Rheumatology Flashcards
1
Q
- Stiff hands (1)
A 36-year-old woman presents to the rheumatology outpatient clinic with a
two-month history of stiff hands and wrists. She mentions that the pain is
particularly bad for the first few hours after waking up and is affecting her work as
a dentist. On examination, the wrists, metacarpophalangeal joints and proximal
interphalangeal joints are swollen and warm. What is the most likely diagnosis?
A. Rheumatoid arthritis
B. Osteoarthritis
C. Septic arthritis
D. Polymyalgia rheumatica
E. Reactive arthritis
A
A
2
Q
- Stiff hands (2)
A 45-year-old woman presents to the rheumatology outpatient clinic with a threemonth
history of stiff hands and wrists. She mentions that the pain is particularly
bad first thing in the morning. On examination, the wrists, metacarpophalangeal
joints and proximal interphalyngeal joints are swollen and warm. A diagnosis of
rheumatoid arthritis is suspected. Which of the following investigations is most
specific for confirming the diagnosis?
A. X-rays
B. Rheumatoid factor levels
C. Anti-citrullinated peptide antibody (anti-CCP) levels
D. C-reactive protein
E. Erythrocyte sedimentation rate
A
C
3
Q
- Stiff hands (3)
A 40-year-old woman presents to the rheumatology outpatient clinic with a threemonth
history of stiff hands and wrists. She mentions that the pain is particularly
bad first thing in the morning. On examination, the wrists, metacarpophalangeal
joints and proximal interphalangeal joints are swollen and warm. A diagnosis of
rheumatoid arthritis is suspected. Blood tests for rheumatoid factor return as
positive. What is the most appropriate management?
A. Non-steroidal anti-inflammatory drugs (NSAIDs)
B. Intramuscular depot injection of methylprednisolone plus NSAIDs
C. Anti-TNF therapy
D. Intramuscular depot injection of methylprednisolone plus NSAIDs and
methotrexate and sulfasalazine
E. Physiotherapy
A
A
4
Q
- Stiff hands (4)
A 50-year-old woman, who has received a recent diagnosis of rheumatoid arthritis,
presents to her GP with ongoing pain and stiffness in her hands and feet. Which
joints are usually spared at onset of rheumatoid arthritis?
A. Proximal interphalangeal joints
B. Distal interphalangeal joints
C. Metacarpophalangeal joints
D. Wrists
E. Metatarsophalangeal joints
A
B
5
Q
- Stiff hands (5)
A 55-year-old man presents to his GP with a 2-week history of pain in his hands.
The pain is particularly bad in his right hand. On examination, brown discoloration
of the nails with onycholysis is noted and the distal interphalangeal joints are
tender on palpation. What is the most likely diagnosis?
A. Rheumatoid arthritis
B. Dermatomyositis
C. Reactive arthritis
D. Osteoarthritis
E. Psoriatic arthritis
A
E
6
Q
- Painful knees (1)
A 75-year-old woman presents to accident and emergency complaining of pain in
her knees. She mentions that this has been troubling her for several months. Pain
is generally worse in the evenings and after walking. On examination, there are
palpable bony swellings on the distal interphalangeal joints of the fingers on both
hands. In addition, there is reduced range of movement and crepitus in the knees.
What is the most likely diagnosis?
A. Rheumatoid arthritis
B. Osteoarthritis
C. Reactive arthritis
D. Polymyalgia rheumatica
E. Gout
A
B
7
Q
- Painful knees (2)
A 79-year-old woman presents to her GP with pain in the left knee. This is
particularly bad in the evenings and is stopping her from sleeping. The GP explains
that her discomfort is most likely due to osteoarthritis and arranges for her to have
an x-ray of the knee. Which of the following descriptions are most likely to describe
the x-ray?
A. Reduced joint space, subchondral sclerosis, bone cysts and osteophytes
B. Increased joint space, subchondral sclerosis, bone cysts and osteophytes
C. Reduced joint space, soft tissue swelling and peri-articular osteopenia
D. Increased joint space, soft tissue swelling and peri-articular osteopenia
E. Normal x-ray
A
A
8
Q
- Painful knees (3)
A 76-year-old man presents to accident and emergency with pain in his knees.
It is worse in the right knee. He describes the pain as being worse in the evening
and after exertion. On examination, bony nodules are palpable on the distal
interphalangeal joints of both his hands. The right knee is swollen and there is a
reduced range of active movement. X-rays show reduction in the joint space,
subchondral sclerosis and osteophyte formation. What is the most appropriate
treatment?
A. Anti-TNF therapy
B. NSAIDs and urgent orthopaedic follow up
C. NSAIDs and GP follow up
D. NSAID and intramuscular depot injection of methylprednisolone with GP
follow up
E. Admit the patient for orthopaedic assessment
A
C
9
Q
- Painful knees (4)
A 32-year-old man presents to accident and emergency with a 1-day history of
pain in the right knee. He also mentions that he has had a fever and is feeling
generally unwell. On examination, the right knee is swollen, warm and extremely
painful to move. What is the most appropriate next step?
A. Empirical intravenous antibiotic treatment
B. X-rays of the right knee
C. Aspiration of the joint and blood cultures
D. Referral for physiotherapy
E. Immobilize the joint
A
C
10
Q
- Painful knees (5)
A 30-year-old man presents to his GP with a 1-week history of painful, swollen
knees and a painful right heel. Further history reveals that he has been experiencing
burning pains while urinating for the past 2 weeks and that his eyes have become
red and itchy. What is the most likely diagnosis?
A. Septic arthritis
B. Gout
C. Ankylosing spondylitis
D. Enteropathic arthritis
E. Reactive arthritis
A
E
11
Q
- Painful knees (6)
A 70-year-old woman presents to accident and emergency with sudden onset pain
and swelling in the right knee. Her past medical history includes hypertension and
hypercholesterolaemia. She is currently taking aspirin, ramipril and simvastatin.
On examination, she is apyrexial and the right knee is swollen. There is reduced
range of movement in the knee due to swelling and pain. X-ray of the right knee
shows chondrocalcinosis. What is the most likely diagnosis?
A. Gout
B. Pseudo-gout
C. Septic arthritis
D. Reactive arthritis
E. Osteoarthritis
A
B
12
Q
- Painful knees (7)
A 74-year-old woman presents to accident and emergency with sudden onset pain
and swelling in the left knee. On examination, she is apyrexial and the left knee is
swollen. There is reduced range of movement in the knee due to swelling and pain.
X-ray of the right knee shows chondrocalcinosis. Microscopy of the fluid aspirated
from the joint is most likely to show:
A. Rhomboidal, weakly positively birefringent crystals under polarized light
microscopy
B. Needle-shaped negatively birefringent crystals under polarized light
microscopy
C. Atypical mononuclear cells
D. Reed Sternberg cells
E. Tophi
A
A
13
Q
- Back pain (1)
A 23-year-old man presents to the rheumatology clinic with lower back and hip
pain. These have been occurring every day for the past two months. Pain and
stiffness are worse in the mornings. He also mentions that his right heel has been
hurting. He is previously fit and well, but had occasions of lower back pain when
he was a teenager. His symptoms have stopped him from playing tennis. Recent
blood tests organized by his GP have shown a raised C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR). What is the most appropriate treatment?
A. NSAID and spinal exercises
B. NSAID and bed rest
C. Oral prednisolone
D. Methotrexate plus sulfasalazine
E. Bed rest
A
A
14
Q
- Back pain (2)
A 32-year-old man presents to the minor injuries walk-in clinic, complaining of
back pain. This had started suddenly that morning after he had lifted a heavy box
at home. He mentions that the pain has been shooting down his left leg and he
cannot walk without the support of his friend. He has not passed urine since the
onset of pain. On neurological examination of the lower limbs, tone and power
cannot be assessed due to pain but there are decreased ankle reflexes and a sacral
anaesthesia. What is the most appropriate next step?
A. Give NSAID analgesia and complete neurological examination
B. Send the patient home with NSAID analgesia and bed rest advice
C. Arrange urgent MRI of spine
D. Give NSAID analgesia and catheterize the patient
E. Send the patient home with NSAID analgesia and advice to avoid heavy
lifting
A
C
15
Q
- Back pain (3)
A 70-year-old woman with a history of vertebral crush fractures presents to the
osteoporosis outpatient clinic. Which of the following investigations is most useful
to assess the extent of her osteoporosis?
A. Spinal x-rays
B. MRI scan
C. Full blood count, bone and liver biochemistry blood tests
D. Vitamin D levels
E. DEXA scan
A
E
16
Q
- Blurred vision
A 20-year-old man presents to accident and emergency with sudden onset pain in
the right eye, with associated blurred vision and discomfort when gazing at the
lights. He has a history of back pain and has recently been diagnosed with
ankylosing spondylosis. What is the most likely cause of his eye pain?
A. Conjunctivitis
B. Retinal detachment
C. Anterior uveitis
D. Corneal ulceration
E. Acute glaucoma
A
C
17
Q
- Shoulder pain (1)
A 70-year-old woman presents to her GP complaining of severe unilateral headache
over the left side of her head. On further questioning, she mentions that she has
been having bilateral shoulder and neck pains over the past few weeks. She has also
been feeling lethargic. On examination, the left side of her scalp is painful to touch.
What is the most likely diagnosis?
A. Polyarteritis nodosa
B. Polymyositis
C. Hypothyroidism
D. Migraine
E. Giant cell arteritis
A
E
18
Q
- Shoulder pain (2)
A 77-year-old woman presents to accident and emergency complaining of severe
unilateral headache over the left side of her head. On examination, the left side of
her scalp is painful to touch. Blood tests reveal a raised ESR and CRP. What is the
most appropriate management?
A. Steroid therapy and arrange urgent temporal artery
biopsy
B. NSAID analgesia and arrange urgent temporal artery biopsy
C. Paracetamol analgesia and discharge with advice to bed rest
D. Arrange urgent MRI head
E. NSAID analgesia and arrange urgent electromyography
A
A
19
Q
- Shoulder pain (3)
A 60-year-old woman presents to her GP with a two-month history of lethargy and
weakness. She mentions that she is finding it increasingly difficult to climb the
stairs and do the housework. On examination, there is wasting and weakness of the
proximal muscles in the upper and lower limbs. What is the most likely diagnosis?
A. Dermatomyositis
B. Polymyositis
C. Polymyalgia rheumatica
D. Kawasaki’s disease
E. Polyarteritis nodosa
A
B
20
Q
- Shortness of breath (1)
A 30-year-old Afro-Carribean woman presents to accident and emergency with a
1-week history of progressive shortness of breath and fever. On further questioning,
she mentions that her hands have been painful and stiff over the past few months
and she has been having recurrent mouth ulcers. Chest x-ray confirms bilateral
pleural effusions and blood tests reveal a raised ESR and a normal CRP. What is the
most likely diagnosis?
A. Systemic lupus erythematosus
B. Systemic sclerosis
C. Sjögren’s syndrome
D. Discoid lupus
E. Beçhet’s disease
A
A
21
Q
- Shortness of breath (2)
A 34-year-old Afro-Carribean woman has been admitted for management and
investigation of increasing shortness of breath. On further questioning, she
mentions that her hands have been painful and stiff over the past few months and
she has been having recurrent mouth ulcers. Chest x-ray confirms bilateral pleural
effusions and blood tests reveal a raised ESR and a normal CRP. A diagnosis of
systemic lupus erythematosus (SLE) is suspected and a full autoantibody screen is
sent to the laboratory. Which of the following auto-antibodies is most specific to
the suspected diagnosis?
A. Anti-nuclear antibody
B. Rheumatoid factor
C. Anti-double stranded DNA antibody
D. Anti-centromere antibody
E. Anti-mitochondrial antibody
A
C
22
Q
- Shortness of breath (3)
A 55-year-old woman presents to her GP with shortness of breath and dry cough. The
symptoms began a few months ago and have progressed. She has a past medical
history of rheumatoid arthritis, diagnosed ten years earlier. On respiratory examination,
there are bibasal fine inspiratory crackles on auscultation. What is the most likely
cause of her symptoms?
A. Pulmonary oedema
B. Consolidation
C. Pleural effusions
D. Pulmonary fibrosis
E. Intrapulmonary nodules
A
D
23
Q
- Shortness of breath (4)
A 27-year-old woman presents to accident and emergency complaining of sudden
onset shortness of breath and right-sided pleuritic chest pain. She has a past medical
history of three miscarriages and a deep venous thrombosis in the right leg. On
examination, pulse is 110 bpm, respiratory rate is 24 bpm, oxygen saturation is 88
per cent on room air. An arterial blood gas shows pH 7.40, PO2 8.0, PCO2 3.1. What
is the diagnostic investigation of choice?
A. Full blood count
B. Chest x-ray
C. D-dimer
D. CT pulmonary angiogram (CTPA)
E. ECG
A
D
24
Q
- Shortness of breath (5)
A 27-year-old woman presents to accident and emergency complaining of sudden
onset shortness of breath, right-sided pleuritic chest pain and haemoptysis. She has
a past medical history of three miscarriages and a deep venous thrombosis in the
right leg. CTPA confirms a large pulmonary embolism. What is the most likely
underlying diagnosis?
A. SLE
B. Primary anti-phospholipid syndrome
C. Raynaud’s disease
D. Systemic sclerosis
E. Beçhet’s disease
A
B
25
Q
- Shortness of breath (6)
A 27-year-old woman presents to accident and emergency complaining of sudden
onset shortness of breath, right-sided pleuritic chest pain and haemoptysis. She has a
past medical history of three miscarriages and a deep venous thrombosis in the right
leg. CTPA confirms a large pulmonary embolism. A diagnosis of anti-phospholipid
syndrome is suspected and a full autoantibody screen is sent. Which of the following
auto-antibodies would confirm the diagnosis if detected?
A. Anti-cardiolipin antibody
B. Anti-centromere antibody
C. Anti-nuclear antibody
D. Anti-mitochondrial antibody
E. Anti-histone antibody
A
A
26
Q
- Dry eyes
A 45-year-old woman presents to the rheumatology clinic with a three-month
history of itchy, dry eyes and a persistently dry mouth. She also mentions that her
fingers have been extremely cold, occasionally turning blue after going outside in
the morning. Shirmer’s test is positive. What is the most likely diagnosis?
A. Systemic sclerosis
B. Raynaud’s disease
C. SLE
D. Primary Sjögren’s syndrome
E. Secondary Sjögren’s syndrome
A
D
27
Q
- Cold hands
A 24-year-old woman presents to her GP complaining of cold hands and feet. This
has been ongoing for the past three months and is especially bad when she goes out
in the mornings and may last for hours. On further questioning, she mentions that
her hands sometimes turn blue or red and that gloves are unhelpful. She has
otherwise been feeling well and has no past medical history. What is the most
appropriate treatment?
A. Propanolol
B. Aspirin
C. Nifedipine
D. Subcutaneous injection of low molecular weight heparin
E. Prednisolone
A
C
28
Q
- Chest discomfort
A 42-year-old woman presents to accident and emergency with retrosternal
discomfort. She was diagnosed with systemic sclerosis a year ago. Which of the
following statements is true about systemic sclerosis?
A. Microstomia is only seen in diffuse cutaneous systemic sclerosis
B. Skin involvement is limited to face, hands and feet in limited cutaneous
systemic sclerosis
C. Oesophageal dysmotility is only seen in limited cutaneous systemic
sclerosis
D. Anti-double stranded DNA antibodies are normally detected in patients
with systemic sclerosis
E. Raynaud’s phenomenon occurs as a result of skin fibrosis (scleroderma)
A
B
29
Q
- Painful joints
A 30-year-old woman presents to accident and emergency with worsening stiffness
in the hands, wrists and feet. She mentions that the pain has been particularly bad
in the mornings. On examination, there is a palpable spleen. Initial blood tests reveal
a low neutrophil count and a raised C-reactive protein. The most likely diagnosis is:
A. Felty’s syndrome
B. Reactive arthritis
C. Still’s disease
D. Infectious mononucleosis
E. Serum sickness
A
A
30
Q
- Joint pain (1)
A 53-year-old man, who works as a chef, presents to accident and emergency with
sudden onset severe pain, tenderness and swelling of the first metatarsophalangeal
joint. The pain is making it difficult for him to mobilize. He has had two previous
similar episodes. Blood tests reveal a raised serum urate level. The most likely
diagnosis is:
A. Gout
B. Pseudo-gout
C. Septic arthritis
D. Reactive arthritis
E. Osteoarthritis
A
A
31
Q
- Joint pain (2)
A 59-year-old man presents to his GP with sudden onset severe pain, tenderness
and swelling of the first metatarsophalangeal joint. He is known to suffer from
acute gout and has had several previous similar episodes. What is the most
appropriate treatment?
A. Allopurinol
B. NSAIDs
C. Conservative measures including reduced alcohol intake and weight loss
D. Intra-articular steroid injection
E. Methotrexate
A
B
32
Q
- Skin reaction (1)
A 30-year-old Turkish man presents to accident and emergency with oral ulcers,
genital ulcers and painful legs. On examination, there are apthous ulcers in the
mouth, genital ulceration, erythema nodosum over the shins. He is admitted under
the medical team on call and a skin pathergy test is positive. What is the most likely
diagnosis?
A. Henoch–Schönlein purpura
B. Lyme disease
C. Berger’s disease
D. Caplan’s syndrome
E. Behçet’s disease
A
E
33
Q
- Skin reaction (2)
A 23-year-old woman presents to accident and emergency with a purpuric rash
over the buttocks and lower limbs and haematuria. She is finding it difficult to
mobilize due to pain in her ankles and knees. What is the most likely diagnosis?
A. Henoch–Schönlein purpura
B. Perthes’ disease
C. Behçet’s disease
D. Still’s disease
E. Ehlers–Danlos syndrome
A
A
34
Q
- Bone pain (1)
A 67-year-old man presents to his GP with pain in his pelvis. During the consultation,
he mentions that his friends have been commenting that his head appears larger
than before. In addition, he has noticed deterioration in hearing in his left ear. On
neurological examination, a left-sided sensorineural deafness in detected. Closer
inspection of the legs reveals bowing of the tibia. What is the most likely diagnosis?
A. Osteomalacia
B. Osteoporosis
C. Acromegaly
D. Ricketts
E. Paget’s disease
A
E
35
Q
- Bone pain (2)
In a patient with Paget’s disease of the bone, which of the following blood test
results are most likely to be seen?
A. Normal serum calcium, normal serum phosphate, raised serum alkaline
phosphatase
B. Normal serum calcium, normal serum phosphate, normal serum alkaline
phosphatase
C. Raised serum calcium, low serum phosphate, normal serum alkaline
phosphatase
D. Normal serum calcium, low serum phosphate, raised serum alkaline
phosphatase
E. Low serum calcium, low serum phosphate, low serum alkaline
phosphatase
A
A
