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  • Question 1 - A 67 year old man reports weight loss. Labs show a raised alkaline...

    Incorrect

    • A 67 year old man reports weight loss. Labs show a raised alkaline phosphatase at 290 U/L (normal range 35-120). Plain radiographs reveal sclerotic lesions of the bone. Which of the following is the most likely cause of these findings?

      Your Answer: Osteomalacia

      Correct Answer: Prostate cancer

      Explanation:

      Osteoblastic (or sclerotic) bony metastases, characterized by deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma. The other cancers listed in the options are osteolytic.

    • This question is part of the following fields:

      • Rheumatology
      82.4
      Seconds
  • Question 2 - A 55 year old female presents with progressive dyspnoea, dry cough and fever....

    Incorrect

    • A 55 year old female presents with progressive dyspnoea, dry cough and fever. She started methotrexate therapy six weeks ago. The current regimen includes methotrexate 15 mg/ week, folic acid 5 mg/day and aspirin 75 mg/day. There is no history of any other chronic illness. Vitals are as follows: Temp: 37.8C, pulse: 100 beats/min, BP: 110/80mmHg and SaO2: 90% on air. Examination reveals synovitis in both wrists, and metacarpophalangeal joints. On auscultation, there are scattered crepitations. Blood test reports are given below: Haemoglobin: 13.1g/dl (13.0 – 18.0 g/dL), WBC: 8.2 x109/l (4 – 11 x 109/l), Neutrophils: 5.1×109/l (1.5 – 7 x 109/l), Platelets: 280 x109/l (150 – 400 x 109/L), ESR: 48 mm/hr (0 – 30 mm/1st hr), Urea, electrolytes and creatinine: normal. CXR: patchy airspace shadows bilaterally What is the most likely diagnosis?

      Your Answer: Atypical tuberculosis

      Correct Answer: Methotrexate pneumonitis

      Explanation:

      Pneumonitis is a serious and unpredictable side-effect of treatment with methotrexate (MTX) that may become life-threatening. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxaemia and tachypnoea are always present and crackles are frequently audible. Chest radiography reveals a diffuse interstitial or mixed interstitial and alveolar infiltrate, with a predilection for the lower lung fields. Pulmonary function tests show a restrictive pattern with diminished diffusion capacity. Lung biopsy reveals cellular interstitial infiltrates, granulomas or a diffuse alveolar damage pattern accompanied by perivascular inflammation. Most patients present in the first few months of starting methotrexate. It is important that all patients receiving methotrexate be educated concerning this potential adverse reaction and instructed to contact their physicians should significant new pulmonary symptoms develop while undergoing therapy. If methotrexate pneumonitis is suspected, methotrexate should be discontinued, supportive measures instituted and careful examination for different causes of respiratory distress conducted. This may be treated with corticosteroids once underlying infection has been excluded.

    • This question is part of the following fields:

      • Rheumatology
      80.3
      Seconds
  • Question 3 - An 18 year old girl presents with short history of marked, right hip...

    Correct

    • An 18 year old girl presents with short history of marked, right hip pain and an associated limp. She has a history of acute lymphoblastic leukaemia for which she completed treatment for last six months.

      Your Answer: Avascular necrosis of the femoral head

      Explanation:

      Avascular necrosis (AVN) of the femoral head is a pathological process that results from disruption of the blood supply to the bone and occurs most commonly in the femoral epiphysis. Patients usually present with pain and limited joint motion. The mechanism involves impaired circulation to a specific area that ultimately becomes necrotic. AVN is most frequently associated with high doses of oral and intravenous corticosteroids and prolonged duration of therapy. Cancer patients receiving chemotherapy are usually also treated with corticosteroids.

    • This question is part of the following fields:

      • Rheumatology
      29.6
      Seconds
  • Question 4 - Which of the following options best describes rheumatoid factor? ...

    Incorrect

    • Which of the following options best describes rheumatoid factor?

      Your Answer: IgG against the Fc portion of IgM

      Correct Answer: IgM against the Fc portion of IgG

      Explanation:

      Rheumatoid factor is an IgM antibody that targets the Fc portion of IgG.

    • This question is part of the following fields:

      • Rheumatology
      20.2
      Seconds
  • Question 5 - A 42 year old male arrives at the clinic due to cough and...

    Correct

    • A 42 year old male arrives at the clinic due to cough and haemoptysis. Examination shows nasal mucosal ulceration. The doctor suspects Wegener's granulomatosis. Which anatomical area would be most commonly involved in this condition?

      Your Answer: Lungs

      Explanation:

      Granulomatosis with polyangiitis (GPA, previously known as Wegener’s granulomatosis) is a systemic vasculitis that affects both small and medium-sized vessels. Patients typically initially suffer from a limited form that may consist of constitutional symptoms and localized manifestations such as chronic sinusitis, rhinitis, otitis media, ocular conditions. In later stages, more serious manifestations may arise, including pulmonary complications and glomerulonephritis, although the skin, eyes, and heart may also be involved but these lesions are less common.
      Diagnosis is based on laboratory testing (positive for PR3-ANCA/c-ANCA), imaging, and biopsy of affected organs, which demonstrate necrotizing granulomatous inflammation. GPA is treated with immunosuppressive drugs, typically consisting of glucocorticoids combined with methotrexate, cyclophosphamide, or rituximab. Relapses are common and the following systems are affected: Lower respiratory tract (95% of cases), renal involvement (80% of cases), skin lesions (45% of cases), ocular involvement (45% of cases) and cardiac involvement (33% of cases).

    • This question is part of the following fields:

      • Rheumatology
      25.8
      Seconds
  • Question 6 - A 32 year old woman presents with a painful elbow which she has...

    Incorrect

    • A 32 year old woman presents with a painful elbow which she has been feeling for the past two weeks. Which of the following will be consistent with a diagnosis of tennis elbow?

      Your Answer: Pain on pronation of the forearm

      Correct Answer: Pain on wrist extension against resistance

      Explanation:

      Lateral epicondylitis (tennis elbow) is an overuse injury of the hand and finger extensor tendons that originate in the lateral humeral epicondyle that occurs following repeated or excessive pronation/supination and extension of the wrist (e.g., in racquet sports). Clinical features include pain and tenderness over the lateral epicondyle and along extensor muscles and thickening of the tendons. The examiner holds the patient’s hand with the thumb placed over the lateral epicondyle – The patient makes a fist, supinates the forearm, deviates radially, and extends the fist against the examiner’s resistance which will result in pain over the lateral epicondyle. Conservative treatment includes rest, physiotherapy and orthotic braces. If this fails corticosteroids and lidocaine injections are employed. Surgery is indicated in patients with persistent symptoms despite 6 months of conservative treatment. Excision of abnormal tendon tissue; longitudinal incisions (tenotomies) in scarred and fibrotic areas to promote healing.

    • This question is part of the following fields:

      • Rheumatology
      57.1
      Seconds
  • Question 7 - A 60 year old male presents with one month history of generalized headache,...

    Incorrect

    • A 60 year old male presents with one month history of generalized headache, fever and malaise. He also complains of scalp sensitivity while combing his hair. In order to confirm the diagnosis, which of the following would be the definite test?

      Your Answer: Antinuclear antibody test

      Correct Answer: Temporal artery biopsy

      Explanation:

      Temporal arteritis is a chronic large- and medium-sized vessel vasculitis that typically involves the temporal arteries. Classical symptoms include temporal headaches, jaw claudication, amaurosis fugax. Physical exam shows scalp tenderness, palpation of the temporal area may demonstrate an absent pulse, knot-like swelling, and vision loss. Lab results reveal an increased erythematous sedimentation rate and C-reactive protein. Temporal artery biopsy confirms the diagnosis. Management approach: high-dose systemic corticosteroids should be promptly administered even before the diagnosis is established. Temporal artery biopsy confirms the diagnosis. Inability to manage this or administer glucocorticoids might lead to development of blindness.

    • This question is part of the following fields:

      • Rheumatology
      32.1
      Seconds
  • Question 8 - A 45 year old man presents with fever, malaise, weight loss and myalgias...

    Incorrect

    • A 45 year old man presents with fever, malaise, weight loss and myalgias that have been occurring for a month. You suspect polyarteritis nodosa and arrange for some lab investigations. Which of the following abnormality would most likely be present?

      Your Answer: Positive ANCA

      Correct Answer: Elevated creatinine

      Explanation:

      People with polyarteritis nodosa often exhibit anaemia of chronic disease. Leucocytosis and eosinophilia may also be present. ANCA is only rarely positive. As polyarteritis nodosa affects the kidneys as well, the creatinine is elevated in most cases.

    • This question is part of the following fields:

      • Rheumatology
      43.9
      Seconds
  • Question 9 - A 28 year old man was rushed to the hospital after experiencing sudden...

    Incorrect

    • A 28 year old man was rushed to the hospital after experiencing sudden onset chest pain while playing football. He has never felt such pain in the past. However, one of his uncles had a similar sudden discomfort at a young age and he passed away following a heart problem. The following vitals are recorded on examination: BP: 101/74 mmHg RR: 22 breaths/min PR: 87 beats/min Physical examination reveals abnormally long fingers and on asking the man to hold the opposite wrist, the thumb and little finger overlap each other. He is not taking any medication regularly and past medical/surgical history is not significant. He admits to smoking half pack of cigarettes/day for the last 10 years but denies abusing any illicit drugs. Which of the following explanation most likely explains the disease process in this man?

      Your Answer: Overactive elastase enzyme leading to an excessive breakdown of collagen

      Correct Answer: A defect of the glycoprotein structure which usually wraps around elastin

      Explanation:

      Aortic dissection is defined as separation of the layers within the aortic wall. Tears in the intimal layer result in the propagation of dissection (proximally or distally) secondary to blood entering the intima-media space. This can be caused as a result of both congenital or acquired factors like chronic uncontrolled hypertension. This patient shows no sign of hypertension but his physical examination hints towards Marfan Syndrome. Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder affecting the microfibrils and elastin in connective tissue throughout the body. MFS is associated with pathological manifestations in the cardiovascular system (e.g., mitral valve prolapse, aortic aneurysm, and dissection), the musculoskeletal system (e.g., tall stature with disproportionately long extremities, joint hypermobility), and the eyes (e.g., subluxation of the lens of the eye). Decreased collagen production occurs in ageing, hydroxylation defects are present in vitamin C deficiency, copper deficiency affecting lysyl oxidase enzyme occurs in Menke’s disease.

    • This question is part of the following fields:

      • Rheumatology
      66.9
      Seconds
  • Question 10 - A 42 year old female presents with a funny bone sensation in her...

    Incorrect

    • A 42 year old female presents with a funny bone sensation in her right elbow that is accompanied by numbness and tingling in the 4th and 5th digits. The symptoms are aggravated when the elbow is bent for a prolonged period. Which of the following explains the most likely diagnosis?

      Your Answer: Median nerve entrapment syndrome

      Correct Answer: Cubital tunnel syndrome

      Explanation:

      Cubital Tunnel Syndrome is a condition that involves pressure or stretching of the ulnar nerve (also known as the “funny bone” nerve), which can cause numbness or tingling in the 4th and 5th digit, pain in the forearm, and/or weakness in the hand. Epicondylitis of the elbow is a condition associated with repetitive forearm and elbow activities. Both lateral epicondylitis (commonly known as tennis elbow) and medial epicondylitis (commonly known as golfer’s elbow) are characterized by elbow pain during or following elbow flexion and extension. Radial tunnel syndrome is a set of symptoms that include fatigue or a dull, aching pain at the top of the forearm with use. Although less common, symptoms can also occur at the back of the hand or wrist.

    • This question is part of the following fields:

      • Rheumatology
      24.3
      Seconds
  • Question 11 - An 80 year old female, previously diagnosed with polymyalgia rheumatica 18 months back,...

    Incorrect

    • An 80 year old female, previously diagnosed with polymyalgia rheumatica 18 months back, presents to the outpatient clinic with bilateral shoulder stiffness and generalized myalgia. The ESR was found to be 60mm/1st hour at the time of presentation. Prednisolone therapy was initiated at a daily dose of 15 mg along with Calcium and Vitamin supplementation. She reported resolution of her symptoms in one week. However the symptoms relapsed when the prednisolone dose was reduced below the current dose of 12.5 mg daily. How should she be ideally managed?

      Your Answer: Increase the dose of prednisolone and add a bisphosphonate

      Correct Answer: Continue the current dose of prednisolone and start methotrexate

      Explanation:

      Polymyalgia rheumatica, a syndrome characterized by proximal muscle pain and stiffness in older persons, generally is treated with prednisone. Dosages of 15 to 25 mg of prednisone per day can reduce inflammation considerably, although many patients relapse when therapy is tapered. Long-term (18 to 36 months) steroid treatment has been recommended by several studies, but this can result in multiple side effects, including osteoporosis, hypertension, cataracts, and hyperglycaemia. Methotrexate has been used to reduce inflammation in rheumatoid arthritis, systemic vasculitis, and giant cell arteritis, and in some studies has been combined with prednisone to treat polymyalgia rheumatica, decreasing the duration of treatment.

    • This question is part of the following fields:

      • Rheumatology
      35.9
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  • Question 12 - A 28 year old female with a history of psoriatic arthritis would most...

    Incorrect

    • A 28 year old female with a history of psoriatic arthritis would most likely have which of the following hand conditions?

      Your Answer: Proximal interphalangeal arthritis

      Correct Answer: Nail dystrophy

      Explanation:

      Nail dystrophy (pitting of nails, onycholysis, subungual hyperkeratosis), dactylitis, sausage shaped fingers are most commonly seen with psoriatic arthropathy. There is asymmetric joint involvement most commonly distal interphalangeal joints. Uveitis and sacroiliitis may also occur. Arthritis mutilans may occur but is very rare. Cutaneous lesions may or may not develop. When they do, its usually much after the symptoms of arthritis.

    • This question is part of the following fields:

      • Rheumatology
      20.1
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  • Question 13 - Osteopetrosis occurs as a result of a defect in: ...

    Incorrect

    • Osteopetrosis occurs as a result of a defect in:

      Your Answer: Calcium resorption in proximal tubule

      Correct Answer: Osteoclast function

      Explanation:

      It is a metabolic bone disease caused by defective osteoclastic resorption of immature bone. Osteopetrosis is also known as marble bone disease. Osteoclasts are unable to adequately acidify bone matrix. Impaired bone resorption leads to overly dense bone that is more likely to fracture. It is usually treated with bone marrow transplant and high dose calcitriol.

    • This question is part of the following fields:

      • Rheumatology
      8.9
      Seconds
  • Question 14 - Drug-induced lupus erythematosus most often occurs after taking which of the following drugs?...

    Incorrect

    • Drug-induced lupus erythematosus most often occurs after taking which of the following drugs?

      Your Answer: Isoniazid

      Correct Answer: Procainamide

      Explanation:

      Many drugs are responsible for causing drug induced lupus. However, it is most commonly associated with hydralazine, procainamide and quinidine.

    • This question is part of the following fields:

      • Rheumatology
      9.2
      Seconds
  • Question 15 - A 64 year old female presents with sudden onset pain, swelling and stiffness...

    Correct

    • A 64 year old female presents with sudden onset pain, swelling and stiffness in her right knee. Her medical history is significant for osteoarthritis affecting her hand joints and diet controlled diabetes mellitus. On examination, the right knee is swollen, erythematous and tender. Which of the following tests would be most useful in the diagnosis of this case?

      Your Answer: Aspiration and examination of the synovial fluid

      Explanation:

      Arthrocentesis should usually be done when there is a suspicion of pseudogout or septic arthritis as in this case which leads to an early diagnosis and prompt treatment. Polarized microscopy demonstrates weakly positively birefringent rhomboid crystals which are blue when parallel to light and yellow when perpendicular to light. Elevated serum uric acid levels that cause gout are usually found after large consumption of alcohol or meat, or post surgery. Autoimmune diseases like SLE, RA etc require an autoimmune screen.

    • This question is part of the following fields:

      • Rheumatology
      24.8
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  • Question 16 - A 56 year old woman presents to the clinic complaining of shoulder pain...

    Incorrect

    • A 56 year old woman presents to the clinic complaining of shoulder pain that she has been experiencing for the last 4 weeks. She does not remember getting injured previously. The pain worsens on movement especially when she is moving the arm quickly. At night, lying on the affected side is painful. Examination reveals no erythema or swelling. However, pain is felt on passive abduction between 60 to 120 degrees and she is unable to abduct the arm past 70-80 degrees. Flexion and extension are intact. What is the most likely diagnosis?

      Your Answer: Adhesive capsulitis (frozen shoulder)

      Correct Answer: Supraspinatus tendonitis

      Explanation:

      Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse. This patient has the classic painful arc that is a sign of shoulder impingement characteristic of supraspinatus tendonitis.

    • This question is part of the following fields:

      • Rheumatology
      47
      Seconds
  • Question 17 - A 46 year old male, known with Rheumatoid Arthritis presents with a swollen...

    Incorrect

    • A 46 year old male, known with Rheumatoid Arthritis presents with a swollen and painful right ankle. No drug allergies are reported. On examination, the vitals are as follows: Temp: 38.8 BP: 90/60 mmHg Pulse: 110/min. Right ankle examination reveals tenderness, warmth, erythema and tense joint effusion. Blood samples including blood cultures are collected and fluid resuscitation is initiated. Which of the following interventions would be most appropriate for this man?

      Your Answer: Administer i.v. flucloxacillin, and arrange MRI of right ankle

      Correct Answer: Administer i.v. flucloxacillin, and arrange joint aspiration urgently

      Explanation:

      Although microscopic analysis of joint fluid aspirate and culture is the basis of septic arthritis diagnosis and should usually be collected before the administration of antibiotics, the patient is showing signs of septic shock. A delay in antibiotics might lead to worsening of symptoms so they are administered first.

    • This question is part of the following fields:

      • Rheumatology
      52.2
      Seconds
  • Question 18 - A 35 year old sales representative presents with severe pain going down her...

    Correct

    • A 35 year old sales representative presents with severe pain going down her neck and right arm. She admits that this pain is worse on sitting and driving for long periods. Past history is significant for two previous road traffic accidents. Examination reveals weakness and sensory loss over C5/C6 nerve distribution. There is pain with neck movement and particularly extension. Which of the following investigations would be the most helpful in this case?

      Your Answer: MRI scan of the cervical spinal cord

      Explanation:

      Cervical radiculopathy is usually due to compression or injury to a nerve root by a herniated disc or degenerative changes. Levels C5 to T1 are the most commonly affected. It is usually, but not always, accompanied by cervical radicular pain, a sharp and shooting pain that travels from the neck and down the upper limb and may be severe. This needs to be differentiated from pain referred from the musculoskeletal (somatic) structures in the neck, which may be aching rather than sharp, and is more severe in the neck than in the upper limb. The neurological signs of cervical radiculopathy depend on the site of the lesion. The patient may have motor dysfunction, sensory deficits or alteration in tendon reflexes. While pain is a common presenting symptom, not all radiculopathies are painful (i.e. only motor deficits may be obvious). CT scanning cannot accurately demonstrate the commonest cause for cervical radiculopathy (disc herniation) without myelography, which requires hospital admission, lumbar puncture and the use of contrast. In patients with cervical radiculopathy, MRI is the imaging technique of choice for the detection of root compression by disc herniation and osteophytes. MRI allows the nerve roots to be directly visualised. Nerve conduction studies are also useful in determining the nerve roots that are involved.

    • This question is part of the following fields:

      • Rheumatology
      38.6
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  • Question 19 - A 32 year old male who has recently returned from a trip to...

    Correct

    • A 32 year old male who has recently returned from a trip to Thailand presents with congestion of eyes and swelling of the knee joint. He completed a course of antibiotics for dysentery 4 weeks back. He experiences no dysuria and urine examination is normal. Which further information would be most useful in establishing a diagnosis?

      Your Answer: History and physical examination

      Explanation:

      The patient most likely has reactive arthritis which is usually diagnosed on history and clinical examination. The classic triad of symptoms include conjunctivitis, urethritis and arthritis. Arthritis and conjunctivitis may occur 4-6 weeks after a gastrointestinal or genitourinary infection. Arthritis usually occurs acutely, mostly involving the lower limb and is asymmetrical. Blood culture, urine culture and arthrocentesis (joint aspiration) will not yield positive results.

    • This question is part of the following fields:

      • Rheumatology
      51.1
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  • Question 20 - A 36 year old man arrives at the clinic complaining of pain and...

    Incorrect

    • A 36 year old man arrives at the clinic complaining of pain and swelling of the left knee, ankles and right hallux. He has acute conjunctivitis, and dysuria. He suffered from an episode of gastroenteritis two weeks back. Clinical examination shows left Achilles tendonitis and right plantar fasciitis. Radiological examination reveals left sacroiliitis, with evidence of enthesitis, joint erosions and periostitis. HLA-B27 is positive. Which of the following is the most likely diagnosis?

      Your Answer: Ankylosing spondylitis

      Correct Answer: Reiter’s syndrome

      Explanation:

      Reactive arthritis, (formerly known as Reiter’s syndrome), is an autoimmune condition that occurs after a bacterial infection of the gastrointestinal or urinary tract. It is categorized as a seronegative spondylarthritis because of its association with HLA-B27. Reactive arthritis primarily affects young men and usually presents with musculoskeletal or extra‑articular symptoms. The characteristic triad consists of arthritis, conjunctivitis, and urethritis. The diagnosis is based on clinical features such as patient history and physical examination; there are no specific tests for reactive arthritis. Treatment is primarily symptomatic and consists of the administration of NSAIDs, as most patients recover spontaneously. extraarticular dermatologic manifestations include skin lesions of the glans resembling psoriasis (balanitis circinata); hyperkeratinisation of the palms and soles (keratoderma blenorrhagicum), oral ulcers.

    • This question is part of the following fields:

      • Rheumatology
      53
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SESSION STATS - PERFORMANCE PER SPECIALTY

Rheumatology (5/20) 25%
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