Rheumatology MCQs Flashcards
Gout vs septic arthritis presentation
Septic arthritis - very tender, hot, red, low-grade fever. Could be any joint.
Gout - usually first MTP.
Joint aspirate will confirm diagnosis
Should you aspirate hot red joint or start antibiotics first?
Aspirate the joint.
Outline how we bridge methotrexate
About 9 weeks of cross-tapering, high dose pred low dose methotrexate to begin.
What features are common to spondyloarthropathies as a group?
Acute anterior uveitis and skin psoriasis
RF is positive in what % of people?
5-20%
Septic Arthritis Presentation in an IVDU:
* Joint aspiration indicated
* Joint lavage was recommended
* Getting fresh needles from a needle exchange
* Give fluclox as definitely staph A
- Joint aspiration indicated
- Joint lavage was recommended
- Getting fresh needles from a needle exchange
T/F * Allopurinol should not be given in renal impairment
False, lowered dose
normal urate acid levels would exclude gout
No, often low in a flare
Degeneration back pain T/F
* Morning stiffness less than 1h
* Pain with activity
* Better with rest
* Pain with coughing
Morning stiffness less than 1h
Pain with cough
Arthritis diagnosis
* Eg clinical > lab findings when diagnosing
* Positive RF confirms RA
* Inflammatory joint disease with anti-CPP is highly suggestive of RA
T
F
T
Connective tissue diseases such as systemic sclerosis, sjorgens, polymyositosis.
* CREST assoc w anti centrosome
* What does the S in CREST stand for
* Systemic sclerosis and scl-70 with lung problems?
* Heliotropic rash and Sjogrens
* Polymyositis and dermatomyositis associated with malignancy
T
Calcinosis, Reynauds, Esophageal dysfunction, Sclerodactyly, Telangiocentesis
????
- GCA pred should be given before biopsy results
- Overlap between PMR and GCA is 25%
- Start at 40g Prednisone for PMR
- Only give bisphosphonates if prednisone >15g
T
F, 20% have GCA
F (15-20), GCA is 40-60
F
T/F* PMR facts
* Eg Only >50 year olds get pmr
* ESR/CRP always raised
* CK always raised
All false
- Ankylosing spondylitis (treatment)
- Eg anti TNF, physio and NSAIDs
- Surgery for syndesmosis
Both true
- Prednisone and MSK complications
Which is not a recognised side effect of prednisone: - Osteomalacia
- Osteoporosis
- Veretebral compression
- Septic arthritis
- AVN
- Proximal myopathy
Yes - septic, AVN, proximal myopathy, vertebral compression, osteoporosis
Think it doesnt cause osteomalacia
What is true about RA?
* Methotrexate should be lowered in renal impairment
* NSAIDs do not change the disease progression
* DMARDs should not be started until bony erosive disease is present
* MTX starts working in 7 days
T
T
F
F
- In regards to RA
* Sulphazaline and/or methotraxate are first line RA DMARDs
* Methotrexate tends to start working within 7 days
T
F
- For connective tissue disorders
* Anti-centromere ab is related to CREST*
* The S in CREST stands for synovitis
* In diffuse systemic sclerosis, anti-scl70 is associated with lung disease*
* Heliotrope rash and Gottron’s papules are associated with Sjogren’s syndrome
T
F (sclerodactyly)
T
F
- Well-recognised extra-articular features of RA include
o Episcleritis *
o Anterior uveitis *
o Glomerulonephritis*
o Vasculitis *
o Dactylitis*
All of them
Duno about dactylitis - more SpA
o CK is usually high/normal in PMR did not choose for high
o In suspected GCA, prednisone should be started while waiting for the results of the temporal artery biopsy*
o The starting dose of prednisone in PMR is 40-60mg once daily
o GCA occurs in about 25% of cases of PMR
F (it is not high)
T
F
F (20%)
Allopurinol should be delayed until the gout flare has receded
Allopurinol should be withheld during a gout flare
* Cochicine is the preferred acute management
* An intra-articular injection of steroid is the preffered management
* Allopurinol should not be used in renal failure
* Allopurinol prevents the excretion of in_____ the proximal convoluted tubule
T
F
F
T
F
F
- A patient is referred for the assessment of his arthritis. Which of the following are true?
Select one or more:
* The degree of joint pain correlates closely with X-ray and pathological changes
* A positive rheumatoid factor confirms the diagnosis of rheumatoid arthritis
* Clinical findings (history and examination) are more important diagnostically than laboratory tests
* Joint pain is almost always due to significant joint damage
* In inflammatory joint disease, anti-CCP antibodies strongly suggest rheumatoid arthritis
F
F
T
F
T
- Methotrexate
Select one or more
* Monitoring of methotrexate should include CBC and liver function tests
* Methotrexate should not be combined with sulfasalazine or leflunomide due to potentially serious drug interactions.
* Adverse effects of methotrexate can be reduced by supplementing with folic acid
* Can be given in the first and second trimester, but must be stopped before the start of the third trimester of pregnancy
* Methotrexate is normally fully effective within two weeks of commencement
T
F
T
F
F
- Concerning connective tissue diseases
Select one or more
* In diffuse systemic sclerosis, the presence of anti-Scl70 is associated with lung involvement
* CREST syndrome is associated with anti-centromere antibodies
* In the acronym CREST syndrome, the stands for synovitis
* Heliotrope rash and Gottron’s papules are associated with Sjogren’s syndrome
* Polymyositis and dermatomyositis are associated with malignancy
T
T
F
F
T
- A 60 year old man with renal impairment congestive heart failure and previous peptic ulcer presents acutely with a hot, swollen painful knee. Which of the following statements are true.
Select one or more:
* Cox Il selective NSAIDS would be the preferred treatment if gout is confirmed
* Allopurinol is contraindicated in patients with renal impairment
* Intra-articular corticosteroids would be appropriate if uric acid crystals are seen and Gram stain is negative
* A normal serum urate excludes the diagnosis of gout
* Joint aspiration for cell count crystals and microbiology is indicated
F
F
F (Synovial fluid analysis includes cell count, WBC differential,
Gram stain, culture and crystal examination)
F
T
- In a patient with a history of psoriasis and joint pain, the finding of which of these clinical features would increase the likelihood of a diagnosis of psoriatic arthritis?
Select one or more:
* Positive anti-CCP antibody
* Dactylitis
* Achilles enthesitis
* Raynaud’s phenomenon
* Sacrolitis
F
T
T
F (CREST)
F (Ank Spon)
- Concerning vasculitis
Select one or more:
* In polymyalgia rheumatica (PMR), CPK is usually normal
* Vasculitis can present with mononeuritis multiplex
* In GCA prednisone should be started before the result of the temporal artery biopsy is available
* Giant cell arteritis (GCA) overlaps with PMR in 25% of cases
* The recommended starting dose of prednisone in PMR is 40-60mg daily
T
T
T
F
F
- Which of the following statements is true regarding treatment of gout?
Select one or more:
* Colchicine is an effective treatment for acute gout
* Treatment with allopurinol should be delayed until the acute gout attack has resolved
* Low dose Aspirin prevents procimal tubular re-absorption of uric acid
* Allopurinol should be withheld during an acute attack of gout
* Allopurinol increases the urinary excretion of uric acid
T
T
F
F
F
- In polymyalgia rheumatica; which of the following statements is true?
Select one
* Prednisone 60 mg is the standard starting dose
* Muscle biopsy is indicated and shows changes constant with myositis
* The disease is almost never seen in patients under the age of 50 years.
* CRP/ESR is always elevated
* Osteoporosis prophylaxis is only indicated if prednisone dose > 15mg/day
F (15-20)
F
T
F
F
- Concerning Rheumatoid arthritis:
Select one or more:
* Rheumatoid arthritis is associated with HLA B27
* Rheumatoid Arthritis typically presents with swelling and pain in the joints of the hands and feet
* The most common form of eye involvement is anterior uveitis
* Juxta-articular osteoporosis is an early radiological manifestation of rheumatoid arthritis
* Rheumatoid factor is seen in 70-80% of cases of rheumatoid arthritis
F (SpA)
T
F (usually scleritis stuff)
T
T
- In primary osteoarthritis which of the following are true
Select one or more:
* The 1st MCP joint is frequently involved
* Metacarpophalangeal joints are frequently involved
* DIP joint involvement is frequently hereditary
* Women are more frequently affected than males
* Seldom presents before the age of 65
F
F
T
T
F
- Back pain due to degenerative disease is characteristically:
Select one or more:
* Not associated with prolonged morning stiffness
* Associated with syndesmophytes on X-ray
* Not relieved by rest
* Worse on coughing
* Worse with activity
?Mechanical
T
F
F (it is relieved by rest)
F
T
- Well recognised extra-articular features of rheumatoid arthritis include:
Select one or more:
* Vasculitis
* Anterior uveitis
* Episcleritis
* Sjogren’s syndrome
* Glomerulonephritis
T
F (Think SpA)
T
T
T
- Sudden attack of pain in the great toe is usually caused by (select one):
* Rheumatoid arthritis
* Gout
* Psoriatic arthritis
* Rheumatic fever
- Gout
- Which of the following cases presented do you think is most likely to be related to inflammatory back pain?
* 25 year-old female with chronic back pain which is eased with rest
* 34 year-old male with back pain for 5 years which is worst at night
* 60 year-old male with back pain for less than 3 months, which causes pain at night and sleep disturbances
* 29 year-old male with back pain for 3 months which is worsened by exercise
- 34 year-old male with back pain for 5 years which is worst at night
T/F - Hydrochlroquinoine cause bone marrow suppression (myelotoxicity)
T
T/F OA seldomly occurs before 65y/o
False
What is a swan-neck deformity?
- Extension of the DIP and flexion of the PIP
A 60 year old woman presents with widespread pain and fatigue, with low mood. Which of the following does not fit with a diagnosis of Fibromyalgia?
Question 1Answer
Tinnitus
Abdominal pain
5kg weight loss in the last 6 weeks
Headache
5kg weight loss in the last 6 weeks
A 44 year old woman has extreme fatigue and widespread aching for 10 months. All blood tests are normal. A diagnosis of Fibromyalgia is suspected. What would help most to conform the diagnosis?
Question 2Answer
Anxiety and depression score
ANA
Fibromyalgia diagnostic questionnaire
CRP
Fibromyalgia diagnostic questionnaire
A 58 year old woman has a diagnosis of Fibromyalgia. Which treatment has the best long term benefit?
Question 3Answer
Graded Exercise Therapy
Prednisone
Naproxen
Amitripytyline
Graded Exercise Therapy
Fibromyalgia is a central pain sensitization syndome and has a biopsychosocial construct. Which of the following conditions is also recognized as having a similar aetiology?
Question 4Answer
Endometriosis
Inflammatory Bowel disease
Chronic Tenison Headache
Ehrler’s Danlos Syndrome
Chronic tension headache
An 21 year old man has early morning waking, loss of appetite, widespread aching and diminished social contact. He feels exhausted and very low in mood. What question in the history is most important?
Question 5Answer
Do you have pain above and below the waist?
Are you exhausted the day after exertion?
Do you wake feeling unrefreshed?
Have you ever thought of harming yourself?
Have you ever thought of harming yourself?
