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Question 1
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A 50-year-old woman presents to her General Practitioner with widespread pain for the past month. The pain radiates all over but is worse in her shoulders, neck and lower back. It tends to be worse in the mornings and in cold weather. She reports that she is not able to sleep and feels lethargic during the day. Her partner reports that she has been more forgetful recently. She has otherwise been well without recent illnesses. On examination, there is clear tenderness to the affected areas. There are no other significant findings.
Which of the following is an appropriate first-line treatment for this patient?Your Answer: Aerobic exercise
Explanation:Treatment Options for Fibromyalgia Patients
Fibromyalgia is a chronic condition that causes widespread pain, increased sensitivity to pain, and psychological symptoms. Treatment options can be divided into generic and patient-focused treatments. Aerobic exercise is a first-line, generic treatment that has been shown to improve symptoms of pain and physical function. Cognitive behavioral therapy (CBT) is a patient-focused treatment that may be considered for patients with pain-related depression, anxiety, catastrophizing, and/or passive or active coping strategies. Anaerobic exercise should be avoided as it may increase inflammation and oxidative stress. Duloxetine and pregabalin are pharmacotherapy options for patients with severe pain or sleep disturbance, but only after non-pharmacological treatments have failed. It is important to tailor treatment to each patient’s individual needs.
Treatment Options for Fibromyalgia Patients
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This question is part of the following fields:
- Rheumatology
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Question 2
Incorrect
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A 65-year-old woman presents to the Emergency department with increasing breathlessness and coughing up of small amounts of blood over the past one week. She also complains of frequent nosebleeds and headaches over the past two months. She feels generally lethargic and has lost a stone in weight.
She is noted to have a purpuric rash over her feet. Chest expansion moderate and on auscultation there are inspiratory crackles at the left lung base.
Investigations show:
Haemoglobin 100 g/L (115-165)
White cell count 19.9 ×109/L (4-11)
Platelets 540 ×109/L (150-400)
Plasma sodium 139 mmol/L (137-144)
Plasma potassium 5.3 mmol/L (3.5-4.9)
Plasma urea 30.6 mmol/L (2.5-7.5)
Plasma creatinine 760 µmol/L (60-110)
Plasma glucose 5.8 mmol/L (3.0-6.0)
Plasma bicarbonate 8 mmol/L (20-28)
Plasma calcium 2.23 mmol/L (2.2-2.6)
Plasma phosphate 1.7 mmol/L (0.8-1.4)
Plasma albumin 33 g/L (37-49)
Bilirubin 8 µmol/L (1-22)
Plasma alkaline phosphatase 380 U/L (45-105)
Plasma aspartate transaminase 65 U/L (1-31)
Arterial blood gases on air:
pH 7.2 (7.36-7.44)
pCO2 4.0 kPa (4.7-6.0)
pO2 9.5 kPa (11.3-12.6)
ECG Sinus tachycardia
Chest x ray Shadow in left lower lobe
Urinalysis:
Blood +++
Protein ++
What is the most likely diagnosis?Your Answer: Goodpasture's disease
Correct Answer: Granulomatosis with polyangiitis
Explanation:Acid-Base Disorders and Differential Diagnosis of Granulomatosis with Polyangiitis
In cases of metabolic acidosis with respiratory compensation, the primary issue is a decrease in bicarbonate levels and pH, which is accompanied by a compensatory decrease in pCO2. On the other hand, respiratory acidosis with metabolic compensation is characterized by an increase in pCO2 and a decrease in pH, which is accompanied by a compensatory increase in bicarbonate levels.
When nosebleeds are present, the diagnosis of Granulomatosis with polyangiitis is more likely than microscopic polyarteritis due to upper respiratory tract involvement. Goodpasture’s disease is less likely because it does not cause a rash. In particular, 95% of patients with Granulomatosis with polyangiitis develop antineutrophil cytoplasmic antibodies (cytoplasmic pattern) or cANCAs, with proteinase-3 being the major c-ANCA antigen. Conversely, perinuclear or p-ANCAs are directed against myeloperoxidase, are non-specific, and are detected in various autoimmune disorders.
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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 72-year-old man presents for review, complaining of pain in his knees. There is also stiffness in his fingers and he finds it difficult to use his computer. There is a history of hypertension, for which he takes amlodipine 10 mg, and type II diabetes, for which he takes metformin. He had been given a diagnosis of ulcerative colitis some years ago but has had no recent symptoms. On examination, he has a body mass index (BMI) of 34; blood pressure is 150/90 mmHg, and he has swelling and bony deformity of both knees. There is crepitus and anterior knee pain on flexion. Examination of the hands reveals Heberden’s nodes.
Investigations:
Investigation Result Normal value
Haemoglobin 120 g/dl 115–155 g/l
White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
Platelets 240 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate 12 mm/h 0–10mm in the 1st hour
Rheumatoid factor Negative
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
Creatinine 130 μmol/l 50–120 µmol/l
X-ray of both knees reveals reduced joint space, subchondral sclerosis and cyst formation and osteophytes within the joint space.
Which of the following fits best with the diagnosis?Your Answer: Osteoarthritis
Explanation:The woman in the picture appears to have osteoarthritis, which is commonly seen in overweight individuals affecting weight-bearing joints like the knees. The changes in her hands also suggest osteoarthritis. Treatment options include weight reduction, pain relief medication like paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy, or knee replacement surgery. Rheumatoid arthritis is unlikely as her ESR and rheumatoid factor are normal. Seronegative arthritis is also unlikely as it is associated with raised inflammatory markers, which are not present in this case. Enteropathic arthropathy is unlikely as there are no recent symptoms of inflammatory bowel disease. Osteoporosis is not a likely diagnosis as it does not cause knee or finger pain, but rather presents following a fracture.
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This question is part of the following fields:
- Rheumatology
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Question 4
Correct
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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 5
Correct
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A 35-year-old woman presented with fever and joint pain. During her consultation with the doctor, the doctor observed a rash on both cheeks. A kidney biopsy sample showed deposits of immunoglobulin, C3, and fibrinogen in the basement membrane. Her serum analysis revealed elevated levels of anti-dsDNA antibody. What is the most probable diagnosis?
Your Answer: Systemic lupus erythematosus (SLE)
Explanation:Systemic lupus erythematosus (SLE) is an autoimmune disorder that predominantly affects young women. It is characterized by a photosensitive butterfly-shaped rash on the face and joint manifestations. Unlike rheumatoid arthritis, SLE does not cause severe destruction of joints. SLE is a multisystem condition that can affect many systems, including haematological, renal, respiratory, and cardiac systems. The underlying pathological mechanism of damage in SLE is immune complex deposition, which produces antibodies against several nuclear components of the body, especially against double-stranded DNA (dsDNA). Antinuclear antibodies (ANA) and dsDNA are associated with SLE, as is a low C3 and C4. The immunoglobulin, C3 and fibrinogen deposits found in this patient are classic of the immune complex deposition seen in SLE.
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This question is part of the following fields:
- Rheumatology
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Question 6
Correct
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A 54-year-old man was diagnosed with rheumatoid arthritis and started on methotrexate. After six months, there was no improvement. He was switched to a combination of methotrexate and sulfasalazine, but there was still no improvement after a similar period of therapy.
What is the most effective treatment option at this point?Your Answer: Infliximab plus methotrexate
Explanation:Treatment Options for Rheumatoid Disease: A Comparison of Biological Therapies and DMARDs
Rheumatoid disease can be a debilitating condition that requires careful management. When standard disease-modifying anti-rheumatic drugs (DMARDs) fail to provide relief, biological therapies may be prescribed. Infliximab, adalimumab, and etanercept are some of the contemporary biological therapies available. Infliximab, in particular, is often co-prescribed with methotrexate, although it may cause a reversible lupus-like syndrome and tuberculosis reactivation.
Combining gold, leflunomide, and methotrexate is unlikely to help patients who have already failed DMARD therapy. Azathioprine may be considered in severe cases, but biological therapy is the preferred treatment when intensive DMARD therapy fails. The combination of gold and penicillamine is a viable option for patients who meet the criteria for biological therapy, according to National Institute for Health and Care Excellence (NICE) guidelines. DMARD monotherapy, such as leflunomide, is only recommended when dual therapy is contraindicated.
In summary, the choice of treatment for rheumatoid disease depends on the severity of the condition and the patient’s response to previous therapies. Biological therapies may offer relief for patients who have failed DMARD therapy, but careful monitoring for potential side effects is necessary.
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This question is part of the following fields:
- Rheumatology
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Question 7
Correct
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A 55-year-old carpet layer presented with acute pain and swelling affecting his left knee. There is no history of trauma. Past medical history includes haemochromatosis for which he receives regular venesection.
Examination reveals a hot, tender, swollen left knee.
Investigations:
Investigation Result Normal value
Haemoglobin 135 g/l 135–175 g/l
White cell count (WCC) 4.0 × 109/l 4–11 × 109/l
Platelets 200 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 12 mm/h 0–10mm in the 1st hour
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 5.0 mmol/l 3.5–5.0 mmol/l
Creatinine 120 μmol/l 50–120 µmol/l
Knee aspirate: 12 000 white blood cells/ml (majority neutrophils); rhomboid-shaped, weakly positively birefringent crystals. No growth on culture.
Which of the following is the most likely diagnosis in this case?Your Answer: Pseudogout
Explanation:Differential Diagnosis for Knee Aspirate: Pseudogout, Gout, prepatellar Bursitis, Septic Arthritis, Osteoarthritis
A knee aspirate was performed on a patient who presented with knee pain. The aspirate revealed positively birefringent calcium pyrophosphate crystals, indicating pseudogout. This condition is associated with haemochromatosis and can be treated with non-steroidal anti-inflammatory agents, corticosteroid injections, or short courses of oral corticosteroids. Colchicine may also be an option for some patients. Familial pyrophosphate arthropathy, a rare form of the condition, may be linked to mutations in genes related to inorganic phosphate transport.
Gout is a differential diagnosis for this case, but the knee aspirate would reveal negatively birefringent crystals. prepatellar bursitis, a sterile condition not associated with crystals or raised white cell counts, can be ruled out. Septic arthritis would present with a systemic inflammatory response and rhomboid-shaped birefringent crystals would not be present. Osteoarthritis is a chronic condition and would not present acutely, and joint aspirate would not show rhomboid-shaped birefringent crystals.
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This question is part of the following fields:
- Rheumatology
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Question 8
Correct
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A 30-year-old white man comes to his general practitioner complaining of progressive low back pain over the past four years. The pain is worse at night when he lies down and improves as he moves around during the day, but it does not go away with rest. Upon further questioning, he reports having experienced three episodes of acute eye pain with sensitivity to light and blurry vision in the past two years. He sought treatment from an ophthalmologist, and the symptoms resolved with steroids and eye drops. X-rays reveal some inflammatory and arthritic changes in the sacroiliac joints. Despite treatment, the disease has continued to progress, and ten years later, x-rays show calcification of the anterior spinal ligament. What is the most likely positive finding in this patient?
Your Answer: HLA-B27
Explanation:Understanding HLA and Autoimmune Diseases
HLA-B27 is a genetic marker associated with ankylosing spondylitis, an autoimmune disease that primarily affects the spine. This disease is more common in males and typically presents in the 20s and 30s. Other autoimmune manifestations, such as anterior uveitis, can also occur in individuals with HLA-B27. Additionally, young men with this genetic marker may be prone to reactive arthritis after chlamydia or gonorrhoeal urethritis.
Rheumatoid factor, on the other hand, is not associated with HLA-B27 or ankylosing spondylitis. While stiffness that improves with exercise may be seen in rheumatoid arthritis, this disease typically affects peripheral joints and does not lead to calcification of the anterior spinal ligament.
Other HLA markers are associated with different autoimmune diseases. HLA-DR3 is linked to type 1 diabetes mellitus, HLA-DR5 is associated with pernicious anaemia and Hashimoto’s thyroiditis, and HLA-B8 is linked to Graves’ disease. Understanding these genetic markers can aid in the diagnosis and management of autoimmune diseases.
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This question is part of the following fields:
- Rheumatology
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Question 9
Incorrect
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A 25-year-old intravenous drug user (ivDU) comes in with a swollen and painful right knee. Upon examination, there is joint effusion and pyrexia, and frank pus is aspirated. What is the most probable infecting organism?
Your Answer: Haemophilus influenzae
Correct Answer: Staphylococcus aureus
Explanation:Common Organisms in Septic Arthritis
Septic arthritis is a serious condition that occurs when a joint becomes infected. The most common organism causing septic arthritis is Staphylococcus aureus. Pseudomonas spp can also cause septic arthritis, but it is less likely than S. aureus, especially in intravenous drug users. Escherichia coli is another pathogen that can cause septic arthritis, but it is less common than S. aureus. In children under the age of two, Haemophilus influenzae is the most common organism causing septic arthritis. Neisseria gonorrhoeae is a common cause of arthritis in the United States, but it is uncommon in Western Europe. It is important to identify the causative organism in order to provide appropriate treatment for septic arthritis.
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This question is part of the following fields:
- Rheumatology
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Question 10
Correct
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A 33-year-old woman presents to the hospital with recent-onset renal impairment after experiencing sinusitis. Upon chest X-ray, multiple cavitating lung lesions are discovered. The medical team suspects granulomatosis with polyangiitis (GPA). What is the most effective blood test to confirm this diagnosis?
Your Answer: c-ANCA (antineutrophil cytoplasmic antibody)
Explanation:Autoantibodies and their Associated Diseases
Autoantibodies are antibodies produced by the immune system that mistakenly target and attack the body’s own tissues. Here are some common autoantibodies and the diseases they are associated with:
1. c-ANCA (antineutrophil cytoplasmic antibody): GPA, a necrotising small-vessel vasculitis that commonly affects the kidneys and lungs.
2. Antimitochondrial antibody: primary biliary cholangitis.
3. Anti Glomerular basement membrane antibody: Goodpasture’s syndrome, a rare autoimmune disease that affects the lungs and kidneys.
4. p-ANCA (perinuclear ANCA): Eosinophilic Granulomatosis with Polyangiitis (previously known as Churg–Strauss syndrome), a rare autoimmune disease that affects the blood vessels.
5. Anti-acetylcholine receptor antibody: myasthenia gravis, a neuromuscular disorder that causes muscle weakness and fatigue.
Understanding the association between autoantibodies and their associated diseases can aid in diagnosis and treatment.
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This question is part of the following fields:
- Rheumatology
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SESSION STATS - PERFORMANCE PER SPECIALTY
