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Question 1
Incorrect
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A 30-year-old Afro-Caribbean woman presents with bilateral ankle and wrist pain that has been gradually worsening over the past 5 days. She complains of fatigue and feelings of lack of energy. She mentions a dry cough and shortness of breath on exertion, lasting for more than a year. On examination, her vital signs are within normal limits, except for the presence of a mild fever. There are several reddish, painful, and tender lumps on the anterior of the lower legs. A chest X-ray shows bilateral hilar masses of ,1 cm in diameter.
Which of the following test results is most likely to be found in this patient?Your Answer: Elevated cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA)
Correct Answer: Elevated serum angiotensin-converting enzyme (ACE)
Explanation:Differentiating between Elevated Serum Markers in a Patient with Arthropathy and Hilar Lymphadenopathy
The presence of arthropathy and hilar lymphadenopathy in a patient can be indicative of various underlying conditions. In this case, the patient’s elevated serum markers can help differentiate between potential diagnoses.
Elevated serum angiotensin-converting enzyme (ACE) is a common finding in sarcoidosis, which is likely the cause of the patient’s symptoms. Bilateral hilar lymphadenopathy with or without pulmonary fibrosis is the most typical radiological sign of sarcoidosis. Additionally, acute arthropathy in sarcoidosis patients, known as Löfgren syndrome, is associated with erythema nodosum and fever.
On the other hand, elevated cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA) is present in granulomatosis with polyangiitis (GPA), which presents with necrotising granulomatous lesions in the upper and lower respiratory tract and renal glomeruli. It is not typically associated with hilar lymphadenopathy.
Hyperuricaemia and elevated double-stranded (ds) DNA antibody are not relevant to this case, as they are not associated with the patient’s symptoms. Hyperglycaemia is also not a factor in this case.
In conclusion, the combination of arthropathy and hilar lymphadenopathy can be indicative of various underlying conditions. Elevated serum markers can help differentiate between potential diagnoses, such as sarcoidosis and GPA.
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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 68-year-old woman who has suffered many years from aggressive rheumatoid arthritis presents for review. Most recently, she has suffered from two severe respiratory tract infections (which have been treated with oral clarithromycin) and has had worsening left upper quadrant pain. She currently takes low-dose prednisolone for her rheumatoid. On examination, there are obvious signs of active rheumatoid disease. Additionally, you can feel the tip of her spleen when you ask her to roll onto her right-hand side.
Investigations:
Investigation Result Normal value
Haemoglobin 91 g/l 115–155 g/l
White cell count (WCC) 1.9 × 109/l (neutrophil 0.9) 4–11 × 109/l
Platelets 90 × 109/l 150–400 × 109/l
Rheumatoid factor +++
Erythrocyte sedimentation rate (ESR) 52 mm/h 0–10mm in the 1st hour
Which of the following is the most likely diagnosis in this case?Your Answer: Sarcoidosis
Correct Answer: Felty’s syndrome
Explanation:Differential Diagnosis for a Patient with Splenomegaly, Neutropenia, and Active Rheumatoid Disease
Felty’s Syndrome:
The patient’s symptoms of splenomegaly, neutropenia, and active rheumatoid disease suggest Felty’s syndrome. This condition is thought to occur due to the sequestration and destruction of granulocytes, potentially caused by reduced granulocyte growth factors and autoantibodies/immune complexes formed against them. Felty’s syndrome affects 1-3% of patients with rheumatoid arthritis and has a higher prevalence in females. Treatment typically involves the use of methotrexate as a disease-modifying anti-rheumatic drug, with splenectomy reserved as a last resort.Lymphoma:
While lymphoma can present with lymphadenopathy, the absence of B-symptoms such as fever, night sweats, weight loss, or pruritus makes this diagnosis less likely in this case.Myeloma:
Myeloma often presents with anaemia and bone pain, as well as hypercalcaemia. Serum and urine electrophoresis are important investigations for this condition.Sarcoidosis:
Sarcoidosis commonly presents with respiratory symptoms such as wheeze, cough, and shortness of breath, as well as erythema nodosum and lymphadenopathy on examination. While the patient has a history of lower respiratory tract infections, her response to clarithromycin suggests an infective cause rather than sarcoidosis.Tuberculosis:
The patient does not have any clinical features or risk factors for tuberculosis. -
This question is part of the following fields:
- Rheumatology
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Question 3
Incorrect
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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: Osteoporosis
Correct 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
Incorrect
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A 58-year-old woman has been scheduled for a left total knee replacement in one month’s time. She has a past medical history significant for rheumatoid arthritis (RA), for which she takes methotrexate and hydroxychloroquine.
Which of the following investigations would be most important before the patient’s operation?Your Answer: Electrocardiogram (ECG)
Correct Answer: Cervical spine X-rays
Explanation:The Importance of Pre-Operative Testing for a Patient with Rheumatoid Arthritis
Patients with rheumatoid arthritis (RA) require special considerations before undergoing elective surgery. One important test to consider is a cervical spine X-ray, as RA can lead to subluxation and instability in the cervical spine. This is particularly important for patients who will be intubated during surgery, as neck manipulation can exacerbate any underlying instability.
Another important consideration for RA patients is regular eye exams to test for retinal toxicity, especially for those taking hydroxychloroquine as part of their treatment regimen. However, this is not necessarily required before elective surgery.
While rheumatoid factor levels and anti-citrullinated protein antibody levels can be elevated in RA patients, they are not the most important tests to consider before surgery. Instead, a plain film of the cervical spine should be the primary investigation for patients with a history of RA.
Overall, pre-operative testing for RA patients should be tailored to their specific needs and potential risks during surgery.
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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 married man was on a business trip in Thailand when he developed diarrhoea that lasted for 1 week. He returned to the United States and, a few weeks later, visited his primary care physician (PCP) complaining of pain in his knee and both heels. His eyes have become red and he has developed some painless, red, confluent plaques on his hands and feet, which his PCP has diagnosed as psoriasis.
What is the most probable diagnosis?Your Answer: Reactive arthritis
Explanation:Understanding Reactive Arthritis and Differential Diagnosis
Reactive arthritis is a condition characterized by the presence of urethritis, arthritis, and conjunctivitis. It typically occurs 1-3 weeks after an initial infection, with Chlamydia trachomatis and Salmonella, Shigella, and Campylobacter being the most common causative agents. In addition to the classic triad of symptoms, patients may also experience keratoderma blennorrhagica and buccal and lingual ulcers.
When considering differential diagnoses, it is important to note that inflammatory arthritides can be seropositive or seronegative. Seronegative spondyloarthritides include ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, reactive arthritis, and gonococcal arthritis.
Gonococcal arthritis is a form of septic arthritis that typically affects a single joint and presents with a hot, red joint and systemic signs of infection. Ankylosing spondylitis, on the other hand, does not present with any clinical features in this patient. Enteropathic arthritis is associated with inflammatory bowel disease, which is less likely in a patient with a recent history of travel and diarrhea. Psoriatic arthritis is unlikely to present simultaneously with psoriasis in a young, previously healthy patient without any prior history of either condition.
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This question is part of the following fields:
- Rheumatology
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Question 6
Incorrect
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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: antiphospholipid antibody syndrome
Correct 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 7
Incorrect
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A 61-year-old man presented to his general practitioner with complaints of pain in his right big toe. He reported experiencing severe pain that disturbed his sleep at night. The patient has a medical history of hypertension and is currently taking thiazide diuretics. He consumes alcohol most nights of the week. During his last visit to the doctor, he was prescribed antibiotics for painful urination. Upon examination, the doctor observed tenderness, redness, and warmth in the right first metatarsophalangeal joint. The doctor decided to perform joint aspiration.
What is the most probable diagnosis?Your Answer: Osteomyelitis
Correct Answer: Gout
Explanation:Common Joint Disorders and Infections
Gout, psoriatic arthritis, pseudogout, septic arthritis, and osteomyelitis are all joint disorders and infections that can cause pain, swelling, and redness in affected joints. Gout is caused by crystal deposition in the joint, most commonly in the big toe, and can be triggered by certain medications, trauma, infection, surgery, and alcohol consumption. Psoriatic arthritis is associated with psoriatic nail disease and can cause sausage-shaped digits, with DIPJs being the most commonly affected joints. Pseudogout occurs due to the deposition of calcium pyrophosphate dehydrate crystals in the joint and usually affects knee joints in patients with previous joint damage. Septic arthritis is caused by joint infection, with gonococci being the most common organism in young patients and Staphylococcus aureus in older patients with pre-existing joint damage. Osteomyelitis is an infection of the bone caused by various organisms and presents with redness, swelling, pain, and tenderness over the affected bone.
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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 patient presented to his General Practitioner (GP) with complaints of back pain and painful urination. He had visited his GP two days earlier for eye problems. The patient's mother has a history of rheumatoid arthritis, and he also reported experiencing pain in his ankle. What is the most probable diagnosis?
Your Answer: Enteropathic arthropathy
Correct Answer: Reactive arthritis
Explanation:Reactive arthritis is a type of arthropathy that is seronegative and has a positive HLA-B27. It typically presents with arthritis, urethritis, and conjunctivitis, with the knee and sacroiliac joints being the most commonly affected. Enthesitis and mucocutaneous lesions may also be present. Reactive arthritis is often triggered by a previous infection, such as Salmonella, Campylobacter, or Shigella.
Psoriatic arthritis is associated with psoriatic nail disease and can cause sausage-shaped digits, with the distal interphalangeal joints being the most commonly affected.
Osteoarthritis primarily affects articular cartilage, with the knee joint being the most commonly affected. It typically occurs after the age of 50 and is characterized by minimal morning stiffness, bony tenderness, bony enlargement, and crepitus on active motion. Systemic manifestations are not present in osteoarthritis, and it is more common in females, those who have experienced joint trauma, and those who are obese.
Ankylosing spondylitis is an inflammatory disorder that primarily affects the axial skeleton and is more common in men. It is characterized by chronic lower back pain, morning stiffness lasting at least 1 hour, and improvement with exercise. Extra-articular features of ankylosing spondylitis include anterior uveitis, aortic insufficiency, enthesitis, and restrictive lung disease.
Enteropathic arthropathy is commonly associated with inflammatory bowel disease and can become severe during flares of ulcerative colitis and Crohn’s disease.
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This question is part of the following fields:
- Rheumatology
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Question 9
Correct
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A 20-year-old patient presents with purpura on his back, buttocks and extensor surface of his lower limbs. He has dipstick haematuria.
Which one of the following is the most likely diagnosis?Your Answer: Henoch–Schönlein purpura
Explanation:Differential Diagnosis for a Young Man with Purpura and Haematuria
The patient in question presents with a purpuric rash on the back, buttocks, and extensor surfaces of the lower limbs, as well as haematuria. The following is a differential diagnosis of possible conditions that could be causing these symptoms.
Henoch–Schönlein purpura (HSP)
The clinical presentation is entirely typical of HSP, a vasculitic process that results in a purpuric rash and haematuria. It should be noted that platelet numbers are usually normal or raised in HSP, so thrombocytopaenia is not expected.Haemophilia A
This condition is not likely as it results in joint and muscle bleeding, which is not present in this case. Additionally, haemophilia would not cause haematuria.Idiopathic thrombocytopaenic purpura (ITP)
While purpura is a symptom of ITP, a reduced platelet count is typically present. Without a discussion of platelet levels, it is difficult to justify a diagnosis of ITP. Additionally, ITP would not result in haematuria.Leukaemia
If acute leukaemia were causing the symptoms, thrombocytopaenia might be expected. However, the clinical presentation is more compatible with HSP, and thrombocytopaenia alone would not result in haematuria.Thalassaemia trait
There is no indication in the history to suggest this condition, and it would not result in purpura. Thalassaemia trait is typically asymptomatic.In conclusion, the patient’s symptoms are most consistent with HSP, a vasculitic process that results in a purpuric rash and haematuria.
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This question is part of the following fields:
- Rheumatology
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Question 10
Incorrect
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A 56-year-old carpenter presents to the general practitioner (GP) with an acutely swollen and painful left thumb. The pain came on rapidly over the course of 24 hours, without history of trauma or injury. The patient describes the thumb as being extremely painful and particularly tender to touch. The patient is a type 2 diabetic, which is well controlled with metformin. He does not smoke, but drinks around ten pints of beer at weekends.
Examination reveals a swelling, erythema and tenderness over the first metacarpophalangeal joint. The clinician suspects a possible crystal arthropathy.
With regard to gout, which of the following statements is true?Your Answer: A diagnosis of gout is made if there are positively birefringent crystals in the joint aspirate
Correct Answer: Gout may be seen in patients with chronic haemolytic anaemia
Explanation:Mythbusting Gout: Clarifying Common Misconceptions
Gout is a painful and often misunderstood condition. Here are some common misconceptions about gout, and the truth behind them:
1. Gout may be seen in patients with chronic haemolytic anaemia.
2. Gout may occur in those with elevated urate levels (although levels may be normal during an acute attack) such as those with haemolytic anaemia.
3. Gout only affects the first metacarpophalangeal (MCP) joint.
4. Gout most commonly affects the first metatarsophalangeal joint. However, it is not the only joint affected.
5. Allopurinol is effective in the treatment of acute gout.
6. Acute gout is treated with non-steroidal anti-inflammatory drugs (NSAIDs), colchicine or prednisolone, but not allopurinol. Allopurinol is effective in the prevention of gout because it reduces serum urate levels by blocking urate production (xanthine oxidase inhibition).
7. A diagnosis of gout is made if there are positively birefringent crystals in the joint aspirate.
8. Gout is an inflammatory arthritis that occurs as a result of deposition of negatively birefringent urate crystals in the joint.
9. All cases of acute gout have an elevated serum urate.
10. Although a raised serum urate can be used to support the diagnosis, many will not be raised. Similarly, if a patient has a raised serum urate, they do not automatically have the clinical picture of gout.In conclusion, it is important to dispel these common myths about gout in order to properly diagnose and treat this painful condition.
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This question is part of the following fields:
- Rheumatology
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SESSION STATS - PERFORMANCE PER SPECIALTY
