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Question 1
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A 38-year-old woman presents to the clinic with symmetrical polyarthritis affecting her fingers, wrists and elbows. She also reports significant morning stiffness which lasts for up to 90 minutes and is finding it very difficult to get up for work in the morning. There is a history of deep vein thrombosis during her second pregnancy, but no other significant past medical history. Her only medication of note is the oral contraceptive pill.
On examination, she has evidence of active synovitis affecting her wrists and the small joints of her fingers.
Investigations:
Investigation Result Normal value
Haemoglobin 121 g/l 115–155 g/l
White cell count (WCC) 8.1 × 109/l 4–11 × 109/l
Platelets 193 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 110 μmol/l 50–120 µmol/l
Rheumatoid factor Positive
Anti-nuclear factor Weakly positive
Which of the following is the most likely diagnosis?Your Answer: Rheumatoid arthritis
Explanation:Diagnosing Rheumatoid Arthritis: Differential Diagnosis
Rheumatoid arthritis is a common autoimmune disorder that affects the joints, causing morning stiffness and small joint polyarthritis. A positive rheumatoid factor is present in 70% of patients, while anti-CCP antibodies are highly specific for rheumatoid arthritis and can be useful in rheumatoid factor-negative cases.
Other conditions that may present with similar symptoms include systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome, seronegative arthritis, and polymyalgia rheumatica. However, in this case, there are no other features to suggest SLE, one episode of deep vein thrombosis during pregnancy is insufficient to suggest antiphospholipid antibody syndrome, the patient is seropositive for rheumatoid factor ruling out seronegative arthritis, and there is no story of proximal muscle pain which could be suggestive of polymyalgia rheumatica. Therefore, the diagnosis of rheumatoid arthritis is most likely.
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This question is part of the following fields:
- Rheumatology
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Question 2
Correct
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A 65-year-old woman complains of bilateral knee pain that has persisted for 4 months, despite taking paracetamol PRN. Her recent knee X-rays reveal moderate degenerative changes, and she has requested physiotherapy. What additional treatment should be initiated while waiting for physiotherapy?
Your Answer: Topical non-steroidal anti-inflammatories (NSAIDs)
Explanation:Topical non-steroidal anti-inflammatories (NSAIDs) are a good option for patients experiencing knee or hand symptoms. Regular paracetamol or oral NSAIDs are not provided as choices. Co-codamol is effective for moderate-to-severe pain, but should only be used after trying regular paracetamol and NSAIDs due to potential side-effects. Acupuncture is not recommended for osteoarthritis treatment as studies have shown little to no effectiveness. Capsaicin cream can be used if other treatments are ineffective. Glucosamine and chondroitin are not recommended by NICE for osteoarthritis treatment due to inconsistent research outcomes.
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This question is part of the following fields:
- Rheumatology
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Question 3
Correct
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A 68-year-old woman presents with a one-month history of non-specific malaise. She experiences stiffness, particularly in the mornings, and has difficulty lifting her arms to comb her hair. She also has constant pain in her arms, shoulders, and jaw when chewing. She has lost 4 kg in weight and has a persistent headache. She smokes 10 cigarettes a day and drinks 10 units of alcohol per week. On examination, she has tenderness with reduced mobility in the proximal muscles of her arms and legs. Her investigations reveal a low Hb, high WCC, and elevated ESR. What is the most likely diagnosis?
Your Answer: Polymyalgia rheumatica
Explanation:Polymyalgia Rheumatica/Temporal arthritis: Symptoms and Treatment
Polymyalgia rheumatica/temporal arthritis is a condition that can cause a variety of symptoms. It may present with predominantly polymyalgia symptoms such as muscle pain and stiffness, or arthritis symptoms such as headaches, scalp tenderness, and jaw claudication. Systemic features like fever, malaise, and weight loss may also be present. Weakness is not a typical feature, but it may be apparent due to pain or stiffness with weight loss. The ESR (erythrocyte sedimentation rate) is usually very high in this condition.
Temporal arthritis is a serious complication of this condition that can result in blindness. It is important to note that temporal arthritis is a vasculitis that affects medium and large-sized arteries throughout the body, not just the temporal artery. The superficial temporal artery supplies the orbit of the eye and is a branch of the external carotid artery, while the ophthalmic artery supplies the majority of the blood to the eye itself and is a branch of the internal carotid artery. Inflammation and narrowing of the temporal artery can cause blindness.
If temporal arthritis is suspected, it must be treated with high-dose steroids. This condition is a reminder that prompt diagnosis and treatment are crucial to prevent serious complications.
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This question is part of the following fields:
- Rheumatology
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Question 4
Incorrect
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A 61-year-old woman comes to the clinic with complaints of warm, swollen, and painful knuckles, as well as large subcutaneous nodules near her elbows. She also reports experiencing joint stiffness lasting more than an hour in the morning. Upon examination, her PIP joints are hyperextended, and her DIP joints are flexed. If a biopsy were performed on the nodules, what would be the most likely histological appearance?
Your Answer: Amorphous crystalline mass surrounded by macrophages
Correct Answer: Fibrinoid necrosis surrounded by palisading epithelioid cells
Explanation:Differentiating Connective Tissue Pathologies: Histological Characteristics
Connective tissue pathologies can present with a variety of clinical features, making it important to understand their histological characteristics for accurate diagnosis.
Rheumatoid arthritis is characterized by swan neck deformity, subcutaneous nodules, and enlarged knuckles. The histological composition of subcutaneous nodules is areas of fibrinoid necrosis surrounded by palisading epithelioid cells.
Gouty tophi, on the other hand, present as an amorphous crystalline mass surrounded by macrophages.
A cystic space caused by myxoid degeneration of connective tissue is more typical of a ganglion cyst.
Nodular tenosynovitis is a well-encapsulated nodule of polygonal cells within a tendon sheath.
Lastly, pigmented villonodular synovitis is characterized by a darkly pigmented synovium with an exuberant, villous growth.
Understanding the histological characteristics of these connective tissue pathologies can aid in accurate diagnosis and appropriate management.
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This question is part of the following fields:
- Rheumatology
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Question 5
Incorrect
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A patient in their mid-40s wakes up experiencing severe pain, redness, and swelling at the base of their big toe.
What is the most suitable course of treatment for this patient?Your Answer: Allopurinol
Correct Answer: Indomethacin
Explanation:NSAIDs for Gout Treatment
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute attacks of gout. Among the NSAIDs, indomethacin is the most frequently prescribed due to its potent anti-inflammatory properties. However, it is important to note that aspirin and aspirin-containing products should be avoided during acute gout attacks as they can actually trigger or worsen the condition. Therefore, it is crucial to consult with a healthcare provider before taking any medication for gout, especially during an acute attack. Proper use of NSAIDs can help alleviate the pain and inflammation associated with gout, improving the patient’s quality of life.
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This question is part of the following fields:
- Rheumatology
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Question 6
Incorrect
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In which condition is pseudofracture typically observed?
Your Answer: Osteopetrosis
Correct Answer: Osteomalacia
Explanation:Osteomalacia: Causes and Symptoms
Osteomalacia is a condition that occurs due to a deficiency of vitamin D. This condition can be caused by various factors such as malabsorption, renal disease, chronic renal failure, and anticonvulsant therapy. The most common symptom of osteomalacia is bone pain, which is often accompanied by a proximal myopathy. These symptoms are also known as Looser’s zones.
Malabsorption, which is the inability of the body to absorb nutrients from food, can lead to osteomalacia. Renal disease, such as familial hypophosphataemic rickets, can also cause this condition. Chronic renal failure, which is the gradual loss of kidney function, can also lead to osteomalacia. Additionally, anticonvulsant therapy, which is used to treat seizures, can cause a deficiency of vitamin D and lead to osteomalacia.
If you experience bone pain or a proximal myopathy, it is important to seek medical attention. A doctor can diagnose osteomalacia through blood tests and imaging studies. Treatment typically involves vitamin D and calcium supplements, as well as addressing the underlying cause of the deficiency. With proper treatment, the symptoms of osteomalacia can be managed and the condition can be prevented from worsening.
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This question is part of the following fields:
- Rheumatology
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Question 7
Incorrect
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A 24-year-old Caucasian farmer presents to the outpatient department with a complaint of lower back pain that has been bothering him for the past two months. He reports that the pain is at its worst in the morning. He also experiences intermittent pain and swelling in his right ankle, which he injured while running a year ago. Two weeks ago, he visited the Emergency department with a painful red eye, which was treated with eye drops. He is a heavy smoker, consuming 45 cigarettes a day, and drinks five pints of beer every weekend. He denies any skin rashes or mucosal ulceration. His mother had rheumatoid arthritis, and his father had severe gout. On direct questioning, he admits to being diagnosed with chlamydia four months ago. During the examination, his right ankle was swollen at the site of Achilles' tendon insertion, but all other joints were unremarkable. Flexion of the lumbar spine was reduced. What is the most likely diagnosis for this man?
Your Answer: Behçet's syndrome
Correct Answer: Ankylosing spondylitis
Explanation:Spondyloarthritis: A Group of Related Disorders
The patient’s history suggests the presence of spondyloarthritis, which is a group of related but distinct disorders. These include ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and a subgroup of juvenile idiopathic arthritis. HLA-B27 is a predisposing factor for all these disorders and is present in a high percentage of patients with ankylosing spondylitis and reactive arthritis. Ankylosing spondylitis is a severe form of spondyloarthritis that mainly affects the entheses and leads to spinal immobility. TNF-antagonists are the primary treatment, but physiotherapy and non-steroidal anti-inflammatory agents also have a role.
Reactive arthritis is the most common type of inflammatory polyarthritis in young men and is an important differential diagnosis in this case. It typically follows genitourinary infection with Chlamydia trachomatis or enteric infections with certain strains of Salmonella or Shigella. Treatment with doxycycline can sometimes shorten the course of the disease if associated with Chlamydia infection. In general, non-steroidal anti-inflammatories are used for treatment, with intra-articular corticosteroids if large joints are involved.
In conclusion, spondyloarthritis is a group of related disorders that share a common predisposing factor and can cause significant morbidity. Ankylosing spondylitis and reactive arthritis are two of the most common types, and their diagnosis should be considered in patients with suggestive symptoms. Treatment options include TNF-antagonists, non-steroidal anti-inflammatory agents, and physiotherapy.
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This question is part of the following fields:
- Rheumatology
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Question 8
Incorrect
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A 40-year-old farmer presents to the clinic with muscle pain in his lower back, calves and neck. He takes regular paracetamol but this has not helped his symptoms. For the past four weeks, he has become increasingly agitated and reports that he can no longer sleep for more than a few hours because the pain wakes him up. He feels increasingly lethargic and helpless. He also reports that as a result of his pain, he feels that his memory has worsened and he reports a low mood. A Kessler Psychological Distress Scale screening questionnaire is performed and he has a score of 30. His laboratory blood tests are unremarkable.
What is the most appropriate treatment for this patient?Your Answer: Psychotherapy
Correct Answer: Duloxetine
Explanation:Pharmacological Treatments for Fibromyalgia Pain: Choosing the Right Option
Fibromyalgia is a chronic pain disorder that can be challenging to manage. Duloxetine, pregabalin, and tramadol are all appropriate pharmacological treatments for severe pain disturbance in fibromyalgia. However, the choice of which treatment to use depends on the patient’s co-morbidities, clinical presentation, and patient preference.
In this case, the patient has comorbid low mood and possible depression, making duloxetine a reasonable choice. Venlafaxine, another serotonin and norepinephrine reuptake inhibitor, may be theoretically useful, but there is insufficient evidence for its use. Codeine and paracetamol have been shown to be ineffective in treating fibromyalgia pain.
While psychotherapy may be considered for patients with pain-related depression and adverse coping mechanisms, it is not the correct answer for this patient. Overall, choosing the right pharmacological treatment for fibromyalgia pain requires careful consideration of the patient’s individual needs and circumstances.
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This question is part of the following fields:
- Rheumatology
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Question 9
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A 35-year-old woman presents with increasing early-morning bilateral knee pain and stiffness and generalised fatigue. On examination, she is noted to have flat erythema over the malar eminences with sparing of the nasolabial folds. Multiple painless oral ulcers are also noted. Examination of the knee joints reveals tenderness and suprapatellar effusions bilaterally.
Which of these is most specific for the underlying condition?Your Answer: Anti-double-stranded DNA (dsDNA) antibody
Explanation:Systemic lupus erythaematosus (SLE) is an autoimmune disease where the body produces autoantibodies against various antigens, leading to the formation of immune complexes that can deposit in different parts of the body, such as the kidneys. Symptoms of SLE include fatigue, joint pain, rash, and fever. Diagnosis of SLE requires the presence of at least four out of eleven criteria, including malar rash, discoid rash, photosensitivity, oral or nasopharyngeal ulceration, arthritis, serositis, renal disorder, CNS disorders, haematological disorders, positive immunology, and positive ANA. Anti-double-stranded DNA (dsDNA) antibody is highly specific for SLE but only positive in 60% of patients. Other antibodies, such as anti-La antibodies, rheumatoid factor IgG, ANCA, and Scl70, are raised in other autoimmune diseases such as Sjögren’s syndrome, rheumatoid arthritis, and various vasculitides.
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This question is part of the following fields:
- Rheumatology
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Question 10
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A 25-year-old man with inflammatory bowel disease has been experiencing lower back pain, stiffness, and buttock pain for the past six months. He notices that his pain improves after playing squash on Saturdays. He has tested positive for HLA-B27 and his blood tests, including C-reactive protein and erythrocyte sedimentation rate, are normal except for a mild hypochromic microcytic anemia. What is the most likely diagnosis?
Your Answer: Ankylosing spondylitis
Explanation:Understanding Different Types of Arthritis: Ankylosing Spondylitis, Osteoarthritis, Prolapsed Intervertebral Disc, Reactive Arthritis, and Rheumatoid Arthritis
Ankylosing spondylitis is a type of arthritis that commonly affects the sacroiliac joints, causing pain and stiffness that improves with exercise. It may also involve inflammation of the colon or ileum, which can lead to inflammatory bowel disease in some cases. The presence of the HLA-B27 gene is often associated with ankylosing spondylitis. Osteoarthritis, on the other hand, is unlikely in younger individuals and is not linked to bowel disease. Prolapsed intervertebral disc is characterized by severe lower back pain and sciatica, but stiffness is not a typical symptom. Reactive arthritis is usually triggered by a recent GI illness or sexually transmitted infection and is associated with arthritis, a psoriatic type rash, and conjunctivitis. Finally, rheumatoid arthritis rarely affects the sacroiliac joints as the primary site. It is important to understand the differences between these types of arthritis to receive proper diagnosis and treatment.
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This question is part of the following fields:
- Rheumatology
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