Rheumatology 2012 Mrcppass PDF

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Rheumatology

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May2012

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w.MRCPass.ccom Rheum
matology
RheumatollogyQ0011
A355yearoldm manpresen ntswitha6

6monthhisstoryofarthhralgia,mouthulcerattionand
eye irritation.OOnexaminaation,hehaadsomeulccerationintthemouth, bilaterally swollen
wrisstsandredu ucedrangeofmovemeentsofboth hknees.
His investigatioonsshowed d:whitecelllcount11 x10^9/L,C
Creactivep
protein100 0mg/dl,
Rheeumatoidfactornegativve.
Wha atisthelikeelydiagnosiis?
A.Reiterssyndromee
B.Sjogre
enssyndrom
me
C.Ankylosingspondylitis
etssyndrom
D.Behce me
E.Sarcoidosis
Answer:d)Beh
hcetssyndrrome.
Behhcets syndrome is a multisystem m disorder characterissed by recu urrent oral genital

ulceeration,eyeelesions(an
nteriorand dposterior uveitisorrretinalvascu ulitis),skin lesions,
(eryythemanod dosum,papu ulopustularrlesionsfollliculitis)and
dapositivepathergyteest.
Thee pathergy phenomenon is considered an outstanding feature of o Behcet disease.
d
Following a neeedle prick or intradermal injection with saaline or dilu
ute histamiine, the
punncture site becomes inflamed and deveelops a sm mall sterilee pustule due to
hyperactivityooftheskinto
oanyintraccutaneousinsult.

OralUlceration
ninBehcet'sdisease
Dr.K
KhalidYusuffElzohrySo
ohagTeachin
ngHospital2012
2
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Rheumatology
RheumatologyQ002
A 33 year old female with systemic lupus erythematosis has arthralgia involving her
upperlimbs.Shealsohasabutterflyfacialrashandarashonthetrunk.
UrinedipstickshowsnoProteinuriaorhaematuria.Herrenalfunctionisnormal.
Whichoneofthefollowingmedicationsismostappropriate?
A.Methotrexate
B.Prednisolone
C.Azathioprine
D.Hydroxychloroquine
E.Cyclosporin
Answer:D)Hydroxychloroquine.
NSAIDsandhydroxychloroquineareusedforskininvolvementandarthritis.
NSAIDs are used for mild disease. Hydroxychloroquine is useful for disease not
controlled by NSAIDS. Steroids are used in moderate to severe disease.
Immunosuppressive treatments such as azathioprine and cyclophosphamide are used
typicallywhenthereisrenalorcerebaldisease.
Dr.KhalidYusufElzohrySohagTeachingHospital2012
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Rheumatology
RheumatologyQ003
A 75 year old woman with longstanding Rheumatoid arthritis has great difficulty
walkingandcommentsthatbothherlegsarestiffandjumpy.
Whatisthemostlikelycauseofthepresentation?
A.Ankylosingspondylitis
B.Syringomyelia
C.Osteoporosis
D.Atlantoaxialinstability
E.Disccompression
Answer:d)Atlantoaxialinstability.
CervicalcordcompressionduetoatlantoaxialinstabilityisthemostlikelycauseofUMN
nerveweakness.
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Rheumatology
RheumatologyQ004
A50yearoldwomanhassevererheumatoidarthritis.Sheisadmittedwithworsening
breathlessness.
She is currently on ibuprofen, methotrexate, celecoxib, and paracetamol. On
examination,shehasfeaturesofrheumatoidchangesinherhandsandlookspale.There
isnopalpablelymphadenopathyandnoabdominalmasses.
InvestigationsshowedthatherHblevelis7.8g/dlwithaMCVof90,WCC2.1x10^9/l
andplatelets55x10^9/l.
Reticulocytecountis0.3%(0.5%to1.5%).
Whatisthelikelycauseoftheanaemia?
A.NSAIDuseandGIbleed
B.Treatmentwithcelecoxib
C.Treatmentwithmethotrexate
D.Anaemiaofchronicdisease
E.Felty'ssyndrome
Answer:c)Treatmentwithmethotrexate.
The patient has an aplastic anaemia which can be caused by methotrexate or

azathioprine,DMARDs(penicillamineorgold).
Abnormallylowreticulocytecountcanbeattributedtochemotherapy,aplasticanemia,
perniciousanemia,bonemarrowmalignanciesandlowerythropoietinlevels.
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RheumatollogyQ0055
A655yearoldw womanpressentswithd dryeyesandadrymouth.Herinvvestigationssshow:

ANA A strongly positive (11:1600), anttiRo/SSA an
ntibodies strongly
s positive, rheu
umatoid
facttorpositive,,IgGmarkedlyelevatedat42g/l
(norrmal<15g//l),IgMandIgAlevelsaarenormal.
A.Mono
oclonalgamm
mopathyofu
unknownsiggnificance
B.PrimaarySjogren'ssSyndrome
C.SystemicLupusErrythematosu
us
D.Reiter'ssyndromee
E.PolyarteritisNodo
osa
Answer:b)Prim
marySjogreen'sSyndrom
me.
Theeclinicalfeaturesandaareconsisteentwithprim
marySjgreensSyndrom me.
Hyppergammaglobulinaem miaispresen ntin80%offindividualss.ANA,AntiRo/SSAanttibodies
are presentin approximattely90%offindividualssandthere canalsobe eaweakly positive
rheuumatoidfacctor.

DrymouthseeninSjogren
n'ssyndrom
me
Dr.K
ohagTeachin
ngHospital2012
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matology
RheumatollogyQ0066
A555yearoldffemalehas beenonlongtermsteeroidsforchronicobsttructivepulmonary
diseease.Sheco omplainsoffpaininherrrightgroin nradiatingddowntheanteromediaalthigh.
Shehasanantalgicgait.
On examinatio d range of movement especially flexion,
on of the hip, there iss decreased
abductionandinternalrottation.
A.Osteo
oarthritis
B.Rheumatoidarthrritis
C.Metastatichiplession
D.Avasccularnecrosiisofthefem
moralhead
E.Hairlin
nefracture
Answer:d)avascularnecrosisoftheffemoralheaad.
In a
a patient on long term
m steroids presenting with groinn pains radiiating to th
he thigh
assoociatedwithhanantalgicgaitand decreased rangeofmovementoffthehip,th hemost
likelydiagnosissisavasculaarnecrosisofthefemooralhead.
Inth
hisconditio
on,MRIisth hemostsennsitiveand specifictecchniqueand disusefulfforearly
diaggnosis befo
ore collapsee of bone occurs. CT scan and xray are useful to rule
r out
advanceddiseaaseifdurationisnotclear.Bonesscanningismoresensiitivethanxraybut
isno
onspecific.
MRIshowingavascularneecrosisofth
hefemoralh
head
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ007
A60yearoldwomanontreatmentforlongstandingrheumatoidarthritispresentswith
breathlessness.Shecomplainsofadrycough.Theoxygensaturationwasfoundbe85%
onair.
Thechestxrayshowsadiffusebilateralinterstitialinfiltrate.
Bloodculturesandsputumculturesarenegative.
Whichdrugislikelytohavecausedthisadverseeffect?
A.Cyclosporin
B.Cyclophosphamide
C.Gold
D.Methotrexate
E.Sulphasalazine
Answer:d)methotrexate.
Pneumonitisisaseriousandunpredictablesideeffectoftreatmentwithmethotrexate
(MTX)thatmaybecomelifethreatening.Chestradiographyrevealsadiffuseinterstitial
ormixedinterstitialandalveolarinfiltrate,withapredilectionforthelowerlungfields.
Pulmonaryfunctiontestsshowarestrictivepatternwithdiminisheddiffusioncapacity.
Lung biopsy reveals cellular interstitial infiltrates, granulomas or a diffuse alveolar
damagepatternaccompaniedbyperivascularinflammation.
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RheumatollogyQ0088
A 65 year old man preseents has reccently deveeloped an acutely

a pain
nful right kn
nee. On
examination,h hehadatemmperatureo of37.2Cah hotandswo ollenrightkknee.
His whitecellccountwhich hwasraised dat14x100^9/l.AkneeeXraysho owedreducedjoint
spacceandchon ndrocalcinoosis.
Culttureofaspiratedfluidsshowednogrowth.
A.Psoriaaticarthropaathy
C.Pseud
dogout
D.Septicarthritis
E.Osteo
omalacia
Answer:c)pseudogout.
Theeclinicalpictureistypiccalofpseud
dogout.Calcificationo ofthearticu ularcartilage
ewould
be consistent and the cu ulture results excludes septic arrthritis. Thee diagnosis can be
confirmed byy the pressence of calcium pyrophosph
p hate crystaals in join nt fluid
demmonstratinggapositiveb birefringencceunderpo
olarisedlighht.

Calcciumpyroph
hosphatecrrystals
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ009
A60yearoldmanpresentswithapainfulswollenleftkneeaswellaspainandstiffness
ofbothhishands.
Onexaminationhisskinispigmented.Thereistendernessandswellingofthe2ndand
3rdmetacarpophalangealjointsofbothhands,hehashepatomegalyof8cmbelowthe
costalmargin.
Hiskneeisswollenandaspirationofthejointyieldsturbid,strawcolouredfluid.
Whichoneofthefollowingdiagnosisislikely?
A.Wilson'sdisease
B.Haemochromatosis
C.Pseudohypoparathyroidism
D.Pseudopseudohypoparathyroidism
E.Ankylosingspondylitis
Answer:b)haemochromatosis.
The history of abdominal pain together with skin pigmentation and hepatomegaly
suggest the patient has haemochromatosis. Haemochromatosis is associated with
chondrocalcinosis, which commonly affects the 2nd and 3rd metacarpophalangeal
joints.Theacutearthropathyislikelytobepyrophosphatecrystalarthritis.
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RheumatollogyQ0100
A700yearold manpresen ntswithbo

onyswellinggsoftheDIIPjointson
nbothhand
ds.They
werrepainfulayearagobuutarenowpainless.
Themostlikelyydiagnosisiis:
A.Heberdensnodes
B.Bouch
hardsnodess
C.Osler'snodes
D.Goutyytophi
E.Charccot'sjoints
Answer:a)Heb
berden'sno
odes.
Theemostlikelyydiagnosisiisosteoarth
hritis.AttheeDIPjoints,,swellingarreknownass
HebberdensnodesandattthePIPjoin nts,theyareeknownasBouchardssnodes.

Heb
berden'snode
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ011
A60yearoldmanpresentswithgoutytophi.Hehasbeencommencedonallopurinol
butdevelopsseverejointpains3dayslater.Onexamination,hehasatemperatureof
39Canderythematousswellingofhiswrists,kneesandankles.
Investigationsreveal:urate0.6(0.230.45),creactiveprotein180mg/L.
Whichofthefollowingislikelytohavecausedthepresentation?
A.Allopurinol
B.Colchicine
C.Prednisolone
D.Pseudogout
E.Septicarthritis
Answer:a)allopurinol.
Allopurinol blocks uric acid production and is the drug most often used in longterm
treatmentforolderpatientsandoverproducersofuricacid.Allopurinolistakenorally
once a day in doses of 100 mg to 600 mg, depending on the patient's response to
treatment.
Between 3% to 5% of patients experience leukopenia, thrombocytopenia, diarrhea,
headache,andfever.
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RheumatollogyQ0122
A 35 year old retired athlete presen

nts with sevvere burnin
ng pain affe
ecting the right
r leg
and foot. 4 months earlier, he had several arrthroscopic washouts for septic arthritis
a
affeectinghisrigghtknee,wwhichfollow
wedaninjuryy.
Examinationreevealsared ducedrangeofmovem mentofthee rightknee eandankle e. There
wassdiffuseswellingoftheerightlegaandfootwitthoverlyinggcool,scalyskin.
A.Comp
partmentsyn
ndrome
B.Deepveinthromb
bosis
C.Reflexxsympatheticdystrophyy
D.Raynaaud'sphenomenonaffecctingtheleg
E.Venou
usvaricositiees
Answer:c)refleexsympath
heticdystrophy.
Thissclinicalsceenarioisco
ompatiblew withadiagn nosisofrefllexsympatheticdystro ophyor
commplex regio onal pain syndrome
s ffollowing the previou
us injury. Reflex
R symppathetic
dysttrophy, also o known ass RSD, is a condition of burning pain, stiffn
ness, swelling, and
disccolorationooftheaffecttedarea.
Theepainisoftensevereaanddisprop portionatettothesignssandfollow wsanonan natomic
distribution.Th heskinchanngesareduetotheasssociatedauttonomicdyysfunction.

Refllexsympath
heticdystro
ophyaffectingtherighttfoot
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ012
A 75 year old has had increasing back and leg pains several years. X rays reveal bony
sclerosis of sacroiliac, lower vertebral and upper tibial regions. He mentions greater
difficultyhearingovertherecentyears.
Bloodtestsrevealanelevatedserumalkalinephosphatase.
Whatisthelikelydiagnosis?
A.Paget'sdiseaseofbone
B.Osteoarthritis
C.Osteomalacia
D.Monoclonalgammapothyofuncertainsignificance
E.Multiplemyeloma
Answer:a)Paget'sdiseaseofbone.
In Paget's disease, onset of symptoms is usually insidious, with pain, stiffness, bone
deformity,headaches,decreasingauditoryacuity,andincreasingskullsize.
Signs may be bitemporal skull enlargement with frontal "bossing," dilated scalp veins,
nerve deafness in one or both ears, angioid streaks in the fundus of the eye, and
anterolateralbowingofthethighorlegwithwarmthandperiostealtenderness.
Pageticlesionsaremetabolicallyactiveandhighlyvascularandmayleadtohighoutput
heartfailure.
Deformitiesmaydevelopfrombowingofthelongbonesorosteoarthritisofadjacent
joints.
Pathologicfracturesmaybethepresentingfinding.Characteristicxrayfindingsinclude
increased bone density, abnormal architecture, cortical thickening, bow ing, and
overgrowth.
Biochemistry includes elevated serum alkaline phosphatase (or bonespecific alkaline
phosphatase)andincreasedurinaryexcretionofpyridinolinecrosslinks.Serumcalcium
andphosphoruslevelsusuallyarenormal,butserumcalciummayincreaseduringbed
rest.
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RheumatollogyQ0133
A 55 year old patient preesents with

h a tw o week
w historyy of pain and stiffnesss in her
shouldersand wrists.Theesymptomssimproveo overthedayy.Onexam mination,theerewas
synoovitisofbotthwristsan
ndproximalmusclewasting.HerEESRwas40mm/hr.
A.Derm
matomyositis
B.Systemiclupuserrythematosus
C.Rheum
matoidarthrritis
myalgiarheumatica
D.Polym
E.Osteo
oarthritis
Answer:c)rheumatoidartthritis.
Inamiddleageedfemale, acutearthrritisofshou
uldersandw
wristsalonggwithsynovvitisare
high
hlysuggestiveofacuteRhematoid dArthritis.

Synovitisinvolvvingthewriistinrheum
matoidarthrritis
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ014
A 45 year old woman presents with numbness and weakness of her upper and lower
limbs.Shedevelopedasthmaattheageof30.
Onexaminationshelooksunwell.Shehaspalpablepurpuraoverherfaceandoverher
elbowsandknees.
Onneurologicalexaminationshehasarightsidedwristdropandthereisweaknessof
dorsiflexion of her right foot. Sensation is also impaired over the dorsum of her right
foot.
Investigations:
CXRisnormal.
Hb10.9g/dL
MCV90fl
WBC23x10^9/l
Eosinophils12%
ANCAnegative
A.Polyarteritisnodosa
B.ChurgStrausssyndrome
C.SLE
D.Allergicbronchopulmonaryaspergillosis
E.Takayasu'sarteritis
Answer:b)ChurgStrausssyndrome.
Thecombinationofmononeuritismultiplex,asthma,eosinophilia.
The American College of Rheumatology (ACR) has proposed 6 criteria for diagnosis of
ChurgStrausssyndrome.Thepresenceof4ormorecriteriayieldsasensitivityof85%
andaspecificityof99.7%.
Thesecriteriaare
(1)asthma(wheezing,expiratoryrhonchi)
(2)eosinophiliaofmorethan10%inperipheralblood
(3)paranasalsinusitis
(4)pulmonaryinfiltrates(maybetransient)
(5)histologicalproofofvasculitiswithextravasculareosinophils
(6)mononeuritismultiplexorpolyneuropathy
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Vasculiticrashontheskin
nofapatien
ntwithChurrgStrausssyyndrome

Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ015
A40yearoldmanhasgeneralisedjointpainsandstiffness,particularlyintheknees.He
alsohassore,dryeyesanddifficultytoleratingcontactlenses.Onexaminationthereare
nojointswellingsoreffusions.HisESRis80mm/hour,RheumatoidFactorpositivewith
atitreof1/1024.
Whichofthefollowingislikely?
A.PositiveantibodiestoRoandLaantigens
B.PositiveantiSCL70antibody
C.Positiveantimitochondrialantibodies
D.PositiveantiSmantibodies
E.PositiveANCA
Answer:a)positiveantibodiestoRoandLaantigens.
RoisalsoknownasantissAandLaisknownasantissBantibody,botharediagnostic
tests for Sjogrens. The history of dry eyes (keratoconjunctivitis sicca) and joint pains
withstronglypositiveRhFgoeswithSjogrens.
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Rheumatology
RheumatologyQ016
A45yearoldmanhasrecurrentsinusitisandhaemoptysis.Healsohashaematuriaand
mildrenalimpairment.
TestsaresentforsuspectedWegener'sgranulomatosis.
WhichoneofthefollowingtestshasgreatestspecificityforWegener'sgranulomatosis?
A.Antiglomerularbasementantibody
B.PANCApositiveantibodiesproteinase3
C.PANCApositiveantibodiesmyeloperoxidase
D.CANCApositiveantibodiesproteinase3
E.CANCApositiveantibodiesmyeloperoxidase
Answer:d)cANCApositiveantibodiesproteinase3.
Onimmunofluoresecnce,ifANCAarepresent,thestainingpatternmaybecytoplasmic
(cANCA)orperinuclear(pANCA).TypicalantigenspecificityincludescANCAproteinase
3 which is more common in Wegener's granulomatosis. p ANCA myeloperoxidase is
morecommoninpolyarteritisnodosa.
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Rheumatology
RheumatologyQ017
Aladywithwhiplashinjury5yearsagopresentswithpainsintheneckandshoulder.
Theywerenotrelievedby12cocodamolsaday.
Whatshouldbedonenext?
A.Amitryptilline
B.NSAIDs
C.Physiotherapy
D.Morphine
E.Gabapentin
Answer:C)physiotherapy.
Whiplash injuries and radiculopathies causing back pains can be difficult to treat with
medications. Physiotherapy has an important role for symptom relief in combination
withanalgesia.
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Rheumatology
RheumatologyQ018
A 45 year old man presents with a week history of a painful right leg. He has had
previous episodes of erythema nodosum, recurrent oral and scrotal ulceration.
Examinationrevealsadiffuselyswollenleftleg.
Whatisthelikelycauseofhisswollenleg?
A.Baker'scyst
B.Gonococcalarthritis
C.Reactivearthritis
D.Deepveinthrombosis
E.Cellulitis
Answer:d)Deepveinthrombosis.
TheoveralldiagnosisisBehcet'ssyndrome.Thereisathrombotictendency,hencethe
likelycauseofaDVT.
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RheumatollogyQ0199
A455yearoldwwomanpressentswithp paininthewrist.Thep
painiscenttredoverth
heradial
stylo ncreasedbyyabductionofthethum
oidandisin mbagainstresistance.
Wha atisthemoostlikelydia
agnosis?
A.Carpaaltunnelsyndrome
C.DeQu
uervainsten
nosynovitis
D.Osteo
oarthritis
E.Adducctorpollicisssynovitis
Answer:c)DeQ
Quervain'stenosynovittis.
TheepainintheethumbonresistedabductionisttypicalofDe eQuervains.
De Quervain's disease occurs
o moree frequenttly in w om men. The age
a group usually
affeectedis30tto50yearo olds.
Thee history often is of unaccustomeed or excessive activity such as rose pruning. The
patiientcomplaainsofpainontheradiialsideofth hewrist.Ab bductionofthethumbagainst
resistance is painful.
p Finkkelstein's teest is posittive. This iss performed with the thumb
flexedacrossth hepalmofthehand,aaskingthep patienttom movethewrristintoflexxionand
ulnaardeviation n.
Thiss stresses the
t tendonss of abducttor pollicis longus and d extensor pollicis breevis and
reprroducestheepainofdeeQuervain'sstenosynovvitis.

Finkkelstein'steest
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ020
A43yearrheumatoidarthritiswasinvestigatedroutinelyandhadthefollowingresults:
Haemoglobin11.2g/dL
Platelets385x10^9/L
WhiteCellCount8.2x10^9/L
MCV110fL
Whichdrugisshelikelytohavebeenon?
A.Aspirin
B.Rituximab
C.Methotrexate
D.Vincristine
E.Hydroxychloroquine
Answer:C)Methotrexate
Methotrexate is associated with bone marrow suppression, and can lead to

pancytopeniaoramegaloblasticanaemia,especiallyiffolatetreatmentisnotgivenas
well.
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Rheumatology
RheumatologyQ021
A75yearoldwomanhasrecentlybeencommencedonalendronateforosteoporosis.
Whatisthemechanismofactionofalendronate?
A.Increasesosteoblastactivity
B.Inhibitsosteoclastactivity
C.IncreasesvitaminDabsorption
D.Causeshypercalcaemia
E.Increasestheactionofoestrogenonbone
Answer:b)Inhibitsosteoclastactivity.
Alendronate is a bisphosphonate which can increase bone mineralisation by inhibiting

osteoclasticactivity.
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Rheumatology
RheumatologyQ022
An 75 year old man presents with bilaterally painful knees. He has bilateral reduced
knee movements and crepitus. X ray shows sclerosis, osteophytes and loss of joint
space.
Whichoneofthefollowingisthemostappropriateinitialtreatment?
A.Ibuprofen
B.Ibuprofenandlansoprazole
C.Paracetamol
D.Codeinephosphate
E.Celecoxib
Answer:c)paracetamol.
Theprinciplegoalofsystemictherapyinosteoarthritisistoprovideeffectivepainrelief
with least associated toxicity. Paracetamol is the recommended initial therapy,
especiallyintheelderlyduetopossiblegastrointestinalupset.
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Rheumatology
RheumatologyQ023
A35yearoldwomanrecentlyarrivedintheUKfromGhana.Shecomplainsofneckpain
withpinsandneedlesaffectingtherightarmassociatedwithaweakgrip.
Examination reveals tenderness over the cervical spine. X rays of the cervical spine
shownarrowingoftheC3/4andC4/5jointspaceandpartialcollapseofC4.
Investigationsshow:
Hb9.5g/dl
WCC11.1
platlets520
ESR120mminthefirsthour
CRP250g/l
Calcium2.21micromol/l
Albumin32g/l
alkalinephosphatase210units/l
phosphate0.8micromol/l.
Whatisthemostlikelydiagnosis?
A.Pottsdisease
B.Osteoporosis
C.Multiplemyeloma
D.Ankylosingspondylitis
E.Syringomyelia
Answer:a)Pottsdisease.
Potts disease is tuberculous infection of the spine with associated collapse of the
vetebral body. The infection spreads from tw o adjacent vertebrae into the adjoining
discspace.Ifonlyonevertebraisaffected,thediscisnormal,butiftwoareinvolved
theintervertebraldisc,whichisavascular,collapses.
Signs and symptoms include: Localised back pain, Paravertebral swelling, Neurological
signsincludingparaplegia.
Drug treatment (antituberculous drugs) is generally sufficient for Potts disease, with
spinal immobilisation if required. Surgery is required if there is spinal deformity or
neurologicalsignsofspinalcordcompression.
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Potttsdiseaseo
onanMRI

Dr.K
ohagTeachin
ngHospital2012
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RheumatollogyQ0244
A 35
3 year old woman presents w with tight skin over her hand
ds with Raynauds
pheenomenon. Shehasulccerationof thefingerttipsandasssociatedsm mallwhitedeposits.
Shehasnotedincreasingb breathlessn
nessoverth
hepastfew years.Renaalfunctioniismildly
imppaired.
A.SLE
B.Ataxiaatelangiectaasia
C.Polym
myositis
D.Limiteedcutaneou
usscleroderm
ma
E.Diffussecutaneoussscleroderm
ma
Answer:d)Lim
mitedcutaneeoussclerod
derma.
Limited cutan neous scleroderma isi also kn nown as CREST

C synddrome (calcinosis,
Rayynauds,(o)eesophagealdysfunction,sclerodacctyly,andteelangiectasia).Limiteddrefers
to the
t extent of skin invvolvement limited to the forearms and facce. They ge
enerally
devvelop pulmo onary hypeertension rather
r than
n pulmonarry fibrosis, leading to
ow ards
breaathlessnesss.

Tigh
htthickened
dskin(sclerrodactyly)seeninSclerroderma
Dr.K
ohagTeachin
ngHospital2012
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RheumatollogyQ0255
A 70
7 year old d woman complains of o pain at the base of
o her right thumb. There
T is
tenddernessand ofrightfirstcarpometaacarpaljointt.
dswellingo
A.DeQu
uervain'sten
nosynovitis
B.Rheumatoidnodu
ule
C.Osteo
oarthritis
D.Psoriaaticarthropaathy
E.Reiterr'ssyndromee
Answer:c)osteeoarthritis.
Osteeoarthritiso
ofthe1stccarpometacarpaljointiiscommon..Swellingissusuallybo
onyhard
dueeosteophyteformation n.PIPjointnodesarekknownasBo
ouchard'saandDIPjoinntnodes
areknownasH Heberden'snodes.
Dr.K
ohagTeachin
ngHospital2012
29
www.MRCPass.com
Rheumatology
RheumatologyQ026
A 70 year old patient has a set of investigations due to lethargy. She complains of
polyuriaandgeneralisedbackpains.Uponinvestigation,shehasthefollowingresults:
Hb8g/dl
MCV100fl
Platelets190x10^9/l
totalprotein90g/l(6076)gm%
Albumin35(3749)g/l
calcium2.9(2.252.7)mmol/l
phosphate0.75(0.88)pmol/l
Whatistheappropriatenextinvestigation?
A.Completeliverfunctiontests
B.Urinaryalbumin
C.Plasmaelectrophoresis
D.24hoururineprotein
E.Uricacid
Answer:C)plasmaelectrophoresis.
The patient has multiple myeloma as indicated by hypercalcaemia, polyuria and bone
pains.
30
www.MRCPass.com
Rheumatology
RheumatologyQ027
A72yearoldladyhasseverepainintheleftkneeandrighthand.AnXrayofthehand
shows osteophytes and an X ray of the knee was normal. On examination, she has
limitedlefthipflexion.
Whatshouldbethenextinvestigationfortheknee?
A.MRIoftheknee
B.Bonescan
C.Arthroscopyoftheknee
D.CTscanoftheknee
E.Ultrasoundoftheknee
Answer:A)MRIoftheknee.
The patients presentation suggests osteoarthritis, but an MRI would be helpful to

exclude other pathology as well as confirm osteoarthritis in the context of a normal
kneeXray.TheMRIisusefulforassessingthestateofthecruciateligamentsandthe
joint cartilage as well as avascular necrosis. Arthroscopy is helpful but invasive in this
instance.
31
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Rheumatology
RheumatologyQ028
A28yearoldpatientwithsystemiclupuserythematosusattendstheobstetricclinicat
25 weeks into her pregnancy. The foetal heart rate is 45 beats per minute. Foetal
echocardiographyshowscompleteheartblock.
Whichoneofthefollowingmaternalautoantibodiesislikelytobepresent?
A.AntiRo(SSA)
B.AntidsDNA
C.AntiLa(SSB)
D.AntiJo1
E.Anticentromere
Answer:a)AntiRo(SSA).
AntiRo antibody is associated with congenital complete heart block. When congenital
complete heart block occurs, SSA antibodies are almost alw ays present in maternal
andfetalserum(maternalantiRo(SSA)antibodycrossestheplacenta).
32
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Rheumatology
RheumatologyQ029
A 34 year old lady with systemic sclerosis complained of lethargy. Her blood pressure
was185/90mmHg.
Fundoscopyshowedcottonwoolspots.InvestigationsshowedthatherU+Eswere:
sodium135mmol/l
potassium4.5mmol/l
urea12mmol/l
creatinine225mol/l
Whatisthetreatmentofchoiceforthispatient?
A.OralCaptopril
B.IVProstacyclin
C.IVLabetalol
D.IVSodiumnitroprusside
E.OralAtenolol
Answer:A)oralcaptopril.
Amajorcomplicationofsclerodermaisrenalcrisis.Thisischaracterisedbyabruptonset
ofseverehypertension,usuallyretinopathy,togetherwithrapiddeteriorationofrenal
functionandheartfailure.
Hypertension should be treated with an ACE inhibitor. This is because the underlying
pathology causing hypertension is angiotensin IIinduced vasoconstriction, and trials
have shown ACE inhibitors to have the best antihypertensive efficacy and improved
survival.
Theaimistoreducepressuregradually,asanabruptfallcanleadtocerebralischemia
/infarctions (as in any accelerated hypertension), and may cause decreased renal
perfusionaswellasacutetubularnecrosis.Calciumchannelblockersmaybeaddedto
ACEinhibitors.Parenteralantihypertensiveagents(suchasintravenousnitroprussideor
labetalol)shouldbeavoidedastheycauseabruptbloodpressuredrops.
33
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matology
RheumatollogyQ0300
A 45 year wom
man presen nts with an 8 month history
h of jo
oint pains and stiffnesss of the
hanndsandfeett.
Examination reeveals a syynovitis of tthe distal interphalan
i ngeal joints,, left indexx finger,
righ
htwristandanklejoints.
Naillpittingwassnoticed.H
HerESRwass20mm/hr.
Whiichoneoffo
followingco onditionsisaassociatedwiththepa atternofjoinntinvolvem ment?
A.SLE
B.Psoriaasis
C.Rheum
matoidarthrritis
D.Septicarthritis
E.Reacttivearthritis
Answer:b)pso
oriasis.
Thee diagnosis is psoriattic arthritiss. Psoriatic arthritis is

i subclassiified according to
diffeerent patte
erns of arrthritis: asyymmetrical oligoarthritis, symmetric polyaarthritis,
spondyloarthro opathyand arthritismutilans.Inaabout20% ofpatientsthereisacchronic,
proggressive, deforming
d arthropath hy in an asymmetric
a cal pattern
n, includingg distal
inteerphalangeaaljointinvolvement.

PsoriaticArthro
opathyno
oteonycholyysisonthenails
Dr.K
ohagTeachin
ngHospital2012
34
www
matology
RheumatollogyQ0311
A 16 year old girl presents with wid

despread paalpable purrpura over legs and buttocks.
Shehasabdom minalpainsaandisnoted dtohaveblloodandprroteinonurrinedipstickk.
Wha atisthemoostlikelydia
agnosis?
A.Juven
niledermatomyositis
B.Juven
nilechronicaarthritis
C.HenochSchnlein
npurpura
D.Rheumatoidarthritis
E.HUSTTTP
Answer:c)Hen
nochSchnlleinpurpuraa.
HennochSchnleinpurpurra(HSP)is asystemic vasculitism mostlyseen ninchildren n.Itisa

mulltisystemdisorderinvo olvingtheskkin,joints,ggastrointesttinalandren naltracts.
Aetiologyisunknown,buttthesyndro omeisoften nprecededbyinfectionssuchasG GroupA
betaa hemolyttic streptococcal resspiratory tractt infecttion, Campylobacter jejuni,
Myccoplasma pneumoniae
p e and virusees such as varicella, hepatitis
h B, EpsteinBarr virus,
andparvovirussB19.
Pathhologyisdu
uetointravasculardep positionofIgAimmuneecomplexesswithactivationof
com
mplement and
a leucocyyte infiltrattion. Patien
nts often present
p witth a purpuric rash
usually involving the butttocks and lower limb bs, arthralggia and join
nt swelling, severe
coliccky abdominal pain an
nd tenderness caused by vasculittisinduced thrombosis in the
gut..
Rennal involvem
ment comm monly preseents as miccroscopic haaematuria and proteinaemia.
Theemostserioouslongterm

com
mplicationfrromHSPisprogressiveerenalfailure.
Dr.K
ohagTeachin
ngHospital2012
35
www
matology
RheumatollogyQ0322
A45
5yearoldm manhasdiffficultyben
ndingtouchinghistoesswhenben ndingover..Hehas
lowerbackpain,stiffness inthethorracicregionandreduceedchestexxpansion.Hislower
ne Xray iss shown ab
spin bove. He has
h negativve rheumaatoid factorr, and a HLAB27
H
genotype.
Wha atisthedia
agnosis?
A.Pagett'sdisease
B.Osteo
oarthritis
C.Marblebonedisease
D.Marfaan'ssyndrom
me
Answer:e)ankkylosingspo
ondylitis.
Ankkylosingspo ondylitisis aseronegativearthrop pathyassocciatedwith HLAB27ge enotype.

It leeads to inccreased stifffness and fusion of the
t vertebrrae causingg a bamboo o spine.
Typically,thesacroiliacjoiintsandhip pjointsareaffected,bu utthoracicandcervicaalspines
areeventuallyaffectedasswell.
Theere is a list of associattions mostlly starting with
w A. Theese are antterior uveittis/iritis,
aortticregurgitaation,aorticaneurysm m,apicalfibrosis,asperrgillosisinfeection,amyyloidosis
andarchilleste endinitis.
Inbbamboospine,thereissfusionoftthevertebrralbodiesandsquaringgoftheverrtebrae.
Onee also expeects syndesm mophytes (thin
( vertical dense sp
picules brid
dging the ve
ertebral
bod dies), Romano lesions (erosion att the cornerr of vertebral bodies) and enthessopathy
(ligaamentorteendoncalciffication).

Bam
mbooSpine
Dr.K
ohagTeachin
ngHospital2012
36
www
matology
RheumatollogyQ0333
A35
5yearoldw womanpreesentswith redscalyp
plaqueson hercheeks andherfoorehead.
Onccloserexammination,therewasplu omehairfolliclesandatrophyofth
uggingofso heskin.
Whaatisthelikeelydiagnosiis?
A.Druginducedlupus
B.Psoriaasis
C.Discoidlupus
D.Sarco
oidosis
E.Lupusspernio
Answer:c)disccoidlupus.
Thee diagnosis is discoid lupus eryythematosu us. Lesions are discreete plaquess, often
erytthematous, scaly, with h extensionn into hair follicles.
f Th
hese lesionss can occurr on the
facee, scalp, in the pinnaee, behind tthe ears or on the neeck. There can also bee active
induuratederyth hemaandccentralatrophicscarrin ng.

Disccoidlupus
Dr.K
ohagTeachin
ngHospital2012
37
www.MRCPass.com
Rheumatology
RheumatologyQ034
A 50 year old patient with active rheumatoid arthritis has failed treatment with gold,
methotrexate,hydroxychloroquineandsulphasalasine.Shehasongoingjointpainsand
erosivedamage.
Whatisthemostappropriatetreatment?
A.Highdoseprednisolone
B.COX2inhibitors
C.Infliximab
D.Ciclosporin
E.Azathioprine
Answer:c)infliximab.
The AntiTNF drugs are infliximab and adalimumab. The criteria for treatment with
these drugs are that patients who have been treated with at least tw o DMARDs
(diseasemodifyingdrugs)continuetohaveactiverheumatoidarthritis.
Examples of the DMARDs are: gold injections, sulphasalazine, hydroxychloroquine,
leflunomide, cyclosporin, azathioprine and methotrexate [One of the tw o must be
methotrexate].
38
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Rheumatology
RheumatologyQ035
A 45 year old woman presents with a year's history of Raynauds phenomenon,

dyspepsiaandjointpains.Onexamination,shehassclerodactylyandsynovitisofsmall
jointsofherhands.HerESRis60mm/hr(<10)butRheumatoidfactorandAntinuclear
Antibodyarebothnegative.
Whatotherclinicalfeatureislikelyinthispatient?
A.Splinterhaemorrhages
B.Erythemamarginatum
C.Butterflyrash
D.Anterioruveitis
E.Smallbowelhypomotility
Answer:e)smallbowelhypomotility.
This woman features of a mixed connective tissue disorder such as CREST/systemic

sclerosis, sclerodactyly, Raynauds, dyspepsia and arthralgia. The other likely
developmentwouldbemalabsorptionwhichisassociatedwithhypomotilityofthesmall
bowel.
39
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Rheumatology
RheumatologyQ036
A 60 year old man is on treatment for chronic heart failure with diuretics. He has
preivous history of athma. He presents with sudden onset of pain and swelling of the
metatarsophalangeal joint of his right big toe. Aspiration of the joint demonstrates
crystalsofmonosodiumurate.
Whatistherecommendedtreatment?
A.Aspirin
B.Colchicine
C.Nonsteroidalantiinflammatorydrugs
D.Cyclooxygenase2inhibitor
E.Allopurinol
Answer:b)Colchicine.
Inthisparticularpatient,colchicineisthebestoption.Inacutegout,eithercolchicineor
NSAIDscanbeused.However,asthmacontraindicatesNSAIDs.
40
www
matology
RheumatollogyQ0377
A35
5yearoldm manisreno ovatinghis apartment whenhesslamsadoo oragainsth
hisfoot.
He developssw welling,eryythemaand dpaininalllthedigits ofhisfoot.HehasannESRof
mm/houran
20m ndatemperratureof36 6C.
A.Porph
hyria
B.Cellullitis
C.Gout
D.Raynaaud'sphenomenon
E.Reflexxsympatheticdystrophyy
Answer:e)reflexsympath
heticdystrophy.
Refllexsympattheticdystrrophyoccurrsfollowinggtraumato oaninjured dpartofth

hebody,
and can progrress to other parts. Itt is due to autonomicc nervous system
s dyssfuction.
Sym
mptomsofeextremepainandburningcanoccur.Analgesicsareoftenunhelpful.
Flusshing,shinyandatroph
hiedskinon
ntheleftleggindicatingreflexsymp
patheticdystrophy
Dr.K
ohagTeachin
ngHospital2012
41
www.MRCPass.com
Rheumatology
RheumatologyQ038
A 42 year old lady has tightening of the skin around her hands and mouth. She has
severaltelangiectasiaonherhands,andcomplainsofseverecoldhandsinwinter.She
wasnoticedtobepale.Investigationsshow:
Hb4.5g/dl
MCV105fl
WCC6x10^9/l
platelets230x10^9/l
Iron22(1429)mol/l
Ferritin155(15200)mol/l
totalironbindingcapacity50(4572)umol/l
Folate11(320)g/l
VitaminB1285(120700pmol/l)
Whatisthelikelycauseofanaemia?
A.Perniciousanaemia
B.Secondaryfolatedeficiency
C.Celiacdisease
D.Methotrexate
E.Bacterialovergrowth
Answer:E)bacterialovergrowth.
Sclerodermacancausefolatedeficiencyduetomalabsorption.However,inthiscase,
thefolatelevelsarenormalandthereisB12deficiency.
B12deficiencycanoccurinconditionswherethereisbacteriaovergrowthinthesmall
intestine (blind loop syndromes) such as jejunal diverticulosis, Crohns disease, fistulas
and scleroderma. The anaerobic organisms metabolise vitamin B12 and impair
absorption.Whensystemicsclerosis(SSc)involvesthesmallintestine,normalperistaltic
movementsarelostandmotilityisimpairedleadingtostasisanddilatation.
42
www
matology
RheumatollogyQ0399
A555yearoldm
mandevelop pssuddeno onsetseverepaininhissrightbigtoe.
Onexaminationhehassw wellingofth hemetacarp pophalangeealjointofh hisrighthallux.The
surrroundskiniiserythemaatous.Itisttendertoto
ouch.Initialinvestigationsreveal araised
whitecell,counntandanelevatedCRP P.
Wha atshouldbeedonetoco
onfirmthed diagnosis?
A.MRIo
ofthetoe
B.Serum
muricacid
C.Serum
mrheumatoid
D.Jointfluidaspirateformicroscopy
E.Serum
mpyrophosp
phatelevels
Answer:d)join
ntfluidaspirateformiccroscopy.
Theelikelydiagnosisisacuutegout.Th heserumin nflammatoryymarkersaareraised, buturic

acid
dlevelsmayybenormall.
Join
nt fluid asp
pirate best test. Polarrised light microscopyy shows strrongly bireffringent
(neggativesign)needleshaapedcrystals.

AcuteGoutinvvolvingthelleftfoot
Dr.K
ohagTeachin
ngHospital2012
43
www.MRCPass.com
Rheumatology
RheumatologyQ040
A 80 year old man developed acute monoarthritis of his right ankle following an
admissionwithcongestivecardiacfailure.Hementionedthathehadankleoedemaand
hadrecentlybeenprescribedfrusemidebytheGP.
A.Rheumatoidarthritis
B.Gout
C.Pseudogout
D.Osteoarthritis
E.Septicarthritis
Answer:b)Gout.
Goutcanbeprecipitatedbydiuretics,e.g.frusemide.
44
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Rheumatology
RheumatologyQ041
A 45 year old has a past history of systemic sclerosis. She now has headaches and
blurredvision.Onexamination,shehasabloodpressureof220/100mmHgandthereis
evidenceofbilateralpapilloedema.
Whichofthefollowingmedicationsshouldbeprescribed?
A.Oralhydrochlorothiazide
B.OralLisinopril
C.SublingualNimodipine
D.IVSodiumNitroprusside
E.IVLabetolol
Answer:b)OralLisinopril.
A major complication of scleroderma is renal crisis which is characterised by abrupt

onsetofseverehypertension.Thehypertensionalmostalwaysisseverewithadiastolic
BPover100mmHgin90%ofpatients.Thereisassociatedhypertensiveretinopathyin
about 85% of patients. ACE inhibitors are first line, with an aim to reduce the blood
pressuregradually.
45
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Rheumatology
RheumatologyQ042
A 50 year old man presents an acute monoarthritis of left knee. Gout is confirmed
followingjointaspirationandexaminationoffluidunderpolarisedlightmicroscopy.He
hadalsounderwentendoscopy3weeksearlierbecauseofindigestionthisconfirmeda
duodenalulcer.
Whichoneofthefollowingisthebesttreatmentforthepatient?
A.Allopurinol
B.Intraarticularcorticosteroidinjection
C.IndomethacinandLansoprazole
D.CelecoxibandLansoprazole
E.IndomethacinandMisoprostol
Answer:b)Intraarticularcorticosteroidinjection.
All nonsteroidals including Cox II selective inhibitors are relatively contraindicated in

the presence of active ulceration. In a large joint such as the knee, the safest option
wouldbeinjectcorticosteroidintothejoint.
46
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Rheumatology
RheumatologyQ043
A 62 year old man has a 5 week history of pain and swelling affecting left knee, both
anklesandhisrightwrist.
Hehaslost6kginweight.
Hisinvestigationsshow:
WCC14.1X10^9/l
Hb10.3X10^9/l
MCV72fl
plt510X10^9/l
ESR63mminthefirsthour
CRP21g/l
CK120iu
RhF1/80
ANAnegative
ENAnegative
XRofhandsandfeetnormal.
A.Paraneoplasticsyndrome
B.Osteoarthritis
C.Polymyositis
D.Scleroderma
E.Behcet'ssyndrome
Answer:a)Paraneoplasticsyndrome.
The CK is not significantly raised. Weight loss and anaemia suggest underlying
malignancy.Paraneoplasticsyndromecanpresentwithanassymetricalarthralgiawhich
morecommonlyaffectsthelowerlimbs.Falsepositiverheumatoidfactorcanoccurbut
shouldbeoflowtitre.
47
www
matology
RheumatollogyQ0444
A 45 year old lady has h

had long staanding arth
hritis of herr hands. Heer has hand
d Xrays
donne.
Whiich of the following X ray cha anges suggests rheum matoid arth hritis instea
ad of a
seroonegativeaarthropathy?
A.Osteo
osclerosis
B.Osteo
ophytes
C.Osteo
oporoticchan
nges
D.Periarticularerosions
E.Losso
ofjointspacee
Answer:d)perriarticularerrosions.
Osteeophytesanndlossofjo
ointspaceaarecommon nlyfoundinnosteoarthritis,althou
ughthey
can alsobefou
undinrheu umatoidartthritis.Periaarticularero
osionsarem
mostsuggeestiveof
rheu
umatoidartthritis.

Periiarticularerrosions
Dr.K
ohagTeachin
ngHospital2012
48
www.MRCPass.com
Rheumatology
RheumatologyQ045
A 76 year old woman presents with weakness of his hand. On examination there was
tenderness, crepitus and bony swellings over the base of the first metacarpal and
wastingoftherightthenareminence.
InvestigationsrevealanESRof25mm/1sthr,aCRPof10mg/L,aUrateconcentrationof
0.42 (0.190.36). Her Rheumatoid factor was 60 IU/L (<30). An xray of the right hand
showed a loss of joint space, periarticular sclerosis and osteophytes of the first
carpometacarpaljoint.
A.Osteoarthritis
B.DeQuervainstenosynovitis
C.Pseudogout
D.Gout
E.Rheumatoidarthritis
Answer:a)osteoarthritis.
Thepatienthasclinicalandradiologicalfeaturesconsistentwithosteoarthritis(OA)of
the1strightcarpometacarpal(CMC)joint.Theconditionischaracterisedbyjointpain,
crepitus and stiffness after movement. Joint swellings are bony in nature (Bouchard's
and Heberden's nodes), unlike boggy swellings which occurs in inflammatory arthritis.
This patients inflammatory markers are mildly raised only, making an inflammatory
arthritisunlikely.
49
www
matology
RheumatollogyQ0466
A700yearoldm manpresen ntswithsevverebackpains.AnHisstotalserumproteiniis85g/l

withhanalbumiinof41g/l.
A chest X rayy shows sevveral lucen dies. A sterrnal bone marrow
ncies in verrtebral bod
aspiirateobtainnsadarkred djellylikem
materialinthesyringe.
Thesmearofa aspirateislikkelytoshowwwhichpro ominentfea atures?

A.Macrophages
B.Osteo
oblasts
C.Plasm
macells
D.Pneumocytes
E.Osteo
osarcoma
Answer:c)Plassmacells.
Thee diagnosis is multiple myeloma. The bone marrow neeedle is likeely to be in

n a lytic
lesio
on filled with
w plasmaa cells. Hiss serum glo
obulins aree high from
m the mon noclonal
gammmopathy.

Apllasmacell
Dr.K
ohagTeachin
ngHospital2012
50
www.MRCPass.com
Rheumatology
RheumatologyQ047
A75yearoldmanpresentswithbilateralhippains.Investigationsreveal:
Correctedcalcium2.5(2.22.6)mmol/l
ESR22mm/1sthr
Alkalinephosphatase800iu/L(50100)
gammaGT22iu/L
A.Osteoporosis
B.Osteomalacia
C.Paget'sdiseaseofthepelvis
D.Polymyalgiarheumatica
E.Multiplemyeloma
Answer:c)Paget'sdiseaseofthepelvis.
This elderly patient presenting with bone pains has significantly elevated alkaline
phosphatasebutnormalcalciumconcentrationssuggestingadiagnosisofPaget's.
51
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matology
RheumatollogyQ0488
A 25 year old Turkish maan was noteed by ophtthalmologistts to have a posteriorr uveitis
requuiringhighdoseimmunosuppresssion.Hehassahistoryo ofrecurrenttmouthulccersand
painnfululcersoonthescrottum.
A.Behceet'ssyndrom
me
B.Reiterssyndromee
C.Ankylosingspondylitis
D.Takayyasu'sarterittis
E.Giantcellarteritiss
Answer:a)Beh
hcet'ssyndrrome.
Behhcet's syndrome is claassically chharacterized d as a triad of symptoms that include

recuurringcropssofmouth ulcers(calledapthousulcers),genitalulcerrs,anduveiitis.The
ulceersareusuaallypainful.Thediseasseismoreffrequentan ndseverein npatientsfrromthe
EastternMediteerraneanan ndAsiathan nthoseofEEuropeandeescent.
Eye manifestattions may result
r in bliindness. In addition, iritis, retinaal vessel occclusions
andopticneurritiscan be found. Hyp popyonuve eitis(pus in
ntheanteriorchamberofthe
eye), which is
i considerred the haallmark off Behets disease, is i in fact a rare
man nifestation. ThearthrittisofBeheetsdiseaseeisusually intermitten nt,selflimitted,not
defoormingandlocalizedto othekneessandankless.

Oralulceration
ninBehcet'ssdisease
Dr.K
ohagTeachin
ngHospital2012
52
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Rheumatology
RheumatologyQ049
A70yearoldwomanhaspolydipsiaandpolyuriafor3months.Shealsocomplainsof
loinpains.Shehasnotbeenonanymedication.Investigationsreveal:
serumurea6(2.57.5)mol/l
serumcreatinine80(60110)mol/l
serumalbumin38g/L(3749)
serumtotalcalcium3.1(2.22.6)
Whatisthelikelycauseofthehypercalcaemia?
A.Multiplemyeloma
B.Sarcoidosis
C.Paget'sdisease
D.Primaryhyperparathyroidism
E.VitaminDtoxicity
Answer:d)Primaryhyperparathyroidism.
PrimaryhyperparathyroidismiscausedbyanoverproductionofPTH.
Excess PTH results in an increase in bone breakdown by means of osteoclastic
resorption with subsequent fibrous replacement and reactive osteoblastic activity.
Historically,inclassicprimaryhyperparathyroidism,nephrolithiasiswasnotedin50%of
patients, and it was the most common clinical presentation of the disease. Additional
manifestations of primary hyperparathyroidism include pancreatitis, peptic ulcer
disease,andcardiovascularabnormalities.
53
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Rheumatology
RheumatologyQ050
A42yearoldladypresentswithbackache.Herbloodresultsareasfollows:
Hb11g/dL
Ca1.9mmol/L
Phosphate0.8mmol/L
Alkalinephosphatase220U/L
Albumin38g/L
Urea7mmol/L
Sodium142mmol/L
Potassium3.9mmol/L
Whatisthediagnosis?
A.Osteoporosis
B.Paget'sdisease
C.Osteomalacia
D.Xlinkedhypophosphataemicrickets
E.Hypoparathyoroidism
Answer:c)osteomalacia.
The patient has osteomalacia with secondary hyperparathyroidism causing low

phosphate levels. Osteomalacia is due to vitamin D deficiency which could be due to
malabsorptionordietarydefiency,orrenal/liverdisease.
54
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Rheumatology
RheumatologyQ051
A 32 year old woman has a deep vein thrombosis. Her previous history included
investigationsformiscarriages.
Investigations revealed: Haemoglobin 11.9 g/dl, White cell count 4 x 10^9/L, Platelet
count30x10^9/L.
Whichofthesearelikelytobeabnormal?
A.Homocysteinelevel
B.ANCA
C.ProteinC
D.Antiphospholipidantibody
E.Coomb'stest
Answer:d)Antiphospholipidantibody.
Antiphospholipid syndrome leads to venous and arterial thrombosis, livedo reticularis,

splinter hemorrhages, leg ulcer, multiinfarct dementia, chorea, Thrmobocytopenia
(40%ofpatients),hemolyticanemiaandlatetermmiscarriages.
55
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Rheumatology
RheumatologyQ052
A 35 year old man presents with acute stiffness swelling of his knees and ankles, a
painful rash on his legs. The ESR was 100 mm/hour. Chest Xray showed hilar
lymphadenopathybilaterally.
Whatisthelikelyprogressionofthearthralgia?
A.Chronicarthritis
B.Septicarthritis
C.Improvementonlywithsteroids
D.Spontaneousimprovement
E.Permanentjointdestruction
Answer:d)spontaneousimprovement.
Thedescriptiontypicalofacutesarcoidosiserythemanodosum,oligoarthropathyand
hilar lymphadenopathy. This usually has a good prognosis, with resolution over 68
weeks.
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Rheumatology
RheumatologyQ053
A75yearoldladypresentswithbackpains.LateralspineXraysandpelvicxraysshow
osteopenia. A serum corrected calcium is 1.8 mmol/l and phosphate is 0.6 mmol/l.
Alkalinephosphataseis360U/l.
Whichdiagnosisismostlikely?
A.Myeloma
B.Osteoporosis
C.Osteomalacia
D.Paget'sdisease
Answer:c)osteomalacia.
Osteomalacia is more likely than osteoporosisdue to the low calcium, low phosphate
andraisedalkalinephosphatse.TheconditioniscausedbylowvitaminDlevels.
Alkalinephosphataseisraisedwhenthereisincreasedosteoblasticactivity,conditions
itmayberaisedin:
Paget'sdisease
osteomalaciaandrickets
renalosteodystrophy
bonemetastases
57
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Rheumatology
RheumatologyQ054
A 22 year old lady has a sw inging fever, half a stone weight loss over 2 months,
generalised myalgia, polyarthralgia affecting wrists, knees, ankles, elbows
metacarpophalangealjointsandasorethroat.
Investigationsshow:Hb9.5g/l,MCV85fl,ESR92mminfirsthour,CRP45g/l,serum
ferritin1600mg/dl,RFnegative,ANAnegative,ENAnegative,ASOtitre<200iu.
B.Ankylosingspondylitis
C.AdultonsetStill'sdisease
D.Inclusionbodymyositis
E.Polymyositis
Answer:c)AdultonsetStill'sdisease.
AdultOnsetStillsDisease(AOSD)isan acutefebrileillness inyoungadults.Itusually

affectsmultipleorgans,butisadiagnosisofexclusion.
Clinical features include a high fever, arthralgia and arthritis, phayngitis, typical rash
(evanescent salmoncolored, macular or maculopapular eruption), lymphadenopathy,
andserositis.Chronicarthritisandconstitutionalsymptomsarecommon.
The triad of fever, rash, and arthralgia are often absent during the first month of the
illness.Theusualjointsaffectedarewrists,knees,andanklesindescendingorder.
Twothirdsofcasesexperiencepolyarticulararthritisandonethirdhavemonoarticular
symptoms.
Approximately 1/3 of patients have chronic persistent disease with progressive joint
damage.
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Rheumatology
RheumatologyQ055
A65yearoldwomanhasaswollen,erythematouskneejoint.Aspirationofthejointwas
performed.Microscopyshowedpositivelybirefringentcrystals.
Whatarethecrystalscomposedof?
A.Calciumcarbonate
B.Magnesiumsulphate
C.Urate
D.Calciumpyrophosphate
E.Aminolaevulinicacid
Answer:D)calciumpyrophosphate.
Pseudogout is caused by the deposition of calcium pyrophosphate deposition rather

than the deposition of uric acid derivatives that cause gout. Also, in pseudogout,
synovialfluidsamplesobtainedwithaspirationhavepositivebirefringence.Thisfinding
isindirectcontrasttothenegativebirefringenceingout.
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Rheumatology
RheumatologyQ056
A45yearoldwomanpresentswithclaudicationinherlowerlimbs.Sheisnotedtohave
absentleftarmpulses.
Thepreviousyearshehadasmallhemisphericcerebrovascularinfarct.
A.Giantcellarteritis
B.Takayasu'sarteritis
C.Familialhypercholesterolaemia
D.Coarctationoftheaorta
E.Antiphospholipidsyndrome
Answer:b)Takayasu'sarteritis.
Takayasu'sarteritisisalargevesselvasculitisofunknownorigin.Thevasculiticprocess
involves structures such as the aorta, great vessels, the sclera and the cardiac
conductiontissues.
Women are affected more than men, usually in the second and third decades of life.
Presentation is often with symptoms such as fever, weight loss, night sweats and
arthralgias. Symptoms related to ischaemia may include ischaemic stroke, visual
disturbancesandclaudication.
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Rheumatology
RheumatologyQ057
A 70 year old man develops weakness of the shoulders and around the hips over a 6
month period. He hasalso noticed weakfinger flexors. He complained of difficulty sw
allow ing liquids. There is no other significant past medical history. He smokes 15
cigarettesadayanddrinksabottleofwineattheweekend.Acreatininekinaselevel
comesbackat120U/l.
A muscle biopsy sample shows myopathic changes. There are also inflammatory
infiltratesandintracytoplasmicvacuolespresent.
A.Polymyositis
B.Fibromyalgia
C.Polymyalgiarheumatica
D.Dermatomyositis
E.Inclusionbodymyositis
Answer:e)inclusionbodymyositis.
The diagnosis is inclusion body myositis (IBM). This is an inflammatory condition

affecting patients over the age of 50. Proximal muscles in the upper and lower limbs,
andfingerflexorsarepredominantlyinvolved.TheonsetofmuscleweaknessinIBMis
generallygradual(overmonthsoryears).Dysphagiaiscommon,occurringin4066%of
patients.
IBMoccursmorefrequentlyinmenthanwomen.CKmaybenormal.Amusclebiopsy
usuallyshowsintracytoplasmicinclusionsandalsoinflammatoryinfiltrates.
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Thigghatrophysseenininclusionbodymyositis

Inclusionbodie
esandinflam
mmatoryin
nfiltrates(arrrows)

Dr.K
ohagTeachin
ngHospital2012
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matology
RheumatollogyQ0588
A 53
5 year old d woman with
w rheummatoid arthhritis was rreferred with iron deeficiency
anaemia. She had exten nsive investtigations. Endoscopy
E showed gaastritis andd antral
erossions, small bow el biopsy shoowing mild villous bluunting, andd apopotic bodies,
Colo
onoscopyw wasnormal.
Wha atisthecau
useoftheseefindings?
A.Meth
hotrexate
B.Azath
hioprinetherrapy
C.Crohn
nsdisease
D.NSAID
Dtherapy
E.Felty'ssyndrome
Answer:d)NSA
AIDtherapyy.
TheeendoscopyyfindingsarresuggestivveofNSAID
Drelatedgasstritis,whicchisthemo
ostlikely
causeofirondeficiencyan
naemia.

NSA
AIDrelatedgastritis
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ059
A 45 year old woman complains of 12 months of mid and lower back pain associated
withstiffnessinhershoulders,wrists,smalljointsofthehands,hipskneesandfeet.The
jointstiffnessismorepronouncedinthemorningandlasts23hoursandisassociated
withseverefatigue.
She also experiences occasional pins and needles affecting all of the right hand and
frequentfrontalandtemporalheadache.
Clinicalexaminationdemonstratesnosynovitisbuttendernessaroundthebaseofthe
cervical spine, across the shoulders, over the costochondral cartilages, greater
trochanterandtheknee.
Investigationsareasfollows:CRP<5g/l,ESR20mminthefirsthour,CK120U/l,serum
immunoglobulinsandproteinelectrophoresisnormal.
Whatisthediagnosis?
A.SLE
B.Polymyalgiarheumatica
C.Fibromyalgia
D.Dermatomyositis
E.Polymyositis
Answer:c)Fibromyalgia.
Theabovesymptomsareallcharacteristicforfibromyalgia.Theinflammatorymarkers
andCKarenotraised,makingtheotherdiagnosesunlikely
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Rheumatology
RheumatologyQ060
A35yearoldmanpresentswithhotswollenelbowjoint.Hehasatemperatureof37C
andCRPof350mg/l.Adiagnosisofsepticarthritisissuspected.
Whichofthefollowingorganismsismostcommonlyisolatedfromjoints?
A.Staphyloccocusaureus
B.Neisseriagonorrhoeae
C.haemolyticstreptococcus
D.Pseudomonasaeruginosa
E.Moraxellacatarrhalis
Answer:a)staphyloccocusaureus.
Staphaureusisthecommonestorganism(over50%).Neisseriagonorrheacanoccurin
patients with sexually transmitted disease. haemolytic streptococci can cause
impetigo,sorethroatandrheumatic fever.Moraxella isagram negativecoccuswhich
cancausepneumoniainCOPDpatients.
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Rheumatology
RheumatologyQ061
A 66 year old lady had a fall and fractured femur. A DEXA scan shows reduced bone
mineraldensityconsistentwithosteoporosis.
Whattreatmentshouldbegiventoreducethelikelihoodoffuturefractures?
A.Alendronate
B.Alendronateandcalcium
C.Alendronate,calciumandvitaminD
D.Calcium
E.VitaminD
Answer:C)alendronate,calciumandvitaminD
Any patient above the age of 65 with osteoporosis is recommended to be on

bisphosphonates.Inaddition,thispatienthassustainedafracture,andshouldalsobe
oncalciumandvitaminD(calcichewD3)aswell.
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Rheumatology
RheumatologyQ062
A82yearoldwomanpresentswithconfusion.OfnoteinherpasthistorywasRaynauds
phenomenon.
Herinvestigationsshow:
haemoglobin9.7g/dl
whitecellcount3.6x10^9/l
plateletcount100x10^9/l
serumtotalprotein120g/l
serumimmunoglobulins:IgA0.75g/l(0.83),IgG16g/l(613),IgM35g/l(0.42.5)
Whichofthefollowingcomplicationsisshelikelydevelop?
A.Urinarytractinfection
B.Hyperviscositysyndrome
C.Pathologicalbonefracture
D.Acuterenalfailure
E.Erythemanodosum
Answer:b)Hyperviscositysyndrome.
ThelikelydiagnosisisWaldenstromsMacroglobulinaemia(WM).
Waldenstroms macroglobulinaemia is a type of nonHodgkins lymphoma. It is a
condition which typically presents in the seventh and eighth decade of life. It is
characterized by the presence of a high level of a macroglobulin immunoglobulin M
[IgM]andelevatedserumviscosityinthepresenceofalymphoplasmacyticinfiltratein
thebonemarrow.Thetreatmentischemotherapy(ChlorambucilorFludarabine).
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Rheumatology
RheumatologyQ063
A 72 year old woman complained of pain at the base of her right thumb. There was
tenderness and swelling of the right first carpometacarpal joint. Finkelsteins test is
negative.
A.Avascularnecrosisofthescaphoid
B.DeQuervain'stenosynovitis
C.Osteoarthritis
D.Psoriaticarthritis
Answer:C)osteoarthritis.
The tenderness at the carpometacarpal joint is most likely due to osteoarthritis in a

patientofthisage.
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matology
RheumatollogyQ0644
A 45
4 year old man presents to thee opthalmo
ologist and was found
d to have anterior
a
uveitis.Uponeenquiry,hehasmouthulcersandarashonhisleg.
A.ALam
myloidosis
B.Familialmediterraaneanfever
C.Behceet'sdisease
myalgiarheumatica
D.Polym
E.SLE
Answer:c)Beh
hcet'sdiseasse.
Beh
hets disease may cause antterior or posterior uveitis, co orneal ulceration,
conjjunctivitis, papillitis, SVC and IVC
I thromb
bosis, pulm
monary em mbolism, errythema
nod
dosum,pusttularlesionss,acneiform mnodules,p
pathergyanndoralulceration.

AnteriorUveitisinBehcet'sdisease
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ065
InapatientwithSLE,theriskofcardiovascularabnormalityisincreasedwithpresence
ofwhichoneofthefollowing?
A.Anticardiolipinantibody
B.AntiRoantibody
C.AntiLaantibody
D.ANAantibody
E.AntiJoantibody
Answer:B)antiRoantibody
AntiRoisimportantinpregnancysinceitisassociatedwithbabiesbornwithcongenital
heartblock.
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Rheumatology
RheumatologyQ066
A50yearoldsecretarynoticedtinglingandnumbnessover thepalmarsurface ofher

thumb,indexandmiddlefingersafterseveralhoursathercomputer.Paininthesame
areasoftenoccuratnight.
Whatisthediagnosis?
B.Gout
C.Dermatomyositis
D.Carpaltunnelsyndrome
E.Psoriaticarthritis
Answer:d)Carpaltunnelsyndrome.
The diagnosis is carpal tunnel syndrome, and the symptoms are due to tenosynovitis
whichisworsenedbyrepetitivestrainimposedbytyping.
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Rheumatology
RheumatologyQ067
A75yearoldmancomplainsofpainandstiffnessinbothhisshoulders.Hehaslost1/2
a stone in last 6 weeks due to loss of appetite. Investigations show : ESR 95 mm/hr,
normochromicnormocyticanaemiaandapositiverheumatoidfactor.
Thelikelydiagnosisis:
A.Fibromyalgia
B.Polymyositis
C.Dermatomyositis
D.PolymyalgiaRheumatica
E.Chronicmyeloidleukaemia
Answer:d)PolymyalgiaRheumatica.
PolymyalgiaRheumaticaisassociatedwithweightloss,anemia&malaise.
It can also be associated with a false positive rheumatoid factor, especially in the
elderly.
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Rheumatology
RheumatologyQ068
A12yearoldboyhasfevers.Hehashadelbow,shoulderandhipandkneepainsover
the last few months. On examination, he has a temperature of 37.5 C and palpable
hepatosplenomegaly.
InvestigationsshowaCRPof30andnegativeANA.
A.Marfan'ssyndrome
B.EhlerDanlossyndrome
C.Perthe'sdisease
D.Juvenilechronicarthritis
E.Osteoarthritis
Answer:d)juvenilechronicarthritis.
Juvenile chronic arthritis (JCA) is a form of seronegative arthritis in the young (adult
formknownasStillsdisease)whichisrheumatoidfactorandANAnegative.Diagnostic
criteria include high fever, hepatomegaly, splenomegaly, lymphadenopathy, serositis
(pleuritis,pericarditis),leucocytosis.Bonedestructionandmicrognathiaoccurs.
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Rheumatology
RheumatologyQ069
A25yearoldladypresentstoclinicwithapainfullyswollenhotrightknee.Shegivesa2
week history of migratory polyarthritis and urethritis. Clinical examination reveals a
pustular skin rash, right Achilles tendinitis and left plantar fasciitis. She is HLAB27
negative.
A.Relapsingpolychondritis
B.Reiterssyndrome
C.Gonoccocalarthritis
D.Nonspecificurethritis
E.Behcet'ssyndrome
Answer:c)Gonoccocalarthritis.
Gonoccocalarthritisclassicallypresentswithahotjointonabackgroundofamigrating
polyarthropathy. It affects w omen more frequently than men (4:1) and its highest
incidence is among sexually active adolescent girls. There is also increased risk during
menstruationandpregnancy.
Twoformsofarthritisexistonewithskinrashesandmultiplejointinvolvement,anda
second,lesscommon,forminwhichdisseminatedgonococcemialeadstoinfectionofa
singlejoint(monoarticular)andjointfluidculturesarepositive.
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Rheumatology
RheumatologyQ070
A50yearoldwomanwithlongstandingrheumatoidarthritis,andasiccasyndrome.She
presentswithincreasingmalaise.Investigationsshowed:
Hb7.5g/dl
Neutrophilcount1.2x10^9/l
plateletcount90x10^9/l
HerESRwas120mm/hrandCRP145mg/dl
Onexamination,shewaspaleandhadpalpablesplenomegalyof6cmedge.
Themostlikelycauseofherhaematologicabnormalitiesis:
A.Anaemiachronicdisease
B.UpperGIbleed
C.Felty'ssyndrome
D.Folatedeficiency
E.Irondeficiency
Answer:c)Felty'ssyndrome.
Felty'ssyndromeisthetriadofseropositivearthritis,splenomegalyandneutropenia.
The cause of Felty's syndrome is not known, but is most commonly associated with
rheumatoidarthritis.
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Rheumatology
RheumatologyQ071
32 year old lady upper middle class white lady who used to be an athlete has been
referred for investigation due to tiredness. She mentions fatigue which is chronic and
occurs even after minor physical w ork. This has been going on for 3 years.
Investigations including CK, ESR, EMGs and muscle biopsy have revealed no obvious
medicalcauseforthis.
Whichofthefollowingisthebesttreatment?
A.Erythropoietininjections
B.Cognitivebehaviouraltherapy
C.Gradedexerciseprogramme
D.Codeine
E.Fluoxetine
Answer:C)Gradedexerciseprogramme.
ChronicFatiguesyndromeisdefinedbysymptomsandnotsigns.Theclinicalprofileof
an individual with CFS is of a highachieving student or athlete who usually is female
(80%), white, and middleclass to upper middleclass. Treatment is largely supportive
andresponsivetosymptomatology.Thisincludesphysicaltherapyandmodestaerobic
oranaerobicexercise(ifpossible)toavoidcardiovasculardeconditioning.Sleepmaybe
addressed with medication; often, melatonin or nighttime amitriptyline is helpful. If
presentandsevere,painoftenisaddressedinapainclinic.
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RheumatollogyQ0722
A45
5yearoldp
patientpressentswithpproximalmuscleweakness,particcularlyinth
helower
limb
bs.Shehasaheliotropicrasharou
undtheeyeesandalsoGGottronspapules.
Whiichoneofth
hefollowing
gantibodieesismoststtronglyasso
ociated?
A.La
B.Ro
C.Jo1
D.SCL7
70
E.AntiD
DsDNA
Answer:C)Jo1
1.
Thee diagnosis is dermato omyositis. Anti Jo1 antibody

a is associated with acute onset
myoositis, particularly dermatomyositis. The limmb girdle or proximal muscles arre most
seveerelyaffectedinbothp polymyositiisanddermmatomyositis.

Gotttron'spapu
ules
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ073
A9yearoldboyisbroughttothepaediatricianwithcomplaintsoffeverfor1week.He
alsohascrackedlips,whicharepainful.
Onexamination,hiseyesareredandhehasalymphnodeinthecervicalregion.Kaw
asakisyndromeissuspected.
Whichofthefollowingisthebesttreatmentchoice?
A.Intravenousimmunoglobulim
B.Hydrocortisone
C.Abxicimab
D.Amoxicillin
E.Lowmolecularweightheparin
Answer:a)Intravenousimmunoglobulin.
ThisisacaseofKawasakissyndrome,whichisalsoknownasmucocutaneouslymph
node syndrome and occurs mainly in children under 10 years of age. It is a form of
vasculitis, which affects coronary arteries and is associated with the development of
coronaryaneurysms.
AspirinandIVimmunoglobulinathighdosesisthetreatmentofchoice.Corticosteroids
used to be contraindicated, but recently trials have shown that it reduced the risk of
heartdamagecausedbycoronaryvesselvasculitis.
Infliximabisalsobeingusedintrials.Warfarinisusedifcoronaryaneurysmsdevelopas
acomplication.
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Rheumatology
RheumatologyQ074
A55yearoldwomanpresentswitha2monthhistoryofpainaffectingthecervicalspine
and both shoulders, this was preceded by pain in the lower back and both hips. Early
morning stiffness lasts until lunchtime and she feels markedly tired and weak.
Examinationrevealsbilateralkneeeffusionsandarightcarpaltunnelsyndrome.
InvestigationsdemonstrateanormochromicnomocyticanaemiaofHb9.8g/dl,ESR72
mm in the first hour, CRP 12 g/l, serum immunoglobulins and protein electrophoresis
show a polyclonal increase in gamma globulins and elevated alpha 1 and alpha 2
globulinsbutnoparaproteinband.
B.Paraneoplasticsyndrome
C.Mixedconnectivetissuedisease
D.Scleroderma
E.Polymyalgiarheumatica
Answer:e)Polymyalgiarheumatica.
Polymyalgia rheumatica (PMR) is a clinical diagnosis based on pain and stiffness of

pelvicgirdleandshoulder.Itismorecommonaftertheageof55.
Incontrasttopolymyositisthereisnomuscularweakness.Earlymorningstiffnessofthe
hipandshouldergirdlesiscommon.Anormochromicnormocyticanaemiaisassociated.
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Rheumatology
RheumatologyQ075
A55yearoldmanpresentswithsuddenonsetofarightsidedfootdropwithnumbness
overthedorsumofhisrightfoot.Hehasweaknessofdorsiflexionandeversionofhis
rightfoot.Thereisanareaofdiminishedsensationoverthedorsumoftherightfoot.He
also has a left wrist drop with loss of sensation over the dorsal aspect of the first
interosseusspace.Forthelasttwomonths,hehaslostweightandhehadgeneralized
myalgia.
Investigationsreveal:
Hb11.5g/dL
WBC13x10^9/l
Neutrophils9.2x10^9/l
Lymphocytes2.2x10^9/l
ESR60mm/1sthour
Urinalysis:Protein++,Blood++
Themostlikelydiagnosisis:
A.Tuberculosis
B.Polyarteritisnodosa
C.Sarcoidosis
E.Systemiclupuserythematosus
Answer:b)Polyarteritisnodosa.
The patient has a systemic illness with mononeuritis multiplex and renal involvement.
Although all the listed conditions can cause mononeuritis, PAN is one of the few
connective tissue disorders that usually occur in middleaged men unlike RA and SLE,
whicharecommonerinfemales.
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RheumatollogyQ0766
A600yearoldmmanpresen ntswithpaininhislefttfoot.Hem
mentionsthaathehashadpoor
mob bility.Generalexaminaationrevealsaswollen nankle.Neu urologicalexxaminationreveals
abseentanklejeerkandweaakfootflexion/extensiiononthelleft.HisESR Ris30mm//hr,CRP
is<5
5mg/l.Jointtxrayreveealssubchonndralfractu ngandanarrowed
ures,softtisssueswellin
jointspace.
Thelikelydiagnnosisis:
A.Charccot'sjoint
B.Osteo
oarthritis
C.Gout
nilechronicaarthritis
D.Juven
E.Previo
ousroadtraffficaccident
Answer:a)Chaarcot'sjoint.
Chaarcot joint or neurop pathic joint disease caan be caussed by diaabetic neurropathy,
syphhillis, syringgomyelia or
o leprosy. The X ray changes are
a reduced d joint space with
periiarticular destruction,
d , subchonddral bodiess, loose boodies and occasionally joint
dislo
ocation.

Chaarcot'sjoint
Dr.K
ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ077
A55yearoldmanpresentswithlethargy,polyuria,polydipsiaandstiffnessofthehands.
Hehasevidenceofanarthopathyaffectingthe2nd&3rdmetacarpophalangealjointsof
bothhands.Xrayconfirmsevidenceofdegenerativediseaseatthesesites.
Whichofthefollowingthelikelydiagnosis?
A.Behcet'ssyndrome
B.Haemochromatosis
C.Amyloidosis
D.Reiter'ssyndrome
E.Osteoarthritis
Answer:b)haemochromatosis.
The characteristic feature of haemochromatotic arthropathy is involvement of the

secondandthirdmetacarpals.Thearthropathycanleadtoextensivejointdestruction.
These patients may have episodes of acute, inflammatory pseudogout from such
deposition.
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Rheumatology
RheumatologyQ078
An22yearoldgirlpresentswitha6weekhistoryofpolyarthralgiawithearlymorning
stiffness.HersymptomsrespondedwellinitiallytoIbuprofenbutshethentheyworsen
again. She is otherw ise well apart from a history of acne which well controlled on
Minocycline.Hermothersevererheumatoidarthritis.
Investigations show : ESR 40 mm/hr, CRP 110 mg/l, rheumatoid factor negative, ANA
stronglypositive(1:1600),antidsDNAantibodiesnegative.
Whatisthelikelycauseofhersymptoms?
A.Druginducedlupus
B.SystemicLupusErythematosus
C.Psoriaticarthropathy
D.Juvenilechronicarthritis
E.Fibromyalgia
Answer:a)Druginducedlupus.
The likely diagnosis is drug induced SLE. Minocycline is one of the causes well
documentedasacauseofdruginducedSLE.
Characteristically,inflammatorymarkerssuchasESR&CRParebothmarkedlyelevated.
ANAcanbestronglypositivebutAntidsDNAantibodiesareusuallynegative.Symptoms
usuallyresolvefollowingwithdrawalofthedrugafterseveralmonths.
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Rheumatology
RheumatologyQ079
A50yearoldwomanpresentstocasualtywitha2dayhistoryofpainandswellingof
theleftankle.Shedeniesanyhistoryofrecenttrauma.Onexamination,shewasfebrile,
temperature38.3C.Theleftanklewasswollenandverytenderwithareducedrange
ofmovement.
Whichofthefollowinginvestigationswouldbemosthelpful?
A.Uratelevel
B.ESR
C.Rheumatoidfactor
D.Aspirationofsynovialfluid
E.KneeXray
Answer:d)aspirationofsynovialfluid.
Joint fluid examination is important in excluding septic arthritis, and can also help to
confimgoutorpseudogout.
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Rheumatology
RheumatologyQ080
A 35 year old woman with newly diagnosed rheumatoid arthritis enquires about risk
factors.
Whichoneofthefollowingisariskfactorforrheumatoidarthritis?
A.Pneumococcalinfection
B.HLADR4
C.SLE
D.HIV
E.Renalfailure
Answer:b)HLADR4.
Riskfactorsforrheumatoidarthritisare:
HLADR4
EBV
parvovirusB19andrubellainfections
bloodtransfusion
smoking(inducesRFproduction)
stress
obesity
PregnancyandOCPareprotective.
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Rheumatology
RheumatologyQ081
A26yearoldmanpresentswitha6monthhistoryoflowbackpain.Thepainradiatesto
his buttocks. There is associated stiffness which is w orse in the morning and after
periodsofinactivity.
Whichofthefollowingsignsismostlikelytobepresent?
A.Footdrop
B.Positivefemoralstretchtest
C.PositiveTrendelenburgtest
D.Sacroiliacjointtenderness
E.Kernigssign
Answer:D)sacroiliacjointtenderness.
Thediagnosisisankylosingspondylitisasthisisayoungpatientwithlowerbackpains
andmorningstiffness.Sacroilitisisacommonmanifestation.
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RheumatollogyQ0822
A62
2yearoldm manhascom mplainsofaapainintheetemples,ffevers,sweaatsandmalaisefor
4w
weeks.Therrightsideoffthefacew
wasmildlysswollenand dheexperieencedvisuaallossin
therighteye.
Oneexamination,hehadp prominentaandtenderttemporalarrteriesonth heright.
Bloo
odtestsrevvealed:
Hb1
12.5g/dl MCV86fl
WCC12x10^9 9/l plattelets212xx10^9/l
ESRof90mm//hr
Whaatisthelikeelydiagnosiis?
A.Pituittarytumour
B.Gravee'sdisease
C.Pagett'sdisease
D.Catarract
E.Temp
poralarteritiss

Answer:e)tem
mporalarterritis.
Theediagnosisistemporalarteritis(giiantcellarte eritis).
Thee complications of Giaant Cell Artthritis are related to arterial infflammation
n. These
include:
blindness
absentpulsses
hypertensioon
angina
stroke
claudication

Prominenttem
mporalarterries
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ohagTeachin
ngHospital2012
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matology
RheumatollogyQ0833
A600yearoldw womanpreesentswith ahistoryo ofprogressivedifficultyyinclimbin ngstairs

andrisingfrom mchairs.
Shealsocomplainsofdiffficultyinsw wallowing.Shecompllainsthatherhandsdiscolour
andbecomeco oldeasily.
On examinatio on she has purple disccolouration of her eyeelids and periorbital oedema.
o
Theereisweakn nessofthemmusclesofh herlimbgirrdles.
Wha atisthelikeelycauseoffthedysphaagia?
A.Oesophagealcanccer
B.Derm
matomyositis
C.SystemicLupusErrythematosu
us
D.Retro
osternalgoitrre
E.Sclero
oderma
Answer:b)Derrmatomyositis.
Thee diagnosis is dermato

omyositis. Dysphagia in dermato omyositis iss primarily due to
weaakness of the striated
d musculatuure of the posterior pharynx.
p Dyysphagia may
m also
resuult from cricopharyngeal obstrucction secondary to infflammation or fibrosiss of the
cricopharyngeu usmuscles.
Heliiotroperash
hindermattomyositis
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ohagTeachin
ngHospital2012
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Rheumatology
RheumatologyQ084
A60yearoldmanisonfrusemideforlegoedema.Hepresentswithapainfulswollen
knee.Histemperatureis38Candhehasawhitecellcountof12x10^9/landCRPof
120mg/l.Uricacidis0.49mmol/l(<0.42).
Ajointaspiraterevealspuscellsandnegativelybirefringentcrystalswithpolarizedlight.
AftertreatmentwithNSAIDsfor48hourshehasnotimprovedandtheswellingpersists.
Therearenoorganismsculturedfromthejointaspirateorbloodcultures.
Whatisthebestcourseofaction?
A.Allopurinol
B.MRItolookforosteomyelitis
C.Intravenousflucloxacillin
D.Arthroscopyandwashout
E.Furtherjointaspirationwithdepomedroneinjection
Answer:e)furtherjointaspirationwithdepomedroneinjection.
This is a case of acute gout which has not settled on medical therapy (NSAIDs or
colchicine).Theraisedinflammatorymarkerscanbeduetoacutegout.Uricacidlevels
are notnecessarilyhigh in acutegout.Adepomedrone(steroid) injectionwithfurther
aspirationofjointfluidisthenextstep.
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Rheumatology
RheumatologyQ085
A40yearoldladypresentswithpolyuriaandthirst.Herserumcalciumof2.85mmol/l
andaparathyroidhormoneof12(18)pmol/l.Shehasnormalrenalfunction.
Whichtestprovidesthebestassessment?
A.CTofherspine
B.DualenergyXrayabsorptiometry
C.VitaminDlevels
D.Isotopebonescan
E.Urinebencejonesprotein
Answer:b)DualenergyXrayabsorptiometry.
Thispatientislikely tohave primaryhyperparathyroidism(secondarytoaparathyroid

adenoma).Thebestassessmentistodeterminetheseverityoflossofbonedensitywith
aDEXAscaninordertoconsiderparathyroidsurgeryisnecessary.
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RheumatollogyQ0866
An445yearoldmanhashadworseniingbackpains,shouldeerpainsandrighthip painfor
8yeears.Thepaainistypicaallyworseaattheend ofday.He alsohasbo onyenlargem mentof
the distal inteerphalangeaal joints. An X ray off the shoullder reveals the preseence of
prominentosteeophytes.TThereissclerosisand narrowinggofthejoin ntspaceat thehip
jointsonthepe elvicXray.
A.Osteo
omyelitis
B.Osteo
oarthritis
C.Osteo
omalacia
E.Pagett'sdisease
Answer:b)oste
eoarthritis.
Theeclinicalhisstorysuggesstsearlyon
nsetosteoarrthritis(whichcanbe idiopathico
oroccur
inaathletes).ThheXrayfeaaturesofosteophytes,sclerosisaandnarrow wingofjoinntspace
aresuggestiveofosteoartthritis.
Osteeophyteon
nashoulderrXray
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ohagTeachin
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Rheumatology
RheumatologyQ087
A35yearoldwomanhasgeneralizedjointpainsandmuscleaches.Shealsocomplains
ofgrittysensationsintheeyeinthemornings.BloodtestsshowAntiNuclearAntibody
++,RheumatoidFactor++.
Whatisthediagnosis?
A.Polylmyositis
B.Reiterssyndrome
C.PrimarySjogrenssyndrome
D.Polyarteritisnodosa
Answer:C)PrimarySjogrenssyndrome.
Dry mouth, dry eyes, fatigue, muscle aches and joint pains are typical of Sjogrens
syndrome.80%ofpatientsareANApositiveand75%areRheumatoidfactorpositive.A
usefuldiagnostictestistheSchirmer'stest,whereapieceoffilterpaperisplacedinthe
corneroftheeyetomeasurethedegreeofwettingafterfiveminutes.
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Rheumatology
RheumatologyQ088
A60yearoldwomanpresentswithatwoweekhistoryofmalaiseandlowerlimbjoint
pains. On examination she had a vasculitic rash over her shins, thighs and buttocks.
Investigationsrevealed:
Hb10.2g/dL
platelets265X10^9/L
creatinine380mol/L
antinuclearantibodiesNegative
antineutrophilcytoplasmicantibodiesNegative
antiglomerularbasementmembraneantibodiesNegative
dipstixurinalysisblood+++
protein+
Whatisthelikelydiagnosiscausingrenalimpairment?
A.Psoriaticarthritis
B.HenochSchonleinpurpura
C.Polymyositis
D.Membranousnephropathy
E.Myeloma
Answer:b)HenochSchonleinpurpura.
The distribution of the rash together with lower limb joint pains are suggestive of
HenochSchonleinpurpura.Thisusuallyoccursinchildrenaged210yearsbutcanoccur
in older age groups. The only w ay of differentiating this condition from other small
vesselvasculitidesisbybiopsy.ThiswouldshowIgAdepositioninvesselwallsondirect
immunofluorescence.
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Rheumatology
RheumatologyQ089
A 28 year old woman presents with a right knee joint pain and a 4 month history of
weightloss.Shethinksshehaslostweightbecauseofdiarrhoea,whichoccursseveral
timesaday.Examinationrevealsaswollen,tenderrightkneejointwithasmalleffusion.
Thelikelydiagnosisis:
A.Reiter'ssyndrome
B.Inflammatoryboweldisease
C.Behcet'sdisease
D.Campylobacterinfection
Answer:b)Inflammatoryboweldisease.
The description of weight loss, diarrhoea and a mono/oligoarthropathy suggests a

diagnosis of inflammatory bow el disease. Peripheral arthritis, peripheral arthralgia
withoutjointswellingoreffusion,degenerativejointdiseaseorseropositivearthritiscan
occur in inflammatory bow el disease. In patients with peripheral arthralgia and
peripheral arthritis, there is a significantly greater prevalence of mucocutaneous
manifestationsofIBDi.e.oralulceration,erythemanodosum,pyodermagangrenosum,
anduveitis.
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Rheumatology
RheumatologyQ090
A professional tennis player presents with shoulder pains especially whilst serving the
ball. He has limited passive and active shoulder abduction to less than 60. His
temperatureis36.5Candhehasanormalwhitecellcount.Thereistendernessaround
theanteriorportionoftheshoulderjoint.
Whichdiagnosisislikely?
A.Glenohumeraljointosteoarthritis
B.Bursitis
C.Tenniselbow
D.Supraspinatustendonitis
E.Septicarthritis
Answer:d)supraspinatustendonitis.
Pain during abduction with limitation of movement is suggestive of supraspinatous

tendonitis. Palpation or compression around the greater tubercle of the humerus is
particularlytender.
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Rheumatology
RheumatologyQ091
A45yearwomanhasraynaudsphenomenon.Shealsohasdifficultyinswallowingand
dyspnoea.
Echocardiographyshowsrightheartstrain.Bloodtestsrevealrenalimpairment.
Whichoneofthefollowingantibodiesisspecifictothislady'scondition?
A.Anticentromereantibody
B.TopoisomeraseI
C.AntidsDNAantibody
D.AntiSCL70antibody
E.Antimitochondrialantibody
Answer:d)antiSCL70antibody.
AntiSCL70antibody(topoisomeraseI)istypicallyfoundinprogressivesystemicsclerosis
(notthelimitedcutaneousform,CREST).
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Rheumatology
RheumatologyQ092
A55yearoldmanpresentswitha6weekhistoryoflethargyanddiffusepurpuricrash.
He is noted to have a right foot drop and a left ulnar nerve palsy. He complains of
arthralgiabuthasnoclinicalevidenceofinflammatoryjointdisease.Echocardiogramis
unremarkable, blood cultures are negative, ESR 80 mm/hr, ANCA negative, ANA
negative,rheumatoidfactorstronglypositive,C31.1g/l(0.751.6),C40.03g/l(0.14
0.5).
Dipstickurinalysisshowsblood++.
A.Takayasu'sarteritis
B.ANAnegativeSLE
C.Culturenegativeendocarditis
D.Cryoglobulinaemia
E.Rheumaticfever
Answer:d)Cryoglobulinaemia.
A low C4 together with a strongly positive rheumatoid factor suggests

cryoglobulinaemia as a cause of mononeuritis multiplex and rash. Palpable purpura,
arthralgia, hepatosplenomegaly, diffuse proliferative glomerulonephritis, Raynaud's
phenomenonandthrombosismayoccur.
Type I cryoglobulinaemia may be associated with lymphoproliferative disorders,
multiple myeloma, and monoclonal gammopathy of uncertain significance, and
macroglobulinaemia.Plasmapheresismayreducethelevelsofcryoglobulin.
Type II cryoglobulinaemia (mixed monoclonal) is usually composed of a monoclonal
component(usually IgG, IgMor IgA) and a polyclonal component(mainly IgG). Causes
are connective tissue diseases, Hepatitis B and C infection, infectious mononucleosis
andlymphoma.
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Rheumatology
RheumatologyQ093
A 70 year old woman with a history of multiple myeloma has a serum calcium of 2.9
mmol/l.Heisprescribedpamidronateinfusionover4days.
Whatisitsmechanismofaction?
A.Promotescalcitonin
B.Increasescalcitriollevels
C.Inhibitosteoclasts
D.inhibitosteoblasts
E.Stimulateparathyroidhormonesecretion
Answer:C)inhibitosteoclasts.
Bisphosphonates inhibits osteoclasts and reduces progression tow ards bone

destruction.
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Rheumatology
RheumatologyQ094
A 80 year old lady presents with a 5 day history of severe left temporal headache
radiating from her eye to the scalp. She had also experienced jaw discomfort during
eating.
Whichofthefollowingdrugsshouldbegivenwhileawaitingresultsofdiagnostictests?
A.Carbamazepine
B.Prednisolone
C.Azathioprine
D.Infliximab
E.Intravenousimmunoglobulin
Answer:b)Prednisolone.
The history suggests temporal arteritis. In view of the vision threatening nature of
disease,thepatientshouldbecommencedonsteroids.Typically60mgofprednisolone
perdayisrecommended.
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RheumatollogyQ0955
A30 0yearoldw
womanhassa3month hhistoryof arthralgia. Thereissw
wellingofth
hedistal
inteerphalangeaaljointsofttheringfingersofthehand.The wristonth herightanddankles
are swollen ass well. Onyycholysis wwas noted on the nails. Her serum inflam mmatory
marrkersareraised.
Whiichofthefoollowingistthelikelydia
agnosis?
A.Polym
myalgiarheumatica
C.Gout
E.SLE
Answer:d)Pso
oriaticarthro
opathy.
Psoriaticarthritiseffectsd distalinterp phalangealjjointstendssbeasymm metrical.

Theereare5typ pesofpsoriaaticarthritis.
Asymmetrical oligoarticular arthritis is thoughtt to be the most comm mon type. Usually,
the digits of the
t hands and feet aare affected d first, with
h inflammaation of thee flexor
tenddon and synovium
s o
occurring ssimultaneou usly, leadin ng to the typical "saausage"
app
pearance(daactylitis).
Thee other typees are symmetrical po olyarthritis, DIP arthro
opathy, arth
hritis mutilaans and
spondylitiswithorwithou utsacroilitiss.

Psoriaticarthro
opathy
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ohagTeachin
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Rheumatology
RheumatologyQ096
A60yearoldladyhassevererheumatoidarthritis.SheiscurrentlyonMethotrexate20
mg weekly for the past 5 months and also has been receiving regular infusions of
Infliximab. Her joint disease dramatically improved. She now presents with fevers,
coughandthereisevidencealargeleftsidedpleuraleffusiononherCXR.
A.Methotrexatepneumonitis
B.CMVinfection
C.Tuberculosis
D.Bronchialcarcinoma
E.Rheumatoidrelatedpulmonaryfibrosis
Answer:c)tuberculosis.
Serious opportunistic infections have been associated with the anti TNF alpha drug
infliximab, but the frequency of TB exceeds that associated with other infections.
Infliximabmayincreasetheriskoflymphoma.
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Rheumatology
RheumatologyQ097
A75yearoldmanpresentswithanacuteonsetofseverepainandswellingoftheleft
elbow.Hementionsthathehadachestinfection3weeksago.Onexamination,hehad
atemperatureof38Candtheleftelbowwaserythematous,swollenandtender.
Whatisthemostappropriateinvestigation?
A.Creactiveprotein
B.Fullbloodcount
C.Jointaspiration
D.Uricacidlevel
E.Xrayofthejoint
Answer:C)jointaspiration.
This patient is likely to have reactive arthritis. How ever, gram stain and culture are
necessarytoexcludesepticarthritis.
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Rheumatology
RheumatologyQ098
A75yearoldmanhassignificantbonypainswhichhavebeenoccuringfor3years.He
presents to the clinic for assessment and the investigations results were obtained
below:
Correctedcalcium2.4(2.22.6)
ESR20mm/1sthr
Alkalinephosphatase625iu/L(50100)
gammaGT42iu/L(1050)
Prostatespecificantigen7.4pg/L(06)
A.Osteoporosis
B.Osteomalacia
C.Metastaticprostaticcarcinoma
D.Paget'sdisease
E.Multiplemyeloma
Answer:d)Paget'sdisease.
Paget'sdiseasecausesahighalkalinephosphataseandnormalcalciumlevels.
Paget'sDiseaserepresentsanimbalanceofboneformationandresorption.Ittypically
beginswithexcessiveboneresorptionfollowedbyexcessiveboneformation.Themain
disturbanceisanexaggerationofosteoclasticboneresorption.
Themostcommonsitesofinvolvementincludethespine,pelvis,skull,femurandtibia.
Skullinvolvementmayproduceenlargementoftheheadcharacterizedbymoreevident
frontalbossinganddilatedsuperficialcranialmuscles.
Conductiveand/orsensorineuralhearinglossmayresultfromdiseaseofthetemporal
boneorossicles.
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Rheumatology
RheumatologyQ099
A75yearoldpatientwithosteoarthritisofthekneehasbeentakingcodeine30mgqds
andalsoparacetamolregularly.Hecontinuestohavekneepains.
Whatisthenextbesttreatment?
A.Diclofenac
B.Morphine
C.Ibuprofengel
D.Higherdoseofcodeine
E.Oralhydrocortisone
Answer:C)ibuprofengel.
NSAIDS tend to be better for pain control in osteoarthritis, but have significant side
effects. Local NSAID application should be considered as well as intraarticular steroid
injections.
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RheumatollogyQ1000
A 40 year old lady presents with a swollen rigght knee. This was asp
pirated. Un
nder the
polaarised microscope, theere were neutrophils +++ and so ome blue rhhomboidal crystals
undderparallelpolarisedligght.
Themostlikelyydiagnosisiis:
A.Osteo
oarthritis
C.Gout
D.Pseud
dogout
E.Septiccarthritis
Answer:d)Pseeudogout.
Thee blue colo

our and po
ositively birefringent crystals un
nder polarised light suggest
pseudogout.Neutrophilleevelsarehigghininfectiion,goutan
ndpseudogout.
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ohagTeachin
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Rheumatology
RheumatologyQ101
A45yearoldmanhasarenaltransplant.Hepresentswithahotswollenankleonthe
leftandfevers.Thesymptomshavebeenpresentfor2days.
Whatshouldbedone?
A.Checkserumuricacidlevel
B.Injectintraarticularsteroids
C.Givecolchicine
D.Sendjointfluidformicroscopyandculture
E.Intravenouscefuroxime
Answer:d)Sendjointfluidformicroscopyandculture.
The differentialdiagnosis isgout(commoninrenalpatients)butthe patientwillbein

immunosupressionandsepticarthritisshouldbeexcludedwithjointfluidculture.
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matology
RheumatollogyQ1022
A40
0yearoldaathletehasp
painonabdductionofh
herarm,parrticularlywhenresiste
ed.
Whiichtendonp pathologyiisaffected?
A.Bicep
pstendonitis
B.Supraaspinatusten
ndonitis
C.Teressminortendo
onitis
D.Infrasspinatustend
dinitis
E.Subsccapularistendonitis
Answer:b)Sup
praspinatustendonitis.
Pain
ninabductionupto90
0degreesissduetosup
praspinatustendonitis.

Illusstrationofssupraspinatusmuscle
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ohagTeachin
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Rheumatology
RheumatologyQ103
A 60 year old man has worsening discomfort in both shoulders. He is haemodialysis

dependent. Past medical history included bilateral carpal tunnel decompression. His
Investigations reveal: haemoglobin 9.8 g/dl, ESR 35 mm/1st hr, C reactive protein 15
mg/L,Urate0.58.
A.Reiter'ssyndrome
B.Amyloidosis
C.Polymyalgiarheumatica
D.Gout
E.Osteomalacia
Answer:b)amyloidosis.
b2microglobulindepositioninjointsmayleadtoamyloidosis. Thiscanoccur10 years

onfromdialysis,andleadtocarpaltunnelsyndrome.
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Rheumatology
RheumatologyQ104
A45yearoldmanpresentswithapainfulswollenknee.Hefeelsgenerallyunwelland
has fever. He has recently had a flulike illness, an erythematous rash on the trunk
followedbyaselflimitingepisodeofdiarrhoea.Adiagnosisofreactivearthritisismade
bytherheumatologist.
Howshouldthepatientbemanaged?
A.Highdosesteroids
B.Broadspectrumivantibiotics
C.Arthroscopyandwashoutofthejoint
D.Ifthesymptomsbecomeschronic,sulphasalazinemaybeuseful
E.Bonescantolookforafocusofinfection
Answer:d)ifthesymptomsbecomeschronic,sulphasalazinemaybeuseful.
The diagnosis is likely to be reactive arthritis following an infectious illness. Although

jointaspirationmaybeuseful,thereisnoneedforarthroscopyatpresent.NSAIDsmay
be used for symptoms control now. If the symptoms persist, sulphasalazine or
methotrexatemaybeuseful.
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matology
RheumatollogyQ1055
A166girlisinveestigatedfo
orswellingaandpainintherightw
wrist,leftkneeandrigh
htankle.
InveestigationssshowapositiveANA1:160withveRheumaatoidfactor..
Wha atissheatriskofdeveeloping?
A.Psoriaasis
B.Butteerflyfacialrassh
C.Erosivvejointdiseaase
D.Uveittis
E.Bamb
boospine
Answer:D)uve
eitis.
Juveenilechroniicarthritisisatermusedtodescrribearthritissoccurringinsomeoneewhois
lesss than 16 years old that lasts forr more than
n three mo
onths. Largee joints tend to be
affeected.Rheumatoidfacttorisoften negative,aandthereispositivean ntinuclearantibody
especially
e in pauciartticular JCA.. Acute anterior uveeitis is most commonly in
pauciarticular juvenile ch hronic arthritis. Stiffneess, amyloiidosis, and osteoporo osis also
occu ur.

Uveeitiscausinggredeye(leenticularpreecipitatesm
maybeseen
n)
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ohagTeachin
ngHospital2012
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matology
RheumatollogyQ1066
A22
2yearoldmmanpresentswitha4w weekhistorryofapainffulswollen leftknee.H
Hehasa
pastt medical history of a treated sexually transmitted disease 6
6 months ago.
a On
examinationth herewasalargeeffusio
oninthelefftknee.
Synovialfluidaanalysissho
owsawhite cellcounto of15x10^9
9/lbutcultu
urewasneggative.
Whiichoneofth hefollowing
gorganismsisthemosstlikelycau
use?
A.Gardn
nerella
B.Chlam
mydia
C.Trepo
onemapallidum
D.Neissseriagonorrh
hoea
E.Tricho
omonasvaginalis
Answer:d)Neisseriagono
orrhoea.
Gonnococcal arrthritis is caaused by aan infection

n with the gramnegattive diplocooccus N
gonnorrhoeae. Neisseria gonorrhoea
g a occurs in
n young adults, ofteen preceded by a
miggratoryarthritis.
Thee bacteremiic phase is a classic ttriad of migratory polyarthritis, tenosynovitis, and
dermmatitis. This patient was
w treated previouslyy for a sexu ually acquire
ed infection
n hence
mayybethereaasonfortheeculturetobenegativee.
Thee initial treatment of choice forr gonococccal arthritiss is a third
dgeneration beta
lactamaseresiistant ceph halosporin (eg, ceftriiaxone, cefftizoxime, cefotaximee) or a
pennicillin,iftheeorganismissensitive.

Mulltipleintraccellulargram
mnegatived
diplococcic
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ohagTeachin
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Rheumatology
RheumatologyQ107
A35yearoldladyhas positiveANA,andhasabutterfly shaped rashonherface.Her

physician makes a diagnosis of SLE. She has flare ups of joint swellings and pains
requiring several months treatment with prednisolone. 1 year later she presents with
hippainlimitinghermobility.
Whichoneofthefollowingisalikelycause?
B.Septicarthritis
C.Juvenilechronicarthritis
D.Avascularnecrosis
E.Perthe'sdisease
Answer:d)avascularnecrosis.
15% of patients with SLE develop avascular necrosis of the bone. Nephritis, vasculitis
andlongtermsteroidusepredisposetoavascularnecrosis.
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Rheumatology
RheumatologyQ108
A50yearoldmanpresentswithchronicrecurrentsinusitisandoccasionalhaemoptysis.
HehasmiddlelobepatchyshadowingonhischestXray.Hiscreatinineis145andurine
dipstickshows++proteinandblood.
Whichtestresultismostlikely?
A.PositivecANCA
B.PositiveANA
C.PositiveKveimtest
D.PositiveASOT
E.SputumAFBpositive
Answer:a)positivecANCA.
Nasalcavity,pulmonaryandrenalgranulomatousinvolvementisclassicalinWegener's
granulomatosis. 70% of patients have a positive cANCA. In addition, w hen ANCA is
positive, PR3 (Wegener's) and MPO (microscopic polyangitis) helps to distinguish
Betweenthetwodifferentialdiagnoses.
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Rheumatology
RheumatologyQ109
A55yearoldfemalepresentscomplainingofbonepainsandmuscularweakness.Her
gaitiswaddlinginnature.
Xrayshowspseudofracturesofherpubicrami.
Investigations show : Serum corrected calcium 2.05 mmol/L, phosphate 0.43 mmol/L,
alkalinephosphatase230U/L.
Whatisthediagnosis?
A.Pseudohypoparathyroidism
B.Secondaryhyperparathyroidism
C.Osteopetrosis
D.Osteomalacia
E.Paget'sdisease
Answer:d)osteomalacia.
The clinical radiological and biochemical features in this patient suggest she has
osteomalacia. Osteomalacia is characterized by a low serum calcium and phosphate
withelevatedserumalkalinephosphatase.
Osteomalacia may be caused by deficiency of vitamin D or phosphate deficiency.
Malabsorption syndromes, renal failure and liver disease can result in vitamin D
deficiency.
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RheumatollogyQ1100
A22yearold Armenianm manpresen ntswithpainandswellingoftheleftknee. Healso
givees a historry of recurrrent episo
odes of fevver, pleuritic pains in the cheest, and
generalised raash. These episodes typically laast for 23 3 days. Exxamination reveals
spleenomegaly,swollenkneesandankkles.Urined dipstickrevveals2+prooteinuria.
A.Ankyllosingspond
dylitis
B.Reacttivearthritis
C.FamilialMediterraaneanfever
D.Tuberculosis
E.Dermatomyositis

Answer:c)Fam
milialMediteerraneanfeever.
Fammilial Mediterranean fever is an inherited d condition n characterrized by reecurrent
epissodesofpaainful inflam
mmation in the abdom men, chest, orjoints. These
T episoodesare
ofteenaccompaaniedbyfevverandsom metimesa rash.Thefirstepisodeeusuallyocccursby
the age of 20 years, butt in some cases, the initial attack occurs much
m laterr in life.
Typically,episo
odeslast12 2to72hourrsandcanvvaryinseveerityandin thelength oftime
Betwweenattacks.
AA amyloidosis commonlly involves the kidneyys, spleen aand GI tract. Colchicin ne given
prophylacticallyinFMFoffferssome protection againsttheedevelopm mentofamyyloidosis
inm
mostpatientts.
Fammilial Mediterranean fever prim marily affeects populaations origginating fro om the
Med diterraneann region, particularly
p people of Armenian,, Arabic, Turkish,
T andd North
African Jew ish ancestry.. Mutationss in the MEFV gene cause
c familial Mediterranean
feveer.

Rashseeninfaamilialmediiterraneanffever
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ohagTeachin
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matology
RheumatollogyQ1111
A 35 year old man presents acutelyy with ureth

hritis, conju
unctivitis an
nd arthritis. He has
beeenhavingjointpainsinthewristandhips.
Oneexamination,hehasarashontheesolesofhisfeetandaalsocircinattebalanitis..
Rheeumatoidfactorisnegaativeandheehasraised dinflammattorymarkerrs.
Wha atisthedia
agnosis?
A.Behceet'ssyndrom
me
C.Reiter'ssyndromee
Answer:c)Reitter'ssyndro
ome.
Reitterssyndro
omeisurethritis,conju unctivitis,se
eronegativeearthritis(ccannotsee,,cannot
peee, cannotclimb atree)).Thetypiccalpatientiisayoung manwithrrecentureth hritis or
dyseentery.Theeseronegatiivearthritissisusuallyaamonooro
oligoarthritiss.
Other featuress are anterior uveitis, keratoderm ma blenorrhagica (broow n absceesses on
palmmsandsolees),mouth ulcers,plan ntarfasciitissandarchilllestendinittis(entheso
opathy),
circinatebalanitis(painlesssrash)anddaorticinco ompetence.Managem mentisusuaallywith
resttandNSAIDDs.

KeraatodermaB
BlenorrhagiccainReiter'ssyndromee
Dr.K
ohagTeachin
ngHospital2012
116
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Rheumatology
RheumatologyQ112
A 50 year old patient with rheumatoid arthritis has the following full blood count
results:Haemoglobin10.5g/dL,Platelets450x10^9/L,WhiteCellCount8.5x10^9/L,
MCV103fL.
Whichdrugisthelikelycauseofthis?
A.Infliximab
B.Ciclosporin
C.Leflunomide
D.Prednisolone
E.Methotrexate
Answer:e)Methotrexate.
MethotrexatemayleadtomacrocytosisasaresultofB12orfolatedeficiency.It may
also be associated with bone marrow suppression, causing leucopenia or
thombocytopaenia. Methotrexate may also cause mouth ulcers, stomatitis, cough and
dyspnoea.
117
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Rheumatology
RheumatologyQ113
A32yearoldmanhashadayearshistoryofbilateralhippainsandbackpains.Thereis
notpastmedicalhistoryoftraumatotheback.Nonsteroidalantiinflammatorydrugs
helpedtorelievehissymptoms.
A.Gluteusmediustendonitis
B.Osteoarthritis
C.Hipfracture
D.Sacroilitis
E.Osteoarthrosis
Answer:D)sacroilitis.
Painandstiffnessinthelowerbackorbuttocks,especiallyinthemorningistypicalof
sacroilitis. It is typically helped by NSAIDS or steroids. X rays will help to confirm the
diagnosis.Itisassociatedwithvariousinflammatorydiseasese.g.ankylosingspondylitis,
psoriaticarthritis.
118
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Rheumatology
RheumatologyQ114
A35yearoldladypresentswithstiffness,painandswellingofherhandsandwrists.On
examinationshehasfirmsubcutaneousnodulesoverherelbows,swellingofherwrists,
ulnardeviationatthemetacarpophalangealjoints,dinnerforkdeformityandswellingof
herproximalinterphalangealjoints.
Investigationsrevealanormocytic,normochromicanaemia,elevatedESRandCRP.
Which is the most commonly used test which could determine whether she is sero
positive?
A.IgAantibody
B.IgMantibody
C.IgEantibody
D.IgDantibody
E.IgGantibody
Answer:b)IgMantibody.
Thepatienthasfeaturesofseropositiverheumatoidarthritis(presenceofrheumatoid
factor).RheumatoidfactorisacirculatingantibodydirectedagainsttheFcfragmentof
immunoglobulin. The antibody may IgM, IgG, or IgA. The commonly employed test
detectstheIgMrheumatoidfactor.
119
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Rheumatology
RheumatologyQ115
A32yearoldmanhasa6monthhistoryofdryeyesandmouth.Onexamination,there
wasevidenceofkeratoconjunctivitis,parotidglandenlargementandaSchirmer'stestis
positive.
HisbloodtestsrevealapositiveANA,RoandLaextranuclearantigensarealsopositive.
Whatisthediagnosis?
A.SLE
B.Rheumatoidarthritis
C.Sjogren'ssyndrome
D.Wegener'sgranulomatosis
E.Pulmonaryeosinophilia
Answer:c)Sjogren'ssyndrome.
The patient has Sjogren's syndrome. Sjgren syndrome is a chronic autoimmune

disorder characterized by xerostomia (dry mouth), xerophthalmia (dry eyes), and
lymphocytic infiltration of the exocrine glands. This triad is also known as the sicca
complex.
The Schirmer test is probably the only test available in the ED to strongly support or
refutesuspicionofSjgrensyndrome.Ateststripoffilterpaperisplacednearthelower
conjunctivalsactomeasuretearformation.Apositivetestoccurswhenlessthan5mm
offilterpaperiswetafter5minutes.
Rheumatoidfactor,ANA,RoandLaantigensarecommonlypresent.
As a result of the lymphocytic infiltration, 10% of patients may develop
pseudolymphoma,alymphoproliferativeprocess.Approximately10%ofthesepatients
candevelopnonHodgkinlymphoma(1%ofallpatientswithSjgrensyndrome).
120
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Rheumatology
RheumatologyQ116
A38yearoldladypresentswithmyalgiaandlethargy.Herbloodtestsshowapositive
ANAwithatitreof1:1024andrheumatoidfactorisnegative.
TheCKisraisedat360U/l.ExtranuclearantigentestsshowanegativeRoandnegative
La,negativeScl70andpositiveribonuclearproteinantibodyat160units.
Whatisthediagnosis?
A.Polymyalgiarheumatica
B.Polymyositis
C.Scleroderma
D.Systemiclupuserythematosus
E.Mixedconnectivetissuedisease
Answer:e)mixedconnectivetissuedisease.
A positive ANA (speckled pattern), raised CK and positive anti RNP antibody suggests
mixedconnectivetissuedisease.
121
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Rheumatology
RheumatologyQ117
A 50 year old man presents to the renal team with uraemic symptoms. He also has
markedlyreducedrangeofmovementatthespinewithaSchoberstestof10mm.
HisCRPis102mg/dlandESR98mm/hr.Urinedipstickshowsproteinuria++++.
He has had treatment with penicillamine in the past for arthritis. He takes regular
ibuprofen.
Whatisthemostlikelycauseofhisrenalsymptoms?
A.Nephriticsyndrome
B.NSAIDnephropathy
C.Scleroderma
D.ALamyloid
E.AAamyloid
Answer:e)AAamyloid.
Nephrotic range proteinuria and renal failure in the context of a prolonged untreated
inflammatoryresponsesuggestsAAamyloid.SincecirculatingserumAAistheprecursor
ofAAamyloiddeposits,reductionoftheprecursorproteinisthemostrationalapproach
atpresentforthemanagementofamyloidosis.
Prevention of amyloidosis is preferable to treatment of the established disease. Thus
aggressivetherapyofrheumaticdiseasessuchasRAandJCAisdesirableinthiscontext.
122
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Rheumatology
RheumatologyQ118
A 45 year old woman presents with confusion. On examination she was pyrexial, had
livedoreticularishadabloodpressureof190/100mmHg.
Examinationoftheabdomenrevealedleftflanktenderness.
Investigationsrevealed:
Hb13.9g/dL
whitecellcount6.5x10^9/L
plateletcount110x10^9/L
serumcreatinine95umol/L
urinedipstickanalysis:blood+++,protein+
Whichoneofthefollowingtestsislikelytobepositive?
A.AntiRoantibody
B.AntiGBMantibody
C.Anticardiolipinantibody
D.ASOT
E.ANCA
Answer:c)Anticardiolipinantibody.
The diagnosis is SLE and antiphopholipid syndrome. The presentation would be

consistent with renal vein thrombosis (flank pain and proteinuria). Antiphospholipid
syndrome(APS)isadisordercharacterizedbyrecurrentvenousorarterialthrombosis
and/or fetal losses associated with typical laboratory abnormalities. These include
persistently elevated levels of antibodies directed against membrane anionic
phospholipids(ie,anticardiolipin[aCL]antibody,antiphosphatidylserine).
Vascular thrombosis DVT, MI, CVA or miscarriages may occur. Other features are
nonthrombotic neurologic symptoms, such as migraine headaches, chorea, seizures,
transverse myelitis, GuillainBarr syndrome, thrombocytopenia or hemolytic anemia,
Livedoreticularis,AvascularnecrosisofboneandPulmonaryhypertension.
Aspirinorwarfarinisrecommendedforpatientswiththromboticsyndromes.
123
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Rheumatology
RheumatologyQ119
A60yearoldladyhaspolyarthropathyduetoRheumatoidArthtitis.
Whichoneofthefollowingmoleculesplaysacentralroleinitspathogenesis?
A.IFNgamma
B.Interleukin8
C.TNFalpha
D.Endotoxin
E.Nitricoxide
Answer:C)TNFalpha.
Inthecontextofrheumatoidarthritis,TNFhasinvolvementincytokineregulation,cell
recruitment,angiogenesis,andtissuedestruction.HenceantiTNFalphaantibodiessuch
asinfliximabareusedintherapy.
124
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Rheumatology
RheumatologyQ120
A 50 year old woman presents with breathlessness. She has a 2 year history of
Raynaud's.Onexamination,shehadtelangiectasiaandtightskinaroundthemouth.Her
investigationsshowanESRof70mm/hrandpositiveanticentromereantibodies.
Whichofthefollowingisatypicallatecomplicationofthisdisorder?
A.Renalhypertensivecrisis
B.Lungmalignancy
C.Pulmonaryhypertension
D.Myositis
E.Mitralregurgitation
Answer:c)Pulmonaryhypertension.
ThediagnosisisCRESTsyndrome.Renalhypertensivecrisisismorecommonindiffuse
systemic sclerosis and pulmonary hypertension is more common in limited cutaneous
scleroderma.
125
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Rheumatology
RheumatologyQ121
An 18 year old girl developed pulmonary haemorrhage and subsequent acute renal
failurerequiringdialysis.Arenalbiopsyshowscrescenticglomerulonephritis.
Whichoneofthefollowingantibodiesislikelytobepresent?
A.Antimitochondrial
B.Anticentromere
C.Antinuclear
D.Antiphospholipid
E.Antimyeloperoxidase
Answer:e)Antimyeloperoxidase.
ThispatientmanifestsapulmonaryrenalsyndromewhichiscommonlyduetoanANCA
positive vasculitis. P ANCA which correlates with antimyeloperoxidase (MPO)
antibodies, is highly sensitive and specific tow ards rapidly progressive
glomerulonephritisandhaemorrhagicalveolarcapillaritis.Lesscommonlythiscouldbe
duetoGoodpasturessyndrome(antiGBMantibodies).
126
www
matology
RheumatollogyQ1222
A 65 year old man with chronic leu

ukaemia presents withh symptom
ms of gout. He was
giveenAllopurinnol.
HowwdoesAllop purinolprevventaccumu ulationofu

uricacid?
A.Byinccreasinguriccacidmetabo
olism
B.Byen
nhancingitsssolubility
C.Byinh
hibitingpurin
nesynthesis
D.Byinh
hibitingpyrim
midinesynth
hesis
E.Byinh
hibitingxanthineoxidasee
Answer:E)Byiinhibitingxaanthineoxid
dase.
Allo
opurinol inh
hibits xanth
hine oxidasse, the enzzyme that catalyzes the converrsion of
hypoxanthinettoxanthineeandofxan nthinetouuricacid.Hyypoxanthineeandxanthhineare
breaakdownpro oductsofpuurine.
Dr.K
ohagTeachin
ngHospital2012
127
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Rheumatology
RheumatologyQ123
A 32 year old woman in the third trimester of her second pregnancy develops acute
onsetrightgroinpain.
Onexamination,allrighthipmovementsarepainfulandsheistenderintherightgroin
and over the greater trochanter. Lumbar spine examination shows an exaggerated
lordosisonlyandtherearenoneurologicallowerlimbdeficits.Initialplainfilmsofthe
hiparenormal.
Themostlikelydiagnosisis:
A.Septicarthritis
B.Hipdislocation
C.Avascularnecrosisofthehip
D.Pregnancyexacerbatingosteoarthritis
E.Pseudogout
Answer:c)Avascularnecrosisofthehip.
Thisisaclassicalpresentationofavascularnecrosisofthefemoralheadinpregnancy.
Transientosteoporosisofthehipisalsoarecognisedcauseofhippaininpregnancy,but
plainradiographswouldusuallyshowmarkedunilateralosteopeniaofthefemoralhead
andacetabulum.
Thearterialsupplytothefemoralheadiseasilydamagedwithanyfemoralneckfracture
displacement.
Atraumatic causes of this are : Alcohol abuse, Chemotherapy, Chronic liver disease,
Corticosteroids, Gaucher disease, Gout, Hemoglobinopathy (eg, sickle cell disease),
Metabolic bone disease, Pregnancy, Radiation, Systemic lupus erythematosus,
Vasculitis.
128
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Rheumatology
RheumatologyQ124
A55yearoldwomanwithpsoriasishassignificantjointpains.
Whichoneofthefollowingiseffectiveinthetreatmentofpsoriaticarthropathy?
A.Codeinephosphate
B.Methotrexate
C.Betainterferon
D.Capacitabine
E.Buprenorphine
Answer:b)Methotrexate.
NSAIDs,sulphasalazine,methotrexateandTNFalphaantagonistsareusefulinpsoriatic
arthropathy.
129
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Rheumatology
RheumatologyQ125
A 65 year old woman attends has a 12 week history of lethargy, neck pains and
weaknessinthelowerlimbs.
She has a long history of lower back pains and generalised osteoarthritis. She takes
diclofenacregularly.
Onexaminationthereiswastingofherupperlimbs.Tonemildlyincreasedinthelower
limbs.Thereisinversionofrightsupinatorreflex,triceps,kneeandanklejerksarebrisk
bilaterally.Rightplantarisextensorandtheleftisflexor.
Investigationsshow:
Hb11.6g/l
WCC8x10^9/l
Plat160x10^9/l
ESR73mm
CRP12mg/l
Na138mmol/l
K4.4mmol/l
Urea5.8mmol/l
Creatinine95umol/l
Protein83g/l
Albumin32g/l
Ca2.33mmol/l
Xraycervicalspineshowsextensiveosteophytes
A.Ankylosingspondylitis
B.Polymyalgiarheumatica
C.Cervicalspondyloarthropathy
D.Multiplesclerosis
E.Syringomyelia
Answer:c)Cervicalspondyloarthropathy.
Cervicalspondylosismaypresentwithassociatedpainsintheneckradiatingdownthe
armsandback.Theremaybeuppermotorneuronsignsintheupperandlowerlimbs.
130
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Rheumatology
RheumatologyQ126
A 70 year man presents with right foot drop, hand numbness, fevers, malaise, weight
loss,polymyalgiaanddiffusejointpainsfor2months.
Onexamination,heappearsunwellandhasatemperatureof38C.
Investigationsreveal:
Hb8.5g/dL
erythrocytesedimentationrate95mm/hr
serumcreatinine220mol/L
urineanalysis:blood++
urinemicroscopy:whitecells&redcellcastsseen
Whichoneofthefollowingisthelikelydiagnosis?
A.Multiplemyeloma
B.Antiphospholipidsyndrome
C.Takayasu'sarteritis
D.Polyarteritisnodosa
E.Goodpasture'ssyndrome
Answer:d)polyarteritisnodosa.
This patient has a mononeuritis multiplex, fever and nephritic renal involvement
suggesting a diagnosis of polyarteritis nodosa. PAN causes transmural necrotizing
inflammationofsmallsizedormediumsizedmusculararteries.PANisararecondition.
Although the causes are unknown in most cases, there is an association with: Hep B
virus, Hep C virus, HIV, Cytomegalovirus, Parvovirus B19 and Human Tlymphotrophic
virus.
Approximately 20% of patients with classic PAN are positive for PANCA. Steroids
(prednisolone) and immunosuppressive (cyclophosphamide) medications form the
backbone of therapy. Plasma exchange is useful as a secondline treatment in PAN
refractorytoconventionaltherapy.
131

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A355yearoldm manpresen ntswitha6

Behhcets syndrome is a multisystem m disorder characterissed by recu urrent oral genital

The patient has an aplastic anaemia which can be caused by methotrexate or

A655yearoldw womanpressentswithd dryeyesandadrymouth.Herinvvestigationssshow:

A 65 year old man preseents has reccently deveeloped an acutely

A700yearold manpresen ntswithbo

A 35 year old retired athlete presen

A 55 year old patient preesents with

Methotrexate is associated with bone marrow suppression, and can lead to

Alendronate is a bisphosphonate which can increase bone mineralisation by inhibiting

Limited cutan neous scleroderma isi also kn nown as CREST

The patients presentation suggests osteoarthritis, but an MRI would be helpful to

Thee diagnosis is psoriattic arthritiss. Psoriatic arthritis is

A 16 year old girl presents with wid

HennochSchnleinpurpurra(HSP)is asystemic vasculitism mostlyseen ninchildren n.Itisa

Ankkylosingspo ondylitisis aseronegativearthrop pathyassocciatedwith HLAB27ge enotype.

A 45 year old woman presents with a year's history of Raynauds phenomenon,

This woman features of a mixed connective tissue disorder such as CREST/systemic

Refllexsympattheticdystrrophyoccurrsfollowinggtraumato oaninjured dpartofth

Theelikelydiagnosisisacuutegout.Th heserumin nflammatoryymarkersaareraised, buturic

A major complication of scleroderma is renal crisis which is characterised by abrupt

All nonsteroidals including Cox II selective inhibitors are relatively contraindicated in

A 45 year old lady has h

A700yearoldm manpresen ntswithsevverebackpains.AnHisstotalserumproteiniis85g/l

Thesmearofa aspirateislikkelytoshowwwhichpro ominentfea atures?

Thee diagnosis is multiple myeloma. The bone marrow neeedle is likeely to be in

Behhcet's syndrome is claassically chharacterized d as a triad of symptoms that include

The patient has osteomalacia with secondary hyperparathyroidism causing low

Antiphospholipid syndrome leads to venous and arterial thrombosis, livedo reticularis,

AdultOnsetStillsDisease(AOSD)isan acutefebrileillness inyoungadults.Itusually

Pseudogout is caused by the deposition of calcium pyrophosphate deposition rather

The diagnosis is inclusion body myositis (IBM). This is an inflammatory condition

Any patient above the age of 65 with osteoporosis is recommended to be on

The tenderness at the carpometacarpal joint is most likely due to osteoarthritis in a

A50yearoldsecretarynoticedtinglingandnumbnessover thepalmarsurface ofher

Thee diagnosis is dermato omyositis. Anti Jo1 antibody

Polymyalgia rheumatica (PMR) is a clinical diagnosis based on pain and stiffness of

The characteristic feature of haemochromatotic arthropathy is involvement of the

A600yearoldw womanpreesentswith ahistoryo ofprogressivedifficultyyinclimbin ngstairs

Thee diagnosis is dermato

Thispatientislikely tohave primaryhyperparathyroidism(secondarytoaparathyroid

The description of weight loss, diarrhoea and a mono/oligoarthropathy suggests a

Pain during abduction with limitation of movement is suggestive of supraspinatous

A low C4 together with a strongly positive rheumatoid factor suggests

Bisphosphonates inhibits osteoclasts and reduces progression tow ards bone

Psoriaticarthritiseffectsd distalinterp phalangealjjointstendssbeasymm metrical.

Thee blue colo

The differentialdiagnosis isgout(commoninrenalpatients)butthe patientwillbein

A 60 year old man has worsening discomfort in both shoulders. He is haemodialysis

b2microglobulindepositioninjointsmayleadtoamyloidosis. Thiscanoccur10 years

The diagnosis is likely to be reactive arthritis following an infectious illness. Although

Gonnococcal arrthritis is caaused by aan infection

A35yearoldladyhas positiveANA,andhasabutterfly shaped rashonherface.Her

A 35 year old man presents acutelyy with ureth

The patient has Sjogren's syndrome. Sjgren syndrome is a chronic autoimmune

The diagnosis is SLE and antiphopholipid syndrome. The presentation would be

A 65 year old man with chronic leu

HowwdoesAllop purinolprevventaccumu ulationofu

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