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  • Question 1 - 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: Gonococcal 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 2 - A 44-year-old gardener comes to her General Practitioner complaining of pain when kneeling...

    Incorrect

    • A 44-year-old gardener comes to her General Practitioner complaining of pain when kneeling on her right knee for the past month. She denies any fevers and is generally in good health. During the examination of her right knee, the doctor notices a slightly tender swelling in front of the patella that feels fluctuant. Although the knee is not red, it is warm to the touch, and the patient experiences some discomfort when flexing it. What are the probable results of joint aspiration?

      Your Answer: Needle-shaped crystals with strong negative birefringence on polarised light microscopy

      Correct Answer: Clear/milky joint aspirate with normal microscopy and culture

      Explanation:

      Diagnosing Prepatellar Bursitis: Understanding Joint Aspirate Results

      Prepatellar bursitis, also known as housemaid’s knee, is a common condition caused by inflammation of the prepatellar bursa. This can result from repetitive microtrauma, such as prolonged kneeling. Patients typically present with localised, mildly tender swelling over the patella, which can be warm but not hot. Aspiration of the aseptic bursa will reveal a clear and/or milky aspirate that has negative Gram staining and normal microscopy.

      When examining joint aspirate results, it is important to consider other potential diagnoses. Gram-positive cocci, for example, would be grown in the case of Staphylococcus aureus infection, a common cause of septic bursitis. However, in the absence of fever, erythema, and reduced range of motion, septic arthritis is unlikely. Similarly, needle-shaped crystals with strong negative birefringence on polarised light microscopy are seen in gout, but this condition typically presents with acute pain, redness, and inflammation.

      Rhomboid-shaped crystals with weak positive birefringence on polarised light microscopy are seen in pseudogout, which can affect the knee. However, this condition typically affects the entire knee joint and is more common in the elderly.

      In summary, a clear or milky joint aspirate with normal microscopy and culture is consistent with prepatellar bursitis. Other potential diagnoses should be considered based on the patient’s history and examination findings.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 3 - A 65-year-old woman complains of bilateral knee pain that has persisted for 4...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 4 - You are asked to see a 35-year-old man with a three year history...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 5 - What is the most probable diagnosis for a 70-year-old woman who presents with...

    Correct

    • 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 6 - A 27-year-old semi-professional rugby player presents with a red, hot, swollen left knee....

    Incorrect

    • A 27-year-old semi-professional rugby player presents with a red, hot, swollen left knee. There has been no history of trauma. He recently had a negative sexual health check and has not had any new partners since. Upon examination, the left knee is unable to fully extend and there is a large effusion. The clinical suspicion is septic arthritis. What is the most probable organism responsible for this condition?

      Your Answer: Streptococcus viridans

      Correct Answer: Staphylococcus aureus

      Explanation:

      Septic Arthritis: Causes and Treatment

      Septic arthritis is a rheumatological emergency that requires urgent attention. A red, hot, swollen joint may indicate septic arthritis, which can be caused by a variety of pathogens. The most common pathogen is Staphylococcus aureus, and joint destruction can occur within 24 hours if left untreated. It is important to consider and treat septic arthritis urgently or until firmly excluded by joint aspiration. The empirical antibiotic regime should be consulted in local health authority guidelines or with a microbiologist. Intravenous drugs should be used for 2 weeks and a total course of 6 weeks completed. Other pathogens that can cause septic arthritis include Neisseria gonorrhoeae, Mycobacterium tuberculosis, Streptococcus viridans, and Salmonella typhi. It is important to consider the patient’s medical history and risk factors when determining the cause of septic arthritis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 7 - In which condition is pseudofracture typically observed? ...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 8 - In which joint would the presence of osteoarthritic changes be atypical? ...

    Incorrect

    • In which joint would the presence of osteoarthritic changes be atypical?

      Your Answer: The elbow joint

      Correct Answer: Shoulder joint

      Explanation:

      Osteoarthrosis and Common Deformities in the Hand

      Osteoarthrosis (OA) is a prevalent type of arthritis that often affects the hand. Upon examination of the joints, it is common to find small bone spurs known as nodes on the tops of joints. These nodes can take on different names depending on their location. For instance, if they occur at the joint next to the fingernail, they are called Heberden’s nodes. On the other hand, if they occur at the PIP joints, they are referred to as Bouchard’s nodes. It is worth noting that shoulder joint involvement is rare in OA.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 9 - A 68-year-old woman who has suffered many years from aggressive rheumatoid arthritis presents...

    Incorrect

    • A 68-year-old woman who has suffered many years from aggressive rheumatoid arthritis presents for review. Most recently, she has suffered from two severe respiratory tract infections (which have been treated with oral clarithromycin) and has had worsening left upper quadrant pain. She currently takes low-dose prednisolone for her rheumatoid. On examination, there are obvious signs of active rheumatoid disease. Additionally, you can feel the tip of her spleen when you ask her to roll onto her right-hand side.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 91 g/l 115–155 g/l
      White cell count (WCC) 1.9 × 109/l (neutrophil 0.9) 4–11 × 109/l
      Platelets 90 × 109/l 150–400 × 109/l
      Rheumatoid factor +++
      Erythrocyte sedimentation rate (ESR) 52 mm/h 0–10mm in the 1st hour
      Which of the following is the most likely diagnosis in this case?

      Your Answer: Lymphoma

      Correct Answer: Felty’s syndrome

      Explanation:

      Differential Diagnosis for a Patient with Splenomegaly, Neutropenia, and Active Rheumatoid Disease

      Felty’s Syndrome:
      The patient’s symptoms of splenomegaly, neutropenia, and active rheumatoid disease suggest Felty’s syndrome. This condition is thought to occur due to the sequestration and destruction of granulocytes, potentially caused by reduced granulocyte growth factors and autoantibodies/immune complexes formed against them. Felty’s syndrome affects 1-3% of patients with rheumatoid arthritis and has a higher prevalence in females. Treatment typically involves the use of methotrexate as a disease-modifying anti-rheumatic drug, with splenectomy reserved as a last resort.

      Lymphoma:
      While lymphoma can present with lymphadenopathy, the absence of B-symptoms such as fever, night sweats, weight loss, or pruritus makes this diagnosis less likely in this case.

      Myeloma:
      Myeloma often presents with anaemia and bone pain, as well as hypercalcaemia. Serum and urine electrophoresis are important investigations for this condition.

      Sarcoidosis:
      Sarcoidosis commonly presents with respiratory symptoms such as wheeze, cough, and shortness of breath, as well as erythema nodosum and lymphadenopathy on examination. While the patient has a history of lower respiratory tract infections, her response to clarithromycin suggests an infective cause rather than sarcoidosis.

      Tuberculosis:
      The patient does not have any clinical features or risk factors for tuberculosis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 10 - 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: Anti-cyclic citrullinated peptide (CCP) positivity

      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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 11 - A 49-year-old carpet layer presents to the clinic for review. He has been...

    Incorrect

    • A 49-year-old carpet layer presents to the clinic for review. He has been complaining of severe anterior knee pain for a few days. On examination, you notice that the left knee is warm and there is swelling on the patella. There is local pain on patellar pressure and pain with knee flexion.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 131 g/l 135–175 g/l
      White cell count (WCC) 5.2 × 109/l 4–11 × 109/l
      Platelets 185 × 109/l 150–400 × 109/l
      Erythrocyte sedimentation rate (ESR) 12 mm/h 0–10mm in the 1st hour
      Knee aspirate: Gram stain negative for bacteria; fluid contains occasional white cells; culture is negative.
      Which of the following is the most likely diagnosis in this case?

      Your Answer:

      Correct Answer: Pre–patellar bursitis

      Explanation:

      Differentiating Knee Conditions: A Case-Based Approach

      A patient presents with a red, tender, and inflamed knee. The differential diagnosis includes prepatellar bursitis, osteoarthritis, localised cellulitis, rheumatoid arthritis, and gout.

      prepatellar bursitis, also known as housemaid’s knee, carpet layer’s knee, or nun’s knee, is often caused by repetitive knee trauma. Treatment involves non-steroidal anti-inflammatory agents and local corticosteroid injection. Septic bursitis requires appropriate antibiotic cover and drainage.

      Osteoarthritis is a diagnosis of exclusion and does not typically cause a red, tender, inflamed knee. Knee aspirate in this case would not show white cells.

      Localised cellulitis may result in erythema but is unlikely to cause knee swelling. Knee aspirate in this case would not show white cells.

      Rheumatoid arthritis is unlikely to present in men of this age and typically affects small joints of the fingers, thumbs, wrists, feet, and ankles.

      Gout can be diagnosed through the presence of negatively birefringent crystals seen on joint microscopy.

      In conclusion, a thorough evaluation of the patient’s symptoms and appropriate diagnostic tests are necessary to differentiate between these knee conditions.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 12 - A 50-year-old woman visits the Rheumatology Clinic seeking modification of her DMARDs for...

    Incorrect

    • A 50-year-old woman visits the Rheumatology Clinic seeking modification of her DMARDs for the treatment of her rheumatoid arthritis. She is informed that she will require frequent liver checks and eye exams due to the potential side-effects of these medications. What is the most probable combination of treatment she will receive for her condition?

      Your Answer:

      Correct Answer: Methotrexate plus hydroxychloroquine

      Explanation:

      Medication Combinations for Treating Rheumatoid Arthritis

      When treating rheumatoid arthritis, the first-line medication is a DMARD monotherapy with methotrexate. Short-term steroids may also be used in combination with DMARD monotherapy to induce remission. Hydroxychloroquine is another medication that can be used, but patients should be closely monitored for visual changes as retinopathy and corneal deposits are common side effects.

      Etanercept is not a first-line treatment for rheumatoid arthritis, and methotrexate should not be given in combination with a TNF-alpha inhibitor like etanercept. Methotrexate plus sulfasalazine is an appropriate medication combination for treating rheumatoid arthritis, but regular eye checks are not required as neither medication affects vision.

      If a patient has failed treatment with methotrexate, sulfasalazine plus hydroxychloroquine may be a regimen to consider trialling. However, it is important to note that new-onset rheumatoid arthritis should be treated with a DMARD monotherapy first line, with the addition of another DMARD like methotrexate as the first-line option.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 13 - 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 14 - 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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 15 - 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:

      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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      • Rheumatology
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  • Question 16 - A 68-year-old woman presents with a one-month history of non-specific malaise. She experiences...

    Incorrect

    • A 68-year-old woman presents with a one-month history of non-specific malaise. She experiences stiffness, particularly in the mornings, and has difficulty lifting her arms to comb her hair. She also has constant pain in her arms, shoulders, and jaw when chewing. She has lost 4 kg in weight and has a persistent headache. She smokes 10 cigarettes a day and drinks 10 units of alcohol per week. On examination, she has tenderness with reduced mobility in the proximal muscles of her arms and legs. Her investigations reveal a low Hb, high WCC, and elevated ESR. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Polymyalgia rheumatica

      Explanation:

      Polymyalgia Rheumatica/Temporal arthritis: Symptoms and Treatment

      Polymyalgia rheumatica/temporal arthritis is a condition that can cause a variety of symptoms. It may present with predominantly polymyalgia symptoms such as muscle pain and stiffness, or arthritis symptoms such as headaches, scalp tenderness, and jaw claudication. Systemic features like fever, malaise, and weight loss may also be present. Weakness is not a typical feature, but it may be apparent due to pain or stiffness with weight loss. The ESR (erythrocyte sedimentation rate) is usually very high in this condition.

      Temporal arthritis is a serious complication of this condition that can result in blindness. It is important to note that temporal arthritis is a vasculitis that affects medium and large-sized arteries throughout the body, not just the temporal artery. The superficial temporal artery supplies the orbit of the eye and is a branch of the external carotid artery, while the ophthalmic artery supplies the majority of the blood to the eye itself and is a branch of the internal carotid artery. Inflammation and narrowing of the temporal artery can cause blindness.

      If temporal arthritis is suspected, it must be treated with high-dose steroids. This condition is a reminder that prompt diagnosis and treatment are crucial to prevent serious complications.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 17 - 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:

      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.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 18 - A 79-year-old woman, with a history of recurrent falls, had a recent fall...

    Incorrect

    • A 79-year-old woman, with a history of recurrent falls, had a recent fall on her outstretched right hand. An X-ray revealed a fracture of the distal radius with volar displacement. She has multiple risk factors for osteoporosis, and a DEXA scan was requested. What score is indicative of a diagnosis of osteoporosis?

      Your Answer:

      Correct Answer: T score: < −2.5

      Explanation:

      When it comes to bone density, T scores are an important measure to understand. A T score of less than -2.5 is indicative of osteoporosis, while a T score between -1 and -2.5 suggests osteopenia. On the other hand, a T score of 0-1 is considered normal, but may still require monitoring. A T score greater than 2.5 is also normal, but may not be the case if the patient has experienced a fragility fracture. It’s important to note that Z scores, which take into account age and gender, can also provide insight into bone density. Understanding T scores and their implications can help healthcare professionals and patients take preventative measures to maintain bone health.

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  • Question 19 - 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:

      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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  • Question 20 - A 33-year-old paediatric nurse presents with complaints of fatigue, joint discomfort throughout her...

    Incorrect

    • A 33-year-old paediatric nurse presents with complaints of fatigue, joint discomfort throughout her body, and a rash on her face that has worsened since returning from a recent trip to Portugal. On examination, there is no evidence of small joint synovitis, but the facial rash is prominent. Blood tests reveal a haemoglobin level of 103 g/l, MCV of 88.8 fl, platelet count of 99 × 109/l, and a WCC of 2.8 × 109/l. What is the most appropriate treatment option at this stage?

      Your Answer:

      Correct Answer: Hydroxychloroquine

      Explanation:

      The patient in this scenario has systemic lupus erythematosus (SLE) with mild symptoms, primarily affecting the joints and skin. The first-line treatment for this type of SLE is hydroxychloroquine, which can induce remission and reduce recurrence. However, patients on this medication must be monitored for drug-induced retinopathy. Methotrexate may be used in more severe cases with active joint synovitis. Sun avoidance is important to prevent flares, but it is not enough to treat the patient’s current symptoms. Infliximab is not typically used to treat SLE, and rituximab is reserved for last-line therapy. Azathioprine is commonly used as a steroid-sparing agent in SLE, but hydroxychloroquine is more appropriate for this patient’s current presentation. The main adverse effect of azathioprine is bone marrow suppression, which can be life-threatening in some patients.

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  • Question 21 - 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 22 - A 40-year-old farmer presents to the clinic with muscle pain in his lower...

    Incorrect

    • A 40-year-old farmer presents to the clinic with muscle pain in his lower back, calves and neck. He takes regular paracetamol but this has not helped his symptoms. For the past four weeks, he has become increasingly agitated and reports that he can no longer sleep for more than a few hours because the pain wakes him up. He feels increasingly lethargic and helpless. He also reports that as a result of his pain, he feels that his memory has worsened and he reports a low mood. A Kessler Psychological Distress Scale screening questionnaire is performed and he has a score of 30. His laboratory blood tests are unremarkable.
      What is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Duloxetine

      Explanation:

      Pharmacological Treatments for Fibromyalgia Pain: Choosing the Right Option

      Fibromyalgia is a chronic pain disorder that can be challenging to manage. Duloxetine, pregabalin, and tramadol are all appropriate pharmacological treatments for severe pain disturbance in fibromyalgia. However, the choice of which treatment to use depends on the patient’s co-morbidities, clinical presentation, and patient preference.

      In this case, the patient has comorbid low mood and possible depression, making duloxetine a reasonable choice. Venlafaxine, another serotonin and norepinephrine reuptake inhibitor, may be theoretically useful, but there is insufficient evidence for its use. Codeine and paracetamol have been shown to be ineffective in treating fibromyalgia pain.

      While psychotherapy may be considered for patients with pain-related depression and adverse coping mechanisms, it is not the correct answer for this patient. Overall, choosing the right pharmacological treatment for fibromyalgia pain requires careful consideration of the patient’s individual needs and circumstances.

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  • Question 23 - A 52-year-old man comes to the clinic complaining of a severely painful, swollen,...

    Incorrect

    • A 52-year-old man comes to the clinic complaining of a severely painful, swollen, and red left big toe. He states that it started yesterday and has become so excruciating that he cannot put on shoes. The patient has a medical history of type 2 diabetes and was diagnosed with a stomach ulcer last year. The diagnosis is a first episode of acute gout. What would be the most suitable initial treatment?

      Your Answer:

      Correct Answer: Colchicine

      Explanation:

      Treatment Options for Acute Gout Flare in a Patient with Peptic Ulcer Disease

      When managing an acute gout flare in a patient with a history of peptic ulcer disease, it is important to consider the potential risks and benefits of different treatment options. Colchicine and non-steroidal anti-inflammatory drugs (NSAIDs) are both effective first-line treatments, but NSAIDs should be used with caution in patients with a history of peptic ulcer disease. If NSAIDs are used, proton-pump cover should be provided for gastric protection. Allopurinol should not be started until after the acute attack has been resolved, and paracetamol may be used as an adjunct for pain relief but would not treat the underlying cause of pain. Prednisolone may be used in patients unable to tolerate NSAIDs or colchicine, but there is no contraindication to a trial of oral colchicine in this patient. Overall, the choice of treatment should be individualized based on the patient’s medical history and preferences.

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  • Question 24 - A 25-year-old intravenous drug user (ivDU) comes in with a swollen and painful...

    Incorrect

    • A 25-year-old intravenous drug user (ivDU) comes in with a swollen and painful right knee. Upon examination, there is joint effusion and pyrexia, and frank pus is aspirated. What is the most probable infecting organism?

      Your Answer:

      Correct Answer: Staphylococcus aureus

      Explanation:

      Common Organisms in Septic Arthritis

      Septic arthritis is a serious condition that occurs when a joint becomes infected. The most common organism causing septic arthritis is Staphylococcus aureus. Pseudomonas spp can also cause septic arthritis, but it is less likely than S. aureus, especially in intravenous drug users. Escherichia coli is another pathogen that can cause septic arthritis, but it is less common than S. aureus. In children under the age of two, Haemophilus influenzae is the most common organism causing septic arthritis. Neisseria gonorrhoeae is a common cause of arthritis in the United States, but it is uncommon in Western Europe. It is important to identify the causative organism in order to provide appropriate treatment for septic arthritis.

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  • Question 25 - 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:

      Correct Answer: Systemic sclerosis

      Explanation:

      Types of Arthritis and Infections that can Cause Tenosynovitis

      Tenosynovitis is a condition where the tendon sheath becomes inflamed, causing pain and swelling. It can be caused by various types of arthritis and infections. Here are some of the most common causes:

      Systemic Sclerosis: This autoimmune disease causes fibrosis of connective tissue, resulting in hard and thickened skin, swollen digits, and Raynaud’s phenomenon. Tenosynovitis in systemic sclerosis is non-tender and without swelling of the tendons.

      Rheumatoid Arthritis: Tenosynovitis due to rheumatoid arthritis causes pain and swelling of tendons. It usually involves the interphalangeal, metacarpophalangeal, and wrist joints, and can cause deformities such as swan neck and Boutonnière’s deformity.

      Gout: Gout can cause tenosynovitis, which is very painful and presents with redness and swollen tendons. It typically affects the metatarsophalangeal joints.

      Disseminated Gonococcal Infection: This infection can cause acute migratory tenosynovitis, especially in younger adults. Women may be asymptomatic, while men may present with urethral discharge or dysuria.

      Reactive Arthritis: This type of arthritis causes pain and swelling of tendons, commonly affecting the knees or sacrum. It is an acutely inflammatory process and would therefore be swollen and tender.

      In conclusion, tenosynovitis can be caused by various types of arthritis and infections, and it is important to identify the underlying cause in order to provide appropriate treatment.

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  • Question 26 - A 38-year-old woman presents to the clinic with symmetrical polyarthritis affecting her fingers,...

    Incorrect

    • A 38-year-old woman presents to the clinic with symmetrical polyarthritis affecting her fingers, wrists and elbows. She also reports significant morning stiffness which lasts for up to 90 minutes and is finding it very difficult to get up for work in the morning. There is a history of deep vein thrombosis during her second pregnancy, but no other significant past medical history. Her only medication of note is the oral contraceptive pill.
      On examination, she has evidence of active synovitis affecting her wrists and the small joints of her fingers.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 121 g/l 115–155 g/l
      White cell count (WCC) 8.1 × 109/l 4–11 × 109/l
      Platelets 193 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 110 μmol/l 50–120 µmol/l
      Rheumatoid factor Positive
      Anti-nuclear factor Weakly positive
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Rheumatoid arthritis

      Explanation:

      Diagnosing Rheumatoid Arthritis: Differential Diagnosis

      Rheumatoid arthritis is a common autoimmune disorder that affects the joints, causing morning stiffness and small joint polyarthritis. A positive rheumatoid factor is present in 70% of patients, while anti-CCP antibodies are highly specific for rheumatoid arthritis and can be useful in rheumatoid factor-negative cases.

      Other conditions that may present with similar symptoms include systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome, seronegative arthritis, and polymyalgia rheumatica. However, in this case, there are no other features to suggest SLE, one episode of deep vein thrombosis during pregnancy is insufficient to suggest antiphospholipid antibody syndrome, the patient is seropositive for rheumatoid factor ruling out seronegative arthritis, and there is no story of proximal muscle pain which could be suggestive of polymyalgia rheumatica. Therefore, the diagnosis of rheumatoid arthritis is most likely.

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  • Question 27 - A 25-year-old male immigrant from Turkey presents with complaints of recurrent painful oral...

    Incorrect

    • A 25-year-old male immigrant from Turkey presents with complaints of recurrent painful oral ulcers, genital ulcers, tender nodules on the extensor surface of the tibia and arthritis of both knees and ankles for the past 3 months. He has also had episodes of severe eye pain. He had an episode of pulmonary embolism due to deep vein thrombosis of the right leg 1 month ago. On examination, the oral cavity shows the presence of small shallow ulcers with a yellow necrotic centre. Genital examination reveals ulcers on the shaft of the penis and scrotal scars. The glans is spared. Non-specific inflammatory response is observed after intradermal injection of normal saline. Investigations revealed:
      Investigation Result Normal value
      White cell count (WCC) 20 × 109/l 4–11 × 109/l
      Erythrocyte sedimentation rate (ESR) 80 mm/h 0–10mm in the 1st hour
      C-reactive protein (CRP) Positive
      Anti-Saccharomyces cerevisiae antibodies Positive
      Which one of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Behçet’s syndrome

      Explanation:

      Behçet’s Syndrome: A Multisystem Disorder with Recurrent Oral and Genital Ulcerations

      Behçet’s syndrome is a multisystem disorder that primarily affects young people from the Mediterranean region, the Middle East, and the Far East. The syndrome is characterized by recurrent oral and genital ulcerations, as well as ocular involvement. The main pathologic lesion is systemic perivasculitis with early neutrophil infiltration and endothelial swelling. In some patients, vasculitis of the vasa vasorum can result in the formation of pseudo-aneurysms. Anti-Saccharomyces cerevisiae antibodies are present in patients with Behçet’s syndrome. The recurrent aphthous ulcerations are essential for the diagnosis, and a non-specific skin inflammatory reactivity to any scratches or intradermal saline injection (pathergy test) is a common and specific manifestation. Genital ulcers are painful, do not affect the glans penis or urethra, and produce scrotal scars. Thromboembolic events are a component of the disease itself, with superficial or deep peripheral vein thrombosis seen in 30% of patients. Pulmonary emboli are a rare but possible complication.

      Other possible diagnoses, such as extra intestinal Crohn’s disease, occult malignancy, systemic lupus erythematosus (SLE), and rheumatoid arthritis, can be ruled out based on the absence of certain clinical features and the presence of anti-Saccharomyces cerevisiae antibodies.

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  • Question 28 - A 68-year-old man visits his doctor's office, reporting a recent onset of a...

    Incorrect

    • A 68-year-old man visits his doctor's office, reporting a recent onset of a red, swollen, and hot great left toe. He denies any injury to the toe and has a medical history of hypertension, which is being treated with a single medication. The doctor suspects acute gout as the diagnosis.
      What medication is most likely responsible for triggering the acute gout?

      Your Answer:

      Correct Answer: Bendroflumethiazide

      Explanation:

      Understanding Gout and its Causes: A Review of Medications and Differential Diagnosis

      Gout is a type of inflammatory arthritis caused by the deposition of urate crystals in the joint. This article reviews the causes of gout, which can be primary or secondary hyperuricaemia. Secondary hyperuricaemia can be caused by overproduction or decreased renal excretion, including the use of thiazide diuretics like bendroflumethiazide. The differential diagnosis for an acute red, hot swollen joint includes septic arthritis, gout, pseudogout, inflammatory monoarthritis, and post-traumatic causes. Treatment for gout includes medications for chronic and acute gout, such as non-steroidal anti-inflammatory drugs, colchicine, or prednisolone. This article also discusses the effects of medications like colchicine, propranolol, lisinopril, and moxonidine on gout and other conditions.

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  • Question 29 - A 72-year-old man presents for review, complaining of pain in his knees. There...

    Incorrect

    • A 72-year-old man presents for review, complaining of pain in his knees. There is also stiffness in his fingers and he finds it difficult to use his computer. There is a history of hypertension, for which he takes amlodipine 10 mg, and type II diabetes, for which he takes metformin. He had been given a diagnosis of ulcerative colitis some years ago but has had no recent symptoms. On examination, he has a body mass index (BMI) of 34; blood pressure is 150/90 mmHg, and he has swelling and bony deformity of both knees. There is crepitus and anterior knee pain on flexion. Examination of the hands reveals Heberden’s nodes.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 120 g/dl 115–155 g/l
      White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
      Platelets 240 × 109/l 150–400 × 109/l
      Erythrocyte sedimentation rate 12 mm/h 0–10mm in the 1st hour
      Rheumatoid factor Negative
      Sodium (Na+) 142 mmol/l 135–145 mmol/l
      Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
      Creatinine 130 μmol/l 50–120 µmol/l
      X-ray of both knees reveals reduced joint space, subchondral sclerosis and cyst formation and osteophytes within the joint space.
      Which of the following fits best with the diagnosis?

      Your Answer:

      Correct Answer: Osteoarthritis

      Explanation:

      The woman in the picture appears to have osteoarthritis, which is commonly seen in overweight individuals affecting weight-bearing joints like the knees. The changes in her hands also suggest osteoarthritis. Treatment options include weight reduction, pain relief medication like paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy, or knee replacement surgery. Rheumatoid arthritis is unlikely as her ESR and rheumatoid factor are normal. Seronegative arthritis is also unlikely as it is associated with raised inflammatory markers, which are not present in this case. Enteropathic arthropathy is unlikely as there are no recent symptoms of inflammatory bowel disease. Osteoporosis is not a likely diagnosis as it does not cause knee or finger pain, but rather presents following a fracture.

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  • Question 30 - A 20-year-old woman presents with a painful left hip and groin and is...

    Incorrect

    • A 20-year-old woman presents with a painful left hip and groin and is struggling to weight-bear. She completed therapy for acute myeloblastic leukaemia some six months earlier.
      On examination, she walks with a limp and there is limitation of hip flexion, internal and external rotation.
      Investigations:
      Investigation Result Normal Value
      Haemoglobin 121 g/l 115–155 g/l
      White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
      Platelets 191 × 109/l 150–400 × 109/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
      Creatinine 130 μmol/l 50–120 µmol/l
      C-reactive protein (CRP) 12 mg/l 0–10 mg/l
      The left hip X-ray shows joint sclerosis with collapse of the femoral head.
      Which one of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Avascular necrosis

      Explanation:

      Differentiating Arthritis Types: Avascular Necrosis, Gout, Osteoarthritis, Pseudogout, and Septic Arthritis

      Arthritis is a common condition that affects the joints, causing pain, stiffness, and inflammation. However, there are different types of arthritis, each with its own causes, symptoms, and treatments. Here are some key points to differentiate between avascular necrosis, gout, osteoarthritis, pseudogout, and septic arthritis:

      Avascular necrosis is a condition where the bone tissue dies due to a lack of blood supply. It can be caused by corticosteroid use, malignancy, or trauma. Femoral head collapse is a classic radiographic change in avascular necrosis.

      Gout is a type of crystal arthritis that usually affects peripheral joints, such as the big toe, ankle, or knee. It is caused by the buildup of uric acid crystals in the joint, leading to sudden attacks of pain, redness, and swelling.

      Osteoarthritis is a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time. It is more common in older adults and can affect any joint, but femoral head collapse does not occur in osteoarthritis.

      Pseudogout is another type of crystal arthritis that usually affects peripheral joints. It is caused by the buildup of calcium pyrophosphate crystals in the joint, leading to similar symptoms as gout.

      Septic arthritis is a bacterial infection of the joint that can cause severe pain, swelling, and fever. It is a medical emergency and requires prompt treatment with antibiotics. While septic arthritis should always be considered in a monoarthritis, it is less likely in cases where there are classic radiographic changes of avascular necrosis, risk factors, and a normal CRP without history of fever.

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