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  • Question 1 - A 30-year-old science teacher is diagnosed with tenosynovitis of the fingers of the...

    Incorrect

    • 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: Rheumatoid arthritis

      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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 2 - In which disease is the distal interphalangeal joint typically impacted? ...

    Correct

    • In which disease is the distal interphalangeal joint typically impacted?

      Your 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 3 - A 20-year-old student midwife presents with increasing pain and swelling of the ring...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 4 - A 25-year-old intravenous drug user (ivDU) comes in with a swollen and painful...

    Correct

    • 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: 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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      • Rheumatology
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  • Question 5 - A 40-year-old patient presented to his General Practitioner (GP) with complaints of back...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 6 - A 63-year-old woman visits her GP complaining of pain and swelling in her...

    Incorrect

    • 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: Episcleritis

      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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 7 - A 35-year-old nun is seen in the Rheumatology Clinic every year for her...

    Correct

    • 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: 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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      • Rheumatology
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  • Question 8 - A 27-year-old construction worker complains of worsening pain in his feet over the...

    Incorrect

    • 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: Drug induced arthritis

      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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      • Rheumatology
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  • Question 9 - A patient in their mid-40s wakes up experiencing severe pain, redness, and swelling...

    Incorrect

    • 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: Sulfinpyrazone

      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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 10 - A 50-year-old man presents to the Emergency Department with a painful and swollen...

    Incorrect

    • 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: Escherichia coli

      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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      • Rheumatology
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  • Question 11 - A 30-year-old white man comes to his general practitioner complaining of progressive low...

    Incorrect

    • A 30-year-old white man comes to his general practitioner complaining of progressive low back pain over the past four years. The pain is worse at night when he lies down and improves as he moves around during the day, but it does not go away with rest. Upon further questioning, he reports having experienced three episodes of acute eye pain with sensitivity to light and blurry vision in the past two years. He sought treatment from an ophthalmologist, and the symptoms resolved with steroids and eye drops. X-rays reveal some inflammatory and arthritic changes in the sacroiliac joints. Despite treatment, the disease has continued to progress, and ten years later, x-rays show calcification of the anterior spinal ligament. What is the most likely positive finding in this patient?

      Your Answer: HLA-DR5

      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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      • Rheumatology
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  • Question 12 - A 42-year-old known intravenous (iv) drug user presents to her general practitioner with...

    Incorrect

    • 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: Subchondral cyst formation

      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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      • Rheumatology
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  • Question 13 - A 54-year-old man visits his GP complaining of pain and swelling in his...

    Incorrect

    • 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: Oral amoxicillin and refer for urgent aspiration

      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.

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      • Rheumatology
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  • Question 14 - A 72-year-old man presented to his GP with complaints of fatigue, unintentional weight...

    Incorrect

    • 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: Muscle biopsy

      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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      • Rheumatology
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  • Question 15 - A 35-year-old woman presents with increasing early-morning bilateral knee pain and stiffness and...

    Incorrect

    • 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: Rheumatoid factor IgG

      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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      • Rheumatology
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  • Question 16 - A 58-year-old woman has been scheduled for a left total knee replacement in...

    Correct

    • 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: 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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      • Rheumatology
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  • Question 17 - You are asked to see a 35-year-old man with a three year history...

    Incorrect

    • 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: Systemic lupus erythematosus

      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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      • Rheumatology
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  • Question 18 - A 76-year-old woman, who was previously in good health, presents for review. For...

    Incorrect

    • 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: Rheumatoid arthritis

      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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  • Question 19 - A 32-year-old Afro-Caribbean woman comes to the clinic with concerns about her appearance....

    Incorrect

    • 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: Systemic sclerosis

      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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  • Question 20 - A 49-year-old carpet layer presents to the clinic for review. He has been...

    Correct

    • 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: 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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  • Question 21 - A 24-year-old Caucasian farmer presents to the outpatient department with a complaint of...

    Incorrect

    • 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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  • Question 22 - A 40-year-old school teacher who enjoys running long distances comes to the clinic...

    Incorrect

    • 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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  • Question 23 - A 35-year-old man presents with a 5-day history of pain and swelling affecting...

    Incorrect

    • 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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      • Rheumatology
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  • Question 24 - A previously healthy 60-year-old hypertensive teacher complains of pain, redness, and swelling in...

    Incorrect

    • 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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  • Question 25 - A 27-year-old man presents to his primary care physician with complaints of worsening...

    Incorrect

    • 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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  • Question 26 - A 28-year-old man comes to the Clinic complaining of lower back pain and...

    Incorrect

    • 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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  • Question 27 - A 40-year-old woman presents with pain of the hand, wrist, ankle and knee...

    Incorrect

    • 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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  • Question 28 - A 65-year-old man visits his General Practitioner (GP) complaining of a swollen and...

    Incorrect

    • 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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      • Rheumatology
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  • Question 29 - A 50-year-old woman presents with complaints of fatigue. She reports experiencing dysphagia, a...

    Incorrect

    • 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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  • Question 30 - A 65-year-old woman complains of bilateral knee pain that has persisted for 4...

    Incorrect

    • 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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      • Rheumatology
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