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Phase 2a > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What is rheumatoid inflammation?

A

The movement of fluid and white blood cells into extra-vascular tissue

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2
Q

What are the 4 pillars of inflammation?

A

Red, painful, hot, swollen

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3
Q

Does pain ease with use in inflammatory or degenerative problems?

A

Inflammatory

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4
Q

Is there stiffness in inflammatory or degenerative problems?

A

Both

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5
Q

If stiffness prolonged in inflammatory or degenerative problems?

A

Inflammatory

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6
Q

Is there swelling in inflammatory or degenerative problems?

A

Inflammatory

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7
Q

Is the joint hot and red in inflammatory or degenerative problems?

A

Inflammatory

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8
Q

Is the patient typically older in inflammatory or degenerative problems?

A

Degenerative

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9
Q

Is psoriasis associated with inflammatory or degenerative problems?

A

Inflammatory

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10
Q

Does the pain respond to NSAIDs in inflammatory or degenerative problems?

A

Inflammatory

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11
Q

Is there clicks/ clunks in joints in inflammatory or degenerative problems?

A

Degenerative

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12
Q

Does pain increase with use in inflammatory or degenerative problems?

A

Degenerative

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13
Q

What would pain at rest and at night be indicative of?

A

Tumour
Infection
Fracture

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14
Q

What would pain and stiffness in joints in the morning, at rest and with use be indicative of?

A

Inflammatory causes

Infection

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15
Q

What would pain on use at the end of the day be indicative of?

A

Osteoarthritis

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16
Q

What would pain and paresthesia in dermatomal distribution, worsened by specific activity be indicative of?

A

Neuralgic pain

Root or peripheral nerve compression

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17
Q

Where does osteoarthritis typically affect?

A

First weight bearing joints= Spine and base of spine, knee, ankle
Then smaller joints= Base of thumb, first metatarsal, metacarpals

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18
Q

What would discrete episodes of pain in the base of the big toe with complete recovery in-between be indicative of?

A

Gout

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19
Q

What is ESR?

A

Erythrocyte sedimentation rate

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20
Q

What causes ESR to raise?

A
  • Inflammation/ infection

- SLE

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21
Q

What is CRP?

A

Acute phase protein

Changes very rapidly in response to inflammation/ infection

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22
Q

What would a high CRP and normal ESR show?

A

There is inflammation/ infection that is recent onset

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23
Q

What is HLA B27?

A

An antigen presenting cell encoded by MHC on chromosome 6. If it is +ve it is associated with autoimmune disease

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24
Q

What cells are in the media of a vessel cell wall?

A

Vascular smooth muscle

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25
Q

What are the layers of a vessel wall?

A

Intima
Media
Adventitia

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26
Q

What histological changes occur in giant cell arteritis?

A

Cells blur the edges between the media and adventitia so there are no longer clear differentiations. Also luminal narrowing.

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27
Q

How does immune activation lead to ischaemia, infarction and aneurysm?

A

There are activated immune cells which infiltrate vessel walls and lead to direct damage, leading to smooth muscle cell remodelling. This causes weakening and occlusion of the blood vessel.

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28
Q

What are the two ways of classifying vasculitis ?

A
  • Vessel size

- Consensus classification

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29
Q

What are the two diseases of large-vessel vasculitis?

A
  • Takayasu arteritis

- Giant cell arteritis

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30
Q

Name a vascular disease that is ANCA associated?

A
  • Microscopic polyangitis

- Wegener’s (Granulomatosis with polyangiitis)

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31
Q

What are the two diseases of medium-vessel vasculitis?

A
  • Polyarteritis nodosa

- Kawasaki disease

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32
Q

What is the commonest immune complex vasculitis?

A

IgA Vasculitis

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33
Q

What is the most common vasculitis?

A

Giant cell arteritis

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34
Q

What are the complications of GCA?

A

Strokes, blindness (A stroke affecting the retinal vessels)

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35
Q

How is GCA confirmed?

A

Temporal artery biopsy or ultrasound

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36
Q

How is GCA treated?

A

Oral prednisolone which is tapered off over 12-18 months

IV methylprednisolone if visual symptoms persist

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37
Q

What are some complications of steroid use?

A
  • Steroid induced diabetes
  • Osteoporosis
  • Immunosuppression= Infection
  • Peptic ulceration
  • Weight gain
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38
Q

A 73 year old male reports fatigue, sore throat, headache at each temples, and two superficial temporal lumps. He also has a tender neck. He has a raised CRP and raised WBC. His CT was all normal. A week later he awoke with no vision in left eye, and a severe headache. The disc was pale. What is it likely to be and what test should be ordered to confirm. What should his treatment be?

A

Giant cell arteritis

  • Temporal artery biopsy to view cellular infiltrates and breaking up of the internal elastic lamina
  • Start him on high dose oral prednisolone but with oral Ad Cal and lansoprazole to prevent GI/Bone issues
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39
Q

How is prosthetic infection diagnosed?

A
  • Histology
  • Examination
  • X rays
  • FBC, ESR, CRP
  • Microbiology culture following aspiration (diagnostic)
  • Alpha defensin blood test
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40
Q

How is prosthetic infection treated?

A
  • Antibiotic treatment after aspiration
  • Debridement and implant retention
  • Excision arthroplasty
  • Exchange arthroplasty
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41
Q

What is meant by “radical debridement” in relation to prosthetic infection?

A

Complete surgical removal of any infected tissue/material to leave a sterile environment.

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42
Q

What is good musculoskeletal health?

A

Healthy/ disease-free muscles, joints and bone with the ability to carry out a wide range of physical activities, both effectively and symptom free

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43
Q

How prevalent are MSK conditions?

A

30% of England’s population

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44
Q

List some modifiable risk factors for MSK conditions?

A

Vit D/ Calcium
BMI in correct range
Ensure safety within physical activity (warm ups, not lifting too heavy items)
Injury prevention- good lighting, hand rails

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45
Q

List some accessible community facilities for physical activity?

A

Parks
Cycle paths
Swimming pools

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46
Q

List some supervised physical activity facilities?

A

Walking clubs
Aqua aerobics
Dance clubs

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47
Q

Joint pain can be categorised into inflammatory and non-inflammatory causes. Give 3 inflammatory and 2 non-inflammatory causes of joint pain

A

Inflammatory:
- Autoimmune (1) / RA, Spondylo-arthropathies (1) Connective Tissue Disease (1)
- Crystal Arthritis (1)
- Infection (1)
Non-inflammatory:
- Degenerative (1) OA (1) other degenerative example (1)
- Non-degenerative (1) Fibromyalgia (1) other non-degenerative example (1)

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48
Q

What clinical features that are found in the hands of a patient with Rheumatoid Arthritis?

A
  • Ulnar Deviation (1)
  • Swan neck deformity (1)
  • Distal Interphalangeal join sparing (1)
  • Z-thumb (1)
  • Swollen Joints (1
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49
Q

A patient is HLA-B27+, give 3 differential diagnoses.

A
  • Ankylosing spondylitis (1)
  • Psoriatic arthritis( 1)
  • Iriitis/ Acute anterior uveitis (1)
  • Reactive arthritis (1)
  • Enteropathic arthritis (1)
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50
Q

Give a pharmacological treatment for a patient with osteoporosis?

A
  • Bisphosphonate (1) Alendronate (1) Alendronic acid (1)
  • Denosumab (1)
  • Teriparatide (1)
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51
Q
  1. Which antibody is specific for SLE?
A
  • Double-stranded DNA (1) / Anti-dsDNA (1
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52
Q

Which condition must always be ruled out in an acutely inflamed joint, and how could you investigate for this if you suspected it?

A
  • Septic Arthritis (1)

- Joint aspiration for snynovial fluid (1) MC&S (1)

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53
Q

What is the medical term given to a distal interphalangeal joint swelling in a patient with Osteoarthritis?

A

Heberden’s Nodes

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54
Q

Greg comes into your GP Clinical complaining of an aching pain in his hand and arm. The pain is worse at night and has paraesthesia in his thumb, he tells you the pain is relieved if he hangs his hand over the edge of the bed. Greg has a wife and 3 children which his supports by working full time as a painter-decorator.
What condition does Greg have?

A

Carpal Tunnel Syndrome

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55
Q

What nerve is affected in carpal tunnel syndrome?

A

Median nerve

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56
Q

Molly, a 5-year-old child presents to A&E with a fracture in the distal humerus. It passes through the growth plate and epiphysis yet spares the metaphysis. She is in a lot of pain and scared because this is the first time she’s ever been in hospital.
What classing system is used for these types of fractures? What stage is Molly’s fracture at?

A

Salter-Harris Classification

Class 3

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57
Q

Molly, a 5-year-old old child presents to A&E with a fracture in the distal humerus. It passes through the growth plate and epiphysis yet spares the metaphysis. She is in a lot of pain and scared because this is the first time she’s ever been in hospital.
Do you suspect that Molly’s injuries are caused by Non-Accidentally Injury. Justify your answer

A

We should always be conscious of NAI as a potential cause (1) but in this case it is unlikely

  • First time in hospital
  • Site is fairly typical for child injury (Ribs and back are more suspicious)
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58
Q

Jean, a 63-year-old woman, has just had a DEXA Scan. Her results show a T score of -2.2 and Z score of -1.5.
Explain what is meant by a T / Z score

A
  • T= Bone density (score/standard deviations away from) compared to a 25 year-old of the same gender (1)
  • Z= bone density compared to the average for their age of the same gender (1)
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59
Q

What would a T score of -2.2 indicate?

A

Osteopenia (Osteoporosis < -2.5)

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60
Q

What does a FRAX score calculate?

A

The risk of fracture in the next ten years

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61
Q

Give an example of when you might prescribe allopurinol?

A

Long term (1) treatment of Gout (1)

  • Kidney stones (1) prevent uric acid/calcium oxalate (1)
  • Hyperuricaemia (1) e.g in Tumour Lysis Syndrome (1)
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62
Q

How does allopurinol work?

A

Xanthine Oxidase Inhibitor

  • Xanthine oxidase metabolises xanthine into uric acid
  • Therefore inhibiting XO lowers plasma uric acid (1) and precipitation of uric acid in joints/kidneys
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63
Q

What medication would you prescribe for a patient with temporal arteritis?

A

Corticosteroid= Prednisolone

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64
Q

What proportion of women over 50 will have a fracture due to osteoporosis?

A

Half

65
Q

Name two properties of bone, other than bone mineral density, which contribute to bone strength

A 
Bone size
Bone quality (bone turnover, architecture and mineralisation)
66
Q

What are the most commonly used drugs for osteoporosis

A
  • Bisphosphonates (oral aldendronate)

- Denosumab= a monolconal antibody to RANK ligand

67
Q

What is the function of osteoblasts?

A

Build bone

68
Q

What is the function of mineral within bone?

A

Strength and stiffness

69
Q

What is the function of collagen I within bone?

A

Toughness

70
Q

What is the function of collagen I within bone?

A

Elasticity

71
Q

What do osteoclasts derive from?

A

Haemopoetic stem cells (multinucleated)

72
Q

What do osteoblasts derive from?

A

Mesenchymal precursor

73
Q

How does low oestrogen lead to weaker bones?

A

Low oestrogen results in increased numbers of osteoclasts, premature arrest of osteoblasts and perforation of trabeculae

74
Q

What age is peak bone mass reached?

A

25-30

75
Q

How would calcium deficiency lead to weaker bones?

A

Low calcium leads to increased PTH release, thus bone resorption

76
Q

What causes PTH release

A

low serum calcium

77
Q

What is the action of PTH

A

Increases calcium absorption in the intestine by increasing calcitriol
Increasing bone resorption thus increasing serum calcium and phosphate
Decreases phosphate reabsorption thus increasing urinary phosphate
Increasing calcium reabsorption in the distal tubule thus decreasing urinary calcium

78
Q

Where is PTH released from

A

PTH is released from chief cells of the parathyroid glands

79
Q

What is calcitonin and where is it released from?

A

It is released from parafollicular cells in response to high calcium, causing lower bone resorption

80
Q

What triggers FGF-23 release?

A

rise in phosphate, rise in PTH, dietary phosphate loading or high vitamin D levels

81
Q

Where is FGF-23 released from?

A

Osteocytes

82
Q

What is the action of FGF-23?

A

It acts to decrease whole body phosphate by decreasing 1-alpha-hydroxylation of vitamin D which decreases gut absorption of phosphate, and decreases expression of Na transporter in the renal tubule, which increases renal phosphate excretion

83
Q

What bones are made by intramembranous ossification?

A

Flat bones, clavicle and mandible are formed through intramembranous ossification.
Intramembranous ossification is a mesenchymal cell that forms into a flat sheet. Osteoid form.

84
Q

What is the precursor to endochondrial ossification?

A

Hyaline

85
Q

What is the name of the connective tissue that holds multiple fascicles to form a muscle?

A

Epimysium

86
Q

What is endomysium?

A

Connective tissue between fibres

87
Q

Breifly describet the structure of collagen within bones

A

Collagen is made of three types of collagen that are tightly coiled together. 3 collagen molecules come together to form the 3 stranded tropocollagen molecules. These are then assembled into a collagen fibril

88
Q

What is woven/fibrous bone?

A

Disorganised bone made after a fracture. It is mechanically weak

89
Q

What is lamellar bone?

A

Slowly made bone with an organised layered (lamella) structure. It is mechanically strong

90
Q

What minerals are within bone?

A

Hydroxyapetite, a crystalline form of calcium phosphate

91
Q 
What is used to inhibit osteoclasts from bone resorption? 
A) RANK
B) RANKL
C) OPG
D) GLUT-2
E) Calcitonin
A

OPG

Osteoblasts secrete RANKL which binds to RANK on osteoclast precursors. This stimulates the osteoclast precursors to differentiate into osteoclasts, causing resorption.
OPG competitively inhibits RANK/RANKL by binding to RANK thus blocking the interaction, and inhibiting bone resorption.

92
Q 
What is used to inhibit osteoclasts from bone resorption? 
A) RANK
B) RANKL
C) OPG
D) GLUT-2
E) Calcitonin
A

OPG

OPG competitively inhibits RANK/RANKL by binding to RANK thus blocking the interaction, and inhibiting bone resorption.

93
Q

What do ligaments connect?

A

Bone to bone

94
Q 
What is a disease in which there is excessive and unorganised deposition and resorption of the bone?
A) Osteoporosis
b) Osteomalacia 
C) Osteopenia
D) Osteogenesis imperfecta
E) Paget’s disease
A

E

95
Q 
In what disease is there brittle bones due to inefficient collagen?
A) Osteoporosis
b) Osteomalacia 
C) Osteopenia
D) Osteogenesis imperfecta
E) Paget’s disease
A

D

96
Q 
In what disease is there Poorly mineralised matrix due to vitamin D or calcium deficiency?
A) Osteoporosis
b) Osteomalacia 
C) Osteopenia
D) Osteogenesis imperfecta
E) Paget’s disease
A

B

97
Q

What is a normal blood test result for osteomalacia (Ca, phosphate, alk phos and PTH)?

A

decreased calcium, decreased phosphate, increased alk phos, raised PTH

98
Q

What is a normal blood test result for paget’s disease (Ca, phosphate, alk phos and PTH)?

A

normal calcium, normal phosphate, raised alk phos, normal PTH

99
Q

What is a normal blood test result for Osteoporrosis (Ca, phosphate, alk phos and PTH)?

A

Normal calcium, normal phosphate, normal alk phos, normal PTH

100
Q

What is looked at in the FRAX score?

A

Glucorticoids
Smoking status
Rheumatoid arthritis
Alcohol

101
Q

What is looked at in the FRAX score?

A 
Glucorticoids
Smoking status
Rheumatoid arthritis
Alcohol 
BMI
Previous fracture
Age
102
Q

Where is measured in a DEXA scan?

A

Lumbar spine

Proximal femur

103
Q

What is a fracture where the bone is broken into more than 2 pieces?

A

Comminuted

104
Q

What is the gold standard diagnosis for osteoporosis?

A

DEXA scan showing -2.5 or less

105
Q

Briefly explain the RANK/RANKL system

A

Osteoblasts secrete RANKL which binds to RANK on osteoclast precursors. This stimulates the osteoclast precursors to differentiate into osteoclasts, causing resorption.
OPG competitively inhibits RANK/RANKL

106
Q

Give some examples of inflammatory artritis

A
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Reactive arthritis
  • Crystal arthritis
107
Q

What are the clinical features of RA?

A
  • Symmetrical small joints in hands and feet
  • Joints warm and tender
  • Morning stiffness
  • No spinal involvement
108
Q

What are gout crystals made of?

A

Monosodium urate

109
Q

What are psudogout crystals made of?

A

Calcium pyrophosphate

110
Q

How is rheumatoid arthritis treated?

A

DMARDS= Sulfasalzazine and methotrexate

111
Q

What are the radiological features of osteoarthritis?

A
  • Joint space narrowing
  • Osteophyte formation
  • Subchondral sclerosis
  • Subchondral cysts
  • Abnormalities of bone contour
112
Q

What is the medical term given to a proximal interphalangeal joint swelling in a patient with Osteoarthritis?

A

Bouchard’s Nodes

113
Q

What are the common rashes in lupus?

A
  • Butterfly rash
  • Discoid lupus rash
  • Photosensitive rash
114
Q

What would be a blood test result of SLE?

A
  • Leucopenia, lyphopenia, thrombocytopenia
  • Anaema
  • Very raised ESR, normal or slightly raised CRP
  • Creatinine and urea raised if renal disease is advanced
  • Low C4 and C3 complement
115
Q

What autoantibodies are associated with SLE?

A
  • ANA (95% +ve= screening test)
  • Anti- dsDNA (60%+ve= SLE specific)
  • RhF (40% +ve)
116
Q

What deformities occur with rheumatoid arthritis?

A
  • Ulnar deviation of fingers
  • Swan neck
  • Boutonniere
117
Q

What systems can be involved in rhaumatoid arthritis?

A
  • Lungs
  • Heart
  • Eyes
  • Neurological
  • Kidneys
  • Skin
118
Q

What is anti-CCP associated with?

A

Rheumatoid Arthritis

119
Q

What is high rheumatoid factor associated with?

A

Rheumatoid arthritis

SLE, Sarcoidosis

120
Q

What is positive ANA associated with?

A 
SLE
Rheumatoid arthritis
Primary Sjorgrens syndrome
Systemic sclerosis
Dermatomyositis
121
Q

What is Anti-dsDNA associated with?

A

SLE

122
Q

What is the most common bacteria that infects natural joints?

A

Staph aureus

123
Q

What is the most common bacteria that infects prosthetic joints?

A

Coag -ve staph

124
Q

Why do patients with septic arthritis need to stop any methotrexate and anti tnf-alpha medication?

A

These are immunosuppressive

125
Q

A patient that is young man who has sex with other men. He presents to A&E with a very hot painful knee, 1st and 2nd right metatarsal and hip. His knee is swollen and red, and he has a high fever. He also has a pustular rash on the palms of his feet. What is it likely to be and how would it be diagnosed?

A

Septic arthritis with N. Gonorrhoea
Gonococcal infection often presents with the rash, and with multiple sites (in other SA will be monoarthritic and no rash)

Urgent joint aspiration will show purulent fluid. Send for culture. His CRP and WCC will be raised, and ESR may also be raised. Also do skin swab.

126
Q

What is the main role of osteocytes?

A

Maintain bone tissue

127
Q

What are osteogenic cells?

A

The cells that develop into osteoblasts

128
Q

What is the name for the central (shaft) part of the bone?

A

Diaphysis

129
Q

What are some red flag symptoms for bone malignancy?

A
  • Rest pain
  • Night pain
  • Lump present
  • Loss of function
  • Neurological symptoms
  • Fever, malaise, weight loss, night sweat
130
Q

What are some types of malignant primary bone tumour?

A
  • Osteosarcoma
  • Ewing’ sarcoma
  • Chondrosarcoma
131
Q

What is Browns tumour?

A

Not a true tumour- appears in

Hyperarathyroidism

132
Q

What is bence jones protein associated with?

A

Multiple myeloma

133
Q

What is the Enneking staging system used for?

A

Malignant bone tumour

134
Q

Where do metastatic bone tumours usually come from?

A
  • Lungs (Bronchus)
  • Breast
  • Prostate
  • Thyroid
  • Kidney
135
Q

List some benign bone tumours

A
  • Osteoblastoma
  • Osteochondroma
  • Enchrondromas
136
Q

What age group is most commonly affected by primary bone tumours?

A

Children and young adults

137
Q

What is the most common malignant primary bone tumour?

A

Osteosarcoma

138
Q

What would be a typical x ray of osteoarthritis?

A

LOSS

  • Loss of joint space
  • Osteophytes
  • Subarticular sclerosis
  • Subchondral cysts
139
Q

What would be a typical x ray of RA?

A
  • Loss of joint space
  • Erosion
  • Soft tissue swelling
  • Soft bones
140
Q

What would be a typical x ray of osteosarcoma?

A
  • Bone destruction and formation
  • Soft tissue calcification
  • Sunburst appearance
141
Q

What would be a typical x ray of pseudogout?

A

Linear calcification parallel to articular surface

142
Q

What would be a typical x ray of ankylosing spondylitis?

A
  • Can be normal
  • Erosion and sclerosis of the margins of sacroiliac joints
  • Progressive calcification
  • Bamboo spine
143
Q

What would be a typical x ray of psoriatic arthritis?

A
  • Central erosions

- “Pencil in a cup”” deformity in the interphalangeal joints

144
Q

What are the key principles in orthopaedics?

A
  • Improve pain
  • Reduce disability
  • Improve function
145
Q

What are the 4 Rs of fracture treatement?

A
  • Resuscitate (ABCs)
  • Reduce= Realign fracture if it is misaligned
  • Retain position
  • Rehabilitation
146
Q

List some ways of holding a fracture in position

A 
Cast
Sling
Metal work= plates and screws
Bed Rest
Halo
Intramedullary rod 
Thomas Splint
147
Q

What are the ABCS of X rays?

A
  • Alignment= dislocation?
  • Bone= Fracture
  • Cartilage= Widened joints
  • Soft tissue- swelling, effusions
148
Q

What are the ways of describing a fracture?

A
  • What bone is involved?
  • Intra/extra articular involvement
  • What position on the bone
  • Pattern= Transverse, oblique, spiral etc
  • Condition= Comminuted, segmental, impacted etc
  • Displacement
149
Q

What are the stages of the bone remodelling cycle?

A
  1. Resting
  2. Resorption
  3. Formation
  4. Mineralisation
150
Q

What are the stages of callus formation?

A
  1. Bleeding
  2. Soft callus
  3. Bony callus
  4. Remodelling
151
Q

What is the steps of purines into urate crystals?

A

Purines- Hypoxanthine- Xanthine- Uric acid- (Monosodium urate)

Catalyzed by xanthine oxidase

152
Q

Your certain that a patient is having an acute attack of gout, but on blood tests, their serum uric acid is below average. Why is this?

A

During an acute attack all the uric acid has left the blood to accumulate within a joint, so the blood uric acid may be raised, normal or even low

153
Q

Which of the following clinical features is typical of osteoarthritis
A) 60 mins of early morning stiffness
B) Painful, swelling across metacarpophalangeal joints and proximal interphalangeal joints
C) Pain in 1st carpo-metacarpal joints
D) Mobile, subcut nodules at points of pressure
E) Alternating buttock pain

A

Correct answer= C

154
Q 
Which of the following is an extra-articular manifestation of rheumatoid arthritis
A) Sub cut nodules
B) Episcleritis
C) Peripheral sensory neuropathy
D) Pericardial effusion
E) All of the above
A

Correct answer= E

155
Q 
Which of the following is a classical feature of RA on X-ray
A) Periarticular sclerosis
B) Sub-Chondral cysts
C) Osteophytes
D) Peri-articular erosions
E) New bone formation
A

Correct answer=D

156
Q

Which of the following could reduce the risk of gout
A) A diet with a high red meat content
B) A diet rich in dairy
C) Drinking >5 cans of non-diet fizzy drinks per day
D) A diet rich in sugary foodstuff
E) Switching from drinking beer to lager

A

Correct answer= B

157
Q 
Which of the following is not an autoimmune connective tissue disease
A) SLE
B) Ehler Danlos syndrome
C) Primary Sjorgren's syndrome
D) Systemic sclerosis
E) Dermatomyositis
A

Correct answer= B

158
Q 
A 23 year old woman presents with mouth ulcers, fever, painful white fingers and pleuritic chest pain. She is ANA +ve, high ESR and low WCC. Which of the following would not be expected to be associated
A) Deforming arthritis
B) Photosensitive rash
C) Seizures
D) Pulmonary embolism
E) Thrombocytosis
A

Correct answer= E

159
Q 
Which of the following is used in the treatment of SLE
A) Anti TNF
B) Anti-malarials
C) Ustekinuab (IL12/13 blocker)
D) Sulfasalzine
E) Allopurinol
A

Correct answer= B

Phase 2a (31 decks)

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