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Question 1
Incorrect
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A 58-year-old woman has been scheduled for a left total knee replacement in one month’s time. She has a past medical history significant for rheumatoid arthritis (RA), for which she takes methotrexate and hydroxychloroquine.
Which of the following investigations would be most important before the patient’s operation?Your Answer: Electrocardiogram (ECG)
Correct Answer: Cervical spine X-rays
Explanation:The Importance of Pre-Operative Testing for a Patient with Rheumatoid Arthritis
Patients with rheumatoid arthritis (RA) require special considerations before undergoing elective surgery. One important test to consider is a cervical spine X-ray, as RA can lead to subluxation and instability in the cervical spine. This is particularly important for patients who will be intubated during surgery, as neck manipulation can exacerbate any underlying instability.
Another important consideration for RA patients is regular eye exams to test for retinal toxicity, especially for those taking hydroxychloroquine as part of their treatment regimen. However, this is not necessarily required before elective surgery.
While rheumatoid factor levels and anti-citrullinated protein antibody levels can be elevated in RA patients, they are not the most important tests to consider before surgery. Instead, a plain film of the cervical spine should be the primary investigation for patients with a history of RA.
Overall, pre-operative testing for RA patients should be tailored to their specific needs and potential risks during surgery.
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This question is part of the following fields:
- Rheumatology
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Question 2
Correct
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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: 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 3
Correct
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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: 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 4
Correct
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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: 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 5
Correct
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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: 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 6
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: Methotrexate plus sulfasalazine
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 7
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: Muscle biopsy
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 8
Correct
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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: 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 9
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: Stop allopurinol and start non-steroidal anti-inflammatory drugs (NSAIDs)
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 10
Incorrect
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In which condition is pseudofracture typically observed?
Your Answer: Osteopetrosis
Correct Answer: Osteomalacia
Explanation:Osteomalacia: Causes and Symptoms
Osteomalacia is a condition that occurs due to a deficiency of vitamin D. This condition can be caused by various factors such as malabsorption, renal disease, chronic renal failure, and anticonvulsant therapy. The most common symptom of osteomalacia is bone pain, which is often accompanied by a proximal myopathy. These symptoms are also known as Looser’s zones.
Malabsorption, which is the inability of the body to absorb nutrients from food, can lead to osteomalacia. Renal disease, such as familial hypophosphataemic rickets, can also cause this condition. Chronic renal failure, which is the gradual loss of kidney function, can also lead to osteomalacia. Additionally, anticonvulsant therapy, which is used to treat seizures, can cause a deficiency of vitamin D and lead to osteomalacia.
If you experience bone pain or a proximal myopathy, it is important to seek medical attention. A doctor can diagnose osteomalacia through blood tests and imaging studies. Treatment typically involves vitamin D and calcium supplements, as well as addressing the underlying cause of the deficiency. With proper treatment, the symptoms of osteomalacia can be managed and the condition can be prevented from worsening.
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This question is part of the following fields:
- Rheumatology
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