Sce Rheum at Ology Sample q

7/29/2019 Sce Rheum at Ology Sample q

1/42

Updated 06/02/2012

Specialty Certificate in Rheumatology Sample Questions

Question 1

A 40-year-old man had severe pain in one leg affecting both the buttock region and the lateral

border and sole of the foot, in association with paraesthesiae of the sole on walking.

What is the correct nomenclature for the nerve root from which these symptoms have arisen?

A L4B L4/L5C L5D L5/S1E S1


2/42

Updated 06/02/2012

Question 2

A 43-year-old woman, with recent-onset rheumatoid factor-positive inflammatory arthritis, washaving 10-weekly intramuscular injections of sodium aurothiomalate. At week 10 she reportedbeing 90% better.

On examination, her hand joints were much less puffy than before treatment and kneeeffusions had resolved. She had developed a shiny, slightly scaly erythematous plaque overthe abdomen and two smaller patches on her limbs. Her serum C-reactive protein had fallenfrom 56 to 4 mg/L (


3/42

Updated 06/02/2012

Question 3

A 46-year-old man presented with a 2-week history of a worsening ulcerating rash over hislower limbs, which had coalesced in places. He also had right knee and left wrist synovitis. Hehad returned from a holiday in Portugal 4 weeks previously. He had ulcerative colitis that had

been diagnosed the previous year, and was taking 5 mg prednisolone daily.

What is the most likely diagnosis?

A discoid lupusB erythema nodosumC granuloma annulareD Lyme diseaseE pyoderma gangrenosum


4/42

Updated 06/02/2012

Question 4

A 32-year-old woman, with severe psoriatic arthritis well-controlled with sulfasalazine andparacetamol, presented to clinic. She had just married and wished to conceive without riskinga flare of her arthritis.

What is the most appropriate treatment strategy?

A add oral prednisoloneB continue sulfasalazineC stop sulfasalazineD stop sulfasalazine and change to oral prednisoloneE stop sulfasalazine and start methotrexate and folic acid


5/42

Updated 06/02/2012

Question 5

A 50-year-old woman was referred by an orthopaedic surgeon with a 2-month history ofsevere pain in her right knee, calf and foot. This had developed 1 week after an arthroscopicmeniscectomy.

On examination, she was tearful and her right leg was swollen, dusky, cool and tender belowthe knee. She found light touch extremely painful and refused to have her knee fullyexamined.

Investigations:

serum C-reactive protein 3 mg/L (


6/42

Updated 06/02/2012

Question 6

A 24-year-old woman presented with acute pain and swelling of her right knee. She had beencomplaining of lower abdominal pain for the previous 3 days. On examination, hertemperature was 37.9C. The right knee was warm and tender with a tense effusion. Several

pustules were seen on her right knee.

Investigations:

white cell count 16.4 109/L (4.011.0)



7/42

Updated 06/02/2012

Question 7

A 20-year-old man of Turkish origin presented with a recurrent monoarthropathy. He alsocomplained of attacks of intermittent fever, abdominal pain and pleuritic chest pain, and had

noted an erythematous rash during these attacks.


A adult-onset Stills diseaseB Behets diseaseC familial Mediterranean feverD HenochSchnlein purpuraE systemic lupus erythematosus


8/42

Updated 06/02/2012

Question 8

A 48-year-old man presented with a 2-month history of arthralgia and a recurrent itchy rashover his trunk and limbs. On examination, he had urticarial lesions all over his trunk. He had

started antihistamine therapy, but with no benefit. No other abnormalities were found onexamination.

A skin biopsy showed a leucocytoclastic vasculitis and a diagnosis of urticarial vasculitis wasmade.

What is the most appropriate next treatment?

A azathioprineB dapsoneC hydroxychloroquine

D naproxenE prednisolone


9/42

Updated 06/02/2012

Question 9

A 61-year-old woman with long-standing rheumatoid arthritis presented with persistent legulcers. She was taking methotrexate. Infliximab had been stopped 2 months previouslyfollowing the appearance of the leg ulcers.

On examination, there were bilateral shallow ulcers on the medial malleoli.

Investigations:

haemoglobin 98 g/L (115165)MCV 89 fL (8096)MCHC 35 g/dL (3235)


neutrophil count 1.0 109/L (1.57.0)

platelet count 180 109/L (150400)

erythrocyte sedimentation rate 60 mm/1st h (


10/42

Updated 06/02/2012

Question 10

A 42-year-old woman with rheumatoid arthritis presented with a 3-day history of malaise andnausea. Because of progressive disease, methotrexate had been changed to leflunomide20 mg daily 2 weeks previously. Her other medication was dihydrocodeine and ibuprofen.

On examination, she had right hypochondrial tenderness.

Investigations:

serum total bilirubin 27 mol/L (122)serum alanine aminotransferase 3276 U/L (535)serum alkaline phosphatase 367 U/L (45105)serum gamma glutamyl transferase 970 U/L (435)

Leflunomide was discontinued.

What is the most appropriate next step in management?

A acetylcysteineB colestyramineC high-dose prednisoloneD intravenous ganciclovirE no additional treatment


11/42

Updated 06/02/2012

Question 11

A 42-year-old man presented with a 6-month history of pain in his right upper arm thatprevented him from working. On examination, there was flattening of the right deltoid contourwith restriction of active and passive shoulder movements, and of neck movements.

What is the most likely cause of his pain?

A adhesive capsulitisB cervical spondylosisC glenohumeral joint osteoarthritisD subacromial bursitisE supraspinatus tendonitis


12/42

Updated 06/02/2012

Question 12

A 72-year-old man presented with a 6-month history of recurrent joint pain and swelling. Hissymptoms had begun with three attacks of arthritis affecting his right wrist, his left ankle andhis right knee. The current attack was more widespread, affecting his hands, wrists, knees

and ankles. He had also developed tender swelling over the extensor aspect of both elbows.His medical history included chronic renal impairment, type 2 diabetes mellitus, hypertensionand heart failure. His current medication comprised bumetanide, spironolactone, lisinopril andsimvastatin.

On examination, he was obese and had widespread synovitis and bilateral olecranon bursitis.

What investigation is likely to be most informative?

A antinuclear antibodiesB erythrocyte sedimentation rate

C rheumatoid factorD serum urateE synovial fluid analysis


13/42

Updated 06/02/2012

Question 13

A 20-year-old woman presented with a 1-week history of tender lumps over the shins andpainful ankles. There was a preceding history of a coryzal type illness. On examination, therewere erythematous subcutaneous nodules over the shins and synovitis of the ankles.

Which investigation is most likely to lead to a diagnosis?

A anti-neutrophil cytoplasmic antibodiesB antinuclear antibodiesC antistreptolysin titreD chest X-rayE skin biopsy


14/42

Updated 06/02/2012

Question 14

A 32-year-old woman with long-standing rheumatoid arthritis had failed to respond totreatment with methotrexate, leflunomide, etanercept and adalimumab.

She had heard that a new antirheumatic agent, rituximab, was available for the treatment ofrheumatoid arthritis and expressed a wish to try it.

What is the most appropriate way to describe the nature of rituximab?

A antimetaboliteB chimeric monoclonal antibodyC humanised monoclonal antibodyD recombinant cytokineE recombinant human receptor fusion protein


15/42

Updated 06/02/2012

Question 15

A 55-year-old man with poorly controlled ankylosing spondylitis was due to start anti-TNFtherapy. A tuberculosis interferon-gamma release assay was used to exclude latent or activetuberculosis. This test involved measurement of the production of interferon-gamma after

incubation of the patients peripheral blood leucocytes with tuberculosis-specific peptides.

Which cells produce the interferon-gamma in this assay?

A eosinophilsB macrophagesC natural killer cellsD neutrophilsE T lymphocytes


16/42

Updated 06/02/2012

Question 16

A 59-year-old woman presented with a 6-month history of fatigue, hand pain and weakness inher arms and legs. As a result, she was no longer able to work as a nurse. She hadhypothyroidism and hyperlipidaemia, and was taking thyroxine only.

On examination, she had dry cracked hands, bilateral basal crackles on chest auscultationand grade 4/5 weakness of the thighs.

Investigations:

haemoglobin 105 g/L (115165)



lymphocyte count 1.0 109/L (1.54.0)




17/42

Updated 06/02/2012

Question 17

An 18-year-old man presented with a 2-year history of lower back pain. He was otherwise welland had no significant medical history. Examination was normal. He had been takingnaproxen with no benefit.

Investigations:

X-ray of lumbar spine see image

What is the most appropriate initial treatment?

A anti-TNF therapyB exercise programmeC intravenous antibioticsD phenylbutazoneE prednisolone


18/42

Updated 06/02/2012

Question 18

A 74-year-old woman presented with a 2-year history of widespread joint pain, Raynaudsphenomenon and recurrent lower limb ulceration. On examination, there were purpuriclesions on her legs associated with numerous punched-out ulcers. There was reduced

sensation in a stocking distribution, and absent ankle and knee reflexes. The plantar reflexeswere downgoing.

Investigations:





19/42

Updated 06/02/2012

Question 19

A 65-year-old man presented with a 24-hour history of shortness of breath and rash. Over theprevious 3 weeks, he had developed a sore throat and joint pains across his fingers, bothknees and left ankle. He was previously well and was taking no regular medication.

On examination, he had palpable purpura on his legs and splinter haemorrhages affecting hisfingernails. His chest was clear. Urinalysis showed red cells 3+.

Investigations:

serum creatinine 125 mol/L (60110)serum C-reactive protein 115 mg/L (


20/42

Updated 06/02/2012

Question 20

A 25-year-old woman with systemic lupus erythematosus had been treated with prednisolone10 mg daily for 4 years. A routine DEXA scan showed T scores of2.7 at the hip and2.5 atthe lumbar spine.

Investigations:

serum creatinine 62 mol/L (60110)estimated glomerular filtration rate (MDRD) >60 mL/min (>60)serum corrected calcium 2.02 mmol/L (2.202.60)serum phosphate 0.78 mmol/L (0.81.4)

plasma parathyroid hormone 11.2 pmol/L (0.95.4)

What is the most appropriate management?

A alendronic acidB calciumC dietary adviceD parathyroidectomyE vitamin D


21/42

Updated 06/02/2012

Question 21

A randomised, controlled, double-blind study was carried out to compare the effect of twodifferent doses of intra-articular methylprednisolone on pain 6 weeks post-injection asassessed by a visual analogue pain score.

What is the most appropriate statistical test to compare the change between baseline and 6-weeks in the two treatment groups?

A chi-squared testB KruskalWallis one-way analysis of varianceC MannWhitney U testD Spearman's rank correlation coefficientE Wilcoxon matched-pairs signed-rank test


22/42

Updated 06/02/2012

Question 22

A 63-year-old man presented with a 2-month history of pain and numbness in the right leg. Hedescribed pain in the right buttock and outer hip, with radiation into the anterior thigh andinner aspect of the shin. He was unable to lie on his right side at night. He had type 2

diabetes mellitus and had been taking metformin and simvastatin for the past 4 years.

On examination, there was wasting of the right quadriceps, an absent right knee reflex andsensory loss to light touch over the anterior thigh.


A femoral neuropathyB meralgia paraestheticaC mononeuritis multiplexD neuralgic amyotrophy

E simvastatin-induced myopathy


23/42

Updated 06/02/2012

Question 23

A 58-year-old man presented with a dry cough and severe breathlessness. He was takingprednisolone 40 mg daily and methotrexate 20 mg weekly for refractory giant cell arteritis,established by temporal artery biopsy 4 months previously.

Investigations:



serum creatinine 105 mol/L (60110)



24/42

Updated 06/02/2012

Question 24

A 49-year-old woman presented with a 4-month history of pain along the medial aspect of herleft foot, which was exacerbated by walking. On examination, there was swelling andtenderness below the medial malleolus of the left foot, weakness in inversion and she was

unable to rise up on tiptoes. There was lowering of the longitudinal arch with planovalgusdeformity.

Which tendon is most likely to be affected?

A extensor digitorum longusB flexor digitorum longusC peroneus longusD tibialis anteriorE tibialis posterior


25/42

Updated 06/02/2012

Question 25

A 21-year-old woman presented with a 4-month history of sweats, malaise, arthralgia and legcramps on walking. She had attended the emergency department on two occasions in theprevious 6 months with self-limiting palpitations.

On examination, her pulse was 100 beats per minute and regular, and her blood pressurewas 110/70 mmHg in the left arm but unrecordable in the right arm. Examination wasotherwise normal.

Investigations:




26/42

Updated 06/02/2012

Question 26

A 36-year-old woman with juvenile-onset rheumatoid arthritis presented with a 1-week historyof weakness of her right wrist. She had recently stopped taking her disease-modifyingantirheumatic drugs in order to start a family.

On examination, she had marked synovitis around her right elbow and was unable to dorsiflexher wrist or extend her fingers, but she could extend her thumb. Muscle power in her upperarm and wrist flexors, reflexes and sensation were normal.


A C7 radiculopathyB cubital tunnel syndromeC Guyons canal syndromeD posterior interosseous neuropathy

E radial neuropathy


27/42

Updated 06/02/2012

Question 27

A 72-year-old woman presented with a 2-year history of joint pains and dry eyes andmouth.

On examination, there was bilateral parotid swelling, Schirmers test was abnormal and herunstimulated salivary flow was reduced.

A minor salivary gland biopsy was performed.

Which cell type predominantly infiltrates the salivary gland in Sjgrens syndrome?

A lymphocyteB macrophageC monocyteD neutrophil

E plasma cell


28/42

Updated 06/02/2012

Question 28

A 52-year-old man presented with a 3-month history of a burning sensation in all of hisfingertips and wrist swelling. He had a 10-year history of intermittently painful joints and a 20-year history of skin psoriasis. He had smoked 20 cigarettes per day for 30 years.

On examination, he had swollen wrists and finger clubbing.

Investigations:






29/42

Updated 06/02/2012

Question 29

A 73-year-old woman presented with 12-month history of moderately severe right knee painthat woke her up at night. She had previously been well. She had been taking paracetamoland codeine with only partial benefit. Previous intra-articular triamcinolone injections and

quadriceps strengthening exercises had not led to sustained benefit.

On examination, her body mass index was 29 kg/m2 (1825). She was tender over the rightknee with crepitus and flexion was limited to 65. There was medial quadriceps wasting.

Investigations:

X-ray of right knee significant medial joint space narrowingwith osteophytes

What is the most appropriate management?

A arthroscopic knee washoutB glucosamine sulphateC knee arthroplastyD naproxenE prednisolone


30/42

Updated 06/02/2012

Question 30

A 26-year-old woman attended the early arthritis clinic with a 3-month history of aninflammatory polyarthritis affecting her hands and feet.

Investigations:






31/42

Updated 06/02/2012

Question 31

A 45-year-old woman with rheumatoid arthritis presented with a 2-week history of milddiscomfort in the left eye.

On examination, there was a localised area of redness involving the temporal bulbarconjunctiva.


A conjunctivitisB episcleritisC iritisD keratoconjunctivitis siccaE scleromalacia


32/42

Updated 06/02/2012

Question 32

A 58-year-old woman with rheumatoid arthritis was being assessed for anti-TNF therapy.

Investigations:

chest X-ray see image

What is the most appropriate treatment?

A co-trimoxazoleB etanerceptC initial antituberculous therapyD prednisolone and azathioprineE rituximab


33/42

Updated 06/02/2012

Question 33

A 34-year-old woman was referred by her general practitioner for screening forantiphospholipid syndrome. She was completely well. One year previously, while taking theoral contraceptive pill, she had had a deep venous thrombosis of the right leg. She had been

treated with warfarin for 3 months and had discontinued the oral contraceptive pill. She wastaking aspirin 75 mg daily.

Investigations:

lupus anticoagulant negative

anticardiolipin antibodies:immunoglobulin G 9 U/mL(


34/42

Updated 06/02/2012

Question 34

A 30-year-old woman presented with a 9-month history of stiffness in her hands andintermittent difficulty in swallowing.

Investigations:

X-ray of hands see image


A dermatomyositisB hyperparathyroidismC limited systemic sclerosisD rheumatoid arthritisE sarcoidosis


35/42

Updated 06/02/2012

Question 35

A 54-year-old man presented with a 4-day history of generalised weakness and intermittentepisodes of passing dark urine. During the previous week, he had been taking colchicine foracute gout affecting the left hallux and instep. He had a history of type 2 diabetes mellitus,

and his regular medication comprised aspirin, metformin, simvastatin and ramipril.

On examination, he had muscle tenderness and the muscle power grade was 4/5. Urinalysisshowed blood 3+, protein 1+, glucose 2+.

Investigations:

serum sodium 138 mmol/L (137144)serum potassium 4.8 mmol/L (3.54.9)serum urea 7.1 mmol/L (2.57.0)serum creatinine 125 mol/L (60110)

serum creatine kinase 6238 U/L (24195)

What substance is most likely to be present in the urine?

A bilirubinB haemoglobinC haemosiderinD myoglobinE urobilinogen


36/42

Updated 06/02/2012

Question 36

A 26-year-old man presented with a 1-week history of pain in his knees and ankles. Hedescribed early morning stiffness of the joints, lasting for 3 hours. Three weeks previously, hehad been on holiday to Bulgaria. While there, he had experienced an episode of diarrhoea

that had lasted 4 days and then settled. He was taking naproxen 250 mg three times a dayand omeprazole 20 mg daily.

On examination, his temperature was 37.5C. Both knees were warm, with an effusion in theleft knee. There was painful movement of both ankles.

Investigations:




platelet count 650 109

/L (150400)

synovial fluid culture negative after 48 h

blood cultures negative after 48 h


A ciprofloxacinB colchicineC flucloxacillin

D methotrexateE prednisolone


37/42

Updated 06/02/2012

Question 37

A 34-year-old woman with a 5-year history of psoriatic arthritis presented with increasing jointpain and swelling of her knees and feet. She was taking methotrexate 20 mg weekly. Low-dose sulfasalazine had previously been withdrawn because of abnormal liver function tests.

On examination, five joints were tender and three were swollen.


A etanerceptB hydroxychloroquineC infliximabD prednisoloneE rituximab


38/42

Updated 06/02/2012

Question 38

A 32-year-old woman presented with a 2-week history of pain and swelling across her anklesand knees. Over the previous 6 months, she had experienced intermittent episodes of bloodydiarrhoea. She was otherwise well and denied any other symptoms.

On examination, she had swollen, tender ankles and knees. She had a tender, nodular rashon both shins.

Investigations:

chest X-ray normal

stool culture negative

What is the most appropriate initial treatment for her musculoskeletal symptoms?

A ciprofloxacinB dapsoneC mesalazineD naproxenE prednisolone


39/42

Updated 06/02/2012

Question 39

A 60-year-old woman complained of difficulty in flexing and extending her left index finger anda feeling of locking.

On examination, she was able to make a fist but unable to extend the index finger fully. Therewas crepitus along the flexor tendon and a nodule was felt in her palm.

What is the most appropriate initial management?

A corticosteroid injection into tendon sheathB ibuprofenC intramuscular methylprednisoloneD surgical decompression of the carpal tunnelE surgical repair of tendon rupture


40/42

Updated 06/02/2012

Question 40

A 50-year-old man with rheumatoid arthritis presented with breathlessness of recent onsetand a dry cough. He had recently started treatment with methotrexate and sulfasalazine. Hewas a non-smoker. He was treated with amoxicillin and clarithromycin but had not improved

after a 1-week course.

On examination, he was tachypnoeic and his temperature was 38.3C.

Investigations:




sputum cultures no growth

blood cultures no growth

chest X-ray bilateral interstitial infiltrates


A acute respiratory distress syndromeB cardiac failureC methotrexate pneumonitisD pneumococcal pneumoniaE pulmonary embolism


41/42

Updated 06/02/2012

Question 41

A 58-year-old woman presented with a 2-year history of Raynauds phenomenon, joint painand stiffness of the fingers.

A serum sample was sent for immunofluorescence on HEp-2 cells (see image).

What immunofluorescence pattern does this show?

A centromereB homogeneousC mitochondrialD nucleolarE ribosomal


42/42

Answer keys:

1. E2. D3. E

4. B5. A6. B7. C8. E9. C10. B11. A12. E13. D14. B

15. E16. C17. B18. B19. B20. E21. C22. A23. C24. E25. D26. D27. A28. B29. C30. A31. B32. C33. D34. C35. D36. E37. A38. E39. A40. C41. A

Sce Rheum at Ology Sample q

Documents

Transcript of Sce Rheum at Ology Sample q