Official data in SubjectManager for the following academic year: 2019-2020
Dr. László István CZIRJÁK (firstname.lastname@example.org), professor
Department of Rheumatology and Immunology
Code of subject: OAK-KIR-T | 2 credit | General Medicine | Clinical module | spring
Prerequisites: OAA-IMM-T completed , OAP-BPR-T completed , OAP-PA2-T completedExam course: yes
14 lectures + 14 practices + 0 seminars = total of 28 hours
The goal of the course is to learn the basic knowledge of clinical immunology and rheumatology, to practice the examination of patients with musculoskeletal and joint complaints, to learn the basics of clinical immunological problems.
Presentations: on NEPTUN Unified Education System
Lynn S. Bickley: Bates´ Guide to Physical Examination and History Taking. (The actual version.)
Harrison´s Principles of Internal Medicine Companion Handbook. Short pocket book. (The actual version.)
Philip Seo (with Alan J. Hakim, Gavin P. R. Cluine, Inam Haq): Oxford American Handbook of Rheumatology, Oxford University Press. (The actual version.)
Passing one written exam during the semester. Examination of the musculoskeletal system.
There is no possibility.
During the practice of another group.
Exam´s questions A. Differential diagnosis, therapy.
1. When do you suspect a systemic autoimmune disease?
2. Necessary procedures if you suspect a systemic autoimmune disease.
Basic laboratory tests, autoantibody screening tests, specific autoantibody tests.
3. Primary, secondary Raynaud´s syndrome. Differential diagnosis,therapy. Evaluation of efficacy. Basic investigations in Raynaud´s syndrome. Diagnostic value of nail fold capillary- microscopy.
4. Differentiating between degenerative and inflammatory rheumatoid conditions.
5. Evaluation of activity and damage in rheumatologic diseases.
6. Differential diagnosis of polyarthritides.
7. Characteristics, diagnosis and differential diagnosis of oligoarthritis and monoarthritis.
8. Differential diagnosis of cervical and shoulder pain.
9. Differential diagnosis of elbow and hand pain.
10. Differential diagnosis of low back pain. Differentiation between inflammatory and non-inflammatory back pain.
11.Rehabilitation of patients with rheumatological and musculoskeletal diseases. Physiotherapy of rheumatic disorders. Physical exercise. Orthesis.
12 Pain relief in rheumatology.
13 Effects and side effects of non steroidal antiinflammatory drugs.
14 Glucocorticoid treatment. Effects, side effects, prevention of side effects.
15 Biological therapies. TNF antagonist biological therapy. Other biological treatments in inflammatory rheumatological diseases. (rituximab,tocilizumab, abatacept, secukinumab). Biosimilars.
15. Infectious side effects of patients with rheumatological disease during systemic treatment (sulphasalazine, methotrexate, leflunomide,azathioprine, corticosteroids, biologicals, kinase inhibitors).
Exam´s questions B. Main inflammatory rheumatic diseases.
1. Diagnostics of rheumatoid arthritis. New classification criteria in rheumatoid arthritis.
Clinical features of the disease. Laboratory and radiological signs.
2. Basic monitoring and therapeutical principals in RA. Assessment of activity and damage.Basic investigations during monitoring of patients.
Activity indexes: DAS28, SDAI, CDAI. What is HAQ index used for? Therapeutical principals in rheumatoid arthritis. Early treatment. Disease modifying therapy. Treat to target (T2T). Strict monitoring of patients.
3. Treatment of RA. Disease modifying drugs in rheumatoid arthritis. Dosage, side effects,
monitoring of patients during treatment with sulphasalazine,methotrexate, leflunomide.
Dosage, side effects, monitoring of patients during treatment with biological therapy, kinase inhibitors. What are the indications for switching disease modifying therapy in rheumatoid arthritis? Assessment of efficacy in the treatment of RA.
4. Diagnosis of SLE. General characteristics, diagnostic steps. Internal manifestations in
lupus. Laboratory tests in lupus. Lupus nephritis. Central nervous system manifestations in lupus.
5. Management and treatment of SLE. Monitoring lupus patients. Therapeutical principals in lupus. Assessment of disease activity and monitoring damage.
6. Primary, secondary antiphospholipid syndrome. Laboratory diagnostics,symptoms, treatment.
7. Sjögren's syndrome - general characteristics. Principals of diagnosis and treatment.
8. Systemic sclerosis. Clinical features, diagnosis. Therapy,assessment of efficacy during
9. Myositis. Main clinical features of polymyositis and dermatomyositis. Classification. Pharmacological and nonpharmacological treatment of myositis. Assessment of efficacy during treatment.
10 Systemic vasculitis. Classification. Primary, secondary vasculitides. Polymyalgia rheumatica, arteritis temporalis. Clinical features and therapy of ANCA associated vasculitides.
11. General characteristics of spondylarthropathies. Peripheral and axial manifestations. Enthesitis. Extraarticular manifestations.
12 Ankylosing spondylitis. Inflammatory back pain. Axial and peripheral involvement in spondylarthropathies. Clinical features and therapy of ankylosing spondylitis. Pharmacological and nonpharmacological treatment of ankylosing spondylitis. Assessment of efficacy during treatment.
13. Psoriatic arthritis. Spondylarthropathies in inflammatory bowel disease.
14. Autoinflammatory syndromes. Sarcoidosis. Macrophage activation syndrome.
Exam´s questions C. Non inflammatory rheumatic diseases.
1. Osteoporosis, clinical features and diagnosis. Primary osteoporosis. Differential diagnosis of secondary osteoporosis.
2. Prevention and treatment of osteoporosis. Pharmacological therapies. Risk factors. Frax index. Prevention. Calcium, vitamin D substitution,role of physiotherapy in the management of osteoporosis.
3. Crystal induced arthropathies. Diagnosis and management of gout.
4. Rheumatological manifestations of metabolic disorders. Acromegaly. Musculo-skeletal abnormalities in diabetes mellitus (DISH syndrome). Musculo-skeletal signs in thyroid disease.
5. Diagnosis, pharmacological and nonpharmacological treatment of fibromyalgia syndrome.
6. Diagnosis and management of osteoarthritis. Clinical features and therapy of knee osteoarthritis. Clinical features and therapy of hip osteoarthritis. Degenerative disorders of the cervical and thoracic spine.
8. Soft tissue disorders.
9. Compression tunnel syndromes.
11. Primary immunodeficiency snydrome: characteristics of CVID. Secondary immunodeficiency disorders. Issue of infectious foci.
12. Bacterial infectious arthritis.
13. Management of anaphylactic shock. List of most common causes.
Mandatory requirements for a successful exam:
1. When do you suspect a systemic autoimmune disease?
2. Autoantibody screening tests, most important specific autoantibody tests.
3. In case of unknown inflammation, what conditions can be considered?
4. Differentiation between pain in degenerative disorders
(osteoarthritis) and inflammatory conditions (arthritis.
5. Main causes of monoarthritis.
6. Main causes of polyarthritis.
7. Main causes of Raynaud´s syndrome.
8. Main causes of proximal muscle weakness.
9. Main causes of dryness of the eyes.
10. What diagnostic steps should be made in upper limb complaints?
11. Most common rheumatological reasons of back pain.
12. Most common non - rheumatological reasons of back pain.
13. Lumboischialgia (sciatica), clinical features.
14. Clinical signs of L4 root damage.
15. Clinical signs of L5 root damage.
16. Clinical signs of S1 root damage.
17. Side effects of NSAIDs.
18. Contraindications of NSAID therapy. Necessary precautions.
19. Side effects of glycocorticoids.
20. What kind of supportive treatment is necessary in case of systemic
21. What is necessary during emergencies in patients on long term
corticosteroid therapy? (infections, injuries)
22. Side effects of cytostatic therapies.
23. Meaning of DMARD.
24. Contraindications and side effects of biological therapy.
25. What are the necessary steps in sterile leukocyturia?
Main rheumatological illnesses.
26. Most common early clinical signs in SLE.
27. Most common laboratory changes in SLE. What is to be done in SLE?
28. Most common clinical signs in antiphospholipid syndrome.
29. Possible reasons of thrombosis in a young patient.
30. Most common early clinical signs in rheumatoid arthritis.
31. Most common laboratory and radiological changes in RA.
32. Most common early clinical signs in ankylosing spondylitis.
33. Most common early clinical signs in psoriatic arthritis.
34. Clinical signs and management in acut arthritis urica.
35. Clinical signs and management in chronic gout.
36. Infectious arthritis, complaints, clinical features, investigations.
Non inflammatory rheumatological conditions.
1. Clinical signs of knee osteoarthritis
2. Clinical signs of hip osteoarthritis
3. Investigations in osteoporosis
4. Calculation of FRAX index
5. Main reasons of secondary osteoporosis
6. Medications that cause osteoporosis. Prevention.
7. Compression fracture of the spine.
8. Most common signs of gout.
9. What should be excluded in case of carpal tunnel syndrome?
10. Management of anaphylactic shock.
Practical skills during patient examination.
1. GALS examination.
2. Characteristic cutaneous signs in rheumatology. (Infectious
arthritis, gout, livedo, scleroderma, erythema, vasculitis, psoriasis).
3. Physical examination of the hand. (synovitis, arterial pulse, skin
signs, characteristic deformities, carpal tunnel syndrome,
Heberden-Bouhard nodes etc.).
4. Differentiation between inflammatory and degenerative back pain.
Pharmacological knowledge necessary in practical and theoretical exam.
2. Specific lymphocyte signaling pathway inhibitors
3. Cytotoxic agents
4.1. Monoclonal antibodies
TNF-alfa or receptor antagonits
IL-1 or receptor antagonists
IL-6 or receptor antagonists
- tocilizumab, sartilumab
CD80/86 (B7) (costimulation)
5. Other immunosupressive agents
Rheumatoid arthritis therapy
2. DMARD - disease modifying antirheumatic drugs
- methotrexate (+leucovorin)
- chloroquin and hydroxychloroquin
- monoclonal antibodies (TNF-alfa, B7, IL-1R, IL-6R, CD20) and kinase
Non steroidal antiinflammatory drugs (NSAID)
1.1. salicilate derivates
- acidum acetilsalicilicum
1.2. Para-aminophenol derivates
- paracetamol (acetaminophen)
1.3. Pirazolon derivates
- metamizol-Na (noraminophenazon-Na-mesylat)
1.4. acidum acetylicum derivates
1.5. Propionic acid derivates
1.6. Enolic acid derivates
1.7. anthranilic acid derivates
1.8. COX-2 specific drugs = coxibs
Medications affecting bone metabolism, calcium homeostasis
1. medications affecting the OPG-RANKL-RANK axis
- denosumab (recombinant OPG)
3. D-vitamins (+Ca)
- synthetic (salmon) calcitonin (salcatonin)
- synthetic (human) calcitonin (recombinant)
1. acute gout treatment
2. Hyperuricaemia treatment
2.1. Uricostatic agents
2.2. Uricolytic agents
2.3. Uricosuric agents