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@finalsinfocusntod uton:Question 1:
A 45-year-old woman presents to her GP with joint pain.
Her pain initially started in her right knee, but she has now
developed pain and stiffness in her 1st and 3rd distal What is the most likely diagnosis?
interphalangeal joints of her right hand. Her symptoms are
worse in the morning and improve throughout the day. Her A. Rheumatoid arthritis
PMH includes Achilles tendonitis, which she is undergoing
physiotherapy for.
B. SLE
On examination, her right 1st and 3rd digits are swollen
with maximal tenderness over the distal interphalangeal
joints.You also notice that her nails have an abnormal C. Osteoarthritis
appearance.
D. Psoriatic arthritis
Her GP completes a basic rheumatological screen which
shows a raised CRP but normal rheumatoid factor and anti-
CCP . E. Polymyositis Diagnosis of psoriatic arthritis
Joint pain
• Symptoms of inflammatory arthritis - joint pain, which is worse after long
periods of rest, features prolonged morning stiffness of >30 minutes, and
improves with activity.
• Mostly affects the DIP joints, RA typically affects the MCPJs
• Typically in an oligoarticular pattern but other patterns can exist
Skin changes
• Psoriasis rash
• Nail changes can take several forms
• Pictured is onycholysis - the nail plate has separated from the nailbed
typically resulting in a well-defined area of white opaque nail
• Skin/nail changes are sometimes absent or unreported and psoriatic rash
or nail changes are not essential to diagnosis.
Features unique to psoriatic arthritis
• Dactylitis – sausage fingers
• Enthesitis – inflammation of a tendon
Investigations
• Mostly based on clinical assessment in secondary care by a specialist
• Seronegative – think PEAR (psoriatic, enteropathic, ank spond, reactive)
• CRP raised in active disease
• X-ray of the hands = pencil in cup deformityQuestion 2:
A 56-year-old man presents to the emergency
department with an acutely painful right knee. On
further questioning he tells you the pain started What is the most appropriate treatment?
yesterday morning, reaching maximum severity at night,
and meant he struggled to sleep at all. He describes the A. Allopurinol
pain as stabbing and has also noticed that his knee is
red and hot to touch. His PMH includes non-Hodgkin’s
lymphoma, for which he is on a chemotherapy regime of B. Naproxen
ICE (ifosfamide, carboplatin, and etoposide), and a
duodenal ulcer. C. Colchicine
On examination, his right knee is grossly swollen and
D. Prednisolone
erythematous. Observations: RR = 14 breaths per
minute, sats 100% on air, BP = 130/94mmHg, HR = 72
beats per minute, and a temperature of 36.9ºC E. Febuxostat
Joint aspiration is performed which shows negatively
birefringent, needle shaped crystals.P art 1:Diagnosis of gout
A 56-year-old man presents to the emergency
department with an acutely painful right knee. On ‘Acutely painful right knee’
further questioning he tells you the pain started • Septic arthritis – patient afebrile
yesterday morning, reaching maximum severity at night, • Gout
and meant he struggled to sleep at all. He describes the • Pseudogout - stems normally mention risk factor
pain as stabbing and has also noticed that his knee is
red and hot to touch. His PMH includes non-Hodgkin’s haemochromatosis, hyperparathyroidism,
lymphoma, for which he is on a chemotherapy regime of acromegaly
ICE (ifosfamide, carboplatin, and etoposide), and a • Haemarthrosis – no precipitating trauma
duodenal ulcer. mentioned
On examination, his right knee is grossly swollen and ‘Non-Hodgkin’s lymphoma, for which he is on a
erythematous. Observations: RR = 14 breaths per chemotherapy regime of ICE’
minute, sats 100% on air, BP = 130/94mmHg, HR = 72
• Chemotherapy is a risk factor for gout as it causes
beats per minute, and a temperature of 36.9ºC hyperuricaemia, due to increased production of
uric acid, released after tumour cell death
Joint aspiration is performed which shows negatively (purines converted to urate)
birefringent, needle shaped crystals.
‘Negatively birefringent, needle shaped crystals’
• Examination of the fluid aspirate under polarised
red light
• Pseudo «» Positive (2 P)
• Negative «» Needles (2 N’s = gout)
• No crystals in septic arthritisP art 2: Management of gout
A bit more about gout:
• The most common inflammatory arthritis
• Triggered following prolonged hyperuricaemia due to purine
breakdown which results in the accumulation of monosodium
urate (MSU) crystals in the joint
• Typically affects 50–60-year-old males
• Acute attacks typically affect the first metatarsal-phalangeal
joint (MTP of the great toe) (70%)
• Pain reaches maximum severity within 24 hours and resolves
in 5-15 days
• In chronic gout, urate crystals deposit to form tophi
surrounding the joint, cartilage and in the joints themselves.
Management of gout
NSAIDs or colchicine are first line in an acute attack of gout
NSAIDs are contraindicated in this patient as they have a
duodenal ulcer.
Prednisolone is second line (NSAIDs / colchicine ineffective or
contraindicated)
Allopurinol (1st line) and febuxostat (2nd line) are both used in
urate lowering therapy – xanthine oxidase inhibitors.Traditionally
thought this makes acute flares of gout worse and delaying urate
lowering therapy until inflammation has settled is still
recommended in guidelinesQuestion 3:
A 37-year-old female attends rheumatology outpatients
Given the most likely diagnosis, which of the
following a referral from her GP after she presented with a
following investigations is most sensitive?
number of different symptoms.These included a pruritic
facial rash that spared the nasolabial folds, bilateral
A. Anti-dsDNA
polyarthralgia of the hands and feet and generally feeling
B. Rheumatoid factor
much more fatigued than normal. She has no relevant PMH
C. Anti-histone
and is not on any medication.
D. Antinuclear antibody
E. Anti-SmithQuestion 3:
A 37-year-old female attends rheumatology outpatients
Most likely diagnosis is systemic lupus erythematous
following a referral from her GP after she presented with a • Malar rash – pictured below, key feature sometimes
mentioned in exam questions is that it’s nasolabial fold
number of different symptoms.These included a pruritic sparing
facial rash that spared the nasolabial folds, bilateral
• Polyarthralgia – inflammatory pattern, normally
polyarthralgia of the hands and feet and generally feeling affecting lots of joints
• Constitutional symptoms – fatigue, some patients have
much more fatigued than normal. She has no relevant PMH weight loss and malaise also
and is not on any medication. • Age demographics – 10:1 female: male ratio, peak
incidence 30-40Sensitivity and specificity of SLE blood tests
Sensitivity Thinking more about lupus and the question:
Sensitivity is like the ability of a test to correctly detect people who really have the In lupus, 99% are ANA positive - this high sensitivity makes it a
condition. So, if a test has high sensitivity, it means it's really good at picking up the useful rule out test, but it has low specificity. People with RA,
condition in people who truly have it. If a test has low sensitivity, it might miss a lot of systemic sclerosis, polymyositis but even positive in a number
people who actually have the condition, giving false-negative results.
of different viruses EBV, parvovirus etc
If you test 100 people with a disease, a test that is 90% sensitive will pick up 90 of
20% are rheumatoid factor positive
those 100
anti-dsDNA: highly specific (> 99%), but less sensitive (70%)
A sensitive test helps rule out a disease when the test is negative (e.g. negative
amylase in pancreatitis). Highly SeNsitive = SNOUT = rule out.
anti-Smith: highly specific (> 99%), sensitivity (30%)
Specificity
Specificity is about the ability of a test to correctly identify people who don't have the Anti-histone is elevated in drug induced lupus
condition. So, if a test has high specificity, it means it's really good at saying someone
doesn't have the condition when they really don't. If a test has low specificity, it might
wrongly identify people who don't have the condition as having it, giving false- Monitoring = CRP and complement (complement is low as C3
positive results. / 4 form complexes with autoantibodies meaning that free
complement is used up)
If you test 100 people without the disease, a test that is 90% specific will say that 10%
have the disease when they don’t
A specific test helps rule a disease in when positive (e.g. urine dipstick for nitrites in
UTI). Highly SPecific = SPIN = rule in.
In simpler terms, sensitivity is about not missing sick people (true positives), and
specificity is about not mislabelling healthy people (true negatives). Both are
important for understanding how reliable a test is.Question 4:
A 56-year-old woman presents to her GP with
. What is the most appropriate management option
increasing pain and stiffness in her hands. She is at this stage?
currently under secondary care for rheumatoid
arthritis, for which she takes methotrexate. She A – IM methylprednisolone
admits she has been under more stress recently.
B – Oral prednisolone
On examination, there is symmetrical swelling,
C – Intra articular methylprednisolone
stiffness and tenderness of the 2nd, 3rd, and 4th
MCPJs and PIPs bilaterally. D – Oral Naproxen
E – Topical ibuprofenManaging a flare of RA in GP
.NICE guidelines
• 1 line = Intra-articular steroid or an
intramuscular steroid
• Given that this patient has
inflammation of multiple small
joints in the hand, IA steroids would
be inappropriate
• 2 ndline = Oral steroids
• NSAIDs can be added in alongside
steroids but shouldn’t be given as
monotherapy
• All patients should be referred to
rheumatology / advice and
guidance in GP .Question 5:
A 44-year-old male presents to his GP with a persistent dry
cough which started 12 weeks ago. He denies any
haemoptysis but reports feeling more out of breath than What is the most likely diagnosis?
normal. He also reports losing a significant amount of
weight and has noticed a new rash appear on his legs, A – Systemic sclerosis
which he would like looked at as well. He has no history of
foreign travel and no relevant PMH. B – Myeloma
Observations: C – Lung Malignancy
RR: 18
BP: 130/76 D – TB
HR: 78
Temp: 38.0 E – Sarcoidosis
Sats: 99
Cardiovascular and respiratory examinations are normal. His
calves are SNT, but he has several, tender, raised
erythematous nodules on his shins bilaterally.
The GP takes some bloods and orders an urgent chest x-ray.
The results are as follows:
Hb 140 (135-180)
Plts 210 (150-400)
WBC 7 (4-11)
Calcium 2.9 (2.1-2.6)
Serum ACE 50 (20-70)
.Sarcoidosis: History
A 44-year-old male presents to his GP with a persistent dry What is sarcoid?
cough which started 12 weeks ago. He denies any • Non-caseating granulomatous inflammatory disease of
haemoptysis but reports feeling more out of breath than unknown aetiology
normal. He also reports losing a significant amount of
weight and has noticed a new rash appear on his legs, • Granulomas are nodules made of macrophages
which he would like looked at as well. He has no history of • Granulomas can deposit anywhere in the body causing a
foreign travel and no relevant PMH. variety of different symptoms
How does it present? - ABUGSLIFE
Observations:
RR: 18 A – Arthropathy, arrythmias
BP: 130/76
HR: 78 B - Bell's Palsy, bilateral hilar lymphadenopathy
Temp: 38.0
Sats: 99 U - Uveitis
Cardiovascular and respiratory examinations are normal. His
calves are SNT, but he has several, tender, raised G - Granulomas, non-caseating
erythematous nodules on his shins bilaterally.
S - Serum calcium/ ACE elevated
The GP takes some bloods and orders an urgent chest x-ray.
The results are as follows: L - Lupus Pernio, liver affected
Hb 140 (135-180)
I - Interstitial fibrosis (upper lobes)
Plts 210 (150-400)
WBC 7 (4-11) F - Fever, swinging
Calcium 2.9 (2.1-2.6)
Serum ACE 50 (20-70)
. E - Erythema NodosumSarcoidosis: Investigations
A 44-year-old male presents to his GP with a persistent dry
cough which started 12 weeks ago. He denies any
haemoptysis but reports feeling more out of breath than Bloods
normal. He also reports losing a significant amount of • FBC may show anaemia, leucopoenia,
weight and has noticed a new rash appear on his legs,
which he would like looked at as well. He has no history of thrombocytopaenia
foreign travel and no relevant PMH. • Hypercalcaemia and hypercalciuria can
occur due to increased vitamin D activation
Observations:
RR: 18 by macrophages in sarcoidosis
BP: 130/76 • Raised ALP if liver involved
HR: 78 • Serum ACE raised - sensitivity of 60% and
Temp: 38.0
Sats: 99 specificity of 70% and are therefore not
reliable in the diagnosis of sarcoidosis
Cardiovascular and respiratory examinations are normal. His
calves are SNT, but he has several, tender, raised Other
erythematous nodules on his shins bilaterally.
• Chest x-ray - bilateral hilar lymphadenopathy
The GP takes some bloods and orders an urgent chest x-ray. • CT – upper zone fibrosis
The results are as follows: • Tissue biopsy of granulomas is gold standard
Hb 140 (135-180)
Plts 210 (150-400) Management
WBC 7 (4-11) • Steroids but only used in disease severe
Calcium 2.9 (2.1-2.6)
Serum ACE 50 (20-70) (organ threatening)
.Question 6
A 59-year-old woman is brought to the emergency
department by her husband with symptoms of fever, Which drug has caused her presentation?
shortness of breath, fatigue, and a sore mouth. She also
notices a number of bruises have appeared on her arms
and legs in the last few days, without any obvious cause. Her A – Flucloxacillin
PMH includes RA, for which she takes methotrexate, and she B – Co-trimoxazole
was recently treated for a diabetic foot infection although
she can’t remember the name of the drug, she was C – Clarithromycin
prescribed to treat it. She has bloods taken which show the
following results: D – Doxycycline
Hb 86 (115-160) E – Gentamicin
Plts 39 (150-400)
WBC 2.7 (4-11)
Neutrophils 1.9 (2-7)
Lymphocytes 0.3 (1-3.5)
Monocytes 0.1 (0.2 – 0.8)Methotrexate side effects
This patient has bone marrow aplasia as characterised by:
. 59-year-old woman is brought to the emergency
department by her husband with symptoms of fever, • Pancytopaenia on bloods
shortness of breath, fatigue, and a sore mouth. She has also • Fever – increased susceptibility to infections due to low WBC
noticed a number of bruises have appeared on her arms • SOB + fatigue – anaemia
and legs in the last few days, without any obvious cause. Her • Bruising – low platelets
PMH includes RA, for which she takes methotrexate, and she • Sore mouth – characteristic of aplastic anaemia (might suggest
was recently treated for a diabetic foot infection although
she can’t remember the name of the drug she was thrush, blood blisters or mouth ulcers)
prescribed to treat it. She has bloods taken which show the Methotrexate and the trimethoprim component of co-trimox both
following results: inhibit folate synthesis through inhibition of dihydrofolate
reductase.This disrupts folate metabolism in the bone marrow which
Hb 86 (115-160) leads to decreased production of blood cells.
Plts 39 (150-400)
WBC 2.7 (4-11) Other adverse effects of methotrexate:
Neutrophils 1.9 (2-7) Mucositis
Lymphocytes 0.3 (1-3.5)
Monocytes 0.1 (0.2 – 0.8)
Myelosuppression
Pneumonitis - most common pulmonary manifestation, similar to
hypersensitivity.Typically develops within a year of starting treatment
either acutely or subacutely and presents with non-productive cough,
dyspnoea, malaise, fever
Pulmonary fibrosis
Liver fibrosisQuestion 7
A 25-year-old male presents to general practice with a Given the most likely diagnosis, what would you
2-week history of lower limb joint pain.The specific expect to find if you aspirated the right knee joint?
joints that are painful are his right knee, left ankle and
numerous MTPJs. He also reveals that he is going to A – Staph aureus
the toilet much more and that it hurts when he passes
urine. He has also been using over the counter eye B – Chlamydia trachomantis
drops over the past few days, as his eyes have been
red and irritated, and has a new rash on his feet. His C – Neisseria gonorrhoea
only PMH is that he was treated for an STI 4 weeks
ago. D - Salmonella enteritidis
E – No organism growthQuestion 7
A 25-year-old male presents to general practice with a This patient has reactive arthritis:
2-week history of lower limb joint pain.The specific • Asymmetrical polyarthralgia of the lower limbs
• Urethritis – dysuria and increased urinary frequency
joints that are painful are his right knee, left ankle and • Conjunctivitis – seen in 10-30%
numerous MTPJs. He also reveals that he is going to • Can’t see pee or climb a tree
the toilet much more and that it hurts when he passes • Keratoderma blennorrhagicum, presenting as hyperkeratotic
urine. He has also been using over the counter eye lesions predominantly on the soles and, less commonly, on the
drops over the past few days, as his eyes have been palms.
red and irritated, and has a new rash on his feet. His
• Common trigger of chlamydia infection 4 weeks prior
only PMH is that he was treated for an STI 4 weeks
ago. Seronegative spondyloarthropathy triggered by either a diarrhoeal
illness or chlamydia infection. Not directly caused by the organism –
it’s thought that the immune response against the precursor infection
causes an inflammatory process in the synovium of the joint pain.
Lasts 4-6 months
Managed with NSAIDs in the acute phase of illness
HLA-B27 associatedQuestion 8
You are an F2 working in rheumatology outpatients. A
35-year-old man attends clinic for a review of his
ankylosing spondylitis. His back pain well controlled
on oral NSAIDs, but he has read online that Which of the following is not associated with
ankylosing spondylitis can affect other parts on his ankylosing spondylitis?
body, and he would like to know more.
A – Achilles tendonitis
B – Heart block
C – Anterior uveitis
D – Aortic regurgitation
E – Bibasal fibrosisAnkylosing spondylitis: 7A ’s
Classic presentation is a young man
presenting with morning back pain and
stiffness that improves throughout the day
However, like most rheum conditions, ank
spond is a multi-system disease…
• A – Anterior uveitis
• A – Aortic regurgitation
• A – Atrioventricular block (heart block)
• A – Apical lung fibrosis (fibrosis of the
upper lobes of the lungs)
• A – Anaemia of chronic disease
• A – Achilles tendonitis
• A - Amyloidosis (CKD)