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Question 1
Incorrect
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A 65-year-old woman complains of discomfort at the base of her left thumb. The right first carpometacarpal joint is swollen and tender.
What could be the probable diagnosis?Your Answer: Avascular necrosis of the scaphoid
Correct Answer: Osteoarthritis
Explanation:Common Hand and Wrist Pathologies
The hand and wrist are common sites of pathology, particularly in postmenopausal women. Osteoarthritis frequently affects the first carpometacarpal joint, causing tenderness, stiffness, crepitus, swelling, and pain on thumb abduction. This can lead to squaring of the hand, radial subluxation of the metacarpal, and atrophy of the thenar muscles.
Scaphoid fractures are also relatively common, often resulting from a fall onto an outstretched hand. The proximal portion of the scaphoid lacks its own blood supply, which can lead to avascular necrosis if a fracture isolates it from the rest of the bone. This produces pain and tenderness on the radial side of the wrist, typically in the anatomical snuffbox, worsened by wrist movement.
De Quervain’s tenosynovitis is another common pathology, characterized by stenosing tenosynovitis of the first dorsal compartment of the wrist. It presents with pain, swelling, and tenderness on the radial aspect of the wrist. Treatment typically involves splinting, with or without corticosteroid injection.
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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 50-year-old woman visits the Rheumatology Clinic seeking modification of her DMARDs for the treatment of her rheumatoid arthritis. She is informed that she will require frequent liver checks and eye exams due to the potential side-effects of these medications. What is the most probable combination of treatment she will receive for her condition?
Your Answer:
Correct Answer: Methotrexate plus hydroxychloroquine
Explanation:Medication Combinations for Treating Rheumatoid Arthritis
When treating rheumatoid arthritis, the first-line medication is a DMARD monotherapy with methotrexate. Short-term steroids may also be used in combination with DMARD monotherapy to induce remission. Hydroxychloroquine is another medication that can be used, but patients should be closely monitored for visual changes as retinopathy and corneal deposits are common side effects.
Etanercept is not a first-line treatment for rheumatoid arthritis, and methotrexate should not be given in combination with a TNF-alpha inhibitor like etanercept. Methotrexate plus sulfasalazine is an appropriate medication combination for treating rheumatoid arthritis, but regular eye checks are not required as neither medication affects vision.
If a patient has failed treatment with methotrexate, sulfasalazine plus hydroxychloroquine may be a regimen to consider trialling. However, it is important to note that new-onset rheumatoid arthritis should be treated with a DMARD monotherapy first line, with the addition of another DMARD like methotrexate as the first-line option.
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This question is part of the following fields:
- Rheumatology
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Question 3
Incorrect
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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:
Correct 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 4
Incorrect
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A 49-year-old carpet layer presents to the clinic for review. He has been complaining of severe anterior knee pain for a few days. On examination, you notice that the left knee is warm and there is swelling on the patella. There is local pain on patellar pressure and pain with knee flexion.
Investigations:
Investigation Result Normal value
Haemoglobin 131 g/l 135–175 g/l
White cell count (WCC) 5.2 × 109/l 4–11 × 109/l
Platelets 185 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 12 mm/h 0–10mm in the 1st hour
Knee aspirate: Gram stain negative for bacteria; fluid contains occasional white cells; culture is negative.
Which of the following is the most likely diagnosis in this case?Your Answer:
Correct Answer: Pre–patellar bursitis
Explanation:Differentiating Knee Conditions: A Case-Based Approach
A patient presents with a red, tender, and inflamed knee. The differential diagnosis includes prepatellar bursitis, osteoarthritis, localised cellulitis, rheumatoid arthritis, and gout.
prepatellar bursitis, also known as housemaid’s knee, carpet layer’s knee, or nun’s knee, is often caused by repetitive knee trauma. Treatment involves non-steroidal anti-inflammatory agents and local corticosteroid injection. Septic bursitis requires appropriate antibiotic cover and drainage.
Osteoarthritis is a diagnosis of exclusion and does not typically cause a red, tender, inflamed knee. Knee aspirate in this case would not show white cells.
Localised cellulitis may result in erythema but is unlikely to cause knee swelling. Knee aspirate in this case would not show white cells.
Rheumatoid arthritis is unlikely to present in men of this age and typically affects small joints of the fingers, thumbs, wrists, feet, and ankles.
Gout can be diagnosed through the presence of negatively birefringent crystals seen on joint microscopy.
In conclusion, a thorough evaluation of the patient’s symptoms and appropriate diagnostic tests are necessary to differentiate between these knee conditions.
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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 27-year-old man presents to his primary care physician with complaints of worsening back pain and stiffness over the past 5 months. He denies experiencing leg pain, loss of bladder or bowel control, or weakness in his lower extremities. The patient reports that the stiffness in his back tends to improve throughout the day. Upon examination, the physician notes mild tenderness directly over the lumbar spine and decreased range of motion with hip flexion. The patient has normal muscle strength in his lower extremities and intact sensation. X-ray results reveal sacroiliitis, vertebral squaring, and a ‘bamboo spine’. Which of the following is most likely associated with this patient’s condition?
Your Answer:
Correct Answer: Positive human leukocyte antigen HLA-B27
Explanation:Understanding Autoimmune Disorders: Differentiating Between Ankylosing Spondylitis, SLE, and Rheumatoid Arthritis
Autoimmune disorders can be difficult to diagnose due to their overlapping symptoms. However, certain laboratory tests can help differentiate between them.
One such test is the human leukocyte antigen (HLA)-B27, which is associated with ankylosing spondylitis. This autoimmune disorder primarily affects men and is characterized by back stiffness that improves throughout the day, sacroiliitis, and a bamboo spine on radiography.
On the other hand, positive antinuclear antibodies and anti-double-stranded DNA antibodies are associated with systemic lupus erythematosus (SLE). Patients with SLE may experience joint pain, skin rashes, and organ involvement.
Lastly, positive anti-cyclic citrullinated peptide (CCP) antibodies are associated with rheumatoid arthritis. This autoimmune disorder is characterized by joint pain, swelling, and stiffness, and can lead to joint deformities if left untreated.
In summary, understanding the specific laboratory tests associated with different autoimmune disorders can aid in their diagnosis and treatment.
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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 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:
Correct 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 7
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:
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 8
Incorrect
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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:
Correct 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 50-year-old woman presents with complaints of fatigue. She reports experiencing dysphagia, a dry mouth, a gritty feeling in her eyes, and heightened sensitivity to light.
What is the probable diagnosis?Your Answer:
Correct Answer: Sjögren syndrome
Explanation:Comparison of Symptoms: Sjögren Syndrome, Haemochromatosis, Hepatitis C Virus Infection, Oesophageal Carcinoma, and Polymyositis
Sjögren syndrome is a condition that causes inflammation and destruction of exocrine glands, resulting in dry and gritty eyes, dry mouth, photosensitivity, fatigue, and joint pain. Patients may also experience excessive watering or deposits of dried mucous in the corner of the eye, recurrent attacks of conjunctivitis, and parotid swelling. On examination, xerostomia can be detected as a diminished salivary pool, a dried fissured tongue, and chronic oral candidiasis.
Haemochromatosis, on the other hand, is characterized by a pigmented (tanned) appearance and may cause dry mouth and thirst due to diabetes.
Hepatitis C virus infection can be associated with a secondary Sjögren syndrome, but there is no indication of this in the question.
Oesophageal carcinoma is unlikely to cause ocular symptoms.
Polymyositis does not present with any history of muscle weakness.
In summary, while some symptoms may overlap between these conditions, a thorough examination and medical history are necessary to accurately diagnose and differentiate them.
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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 woman in her 20s starts experiencing consistent lower back pain and stiffness that improves with physical activity. As she enters her 30s, she develops arthritis in her hips and shoulders, and by her 40s, she notices reduced mobility in her lumbar spine. She has no significant medical issues. What condition is most commonly associated with these symptoms?
Your Answer:
Correct Answer: Ankylosing spondylitis
Explanation:The symptoms described suggest a diagnosis of ankylosing spondylitis, a chronic form of seronegative spondyloarthropathy that primarily affects the axial skeleton. Diagnosis is made using the modified New York criteria, which includes clinical and radiological criteria. HLA-B27 and sacroiliitis on MRI play a major role in the recently proposed ASAS diagnostic algorithm. Radiographic sacroiliitis is required for eligibility for anti-TNF treatment. Other conditions, such as pseudogout, Lyme disease, osteoarthritis, and rheumatoid arthritis, are unlikely diagnoses. Timely diagnosis requires a high index of suspicion.
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This question is part of the following fields:
- Rheumatology
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Question 11
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:
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 12
Incorrect
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An 81-year-old woman presents to Accident and Emergency with recurrent chest infections over the last year. She has suffered from rheumatoid arthritis for a long time and is on methotrexate and sulfasalazine. On examination, there are some crepitations at the right lung base and splenomegaly. She has some abnormal discolouration on her legs.
Full blood counts showed:
Investigation Result Normal value
Haemoglobin (Hb) 96 g/l 115–155 g/l
White cell count (WCC) 3.2 × 109/l 4–11 × 109/l
Neutrophils 0.8 × 109/l 1.7–7.5 × 109/l
Lymphocytes 1.5 × 109/l 1.0–4.5 × 109/l
Eosinophils 0.6 × 109/l 0.0–0.4 × 109/l
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Felty syndrome
Explanation:Differential diagnosis for a patient with rheumatoid arthritis, splenomegaly, neutropenia, and skin changes
Felty syndrome and other potential diagnoses
Felty syndrome is a rare complication of rheumatoid arthritis that affects about 1% of patients. It is characterized by the presence of three main features: splenomegaly (enlarged spleen), neutropenia (low white blood cell count), and recurrent infections. Skin changes on the lower limbs, such as ulcers or nodules, are also common in Felty syndrome. The exact cause of this syndrome is unknown, but it is thought to be related to immune dysregulation and chronic inflammation.
Other conditions that may present with similar symptoms include chronic lymphocytic leukemia (CLL), non-Hodgkin’s lymphoma, Hodgkin’s lymphoma, and drug-induced neutropenia. CLL is a type of blood cancer that affects mainly older adults and causes the accumulation of abnormal lymphocytes in the blood, bone marrow, and lymph nodes. However, in this case, the patient’s white blood cell count is low, which is not typical of CLL. Non-Hodgkin’s lymphoma and Hodgkin’s lymphoma are types of cancer that affect the lymphatic system and may cause lymphadenopathy (enlarged lymph nodes), fever, night sweats, and weight loss. However, there is no evidence of lymph node involvement or systemic symptoms in this scenario.
Drug-induced neutropenia is a potential side effect of methotrexate, which is a commonly used medication for rheumatoid arthritis. However, splenomegaly is not a typical feature of methotrexate toxicity, and respiratory complications are more common than hematological ones. Therefore, the most likely diagnosis in this case is Felty syndrome, which requires close monitoring and management of the underlying rheumatoid arthritis. In severe cases, splenectomy (surgical removal of the spleen) may be considered to improve neutropenia and reduce the risk of infections.
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This question is part of the following fields:
- Rheumatology
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Question 13
Incorrect
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A 44-year-old gardener comes to her General Practitioner complaining of pain when kneeling on her right knee for the past month. She denies any fevers and is generally in good health. During the examination of her right knee, the doctor notices a slightly tender swelling in front of the patella that feels fluctuant. Although the knee is not red, it is warm to the touch, and the patient experiences some discomfort when flexing it. What are the probable results of joint aspiration?
Your Answer:
Correct Answer: Clear/milky joint aspirate with normal microscopy and culture
Explanation:Diagnosing Prepatellar Bursitis: Understanding Joint Aspirate Results
Prepatellar bursitis, also known as housemaid’s knee, is a common condition caused by inflammation of the prepatellar bursa. This can result from repetitive microtrauma, such as prolonged kneeling. Patients typically present with localised, mildly tender swelling over the patella, which can be warm but not hot. Aspiration of the aseptic bursa will reveal a clear and/or milky aspirate that has negative Gram staining and normal microscopy.
When examining joint aspirate results, it is important to consider other potential diagnoses. Gram-positive cocci, for example, would be grown in the case of Staphylococcus aureus infection, a common cause of septic bursitis. However, in the absence of fever, erythema, and reduced range of motion, septic arthritis is unlikely. Similarly, needle-shaped crystals with strong negative birefringence on polarised light microscopy are seen in gout, but this condition typically presents with acute pain, redness, and inflammation.
Rhomboid-shaped crystals with weak positive birefringence on polarised light microscopy are seen in pseudogout, which can affect the knee. However, this condition typically affects the entire knee joint and is more common in the elderly.
In summary, a clear or milky joint aspirate with normal microscopy and culture is consistent with prepatellar bursitis. Other potential diagnoses should be considered based on the patient’s history and examination findings.
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This question is part of the following fields:
- Rheumatology
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Question 14
Incorrect
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A 30-year-old science teacher is diagnosed with tenosynovitis of the fingers of the left hand, although she is not experiencing any tenderness or swelling of the affected fingers.
In which one of the following conditions can tendinitis/tenosynovitis present without being swollen and tender?Your Answer:
Correct Answer: Systemic sclerosis
Explanation:Types of Arthritis and Infections that can Cause Tenosynovitis
Tenosynovitis is a condition where the tendon sheath becomes inflamed, causing pain and swelling. It can be caused by various types of arthritis and infections. Here are some of the most common causes:
Systemic Sclerosis: This autoimmune disease causes fibrosis of connective tissue, resulting in hard and thickened skin, swollen digits, and Raynaud’s phenomenon. Tenosynovitis in systemic sclerosis is non-tender and without swelling of the tendons.
Rheumatoid Arthritis: Tenosynovitis due to rheumatoid arthritis causes pain and swelling of tendons. It usually involves the interphalangeal, metacarpophalangeal, and wrist joints, and can cause deformities such as swan neck and Boutonnière’s deformity.
Gout: Gout can cause tenosynovitis, which is very painful and presents with redness and swollen tendons. It typically affects the metatarsophalangeal joints.
Disseminated Gonococcal Infection: This infection can cause acute migratory tenosynovitis, especially in younger adults. Women may be asymptomatic, while men may present with urethral discharge or dysuria.
Reactive Arthritis: This type of arthritis causes pain and swelling of tendons, commonly affecting the knees or sacrum. It is an acutely inflammatory process and would therefore be swollen and tender.
In conclusion, tenosynovitis can be caused by various types of arthritis and infections, and it is important to identify the underlying cause in order to provide appropriate treatment.
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This question is part of the following fields:
- Rheumatology
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Question 15
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:
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 16
Incorrect
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A 76-year-old woman, who was previously in good health, presents for review. For the past 2–3 months, she has suffered from increasing pain and stiffness, particularly in the early part of the day, affecting her shoulders and, most recently, her hips. There has also been low-grade fever and she has lost 4 kg in weight. Examination reveals normal proximal muscle strength.
Investigations:
Investigation Result Normal value
Haemoglobin 111 g/l 115–155 g/l
Mean corpuscular volume (MCV) 96 fl 76–98 fl
White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
Platelets 345 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 75 mm/h 0–10mm in the 1st hour
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 5.0 mmol/l 3.5–5.0 mmol/l
Creatinine 130 μmol/l 50–120 µmol/l
Creatine kinase 31 IU/l 23–175 IU/l
Alanine aminotransferase (ALT) 45 IU/l 5–30 IU/l
Chest X-ray (CXR) Slight cardiomegaly, otherwise normal
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Polymyalgia rheumatica (PMR)
Explanation:Differential Diagnosis for a Patient with Shoulder and Pelvic Girdle Pain
Polymyalgia rheumatica (PMR) is a likely diagnosis for a patient presenting with shoulder and pelvic girdle pain without muscle weakness and a markedly raised ESR. Rapid improvement of symptoms with corticosteroids and a subsequent fall in ESR confirms the diagnosis. Temporal arthritis, a vasculitis associated with PMR, should also be considered in patients over 50 presenting with headache, vision loss, and jaw claudication. Myositis and dermatomyositis are less likely diagnoses due to the patient’s normal CK and lack of muscle weakness. Rheumatoid arthritis is unlikely given the patient’s age and the classic joint involvement pattern.
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This question is part of the following fields:
- Rheumatology
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Question 17
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:
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 18
Incorrect
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Which joint is usually spared from osteoarthritis?
Your Answer:
Correct Answer: Elbow joint
Explanation:Osteoarthritis in the Hand and Elbow
Osteoarthritis (OA) is a prevalent form of arthritis that commonly affects the hand, particularly the joints. The joints may exhibit several deformities, including the development of small bone spurs called nodes. These nodes are referred to as Heberden’s nodes when they occur at the joint next to the fingernail and Bouchard’s nodes when they occur at the middle joints. The base of the thumb may also appear squared off, accompanied by swelling and tenderness. Soft tissue laxity can result in instability at the base of the thumb.
In contrast, elbow OA is relatively uncommon.
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This question is part of the following fields:
- Rheumatology
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Question 19
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:
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 20
Incorrect
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A 20-year-old woman presents with a painful left hip and groin and is struggling to weight-bear. She completed therapy for acute myeloblastic leukaemia some six months earlier.
On examination, she walks with a limp and there is limitation of hip flexion, internal and external rotation.
Investigations:
Investigation Result Normal Value
Haemoglobin 121 g/l 115–155 g/l
White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
Platelets 191 × 109/l 150–400 × 109/l
Sodium (Na+) 140 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
C-reactive protein (CRP) 12 mg/l 0–10 mg/l
The left hip X-ray shows joint sclerosis with collapse of the femoral head.
Which one of the following is the most likely diagnosis?Your Answer:
Correct Answer: Avascular necrosis
Explanation:Differentiating Arthritis Types: Avascular Necrosis, Gout, Osteoarthritis, Pseudogout, and Septic Arthritis
Arthritis is a common condition that affects the joints, causing pain, stiffness, and inflammation. However, there are different types of arthritis, each with its own causes, symptoms, and treatments. Here are some key points to differentiate between avascular necrosis, gout, osteoarthritis, pseudogout, and septic arthritis:
Avascular necrosis is a condition where the bone tissue dies due to a lack of blood supply. It can be caused by corticosteroid use, malignancy, or trauma. Femoral head collapse is a classic radiographic change in avascular necrosis.
Gout is a type of crystal arthritis that usually affects peripheral joints, such as the big toe, ankle, or knee. It is caused by the buildup of uric acid crystals in the joint, leading to sudden attacks of pain, redness, and swelling.
Osteoarthritis is a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time. It is more common in older adults and can affect any joint, but femoral head collapse does not occur in osteoarthritis.
Pseudogout is another type of crystal arthritis that usually affects peripheral joints. It is caused by the buildup of calcium pyrophosphate crystals in the joint, leading to similar symptoms as gout.
Septic arthritis is a bacterial infection of the joint that can cause severe pain, swelling, and fever. It is a medical emergency and requires prompt treatment with antibiotics. While septic arthritis should always be considered in a monoarthritis, it is less likely in cases where there are classic radiographic changes of avascular necrosis, risk factors, and a normal CRP without history of fever.
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This question is part of the following fields:
- Rheumatology
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Question 21
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:
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 22
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:
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 23
Incorrect
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In which joint would the presence of osteoarthritic changes be atypical?
Your Answer:
Correct Answer: Shoulder joint
Explanation:Osteoarthrosis and Common Deformities in the Hand
Osteoarthrosis (OA) is a prevalent type of arthritis that often affects the hand. Upon examination of the joints, it is common to find small bone spurs known as nodes on the tops of joints. These nodes can take on different names depending on their location. For instance, if they occur at the joint next to the fingernail, they are called Heberden’s nodes. On the other hand, if they occur at the PIP joints, they are referred to as Bouchard’s nodes. It is worth noting that shoulder joint involvement is rare in OA.
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This question is part of the following fields:
- Rheumatology
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Question 24
Incorrect
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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:
Correct 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 25
Incorrect
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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:
Correct 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 26
Incorrect
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A 65-year-old man visits his General Practitioner (GP) complaining of a swollen and painful first metatarsophalangeal joint that has been bothering him for a week. He reports that the pain became unbearable last night. The patient denies any fever or toe injuries. Upon examination, the joint appears red, swollen, and warm to touch. The patient has a history of gout, peptic ulcer, and is currently taking allopurinol 300 mg once a day for gout prophylaxis. What is the most appropriate next step in management?
Your Answer:
Correct Answer: Continue allopurinol and start oral colchicine
Explanation:Managing Gout Attacks in Patients on Allopurinol: Options and Considerations
When a patient on allopurinol develops a gout attack, it is important to manage the acute inflammation while continuing the prophylactic treatment. Here are some options and considerations:
– Continue allopurinol and start oral colchicine: Colchicine can be used for acute treatment, but allopurinol should not be stopped.
– Increase allopurinol dose: The dose may need to be increased up to 600 mg for better prophylaxis, but not during an acute attack.
– Stop allopurinol and recommence two weeks after acute inflammation settled: Allopurinol should not be stopped during an attack. It should be continued at the same dose.
– Stop allopurinol and start non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs can control acute pain, but not appropriate for patients with a history of peptic ulcer.
– Stop allopurinol and recommence at a higher dose after acute inflammation has settled: Allopurinol should not be stopped during an attack. The dose can be reviewed and increased after the attack has settled down.In summary, managing gout attacks in patients on allopurinol requires a careful balance between acute treatment and prophylaxis. Each option should be considered based on the patient’s individual circumstances and medical history.
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This question is part of the following fields:
- Rheumatology
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Question 27
Incorrect
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A 65-year-old woman presents with a one-month history of non-specific malaise. She reports stiffness, particularly in the mornings, and difficulty lifting her arms to comb her hair. She experiences constant aching in her arms and shoulders and jaw pain when chewing. She has also 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, her temperature is 38°C, pulse is 84 beats/min, and BP is 125/80 mmHg. Investigations reveal abnormal blood results. What is the most appropriate next step in her evaluation?
Your Answer:
Correct Answer: Erythrocyte sedimentation rate
Explanation:Polymyalgia Rheumatica/Temporal arthritis: Symptoms and Importance of Diagnosis
Polymyalgia rheumatica/temporal arthritis is a condition that may present with predominantly polymyalgia symptoms such as proximal muscle pain, stiffness, or arthritis symptoms such as headaches, scalp tenderness, and jaw claudication. It is also common for the condition to have systemic involvement, including fever, malaise, and weight loss. One of the key indicators of this condition is a very high ESR.
The main reason for diagnosing and treating polymyalgia rheumatica/temporal arthritis is to prevent blindness. This condition can cause inflammation in the blood vessels that supply the eyes, leading to vision loss. Therefore, early diagnosis and treatment are crucial to prevent this complication.
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This question is part of the following fields:
- Rheumatology
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Question 28
Incorrect
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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:
Correct 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 29
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:
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 30
Incorrect
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An 80-year-old man presents with complaints of stiffness and pain in both shoulders. He has experienced a weight loss of one stone over the past eight weeks and reports feeling lethargic with a decreased appetite. Upon investigation, a positive rheumatoid factor, normochromic normocytic anaemia, and a significantly elevated ESR (100 mm/hr) were found. What is the most probable diagnosis?
Your Answer:
Correct Answer: Polymyalgia rheumatica
Explanation:Polymyalgia rheumatica is an inflammatory disease that causes pain and stiffness in the shoulder and pelvic girdle muscles, along with systemic symptoms such as fever and weight loss. It is often associated with giant cell arthritis. Diagnosis can be difficult, but response to a moderate dose of steroids is a useful indicator. Non-steroidal anti-inflammatories are not recommended. Other inflammatory conditions should be excluded, such as rheumatoid arthritis, systemic lupus erythematosus, polymyositis, and polyarteritis nodosa.
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This question is part of the following fields:
- Rheumatology
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Question 31
Incorrect
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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:
Correct 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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Question 32
Incorrect
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A 72-year-old man presented to his GP with complaints of fatigue, unintentional weight loss, and night sweats. He reported feeling generally down. Upon further questioning, he mentioned experiencing stiffness and pain in his shoulders and neck, particularly in the morning and lasting for about half an hour.
What would be the most appropriate investigation to perform in this case?Your Answer:
Correct Answer: Erythrocyte sedimentation rate (ESR)
Explanation:Understanding the Diagnosis of Polymyalgia Rheumatica
Polymyalgia rheumatica (PMR) is a condition that causes pain and stiffness in proximal muscle groups, often accompanied by systemic symptoms. While other potential diagnoses such as infections or neoplasia should be considered, PMR is typically characterised by raised levels of inflammatory markers, particularly erythrocyte sedimentation rate (ESR). Treatment with corticosteroids usually results in rapid improvement, and lack of response to steroids may indicate a need to re-evaluate the diagnosis. Autoantibody screening and nerve conduction velocity tests are not helpful in diagnosing PMR, while muscle biopsy may be performed to exclude polymyositis. A temporal artery biopsy may be considered if the patient has symptoms of giant cell arthritis.
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This question is part of the following fields:
- Rheumatology
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Question 33
Incorrect
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A 50-year-old man presents to the Emergency Department with a painful and swollen left knee that has been bothering him for the past 2 days. He is running a fever. The patient has a history of rheumatoid arthritis, which was recently diagnosed and is being treated with NSAIDs and low-dose oral corticosteroids. He reports that he visited his general practitioner 5 days ago for a painful right ear, and was prescribed antibiotics for an ear infection. Upon examination, the left knee is swollen, red, tender, and slightly flexed, leading to a diagnosis of septic arthritis. What is the most likely causative organism in this case?
Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Common Bacterial Causes of Septic Arthritis
Septic arthritis can be caused by a variety of bacterial organisms. Among them, Staphylococcus aureus is the most common aetiological agent in Europe and the United States. Streptococcus pyogenes is the next most commonly isolated bacteria, often associated with autoimmune diseases, chronic skin infections, and trauma. Gram-negative bacilli, such as Escherichia coli, account for approximately 10-20% of cases, with a higher prevalence in patients with a history of intravenous drug abuse, extremes of age, or immunocompromised status. Historically, Haemophilus influenzae, S. aureus, and group A streptococci were the most common causes of infectious arthritis in children younger than 2 years, but the overall incidence of H. influenzae is decreasing due to vaccination. Pseudomonas aeruginosa, a less common cause, may affect children, the elderly, intravenous drug users, and immunocompromised patients.
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This question is part of the following fields:
- Rheumatology
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Question 34
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:
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 35
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:
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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Question 36
Incorrect
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A 40-year-old woman presents with pain of the hand, wrist, ankle and knee which is asymmetrical and has been going on for the past few months. She has developed a rash on her face and has developed a dry cough and pain on inspiration. She has a child but has had two previous miscarriages (Gravida 3, Para 1). She has no other concurrent medical problems or medications.
Testing for which one of the following autoantibodies is most likely to reveal the diagnosis in this patient?Your Answer:
Correct Answer: Anti-dsDNA
Explanation:Understanding Autoantibodies: Differentiating Connective Tissue Diseases
Autoantibodies are antibodies produced by the immune system that mistakenly attack the body’s own tissues. These antibodies can be used as diagnostic markers for various connective tissue diseases. Here, we will discuss the different types of autoantibodies and their association with specific diseases.
Anti-dsDNA is highly specific for systemic lupus erythematosus (SLE), a multisystem connective tissue disease that can affect the heart, lungs, kidneys, and brain. Patients with SLE may present with a malar rash, polyarthritis, and pleuritis, as well as an increased rate of miscarriage.
Anti-Jo is associated with myositis, such as polymyositis or dermatomyositis, which present with muscle pain and a rash but no pleuritic pain or an associated history of miscarriage.
Anti-Ro is associated with Sjögren syndrome, which can have similar features to SLE, including myalgia or polyarthralgia in 50% of patients, as well as skin features of purpura and annular erythema. However, it will not cause pleuritic pain.
Anti-centromere is associated with limited cutaneous scleroderma, a multisystem autoimmune disease resulting in abnormal growth of connective tissue. It can cause nonspecific musculoskeletal pain but not an associated history of pleuritic and miscarriage.
Anti-Rh is an antibody to a receptor on blood cells and is not associated with connective tissue disease.
In conclusion, the presence or absence of autoantibodies does not confirm or exclude a diagnosis of connective tissue disease. A diagnosis is based on a combination of clinical presentation and laboratory tests. Understanding the association between autoantibodies and specific diseases can aid in the diagnosis and management of these complex conditions.
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This question is part of the following fields:
- Rheumatology
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Question 37
Incorrect
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A 30-year-old woman had chronic inflammatory disease that affected her spine, sacroiliac joints and large peripheral joints. X-rays confirmed a diagnosis of ankylosing spondylitis.
The majority of patients with this disease are positive for which one of the following molecules?Your Answer:
Correct Answer: HLA-B27
Explanation:The Role of Human Leukocyte Antigens in Autoimmune Diseases
Human leukocyte antigens (HLAs) play a crucial role in the development of autoimmune diseases. Different HLAs are associated with specific autoimmune conditions. For example, HLA-B27 is present in 90% of patients with ankylosing spondylitis, as well as reactive arthritis and acute anterior uveitis. HLA-Cw6 is associated with psoriasis vulgaris, while HLA-B8 is linked to hyperthyroidism (Graves’ disease). HLA-DR4 is associated with rheumatoid arthritis and type 1 diabetes mellitus, and HLA-DR2 is linked to systemic lupus erythematosus (SLE) in Japanese people, multiple sclerosis, and Goodpasture syndrome. Understanding the role of HLAs in autoimmune diseases can help with diagnosis and treatment.
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This question is part of the following fields:
- Rheumatology
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Question 38
Incorrect
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In which condition is pseudofracture typically observed?
Your Answer:
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 39
Incorrect
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A middle-aged man without prior medical history is experiencing increasing back pain and right hip pain for the past decade. The pain worsens towards the end of the day. He has bony enlargement of the distal interphalangeal joints. Radiographs reveal prominent osteophytes involving the vertebral bodies and sclerosis with narrowing of the joint space at the right acetabulum. What is the most likely pathologic process occurring in this patient?
Your Answer:
Correct Answer: Osteoarthritis
Explanation:Differentiating Types of Arthritis
Degenerative osteoarthritis is a condition that becomes more prevalent and symptomatic as one ages. It is characterized by the erosion and loss of articular cartilage. On the other hand, rheumatoid arthritis typically affects the small joints of the hands and feet, leading to marked joint deformity due to a destructive pannus. Gouty arthritis, on the other hand, is more likely to cause swelling and deformity with joint destruction, and the pain is not related to usage. Osteomyelitis, meanwhile, is an ongoing infection that produces marked bone deformity, not just joint narrowing. Lastly, Lyme disease produces a chronic arthritis, but it is typically preceded by a deer tick bite with a skin lesion. It is much less common than osteoarthritis. By the differences between these types of arthritis, proper diagnosis and treatment can be given to patients.
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This question is part of the following fields:
- Rheumatology
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Question 40
Incorrect
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A 27-year-old construction worker complains of worsening pain in his feet over the past two weeks, describing it as feeling like he is walking on gravel. He also reports experiencing lower back pain.
The patient recently returned from a trip to Spain two months ago and recalls having a brief episode of urethral discharge, but did not seek medical attention for it.
What is a possible diagnosis?Your Answer:
Correct Answer: Reactive arthritis
Explanation:Reactive Arthritis
Reactive arthritis is a medical condition that is characterized by a combination of symptoms including seronegative arthritis, urethritis, and conjunctivitis. The condition is often associated with sacroiliitis and painful feet, which reflects plantar fasciitis. Reactive arthritis is known to occur after gastrointestinal infections with Shigella or Salmonella, as well as following non-specific urethritis.
Gonococcal arthritis, on the other hand, tends to occur in patients who are systemically unwell and have features of septic arthritis. It is important to note that reactive arthritis is not contagious and cannot be spread from one person to another.
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This question is part of the following fields:
- Rheumatology
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Question 41
Incorrect
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A 54-year-old man visits his GP complaining of pain and swelling in his right elbow. He mentions feeling generally unwell for the past few days and remembers hitting his elbow while cycling the previous week. During the examination, his temperature is 37.7 °C, his heart rate is 78 bpm, and his blood pressure is 124/78 mmHg. There is a warm, erythematous swelling on the posterior aspect of his right elbow.
What is the most suitable course of action for this probable diagnosis?Your Answer:
Correct Answer: Oral flucloxacillin and refer for urgent aspiration
Explanation:Management of Suspected Infected Olecranon Bursitis
Suspected infected olecranon bursitis requires prompt management to prevent complications. The following options are available:
Option 1: Oral flucloxacillin and refer for urgent aspiration
Empirical antibiotics, such as oral flucloxacillin, should be started immediately to cover for staphylococci and streptococci. However, urgent same-day aspiration should also be arranged to confirm the diagnosis and obtain antibiotic susceptibility.Option 2: Arrange for corticosteroid injection
If there are no signs of infection, corticosteroid injection may be considered after conservative measures have failed in aseptic olecranon bursitis. However, in suspected septic olecranon bursitis, urgent antibiotics and aspiration are required.Option 3: Oral flucloxacillin only
Empirical oral flucloxacillin should be started as soon as possible in suspected infected olecranon bursitis. However, referral for urgent aspiration is also necessary to confirm the diagnosis and obtain antibiotic susceptibility.Option 4: Oral amoxicillin and refer for urgent aspiration
Flucloxacillin, not amoxicillin, should be given for suspected septic olecranon bursitis to cover the most common organisms. Urgent aspiration should also be arranged to confirm the diagnosis and obtain antibiotic susceptibility.Option 5: Refer for urgent aspiration
Urgent aspiration is necessary to confirm the diagnosis and obtain antibiotic susceptibility. Empirical antibiotics should be started first while awaiting culture results. If the patient is seen in the Emergency Department, aspiration may be done first before starting antibiotics. -
This question is part of the following fields:
- Rheumatology
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Question 42
Incorrect
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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:
Correct 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 43
Incorrect
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A 79-year-old woman, with a history of recurrent falls, had a recent fall on her outstretched right hand. An X-ray revealed a fracture of the distal radius with volar displacement. She has multiple risk factors for osteoporosis, and a DEXA scan was requested. What score is indicative of a diagnosis of osteoporosis?
Your Answer:
Correct Answer: T score: < −2.5
Explanation:When it comes to bone density, T scores are an important measure to understand. A T score of less than -2.5 is indicative of osteoporosis, while a T score between -1 and -2.5 suggests osteopenia. On the other hand, a T score of 0-1 is considered normal, but may still require monitoring. A T score greater than 2.5 is also normal, but may not be the case if the patient has experienced a fragility fracture. It’s important to note that Z scores, which take into account age and gender, can also provide insight into bone density. Understanding T scores and their implications can help healthcare professionals and patients take preventative measures to maintain bone health.
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This question is part of the following fields:
- Rheumatology
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Question 44
Incorrect
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A 52-year-old man comes to the clinic complaining of a severely painful, swollen, and red left big toe. He states that it started yesterday and has become so excruciating that he cannot put on shoes. The patient has a medical history of type 2 diabetes and was diagnosed with a stomach ulcer last year. The diagnosis is a first episode of acute gout. What would be the most suitable initial treatment?
Your Answer:
Correct Answer: Colchicine
Explanation:Treatment Options for Acute Gout Flare in a Patient with Peptic Ulcer Disease
When managing an acute gout flare in a patient with a history of peptic ulcer disease, it is important to consider the potential risks and benefits of different treatment options. Colchicine and non-steroidal anti-inflammatory drugs (NSAIDs) are both effective first-line treatments, but NSAIDs should be used with caution in patients with a history of peptic ulcer disease. If NSAIDs are used, proton-pump cover should be provided for gastric protection. Allopurinol should not be started until after the acute attack has been resolved, and paracetamol may be used as an adjunct for pain relief but would not treat the underlying cause of pain. Prednisolone may be used in patients unable to tolerate NSAIDs or colchicine, but there is no contraindication to a trial of oral colchicine in this patient. Overall, the choice of treatment should be individualized based on the patient’s medical history and preferences.
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This question is part of the following fields:
- Rheumatology
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Question 45
Incorrect
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A 32-year-old woman comes to the clinic for evaluation. She has been experiencing a red rash on her face for 6-12 months and is now having joint pain in multiple areas. She also reports having chest pain that feels like it's coming from the lining of her lungs. During the examination, her blood pressure is measured at 155/92 mmHg, and she has a butterfly-shaped rash on her face.
The following tests were conducted:
- Haemoglobin: 119 g/l (normal range: 115-155 g/l)
- White cell count (WCC): 4.2 × 109/l (normal range: 4-11 × 109/l)
- Platelets: 192 × 109/l (normal range: 150-400 × 109/l)
- Sodium (Na+): 140 mmol/l (normal range: 135-145 mmol/l)
- Potassium (K+): 4.9 mmol/l (normal range: 3.5-5.0 mmol/l)
- Creatinine: 160 μmol/l (normal range: 50-120 µmol/l)
- Erythrocyte sedimentation rate (ESR): 66 mm/hr (normal range: 0-10mm in the 1st hour)
- Anti-nuclear antibody (ANA): positive
- Urine: blood and protein present
What is the most likely diagnosis?Your Answer:
Correct Answer: Systemic lupus erythematosus (SLE)
Explanation:Differentiating Systemic Lupus Erythematosus from Other Connective Tissue Diseases
Systemic lupus erythematosus (SLE) is a complex autoimmune disease that can present with a variety of symptoms. Patients may experience pleuritic chest pain, arthralgia, and a typical rash, which are all indicative of SLE. Anti-nuclear antibodies are typically positive, although they are not specific to lupus. Treatment for SLE involves glucocorticoids as the mainstay, with second-line agents including cyclophosphamide, hydroxychloroquine, and azathioprine. BLyS inhibitors are also showing promise in clinical trials.
Other connective tissue diseases, such as granulomatosis with polyangiitis (GPA), rheumatoid arthritis, systemic sclerosis, and mixed connective tissue disease, have distinct features that differentiate them from SLE. GPA is a necrotising small-vessel vasculitis that commonly affects the kidneys and lungs, with palpable purpura on the extremities. Rheumatoid arthritis typically presents with joint pain and swelling, but without a butterfly rash or hypertension. Systemic sclerosis affects the skin on the face, forearms, and lower legs, with Raynaud’s, sclerodactyly, and telangiectasia. Mixed connective tissue disease has features of SLE, but without any other connective tissue disease symptoms.
It is important to differentiate between these diseases to provide appropriate treatment and management for patients.
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This question is part of the following fields:
- Rheumatology
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Question 46
Incorrect
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A 38-year-old woman with a 12-year history of rheumatoid arthritis is admitted with a ‘flare’. She is a familiar patient to the ward and has previously been prescribed methotrexate, gold and sulphasalazine. The last two medications were effective for the first two years but then became less helpful even at higher doses. She is currently taking oral steroids.
On examination: there is active synovitis in eight small joints of the hands and the left wrist.
What is the most appropriate next course of treatment for this patient?Your Answer:
Correct Answer: Enrol in biological therapy programme
Explanation:Treatment Options for Severe Rheumatoid Arthritis
Severe rheumatoid arthritis can be a challenging condition to manage, especially when conventional disease-modifying anti-rheumatic drugs (DMARDs) fail to provide relief. In such cases, biological therapies may be recommended. Here are some treatment options for severe rheumatoid arthritis:
Enrol in Biological Therapy Programme
Patients with highly active disease despite trying three previous agents for a therapeutic treatment duration may be candidates for biological treatments. TNF-alpha inhibitors and anti-CD20 are examples of biological treatments that are routinely used in the UK.Maintain on Steroids and Add a Bisphosphonate
Short-term treatment with glucocorticoids may be offered to manage flares in people with recent-onset or established disease. However, long-term treatment with glucocorticoids should only be continued when the long-term complications of glucocorticoid therapy have been fully discussed and all other treatment options have been offered.Commence Leflunomide
Severe disease that has not responded to intensive therapy with a combination of conventional DMARDs should be treated with biological agents. Leflunomide is one of the DMARDs that can be used in combination therapy.Use Methotrexate/Leflunomide Combination
Patients who have not responded to intensive DMARD therapy may be prescribed a biological agent, as per NICE guidelines. Methotrexate and leflunomide are two DMARDs that can be used in combination therapy.Avoid Commencing Penicillamine
DMARD monotherapy is only recommended if combination DMARD therapy is not appropriate. Patients without contraindications to combination therapy should not be prescribed penicillamine. -
This question is part of the following fields:
- Rheumatology
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Question 47
Incorrect
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A 35-year-old nun is seen in the Rheumatology Clinic every year for her long-standing seropositive arthritis affecting her hands, knees, and hips. Her arthritis is linked to another chronic condition she also experiences.
Your Answer:
Correct Answer: Systemic lupus erythematosus (SLE) arthritis
Explanation:Seropositive and Seronegative Arthritis: Types and Characteristics
Seropositive arthritis is characterized by the presence of rheumatoid factor, an antibody targeted against the Fc portion of immunoglobulins. While rheumatoid factor can be present in systemic lupus erythematosus (SLE), seropositive SLE generally indicates more severe disease progression. On the other hand, reactive arthritis, psoriatic arthritis, ankylosing spondylitis, and enteropathic arthritis are all seronegative arthritis, meaning that rheumatoid factor is classically not present.
Reactive arthritis is usually precipitated by a gastrointestinal or genitourinary infection occurring before the onset of arthritic symptoms. The classic triad of reactive arthritis is conjunctivitis, asymmetric oligoarthritis, and urethritis. The condition may be self-limiting, but in some patients, it may become chronic or recur frequently.
Psoriatic arthritis is classically found in patients with psoriasis, but in around 1 in 6 people, it may present many years before psoriatic skin symptoms. Ankylosing spondylitis, on the other hand, is a chronic disorder of an inflammatory nature characterized by sacroiliac joint involvement and linked to the HLA-B27 antigen. Enteropathic arthritis is associated with inflammatory bowel disease and can affect any joint, but it most commonly affects the spine and lower limb joints. Approximately 1 in 5 people with inflammatory bowel disease will develop the condition.
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This question is part of the following fields:
- Rheumatology
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Question 48
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:
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 49
Incorrect
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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:
Correct 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 50
Incorrect
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A 63-year-old woman visits her GP complaining of pain and swelling in her fingers and wrists. The pain has been gradually worsening over the past few months, and she is having difficulty opening jars at home. She reports that her fingers are stiff when she wakes up but gradually loosen throughout the morning.
Upon examination, the GP notes symmetrical swelling of the MCP and PIP joints, which are tender to pressure and have stress pain on passive movement. The patient also has swan neck and boutonnière deformities of the fingers. The GP diagnoses the patient with rheumatoid arthritis and refers her to a rheumatologist. The GP prescribes anti-inflammatory medications and advises the patient to rest her fingers and wrists.
What is the most common ocular extra-articular manifestation of rheumatoid arthritis in a patient who is 63 years old?Your Answer:
Correct Answer: Keratoconjunctivitis sicca
Explanation:Ocular Manifestations of Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic inflammatory polyarthropathy that primarily affects small joints, causing symmetrical joint tenderness and swelling. It is an autoimmune disease with genetic and environmental risk factors. RA can result in marked physical disability, and extra-articular features are more common in rheumatoid factor-positive patients with long-standing disease. Ocular manifestations of RA include keratoconjunctivitis sicca, also known as dry eye syndrome, which is the most common ocular extra-articular manifestation. Scleromalacia perforans, a thinning of the sclera, is associated with RA but presents less often than keratoconjunctivitis sicca. Episcleritis and scleritis are also associated with RA but are less common than keratoconjunctivitis sicca. Orbital apex syndrome may involve the optic nerve, causing a palsy, but this is very rare. It is important for healthcare providers to be aware of these ocular manifestations and monitor patients with RA for any changes in their vision or eye health.
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This question is part of the following fields:
- Rheumatology
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Question 51
Incorrect
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In which disease is the distal interphalangeal joint typically impacted?
Your Answer:
Correct Answer: Psoriatic arthritis
Explanation:Characteristics of Different Arthritis Types
Psoriatic arthritis is a type of arthritis that commonly affects the distal interphalangeal (DIP) joints. It is often accompanied by psoriasis around the adjacent nail, and other joint involvement is typically more asymmetric than in rheumatoid arthritis. On the other hand, Reactive arthritis is characterized by uveitis, urethritis, and arthritis that does not involve the DIP. Gout, another type of arthritis, does not typically affect the DIP either. While rheumatoid arthritis can occasionally affect the DIP, it is classically a MCP and PIP arthritis. Lastly, bursitis is a pathology of the bursa, not the joint itself. the characteristics of different types of arthritis can aid in proper diagnosis and treatment.
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This question is part of the following fields:
- Rheumatology
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Question 52
Incorrect
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A 27-year-old male presents with lower back pain and painful feet that feel like walking on pebbles. He has been generally healthy, but he recently returned from a trip to Corfu where he had a diarrheal illness. He admits to infrequently taking ecstasy but takes no other medication. On examination, he has limited movement and pain in the sacroiliac joints and soreness in the soles of his feet upon deep palpation. What is the most probable diagnosis?
Your Answer:
Correct Answer: Reactive arthritis
Explanation:After a diarrhoeal illness, the patient may be at risk of developing reactive arthritis, which is a possible diagnosis for both sacroiliitis and plantar fasciitis. However, it is less likely to be related to inflammatory bowel disease (IBD) if there is only one acute episode of diarrhoea.
Sacroiliitis is a condition that affects the sacroiliac joint, which is located at the base of the spine where it connects to the pelvis. It causes inflammation and pain in the lower back, buttocks, and legs. Plantar fasciitis, on the other hand, is a condition that affects the plantar fascia, a thick band of tissue that runs along the bottom of the foot. It causes pain and stiffness in the heel and arch of the foot.
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This question is part of the following fields:
- Rheumatology
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Question 53
Incorrect
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What is the most probable diagnosis for a 70-year-old woman who presents with bilateral shoulder pain and stiffness, fatigue, weight loss, and elevated ESR levels?
Your Answer:
Correct Answer: Polymyalgia rheumatica (PMR)
Explanation:Differentiating between Rheumatic Diseases: A Case Study
Polymyalgia rheumatica (PMR) is a common inflammatory rheumatic disease in the elderly population, presenting as pain and stiffness in the neck, shoulders, upper arms, and hips. In contrast, polymyositis is an autoimmune connective tissue disease that results in proximal muscle weakness. Multiple myeloma is a malignancy of plasma cells, causing bone pain, renal failure, and anaemia. Rheumatoid arthritis is a chronic inflammatory, symmetrical polyarthropathy that tends to cause joint stiffness and pain within the small joints, as well as causing fatigue. Osteoarthritis is a degenerative arthritis that commonly affects the knee, hip, spine, and hands.
In this case study, the patient presented with shoulder stiffness, fatigue, low-grade fever, and anaemia. A diagnosis of PMR was made clinically and with the aid of a raised ESR. Treatment is with oral prednisolone, which should be reduced gradually once symptoms are controlled to avoid the risks of chronic steroid use.
It is important to differentiate between these rheumatic diseases as they have different underlying causes, presentations, and treatments. A thorough history, physical examination, and appropriate investigations are necessary for accurate diagnosis and management.
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This question is part of the following fields:
- Rheumatology
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Question 54
Incorrect
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A 32-year-old Afro-Caribbean woman comes to the clinic with concerns about her appearance. She has noticed hair loss, a rash on her face, and mouth ulcers. Additionally, she has been experiencing joint pain and has been taking paracetamol and ibuprofen to manage it. This is her second visit to the clinic, and the registrar has already sent off some immunology tests. The results show a positive dsDNA antibody. What is the most probable diagnosis?
Your Answer:
Correct Answer: Systemic lupus erythematosus (SLE)
Explanation:Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women. It is caused by the deposition of immune complexes and can have a wide range of clinical effects, including a butterfly-shaped rash on the cheeks and nose, joint pain, and involvement of multiple organ systems such as the kidneys, lungs, and heart. SLE is associated with the presence of ANA and dsDNA antibodies, as well as low levels of C3 and C4 in the blood.
Mixed connective tissue disease (MCTD) is a syndrome that shares features with several other rheumatological conditions, including SLE, scleroderma, myositis, and rheumatoid arthritis. Common symptoms include fatigue, joint pain, pulmonary involvement, and Raynaud’s phenomenon. MCTD is strongly associated with anti-RNP antibodies.
Rheumatoid arthritis is an inflammatory arthritis that typically affects middle-aged women and causes symmetrical joint pain and stiffness, particularly in the hands and feet. If left untreated, it can lead to deformities that affect function. Rheumatoid arthritis is associated with the presence of autoantibodies such as rheumatoid factor and anti-CCP.
Polymyositis is an autoimmune myositis that causes weakness and loss of muscle mass, particularly in the proximal muscles. Other symptoms may include malaise and difficulty swallowing. Polymyositis is associated with anti-Jo1 autoantibodies.
Systemic sclerosis, also known as diffuse scleroderma, is an autoimmune disease that primarily affects women aged 30-50. It causes collagen accumulation, leading to thickening of the skin and vasculitis affecting small arteries. Systemic sclerosis can affect multiple organ systems, including the skin, lungs, kidneys, and gastrointestinal tract. It is associated with anti-Scl70 antibodies.
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This question is part of the following fields:
- Rheumatology
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Question 55
Incorrect
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A 32-year-old woman fell off her horse while horse-riding and is now experiencing severe foot pain. Her foot was trapped in the stirrup during the fall. An x-ray revealed displacement of her second and third metatarsal from the tarsus. What is the name of this injury?
Your Answer:
Correct Answer: Lisfranc Injury
Explanation:Common Foot Injuries and Their Characteristics
Lisfranc injury is a type of foot injury that occurs when one or more metatarsal bones are displaced from the tarsus. This injury is usually caused by excessive kinetic energy being placed on the midfoot, such as in a traffic collision. There are two types of Lisfranc injuries: direct and indirect. A direct injury occurs when the foot is crushed by a heavy object, while an indirect injury occurs when there is sudden rotational force on a plantar flexed foot.
March fracture is another common foot injury that is caused by repetitive stress on the distal third of one of the metatarsal bones. This injury is often seen in soldiers and hikers who walk long distances. The onset of foot pain is gradual and progressive, and there is often trauma associated with it.
Hallux Rigidus is a degenerative arthritis that causes bone spurs at the metatarsophalangeal joint of the big toe, making it painful and stiff. Jones fracture is a fracture in the meta-diaphyseal junction of the fifth metatarsal of the foot. Proximal fifth metatarsal avulsion fracture is caused by forcible inversion of the foot in plantar flexion, such as when stepping on a kerb or climbing steps.
These different foot injuries have their own unique characteristics and causes. these injuries can help individuals take preventative measures to avoid them and seek appropriate treatment if necessary.
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This question is part of the following fields:
- Rheumatology
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Question 56
Incorrect
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A 65-year-old woman presents with a four-month history of finding it more difficult to get out of her chair. She also complains of a right-sided temporal headache, which is often triggered when she brushes her hair. A diagnosis of polymyalgia rheumatica with temporal arthritis is suspected.
Which of the following blood tests is most useful in supporting the diagnosis?Your Answer:
Correct Answer: Plasma viscosity
Explanation:Diagnostic Markers for Polymyalgia Rheumatica and Temporal arthritis
Polymyalgia rheumatica and temporal arthritis are inflammatory conditions that can cause significant morbidity if left untreated. Here are some diagnostic markers that can help support or rule out these conditions:
Plasma viscosity: A raised plasma viscosity can support a diagnosis of polymyalgia rheumatica with temporal arthritis, but it is a nonspecific inflammatory marker.
Creatine kinase: A raised creatine kinase is not supportive of a diagnosis of polymyalgia rheumatica or temporal arthritis.
Monospot test: A positive monospot test is supportive of a diagnosis of Epstein–Barr virus (EBV), but not polymyalgia rheumatica or temporal arthritis.
Whole cell count (WCC): A raised WCC is not supportive of a diagnosis of polymyalgia rheumatica or temporal arthritis.
Bence Jones proteins: Presence of Bence Jones protein is supportive of a diagnosis of multiple myeloma, but not polymyalgia rheumatica or temporal arthritis.
If temporal arthritis is suspected, immediate treatment with prednisolone is crucial to prevent permanent loss of vision. A temporal artery biopsy can confirm the diagnosis.
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This question is part of the following fields:
- Rheumatology
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Question 57
Incorrect
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A 50-year-old woman with a history of rheumatoid arthritis is experiencing shortness of breath during light activity and has developed a dry cough. Upon testing, her oxygen saturation was found to be 87% while breathing normally. A chest x-ray revealed a diffuse bilateral interstitial infiltrate. Despite an extensive infection screening, no infections were found, leading doctors to believe that her symptoms are a result of a drug she is taking. Which medication is the most likely culprit for this adverse reaction?
Your Answer:
Correct Answer: Methotrexate
Explanation:Potential Side Effects of Common Rheumatoid Arthritis Medications
Methotrexate, a commonly prescribed medication for rheumatoid arthritis, has been known to cause acute pneumonitis and interstitial lung disease. Although this is a rare complication, it can be fatal and should be closely monitored. Azathioprine, another medication used to treat rheumatoid arthritis, can lead to bone marrow suppression and increase the risk of infection. Cyclosporin, often used in combination with other medications, can cause neurological and visual disturbances. Hydroxychloroquine, while generally well-tolerated, can lead to abdominal pain and visual disturbances in cases of toxicity. Sulfasalazine, another medication used to treat rheumatoid arthritis, can affect liver function tests and cause bone marrow suppression, requiring careful monitoring.
It is important for patients to be aware of the potential side effects of their medications and to communicate any concerns with their healthcare provider. Regular monitoring and follow-up appointments can help to identify and manage any adverse effects. With proper management, the benefits of these medications can outweigh the risks for many patients with rheumatoid arthritis.
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This question is part of the following fields:
- Rheumatology
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Question 58
Incorrect
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A 42-year-old known intravenous (iv) drug user presents to her general practitioner with complaints of fever, morning stiffness, and joint pain. The patient reports a constant, dull pain in the distal interphalangeal (DIP) joints bilaterally, with an intensity of 3/10. Her medical history is unremarkable, but her family history includes a skin condition and rheumatoid arthritis. The patient consumes 15 alcoholic units per week and smokes two packs of cigarettes per day. On physical examination, the patient is febrile with a temperature of 38.1 °C. The DIP joints are warm and swollen, and there is symmetric nail pitting. What is the most likely diagnosis for this patient's current presentation?
Your Answer:
Correct Answer: Appearance of a silver, scaly rash
Explanation:Differentiating Arthritides: Understanding Clinical and Laboratory Findings
Arthritis is a common condition that affects the joints, and it can be challenging to distinguish between the various types that exist. However, by considering the patient’s medical history, physical examination, and laboratory findings, clinicians can make an accurate diagnosis.
For instance, psoriatic arthritis is an inflammatory subtype of arthritis that often affects the DIP joints, sausage digits, and nails. The classic X-ray finding of psoriatic arthritis is the pencil in a cup appearance, although it is not specific to the disease. In contrast, rheumatoid arthritis is characterized by PIP and MCP joint involvement, wrist and cervical spine pain, and positive rheumatoid factor and anti-CCP antibodies.
Septic arthritis is a medical emergency that usually involves large joints and is associated with high fever, chills, and rapid joint destruction. Synovial fluid analysis may reveal Gram-positive cocci in cases of septic arthritis caused by Staphylococcus aureus.
Osteoarthritis, on the other hand, is a degenerative joint disease that is associated with subchondral cyst formation, joint space narrowing, and osteophyte formation. It typically affects the DIP and PIP joints and large weight-bearing joints, but it is not an inflammatory arthritis.
In summary, understanding the clinical and laboratory findings associated with different types of arthritis is crucial for accurate diagnosis and appropriate management.
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This question is part of the following fields:
- Rheumatology
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Question 59
Incorrect
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A previously healthy 60-year-old hypertensive teacher complains of pain, redness, and swelling in the left knee that began 10 hours ago. The patient has a family history of hypertension and joint issues. What is the most crucial investigation to determine the cause of the knee symptoms?
Your Answer:
Correct Answer: Joint aspiration for microscopy and culture
Explanation:Importance of Joint Aspiration in Identifying the Cause of Acute Monoarthropathy
When a patient presents with acute monoarthropathy, it is important to identify the cause of their symptoms. The most important investigation in this case is joint aspiration. This procedure involves taking a sample of fluid from the affected joint and examining it under a microscope to identify any infective organisms. This is crucial in cases where septic arthritis is suspected, as appropriate therapy can be guided based on the results. On the other hand, if the cause is gout, joint aspiration can reveal the presence of crystals in the fluid. X-rays are of no value in septic arthritis as they only become abnormal following joint destruction. Therefore, joint aspiration is the most important investigation in identifying the cause of acute monoarthropathy.
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This question is part of the following fields:
- Rheumatology
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Question 60
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:
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 61
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:
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 62
Incorrect
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You are asked to see a 35-year-old man with a three year history of recurrent episodes of asymmetrical joint pains involving his knees, ankles and elbows. Two to four joints tend to be affected at any one time and each joint may be affected from two to four weeks each time.
In the last decade he has also had recurrent painful mouth sores. On this occasion, he also complains of a severe occipital headache, mild abdominal pain and some discomfort on passing urine.
On examination, his temperature is 38°C. His left knee and right ankle joints are painful, swollen and tender. Superficial thrombophlebitis is noted in the right leg.
Investigations show:
Hb 99 g/L (130-180)
WCC 11.6 ×109/L (4-11)
Platelets 420 ×109/L (150-400)
ESR 60 mm/hr (0-15)
Plasma sodium 138 mmol/L (137-144)
Plasma potassium 4.3 mmol/L (3.5-4.9)
Plasma urea 6.9 mmol/L (2.5-7.5)
Plasma creatinine 95 µmol/L (60-110)
Plasma glucose 5.8 mmol/L (3.0-6.0)
What is the most likely diagnosis?Your Answer:
Correct Answer: Behçet's syndrome
Explanation:Behçet’s Syndrome
Behçet’s syndrome is a medical condition that is characterized by a range of symptoms. These symptoms include recurrent oral and genital ulcers, uveitis, seronegative arthritis, central nervous system symptoms, fever, thrombophlebitis, erythema nodosum, abdominal symptoms, and vasculitis. The condition is often marked by periods of exacerbations and remissions, which can make it difficult to manage.
One of the most common symptoms of Behçet’s syndrome is the presence of oral and genital ulcers that recur over time. These ulcers can be painful and may make it difficult to eat or engage in sexual activity. Uveitis, or inflammation of the eye, is another common symptom of the condition. This can cause redness, pain, and sensitivity to light.
Seronegative arthritis, which is a type of arthritis that does not show up on blood tests, is also associated with Behçet’s syndrome. This can cause joint pain and stiffness, as well as swelling and inflammation. Central nervous system symptoms, such as headaches, confusion, and seizures, may also occur.
Other symptoms of Behçet’s syndrome include fever, thrombophlebitis, erythema nodosum, abdominal symptoms, and vasculitis. These symptoms can vary in severity and may come and go over time. Managing Behçet’s syndrome can be challenging, but with proper treatment and care, many people are able to live full and active lives.
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This question is part of the following fields:
- Rheumatology
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Question 63
Incorrect
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An 80-year-old man comes to the doctor with complaints of widespread aches, bone pains, headaches, and nerve entrapment syndromes that have been bothering him for several years. His blood work reveals an elevated serum alkaline phosphatase, and his urine test shows an increased urinary hydroxyproline. The X-ray of his skull displays a mix of lysis and sclerosis with thickened trabeculae. What medication would be appropriate for this patient?
Your Answer:
Correct Answer: Oral bisphosphonates to inhibit osteoclastic activity
Explanation:Treatment Options for Paget’s Disease: Oral Bisphosphonates and More
Paget’s disease is a condition characterized by abnormal bone remodeling, which can lead to a range of symptoms including bone pain, fractures, and osteoarthritis. Diagnosis is typically made through radiograph findings and laboratory tests. Treatment options vary depending on the severity of symptoms, with physiotherapy and NSAIDs being effective for mild cases. However, for more severe cases, oral bisphosphonates and calcitonin may be necessary to inhibit osteoclastic activity. Chelation therapy, antidepressant medication, and chemotherapy for osteosarcoma are not indicated for Paget’s disease. Operative therapy may be necessary for patients with degenerative joint disease and pathological fractures, but should be preceded by treatment with oral bisphosphonates or calcitonin to reduce bleeding.
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This question is part of the following fields:
- Rheumatology
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Question 64
Incorrect
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A 33-year-old paediatric nurse presents with complaints of fatigue, joint discomfort throughout her body, and a rash on her face that has worsened since returning from a recent trip to Portugal. On examination, there is no evidence of small joint synovitis, but the facial rash is prominent. Blood tests reveal a haemoglobin level of 103 g/l, MCV of 88.8 fl, platelet count of 99 × 109/l, and a WCC of 2.8 × 109/l. What is the most appropriate treatment option at this stage?
Your Answer:
Correct Answer: Hydroxychloroquine
Explanation:The patient in this scenario has systemic lupus erythematosus (SLE) with mild symptoms, primarily affecting the joints and skin. The first-line treatment for this type of SLE is hydroxychloroquine, which can induce remission and reduce recurrence. However, patients on this medication must be monitored for drug-induced retinopathy. Methotrexate may be used in more severe cases with active joint synovitis. Sun avoidance is important to prevent flares, but it is not enough to treat the patient’s current symptoms. Infliximab is not typically used to treat SLE, and rituximab is reserved for last-line therapy. Azathioprine is commonly used as a steroid-sparing agent in SLE, but hydroxychloroquine is more appropriate for this patient’s current presentation. The main adverse effect of azathioprine is bone marrow suppression, which can be life-threatening in some patients.
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This question is part of the following fields:
- Rheumatology
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Question 65
Incorrect
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A 45-year-old patient is referred for investigation of hypertension. On examination, she has a beaked nose and telangiectasia on the face. There is evidence of tight, waxy skin of the fingers, with calcification on one finger. She has had Raynaud’s disease for many years.
Which of the following autoantibodies is most likely to be positive?Your Answer:
Correct Answer: Anti-centromere antibody
Explanation:Differentiating Autoantibodies in Connective Tissue Diseases
Connective tissue diseases are a group of autoimmune disorders that affect various parts of the body. Differentiating between these diseases can be challenging, but autoantibodies can provide valuable clues. Here are some common autoantibodies and the connective tissue diseases they are associated with:
1. Anti-centromere antibody: This antibody is most likely to be present in limited systemic sclerosis (CREST).
2. Anti-Scl-70: This antibody is found in diffuse systemic sclerosis.
3. Anti-RNP antibody: This antibody is found in mixed connective tissue disease.
4. Anti-Ro antibody: This antibody is classically positive in Sjögren’s syndrome or systemic lupus erythematosus.
5. Anti-Jo-1 antibody: This antibody is commonly raised in polymyositis.
By identifying the specific autoantibodies present in a patient, healthcare providers can better diagnose and manage connective tissue diseases.
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This question is part of the following fields:
- Rheumatology
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Question 66
Incorrect
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A 40-year-old teacher presents with complaints of lethargy and widespread aches and pains, particularly in the shoulders and hands. She has been absent from work for the past 5 months due to her symptoms. Her medical history includes a diagnosis of irritable bowel syndrome. Despite a brief course of steroids and anti-inflammatory medication, she has not experienced any improvement. Physical examination reveals multiple tender points in different muscle groups, but no evidence of joint disease. What is the probable diagnosis?
Your Answer:
Correct Answer: Fibromyalgia
Explanation:Understanding Fibromyalgia and Differential Diagnosis
Fibromyalgia is a functional condition that affects voluntary muscles, commonly presenting in females aged 20-40 years. It is characterized by multiple trigger points over soft tissues in the neck, intrascapular region, and spine, along with poor sleep patterns and fatigue. While there is no known cure, patients are encouraged to establish a regular sleep pattern and participate in a graded exercise program. Differential diagnosis is important to exclude other rheumatological conditions that may present similarly but have different treatment options. Polymyalgia rheumatica, polymyositis, hypothyroidism, and systemic lupus erythematosus are some of the conditions that need to be ruled out. Steroids are the mainstay of treatment for polymyalgia rheumatica, while hypothyroidism presents with different symptoms such as constipation, dry hair, and weight gain. Systemic lupus erythematosus typically presents with a butterfly rash over the face and other symptoms such as anaemia, pleuritic chest pain, and haematuria.
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This question is part of the following fields:
- Rheumatology
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Question 67
Incorrect
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A 25-year-old male immigrant from Turkey presents with complaints of recurrent painful oral ulcers, genital ulcers, tender nodules on the extensor surface of the tibia and arthritis of both knees and ankles for the past 3 months. He has also had episodes of severe eye pain. He had an episode of pulmonary embolism due to deep vein thrombosis of the right leg 1 month ago. On examination, the oral cavity shows the presence of small shallow ulcers with a yellow necrotic centre. Genital examination reveals ulcers on the shaft of the penis and scrotal scars. The glans is spared. Non-specific inflammatory response is observed after intradermal injection of normal saline. Investigations revealed:
Investigation Result Normal value
White cell count (WCC) 20 × 109/l 4–11 × 109/l
Erythrocyte sedimentation rate (ESR) 80 mm/h 0–10mm in the 1st hour
C-reactive protein (CRP) Positive
Anti-Saccharomyces cerevisiae antibodies Positive
Which one of the following is the most likely diagnosis?Your Answer:
Correct Answer: Behçet’s syndrome
Explanation:Behçet’s Syndrome: A Multisystem Disorder with Recurrent Oral and Genital Ulcerations
Behçet’s syndrome is a multisystem disorder that primarily affects young people from the Mediterranean region, the Middle East, and the Far East. The syndrome is characterized by recurrent oral and genital ulcerations, as well as ocular involvement. The main pathologic lesion is systemic perivasculitis with early neutrophil infiltration and endothelial swelling. In some patients, vasculitis of the vasa vasorum can result in the formation of pseudo-aneurysms. Anti-Saccharomyces cerevisiae antibodies are present in patients with Behçet’s syndrome. The recurrent aphthous ulcerations are essential for the diagnosis, and a non-specific skin inflammatory reactivity to any scratches or intradermal saline injection (pathergy test) is a common and specific manifestation. Genital ulcers are painful, do not affect the glans penis or urethra, and produce scrotal scars. Thromboembolic events are a component of the disease itself, with superficial or deep peripheral vein thrombosis seen in 30% of patients. Pulmonary emboli are a rare but possible complication.
Other possible diagnoses, such as extra intestinal Crohn’s disease, occult malignancy, systemic lupus erythematosus (SLE), and rheumatoid arthritis, can be ruled out based on the absence of certain clinical features and the presence of anti-Saccharomyces cerevisiae antibodies.
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This question is part of the following fields:
- Rheumatology
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Question 68
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:
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 69
Incorrect
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A 35-year-old male executive presents to you after being referred from the Emergency department. He has been experiencing a painful and swollen left knee for the past 24 hours. He denies any history of joint problems or trauma. Additionally, he has noticed redness and soreness in both eyes over the last two days. He is a non-smoker, married, and consumes about 10 units of alcohol weekly. He recently returned from a business trip to Amsterdam two weeks ago.
During examination, his temperature is 38.5°C, and he has a brown macular rash on the soles of his feet. His left knee is hot, swollen, and tender to palpate, while no other joint appears to be affected.
Investigations reveal Hb 129 g/L (130-180), WBC 14.0 ×109/L (4-11), Platelets 200 ×109/L (150-400), ESR 75 mm/hr (0-15), Plasma sodium 140 mmol/L (137-144), Plasma potassium 4.1 mmol/L (3.5-4.9), Plasma urea 5.6 mmol/L (2.5-7.5), Blood cultures without growth after 48 hours, and Urinalysis without blood, glucose, or protein detected. Knee x-ray shows soft tissue swelling around the left knee.
What is the most likely diagnosis?Your Answer:
Correct Answer: Reactive arthritis
Explanation:Reactive Arthritis
Reactive arthritis is a medical condition that is typically characterized by a combination of three symptoms: urethritis, conjunctivitis, and seronegative arthritis. This type of arthritis usually affects the large weight-bearing joints, such as the knee and ankle, but not all three symptoms are always present in a patient. Reactive arthritis can be triggered by either a sexually transmitted infection or a dysenteric infection. One of the most notable signs of this condition is the appearance of a brown macular rash known as keratoderma blennorrhagica, which is usually seen on the palms and soles.
The main treatment for reactive arthritis involves the use of non-steroidal anti-inflammatory drugs (NSAIDs). These medications can help to alleviate the pain and inflammation associated with the condition. Additionally, antibiotics may be prescribed to individuals who have recently experienced a non-gonococcal venereal infection. This can help to reduce the likelihood of that person developing reactive arthritis. Overall, the symptoms and treatment options for reactive arthritis can help individuals to manage this condition and improve their quality of life.
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This question is part of the following fields:
- Rheumatology
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Question 70
Incorrect
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A 35-year-old man presents to the outpatient department with complaints of lower back pain. He used to be an active soccer player but has had to give up due to the pain.
During the examination, there is no skin rash or history of gastrointestinal or genitourinary symptoms. The patient reports difficulty standing straight and walking in a stooped position for hours each morning before being able to stand up straight. Additionally, there is redness and pain around the right heel, and Schober's test is positive.
What abnormalities may be found on the patient's ECG?Your Answer:
Correct Answer: A-V dissociation, deep S in V1 and tall R in V5
Explanation:Ankylosing Spondylitis and Cardiac Manifestations
Ankylosing spondylitis (AS) is a systemic disorder that affects multiple systems in the body. One of the extra-articular manifestations of AS is cardiac involvement, which can lead to heart block and aortic regurgitation. Chronic aortic regurgitation can cause left ventricular hypertrophy, resulting in deep S in V1 and tall R in V5. A-V dissociation is the ECG manifestation of heart block. Mortality rates are higher in patients with AS, with circulatory disease being the most common cause of death.
P-pulmonale is not a typical manifestation of AS, but it can occur in cases of pulmonary hypertension when the right atrium is enlarged. Pulmonary fibrosis, which can occur in AS, can theoretically lead to pulmonary hypertension and p-pulmonale. Right bundle branch block is a non-specific ECG finding that can occur without any heart disease or in conditions such as atrial septal defect, ischemic heart disease, or pulmonary embolism.
In conclusion, AS is a systemic disorder that can affect multiple systems in the body, including the heart. Cardiac involvement can lead to heart block and aortic regurgitation, which can cause left ventricular hypertrophy. Mortality rates are higher in patients with AS, with circulatory disease being the most common cause of death. While p-pulmonale is not a typical manifestation of AS, it can occur in cases of pulmonary hypertension. Right bundle branch block is a non-specific ECG finding that can occur in various conditions.
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This question is part of the following fields:
- Rheumatology
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Question 71
Incorrect
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A 40-year-old homemaker with long-standing psoriasis visits her GP with worsening joint pains over the past six months. Upon examination, the GP suspects potential psoriatic arthropathy and refers the patient to a rheumatologist. What is a severe manifestation of psoriatic arthropathy?
Your Answer:
Correct Answer: Arthritis mutilans
Explanation:Psoriatic Arthritis: Common Presentations and Misconceptions
Psoriatic arthritis is a type of arthritis that affects some individuals with psoriasis. While it can present in various ways, there are some common misconceptions about its symptoms. Here are some clarifications:
1. Arthritis mutilans is a severe form of psoriatic arthritis, not a separate condition.
2. Psoriatic arthritis can have a rheumatoid-like presentation, but not an osteoarthritis-like one.
3. The most common presentation of psoriatic arthritis is distal interphalangeal joint involvement, not proximal.
4. Psoriatic spondylitis is a type of psoriatic arthritis that affects the spine, not ankylosing spondylitis.
5. Asymmetrical oligoarthritis is a common presentation of psoriatic arthritis, not symmetrical oligoarthritis.
Understanding these presentations can help with early diagnosis and appropriate treatment of psoriatic arthritis.
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This question is part of the following fields:
- Rheumatology
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Question 72
Incorrect
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A 28-year-old man comes to the Clinic complaining of lower back pain and early morning stiffness that gradually improves as the day goes on. Upon examination, there is a decrease in forward flexion with a positive Schober's test. A lumbar sacral X-ray confirms changes indicative of ankylosing spondylitis. What would be the primary treatment option to consider?
Your Answer:
Correct Answer: Ibuprofen
Explanation:The first-line treatment for ankylosing spondylitis is non-steroidal anti-inflammatories (NSAIDs) like ibuprofen, which should be used alongside physiotherapy and exercise. Long-term NSAID use requires gastro protection with a proton-pump inhibitor. If morning or night pain persists despite NSAIDs, a long-acting preparation can be tried. Tumour necrosis factor (TNF)-alpha inhibitors like etanercept are recommended for poorly controlled ankylosing spondylitis after NSAIDs. Methotrexate is only useful in cases with extensive peripheral joint involvement, which is not mentioned in the vignette. Oral steroids like prednisolone are not first-line management, but intra-articular corticosteroids may be considered for poorly controlled sacroiliitis. Sulfasalazine, a disease-modifying agent used in rheumatoid arthritis, is only useful in ankylosing spondylitis patients with peripheral joint involvement, which is not mentioned in the vignette.
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This question is part of the following fields:
- Rheumatology
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Question 73
Incorrect
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A 27-year-old semi-professional rugby player presents with a red, hot, swollen left knee. There has been no history of trauma. He recently had a negative sexual health check and has not had any new partners since. Upon examination, the left knee is unable to fully extend and there is a large effusion. The clinical suspicion is septic arthritis. What is the most probable organism responsible for this condition?
Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Septic Arthritis: Causes and Treatment
Septic arthritis is a rheumatological emergency that requires urgent attention. A red, hot, swollen joint may indicate septic arthritis, which can be caused by a variety of pathogens. The most common pathogen is Staphylococcus aureus, and joint destruction can occur within 24 hours if left untreated. It is important to consider and treat septic arthritis urgently or until firmly excluded by joint aspiration. The empirical antibiotic regime should be consulted in local health authority guidelines or with a microbiologist. Intravenous drugs should be used for 2 weeks and a total course of 6 weeks completed. Other pathogens that can cause septic arthritis include Neisseria gonorrhoeae, Mycobacterium tuberculosis, Streptococcus viridans, and Salmonella typhi. It is important to consider the patient’s medical history and risk factors when determining the cause of septic arthritis.
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This question is part of the following fields:
- Rheumatology
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Question 74
Incorrect
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A 78-year-old retired general practitioner (GP) has been experiencing increasing swelling and tenderness of the right knee. Symptoms have been progressively worsening over four days. There is no history of trauma, and he has had no similar symptoms previously. The patient suspects that he may have pseudogout of the knee.
What is the most common tissue for calcium pyrophosphate crystal deposition in patients with pseudogout?Your Answer:
Correct Answer: Synovium
Explanation:Sites of Crystal Deposition in Pseudogout
Pseudogout is a condition characterized by the deposition of calcium pyrophosphate dihydrate (CPPD) crystals in various tissues of the body. The most common site of deposition is the synovial fluid, which can lead to joint inflammation and pain. However, CPPD crystals can also be deposited in other tissues such as cartilage, ligaments, tendons, and bursae.
Cartilage is another common site for CPPD crystal deposition, and pseudogout is also known as chondrocalcinosis. Deposition in the ligaments and tendons is possible but less common than in the synovium. Bursae deposition is also possible but less common than synovium deposition.
In summary, while CPPD crystals can be deposited in various tissues in pseudogout, the synovium is the most common site of deposition, followed by cartilage, ligaments, tendons, and bursae.
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This question is part of the following fields:
- Rheumatology
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Question 75
Incorrect
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A 40-year-old school teacher who enjoys running long distances comes to the clinic complaining of cramp-like pain in the forefoot that has been bothering them for the past week. During the examination, tenderness was noted over the dorsal distal portion of the second metatarsal. What is the probable diagnosis?
Your Answer:
Correct Answer: March fracture
Explanation:Common Foot Injuries and Their Causes
March fracture, Lisfranc injury, Hallux Rigidus, Jones fracture, and proximal fifth metatarsal avulsion fracture are all common foot injuries that can cause significant pain and discomfort. A March fracture is a stress fracture of one of the metatarsal bones caused by repetitive stress, often seen in soldiers and hikers. Lisfranc injury occurs when one or more metatarsal bones are displaced from the tarsus due to excessive kinetic energy, such as in a traffic collision. Hallux Rigidus is degenerative arthritis that causes bone spurs at the metatarsophalangeal joint of the big toe, resulting in stiffness and pain. Jones fracture is a fracture in the fifth metatarsal of the foot, while proximal fifth metatarsal avulsion fracture is caused by forcible inversion of the foot in plantar flexion.
Based on the onset of symptoms and tenderness over the distal portion of the second metatarsal, a March fracture is the most likely diagnosis. It is important to seek medical attention for any foot injury to prevent further damage and ensure proper healing.
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This question is part of the following fields:
- Rheumatology
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Question 76
Incorrect
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A 68-year-old man visits his doctor's office, reporting a recent onset of a red, swollen, and hot great left toe. He denies any injury to the toe and has a medical history of hypertension, which is being treated with a single medication. The doctor suspects acute gout as the diagnosis.
What medication is most likely responsible for triggering the acute gout?Your Answer:
Correct Answer: Bendroflumethiazide
Explanation:Understanding Gout and its Causes: A Review of Medications and Differential Diagnosis
Gout is a type of inflammatory arthritis caused by the deposition of urate crystals in the joint. This article reviews the causes of gout, which can be primary or secondary hyperuricaemia. Secondary hyperuricaemia can be caused by overproduction or decreased renal excretion, including the use of thiazide diuretics like bendroflumethiazide. The differential diagnosis for an acute red, hot swollen joint includes septic arthritis, gout, pseudogout, inflammatory monoarthritis, and post-traumatic causes. Treatment for gout includes medications for chronic and acute gout, such as non-steroidal anti-inflammatory drugs, colchicine, or prednisolone. This article also discusses the effects of medications like colchicine, propranolol, lisinopril, and moxonidine on gout and other conditions.
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This question is part of the following fields:
- Rheumatology
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Question 77
Incorrect
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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:
Correct 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 78
Incorrect
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A 35-year-old man presents with a 5-day history of pain and swelling affecting the right knee and left ankle. On further questioning, he complained of dysuria and had woken with both eyes ‘stuck together’ for the last three days. He thinks that his urinary symptoms may be linked to the unprotected sex he had three weeks ago. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Reactive arthritis
Explanation:Differential Diagnosis for a Patient with Reactive Arthritis Symptoms
A patient presents with arthropathy, conjunctivitis, and urethritis, which are classic symptoms of reactive arthritis. The probable underlying cause is chlamydial infection or gonorrhea, as the patient has had recent unprotected sex. Primary syphilis, genital herpes, trichomoniasis, and E. coli infection are unlikely differential diagnoses. Syphilis causes a painless sore on the genitals, while genital herpes presents with blisters and is not associated with arthropathy. Trichomoniasis is commonly asymptomatic and presents with dysuria, frequency, and balanitis in men. E. coli is a common cause of UTI, but the patient’s symptoms are broader than those of a typical UTI.
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This question is part of the following fields:
- Rheumatology
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Question 79
Incorrect
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A 20-year-old student midwife presents with increasing pain and swelling of the ring finger of her left hand. The pain and swelling started two days ago and is now extremely uncomfortable to the point the patient has been avoiding using the left hand altogether. She cannot remember injuring the affected area, and is usually fit and well, without medical conditions to note except an allergy to peanuts.
On examination, the affected finger is markedly swollen and erythematosus, with tenderness to touch – especially along the flexor aspect of the finger. The patient is holding the finger in slight flexion; attempts at straightening the finger passively causes the patient extreme pain. The patient is diagnosed with tenosynovitis.
About which one of the following conditions should the presence of acute migratory tenosynovitis in young adults, particularly women aged 20, alert the doctor?Your Answer:
Correct Answer: Disseminated gonococcal infection
Explanation:Migratory tenosynovitis can be caused by disseminated gonococcal infection in younger adults, particularly women. It is important to test for C6-C9 complement deficiency. Rheumatoid arthritis can also cause tenosynovitis, but it is not migratory and is usually found in the interphalangeal, metacarpophalangeal, and wrist joints. Scleroderma can cause tenosynovitis, but it is not migratory either. Fluoroquinolone toxicity may increase the risk of tendinopathy and tendon rupture, but it does not cause migratory tenosynovitis. Reactive arthritis can cause tendinitis, but it is more prevalent in men and is not migratory. It is a rheumatoid factor-seronegative arthritis that can be linked with HLA-B27.
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This question is part of the following fields:
- Rheumatology
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Question 80
Incorrect
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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:
Correct 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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