Specialty Certificate in Rheumatology Sample Questions Question 1 A 40-year-old 40-year-old man had severe severe pain in in one leg affecting both the buttock region region and the lateral lateral border and sole of the foot, in association with paraesthesiae of the sole on walking. What is the correct nomenclature for the nerve root from which these symptoms have arisen? A B C D E
L4 L4/L5 L5 L5/S1 S1
Updated 06/02/2012
Question 2 A 43-year-old 43-year-old woman, woman, with with recent-onset recent-onset rheumatoid rheumatoid factor-positiv factor-positive e inflammatory inflammatory arthritis, arthritis, was was having 10-weekly intramuscular injections of sodium aurothiomalate. At week 10 she reported being “90% better”. On examination, her hand joints were much less puffy than before treatment and knee effusions had resolved. She had developed a shiny, slightly scaly erythematous plaque over the abdomen and two smaller patches on her limbs. Her serum C-reactive protein had fallen from 56 to 4 mg/L (<10). What is the most appropriate next step in management? A B C D E
continue sodium aurothiomal aurothiomalate ate and seek seek a dermatologi dermatological cal opinion opinion continue sodium aurothiomalate and treat with topical hydrocortisone reduce sodium aurothiomalate to 25 mg per week stop sodium aurothiomalate stop sodium aurothiomalate until the rash has settled and then reintroduce
Updated 06/02/2012
Question 3 A 46-year-old 46-year-old man presented presented with a 2-week history history of a worsening worsening ulcerating ulcerating rash over his lower limbs, which had coalesced in places. He also had right knee and left wrist synovitis. He had returned from a holiday in Portugal 4 weeks previously. He had ulcerative colitis that had been diagnosed the previous year, and was taking 5 mg prednisolone daily. What is the most likely diagnosis? A B C D E
discoid lupus lupus erythema nodosum granuloma annulare Lyme disease pyoderma gangrenosum
Updated 06/02/2012
Question 4 A 32-year-old 32-year-old woman, woman, with with severe psoriatic arthritis well-controlle well-controlled d with sulfasalazin sulfasalazine e and paracetamol, presented to clinic. She had just married and wished to conceive without risking a flare of her arthritis. What is the most appropriate treatment strategy? A B C D E
add oral prednisolone prednisolone continue sulfasalazine stop sulfasalazine stop sulfasalazine and change to oral prednisolone stop sulfasalazine and start methotrexate and folic acid
Updated 06/02/2012
Question 5 A 50-year-old 50-year-old woman woman was referred by an orthopaedic orthopaedic surgeon surgeon with with a 2-month history of severe pain in her right knee, calf and foot. This had developed 1 week after an arthroscopic meniscectomy. On examination, she was tearful and her right leg was swollen, dusky, cool and tender below the knee. She found light touch extremely painful and refused to have her knee fully examined. Investigations: serum C-reactive protein
3 mg/L (<10)
Doppler ultrasound scan
normal
What is the most likely diagnosis? A B C D E
complex regional regional pain pain syndrome syndrome deep venous thrombosis popliteal artery dissection septic arthritis synovial leak
Updated 06/02/2012
Question 6 A 24-year-old 24-year-old woman presented presented with acute acute pain pain and swelling swelling of her her right right knee. She had been been complaining of lower abdominal pain for the previous 3 days. On examination, her temperature was 37.9°C. The right knee was warm and tender with a tense effusion. Several pustules were seen on her right knee. Investigations: 16.4
serum C-reactive protein
120 mg/L (<10)
synovial fluid analysis: appearance of fluid white cell count neutrophil count Gram stain crystals culture
turbid 80 000/mL (<200) >90% negative absent negative
What is the most likely diagnosis? A B C D E
109/L (4.0 –11.0) –11.0)
white cell count
enteropathic enteropathic arthritis arthritis gonococcal arthritis reactive arthritis rheumatoid arthritis tuberculous arthritis
Updated 06/02/2012
Question 7 A 20-year-old 20-year-old man of Turkish Turkish origin presented with a recurrent recurrent monoarthrop monoarthropathy. athy. He also complained of attacks of intermittent fever, abdominal pain and pleuritic chest pain, and had noted an erythematous rash during these attacks. What is the most likely diagnosis? A B C D E
adult-onset adult-onset Still’s disease Behçet’s Behçet’s disease familial Mediterranean fever Henoch –Schönlein –Schönlein purpura systemic lupus erythematosus
Updated 06/02/2012
Question 8 A 48-year-old 48-year-old man presented presented with a 2-month history history of arthralgia arthralgia and and a recurrent recurrent itchy itchy rash over his trunk and limbs. On examination, he had urticarial lesions all over his trunk. He had started antihistamine therapy, but with no benefit. No other abnormalities were found on examination. A skin biopsy biopsy showed showed a leucocytocla leucocytoclastic stic vasculitis vasculitis and a diagnosis diagnosis of urticarial urticarial vasculitis vasculitis was was made. What is the most appropriate next treatment? A B C D E
azathioprine azathioprine dapsone hydroxychloroquine naproxen prednisolone
Updated 06/02/2012
Question 9 A 61-year-old 61-year-old woman woman with with long-standing long-standing rheumatoid rheumatoid arthritis arthritis presented presented with with persistent persistent leg ulcers. She was taking methotrexate. Infliximab had been stopped 2 months previously following the appearance of the leg ulcers. On examination, there were bilateral shallow ulcers on the medial malleoli. Investigations: haemoglobin MCV MCHC white cell count neutrophil count platelet count erythrocyte sedimentation rate
98 g/L (115 –165) –165) 89 fL (80 –96) –96) 35 g/dL (32 –35) –35) 9 4.8 10 /L (4.0 –11.0) –11.0) 9 1.0 10 /L (1.5 –7.0) –7.0) 9 180 10 /L (150 –400) –400) 60 mm/1st h (<30)
serum immunoglobulin G serum immunoglobulin A serum immunoglobulin M rheumatoid factor
23.0 g/L (6.0 –13.0) –13.0) 1.2 g/L (0.8 –3.0) –3.0) 2.3 g/L (0.4 –2.5) –2.5) 48 kIU/L (<30)
What is the most likely diagnosis? A B C D E
cryoglobulinaemia cryoglobulinaemia delayed drug reaction to infliximab Felty’s syndrome leucocytoclastic vasculitis rheumatoid vasculitis
Updated 06/02/2012
Question 10 A 42-year-old 42-year-old woman woman with with rheumatoid arthritis presented presented with a 3-day 3-day history of malaise and and nausea. Because of progressive disease, methotrexate had been changed to leflunomide 20 mg daily 2 weeks previously. Her other medication was dihydrocodeine and ibuprofen. On examination, she had right hypochondrial tenderness. Investigations: serum total bilirubin serum alanine aminotransferase serum alkaline phosphatase serum gamma glutamyl transferase
27 µmol/L (1 –22) –22) 3276 U/L (5 – (5 –35) 35) 367 U/L (45 – (45 –105) 105) 970 U/L (4 – (4 –35) 35)
Leflunomide was discontinued. What is the most appropriate next step in management? A B C D E
acetylcysteine acetylcysteine colestyramine high-dose prednisolone intravenous ganciclovir no additional treatment
Updated 06/02/2012
Question 11 A 42-year-old 42-year-old man presented presented with a 6-month 6-month history history of pain in his right right upper arm that prevented him from working. On examination, there was flattening of the right deltoid contour with restriction of active and passive shoulder movements, and of neck movements. What is the most likely cause of his pain? A B C D E
adhesive adhesive capsulitis capsulitis cervical spondylosis glenohumeral joint osteoarthritis subacromial bursitis supraspinatus tendonitis
Updated 06/02/2012
Question 12 A 72-year-old 72-year-old man presented presented with a 6-month history history of recurrent recurrent joint pain and swelling. swelling. His His symptoms had begun with three attacks of arthritis affecting his right wrist, his left ankle and his right knee. The current attack was more widespread, affecting his hands, wrists, knees and ankles. He had also developed tender swelling over the extensor aspect of both elbows. His medical history included chronic renal impairment, type 2 diabetes mellitus, hypertension and heart failure. His current medication comprised bumetanide, spironolactone, lisinopril and simvastatin. On examination, he was obese and had widespread synovitis and bilateral olecranon bursitis. What investigation is likely to be most informative? A B C D E
antinuclear antinuclear antibodies antibodies erythrocyte sedimentation rate rheumatoid factor serum urate synovial fluid analysis
Updated 06/02/2012
Question 13 A 20-year-old 20-year-old woman woman presented presented with a 1-week 1-week history of tender lumps over over the shins shins and painful ankles. There was a preceding history of a coryzal type illness. On examination, there were erythematous subcutaneous nodules over the shins and synovitis of the ankles. Which investigation is most likely to lead to a diagnosis? A B C D E
anti-neutrophil anti-neutrophil cytoplasmic cytoplasmic antibodies antibodies antinuclear antibodies antistreptolysin titre chest X-ray skin biopsy
Updated 06/02/2012
Question 14 A 32-year-old 32-year-old woman woman with with long-standing long-standing rheumatoid rheumatoid arthritis arthritis had failed to respond respond to treatment with methotrexate, leflunomide, etanercept and adalimumab. She had heard that a new antirheumatic agent, rituximab, was available for the treatment of rheumatoid arthritis and expressed a wish to try it. What is the most appropriate way to describe the nature of rituximab? A B C D E
antimetabolite antimetabolite chimeric monoclonal antibody humanised monoclonal antibody recombinant cytokine recombinant human receptor fusion protein
Updated 06/02/2012
Question 15 A 55-year-old 55-year-old man with poorly poorly controlled controlled ankylosing ankylosing spondylitis was was due to start start anti-TNF anti-TNF therapy. A tuberculosis interferon-gamma release assay was used to exclude latent or active tuberculosis. This test involved measurement of the production of interferon-gamma after incubation of the patient’s peripheral blood leucocytes with tuberculosis-specific peptides. Which cells produce the interferon-gamma in this assay? A B C D E
eosinophils eosinophils macrophages natural killer cells neutrophils T lymphocytes
Updated 06/02/2012
Question 16 A 59-year-old 59-year-old woman woman presented presented with with a 6-month history of of fatigue, hand pain and weakness weakness in her arms and legs. As a result, she was no longer able to work as a nurse. She had hypothyroidism and hyperlipidaemia, and was taking thyroxine only. On examination, she had dry cracked hands, bilateral basal crackles on chest auscultation and grade 4/5 weakness of the thighs. Investigations: haemoglobin white cell count neutrophil count lymphocyte count platelet count erythrocyte sedimentation rate
105 g/L (115 –165) –165) 9 4.3 10 /L (4.0 –11.0) –11.0) 9 2.2 10 /L (1.5 –7.0) –7.0) 9 1.0 10 /L (1.5 –4.0) –4.0) 9 184 10 /L (150 –400) –400) 32 mm/1st h (<20)
serum creatine kinase serum C-reactive protein
403 U/L (24 – (24 –170) 170) 15.4 mg/L (<10)
antinuclear antibodies rheumatoid factor
1:320 (negative at 1:20 dilution) 64 kIU/L (<30)
chest X-ray
normal
What is the most likely diagnosis? A fibromyalgia fibromyalgia B polymyalgia rheumatica C polymyositis D rheumatoid arthritis E sarcoidosis
Updated 06/02/2012
Question 17 An 18-year-old 18-year-old man presented presented with a 2-year history history of lower lower back pain. He was was otherwise otherwise well well and had no significant medical history. Examination was normal. He had been taking naproxen with no benefit. Investigations: X-ray of lumbar spine
What is the most appropriate initial treatment? A B C D E
anti-TNF therapy therapy exercise programme intravenous antibiotics phenylbutazone prednisolone
Updated 06/02/2012
see image
Question 18 A 74-year-old 74-year-old woman woman presented presented with with a 2- year history of widespread joint pain, Raynaud’s phenomenon and recurrent lower limb ulceration. On examination, there were purpuric lesions on her legs associated with numerous punched-out ulcers. There was reduced sensation in a stocking distribution, and absent ankle and knee reflexes. The plantar reflexes were downgoing. Investigations: white cell count platelet count erythrocyte sedimentation rate
10.2 109/L (4.0 –11.0) –11.0) 9 450 10 /L (150 –400) –400) 89 mm/1st h (<30)
serum creatinine serum alanine aminotransferase serum alkaline phosphatase serum complement C3 serum complement C4
130 µmol/L (60 –110) –110) 68 U/L (5 – (5 –35) 35) 192 U/L (45 – (45 –105) 105) 45 mg/dL (65 –190) –190) 5 mg/dL (15 –50) –50)
anti-neutrophil cytoplasmic antibodies antinuclear antibodies rheumatoid factor
negative negative 150 kIU/L (<30)
ulcer biopsy
small vessel leucocytoclastic vasculitis
What is the most likely diagnosis? A B C D E
microscopic microscopic polyangiitis polyangiitis mixed essential cryoglobulinaemia rheumatoid vasculitis systemic lupus erythematosus Wegener’s granulomatosis
Updated 06/02/2012
Question 19 A 65-year-old 65-year-old man presented presented with a 24-hour history history of shortness shortness of breath and rash. rash. Over the the previous 3 weeks, he had developed a sore throat and joint pains across his fingers, both knees and left ankle. He was previously well and was taking no regular medication. On examination, he had palpable purpura on his legs and splinter haemorrhages affecting his fingernails. His chest was clear. Urinalysis showed red cells 3+. Investigations: serum creatinine serum C-reactive protein
125 µmol/L (60 –110) –110) 115 mg/L (<10)
chest X-ray
normal
blood cultures 3
no growth
echocardiogram
no vegetations
What is the most appropriate initial management? A B C D E
intravenous intravenous cyclophospha cyclophosphamide mide intravenous methylprednisolone methylprednisol one oral methotrexate oral mycophenolate mofetil plasmapheresis
Updated 06/02/2012
Question 20 A 25-year-old 25-year-old woman woman with with systemic lupus lupus erythematosus erythematosus had been treated with with prednisolone prednisolone 10 mg daily for 4 years. A routine DEXA scan showed T scores of – of –2.7 2.7 at the hip and –2.5 –2.5 at the lumbar spine. Investigations: serum creatinine estimated glomerular filtration rate (MDRD) serum corrected calcium serum phosphate
62 µmol/L (60 –110) –110) >60 mL/min (>60) 2.02 mmol/L (2.20 – (2.20 –2.60) 2.60) 0.78 mmol/L (0.8 –1.4) –1.4)
plasma parathyroid hormone
11.2 pmol/L (0.9 – (0.9 –5.4) 5.4)
What is the most appropriate management? A B C D E
alendronic alendronic acid calcium dietary advice parathyroidectomy vitamin D
Updated 06/02/2012
Question 21 A randomised, randomised, controlled, controlled, double-blind double-blind study study was was carried carried out to compare compare the effect of two two different doses of intra-articular methylprednisolone on pain 6 weeks post-injection as assessed by a visual analogue pain score. What is the most appropriate statistical test to compare the change between baseline and 6weeks in the two treatment groups? A B C D E
chi-squared chi-squared test Kruskal –Wallis –Wallis one-way analysis of variance Mann –Whitney –Whitney U test Spearman's rank correlation coefficient Wilcoxon matched-pairs signed-rank test
Updated 06/02/2012
Question 22 A 63-year-old 63-year-old man presented presented with a 2-month history history of pain pain and numbness numbness in the right right leg. He described pain in the right buttock and outer hip, with radiation into the anterior thigh and inner aspect of the shin. He was unable to lie on his right side at night. He had type 2 diabetes mellitus and had been taking metformin and simvastatin for the past 4 years. On examination, there was wasting of the right quadriceps, an absent right knee reflex and sensory loss to light touch over the anterior thigh. What is the most likely diagnosis? A B C D E
femoral neuropathy neuropathy meralgia paraesthetica mononeuritis multiplex neuralgic amyotrophy simvastatin-induced simvastatin-i nduced myopathy
Updated 06/02/2012
Question 23 A 58-year-old 58-year-old man presented presented with a dry cough cough and severe severe breathlessn breathlessness. ess. He was was taking prednisolone 40 mg daily and methotrexate 20 mg weekly for refractory giant cell arteritis, established by temporal artery biopsy 4 months previously. Investigations: haemoglobin white cell count
121 g/L (130 –180) –180) 9 6.1 10 /L (4.0 –11.0) –11.0)
serum creatinine
105 µmol/L (60 –110) –110)
serum C-reactive protein
98 mg/L (<10)
HIV antibodies
negative
chest X-ray
see image
What is the most likely diagnosis? A B C D E
aspergillosis aspergillosis cardiac failure methotrexate pneumonitis pulmonary embolism staphylococcal pneumonia
Updated 06/02/2012
Question 24 A 49-year-old 49-year-old woman woman presented presented with with a 4-month history of of pain along along the medial medial aspect aspect of her her left foot, which was exacerbated by walking. On examination, there was swelling and tenderness below the medial malleolus of the left foot, weakness in inversion and she was unable to rise up on tiptoes. There was lowering of the longitudinal arch with planovalgus deformity. Which tendon is most likely to be affected? A B C D E
extensor digitorum longus flexor digitorum longus peroneus longus tibialis anterior tibialis posterior
Updated 06/02/2012
Question 25 A 21-year-old 21-year-old woman woman presented presented with with a 4-month 4-month history of sweats, sweats, malaise, arthralgia arthralgia and leg cramps on walking. She had attended the emergency department on two occasions in the previous 6 months with self-limiting palpitations. On examination, her pulse was 100 beats per minute and regular, and her blood pressure was 110/70 mmHg in the left arm but unrecordable in the right arm. Examination was otherwise normal. Investigations: haemoglobin
99 g/L (115 –165) –165)
serum C-reactive protein
23 mg/L (<10)
anti-neutrophil cytoplasmic antibodies
negative
What is the most likely diagnosis? AKawasaki’s AKawasaki’s disease Bmicroscopic polyangiitis Cpolyarteritis nodosa DTakayasu’s arteritis Ethoracic outlet syndrome
Updated 06/02/2012
Question 26 A 36-year-old 36-year-old woman woman with with juvenile-onset juvenile-onset rheumatoid rheumatoid arthritis arthritis presented presented with with a 1-week 1-week history of weakness of her right wrist. She had recently stopped taking her disease-modifying antirheumatic drugs in order to start a family. On examination, she had marked synovitis around her right elbow and was unable to dorsiflex her wrist or extend her fingers, but she could extend her thumb. Muscle power in her upper arm and wrist flexors, reflexes and sensation were normal. What is the most likely diagnosis? A B C D E
C7 radiculopathy radiculopathy cubital tunnel syndrome Guyon’s canal syndrome posterior interosseous neuropathy radial neuropathy
Updated 06/02/2012
Question 27 A 72-year-old 72-year-old woman woman presented presented with with a 2-year history of joint pains pains and dry eyes and mouth. On examination, there was bilateral parotid swelling, Schirmer’s test was abnormal and her unstimulated salivary flow was reduced. A minor salivary salivary gland gland biopsy biopsy was performed. Which cell type predominantly infiltrates the salivary gland in Sjögren’s syndrome? A B C D E
lymphocyte lymphocyte macrophage monocyte neutrophil plasma cell
Updated 06/02/2012
Question 28 A 52-year-old 52-year-old man presented presented with a 3-month history history of a burning sensation sensation in all of of his fingertips and wrist swelling. He had a 10-year history of intermittently painful joints and a 20year history of skin psoriasis. He had smoked 20 cigarettes per day for 30 years. On examination, he had swollen wrists and finger clubbing. Investigations: haemoglobin white cell count platelet count
134 g/L (130 –180) –180) 9 9.4 10 /L (4.0 –11.0) –11.0) 9 456 10 /L (150 –400) –400)
serum C-reactive protein
15 mg/L (<10)
rheumatoid factor
50 kIU/L (<30)
What is the most likely diagnosis? A B C D E
carpal tunnel tunnel syndrome syndrome hypertrophic osteoarthropathy osteoarthritis psoriatic arthropathy rheumatoid arthritis
Updated 06/02/2012
Question 29 A 73-year-old 73-year-old woman woman presented presented with with 12-month history of moderately moderately severe severe right knee knee pain that woke her up at night. She had previously been well. She had been taking paracetamol and codeine with only partial benefit. Previous intra-articular triamcinolone injections and quadriceps strengthening exercises had not led to sustained benefit. On examination, her body mass index was 29 kg/m 2 (18 –25). –25). She was tender over the right knee with crepitus and flexion was limited to 65°. There was medial quadriceps wasting. Investigations: X-ray of right knee
What is the most appropriate management? A B C D E
arthroscopic arthroscopic knee washout glucosamine sulphate knee arthroplasty naproxen prednisolone
Updated 06/02/2012
significant medial joint space narrowing with osteophytes
Question 30 A 26-year-old 26-year-old woman woman attended attended the early early arthritis arthritis clinic clinic with a 3-month 3-month history history of an inflammatory polyarthritis affecting her hands and feet. Investigations: haemoglobin white cell count platelet count erythrocyte sedimentation rate
125 g/L (115 –165) –165) 9 7.3 10 /L (4.0 –11.0) –11.0) 9 350 10 /L (150 –400) –400) 40 mm/1st h (<20)
X-rays of hands and wrists
periarticular osteopenia
What investigation is most likely to distinguish between persistent and self-limiting arthritis? A B C D E
anti-citrullinated anti-citrullinated peptide peptide antigen antigen antibodies antibodies antinuclear antibodies IgA rheumatoid factor IgG rheumatoid factor IgM rheumatoid factor
Updated 06/02/2012
Question 31 A 45-year-old 45-year-old woman woman with with rheumatoid arthritis presented presented with a 2-week 2-week history history of mild discomfort in the left eye. On examination, there was a localised area of redness involving the temporal bulbar conjunctiva. What is the most likely diagnosis? A B C D E
conjunctivitis conjunctivitis episcleritis iritis keratoconjunctivitis keratoconjunctiviti s sicca scleromalacia
Updated 06/02/2012
Question 32 A 58-year-old 58-year-old woman woman with with rheumatoid arthritis was was being assessed for anti-TNF therapy. therapy. Investigations: chest X-ray
What is the most appropriate treatment? A B C D E
co-trimoxazole co-trimoxazole etanercept initial antituberculous therapy prednisolone and azathioprine rituximab
Updated 06/02/2012
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Question 33 A 34-year-old 34-year-old woman woman was referred by her general general practitioner practitioner for screening screening for antiphospholipid syndrome. She was completely well. One year previously, while taking the oral contraceptive pill, she had had a deep venous thrombosis of the right leg. She had been treated with warfarin for 3 months and had discontinued the oral contraceptive pill. She was taking aspirin 75 mg daily. Investigations: lupus anticoagulant
negative
anticardiolipin antibodies: immunoglobulin G immunoglobulin M
9 U/mL(<23) 10 U/mL(<11)
anti-β anti-β2-glycoprotein-1 antibodies: immunoglobulin G immunoglobulin M
105 U/mL(<10) 98 U/mL(<11)
What is the most appropriate management? A B C D E
add clopidogrel clopidogrel change aspirin to warfarin Doppler ultrasound scan of right calf repeat anti-β anti- β2-glycoprotein-1 antibodies in 12 weeks repeat anticardiolipin anticardiolipi n antibodies in 6 weeks
Updated 06/02/2012
Question 34 A 30-year-old 30-year-old woman woman presented presented with with a 9-month history of of stiffness in her hands and and intermittent difficulty in swallowing. Investigations: X-ray of hands
What is the most likely diagnosis? A dermatomyositis dermatomyositis B hyperparathyroidism C limited systemic sclerosis D rheumatoid arthritis E sarcoidosis
Updated 06/02/2012
see image
Question 35 A 54-year-old 54-year-old man presented presented with a 4-day history history of generalised generalised weakness and intermittent intermittent episodes of passing dark urine. During the previous week, he had been taking colchicine for acute gout affecting the left hallux and instep. He had a history of type 2 diabetes mellitus, and his regular medication comprised aspirin, metformin, simvastatin and ramipril. On examination, he had muscle tenderness and the muscle power grade was 4/5. Urinalysis showed blood 3+, protein 1+, glucose 2+. Investigations: serum sodium serum potassium serum urea serum creatinine serum creatine kinase
138 mmol/L (137 –144) –144) 4.8 mmol/L (3.5 –4.9) –4.9) 7.1 mmol/L (2.5 –7.0) –7.0) 125 µmol/L (60 –110) –110) 6238 U/L (24 – (24 –195) 195)
What substance is most likely to be present in the urine? A B C D E
bilirubin haemoglobin haemosiderin myoglobin urobilinogen
Updated 06/02/2012
Question 36 A 26-year-old 26-year-old man presented presented with a 1-week history history of pain pain in his knees and and ankles. ankles. He described early morning stiffness of the joints, lasting for 3 hours. Three weeks previously, he had been on holiday to Bulgaria. While there, he had experienced an episode of diarrhoea that had lasted 4 days and then settled. He was taking naproxen 250 mg three times a day and omeprazole 20 mg daily. On examination, his temperature was 37.5°C. Both knees were warm, with an effusion in the left knee. There was painful movement of both ankles. Investigations: haemoglobin white cell count neutrophil count platelet count
116 g/L (130 –180) –180) 9 12.3 10 /L (4.0 –11.0) –11.0) 9 10.9 10 /L (1.5 –7.0) –7.0) 9 650 10 /L (150 –400) –400)
synovial fluid culture
negative after 48 h
blood cultures
negative after 48 h
What is the most appropriate treatment? A B C D E
ciprofloxacin ciprofloxacin colchicine flucloxacillin methotrexate prednisolone
Updated 06/02/2012
Question 37 A 34-year-old 34-year-old woman woman with with a 5-year history history of psoriatic arthritis presented presented with increasing increasing joint joint pain and swelling of her knees and feet. She was taking methotrexate 20 mg weekly. Lowdose sulfasalazine had previously been withdrawn because of abnormal liver function tests. On examination, five joints were tender and three were swollen. What is the most appropriate treatment? A B C D E
etanercept etanercept hydroxychloroquine infliximab prednisolone rituximab
Updated 06/02/2012
Question 38 A 32-year-old 32-year-old woman woman presented presented with with a 2-week 2-week history of pain and and swelling swelling across across her ankles ankles and knees. Over the previous 6 months, she had experienced intermittent episodes of bloody diarrhoea. She was otherwise well and denied any other symptoms. On examination, she had swollen, tender ankles and knees. She had a tender, nodular rash on both shins. Investigations: chest X-ray
normal
stool culture
negative
What is the most appropriate initial treatment for her musculoskeletal symptoms? A B C D E
ciprofloxacin ciprofloxacin dapsone mesalazine naproxen prednisolone
Updated 06/02/2012
Question 39 A 60-year-old 60-year-old woman woman complained complained of difficulty difficulty in flexing and and extending extending her left left index finger finger and a feeling of ‘locking’. On examination, she was able to make a fist but unable to extend the index finger fully. There was crepitus along the flexor tendon and a nodule was felt in her palm. What is the most appropriate initial management? A B C D E
corticosteroid corticosteroid injection injection into into tendon sheath ibuprofen intramuscular methylprednisolone methylprednis olone surgical decompression of the carpal tunnel surgical repair of tendon rupture
Updated 06/02/2012
Question 40 A 50-year-old 50-year-old man with rheumatoid rheumatoid arthritis arthritis presented presented with with breathlessnes breathlessness s of recent recent onset and a dry cough. He had recently started treatment with methotrexate and sulfasalazine. He was a non-smoker. He was treated with amoxicillin and clarithromycin but had not improved after a 1-week course. On examination, he was tachypnoeic and his temperature was 38.3°C. Investigations: haemoglobin white cell count neutrophil count
146 g/L (130 –180) –180) 9 16.1 10 /L (4.0 –11.0) –11.0) 9 12.0 10 /L (1.5 –7.0) –7.0)
sputum cultures blood cultures
no growth no growth
chest X-ray
bilateral interstitial infiltrates
What is the most likely diagnosis? A B C D E
acute respiratory respiratory distress syndrome cardiac failure methotrexate pneumonitis pneumococcal pneumonia pulmonary embolism
Updated 06/02/2012
Question 41 A 58-year-old 58-year-old woman woman presented presented with with a 2- year history of Raynaud’s phenomenon, joint pain and stiffness of the fingers. A serum sample sample was was sent for immunofluorescenc immunofluorescence e on HEp-2 HEp-2 cells (see (see image). image).
What immunofluorescence pattern does this show? A B C D E
centromere homogeneous mitochondrial nucleolar ribosomal
Updated 06/02/2012
Answer keys: 1. E 2. D 3. E 4. B 5. A 6. B 7. C 8. E 9. C 10. B 11. A 12. E 13. D 14. B 15. E 16. C 17. B 18. B 19. B 20. E 21. C 22. A 23. C 24. E 25. D 26. D 27. A 28. B 29. C 30. A 31. B 32. C 33. D 34. C 35. D 36. E 37. A 38. E 39. A 40. C 41. A
Updated 06/02/2012
