Week 2 - MSK Rheumatology Formative

Question 1

Which of the following is NOT a recognised feature of anti-phospholipid syndrome

Select one:

a. livedo reticularis
b. thrombocytosis
c. migraine
d. recurrent pregnancy loss
e. venous thrombosis

Answer 1

Thrombocytosis
APS - Coag defects, Livedo reticularis, Obstertrics (recurrent miscarriages typically 2nd/3rd trimester), Thrombocytopenia

Thrombocytopenia (as well as neutropenia and lymphopenia) are features of most connective tissue diseases (with the exception of rheumatoid arthritis)
. In rheumatoid arthritis thrombocytosis and a moderate neutrophilia can occur as markers of inflammation).

Question 2

Which of these autoantibodies is most specific for SLE?

Select one:

a. Anti-DNA binding antibody
b. Anti-Scl-70
c. Anti-Ro antibody
d. Anti-nuclear antibody
e. Anti-smooth muscle antibody

Answer 2

Anti-DNA binding antibody

Question 3

In SLE when disease is active complement levels rise

Select one:

True

False

Answer 3

False

Complement is consumed in the response to the formation of immune antigen/antibody complexes. Low levels are a sign of SLE being active

Question 4

In SLE, patients will likely be on oral steroids long term

Select one:

True

False

Answer 4

False

Steroids should only be used when required and for short periods to suppress disease activity whilst other agents are introduced. Long term use of steroids is associated with an increased risk of cardiovascular disease, T2 diabetes and osteoporosis amongst others.

Question 5

Which would be the most appropriate first test to do in a patient with suspected SLE?

Select one:

a. MRI brain
b. Urinalysis
c. Renal biopsy
d. Anti-mitochondrial antibody
e. Nerve conduction studies

Answer 5

Urinalysis

It is essential to screen for renal disease in SLE and urinalysis is a simple bedside test. If there is evidence of blood or protein in the urine then further investigations such as renal biopsy may be indicated.

Anti-mitochondrial antibody is associated with Primary Biliary Cirrhosis.
MRI brain and nerve conduction studies may be performed in a patient with SLE displaying neurological symptoms.

Question 6

A patient is diagnosed in the respiratory clinic as having pulmonary fibrosis. The chest physician notes that she has Raynaud’s phenomenon, dry eyes, facial telangiectasia and puffy hands. What is the most likely diagnosis?
Select one:

• a. Diffuse systemic sclerosis
• b. Primary Sjogren’s syndrome
• c. Systemic lupus erythematosus
• d. Limited systemic sclerosis
• e. Rheumatoid arthritis

Answer 6

Diffuse systemic sclerosis

This complex is most suggestive of diffuse systemic sclerosis. Pulmonary fibrosis is less likely in limited systemic sclerosis and primary Sjogren’s syndrome.

Question 7

Which of the following is NOT a recognised feature of limited systemic sclerosis?

Select one:

a. Raynaud’s phenomenon
b. Butterfly rash
c. Anti-centromere antibody
d. Calcinosis
e. Pulmonary hypertension

Answer 7

Butterfly rash

• Butterfly rash is classically a feature of systemic lupus erythematosus.
• Although not included in the previous acronym ‘CREST’ pulmonary hypertension is the most serious complication of limited systemic hypertension.
• Anti-centromere antibodies, Raynaud’s phenomenon and calcinosis are all characteristics of limited systemic sclerosis.

Question 8

Which of the following tests may help in the diagnosis of Sjogren’s syndrome?

Select one:

a. Schilling test
b. Schubert’s test
c. Schirmer test
d. Schrodinger’s test
e. Schober test

Answer 8

Schirmer test

Schirmer test involves placing a strip of filter paper under the lower eye lid to assess tear production.

Schober test is a measure of spinal flexion in ankylosing spondylitis. Schilling test is a test to measure Vit B12 absorption.
Schrodinger described a thought experiment in quantum physics.
Schubert was a composer.

Question 9

A 69 year old woman complains of pain at the base of her thumbs. On examination she has bony swelling of her thumb carpometacarpal (CMC) joints and finger DIP joints. Blood tests show a positive ANA and a positive anti-RNP antibody. Hand radiographs show loss of joint space, subchondral sclerosis, subchodral cysts and osteophytes at thumb CMC and finger DIP joints. What is the most likely cause of her joint pain.

• a. Mixed connective tissue disease
• b. Limited systemic sclerosis
• c. Systemic lupus erythematosus
• d. Primary Sjogren’s syndrome
• e. Osteoarthritis

Answer 9

Osteoarthritis
The clinical and radiological features are classic for osteoarthritis.

False positive immunological tests are common and immunology should only be checked if there is reason to suspect a connective tissue disease. If the immunology was relevant then the immunology would be most consistent with SLE or MCTD.

Question 10

Which of the following best describes the therapeutic approach to connective tissue diseases? Select one:

• a. Physiotherapy and if necessary surgery to stabilise the joints
• b. Discharge to general practitioner with a request for rereferral if major organ involvement occurs
• c. Immunosuppression with an aim to normalise antibody levels
• d. Treat symptomatically and monitor closely for major complications
• e. Start high dose steroids on diagnosis

Answer 10

Treat symptomatically and monitor closely for major complications
Treatment should be tailored to the individual patient (although generally in SLE hydroxychloroquine would be started routinely).

However, close monitoring to identify complications early is necessary.

Question 11

Approximately what percentage of patients with rheumatoid arthritis are NEGATIVE for serological rheumatoid factor?

Select one:

• 50%
• 15%
• 1.5%
• 85%
• 25%

Answer 11

Rheumatoid arthritis is the most prevalent seropositive inflammatory arthropathy although around 15% of patients with the disease are negative for serological Rheumatoid factor.

Question 12

You’re a GP and a 65 year old man attends for review of a painful right first MTP joint. On examination, the joint is red, warm and swollen and there is a white, chalky material discharging from the joint.
What is the most likely radiological picture associated with this presentation?

Select one:

• A hyperthrophic arthritis
• An erosive arthritis

Answer 12

The most likely diagnosis for this patient based upon the clinical information available is gout.
This crystal arthopathy is associated with erosive joint changes.

Question 13

Which of the following tests is not useful in a patient who presents with symmetrical, small joint swelling. On examination there is a nodule on his elbow but there are no other skin changes. Systemic examination reveals features of pulmonary fibrosis. Select one:

• a. Hand and feet X rays
• b. Anti-CCP antibody
• c. Chest X-ray
• d. Anti-ds DNA antibody
• e. PV and /or CRP

Answer 13

Anti dsDNA antibodies

PV and CRP are not specific for any condition but may suggest inflammation.
A chest x-ray may reveal pulmonary fibrosis.
Anti CCP antibodies are specific for RA which is what seems likely from the clinical picture.
X-rays may give prognostic information in rheumatoid arthritis.
Anti dsDNA antibodies are useful for SLE diagnosis

Question 14

Which part of the joint is the primary site of inflammation in rheumatoid arthritis?

Select one:

a. Bone
b. Capsule of the joint
c. Tendon attachment to the bone
d. Cartilage
e. Synovium

Answer 14

Synovium
Synovium is the primary site in RA.

Cartilage changes are primarily seen in osteoarthritis.
Entheses regions (tendon or ligament attachment to bone) are effected mainly in psoriatic arthritis.
There is no auto-immune systemic disease that affects bone or capsule.

Question 15

Which of the following are included in the Modified New York criteria for diagnosis of Ankylosing spondylitis?

Select one or more:

• a. Back pain worse at rest relieved by movement
• b. Back pain for >3 months
• c. X ray changes of sacroiliitis
• d. Back pain worse on movement relieved by rest
• e. Age >45 years

Answer 15

Back pain worse at rest relieved by movement
Back pain > 3 months,
X ray changes of sacroiliitis

Patients with ankylosing spondylitis tend to be younger at onset, typically under 45 years.

• Inflammatory back pain is typically worse at rest, and better on movement, which is the opposite of mechanical back pain

Question 16

A 55 year old patient who was diagnosed with rheumatoid arthritis 2 years ago takes methotrexate, sulphasalazine and hydroxycholoroquine. She is struggling with her arthritis and her rheumatologist said that her arthritis is very active. Which following treatment is most appropriate. Select one:

• a. Allopurinol
• b. Colchicine
• c. Febuxostat
• d. Anti TNF therapy
• e. Anti-inflammatory agents

Answer 16

Anti-TNF therapy

When rheumatoid arthritis patients have severe (as assessed by DAS score) disease despite triple therapy next option is biologic therapy.

Allopurinol, Feuxostat and Colchicine are gout treatments.
It is likely she is already on anti-inflammatory agents, even if she is not, commencing them will give only partial if any, symptomatic improvement.

Question 17

A patient has had successful treatment of acute gout but has had 4 flares this year. The most appropriate treatment to prevent further attacks would be:

Select one:

• a. Sulfasalazine
• b. Prednisolone
• c. Naproxen
• d. Allopurinol
• e. Colchicine

Answer 17

Allopurinol
The most common choices include Allopurinol or Febuxostat.

• The indications for commencing urate lowering therapy include more than a single flare in 12 months, no adjustable lifestyle or health factors or deposition of tophus.
• When these are commenced, the first 6 months of treatment should be given with NSAID or colchicine cover to prevent a flare of gout which can be precipitated by commencing urate lowering therapy.

Question 18

Which extraarticular manifestations are common in the spondyloarthritides?

Select one or more:

• a. Uveitis
• b. Aortic valve incompetence
• c. Dactylitis
• d. Achilles tendonitis
• e. Gottron’s papules

Answer 18

Uveitis
Aortic valve incompetence,

Dactylitis

Achilles tendonitis,

Gottron’s papules are seen over the dorsum of the hands in dermatomyositis

Question 19

Which of the following conditions are included in the spondyloarthopathies?

Select one or more:

a. Psoriatic arthritis
b. Gout
c. Reactive arthritis
d. Rheumatoid arthritis
e. Ankylosing spondylitis

Answer 19

Psoriatic arthritis, Reactive arthritis & Ankylosing spondylitis,

Rheumatoid arthritis more typically affects small joints eg PIP and MCP joints of hands and also MTP joints in feet, and tends to spare the axial skeleton

Gout is a crystal arthropathy

Question 20

Which of the following statements about changes on X-ray is correct? Select one:

• a. Subchondral sclerosis is seen in psoriatic arthritis
• b. Peri-articular osteopenia and erosions are seen in rheumatoid arthritis
• c. Punched out lesions are seen often in osteoarthritis
• d. Chondro-calcification is a typical feature in gout
• e. Pencil-in cup change is characteristic of pseudogout

Answer 20

Peri-articular osteopenia and erosions are seen in rheumatoid arthritis

• Subchondral sclerosis is seen in osteoarthritis,
• punched out lesions are typically seen with gout,
• chondrocalcification in pseudo-gout and
• pencil-in cup change seen in psoriatic arthritis.

Question 21

Which of the following is not a common finding on the examination of an osteoarthritic joint?

Select one:

a. Synovitis
b. Crepitus
c. Tenderness
d. Joint effusion
e. Bony swelling

Answer 21

Synovitis

Joints affected by osteoarthritis may have effusion and demonstrate crepitus on movement. Bony swelling and tenderness are also common.
Synovitis is usually associated with inflammatory arthritis and the joints affected can help to predict which disease is underlying the changes.

Question 22

A patient describes pain around their shoulders and thighs with marked morning stiffness. This improves as the day goes on. Their CRP is 120. The most likely diagnosis is:
Select one:

• a. Polymyalgia rheumatica
• b. Sjogrens syndrome
• c. Fibromyalgia
• d. Osteoarthritis
• e. Polymyositis

Answer 22

Polymyalgia rheumatica.
- This is characterised by pain and stiffness of the proximal limb muscles, which improves with exercise. It is associated with significantly raised inflammatory markers.
In polymyositis the main symptom is usually muscle weakness rather than pain. Weakness is more apparent with exercise.

Fibromyalgia causes widespread pain, with marked muscle tenderness along with fatigue, disturbed sleep pattern and a feeling of “brain fog”.
OA causes joint pain which is worse with exercise. Sjogrens syndrome is typified by sicca symptoms (dry eyes and dry mouth), along with joint pain.

Question 23

In a patient with fibromyalgia what blood abnormalities would you expect to see?

Select one:

a. Raised plasma viscosity
b. Raised CRP
c. No abnormality
d. Anaemia
e. Positive anti-nuclear antibody

Answer 23

No abnormality

You would not expect to see any abnormalities. This is a diagnosis based on clinical features alone.

Question 24

Please match the following sites of pain and diagnosis

• Restricted rotation of the shoulder
• Tenderness in the heel on walking
• Tenderness over the greater trochanter
• Tenderness over the medial epicondyle
• Tenderness over the lateral epicondyle of the elbow
• Trochanteric bursitis
• Golfer’s elbow
• Adhesive capsulitis
• Plantar fascitiis
• Tennis elbow

Answer 24

Restricted rotation of the shoulder
- adhesive capsulitis Tenderness in the heel on walking
- plantar fasciitis Tenderness over the greater trochanter
- trochanteric bursitis Tenderness over the medial epicondyle
- golfer’s elbow Tenderness over the lateral epicondyle
- tennis elbow

Question 25

A patient has noticed gradually increasing tiredness of muscles on activity, particularly climbing stairs and drying her hair. She has also developed a purplish rash around her eyes and over her chest. What is the most likely diagnosis?
Select one:

• a. Systemic sclerosis
• b. Fibromyalgia syndrome
• c. Polymyalgia rheumatica
• d. Dermatomyositis
• e.Sjogrens syndrome

Answer 25

Dermatomyositis

This is a heliotrope rash. The muscle features in the condition tend to be of fatigue and weakness rather than pain. CK is significantly raised.

Question 26

Polymyalgia rheumatica principally affects patients over the age of 50 years

Select one:

True

False

Answer 26

True - It is extremely unusual to see this condition in patients under the age of 50.

Question 27

Polymyalgia Rheumatica is a condition mainly seen in middle aged and elderly women (although it does affect men), resulting in aching pain around the shoulder and pelvic girdles with stiffness and weakness. Which blood test would be most useful in the diagnosis of polymyalgia rheumatica? Select one:

• Liver function tests
• Erythrocyte sedimentation rate
• Erythrocyte saturation rate
• Thyroid function tests

Answer 27

There is no specific marker or test for PMR but the inflammatory marker ESR is usually highly elevated.

The Bird Criteria can be used to help make the diagnosis of this condition, which can be challenging. The presence of 3 or more of the following criteria is said to be diagnostic:

1. Age over 65 2. ESR over 40 mm/hr
2. Bilateral upper arm tenderness
3. Morning stiffness of more than 1 hour
4. Onset of illness less than 2 weeks
5. Depression and/or weight loss

Question 28

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Answer 28

Eosinophilic Granulomatosis with polyangiitis.(eGPA)

• Triad of late onset asthma, rhinitis and eosinophilia should always raise the suspicion of eosniophilic granulomatosis with polyangiitis(Churg-Strauss syndrome).
• Neurologica and cardiac involvement are quite common features of this condition.
• The raised anti and p ANCA further corroborate this diagnosis.

Question 29

Which of the following are true?
Select one or more:

a. Steroids can be used to reduce inflammation in acute gout.
b. Colchicine can only be used for up to 3 days in gout.
c. Allopurinol reduces urate in gout by inhibiting xanthine oxidase
d. Allopurinol should be titrated until target serum urate is achieved (below 360 micromol/L).
e. Allopurinol should be stopped during acute gout flares.

Answer 29

In acute gout steroids, NSAIDs or colchicine can be given to settle the acute attack.
Allopurinol reduces urate in gout by inhibiting xanthine oxidase
Serum urate should be measured regularly and dose of Allopurinol increased gradually until target serum urate (

Thereafter if Allopurinol is started as prophylaxis, it should be started at a low dose ( typically 100mg) while covering with low dose colchicine, NSAID or steroids for approximately 6 months.

Allopurinol should NOT be stopped during acute flares.

Question 30

Fibromyalgia syndrome can be treated successfully with a reducing course of prednisolone

Select one:

True

False

Answer 30

Treatment of fibromyalgia is complex and combines medical therapies such as atypical analgesics (amitriptyline, gabapentin) with graded exercise and psychological approaches such as cognitive behavioural therapy. There is no indication for steroids