing spondylitis
    • Psoriatic arthritis
    • Reactive arthritis
  24. What are the criteria for ankylosing spondylitis?
    • <50 years with chronic back pain
    • Morning stiffness >30mins
    • Improvement of back pain with exercise not rest
    • Awakening from back pain in second half of night
    • Alternating buttock pain
  25. Give 3 interventions used in AS
    • Analgesia: Slow release NSAIDs ON
    • Biologics: Infliximab very effective
    • Physio: Morning exercise to improve function and prevent kyphosis/lung restriction
  26. Give a brief description of the criteria for diagnosing psoriatic arthritis
    • Current psoriasis or personal/family history (2)
    • Nail changes (1)
    • RF negative (1)
    • Previous confirmed dactylitis (1)
    • X-ray of ossified joint margins (1)
  27. Where do bony erosions occur in:
    Psoriatic arthritis
    Rheumatoid arthritis
    SLE
    • Central in the joint (pencil in cup)
    • Juxta-articular
    • No erosions, purely synovial
  28. Give 4 nail changes seen in psoriasis
    • Pitting
    • Onycholysis
    • Discoloration
    • Hyperkeratosis
  29. Give 5 features seen in a reactive arthritis
    • Acute onset
    • Asymmetrical
    • Lower limb
    • Post-infection
    • Associated features; conjunctivitis, Reiter's
  30. In ANY rheumatological arthritis, what 5 treatments are always recommended? (Rule of Thumb)
    • NSAIDs
    • Local corticosteroid injections
    • 5-ASA/methotrexate
    • TNF-alpha i.e. infliximab
    • Physiotherapy for muscle strength/flexibility
  31. Outline the typical presentation of polymyalgia rheumatica
    • >50 yoa
    • Sudden onset
    • Severe pain and stiffness
    • Limb-girdle pattern
    • Rheumatology characteristics
  32. Outline the typical presentation of giant cell arteritis
    • >50 years
    • Severe headaches
    • Scalp/temple tenderness
    • Jaw claudication
    • Tender/swollen temporal/occipital arteries
    • Sudden, painless unilateral vision loss
  33. What investigations are useful in suspected GCA?
    • FBC: Normocytic/chromic anaemia
    • ESR/CRP: Raised/Very high
    • Temporal artery biopsy from affected side
  34. Give 3 long-term complications of temporal arteritis
    • Permanent unilateral visual loss
    • Complications of stroke
    • Osteopenia from high dose corticosteroids
  35. Give 5 systems affected by SLE and how
    • MSK: Small joint pain but clinically normal
    • Skin: Butterfly erythema, photosensitivity
    • Lungs: Bilateral pleurisy/effusion
    • CVS: Pericarditis/effusion
    • Renal: Lupus nephritis
  36. Give 3 antibodies that may be present in SLE
    • ANA
    • Anti-dsDNA
    • Anti-phospholipid
  37. Outline the natural history of SLE and its treatment
    • Present with malaise, fatigue and possibly features from the affected systems
    • Exacerbations and complete remissions
    • Acute attacks require short courses of oral corticosteroids or IM injections if local
  38. What is the antiphospholipid syndrome?
    • Recurrent arterial or venous thrombosis and/or recurrent miscarriages
    • Persistent presence of antiphospholipid antibodies; cardiolipin, lupus anticoagulant
    • No other possible cause
  39. How does scleroderma typically present?
    • CREST syndrome in 70%
    • Calcinosis
    • Raynaud's
    • Esophageal dysmotility
    • Sclerodactyly
    • Telangiectasia
  40. Outline the pathophysiology of Paget's disease
    • Altered gene expression in osteoclasts causes bone resorption
    • Compensatory deposition of woven bone, which lacks structure
    • Eventually formation exceeds resorption
  41. Outline the typical presentation of Paget's
    • Incidental in 60-80%; x-ray or ALP
    • Most commonly affects pelvis, L-Spine, femur, T-Spine
    • Central bone pain or nerve compression
  42. What investigations are useful in suspected paget's?
    • X-ray: Early lytic lesions (especially skull) and late sclerotic lesions
    • Bloods: ALP raised
    • Bone profile: Calcium and phosphate normal
  43. What investigations are typically used in suspected rheumatological disease?
    • Joint aspirate (in monoarthropathy)
    • Bloods: FBC, U+E (if app), ESR, CRP, ALP
    • Bone profile
    • Imaging: X-ray of site, CT/MRI if app
    • Autoantibodies
  44. What investigations are typically used in suspected osteomalacia?
    • Bone profile: Calcium normal but raised PTH
    • LFTs: Raised ALP
  45. How does osteomalacia typically present?
    • Vague features; bone pain or myositis
    • Pathological fracture
    • "Waddling" gait due to proximal myopathy
  46. What is the definition of osteoporosis?
    • Disease characterised by low bone mass and micro-architectural deterioration, leading to enhanced fragility and fracture risk
    • Bone density 2.5 standard deviations below young healthy adult mean value (T score <-2.5)
  47. Give 5 risk factors for osteoporosis
    • Oestrogen deficiency
    • Vit D deficiency
    • Glucocorticoid use
    • Smoking
    • Low BMI
  48. What investigation is used to quantify osteoporosis?
    DXA: Bone density of L-Spine/femur to determine T-score
  49. Give 5 indications for DXA scanning
    • Radiographic osteopenia
    • BMI <19
    • Known BMD-dependent risk factors
    • Glucocorticoid therapy (<65yoa)
    • Previous pathological fracture
  50. Give 5 interventions in the primary prevention of osteoporotic fracture
    • Pharmacological
    • Supplements: Calcium and Vit D
    • Exercise: Weight bearing to increase BMD
    • Smoking cessation
    • PT/OT: Reduce fall likelihood
  51. Give 3 pharmacological interventions in the primary prevention of osteoporotic fractures
    • Bisphosphonates
    • Strontium ranelate
    • Vitamin supplementation

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