1. Martin Edobor, John Lewin
Rheumatology Crash Course

2. Objectives
• Go through GALS screen OSCE station
• Cover key Rheum Topics
• Practice SBA
• General Advice

3. OSCE

4. Gals screen - Introduction
1. Introduces self and states role
2. Consent and obtains patients name
3. Offers a chaperone
4. Exposure of patient (giving them privacy to do so)
5. Asks the following questions: What is your occupation? Do you have any pain
or stiffness in any joints, muscles
or your back? Do you have any difficulty climbing the stairs? Do you have any
difficulty washing or dressing?
6. General inspection for obvious scars, deformities, abnormal posture or muscle
wasting

5. 7. GAIT: asks patient to walk away and turn and come back, checking for:
Smoothness of movement, abnormalities in gait, normal heel toe strike, normal‐
turning speed, normal
posture and arm swing
Gals screen - Gait

6. Gals screen – Spine (1)
SPINE: inspect from the back, looking for:
Any deformities such as scoliosis
Level shoulders and iliac crests
Normal cervical and lumbar lordosis
9. Checks muscle bulk in the paraspinals, shoulder girdle, gluteals, calves

7. 10. Inspects the popliteal fossa and Achilles tendon
11. Feels supraspinatus and lightly squeezes trapezius to test for fibromyalgia
12. Runs finger down back to check for tenderness
13. Movements:
Side to side, rotate upper torso without moving hips‐ ‐
Press ear to shoulder
Open jaw and move side to side‐ ‐
Flex and extend neck, rotate head
Gals screen – Spine (2)

8. ARMS: General inspection, comment on deformity or erythema over the joints,
Dupuytren’s or thenar wasting in the hand, pitting psoriasis in the nails
16. Feels the temperature of the joints then squeezes across the metacarpals for
tenderness
17. Movements:
 Put hands behind head and push elbows back, touch the small of back, ‘pray’
with hands together then
back to back
 Flex and extend elbows, pronation and supination, flex and extend wrists
18. Hands:
 Power grip
 Precision movements (thumb to each finger in turn)
Gals screen - Arms

9. LEGS: General inspection for muscle wasting, fasciculations, skin rashes,
nodules, swelling, deformity or
erythema over the joints, calluses or ulcers on soles
20. Feels the temperature of the joints then squeezes across the metatarsals for
tenderness
21. Movements:
 Flex and extend hips, knees and ankles
 Internal rotation at hips and knees
 Inversion and eversion at the ankle
 Crepitus and bulge test at the knee
Gals screen - Legs

10. 22. Thanks patient, offers to help them dress
23. To complete my examination, would like to do a full neurological examination
of the upper and lower limbs and
a full cranial nerve exam
24. Presents findings in a clear and fluent manner, for example
“This patient doesn’t have any pain or stiffness in any of his joints, muscles or
back. He has no difficulty climbing stairs or washing and dressing. On general
inspection, there were no obvious scars, deformities, abnormal posture or muscle
wasting. On examination GAIT was smooth with no abnormalities. He displayed
no weakness and normal range of movement in arms, leg and spine. This patient
has a normal GALS screen”
Gals screen - Closing

11. Rheumatoid Arthiritis (1)
A chronic symmetrical inflammatory polyarthititis with systemic
involvement
Epidemiology: F>M 3:1, ages 30-50
Associated with HLA-DR4
Pathology: Autoantibodies (IgM) to Fc of IgG, forming immune complexes
which deposit in joints leading to inflamation.
Symptoms: Pain (decrease with activity), swelling, morning stiffness
>30mins,.
Joint Involvement: MCP, MIP, PIP, MTP SYMETRICAL!

12. Rheumatoid Arthritis (4)
Systemic extra-articular involvement:
Skin: Rhumatoid nodules, synivotendonitis
Lungs: Effusions, nodules, fibroisis, Caplans syndrome: a combination of
pneumoconiosis and RA
Eyes: Sclertis (painful red eye), Episcleritis(non-painful red eye), Sorgjerns
syndrome
Neural: Mononeuritis multiplex, Carpal tunnel
Felty Syndrome: RA with splenomegaly and neutropenia
Normochromic normocytic anaemia

13. Rheumatoid Arthritis (5)
Investigations
ESR, CRP Increased
Possible Anaemia
RF +ve in 70% of cases, Anti-ccp positive in >90% of cases
CXR –Swelling of soft tissue, erosions, joint narrowing, juxto-articular
osteopenia

14. Rheumatoid Arthritis (6)
Management
2009 NICE guidelines it is recommend that patients with newly
diagnosed active RA start a combination of DMARDs (including
methotrexate and at least one other DMARD, plus short-term
glucocorticoids)
1.DMARDS
Methotrexate (s.e derange LFT’s renal, neutopenia, PF, teratogenic)
•Sulfasalazine (s.e infertility, G6PD heamolysis)
•Lefunimide
Others e.g Azathriopine, Gold
(Also add prednisolone)

15. The current indication for a TNF-inhibitor is an inadequate response to
at least two DMARDs including methotrexate
4. Anti TNF alpha, use if DMARDS failed
e.g Entgeracept, Adelumimab , Infliximab
Side effects increase risk of cancer, infection, reversible refulx and
demylinating disease.
If a diagnosis of RA is yet to be made, you can give your patient NSAIDS (if
no contraindication) or a steroid injection

16. A 47 year old woman presents to A+E with dyspnoea. An X-ray
confirms a large right sided pleural effusion. Fluid is then aspirated
from the right lung. Clinical chemistry analysis showed a pleural
fluid lactate dehydrogenase (LDH): serum LDH ratio of 0.76. Which
of the following is the most likely cause of this patient’s pleural
effusion?
• Meigs’ syndrome
• Hypothyroidism
• Constrictive pericarditis
• Nephrotic syndrome
• Rheumatoid arthritis

17. Pleural effusions
• Transudate
– Increased venous pressure
– Hypoproteinaemia
– Hypothyroidism
– Meigs syndrome
• Exudate
– Increased capillary perm 2ndry to cytokines
• Infection
• Inflammation
• Malignancy

18. SBA question
• A 53 year old woman with stable rheumatoid
arthritis is to undergo an elective cholecystectomy.
Arthropathy is the only finding on clincial
examination. Which of the following is the most
important investigation prior to the procedure?
• A) Chest X-ray
• B) Echocardiography
• C) ABG
• D) Cervical spine imaging
• E) Uric acid levels

19. ANSWER
• C) 1 in 3 patients with RA have atlanto-axial
subluxation.
• Hyperextension of C-spine during intubation risks
cervical myelopathy
• Imaging and extra care during anaesthesia is
necessary

20. Connective Tissue Diseases

21. Systemic Lupus Erythematosus (1)
SLE an “Systemic, inflammatory, multisystem disorder”
Autoimmune disease in which auto-antibodies and immune complexes
cause damage to organs.
Epidemiology: High prevalence in Afro-carribeans, Peak age of onset 20-
40 years
Aetiology: Hereditary , Genetic, Immune system disorder (Autoantibody
production + impaired tolerance), UV light , Drugs.

22. Clinical features
• Musculoskeletal 90% :
-Symmetrical, small joint, arthralgia, - Jaccoud’s arthropathy –Joint
deformity resembling RA – rare
• Cutaneous 75%
-Malar Rash:
-Discoid Lupus
• Neurology 60%
-Cerebral Lupus
• Lungs 50%
-Recurent pleurisy and BILATERAL pleural effusions
- “Shrinking Lung syndrome’
• Renal 30% (Histological changes are frequent)
- Regular screening for urine for blood and protein required

23. ‘ A RASH POIN MD’
• Arthralgia
• Renal problems
• Anti-nuclear antibodies
• Serositis
• Haematological disorder
• Photosensitivity
• Oral ulcers
• Immunological disorder
• Neurological disorder
• Malar rash
• Discoid rash
• >4 out of 11 needed

24. Investigations

25. Investigations
• Bloods
FBC: Leucopenia, lymphopenia and/or thrombocytopenia
ESR: Raised
CRP: Normal
U+E: Urea and Creatinine raised in advanced renal disease
• Urine Testing: Protein in urine and RBC Caste
• Complement: Low C3 Low C4
Imaging
• CT– infarcts or haemorrhage with evidence of cerebral atrophy
• MRI – lesions in white matter

26. Serum Antinuclear Antibodies (ANA) Positive >95%
Double stranded DNA Specific for SLE
Positive 60%
ENA: Anti-Ro and Anti-LA Detected
RF Positive in 40% of patients
Anticardiolipin antibodies Present in 35-45% of patients
Serological Syphilis Test False Positive 1/3rd
Immunoglobulins ↑ (IgG and IgA)
Investigation-Serology

27. A 32 year old pregnant woman with a history of malar rash,
photosensitivity and joint pain in her hands is seen in antenatal
clinic. An appropriate autoantibody screen is performed. Which of
following autoantibodies are most associated with poor fetal cardiac
function with respect to this patient?
• Anti-dsDNA
• Antinuclear
• Antiphospholipid
• Anti-Ro
• Anti-La

28. Management
• Symptomatic treatment
-NSAIDS
-Antimalarials: e.g hydroxychloroquine
• Corticosteroids and immunosuppressive drugs
-Single dose I.M corticosteroids for flares
-immunosuppressive drugs for severe thrombocytopenia,
renal and cerebral diseases.

29. What is the best test to distinguish between a
lupus flare and an infection in a patient with
lupus?

30. Answer
ESR and CRP
ESR increased, CRP normal in flare
ESR and CRP both increased in infection

31. Drugs that worsen SLE
• Penicillamine – what is this?
• Procainamide – what is this?
• Hydralazine – what is this?
• All associated with drug induced lupus
• Which antibody is associated with drug induced
lupus?

32. Sjogren’s Syndrome
2 types:
Primary Sjogren’s:
9:1 F:M ratio
Secondary Sjogren’s:
Associated with CT diseases: RA, SLE, Systemic Sclerosis
Classic Features
1.Decreased tear production
—Dry eyes
—Keratoconjunctivitis sicca
2.Decreased salivation
—Dry mouth
—Caries
Other features:
—Arthritis, Raynaud’s , Interstitial Nephritis

33. Investigations
• Measure the affected areas: Conjunctival dryness
• “Schirmer’s Test”:
Filter paper under lower lid, measure distance along paper that tears are
absorbed
5mm in 5mins = +ve
• Blood tests:FBC:
Increased Ig
Autoantibodies: Anti-Ro + Anti-La(70%), RF+, ANA+(70%)
Treatment
•No cure
•Symptomatic relief:
Eye drops (artificial tears)
Gels, frequent drinks, sugar free gum/pastilles etc.
NSAIDs and immunosuppressants in severe systemic disease

34. A 42 year old woman presents to her GP with dry eyes, dry mouth
and joint pain. She undergoes a Schirmer’s test which reveals a tear
absorption rate of 3mm in 5 minutes. Concerning the diagnosis,
which of following is most true?
• Patients are at an increased risk of non-Hodgkin’s
lymphoma
• Women are three times more likely to be affected
than men
• The peak onset of age is in the 6th
decade of life
• Rheumatoid factor is positive in 70% of patients
• Is associated with anti-mitochondrial antibodies

35. Systemic Sclerosis

36. What is it?
• Chronic multisystem disease
• Mainly affects skin and associated with Raynaud’s
• F:M 3-5:1
• Presents between age 30-50
• 2 main types:
i. Limited cutaneous scleroderma
ii. Diffuse cutaneous scleroderma

37. Clinical Features
1. Limited cutaneous scleroderma (60%)
– Initially get Raynaud’s
– Followed by slow skin changes - hands, feet and
forearms
– Thickened skin
– (Formerly known as CREST syndrome)
– Calcinosis, Raynauds, Esophagitis, Sclerodactly,
Telangiectasia

38. Clinical Features
2. Diffuse cutaneous scleroderma (40%)
– Initially get Raynaud’s
– More rapid and widespread skin changes
– Also affects:
1. Oesophagus (like limited type)
2. Lungs: Pulmonary fibrosis , pulmonary vascular
disease, causing pulmonary HTN
3. Kidneys: Acute or chronic renal failure
4. Heart: pericarditis, pericardial effusion,
myocarditis, arrythmias

39. Investigations
• Blood tests:
– FBC: normochromic, normocytic anaemia, raised ESR
– Autoantibodies (NOT present in all):
• Limited cutaneous: anti-centromere
• Diffuse cutaneous: anti-Scl70, anti-RNA pol I + III
• Radiology: XR, CT and barium swallow
• Oesophageal manometry

40. Treatment
• No cure
• Symptomatic relief:
– Immunosuppression with iv cyclophosphamide
– ACE inhibitors or ATII receptor antagonists for HTN
– Hand warmers/ Ca channel blockers for Raynaud’s

41. Overview
Polymyositis is a rare, subacute inflammatory
myopathy.

42. OverviewOverview
• Very rare (2-10/million); ♀ > ♂
• Subacute: weeks to months with typical delay
before presentation
• Inflammation of striated muscle
• Aetiology complex and uncertain

43. Clinical featuresClinical features
• Proximal muscle weakness:
– Progressive
– Symmetrical
• Which sort of movements are initially affected?
• Distal weakness may occur later
• Ocular and other facial muscles spared
even in advanced, untreated cases

44. Clinical Features
• Respiratory, oesophageal & laryngeal muscles can be
affected
• Weakness is associated with wasting.
• Isolated Polymyositis is incredibly rare. More
commonly it is associated with either:
– Systemic autoimmune or connective tissue disease
– Viral or bacterial infection
• Systemic symptoms including Raynaud’s phenomenon.

45. InvestigationsInvestigations
1 CK – raised (up to 50-fold)
2 Electromyography (EMG) show abnormalities.
3 Muscle biopsy. This is the definitive test

47. Management
• Goal is to improve muscle strength.
• First-line is 3 month trial of oral Prednisolone. This
fails in 75% of patients
• If this fails, other immunosuppressive drugs used.
e.g. methotrexate, azathioprine, mycophenolate
• If immunosuppression fails, rethink diagnosis. (Repeat
biopsy!)

48. Any questions?

49. Take-home messages
SLE is a systemic, inflammatory, multisystem disorder. It is
an autoimmune disease in which auto-antibodies and
immune complexes cause damage to organs.
Sjogren’s Syndrome is a chronic inflammatory condition due
to immunologically mediated destruction of epithelial
exocrine glands
Systemic Sclerosis is a chronic multisystem disease. It
mainly affects skin and is associated with Raynaud’s
Polymyositis is a subacute inflammatory myopathy of a
proximal-to-distal progressive symmetrical pattern

50. Gout
• What do you know?

51. Gout
• Hyperuricaemia and uric acid crystals
• Predilection for MTP joint (70%)
• Presenting features?
• Risk factors

52. Gout Risk Factors
• Alcohol
• Drugs – which ones?
• High purine diet
• High cell turnover
• CKD

53. Ix
• MUST RULE OUT SEPTIC ARTHRITIS
• Joint aspirate – negatively birefringent needle
shaped crystals under polarised light
• X-ray
• U+Es
• Serum uric acid – may be normal in acute attack

54. A 67 year old man with gastro-oesophageal reflux disease (GORD)
presents with an acutely painful swollen right metatarsophalangeal
joint. Joint aspiration reveals the presence of needle shaped
crystals that are negatively birefringent when viewed under
polarised light. Which of the following is the most appropriate initial
treatment option in this patient?
• Colchicine
• Indomethacin
• Allopurinol
• Steroids
• Febuxostat

55. Rx
• NSAIDs /colchicine/ steroids for acute phase
• Allopurinol/ Febuxostat/ Rasbicurase for chronic
phase
• What if patient is on azathioprine?

56. Azathioprine toxicity
• Nausea
• Fatigue
• Rash
• Hair loss
• BONE MARROW SUPPRESSION
• Need to measure thiopurine S-methyltransferase
levels before you start a patient on AZT

57. Pseudogout
• What do you know?

58. Pseudogout
• Calcium pyrophosphate crystals
• Tends to affect larger joints
• Risk factors?

59. Pseudogout risk factors
• Hypomagnesaemia
• Hypophosphataemia
• HAEMOCHROMATOSIS
• WILSON’S DISEASE
• HYPERPARATHYROIDISM

60. Ix
• MUST RULE OUT SEPTIC ARTHRITIS
• Polarised light microscopy of joint fluid
• X-ray
• Consider secondary causes (esp if under 60)
• Calcium
• Magnesium
• Iron studies
• Caeruloplasmin

61. Practice SBA’s
1. Which one of the following systems is most commonly affected in
SLE?
A. Joints
B. Skin
C. Chest
D. Kidney
E. Heart

62. Clinical features
• Musculoskeletal 90% :
-Symmetrical, small joint, arthralgia, - Jaccoud’s arthropathy –Joint
deformity resembling RA – rare
• Cutaneous 75%
-Malar Rash:
-Discoid Lupus
• Neurology 60%
-Cerebral Lupus
• Lungs 50%
-Recurent pleurisy and BILATERAL pleural effusions
- “Shrinking Lung syndrome’
• Renal 30% (Histological changes are frequent)
- Regular screening for urine for blood and protein required

63. 2.You review the hands of a 60-year-old man who is complaining of
'arthritis' in his hands:

64. A. Rheumatoid arthritis
B. Systemic Sclerosis
C. Systemic Fungal infection
D. Psoriatic Arthritis
E. Reiter's Syndrome

65. 3. A 49 year old man suddenly experiences severe pain in his left
ankle while walking. His past medical history is unremarkable,
except for a recent course of antibiotics for gastroenteritis. Clinical
examination reveals an inability to plantar flex the left foot. Which of
the following antibiotics was the patient most likely to have been
taking?
• Erythromycin
• Metronidazole
• Amoxicillin
• Cefalexin
• Ciprofloxacin

66. 4. A 57-year-old man presents to his GP due to pain in his right knee. An
x-ray shows osteoarthritis. He has no past medical history of note. What
is the most suitable treatment option for the management of his pain?
A.Oral Doclofenac with omeprazole
B.Oral glucosamine
C.Oral Diclofenac
D.Oral Ibuprofen
E.Oral paracetamol

67. 5. You refer a 24-year-old female to rheumatology with intermittent pain
and swelling of the metacarpal phalangeal joints for the past 3 months.
An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid
factor is positive and a diagnosis of rheumatoid arthritis is made. What
initial management is she most likely to be given to help slow disease
progression?
A.Infliximab
B.Methotrexate
C.Sulfasalazine
D.Methotrexate + sulfasalazine + short-course of prednisolone
E.Diclofenac

68. Rheumatoid Arthritis (6)
Management
2009 NICE guidelines it is recommend that patients with newly
diagnosed active RA start a combination of DMARDs (including
methotrexate and at least one other DMARD, plus short-term
glucocorticoids)
1.DMARDS
Methotrexate (s.e derange LFT’s renal, neutopenia, PF, teratogenic)
•Sulfasalazine (s.e infertility, G6PD heamolysis)
•Lefunimide
Others e.g Azathriopine, Gold
(Also add prednisolone)

69. 6. A 25-year-old man presents complaining of dysuria and pain in his left
knee. Three weeks previously he had suffered a severe bout of
diarrhoea. What is the most likely diagnosis?
A.Reactive Arthritis
B.Disseminated gonococcal infection
C.Bechet’s disease
D.Ulcerative colitis
E.Rheumatoid arthritis

70. 7. A 38 year old intravenous drug user presents with an acutely
painful swollen left knee and a temperature of 38.30
C. Joint
aspiration reveals a turbid, yellow fluid which is sent for culture.
Which of the following is the most appropriate initial empirical
treatment?
• Intravenous flucloxacillin and intravenous
benzylpenicillin
• Oral metronidazole
• Oral amoxicillin and oral erythromycin
• Intravenous cefotaxime and intravenous
gentamycin
• Oral flucloxacillin and oral penicillin V

71. 8 A 72 year old lady presents with a two year history of right hip
pain. She mentions that it is particularly troublesome after she has
walked to the shops. X-ray shows loss of joint space and
subchondral sclerosis and cysts. Which of the following is the most
effective treatment for this lady?
• Physiotherapy
• Weight loss
• Joint replacement
• NSAIDs
• Glucosamine and chondroitin sulphate

72. 9. Which one of the following is least associated with systemic lupus
erythematous?
A.Anti-nulcear antibodies
B.Anti-Sm Antibodies
C.Elevated ESR
D.Elevated C3 And C4 levels
E.Elevated anti-dsDNA titres in active disease

73. SLE: ANA is 99% sensitive - anti-Sm & anti-dsDNA are 99% specific
C3, C4 are low in SLE not elevated

74. 10. You are doing the annual review of a 50-year-old woman who has
rheumatoid arthritis. Which one of the following complications is most
likely to occur as a result of her disease?
A. Chronic lymphocytic leukaemia
B. Hypertension
C. Colorectal Caner
D. Type 2 diabetes mellitus
E. Ischaemic heart disease

75. 11 A 38 year old woman with known rheumatoid arthritis presents
with a history of shortness of breath, easy bruising and recurrent
chest infections. On clinical examination there is splenomegaly.
Which of the following is the most likely explanation for this
presentation?
• Sulphasalazine
• Methotrexate
• Penicillamine
• Felty’s syndrome
• All of the above

76. 12 A 50 year old woman undergoes a DEXA bone scan which
reveals a T score of -2.6. Taking the history reveals a strong family
history of breast cancer and a 30 pack year smoking history. Which
of the following treatment options is most appropriate for this
patient?
• Alendronate
• Strontium Ranelate
• Vitamin D
• Calcitonin
• Raloxifene

77. Can you any name anti-osteoporotic
medications and their side effects?

78. • Anti-SSA
• Anti-topoisomerase-I
• Anti-centromere
• Anti-liver kidney microsomal
• Anti-Jo1