MRCP Part 1 Rheumatology best of five

Rheumatology An 80 year old male presents with a painful hip and knee.. Rheumatology A 68 year old female has had pain in her left knee for numerous years.. Rheumatology A 45 year old wo

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PREFACE

This is the first edition of MRCP Part 1 Rheumatology best of five that I have had the honor of working on MRCP Part

1 Rheumatology best of five is a part of a huge work include all sections of internal medicine Endocrinology,

Gastroenterology, Cardiology, Infectious Diseases and GUM, Respiratory medicine, Rheumatology, Dermatology,

Nephrology, Psychiatry, Ophthalmology, Neurology, Clinical hematology, Clinical Pharmacology, Therapeutics and Toxicology and oncology, Geriatric medicine and Clinical sciences witch include Cell, molecular and membrane

biology, Clinical anatomy, Clinical biochemistry and metabolism, Clinical physiology, Genetics, Statistics,

epidemiology and evidence-based medicine and Immunology

The care of patients is a privilege As physicians, we owe it to our patients to be intelligent, contemporary, and curious Continuing education takes many forms; many of us enjoy the intellectual stimulation and active learning challenge of the question-answer format It is in that spirit that I offer the 1st edition of the MRCP Part 1 Rheumatology best of five

to students, house staff, and practitioners I hope that from it you will learn, read, investigate, and question The

questions and answers are particularly conducive to collaboration and discussion with colleagues This edition

contains over 183 questions that, whenever possible, utilize realistic patient scenarios including radiographic or

pathologic images Similarly, the answers attempt to explain the correct or best choice

“We are here to add what we can to life, not to get what we can from life.” We hope this addition to your life stimulates your mind, challenges your thinking, and translates to your patients

I would like to thank all my friends and members of my group that participate effectively in producing this work It is truly inspirational to remind ourselves why we love medicine broadly, and internal medicine specifically

Of course, none of this would be possible without the loving support of our families, for which we are truly thankful They were patient and encouraging, as we transformed (often not quietly) a mountain of page proofs into this book

Rheumatology

A 65 year old woman is recovering in hospital following a knee replacement She is known to

have a history of alcohol excess and has had previously a duodenal ulcer for which she is on

omeprazole What would you prescribe for prophylaxsis for a DVT while she is post op.?

LMWH should be used for all prophylaxsis of DVTs due to its efficacy, ease of administration and it does

not require monitoring unlike IV heparin Although it can not be as easily reversed as heparin

Rheumatology

A 64 year old gentleman who is known to drink alcohol excessively presents with a red, hot

swollen ankle What investigation should be performed for a definitive diagnosis?

A Ankle X-ray

B Joint aspiration and culture

C Joint aspiration and microscopy

D Blood culture

E Urate levels

The most likely diagnosis here is gout due to the history and known alcohol excess Joint aspiration and

microscopy may show negatively birefringent crystal which are needle-shaped Serum urate levels are

useful however they can be low in acute attacks of gout

Rheumatology

An 80 year old male presents with a painful hip and knee He is known to have a peptic ulcer

and is on omeprazole He has limited internal rotation of the hip What analgesia do you

An 19 year old male presents with back pain and morning stiffness It is relieved with exercise

An X-ray was performed of his lumbar spine and showed obliteration of the sacroiliac junction

What treatment is the most appropriate?

The most likely diagnsois is ankylosing spondylitis NSAIDs and regular physiotherapy are the most useful

in the management od this patient Bed rest and cotisol injections are not useful

Rheumatology

A 68 year old female has had pain in her left knee for numerous years She is now waking up in

the middle of the night with the pain and her knee is giving way and she has fallen several

times The knee is unstable on examination There is evidence of Herberdens and Bouchards

nodes on the hands How would you manage this patient?

A Referral for joint replacement

B Paracetamol

C NSAIDs

D Physiotherapy

E Cortisol injection

This patient clearly has severe osteoarthritis of the knee with significant symptoms and instability A

knee replacement is thus indicated

Rheumatology

A 4 year old girl is complaining of pain in her thigh and hip On examination she is tender on

palpation of the thigh Her bloods show elevated inflammatory markers An ultrasound and

x-ray of the hip and femur is normal What is the most likely diagnosis?

The most likely is osteomyelitis as the pain is in the thigh It is unlikely to be a fracture or bone tumour

due to the normal x-ray However osteomyelitis does not show up on the x-ray initially and then later it

can show haziness and loss of density of the bone, then followed by subperiosteal reaction and

sequestrum Septic arthritis is unlikely as the joint is normal Perthes disease is osteochondritis of the

epiphysis of the femoral head and there would normally be x-ray findings with the earliest being

widening of the joint space, followed by loss of the nuclear femoral head with patchy density It does

not cause raised inflammatory markers

Rheumatology

A 13 year old boy is complaining of left hip pain On examination, internal rotation of the hip is

very limited What is the most likely diagnosis?

A Perthes disease

B Ewings Sarcoma

C Slipped upper femoral epiphysis

D Non-Accidental Injury

E Juvenile Idiopathic Arthritis

Slipped upper femoral epiphysis is the most likely diagnosis It normally affects children between 10 and

16 It is associated with obesity and hypogonadism There is limited internal rotation and adduction of

the hip Perthes disease is osteochondritis of the femoral head and typically affects a younger age group those between 3 and 11 On examination unlike SUFE there is limited movement in all directions The

history and clinical findings are not indicative of the other diagnoses

Rheumatology

A 3 year old girl is generally unwell and pyrexial She is also unable to weight bear due to hip

pain Her inflammatory markers are markedly raised An X-ray shows a widened joint space

What is the most likely diagnosis?

The most likely diagnosis here is septic arthritis due to the history and raised inflammatory markers An

early feature on x-ray is a widened joint space Osteomyelitis is less likely due to the pain being in the

joint, the sudden onset and how unwell the patient is The other diagnosis do not cause the patient to

be pyrexial or unwell Perthes disease is osteochondritis of the femoral head, affecting children aged

between 3 and 11 years It presents with pain in the hip or knee and causes a limp

Rheumatology

A 9 year old boy is complaining of hip and groin pain On examination he walks with a limp and

there is limited restriction of all movements of the joint An x-ray reveals flattening of the

femoral head What is the most likely diagnosis?

A Septic Arthritis

B Osteomyelitis

C Ewings Sarcoma

D Perthes disease

E Slipped upper femoral epiphysis

Perthes disease is the most likely diagnosis due to the history, the restriction of all hip joint movements

and the x-ray findings It begins with widened joint space and then reduced density and flattened

femoral head and the further deformity The patient is too well for this to be a septic arthritis SUFE

affects older children and predominantly internal rotation and adduction

Rheumatology

A 32 year old female presents with painful wrists and hands Her wrists and hands are very stiff

in the morning and only loosen off after 2 hours On examination there is active synovitis in

both wrists and over several PIPs and MCPs What test is useful in aiding the diagnosis?

A Rheumatoid Factor

B X-ray if hands and wrists

C Urate levels

D Anti dsDNA

E Inflammatory markers

The history is very indicative of Rheumatoid arthritis and Rheumatoid factor is positive in about three

quarters of all patients X-rays are useful in monitoring for erosions as the disease progresses and in

guiding therapy however is unlikely to show significant changes indicative of RA at this early stage

Rheumatology

A 55 year old female presents with knee pain She has problems for sometime with pain in her

DIPs and the base of her thumb On examination there is pain on the medial aspect of the knee joint and there is evidence of Bouchard and Herberdens nodes She is tiff in the morning

however the pain worsens in the evening and after movement She has a family history of

osteoarthritis What investigation will give the definitive diagnosis?

A Synovial membrane biopsy

B Rheumatoid Factor

C X-ray of knee

D Inflammatory markers

E X-ray of hands

This woman most likely has nodal generalised osteoarthritis This is a subset which leads to multiple

joint involvement of OA, which can be severe and sudden onset, predominantly the knee hips and hands with Bouchard and Heberdens nodes It is thought to be an autoimmune disease and a synovial

membrane biopsy would show immune complex deposition

Rheumatology

A 45 year old woman with a 10 year history of Rheumatoid Arthritis develops suddenly a

painful, hot, swollen, tender knee with very restricted movement How would you investigate?

A Joint fluid aspiration for crystal examination

B Joint fluid aspirate for microscopy and culture

C Inflammatory markers

D X-ray of the knee

E Blood culture

Despite the history of Rheumatoid arthritis, this history should always raise suspicion of a septic arthritis

and therefore joint aspiration for microscopy and culture should be performed

Rheumatology

A patient with SLE presents with deteriorating vision over the last few months On examination

there is no evidence of redness in the sclera however it is difficult to perform opthalmoscopy

due to opacities in the lenses of the eyes Given the likely diagnosis, how you manage this?

This patient has cataracts, which can occur at an earlier age in systemic lupus erythematosus and thus

she should be referred to an ophthalmologist for surgical removal of the lens

Rheumatology

A 64 year old gentleman presents with a left sided headache which is severe He has noticed his

scalp is very tender when brushing his hair What treatment is required to ensure no vision loss

E Azathioprine

The most likely diagnosis is temporal arteritis which can lead to sudden vision loss A high dose of oral

steroids is required to reduce the risk of visual loss Intravenous steroids are utilised if there is vision loss

in one eye to try to avoid vision loss in the other eye

Rheumatology

A 42 year old gentleman presents with difficulty climbing stairs and combing his hair He is

suffering from general malaise and is feeling feverish On examination there is a proximal

muscle weakness, a purplish rash around his eyelids and papules over his knuckles What is the

most likely diagnosis?

A 15 year old female is brought to the GP as her parents have noticed she has a poor posture

with rounded shoulders and a humped back On examination there is severe kyphosis of the

thoracic area Given the likely diagnosis, what would you not expect to see on a thoracic Xray?

A Hyperkyphosis

B Schmorls nodes

C Irregular vertebral end plates

D Wedge shaped vertebral bodies

E Osteophytes

The most likely diagnosis is Scheurmanns disease This is an osteochondroses and it affects the normal

ossification of ring epiphyses of thoracic vertebrae It affects typically girls aged 13 to 16 It leads to

wedge shaped vertebrae and thus kyphosis Other features on Xray is narrow intervertebral spaces,

Schmorls node (which are herniations of nucleus pulposus of vertebral plates) and irregular end plates

Rheumatology

A 32 year old gentleman presents to A+E following a back injury He is suffering from

numbness, paraesthesia and weakness of the leg and has been unable to pass urine On

examination there is loss of peri anal sensation and it confirms reduced power and numbness in the left leg What is your next course of action?

A 22 year old male who plays many sports regularly complains of intermittent swelling of his

knee and locking He suffers from knee pain after exercising Arthroscopy is performed and

shows several loose bodies in the synovial cavity What is the most likely diagnosis?

A ACL rupture

B Osteoarthritis

C Septic Arthritis

D Osteochondritis dissecans

E Meniscal Tear

Osteochondritis dissecans is the most likely diagnosis It leads to local necrosis of the articular cartilage

and underlying bone which leads to the formation of a loose body The knee is commonly affected

especially the medial femoral condyle Osteoarthritis is unlikely at this age An ACKL rupture leads to a

haemarthrosis A meniscal tear can occur but does not lead to the arthroscopy findings

Rheumatology

When managing polymyositis and dermatomyositis, what blood test can be utilised for

monitoring the result?

The most beneficial blood test to monitor the response to treatment and activity of the disease is CK

The other blood results may be raised in some cases of polymyositis and dermatomyositis however are

not raised in all cases and are therefore less useful

Rheumatology

A 70 year old female presents with sudden onset swollen and painful knee She is generally

unwell with a fever What is the most likely diagnosis?

The most likely diagnosis is septic arthritis and in any patient with this history then a septic joint is

presumed until proven otherwise Gout can present similarly however is not associated with fever and

malaise

Rheumatology

A 20 year old male presents with pain and stiffness in his lumbar spine relived by exercise He is

positive for HLA B27 gene What is the most likely diagnosis?

The history and age of the patient is very indicative of ankylosing spondylitis In the majority of patients

the HLA B27 gene is present The other diagnoses do not fit with the history given

Rheumatology

A 25 year old gentleman presents to his GP with pains in his left knee and ankles He is also

suffering from dysuria and red eye He has noticed plaques on the palms of his hands and soles

of his feet and a rash on his glans penis What is the most likely diagnosis?

Reiters syndrome is the triad of arthritis, urethritis and conjunctivitis It can be associated with

keratoderma blennorrhagic which are psoriatic like lesions It most often follows chlamydia or GI

infections such as with shigella, campylobacter and salmonella Reactive arthritis can lead to an

asymmetrical lower limb arthritis also but not the other features The other diagnoses are much less

likely

Rheumatology

A 67 year old present with severe thoracic back pain His bloods revealed renal impairment and

an xray shows osteolytic lesions in his vertebrae What is the most likely diagnosis?

lead to renal impairment Pagets disease leads to areas of bone growth and resorption Prostate cancer

can lead to osteolytic and osteoblastic lesions and there is often other associated symptoms such as

hesitancy etc Osteoporosis does not explain the features

Rheumatology

A 45 year old female has noticed arm weakness She has noticed hat she has found it

increasingly difficult to brush her hair, lift objects and climb stairs On examination there is

evidence of reduced power in her proximal muscles and wasting and bloods reveal an elevated

CK What is the most likely diagnosis?

The history and clinical findings are indicative of polymyositis Dysphagia and dysphonia can develop

Distal muscles are spared Polymyalgia rheumatica presents with pain and stiffness of the hip and

shoulder girdles and proximal muscles unlike Polymyositis where pain is not a common feature The

history is not indicative of myasthenia gravis or fibromyalgia and CK is elevated

Rheumatology

A patient with psoriasis develops swelling and pain in the joints of her hands On examination

there is swelling and tenderness in the DIPs What treatment is most useful?

This patient has developed psoriatic arthritis and methotrexate is utilised as it can lead to major

deformities It must be closely monitored

Rheumatology

A 42 year old farmer presents with arthralgia and myalgia, malaise and intermittent fever

There is evidence of lymphadenopathy and hepatosplenomegaly Given the likely diagnosis,

what treatment should be utilised?

A Doxycycline

B Co amoxiclav and doxycycline

C Doxycycline and rifampicin and gentamicin

D Rifampicin and gentamicin

E Doxycycline and Gentamicin

The most likely diagnosis is brucellosis as it is common in farm workers The drug combination which

leads to lowest risk of relapse is triple therapy with doxycycline, rifampicin and gentamicin Co

trimoxazole can be utilised for an oral alternative

Rheumatology

A 60 year old female from Asia presents complaining of pain in her bones and muscle weakness

An xray is performed of the femur and reveals linear low density areas surrounded by sclerotic

areas Bloods revealed elevated ALP, low phosphate and normal calcium levels What is the

most likely diagnosis?

The diagnosis is osteomalacia with the characteristic evidence of Loosers zones on the xray It leads to

elevated ALP and low phosphate due to parathroid hormone excretion In Pagets disease the ALP is also

elevated however calcium and phosphate levels are normal However unlike osteomalacia there is

evidence on x-ray of sclerotic phase of bone expansion and loss of distinction between cortex and

trabeculae Osteoporosis does not lead to the x-ray or blood results and only causes pain when there

has been a fracture Similarly hyperparathyroidism and renal osteodystrophy do not lead to the features

described

Rheumatology

A 63 year old female is found to have a pathological fracture of her femur An Xray showed

patchy sclerosis, thickening of the trabeculae and loss of distinction between the trabeculae

and cortex What treatment should be initiated?

The diagnosis is Pagets disease and bisphosphonates should be utilised They are analogues of bone

pyrophosphate and adhere to hydroxyapatite and aims to inhibit osteoclasts

Rheumatology

A 40 year old man presents with arthralgia He also gives a history of steatorrhoea and

abdominal pain A biopsy of the small bowel reveals stunted villi with PAS positive

macrophages What is characteristic of this disease?

A Positive Rheumatoid Factor

B ANA positive

C Bacilli within macrophages on electron microscopy

D Positive faecal calprotectin

E Raised ESR

The diagnosis is likely to be Whipples disease And as well as PAS positive macrophages there is evidence

of bacilli within macrophages The rest of the options are not specific features

Rheumatology

A 24 year old known to have chlamydia presents with swelling in her knee and ankle What is

the most likely diagnosis?

A Gout

B Septic Arthritis

C Rheumatoid arthritis

D Reiters Syndrome

E Reactive arthritis

The most likely diagnosis is reactive arthritis secondary to Chlamydia trachomatis Reiters syndrome is

the triad of arthritis, conjunctivitis and urethritis and often there is characteristic skin changes The

other options are much less likely

Rheumatology

A 20 year old with back pain which is relieved with exercise and is associated with morning

stiffness An Xray shows obscuring of the sacroiliac joints Which of the following treatments is

E Physiotherapy and Spinal extension exercises

The most likely diagnosis is ankylosing spondylitis The treatment includes NSAIDs and spinal extension

exercises and regular physiotherapy Spinal osteotomy is rarely used for severe deformity The other

options are not useful

Rheumatology

What is the most characteristic finding on Xray of a patient with ankylosing spondylitis?

A Scoliosis

B Osteophytes

C Narrowed disc space

D Subchondral bony sclerosis at sacroiliac joints

E Widened disc space

The characteristic early x-ray findings is subchondral bony sclerosis on the iliac sides of the sacroiliac

joints It eventually leads on to bamboo spine The other options are not characteristic

Rheumatology

What would you expect to find in the blood results of a patient with osteoporosis?

A Low PTH levels

B Low calcium levels

C High ALP levels

D High phosphate levels

E Normal calcium, phosphate and ALP levels

The blood results are typically normal for calcium, phosphate, alkaline phosphatase, vitamin D and PTH

levels

Rheumatology

A 22 year old who has recently recovered from an episode of shigella gastroenteritis, presents

with pain and swelling of his left knee and ankle He also has noticed red eyes and a rash on his

glans penis and plaques on his palms and soles What other feature if present is highly

indicative of Reiters Syndrome?

Keratoderma blenorrhagica which are brown yellow waxy lesions on the soles and palms are highly

indicative of Reiters Syndrome

Rheumatology

A 62 year old female with known osteoarthritis and diabetes presents with sudden swelling and

pain in her left knee It is hot, red and tender What investigation should be performed?

A Joint fluid microscopy

B Analgesia

C Xray of knee

D Joint aspiration for gram stain, microscopy and culture

E Blood culture

With this history septic arthritis should be at the top of the differential diagnosis and therefore joint

aspiration for gram stain, microscopy and culture is essential An xray is not diagnostic Fluid microscopy

on its own is only useful for diagnosis of gout and pseudogout The history could make gout a possible

diagnosis however a septic arthritis must always be excluded Patients are usually systemically unwell

and pyrexial in septic arthritis

Rheumatology

A 32 year old female with psoriasis presents with painful swollen fingers with some deformity

What is the most appropriate treatment?

This lady is presenting with psoriatic arthritis Methotrexate or ciclosporin can be utilised in severe

disease Etanercept is also very useful but should only be utilised once methotrexate or ciclosporin fail

Sulfasalazine can be utilised in more mild disease

E Elevated urea or creatinine

The blood results included in the diagnostic criteria are elevated urea and creatinine and Hep B

infection

Rheumatology

How do you monitor the response of Giant cell arteritis to treatment?

A Positive to negative temporal artery biopsy

B Clinical response

C Nil

D CRP

E ESR

ESR is useful for monitoring the response to treatment A biopsy is not utilised to monitor response as

although a positive biopsy confirms the diagnosis, it may be negative due to skip lesions and thus is not

utilised

Rheumatology

A 60 year old female presents with pain and stiffness of the shoulder, neck and hips She is stiff

for up to one hour in the morning Her ESR is elevated What is the most likely diagnosis?

The symptoms are indicative of PMR Polymyositis leads to symmetrical proximal muscle weakness but

pain is unusual Frozen shoulder restricts all movements of the shoulders The joints involved are not

typical of Rheumatoid arthritis

Rheumatology

A patient with rheumatoid arthritis for numerous years present with shortness of breath,

mouth ulcers and malaise Bloods reveal a pancytopenia What medications is likely to be the

cause?

A Gold

B Hydroxychloroquine

E History of severe pain and stiffness in the knees

The management of the patient should be guided with the history and severity of the symptoms

Rheumatology

A 68 year old male presents with leg pain on walking His leg feel heavy and sometimes numb It

is worse walking down hill and is relieved when he stops and sits down What is the most likely

osteophyte formation and a hypertrophic ligamentum flavum There can be reduction of spinal diameter due to osteoarthritis An x-ray is normal and straight leg raising test is negative It is often exacerbated

by extension of the spine and thus going downhill can be worse and when sitting down This is the main

differentiating feature from its main differential Intermittent claudication where these features are not

seen

Rheumatology

A 72 year old male has been suffering from neck pain for a number of years He is now

complaining of worsened pain and his left arm feeling weak and numb On examination he has

sensory loss in C5 and C6 dermatomes and he has 4/5 power in left shoulder abduction Which

of the following is the most likely diagnosis?

A Cervical spondylosis

B Polymyalgia Rheumatica

C Prolapsed cervical disc C7/T1

D Prolapsed cervical disc C5/C6

E Osteoarthritis

The diagnosis is prolapsed disc C5 C6 due to the history and clinical findings Cervical spondylosis occurs

secondary to osteoarthritis Disc spaces are sometimes narrowed and osteophytes can impinge on the

nerve but there is usually no muscle weakness

Rheumatology

A 72 yea old male with cervical spondylosis presents with pain and weakness in both arms He

has also noticed them feeling numb and tingling On examination there is evidence of LMN

signs in his arms and UMN signs in his legs How would you manage this patient?

A Analgesia

B Urgent CT of Head and Neck

C Urgent neurosurgical referral

D Support collar

E Urgent C-spine X-ray

This gentleman must be urgently referred to the neurosurgeons as there are features of a central disc

prolapse and cord compression

Rheumatology

A 37 year old female twisted her ankle a few weeks earlier Since then she has had pain in her

foot She describes this as burning and is sometimes tingling The symptoms are reproduced by

pressing behind the medial malleolus What is the most likely cause?

A Spinal nerve root compression

B Common peroneal nerve injury

C Posterior tibial nerve compression

D Fractured medial malleoli

This patient is suffering from tarsal tunnel syndrome which is due to compression of the posterior tibial

nerve In common peroneal nerve injury there is foot drop and sensory loss is over the front and lateral

half of the leg and dorsum of the foot

Rheumatology

A patient with rheumatoid arthritis is complianing of pain her left hand which is worse in the

morning and sometimes wakes her from sleep She also feels her hand is numb On

examination there is loss of sensation in her left thumb index, middle and radial half of ring

finger What clinical feature may you also observe?

A Not associated with obesity

B Pain worse when resting

C Pain relieved if the wrist is hyperfelexed

D Weakness and wasting of the muscles of the thenar eminence

E Negative Tinels test

The diagnosis is carpal tnnel syndrome and the only option which is also a feature is weakness and

wasting of the thenar muscles

Rheumatology

A 23 year old female presents with a discoid rash She is also complaining of painful joints and

has noticed her skin being very sensitive in the sun She has also noticed an increased frequency

of oral ulcers What is the most likely diagnosis?

The most likely diagnosis is systemic lupus erythematosus given the history and findings The history is

not indicative of any of the of the other diagnoses There is specific criteria for the diagnosis of SLE

Rheumatology

A 65 year old presents with headache He is also feeling feverish and generally unwell He has

also noticed his scalp is sensitive when he brushes his hair and is having pain when chewing

What treatment should you initiate?

The history is indicative of giant-cell arteritis and thus oral steroids must be initiated IV steroids are only utilised if there is sudden vision loss to ensure there is no loss of vision in other eye Obviously a

rheumatology referral will be required however this should not delay the initiation of steroids which

must be commenced immediately

Rheumatology

A 65 year old presents with headache He is also feeling feverish and generally unwell He has

also noticed his scalp is sensitive when he brushes his hair and is having pain when chewing

What will make the definitive diagnosis?

A CT angiogram

B Rheumatoid factor

C Temporal artery biopsy

D Antinuclear antibody test

E ESR

The definitive diagnosis is via a temporal artery biopsy However there can be skip lesions and a negative biopsy does not exclude the diagnosis

Rheumatology

A 63 year old female is complaining of pain around her shoulders and hip She is very stiff in the

morning She is feeling fatigued What is the most likely diagnosis?

systemic features such as malaise, pyrexia, depression and night sweats, anorexia and weight loss

Rheumatoid arthritis does not typically effect these joints

Rheumatology

A 19 year old male presents generally unwell, feeling feverish He has noticed a salmon pink,

maculopapular rash on his trunk and arms He is complaining of joint pain with painful and

swollen distal interphalangeal joints are swollen What is the most likely diagnosis?

The most likely diagnosis is adult-onset Stills disease It affects [predominantly the age group 15 to 35 It

usually present with a salmon pink maculo papular rash, pyrexia (typically in the evening) and arthritis

(which can be worsened during the pyrexial period) The rash is usually on the trunks and legs but can be

on face and arms and usually appears during pyrexia A sore throat can also be a feature, as can

hepatosplenomegaly, generalised lymphadenopathy, and polyserositis including pericarditis and

pleuritis The other options do not explain all of the symptoms

Rheumatology

A 33 year old gentleman has noticed recurrent mouth and genital ulcers He is also suffering

from diarrhoea intermittently and has complained of red eyes What is the most likely

E SLE

The most likely diagnosis to explain all of these symptoms is Behcets disease It is presumed to be

autoimmune and can effect multiple organ systems The diagnosis do not account for all of the

symptoms SLE can lead to mouth ulcers but not genital Lichen planus and Pemphigus are not

associated with red eye or diarrhoea

Rheumatology

A 45 year old patient with a raised BMI presents with a hot, swollen, red very painful big toe

What investigation would give the definitive diagnosis?

This patient has most likely gout Although urate levels can be high they can also be low during an acute

attack Fluid aspiration for microscopy which reveals negatively birefringent crystals

Rheumatology

A 45 year old patient with a raised BMI presents with a hot, swollen, red very painful big toe

What is the most likely diagnosis?

Gout is the most likely diagnosis given the acuteness and clinical findings and the joint involved The first MTP is often the most common joint to be affected Although other joints such as knees , ankles and

wrists can be involved It is excruciating pain and very tender and can wake the patient from sleep Due

to the severe inflammatory response it can lead to malaise and pyrexia It leads to hot tender and

erythematous joints which when resolving the skin can desquamate and be pruritic Pseudogout usually

is associated with other disease such as OA and most commonly affects the knees and ankles If there is

any suspicion of septic arthritis then this must be excluded

Rheumatology

A 13 year old boy presents to is GP HE has been generally unwell with a fever for

approximately one week On examination there is evidence of bilateral conjunctivitis, cervical

lymphadenopathy, erythema and desquamation and oedema of his hands and feet and his lips

appear red and dry Given the likely diagnosis, what treatment should be given?

The most likely diagnosis is Kawasakis This can lead to effects on the cardiovascular system and other

systems Aspirin and intravenous immunoglobulin used in conjunction lead to a lower incidence of

coronary artery abnormalities The treatment should begin within the first ten days

Rheumatology

A 13 year old boy presents to is GP He has been generally unwell with a fever for

approximately one week On examination there is evidence of bilateral conjunctivitis, cervical

lymphadenopathy, erythema and desquamation and oedema of his hands and feet and his lips

appear red and dry What is the most likely diagnosis?

lymphadneopathy, erythema, desquamation and oedema of palms and soles and a polymorphic rash

The other options do not account for all clinical features

Rheumatology

A 72 year old female who is overweight presents with pains in her fingers She has also noticed

some pain in her knees These are worst after movement and at the end of the day On

examination there is nil of note on knee examination and there is evidence of hard swelling at

the PIPs and DIPs What is the most likely diagnosis?

The most likely diagnosis is OA This is indicated by the history with pain worst after movement and at

the end of the day There is also evidence of Bouchards and Heberdens nodes There may be some

effusion in affected joints and crepitus RA differs in that the pain is worst in the morning and there is

morning stiffness

Rheumatology

A 42 year old female presents with dry, gritty eyes and a dry mouth She is feeling tired and is

having some difficulty swallowing What is the most likely diagnosis?

A Iron deficiency Anaemia

B Sjogrens syndrome

C SLE

D Rheumatoid Arthritis

E Malignancy

The most likely diagnosis is Sjogrens syndrome where there is inflammation and the destruction of

exocrine glands It predominantly affects the salivary and lacrimal glands leading to dry eyes and mouth

It can be primary (often associated with HLA-DR3) or secondary such in association with SLE Due to the

dry eyes this can lead to recurrent conjunctivitis and the dry mouth difficulty swallowing

Rheumatology

A 28 year old female presents with joint pain in her wrists and hands These are worst in the

morning with significant morning stiffness On examination there is evidence of active synovitis What blood test should be performed?

This patient most likely has RA RF should be measured and is specific if the history is indicative although

it can be positive in other autoimmune diseases A positive RF is associated with a worse prognosis

Rheumatology

A 32 year old female presents with muscle weakness She is finding it difficulty to climb stairs

and brush her hair Over her knuckles there is erythematous scaly papules What is the most

likely diagnosis?

A Systemic lupus erythematosus

A 32 year old female presents with muscle weakness She is finding it difficulty to climb stairs

and brush her hair Over her knuckles there is erythematous scaly papules and a purplish rash

around her eyes What associated disease should be suspected?

The most likely diagnosis is dermatomyositis This can often be associated with a malignancy such as

lung, oesophageal, breast, colon and ovarian tumours Therefore patient should be monitored for this.

Rheumatology

A 39 year old male presents with proximal muscle weakness He has been feeling generally

unwell for several months He has noticed a malar rash with a purplish rash around his eyes

There is erythematous scaly lesions on his arms His CK is elevated How do you make the

definitive diagnosis?

A CT Chest abdomen and Pelvis

B Skins scrapings

C ANA

D Rheumatoid Factor

E Muscle biopsy

The history is suggestive of dermatomyositis A definitive diagnosis is made by a muscle biopsy If there

is evidence of Gottrons papules and proximal muscle weakness this may avoid the need for a biopsy as

these are pathognomonic A CT CAP would only be indicated if you suspect an underlying malignancy

ANA and RF are not specific for the diagnosis

Rheumatology

A 52 year old woman with previous history of IBS presents with general aches and pains all over with

stiffness in her hands and wrist, not worse at any time of the day She has been unable to sleep because

of the pain and is very fatigued She is also suffering from band like headaches On examination there

are multiple tender spots over her hips and back Blood results including auto antibodies are normal

What is the most likely diagnosis?

Fibromyalgia is the most likely diagnosis It leads to generalised musculoskeletal pain, stiffness,

tenderness, sleep disturbance and easy fatigability It usually affects woman from 30 to 60 years of age

Diagnostic criteria are set out but the ACR and include ; widespread pain for 3 months; pain on palpation

of certain trigger point e.g greater trochanter, second rib, occiput; There is nil of note on examination

and all blood investigations are normal

Rheumatology

A 52 year old male presents with malaise, fever, headache and arthralgia He complains of myalgia on

exertion He describes loss of sensation in his feet and notices his hands turn white and are painful in

the cold He is found to be hypertensive and a raised ESR What is the most likely diagnosis?

A Adult onset Stills disease

B Polymyalgia rheumatica

C Systemic lupus erythematosus

D Rheumatoid Arthritis

E Polyarteritis nodosa

The most likely diagnosis is PAN PAN is a vasculitis which affects medium sized vessels It can affect

multiple organ systems It often presents with non specific features such as malaise etc and then

features of the systems affected such as peripheral neuropathy, mononeuritis multiplex, hypertension

etc There is a diagnostic criteria set out by the ACR The features described are e not typical of RA> PMR

is not associated with the neurological features SLE does not normally present in this way

Rheumatology

What should patients be warned about whilst on Raloxifene?

A Higher risk of clotting

B Increases bone density

C Higher risk of breast cancer

D Can cause GI upset

E Must be taken in the morning, an hour before food

Raloxifene is a selective oestrogen receptor modulator and thus can increase the risk of developing a

thromboembolic event It can also lead to hot flushes, irregular vaginal bleeding, breast tenderness and

leg cramps Raloxifene increases bone density and reduces fracture risk at the spine