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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 B C D E L4 L4/L5 L5 L5/S1 S1

Updated 06/02/2012

Question 2 A 43-year-old woman, with recent-onset rheumatoid factor-positive inflammatory arthritis, was having 10-weekly intramuscular injections of sodium aurothiomalate. At week 10 she reported being 90% better. On examination, her hand joints were much less puffy than before treatment and knee effusions had resolved. She had developed a shiny, slightly scaly erythematous plaque over the abdomen and two smaller patches on her limbs. Her serum C-reactive protein had fallen from 56 to 4 mg/L (<10). What is the most appropriate next step in management? A B C D E continue sodium aurothiomalate and seek a dermatological opinion continue sodium aurothiomalate and treat with topical hydrocortisone reduce sodium aurothiomalate to 25 mg per week stop sodium aurothiomalate stop sodium aurothiomalate until the rash has settled and then reintroduce

Updated 06/02/2012

Question 3 A 46-year-old man presented with a 2-week history of a worsening ulcerating rash over his lower limbs, which had coalesced in places. He also had right knee and left wrist synovitis. He had returned from a holiday in Portugal 4 weeks previously. He had ulcerative colitis that had been diagnosed the previous year, and was taking 5 mg prednisolone daily. What is the most likely diagnosis? A B C D E discoid lupus erythema nodosum granuloma annulare Lyme disease pyoderma gangrenosum

Updated 06/02/2012

Question 4 A 32-year-old woman, with severe psoriatic arthritis well-controlled with sulfasalazine and paracetamol, presented to clinic. She had just married and wished to conceive without risking a flare of her arthritis. What is the most appropriate treatment strategy? A B C D E add oral prednisolone continue sulfasalazine stop sulfasalazine stop sulfasalazine and change to oral prednisolone stop sulfasalazine and start methotrexate and folic acid

Updated 06/02/2012

Question 5 A 50-year-old woman was referred by an orthopaedic surgeon with a 2-month history of severe pain in her right knee, calf and foot. This had developed 1 week after an arthroscopic meniscectomy. On examination, she was tearful and her right leg was swollen, dusky, cool and tender below the knee. She found light touch extremely painful and refused to have her knee fully examined. Investigations: serum C-reactive protein Doppler ultrasound scan What is the most likely diagnosis? A B C D E complex regional pain syndrome deep venous thrombosis popliteal artery dissection septic arthritis synovial leak 3 mg/L (<10) normal

Updated 06/02/2012

Question 6 A 24-year-old woman presented with acute pain and swelling of her right knee. She had been complaining of lower abdominal pain for the previous 3 days. On examination, her temperature 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 serum C-reactive protein synovial fluid analysis: appearance of fluid white cell count neutrophil count Gram stain crystals culture What is the most likely diagnosis? A B C D E enteropathic arthritis gonococcal arthritis reactive arthritis rheumatoid arthritis tuberculous arthritis 16.4 109/L (4.011.0) 120 mg/L (<10)

turbid 80 000/mL (<200) >90% negative absent negative

Updated 06/02/2012

Question 7 A 20-year-old man of Turkish origin presented with a recurrent monoarthropathy. He also complained of attacks of intermittent fever, abdominal pain and pleuritic chest pain, and had noted an erythematous rash during these attacks. What is the most likely diagnosis? A B C D E adult-onset Stills disease Behets disease familial Mediterranean fever HenochSchnlein purpura systemic lupus erythematosus

Updated 06/02/2012

Question 8 A 48-year-old man presented with a 2-month history of arthralgia and a recurrent itchy rash over his trunk and limbs. On examination, he had urticarial lesions all over his trunk. He had started antihistamine therapy, but with no benefit. No other abnormalities were found on examination. A skin biopsy showed a leucocytoclastic vasculitis and a diagnosis of urticarial vasculitis was made. What is the most appropriate next treatment? A B C D E azathioprine dapsone hydroxychloroquine naproxen prednisolone

Updated 06/02/2012

Question 9 A 61-year-old woman with long-standing rheumatoid arthritis presented with persistent leg ulcers. She was taking methotrexate. Infliximab had been stopped 2 months previously following the appearance of the leg ulcers. On examination, there were bilateral shallow ulcers on the medial malleoli. Investigations: haemoglobin MCV MCHC white cell count neutrophil count platelet count erythrocyte sedimentation rate serum immunoglobulin G serum immunoglobulin A serum immunoglobulin M rheumatoid factor What is the most likely diagnosis? A B C D E cryoglobulinaemia delayed drug reaction to infliximab Feltys syndrome leucocytoclastic vasculitis rheumatoid vasculitis 98 g/L (115165) 89 fL (8096) 35 g/dL (3235) 4.8 109/L (4.011.0) 1.0 109/L (1.57.0) 180 109/L (150400) 60 mm/1st h (<30) 23.0 g/L (6.013.0) 1.2 g/L (0.83.0) 2.3 g/L (0.42.5) 48 kIU/L (<30)

Updated 06/02/2012

Question 10 A 42-year-old woman with rheumatoid arthritis presented with a 3-day history of malaise and nausea. Because of progressive disease, methotrexate had been changed to leflunomide 20 mg daily 2 weeks previously. Her other medication was dihydrocodeine and ibuprofen. On examination, she had right hypochondrial tenderness. Investigations: serum total bilirubin serum alanine aminotransferase serum alkaline phosphatase serum gamma glutamyl transferase Leflunomide was discontinued. What is the most appropriate next step in management? A B C D E acetylcysteine colestyramine high-dose prednisolone intravenous ganciclovir no additional treatment 27 mol/L (122) 3276 U/L (535) 367 U/L (45105) 970 U/L (435)

Updated 06/02/2012

Question 11 A 42-year-old man presented with a 6-month history of pain in his right upper arm that prevented him from working. On examination, there was flattening of the right deltoid contour with restriction of active and passive shoulder movements, and of neck movements. What is the most likely cause of his pain? A B C D E adhesive capsulitis cervical spondylosis glenohumeral joint osteoarthritis subacromial bursitis supraspinatus tendonitis

Updated 06/02/2012

Question 12 A 72-year-old man presented with a 6-month history of recurrent joint pain and swelling. His symptoms had begun with three attacks of arthritis affecting his right wrist, his left ankle and his right knee. The current attack was more widespread, affecting his hands, wrists, knees and ankles. He had also developed tender swelling over the extensor aspect of both elbows. His medical history included chronic renal impairment, type 2 diabetes mellitus, hypertension and heart failure. His current medication comprised bumetanide, spironolactone, lisinopril and simvastatin. On examination, he was obese and had widespread synovitis and bilateral olecranon bursitis. What investigation is likely to be most informative? A B C D E antinuclear antibodies erythrocyte sedimentation rate rheumatoid factor serum urate synovial fluid analysis

Updated 06/02/2012

Question 13 A 20-year-old woman presented with a 1-week history of tender lumps over the shins and painful ankles. There was a preceding history of a coryzal type illness. On examination, there were erythematous subcutaneous nodules over the shins and synovitis of the ankles. Which investigation is most likely to lead to a diagnosis? A B C D E anti-neutrophil cytoplasmic antibodies antinuclear antibodies antistreptolysin titre chest X-ray skin biopsy

Updated 06/02/2012

Question 14 A 32-year-old woman with long-standing rheumatoid arthritis had failed to respond to treatment with methotrexate, leflunomide, etanercept and adalimumab. She had heard that a new antirheumatic agent, rituximab, was available for the treatment of rheumatoid arthritis and expressed a wish to try it. What is the most appropriate way to describe the nature of rituximab? A B C D E antimetabolite chimeric monoclonal antibody humanised monoclonal antibody recombinant cytokine recombinant human receptor fusion protein

Updated 06/02/2012

Question 15 A 55-year-old man with poorly controlled ankylosing spondylitis was due to start anti-TNF therapy. A tuberculosis interferon-gamma release assay was used to exclude latent or active tuberculosis. This test involved measurement of the production of interferon-gamma after incubation of the patients peripheral blood leucocytes with tuberculosis-specific peptides. Which cells produce the interferon-gamma in this assay? A B C D E eosinophils macrophages natural killer cells neutrophils T lymphocytes

Updated 06/02/2012

Question 16 A 59-year-old woman presented with a 6-month history of fatigue, hand pain and weakness in her arms and legs. As a result, she was no longer able to work as a nurse. She had hypothyroidism and hyperlipidaemia, and was taking thyroxine only. On examination, she had dry cracked hands, bilateral basal crackles on chest auscultation and grade 4/5 weakness of the thighs. Investigations: haemoglobin white cell count neutrophil count lymphocyte count platelet count erythrocyte sedimentation rate serum creatine kinase serum C-reactive protein antinuclear antibodies rheumatoid factor chest X-ray What is the most likely diagnosis? A B C D E fibromyalgia polymyalgia rheumatica polymyositis rheumatoid arthritis sarcoidosis 105 g/L (115165) 4.3 109/L (4.011.0) 2.2 109/L (1.57.0) 1.0 109/L (1.54.0) 184 109/L (150400) 32 mm/1st h (<20) 403 U/L (24170) 15.4 mg/L (<10) 1:320 (negative at 1:20 dilution) 64 kIU/L (<30) normal

Updated 06/02/2012

Question 17 An 18-year-old man presented with a 2-year history of lower back pain. He was otherwise well and had no significant medical history. Examination was normal. He had been taking naproxen with no benefit. Investigations: X-ray of lumbar spine see image

What is the most appropriate initial treatment? A B C D E anti-TNF therapy exercise programme intravenous antibiotics phenylbutazone prednisolone

Updated 06/02/2012

Question 18 A 74-year-old woman presented with a 2-year history of widespread joint pain, Raynauds phenomenon and recurrent lower limb ulceration. On examination, there were purpuric lesions on her legs associated with numerous punched-out ulcers. There was reduced sensation in a stocking distribution, and absent ankle and knee reflexes. The plantar reflexes were downgoing. Investigations: white cell count platelet count erythrocyte sedimentation rate serum creatinine serum alanine aminotransferase serum alkaline phosphatase serum complement C3 serum complement C4 anti-neutrophil cytoplasmic antibodies antinuclear antibodies rheumatoid factor ulcer biopsy What is the most likely diagnosis? A B C D E microscopic polyangiitis mixed essential cryoglobulinaemia rheumatoid vasculitis systemic lupus erythematosus Wegeners granulomatosis 10.2 109/L (4.011.0) 450 109/L (150400) 89 mm/1st h (<30) 130 mol/L (60110) 68 U/L (535) 192 U/L (45105) 45 mg/dL (65190) 5 mg/dL (1550) negative negative 150 kIU/L (<30) small vessel leucocytoclastic vasculitis

Updated 06/02/2012

Question 19 A 65-year-old man presented with a 24-hour history of shortness of breath and rash. Over the previous 3 weeks, he had developed a sore throat and joint pains across his fingers, both knees and left ankle. He was previously well and was taking no regular medication. On examination, he had palpable purpura on his legs and splinter haemorrhages affecting his fingernails. His chest was clear. Urinalysis showed red cells 3+. Investigations: serum creatinine serum C-reactive protein chest X-ray blood cultures 3 echocardiogram What is the most appropriate initial management? A B C D E intravenous cyclophosphamide intravenous methylprednisolone oral methotrexate oral mycophenolate mofetil plasmapheresis 125 mol/L (60110) 115 mg/L (<10) normal no growth no vegetations

Updated 06/02/2012

Question 20 A 25-year-old woman with systemic lupus erythematosus had been treated with prednisolone 10 mg daily for 4 years. A routine DEXA scan showed T scores of 2.7 at the hip and 2.5 at the lumbar spine. Investigations: serum creatinine estimated glomerular filtration rate (MDRD) serum corrected calcium serum phosphate plasma parathyroid hormone What is the most appropriate management? A B C D E alendronic acid calcium dietary advice parathyroidectomy vitamin D 62 mol/L (60110) >60 mL/min (>60) 2.02 mmol/L (2.202.60) 0.78 mmol/L (0.81.4) 11.2 pmol/L (0.95.4)

Updated 06/02/2012

Question 21 A randomised, controlled, double-blind study was carried out to compare the effect of two different doses of intra-articular methylprednisolone on pain 6 weeks post-injection as assessed by a visual analogue pain score. What is the most appropriate statistical test to compare the change between baseline and 6weeks in the two treatment groups? A B C D E chi-squared test KruskalWallis one-way analysis of variance MannWhitney U test Spearman's rank correlation coefficient Wilcoxon matched-pairs signed-rank test

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. He described pain in the right buttock and outer hip, with radiation into the anterior thigh and inner aspect of the shin. He was unable to lie on his right side at night. He had type 2 diabetes mellitus and had been taking metformin and simvastatin for the past 4 years. On examination, there was wasting of the right quadriceps, an absent right knee reflex and sensory loss to light touch over the anterior thigh. What is the most likely diagnosis? A B C D E femoral neuropathy meralgia paraesthetica mononeuritis multiplex neuralgic amyotrophy simvastatin-induced myopathy

Updated 06/02/2012

Question 23 A 58-year-old man presented with a dry cough and severe breathlessness. He was taking prednisolone 40 mg daily and methotrexate 20 mg weekly for refractory giant cell arteritis, established by temporal artery biopsy 4 months previously. Investigations: haemoglobin white cell count serum creatinine serum C-reactive protein HIV antibodies chest X-ray 121 g/L (130180) 6.1 109/L (4.011.0) 105 mol/L (60110) 98 mg/L (<10) negative see image

What is the most likely diagnosis? A B C D E aspergillosis cardiac failure methotrexate pneumonitis pulmonary embolism staphylococcal pneumonia

Updated 06/02/2012

Question 24 A 49-year-old woman presented with a 4-month history of pain along the medial aspect of her left foot, which was exacerbated by walking. On examination, there was swelling and tenderness below the medial malleolus of the left foot, weakness in inversion and she was unable to rise up on tiptoes. There was lowering of the longitudinal arch with planovalgus deformity. Which tendon is most likely to be affected? A B C D E extensor digitorum longus flexor digitorum longus peroneus longus tibialis anterior tibialis posterior

Updated 06/02/2012

Question 25 A 21-year-old woman presented with a 4-month history of sweats, malaise, arthralgia and leg cramps on walking. She had attended the emergency department on two occasions in the previous 6 months with self-limiting palpitations. On examination, her pulse was 100 beats per minute and regular, and her blood pressure was 110/70 mmHg in the left arm but unrecordable in the right arm. Examination was otherwise normal. Investigations: haemoglobin serum C-reactive protein anti-neutrophil cytoplasmic antibodies What is the most likely diagnosis? AKawasakis disease Bmicroscopic polyangiitis Cpolyarteritis nodosa DTakayasus arteritis Ethoracic outlet syndrome 99 g/L (115165) 23 mg/L (<10) negative

Updated 06/02/2012

Question 26 A 36-year-old woman with juvenile-onset rheumatoid arthritis presented with a 1-week history of weakness of her right wrist. She had recently stopped taking her disease-modifying antirheumatic drugs in order to start a family. On examination, she had marked synovitis around her right elbow and was unable to dorsiflex her wrist or extend her fingers, but she could extend her thumb. Muscle power in her upper arm and wrist flexors, reflexes and sensation were normal. What is the most likely diagnosis? A B C D E C7 radiculopathy cubital tunnel syndrome Guyons canal syndrome posterior interosseous neuropathy radial neuropathy

Updated 06/02/2012

Question 27 A 72-year-old woman presented with a 2-year history of joint pains and dry eyes and mouth. On examination, there was bilateral parotid swelling, Schirmers test was abnormal and her unstimulated salivary flow was reduced. A minor salivary gland biopsy was performed. Which cell type predominantly infiltrates the salivary gland in Sjgrens syndrome? A B C D E lymphocyte macrophage monocyte neutrophil plasma cell

Updated 06/02/2012

Question 28 A 52-year-old man presented with a 3-month history of a burning sensation in all of his fingertips and wrist swelling. He had a 10-year history of intermittently painful joints and a 20year history of skin psoriasis. He had smoked 20 cigarettes per day for 30 years. On examination, he had swollen wrists and finger clubbing. Investigations: haemoglobin white cell count platelet count serum C-reactive protein rheumatoid factor What is the most likely diagnosis? A B C D E carpal tunnel syndrome hypertrophic osteoarthropathy osteoarthritis psoriatic arthropathy rheumatoid arthritis 134 g/L (130180) 9.4 109/L (4.011.0) 456 109/L (150400) 15 mg/L (<10) 50 kIU/L (<30)

Updated 06/02/2012

Question 29 A 73-year-old woman presented with 12-month history of moderately severe right knee pain that woke her up at night. She had previously been well. She had been taking paracetamol and codeine with only partial benefit. Previous intra-articular triamcinolone injections and quadriceps strengthening exercises had not led to sustained benefit. On examination, her body mass index was 29 kg/m 2 (1825). She was tender over the right knee with crepitus and flexion was limited to 65. There was medial quadriceps wasting. Investigations: X-ray of right knee significant medial joint space narrowing with osteophytes

What is the most appropriate management? A B C D E arthroscopic knee washout glucosamine sulphate knee arthroplasty naproxen prednisolone

Updated 06/02/2012

Question 30 A 26-year-old woman attended the early arthritis clinic with a 3-month history of an inflammatory polyarthritis affecting her hands and feet. Investigations: haemoglobin white cell count platelet count erythrocyte sedimentation rate X-rays of hands and wrists 125 g/L (115165) 7.3 109/L (4.011.0) 350 109/L (150400) 40 mm/1st h (<20) periarticular osteopenia

What investigation is most likely to distinguish between persistent and self-limiting arthritis? A B C D E anti-citrullinated peptide antigen antibodies antinuclear antibodies IgA rheumatoid factor IgG rheumatoid factor IgM rheumatoid factor

Updated 06/02/2012

Question 31 A 45-year-old woman with rheumatoid arthritis presented with a 2-week history of mild discomfort in the left eye. On examination, there was a localised area of redness involving the temporal bulbar conjunctiva. What is the most likely diagnosis? A B C D E conjunctivitis episcleritis iritis keratoconjunctivitis sicca scleromalacia

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 B C D E co-trimoxazole etanercept initial antituberculous therapy prednisolone and azathioprine rituximab

Updated 06/02/2012

Question 33 A 34-year-old woman was referred by her general practitioner for screening for antiphospholipid syndrome. She was completely well. One year previously, while taking the oral contraceptive pill, she had had a deep venous thrombosis of the right leg. She had been treated with warfarin for 3 months and had discontinued the oral contraceptive pill. She was taking aspirin 75 mg daily. Investigations: lupus anticoagulant anticardiolipin antibodies: immunoglobulin G immunoglobulin M anti-2-glycoprotein-1 antibodies: immunoglobulin G immunoglobulin M What is the most appropriate management? A B C D E add clopidogrel change aspirin to warfarin Doppler ultrasound scan of right calf repeat anti-2-glycoprotein-1 antibodies in 12 weeks repeat anticardiolipin antibodies in 6 weeks negative

9 U/mL(<23) 10 U/mL(<11)

105 U/mL(<10) 98 U/mL(<11)

Updated 06/02/2012

Question 34 A 30-year-old woman presented with a 9-month history of stiffness in her hands and intermittent difficulty in swallowing. Investigations: X-ray of hands see image

What is the most likely diagnosis? A B C D E dermatomyositis hyperparathyroidism limited systemic sclerosis rheumatoid arthritis sarcoidosis

Updated 06/02/2012

Question 35 A 54-year-old man presented with a 4-day history of generalised weakness and intermittent episodes of passing dark urine. During the previous week, he had been taking colchicine for acute gout affecting the left hallux and instep. He had a history of type 2 diabetes mellitus, and his regular medication comprised aspirin, metformin, simvastatin and ramipril. On examination, he had muscle tenderness and the muscle power grade was 4/5. Urinalysis showed blood 3+, protein 1+, glucose 2+. Investigations: serum sodium serum potassium serum urea serum creatinine serum creatine kinase 138 mmol/L (137144) 4.8 mmol/L (3.54.9) 7.1 mmol/L (2.57.0) 125 mol/L (60110) 6238 U/L (24195)

What substance is most likely to be present in the urine? A B C D E bilirubin haemoglobin haemosiderin myoglobin urobilinogen

Updated 06/02/2012

Question 36 A 26-year-old man presented with a 1-week history of pain in his knees and ankles. He described early morning stiffness of the joints, lasting for 3 hours. Three weeks previously, he had been on holiday to Bulgaria. While there, he had experienced an episode of diarrhoea that had lasted 4 days and then settled. He was taking naproxen 250 mg three times a day and omeprazole 20 mg daily. On examination, his temperature was 37.5C. Both knees were warm, with an effusion in the left knee. There was painful movement of both ankles. Investigations: haemoglobin white cell count neutrophil count platelet count synovial fluid culture blood cultures What is the most appropriate treatment? A B C D E ciprofloxacin colchicine flucloxacillin methotrexate prednisolone 116 g/L (130180) 12.3 109/L (4.011.0) 10.9 109/L (1.57.0) 650 109/L (150400) negative after 48 h negative after 48 h

Updated 06/02/2012

Question 37 A 34-year-old woman with a 5-year history of psoriatic arthritis presented with increasing joint pain and swelling of her knees and feet. She was taking methotrexate 20 mg weekly. Lowdose sulfasalazine had previously been withdrawn because of abnormal liver function tests. On examination, five joints were tender and three were swollen. What is the most appropriate treatment? A B C D E etanercept hydroxychloroquine infliximab prednisolone rituximab

Updated 06/02/2012

Question 38 A 32-year-old woman presented with a 2-week history of pain and swelling across her ankles and knees. Over the previous 6 months, she had experienced intermittent episodes of bloody diarrhoea. She was otherwise well and denied any other symptoms. On examination, she had swollen, tender ankles and knees. She had a tender, nodular rash on both shins. Investigations: chest X-ray stool culture normal negative

What is the most appropriate initial treatment for her musculoskeletal symptoms? A B C D E ciprofloxacin dapsone mesalazine naproxen prednisolone

Updated 06/02/2012

Question 39 A 60-year-old woman complained of difficulty in flexing and extending her left index finger and a feeling of locking. On examination, she was able to make a fist but unable to extend the index finger fully. There was crepitus along the flexor tendon and a nodule was felt in her palm. What is the most appropriate initial management? A B C D E corticosteroid injection into tendon sheath ibuprofen intramuscular methylprednisolone surgical decompression of the carpal tunnel surgical repair of tendon rupture

Updated 06/02/2012

Question 40 A 50-year-old man with rheumatoid arthritis presented with breathlessness of recent onset and a dry cough. He had recently started treatment with methotrexate and sulfasalazine. He was a non-smoker. He was treated with amoxicillin and clarithromycin but had not improved after a 1-week course. On examination, he was tachypnoeic and his temperature was 38.3C. Investigations: haemoglobin white cell count neutrophil count sputum cultures blood cultures chest X-ray What is the most likely diagnosis? A B C D E acute respiratory distress syndrome cardiac failure methotrexate pneumonitis pneumococcal pneumonia pulmonary embolism 146 g/L (130180) 16.1 109/L (4.011.0) 12.0 109/L (1.57.0) no growth no growth bilateral interstitial infiltrates

Updated 06/02/2012

Question 41 A 58-year-old woman presented with a 2-year history of Raynauds phenomenon, joint pain and stiffness of the fingers. A serum sample was sent for immunofluorescence on HEp-2 cells (see image).

What immunofluorescence pattern does this show? A B C D E centromere homogeneous mitochondrial nucleolar ribosomal

Updated 06/02/2012

Answer keys: 1. E 2. D 3. E 4. B 5. A 6. B 7. C 8. E 9. C 10. B 11. A 12. E 13. D 14. B 15. E 16. C 17. B 18. B 19. B 20. E 21. C 22. A 23. C 24. E 25. D 26. D 27. A 28. B 29. C 30. A 31. B 32. C 33. D 34. C 35. D 36. E 37. A 38. E 39. A 40. C 41. A

Updated 06/02/2012