MSK Formative Flashcards
Which statement concerning gout is incorrect?
- A: Diuretics are a recognised risk factor for gout
- B: Gout can be discounted if the patient does not have tophi
- C: It is the commonest inflammatory arthritis in males
- D: Reduction of the serum uric acid to a sub-saturating concentration is an important goal of treatment
- E: The serum uric acid may fall during an acute attack
= B: Gout can be discounted if the patient does not have tophi
- The majority of patients with gout do not have visible tophi; all other options are correct.
- A: Metastatic malignancy associated with a para-neoplastic syndrome is the most likely diagnosis
- B: Paget’s disease involving the skull, orbit and cervical spine should be suspected and relevant X-rays of these skeletal structures should be arranged
- C: Polymyalgia rheumatic is the most likely diagnosis and the patient should be treated with prednisolone 7.5 mg daily
- D: Prednisolone 40 - 60 mg daily should be commenced and a temporal artery biopsy performed, preferably within a few days
- E: Urgent ophthalmic advice should be sought as acute glaucoma is the most likely diagnosis.
= D: Prednisolone 40 - 60 mg daily should be commenced and a temporal artery biopsy performed, preferably within a few days.
The clinical stem is consistent with temporal arteritis, and associated polymyalgia rheumatica. It is critical to organise an urgent temporal artery biopsy and commence high-dose Prednisolone in this setting, to minimise the risk of visual loss.
Which statement concerning scleroderma is incorrect?
- A: Most patients respond well to prednisolone with many achieving permanent remission
- B: Oedema, skin thickening and depigmentation in the skin may occur
- C: Oesophageal reflux is a frequent manifestation
- D: Raynaud’s phenomenon is commonly present
- E: The presence of interstitial lung disease implies a worse prognosis
= A: Most patients respond well to prednisolone with many achieving permanent remission = INCORRECT
Prednisolone is typically ineffective for most of the symptoms scleroderma; complete remission is rare. All other options are correct.
A 51 year old male presents with mild low back pain and a five day history of severe right buttock and leg pain extending postero-laterally to the ankle. He has also noticed loss of sensation and tingling in the right great toe. Which statement is most correct?
- A: A dissecting aneurysm of the right ilio-femoral artery is likely
- B: A metastatic tumour in the femur is the likely cause
- C: He probably has prodromal herpetic neuralgia and could be expected to manifest vesicles in an S1 dermatomal distribution within the next 10 days
- D: His presentation is typical of unilateral sacro-iliitis
- E: Lumbar nerve root impingement should be suspected
= E: Lumbar nerve root impingement should be suspected
Typical presentation of lumbar radiculopathy: low back pain with pain and sensory disturbance radiating to the distal leg.
Which statement concerning the use of methotrexate (5-20 mg/week) is most correct?
- A: Blood tests for liver and bone marrow function are required indefinitely
- B: Is highly effective for the spondylitic component of ankylosing spondylitis
- C: Liver failure is a frequent complication
- D: Mouth ulcers complicating treatment are reduced by the use of supplementary vitamin C
- E: Should be reserved for the treatment of severe osteoarthritis
= A: Blood tests for liver and bone marrow function are required indefinitely.
- Treatment with Methotrexate requires ongoing monitoring of liver and bone marrow function for as long as the drug is continued; Folic acid (rather than vitamin C) can be used to reduce mouth ulceration.
A 29 year old female, who is three months post-partum after the delivery of her first child, presents with a two week history of unrelenting right wrist pain extending into her thumb. She is afraid she may drop her baby as the pain at times is sharp and very intense. Examination reveals swelling over the radial aspect of the wrist and tenderness of the radial styloid process. Which statement is most correct?
- A: A stress fracture associated with pregnancy related osteoporosis is likely
- B: An X-ray of the wrist should be performed as there is a high probability she has chondrocalcinosis in the triangular fibrocartilage
- C: De Quervains tendinopathy is most likely
- D: Rheumatoid arthritis should be suspected, since it often presents in the post-partum period
- E: She probably has early carpo-metacarpal joint osteoarthritis
= C: De Quervains tendinopathy is most likely
- Symptoms and signs described are typical for de Quervain’s tenosynovitis, which commonly presents in mothers of young children. Rheumatoid arthritis can also present at this time, however this is less common, and the features outlined were less consistent with this.
A 24 year old male aid-worker presents with pain and swelling in his left ankle joint and dactylitis in his right fourth toe after returning from Bangladesh three days ago. He has painless mouth ulcers and bilateral conjunctivitis. He recalls a five day bout of diarrhoea and some rectal bleeding about two weeks ago. He is found to be negative for the HLA B27 antigen.
What is the most likely diagnosis?
- A: Gonococcal arthritis
- B: Inflammatory bowel disease
- C: Reactive arthritis
- D: Rheumatoid arthritis
- E: Viral arthritis
= C: Reactive arthritis
- Clinical scenario is typical for reactive arthritis, secondary to a bacterial gastrointestinal infection. The presence of HLA-B27 can increase the likelihood of persistent symptoms in those affected by reactive arthritis, although its absence does not exclude the disease.
Which statement concerning synovial fluid is incorrect?
- A: Blood which does not clear on aspiration of a joint effusion implies a haemarthrosis
- B: In osteoarthritis (OA), the leukocyte count is usually between 2 000 - 10 000 cells/uL
- C: It is normally very viscous
- D: Specimens should be collected in an EDTA tube and a plain sterile tube for optimal laboratory analysis
- E: When it escapes from a ruptured Baker’s cyst, it may cause a syndrome that mimics a deep vein thrombosis
= B: In osteoarthritis (OA), the leukocyte count is usually between 2 000 - 10 000 cells/uL = INCORRECT
- The joint fluid from an osteoarthritic joint typically has a low leucocyte count (as listed), in contrast to inflammatory and infective states.
A 31 year old Caucasian female presents with a photosensitive rash, arthralgias and pleurisy two weeks following a sore throat and fever. Investigations show an ANA of 1:2 560 with a homogeneous pattern of fluorescence. The C4 is low. The rheumatoid factor is positive at 20 units (RI: < 14). Which statement is correct?
- A: Acute rheumatic fever is the most likely diagnosis
- B: A viral respiratory tract illness is the most likely cause of the findings
- C: Septic arthritis due to streptococcal infection should be suspected
- D: Streptococcal endocarditis should be suspected
- E: Systemic lupus erythematosus (SLE) is more likely than rheumatoid arthritis
= E: Systemic lupus erythematosus (SLE) is more likely than rheumatoid arthritis
Despite the relatively short duration of symptoms, the clinical picture is most suggestive of SLE, in view of the photosensitive rash, arthralgia, serositis, positive ANA and low C4. The borderline positive rheumatoid factor is unlikely to be relevant; a viral illness could not account for the blood test results, and a delayed-onset photosensitive rash is not typical.
A 56 year old female presents with a three month history of symmetrical polysynovitis involving the MCP, wrist, elbow and knee joints. She reports lethargy and a weight loss of 5 kg. Blood tests show a high titre rheumatoid factor of 550 kU/L (RI: < 21), anti CCP antibodies of 370 (RI: < 5) and an elevated CRP at 127 mg/L (RI: < 5). X-rays of the hands and feet show normal joints and no other abnormality. A diagnosis of rheumatoid arthritis is made.
Which statement is the most correct?
= E: The potential for benefit with use of methotrexate should be discussed and this treatment should be recommended.
- Typical features of early rheumatoid arthritis. Early institution of methotrexate is the most important aspect of treatment.
- A: Ankylosing hyperostosis (Forestier’s disease, DISH)
- B: Ankylosing spondylitis
- C: Cauda equina syndrome
- D: Kyphoscoliosis
- E: Lumbar disc prolapse
- F: Metastatic bone cancer
- G: Osteomalacia
- H: Osteomyelitis
- I: Osteoporosis
- J: Paget’s disease of the spine
- K: Primary vertebral tumour
- L: Psoriatic arthritis
- M: Spinal stenosis
- N: Spondylolisthesis
- O: Thoracic disciitis
= I: Osteoporosis
- Typical features on history and imaging for an osteoporotic fracture; Multiple risk factors including age, sex and chronic steroid use.
- A: Ankylosing hyperostosis (Forestier’s disease, DISH)
- B: Ankylosing spondylitis
- C: Cauda equina syndrome
- D: Kyphoscoliosis
- E: Lumbar disc prolapse
- F: Metastatic bone cancer
- G: Osteomalacia
- H: Osteomyelitis
- I: Osteoporosis
- J: Paget’s disease of the spine
- K: Primary vertebral tumour
- L: Psoriatic arthritis
- M: Spinal stenosis
- N: Spondylolisthesis
- O: Thoracic disciitis
= H: Osteomyelitis
Background of recurrent infections, with new mechanical pain, focal tenderness and fever are suggestive of a localised infection.
Osteomyelitis is most likely.
- A: Ankylosing hyperostosis (Forestier’s disease, DISH)
- B: Ankylosing spondylitis
- C: Cauda equina syndrome
- D: Kyphoscoliosis
- E: Lumbar disc prolapse
- F: Metastatic bone cancer
- G: Osteomalacia
- H: Osteomyelitis
- I: Osteoporosis
- J: Paget’s disease of the spine
- K: Primary vertebral tumour
- L: Psoriatic arthritis
- M: Spinal stenosis
- N: Spondylolisthesis
- O: Thoracic disciitis
= B: Ankylosing spondylitis
- Typical presentation of ankylosing spondylitis. This is more common in patients with a family history of AS, psoriasis or inflammatory bowel disease; the presentation described is more suggestive of AS, than psoriatic arthritis.
- A: Ankylosing hyperostosis (Forestier’s disease, DISH)
- B: Ankylosing spondylitis
- C: Cauda equina syndrome
- D: Kyphoscoliosis
- E: Lumbar disc prolapse
- F: Metastatic bone cancer
- G: Osteomalacia
- H: Osteomyelitis
- I: Osteoporosis
- J: Paget’s disease of the spine
- K: Primary vertebral tumour
- L: Psoriatic arthritis
- M: Spinal stenosis
- N: Spondylolisthesis
- O: Thoracic disciitis
= A: Ankylosing hyperostosis (Forestier’s disease, DISH)
- Clinical features and imaging most consistent with diffuse idiopathic skeletal hyperostosis (DISH, Forestier’s disease). AS is unlikely given the late age of symptom onset and imaging findings (localised thoracic hyperostosis).
- A: Ankylosing hyperostosis (Forestier’s disease, DISH)
- B: Ankylosing spondylitis
- C: Cauda equina syndrome
- D: Kyphoscoliosis
- E: Lumbar disc prolapse
- F: Metastatic bone cancer
- G: Osteomalacia
- H: Osteomyelitis
- I: Osteoporosis
- J: Paget’s disease of the spine
- K: Primary vertebral tumour
- L: Psoriatic arthritis
- M: Spinal stenosis
- N: Spondylolisthesis
- O: Thoracic disciitis
= G: Osteomalacia
- Osteomalacia is most likely given history of bone pain and muscle symptoms, in the setting of chronic vitamin D malabsorption from Crohns’ disease and terminal ileal resection.
A 53 year old female presents with a 10-month history of polyarthralgia. Examination shows swelling and tenderness in the MCP and wrist joints of both hands and in the right knee. She also has swollen tender lateral MTP joints in both feet. There is a solitary patch of psoriasis in the scalp. An aspirate from the knee shows 16 000 /uL leukocytes with 85% polymorphs. No crystals or microbial organisms are detected. Rheumatoid factor is negative, but an ANA is 1:640.
- List the three most likely diagnoses. (3 marks)
- List two investigations (blood tests, imaging or others) with high specificity that would be likely to help in determining a diagnosis. (2 marks)
- Treatment with methotrexate 20 mg/week is recommended. Which additional treatment should be advised to reduce the risk of methotrexate toxicity? (1 mark)
- Psoriatic arthritis (1 mark)
- Rheumatoid arthritis (1 mark)
- SLE (1 mark)
(Total 3 marks)
- Blood tests (max of 1 mark): anti-CCP antibodies (1 mark); ENA (1 mark); DNA (1 mark)
- Imaging (max of 1 mark): X-ray hands/feet (1 mark); MRI (1 mark); ultrasound (0.5 marks) (Total 2 marks)
- Folic acid/Folinic acid/Megafol (1 mark) (1 mark)
A severe flare occurs six months later and prednisolone 10 mg daily is added with beneficial effect.
List four important side effects that can complicate long term corticosteroid therapy with doses of prednisolone at or above 10 mg/day. You may choose one from each system. (4 marks)
