Rheumatology

Question 1

1. 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

Answer 1

A

Question 2

2. 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

Answer 2

C

Question 3

3. 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

Answer 3

A

Question 4

4. 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

Answer 4

B

Question 5

5. 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

Answer 5

E

Question 6

6. 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

Answer 6

B

Question 7

7. 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

Answer 7

A

Question 8

8. 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

Answer 8

C

Question 9

9. 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

Answer 9

C

Question 10

10. 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

Answer 10

E

Question 11

11. 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

Answer 11

B

Question 12

12. 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

Answer 12

A

Question 13

13. 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

Answer 13

A

Question 14

14. 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

Answer 14

C

Question 15

15. 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

Answer 15

E

Question 16

16. 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

Answer 16

C

Question 17

17. 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

Answer 17

E

Question 18

18. 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

Answer 18

A

Question 19

19. 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

Answer 19

B

Question 20

20. 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

Answer 20

A

Question 21

21. 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

Answer 21

C

Question 22

22. 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

Answer 22

D

Question 23

23. 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

Answer 23

D

Question 24

24. 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

Answer 24

B

Question 25

25. 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

Answer 25

A

Question 26

26. 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

Answer 26

D

Question 27

27. 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

Answer 27

C

Question 28

28. 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)

Answer 28

B

Question 29

29. 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

Answer 29

A

Question 30

30. 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

Answer 30

A

Question 31

31. 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

Answer 31

B

Question 32

32. 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

Answer 32

E

Question 33

33. 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

Answer 33

A

Question 34

34. 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

Answer 34

E

Question 35

35. 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

Answer 35

A