1. Rheumatoid Questions and Notes on OA and RA

2. A patient presents with rheumatoid arthritis. On examination of her hands, she has several joint deformities which are typical of rheumatoid arthritis. The doctor therefore decides to order blood tests. Give TWO blood tests (no abbreviations) that can be used in the diagnosis of rheumatoid arthritis (2 marks). Rheumatoid factor Anti-citrullinated protein antibodies Anti-cyclic citrullunated peptides Anti-mutated citrullinate vimentin assay Rheumatoid arthritis causes inflammation of the synovial membranes. Describe the histological appearance of a normal synovial joint membrane (2 marks) and the appearance of the synovial membrane in a joint with acute rheumatoid arthritis. (2 marks) Normal: 2 layers, the intima composed of synovial and phagocytic cells (1 mark) (1 mark if lined by synovial cells or phagocytes) and subintima composed of loose connective tissue and blood vessels (1 mark) ACCEPT hyaline cartilage RA: oedematousand inflamed (1 mark) multiplication/proliferation of synovial lining cells forming a pannus (1 mark)

3. The patient says she is having an endoscopy done. Before this is done, the doctor decides to send her for a cervical spine X-ray. Explain why it is important to perform a cervical spine X-ray in this particular patient. (3 marks) Patient could have RA cervical spine with instability (1 mark) Atlanto – axial /C1 – C2 subluxation could occur during endoscopy (1 mark) (have to mention endoscopy to get full mark and reason for compression) causing compression/damage the spinal cord/nerves (1 mark) Patients with rheumatoid arthritis can also develop pleural effusions. (i) Describe the pleura of the lungs. (3 marks) (ii) In an upright posture where would the fluid collect? (1 mark) (i) Serous membrane of two continuous layers: a visceral layer (allow outer) adhered to the lung (1 mark) and a parietal layer (allow inner) which lines the inner aspect of the chest wall, the diaphragm, sides of pericardium & mediastinum (1 mark) NB not just chest wall ) Between the layers is the pleural cavity, a potential space which contains a tiny amount of serous fluid (1 mark) (ii) Costodiaphragmatic recess (1 mark) or costophrenic or space angle

4. List some extra-articular manifestations of rheumatoid arthritis Scleritis Sjogren’s Syndrome Lymphadenopathy Pericarditis Bursitis/nodules Tendon sheath swelling Tenosynovitis Amyloidosis Pleural effusion Fibrosing alveolitis Carpal tunnel syndrome

5. Osteoarthritis ("Wear and Tear")Rheumatoid (Autoimmune) Obesity (Risk factor) Occupation (Risk factor) 3:1 Female:Male ratio Heberden’s Nodes Swan neck deformity Bouchard’s Nodes Ulnar deviation of the MCP joint Crepitations Mainly small joints effected Bony enlargements Symmetry Osteophytes Bilateral Subchodrial cysts Extra-articular manifestations Higher inidence after menopause Morning stiffness worse Stiffness lasts <30mins in the morning Stiffness lasts >30mins in the morning Unilateral Rheumatoid nodules Joint space narrowing Asymmetrical Increased incidence after menopause NOTE: These are not all of the comparisons that can be made, or features of RA and OA. Also, wherever you have two diseases that can be compared easily make sure you are able to distinguish differences between the two easily, for example: Type I vs Type II Diabetes Ulcerative Colitis vs Crohn’s Another cheeky one to think about is Apoptosis vs Necrosis

6. Hand signs for Rheumatoid Arthritis REMEMBER: You need to be able to describe what is happening in each of the signs. Swan-neck deformity: Flexion of the DIP Hyperextension of the PIP joint Boutonniere deformity: Hyperextension of DIP Flexion of PIP NOTE: Swan-neck and Boutonniere sign are the opposite of each other. Ulnar deviation of the MCP joint: The fingers are deviating toward the ulnar bone at the MCP joint

7. These nodes are seen in Osteoarthritis. There are several ways to remember which way round these nodes go: Heberden’s Node: The outer Hebrides are far away, and Heberden’s nodes are the ones furthest away (on the DIP joint) from you. Bouchard’s Node: The French for mouth is ‘bouche’ and the node closest to the mouth (on the PIP) is called Bouchard’s node. (These are simple ways of remembering them. Remember you need to know what PIP and DIP stand for) PIP: Proximal InterPhalangeal Joint DIP: Distal InterPhalangeal Joint

8. The exam questions were taken straight from a past paper, along with the answers, bar the last example. If you have any questions about anything you have read in this, or noticed any mistakes please contact me. Amritpal Sandhu A.Sandhu@warwick.ac.uk