The following groups should be advised to take vitamin D supplementation:

all pregnant and breastfeeding women should take a daily supplement containing 10µg
of vitamin D

all children aged 6 months - 5 years. Babies fed with formula milk do not need to take
a supplement if they are taking more than 500ml of milk a day, as formula milk is
fortified with vitamin D

adults > 65 years

'people who are not exposed to much sun should also take a daily supplement'

Testing for vitamin D deficiency

The key message is that not many people warrant a vitamin D test. The NOS guidelines
specify that testing may be appropriate in the following situtations:

patients with bone diseases that may be improved with vitamin D treatment e.g.
known osteomalacia or Paget's disease

patients with bone diseases, prior to specific treatment where correcting vitamin
deficiency is appropriate e,g, prior to intravenous zolendronate or denosumab

patients with musculoskeletal symptoms that could be attributed to vitamin D

deficiency e.g. bone pain ?osteomalacia

Patients with osteoporosis should always be given calcium/vitamin D supplements so testing

is not considered necessary. People who are at higher risk of vitamin D deficiency (see above)
should be treated anyway so again testing is not necessary.

External Link

Chief Medical Officer

2016 Vitamin D guidance

NICE

2014 Vitamin D recommendations

Question 1 of 134

Reactive arthritis is associated with which one of the following HLA antigens?

HLA-B27
HLA-A3
HLA-DR4
HLA-B5
HLA-DR3
Question 1 of 134

Reactive arthritis is associated with which one of the following HLA antigens?

HLA-B27
HLA-A3
HLA-DR4
HLA-B5
HLA-DR3

Discuss and give feedback

Reactive arthritis
Question 2 of 134

A 47-year-old man with a history of chronic sinusitis presents with shortness of breath to the
Emergency Department. Initial investigations reveal:

Hb 10.4g/dl
Platelets 477 * 109/l
WCC 14.3 * 109/l

ESR 92 mm/h

Urea 20 mmol/l
Creatinine 198 µmol/l

Urine dipstick blood +++

What is the most likely diagnosis?

Mixed cryoglobulinaemia
Churg-Strauss syndrome
Granulomatosis with polyangiitis
Haemolytic uraemic syndrome
Henoch-Schonlein purpura
Question 2 of 134

A 47-year-old man with a history of chronic sinusitis presents with shortness of breath to the
Emergency Department. Initial investigations reveal:

Hb 10.4g/dl
Platelets 477 * 109/l
WCC 14.3 * 109/l

ESR 92 mm/h

Urea 20 mmol/l
Creatinine 198 µmol/l

Urine dipstick blood +++

What is the most likely diagnosis?

Mixed cryoglobulinaemia
Churg-Strauss syndrome
Granulomatosis with polyangiitis
Haemolytic uraemic syndrome
Henoch-Schonlein purpura

The combination of pulmonary and renal involvement combined with a history of chronic sinusitis
points towards a diagnosis of Granulomatosis with polyangiitis.

Discuss and give feedback

Granulomatosis with polyangiitis (Wegener's granulomatosis)

Question 3 of 134

A 50-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A
diagnostic aspiration is performed and sent to microbiology. Which of the following organisms is
most likely to be responsible?

Staphylococcus aureus
Staphylococcus epidermidis
Escherichia coli
Neisseria gonorrhoeae
Streptococcus pneumoniae
Question 3 of 134

A 50-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A
diagnostic aspiration is performed and sent to microbiology. Which of the following organisms is
most likely to be responsible?

Staphylococcus aureus
Staphylococcus epidermidis
Escherichia coli
Neisseria gonorrhoeae
Streptococcus pneumoniae

Septic arthritis - most common organism: Staphylococcus aureus

Discuss and give feedback

Septic arthritis

External links

Patient.info

Septic arthritis review

Question 4 of 134

Low levels of which one of the following types of complement are associated with the
development of systemic lupus erythematous?

C4
C5
C6
C7
C8
Question 4 of 134

Low levels of which one of the following types of complement are associated with the
development of systemic lupus erythematous?

C4
C5
C6
C7
C8

SLE: C3 & C4 low

Low levels of C4a and C4b have been shown to be associated with an increased risk of developing
systemic lupus erythematous.

Discuss and give feedback

SLE: investigations

External media

Systemic lupus erythematosus (SLE) - causes, symptoms, diagnosis & pathology

Osmosis - YouTube 3
Question 5 of 134

Which one of the following is not a risk factor for developing osteoporosis?

Smoking
Obesity
Sedentary lifestyle
Premature menopause
Female sex
Question 5 of 134

Which one of the following is not a risk factor for developing osteoporosis?

Smoking
Obesity
Sedentary lifestyle
Premature menopause
Female sex

Low body mass, rather than obesity is associated with an increased risk of developing osteoporosis

Discuss and give feedback

Osteoporosis: causes

External links

Postgraduate Medical Journal

Review of osteoporosis
Question 6 of 134

A 48-year-old Afro-Caribbean female is admitted with a fever and painful red eyes bilaterally. On
examination, her temperature is 38.3ºC, heart rate 85bpm, respiratory rate 26/min, and oxygen
saturation 93% on room air. Closer examination reveals bilateral swelling of her parotid glands.
A chest x-ray is performed, which reveals bilateral hilar lymphadenopathy. What is the most likely
unifying diagnosis?

HIV
Tuberculosis
Heerfordt syndrome
Lymphoma
Mumps
Question 6 of 134

A 48-year-old Afro-Caribbean female is admitted with a fever and painful red eyes bilaterally. On
examination, her temperature is 38.3ºC, heart rate 85bpm, respiratory rate 26/min, and oxygen
saturation 93% on room air. Closer examination reveals bilateral swelling of her parotid glands.
A chest x-ray is performed, which reveals bilateral hilar lymphadenopathy. What is the most
likely unifying diagnosis?

HIV
Tuberculosis
Heerfordt syndrome
Lymphoma
Mumps

Heerfordt syndrome is a subset of sarcoidosis: a combination of parotid enlargement, fever,

and anterior uveitis.

such as weight loss and night sweats. Mumps would not explain the hilar lymphadenopathy.

Please rate this question:

Discuss and give feedback

Sarcoidosis
Question 7 of 134

A health trust in the United Kingdom which serves a population of 100,000 is planning services for
patients with rheumatoid arthritis. How many of the population would be expected to have the
disease?

100
300
1,000
2,000
10,000
Question 7 of 134

A health trust in the United Kingdom which serves a population of 100,000 is planning services for
patients with rheumatoid arthritis. How many of the population would be expected to have the
disease?

100
300
1,000
2,000
10,000

Discuss and give feedback

Rheumatoid arthritis: epidemiology

Question 8 of 134

A 31-year-old female intolerant of methotrexate is started on azathioprine for rheumatoid arthritis.

Routine blood monitoring shows:

Hb 7.9 g/dl
Plt 97 * 109/l
WBC 2.7 * 109/l

Which of the following factors will predispose her to azathioprine toxicity?

Cimetidine
Rifampicin
Fast acetylator status
Thiopurine methyltransferase deficiency
Alcohol excess
Question 8 of 134

A 31-year-old female intolerant of methotrexate is started on azathioprine for rheumatoid arthritis.

Routine blood monitoring shows:

Hb 7.9 g/dl
Plt 97 * 109/l
WBC 2.7 * 109/l

Which of the following factors will predispose her to azathioprine toxicity?

Cimetidine
Rifampicin
Fast acetylator status
Thiopurine methyltransferase deficiency
Alcohol excess

Azathioprine - check thiopurine methyltransferase deficiency (TPMT) before treatment

Thiopurine methyltransferase (TPMT) deficiency is present in about 1 in 200 people and

predisposes to azathioprine related pancytopaenia

Discuss and give feedback

Azathioprine
Question 9 of 134

Which of the following features are not typically seen in a patient with adult onset Still's disease?

Maculopapular rash
Rheumatoid factor
Pyrexia
High ferritin level
Lymphadenopathy
Question 9 of 134

Which of the following features are not typically seen in a patient with adult onset Still's disease?

Maculopapular rash
Rheumatoid factor
Pyrexia
High ferritin level
Lymphadenopathy

Adult onset Still's disease is typically rheumatoid factor negative

Discuss and give feedback

Still's disease in adults

Question 10 of 134

A 34-year-old woman with a history of antiphospholipid syndrome presents with a swollen and painful
leg. Doppler ultrasound confirms a deep vein thrombosis (DVT). She had a previous DVT 4 months
ago and was taking warfarin (with a target INR of 2-3) when the DVT occurred. How should her
anticoagulation be managed?

Life-long warfarin, increase target INR to 3 - 4

Add in life-long low-dose aspirin
A further 6 months warfarin, target INR 2 - 3
A further 6 months warfarin, target INR 3 - 4
Life-long warfarin, target INR 2 - 3
Question 10 of 134
A 34-year-old woman with a history of antiphospholipid syndrome presents with a swollen and painful
leg. Doppler ultrasound confirms a deep vein thrombosis (DVT). She had a previous DVT 4 months
ago and was taking warfarin (with a target INR of 2-3) when the DVT occurred. How should her
anticoagulation be managed?

Life-long warfarin, increase target INR to 3 - 4

Add in life-long low-dose aspirin
A further 6 months warfarin, target INR 2 - 3
A further 6 months warfarin, target INR 3 - 4
Life-long warfarin, target INR 2 - 3

The evidence base is scanty here but most clinicians would increase the target INR to 3-4 if a patient
has had a further thrombosis with an INR of 2-3. Please see the BCSH guidelines
Discuss and give feedback

Antiphospholipid syndrome
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous
and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder
or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)
A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in
the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with
phospholipids involved in the coagulation cascade

Features
venous/arterial thrombosis
recurrent fetal loss
livedo reticularis
thrombocytopenia
prolonged APTT
other features: pre-eclampsia, pulmonary hypertension.
Associations other than SLE

other autoimmune disorders

lymphoproliferative disorders

phenothiazines (rare)

Management - based on BCSH guidelines

initial venous thromboembolic events: evidence currently supports use of warfarin with a target
INR of 2-3 for 6 months

recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin
then increase target INR to 3-4

arterial thrombosis should be treated with lifelong warfarin with target INR 2-

External links

British Society of Haematology

Antiphospholipid syndrome guidelines

DermIS

Pictures of livedo reticularis

Question 11 of 134

A 41-year-old man with a past history of asthma presents with pain and weakness in his left hand.
Examination findings are consistent with a left ulnar nerve palsy. Blood tests reveal an eosinophilia.
Which one of the following antibodies is most likely to be present?

ANA
Anti-Scl70
pANCA
Antiphospholipid antibodies
cANCA
Question 11 of 134

A 41-year-old man with a past history of asthma presents with pain and weakness in his left hand.
Examination findings are consistent with a left ulnar nerve palsy. Blood tests reveal an eosinophilia.
Which one of the following antibodies is most likely to be present?

ANA
Anti-Scl70
pANCA
Antiphospholipid antibodies
cANCA

This patient has Churg-Strauss syndrome as evidenced by the asthma, mononeuritis and
eosinophilia

Discuss and give feedback

Churg-Strauss syndrome

Churg-Strauss syndrome is an ANCA associated small-medium vessel vasculitis.

Features:

asthma

blood eosinophilia (e.g. > 10%)

paranasal sinusitis

mononeuritis multiplex

pANCA positive in 60%

Comparison of granulomatosis with polyangiitis and Churg-Strauss syndrome

Leukotriene receptor antagonists may precipitate the disease.

Question 12 of 134

A 34-year-old intravenous drug user is admitted with a purpuric rash affecting her legs. Blood tests
reveal the following:

Hb 11.4g/dl
Platelets 489 * 109/l
WCC 12.3 * 109/l

HCV PCR positive

HBsAg negative

Rheumatoid factor positive

C3/C4 reduced

What is the most likely diagnosis?

Polyarteritis nodosa
Henoch-Schonlein purpura
Wegener's granulomatosis
Cryoglobulinaemia
Systemic lupus erythematous
Question 12 of 134

A 34-year-old intravenous drug user is admitted with a purpuric rash affecting her legs. Blood tests
reveal the following:

Hb 11.4g/dl
Platelets 489 * 109/l
WCC 12.3 * 109/l

HCV PCR positive

HBsAg negative

Rheumatoid factor positive

C3/C4 reduced

What is the most likely diagnosis?

Polyarteritis nodosa
Henoch-Schonlein purpura
Wegener's granulomatosis
Cryoglobulinaemia
Systemic lupus erythematous

Hepatitis C infection is associated with type II (mixed) cryoglobulinaemia, suggested by the

purpuric rash, positive rheumatoid factor and reduced complement levels.

Discuss and give feedback

Cryoglobulinaemia
Question 13 of 134

A 72-year-old woman presents with a severe right-sided headache and some blurring of vision that
comes and goes. She has no significant past medical history. On examination, there is tenderness on
palpation of her right temporal region. Visual acuity is 6/36 in her right eye and 6/9 in her left.
Investigations:

Erythrocyte sedimentation rate 154mm/hr (1-36)

C-reactive protein 116mg/L (<10)

What drug should be given initially?

Cyclosporine (intravenous)
Leflunomide (oral)
Methotrexate (oral)
Prednisolone (oral)
Methylprednisolone (intravenous)
Question 13 of 134
A 72-year-old woman presents with a severe right-sided headache and some blurring of vision that
comes and goes. She has no significant past medical history. On examination, there is tenderness on
palpation of her right temporal region. Visual acuity is 6/36 in her right eye and 6/9 in her left.
Investigations:

Erythrocyte sedimentation rate 154mm/hr (1-36)

C-reactive protein 116mg/L (<10)
What drug should be given initially?

Cyclosporine (intravenous)
Leflunomide (oral)
Methotrexate (oral)
Prednisolone (oral)
Methylprednisolone (intravenous)

This patient has temporal arteritis, also known as giant cell arteritis (GCA).
The American College of Rheumatology 1990 criteria requires 3 of the following for GCA
diagnosis:
1. Age >50 y/o
2. New onset localised headache
3. Temporal artery tenderness or decreased pulsation
4. ESR >50mm/hr
5. Temporal artery biopsy positive
licated GCA (no visual involvement and/or jaw/tongue claudication) should be
treated with oral prednisolone 40-60mg daily until symptoms and investigations normalise.

scenario, should be given IV methylprednisolone 500-1000mg for 3 days before starting oral
prednisolone.
-term steroid therapy bone sparing agents (a bisphosphonate and
vitamin D) and a gastroprotective drug (e.g omeprazole) should be prescribed. Also, low dose
aspirin should be considered as it has been shown to reduce the rate of visual loss and
cerebrovascular accidents in GCA.
(Source: Royal College of Physicians guidelines)
Link: http://www.rcplondon.ac.uk/sites/default/files/giant-cell-arteritis-concise-guideline.pdf
Discuss and give feedback

Temporal arteritis
Question 14 of 134

A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal
joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his
allopurinol therapy?

Stop and recommence 4 weeks after acute inflammation has settled

Reduce allopurinol to 100mg od until acute attack has settled
Stop and switch to colchicine prophylaxis
Stop and recommence 2 weeks after acute inflammation has settled
Continue allopurinol in current dose
Question 14 of 134

A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal
joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his
allopurinol therapy?

Stop and recommence 4 weeks after acute inflammation has settled

Reduce allopurinol to 100mg od until acute attack has settled
Stop and switch to colchicine prophylaxis
Stop and recommence 2 weeks after acute inflammation has settled
Continue allopurinol in current dose
Discuss and give feedback

Gout: management

External links

Genetics home reference

Lesch Nyhan Syndrome

Clinical Knowledge Summaries

Gout guidelines

External media

Gout - causes, symptoms, diagnosis, treatment, pathology

Osmosis - YouTube
Question 15 of 134

A 34-year-old is diagnosed with chronic fatigue syndrome. Which one of the following interventions
is most useful?

Graded exercise therapy

Psychodynamic psychotherapy
Graded physiotherapy
Advice to avoid alcohol and caffeine
Low-dose fluoxetine
Question 15 of 134

A 34-year-old is diagnosed with chronic fatigue syndrome. Which one of the following interventions
is most useful?

Graded exercise therapy

Psychodynamic psychotherapy
Graded physiotherapy
Advice to avoid alcohol and caffeine
Low-dose fluoxetine

Discuss and give feedback

Chronic fatigue syndrome

External links

NICE

2007 Chronic fatigue syndrome guidelines

Question 16 of 134

A 54-year-old male presents with abdominal pain, testicular pain, weight loss, left foot drop and livedo
reticularis. You suspect a diagnosis of polyarteritis nodosa and request a full autoantibody screen.
From the options given below, what are you most likely to see when the results of his autoantibody
screen returns if the diagnosis is polyarteritis nodosa?

Positive anti-CCP
Positive rheumatoid factor
Positive cANCA
No autoantibody is likely to be positive
Positive pANCA
Question 16 of 134
A 54-year-old male presents with abdominal pain, testicular pain, weight loss, left foot drop and livedo
reticularis. You suspect a diagnosis of polyarteritis nodosa and request a full autoantibody screen.
From the options given below, what are you most likely to see when the results of his autoantibody
screen returns if the diagnosis is polyarteritis nodosa?

Positive anti-CCP
Positive rheumatoid factor
Positive cANCA
No autoantibody is likely to be positive
Positive pANCA

-specific. The diagnosis should be

considered in patients with various combinations of symptoms, such as unexplained fever, arthralgia,
subcutaneous nodules, skin ulcers, pain in the abdomen or extremities, new foot drop or wrist drop, or
rapidly developing hypertension. The diagnosis is further clarified when clinical findings are
combined with certain laboratory results and other causes are excluded.

the typical aneurysms in medium-sized arteries. Magnetic resonance angiography may show
microaneurysms, but some abnormalities may be too small for it to detect. Thus, magnetic resonance
angiography is not the test used primarily for diagnosis.

the disease is focal; biopsy should

target sites suggested by clinical evaluation. Samples of subcutaneous tissue, sural nerve, and muscle,
if thought to be involved, are preferred to samples from the kidneys or liver; kidney and liver biopsies
may be falsely negative because of sampling error and may cause bleeding from unsuspected
microaneurysms.

microscopic haematuria are the most common abnormalities. Patients may have thrombocytosis,
markedly elevated ESR, anaemia caused by blood loss or renal failure, low serum albumin, and
elevated serum immunoglobulins. AST and ALT are often mildly elevated. Testing for hepatitis B and
C should be done.

Other testing such as pANCA, cANCA, rheumatoid factor, anti-CCP antibody ANA, C3 and C4
complement levels, cryoglobulin levels, Anti-dsDNA and antibodies to extractable nuclear antigens
such as anti-Smith, anti-Ro/SSA, anti-La/SSB, and anti-RNP suggest other diagnoses, such as RA,
SLE, or Sjögren syndrome.
Discuss and give feedback

Polyarteritis nodosa
Question 17 of 134

Which one of the following cytokines is the most important in the pathophysiology of
rheumatoid arthritis?

IFN-beta
IFN-alpha
IL-4
Tumour necrosis factor
IL-2
Question 17 of 134

Which one of the following cytokines is the most important in the pathophysiology of
rheumatoid arthritis?

IFN-beta
IFN-alpha
IL-4
Tumour necrosis factor
IL-2

Rheumatoid arthritis - TNF is key in pathophysiology

Discuss and give feedback

Tumour necrosis factor

Question 18 of 134

A 30-year-old woman presents with bilateral proximal muscle weakness. She is noted to have
blanching of the fingers, especially in cold weather.

Anti-Jo-1 positive
ANA positive
CK 2000 U/L
ESR 60 mm/hr
myopathic changes
EMG

The presence of which of the following conveys the worst prognosis?

Dysphagia
Skin rash
CK >2000 U/L
Interstitial lung disease
Raynaud's phenomenon
Question 18 of 134

A 30-year-old woman presents with bilateral proximal muscle weakness. She is noted to have
blanching of the fingers, especially in cold weather.

Anti-Jo-1 positive
ANA positive
CK 2000 U/L
ESR 60 mm/hr
myopathic changes
EMG

The presence of which of the following conveys the worst prognosis?

Dysphagia
Skin rash
CK >2000 U/L
Interstitial lung disease
Raynaud's phenomenon

Polymyositis is a type of inflammatory myopathy related to dermatomyositis and inclusion body

myositis. The hallmark of polymyositis is weakness and/or loss of muscle mass in the proximal
musculature, and absent skin involvement. The classic laboratory finding is a raised creatinine kinase
(CK) and the Anti-Jo-1 antibody.

polymyositis. ILD is considered to be a major risk factor for premature death in patients with
myositis.
-Jo-1 antibody is a predictor of the presence of ILD at diagnosis, with up to 70% of patients
with the antibody having concurrent ILD. The 5-year survival rate is between 60 and 80%.

Discuss and give feedback

Polymyositis
Question 19 of 134

A 54-year-old female is reviewed in the rheumatology clinic due to dry eyes and arthralgia. A
diagnosis of primary Sjogren's syndrome is suspected. Which one of the following features is least
associated with this condition?

Renal tubular acidosis

Xerostomia
Sensory polyneuropathy
Dilated cardiomyopathy
Raynaud's phenomenon
Question 19 of 134

A 54-year-old female is reviewed in the rheumatology clinic due to dry eyes and arthralgia. A
diagnosis of primary Sjogren's syndrome is suspected. Which one of the following features is least
associated with this condition?

Renal tubular acidosis

Xerostomia
Sensory polyneuropathy
Dilated cardiomyopathy
Raynaud's phenomenon

Discuss and give feedback

Sjogren's syndrome
Question 20 of 134

Which one of the following statements regarding systemic lupus erythematous is true?

It is linked with HLA A5

Onset is typically between 20-40 years old
It is more common in Caucasians
The female:male ratio is 3:1
The incidence has decreased in the past 30 years
Question 20 of 134

Which one of the following statements regarding systemic lupus erythematous is true?

It is linked with HLA A5

Onset is typically between 20-40 years old
It is more common in Caucasians
The female:male ratio is 3:1
The incidence has decreased in the past 30 years

Discuss and give feedback

Systemic lupus erythematosus

Question 21 of 134

A 45-year-old female with a history of rheumatoid arthritis presents to the Emergency Department
with a two day history of a hot, painful, swollen right elbow joint. What is the most appropriate
management?

Joint aspiration
Start infliximab
Oral high-dose prednisolone
Short course of methotrexate
Depomederone injection
Question 21 of 134

A 45-year-old female with a history of rheumatoid arthritis presents to the Emergency Department
with a two day history of a hot, painful, swollen right elbow joint. What is the most appropriate
management?

Joint aspiration
Start infliximab
Oral high-dose prednisolone
Short course of methotrexate
Depomederone injection

Joint aspiration is mandatory in all patients with a hot, swollen joint to rule out septic arthritis.
If this was excluded in the above patient then intra-articular or system steroid therapy may be
considered.

Discuss and give feedback

Septic arthritis

External links

Patient.info

Septic arthritis review

Question 22 of 134

A 32-year-old gentleman is admitted with pain in his legs. On closer questioning, he has difficulty
getting out of the chair and he has fallen several times in doing so. His past medical history includes
Raynaud's which is controlled with nifedipine. On examination, you notice skin changes consistent
with mechanic hands. What is the most likely underlying diagnosis?

Myasthenia gravis
Lambert-Eaton Myasthenic syndrome
McArdle disease
Anti-synthetase syndrome
Drug-induced myopathy
Question 22 of 134

A 32-year-old gentleman is admitted with pain in his legs. On closer questioning, he has difficulty
getting out of the chair and he has fallen several times in doing so. His past medical history includes
Raynaud's which is controlled with nifedipine. On examination, you notice skin changes consistent
with mechanic hands. What is the most likely underlying diagnosis?

Myasthenia gravis
Lambert-Eaton Myasthenic syndrome
McArdle disease
Anti-synthetase syndrome
Drug-induced myopathy

The key to this diagnosis is the proximal myopathy in combination with mechanic hands, which are
associated with anti-synthetase syndrome. It is important to ask about lung symptoms because there is
an association with interstitial lung disease - particularly non-specific interstitial pneumonia or NSIP.

following exercise.

Discuss and give feedback

Myopathies
Question 23 of 134

A 45-year-old man presents with a painful swelling on the posterior aspect of his elbow. There is no
history of trauma. On examination an erythematous tender swelling is noted. What is the most likely
diagnosis?

Synovial cyst
Haemarthrosis
Septic arthritis
Gout
Olecranon bursitis
Question 23 of 134

A 45-year-old man presents with a painful swelling on the posterior aspect of his elbow. There is no
history of trauma. On examination an erythematous tender swelling is noted. What is the most likely
diagnosis?

Synovial cyst
Haemarthrosis
Septic arthritis
Gout
Olecranon bursitis

Discuss and give feedback

Elbow pain
Question 24 of 134

A 25-year-old lady presents to the medical outpatient clinic complaining of a week long history of
fatigue, general body aches and right wrist and knee pain. On examination, there is these joints are
mildly swollen. You also note her to have hardened skin on the fingers of both her hands with some
swelling of the fingers. She also notes her fingers go blue in cold weather. What investigation would
most help confirm the diagnosis?

Anti-cyclic citrullinated peptide antibody

Anti-centromere antibody
Anti-smith antibody
Anti-ribonucleoprotein antibody
Anti-topoisomerase I antibody
Question 24 of 134

A 25-year-old lady presents to the medical outpatient clinic complaining of a week long history of
fatigue, general body aches and right wrist and knee pain. On examination, there is these joints are
mildly swollen. You also note her to have hardened skin on the fingers of both her hands with some
swelling of the fingers. She also notes her fingers go blue in cold weather. What investigation would
most help confirm the diagnosis?

Anti-cyclic citrullinated peptide antibody

Anti-centromere antibody
Anti-smith antibody
Anti-ribonucleoprotein antibody
Anti-topoisomerase I antibody

Anti-ribonucleoprotein (anti-RNP) antibodies have a high sensitivity with mixed connective tissue
disease especially if high titres found, though it can be present in other autoimmune conditions in low
titres.

-topoisomerase I antibodies (anti-Scl-

70) are associated with systemic sclerosis.

-cyclic citrullinated peptides antibody (anti-CCP) are present in most patients with rheumatoid
arthritis.

-smith antibodies have a high specificity for systemic lupus erythematosus. Anti-centromere
antibodies are associated with CREST syndrome

Discuss and give feedback

Mixed connective tissue disease

Question 25 of 134

Which one of the following features is least commonly seen in drug-induced lupus?

Glomerulonephritis
Arthralgia
Myalgia
Malar rash
Pleurisy
Question 25 of 134

Which one of the following features is least commonly seen in drug-induced lupus?

Glomerulonephritis
Arthralgia
Myalgia
Malar rash
Pleurisy

Glomerulonephritis is unusual in drug-induced lupus.

Discuss and give feedback

Drug-induced lupus

External links

DermNet NZ

Drug-induced lupus erythematosus

Question 26 of 134

Which of the following is associated with a good prognosis in rheumatoid arthritis?

Rheumatoid factor negative

HLA DR4
Anti-CCP antibodies
Rheumatoid nodules
Insidious onset
Question 26 of 134

Which of the following is associated with a good prognosis in rheumatoid arthritis?

Rheumatoid factor negative

HLA DR4
Anti-CCP antibodies
Rheumatoid nodules
Insidious onset

Discuss and give feedback

Rheumatoid arthritis: prognostic features

External links

NICE

2009 Rheumatoid guidelines

Question 27 of 134

A 64-year-old man with chronic kidney disease stage 3 secondary to type 2 diabetes mellitus presents
with pain and swelling at the right first metatarsophalangeal joint. On examination the joint is hot,
erythematous and tender to touch, although he can still flex the big toe. What is the most appropriate
initial management?

Colchicine
Prednisolone
Co-codamol 30/500
Allopurinol
Indomethacin
Question 27 of 134
A 64-year-old man with chronic kidney disease stage 3 secondary to type 2 diabetes mellitus presents
with pain and swelling at the right first metatarsophalangeal joint. On examination the joint is hot,
erythematous and tender to touch, although he can still flex the big toe. What is the most appropriate
initial management?

Colchicine
Prednisolone
Co-codamol 30/500
Allopurinol
Indomethacin

Colchicine is useful in patients with renal impairment who develop gout as NSAIDs are relatively
contraindicated.
The BNF advises to reduce the dose by up to 50% if creatinine clearance is less than 50 ml/min and
to avoid if creatinine clearance is less than 10 ml/min.
-codamol 30/500 may be used as an adjunct but would not provide relief as monotherapy.
Prednisolone is an option but would adversely affect his diabetic control.
Discuss and give feedback

Gout: management
External links
Genetics home reference
Lesch Nyhan Syndrome
Clinical Knowledge Summaries
Gout guidelines

External media

Gout - causes, symptoms, diagnosis, treatment, pathology

Osmosis - YouTube 3
Question 28 of 134

A 31-year-old woman who had rheumatoid arthritis diagnosed 5 years ago asks for advice as she is
considering starting a family. She currently has quiescent rheumatoid arthritis which is well controlled
on methotrexate. Which one of the following drugs is it safest to use if she is planning on
becoming pregnant?

Leflunamide
Sulfasalazine
Methotraxate
Rituximab
Gold
Question 28 of 134

A 31-year-old woman who had rheumatoid arthritis diagnosed 5 years ago asks for advice as she is
considering starting a family. She currently has quiescent rheumatoid arthritis which is well controlled
on methotrexate. Which one of the following drugs is it safest to use if she is planning on
becoming pregnant?

Leflunamide
Sulfasalazine
Methotraxate
Rituximab
Gold

Discuss and give feedback

Rheumatoid arthritis: pregnancy

Question 29 of 134

A 25-year-old woman presents with a three day history of dysuria and a painful left knee. During the
review of symptoms she mentions a bout of diarrhoea and crampy abdominal pain three weeks ago.
She is normally fit and well and takes no regular medication. Her father died of colorectal cancer in his
sixth decade. On examination the left knee is red, swollen and hot to touch. What is the most likely
diagnosis?

Reactive arthritis secondary to Salmonella spp.

Reactive arthritis secondary to Chlamydia trachomatis
Rheumatoid arthritis
Ulcerative colitis
Gonococcal arthritis
Question 29 of 134

A 25-year-old woman presents with a three day history of dysuria and a painful left knee. During the
review of symptoms she mentions a bout of diarrhoea and crampy abdominal pain three weeks ago.
She is normally fit and well and takes no regular medication. Her father died of colorectal cancer in his
sixth decade. On examination the left knee is red, swollen and hot to touch. What is the most likely
diagnosis?

Reactive arthritis secondary to Salmonella spp.

Reactive arthritis secondary to Chlamydia trachomatis
Rheumatoid arthritis
Ulcerative colitis
Gonococcal arthritis

Urethritis + arthritis + conjunctivitis = reactive arthritis

Two of the classic three features of reactive arthritis (urethritis, arthritis and conjunctivitis) are present
in this patient. The family history of colorectal cancer is of no particular significance. Symptoms of
reactive arthritis typically appear 1-4 weeks following the initial infection, in this case a diarrhoeal
illness.

Discuss and give feedback

Reactive arthritis
Question 30 of 134

An autoantibody screen reveals that a patient is positive for anti-Jo 1 antibodies. What is the most
likely underlying diagnosis?

Limited cutaneous systemic sclerosis

Mixed connective tissue disease
Dermatomyositis
Polymyositis
Diffuse cutaneous systemic sclerosis
Question 30 of 134

An autoantibody screen reveals that a patient is positive for anti-Jo 1 antibodies. What is the most
likely underlying diagnosis?

Limited cutaneous systemic sclerosis

Mixed connective tissue disease
Dermatomyositis
Polymyositis
Diffuse cutaneous systemic sclerosis

Anti-Jo 1 antibodies are more commonly seen in polymyositis than dermatomyositis

Discuss and give feedback

Extractable nuclear antigens

Question 31 of 134

A 72-year-old woman is reviewed in the osteoporosis clinic. She had a hip fracture 5 years ago after
which she was started on alendronate. This had to be stopped due to persistent musculoskeletal pain.
Risedronate also had to be stopped for similar reasons. Strontium ranelate was therefore started but
this was stopped following the development of a deep vein thrombosis. Her current T-score is -4.1. It
has therefore been decided to start a trial of denosumab. What is the mechanism of action of this
drug?

Monoclonal antibody against osteoprotegerin

Selective oestrogen receptor modulator
Inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
Promotes differentiation of pre-osteoblasts to osteoblasts + inhibits osteoclasts
Pyrophosphate analog which inhibits osteoclast activity
Question 31 of 134

A 72-year-old woman is reviewed in the osteoporosis clinic. She had a hip fracture 5 years ago after
which she was started on alendronate. This had to be stopped due to persistent musculoskeletal pain.
Risedronate also had to be stopped for similar reasons. Strontium ranelate was therefore started but
this was stopped following the development of a deep vein thrombosis. Her current T-score is -4.1. It
has therefore been decided to start a trial of denosumab. What is the mechanism of action of this
drug?

Monoclonal antibody against osteoprotegerin

Selective oestrogen receptor modulator
Inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
Promotes differentiation of pre-osteoblasts to osteoblasts + inhibits osteoclasts
Pyrophosphate analog which inhibits osteoclast activity

Discuss and give feedback

Osteoporosis: management
External links
SIGN
2015 Osteoporosis guidelines
NICE
2008 Osteoporosis: secondary prevention
The National Osteoporosis Guideline Group
NOGG Pocket Guide for Healthcare Professionals
Question 32 of 134

A 20-year-old Nigerian female presents to the Emergency Department with chest pain. She reports a
long history of fatigue and joint pains. Examination reveals a pericardial rub and bilateral pitting
oedema. Observations show only that she has a low grade pyrexia 37.7ºC and blood pressure 170/100
mmHg. Urinalysis shows haematuria and nephrotic-range proteinuria. A urine pregnancy test is
negative. ECG shows saddle-shaped ST-elevation in all leads. Of interest, her blood results show:

Urea 8.2 mmol/l

Creatinine 212 µmol/l
eGFR 33ml/m/m²

Which of the following histopathological findings is most likely on renal biopsy?

Focal proliferative glomerulonephritis

Membranous glomerulonephritis
Diffuse proliferative glomerulonephritis
Focal segmental glomerulosclerosis
Mesangial proliferative glomerulonephritis
Question 32 of 134
A 20-year-old Nigerian female presents to the Emergency Department with chest pain. She reports a
long history of fatigue and joint pains. Examination reveals a pericardial rub and bilateral pitting
oedema. Observations show only that she has a low grade pyrexia 37.7ºC and blood pressure 170/100
mmHg. Urinalysis shows haematuria and nephrotic-range proteinuria. A urine pregnancy test is
negative. ECG shows saddle-shaped ST-elevation in all leads. Of interest, her blood results show:

Urea 8.2 mmol/l

Creatinine 212 µmol/l
eGFR 33ml/m/m²

Which of the following histopathological findings is most likely on renal biopsy?

Focal proliferative glomerulonephritis

Membranous glomerulonephritis
Diffuse proliferative glomerulonephritis
Focal segmental glomerulosclerosis
Mesangial proliferative glomerulonephritis

This question requires you to diagnose the condition and then recall the associated histopathology.
Although they may not be encountered every day in clinical practice, the glomerulonephritides are
favourites of the MRCP examiners.

picture of kidney insult.

m presentation of fever, arthralgia, pericarditis and nephritis associated with the
epidemiological clues (a young black female) suggest in this case a diagnosis of systemic lupus
erythematosus (SLE).
The most common histological pattern seen in lupus nephritis is diffuse proliferative
glomerulonephritis.
Discuss and give feedback

SLE: renal complications

External media

Systemic lupus erythematosus (SLE) - causes, symptoms, diagnosis & pathology

Osmosis - YouTube
Question 33 of 134

A middle aged woman presents with progressive shortness of breath. Chest X ray shows bilateral hilar
lymphadenopathy.

Calcium 2.7mmol/l
Angiotensin converting enzyme 200µg/l (<40µg/l)

Given the likely diagnosis, which of the following features would be associated with a good
prognosis?

Lupus pernio
Hypercalcaemia
Age>40
Erythema nodosum
HLA B13 subtype
Question 33 of 134

A middle aged woman presents with progressive shortness of breath. Chest X ray shows bilateral hilar
lymphadenopathy.

Calcium 2.7mmol/l
Angiotensin converting enzyme 200µg/l (<40µg/l)

Given the likely diagnosis, which of the following features would be associated with a good
prognosis?

Lupus pernio
Hypercalcaemia
Age>40
Erythema nodosum
HLA B13 subtype

This woman has sarcoidosis. Factors associated with a good prognosis include :HLA B8 and
Lofgren's syndrome (bilateral hilar lymphadenopathy, erythema nodosum, polyarthritis and
fever). All the other factors listed above are associated with a poor prognosis.

Discuss and give feedback

Sarcoidosis: prognostic features

Question 34 of 134

Which one of the following is least recognised as a risk factor for developing osteoporosis?

Cushing's syndrome
Turner's syndrome
Hyperparathyroidism
Hypothyroidism
Diabetes mellitus
Question 34 of 134

Which one of the following is least recognised as a risk factor for developing osteoporosis?

Cushing's syndrome
Turner's syndrome
Hyperparathyroidism
Hypothyroidism
Diabetes mellitus

Hyperthyroidism is associated with an increased risk of osteoporosis. Patients with hypothyroidism

who take excessive amounts of levothyroxine may also be at risk of osteoporosis

Discuss and give feedback

Osteoporosis: causes

External links

Postgraduate Medical Journal

Review of osteoporosis
Question 35 of 134

A 43-year-old woman presents with pain in the right elbow. This has been present for the past month
and she reports no obvious trigger. On examination she reports pain on wrist extension against
resistance whilst the elbow is extended. What is the most likely diagnosis?

Cubital tunnel syndrome

Lateral epicondylitis
Carpal tunnel syndrome
Medial epicondylitis
Pronator syndrome
Question 35 of 134

A 43-year-old woman presents with pain in the right elbow. This has been present for the past month
and she reports no obvious trigger. On examination she reports pain on wrist extension against
resistance whilst the elbow is extended. What is the most likely diagnosis?

Cubital tunnel syndrome

Lateral epicondylitis
Carpal tunnel syndrome
Medial epicondylitis
Pronator syndrome

Discuss and give feedback

Lateral epicondylitis

External links

Clinical Knowledge Summaries

Tennis elbow
Question 36 of 134

A 76-year-old female presents with a 1 month history of left sided temporal headaches and jaw
claudication. Biopsy of left temporal artery is negative.

Hb 130 g/l
Platelets 359 * 109/l
WBC 10 * 109/l
CRP 89 mg/l

What is the next best step in management?

Observation
Commence prednisolone
Biopsy the right temporal artery
CT brain
Ultrasound of left temporal artery
Question 36 of 134

A 76-year-old female presents with a 1 month history of left sided temporal headaches and jaw
claudication. Biopsy of left temporal artery is negative.

Hb 130 g/l
Platelets 359 * 109/l
WBC 10 * 109/l
CRP 89 mg/l

What is the next best step in management?

Observation
Commence prednisolone
Biopsy the right temporal artery
CT brain
Ultrasound of left temporal artery

Jaw claudication is a very specific sign for temporal arteritis. A negative temporal artery biopsy can
occur in up to 50 percent of patients, often because the sampled region was not involved in the
pathologic process. Therefore, it is not sensitive enough to rule out temporal arteritis. Therefore,
because vision is threatened, a brief course of steroids should be initiated.

Discuss and give feedback

Temporal arteritis

External links

Royal College of Physicians

Temporal arteritis guidelines

Question 37 of 134

A 57-year-old man presents with pain in his right knee. An x-ray shows osteoarthritis. He has no past
medical history of note. What is the most suitable treatment option for the management of his
pain?

Oral diclofenac with omeprazole

Oral glucosamine
Oral diclofenac
Oral ibuprofen
Oral paracetamol
Question 37 of 134

A 57-year-old man presents with pain in his right knee. An x-ray shows osteoarthritis. He has no past
medical history of note. What is the most suitable treatment option for the management of his
pain?

Oral diclofenac with omeprazole

Oral glucosamine
Oral diclofenac
Oral ibuprofen
Oral paracetamol

Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line

Oral NSAIDs should be used second line in osteoarthritis due to their adverse effect profile.

Discuss and give feedback

Osteoarthritis: management

External links

NICE

2014 osteoarthritis guidelines

Question 38 of 134

A 57-year-old woman presents with a three month history of right-sided hip pain. This seems to have
come on spontaneously without any obvious precipitating event. The pain is described as being worse
on the 'outside' of the hip and is particularly bad at night when she lies on the right hand side.

On examination there is a full range of movement in the hip including internal and external rotation.
Deep palpation of the lateral aspect of the right hip joint recreates the pain.

An x-ray of the right hip is reported as follows:

Right hip: Minor narrowing of the joint space otherwise normal appearance

What is the most likely diagnosis?

Fibromyalgia
Lumbar nerve root compression
Osteoarthritis
Greater trochanteric pain syndrome
Meralgia paraesthetica
Question 38 of 134
A 57-year-old woman presents with a three month history of right-sided hip pain. This seems to have
come on spontaneously without any obvious precipitating event. The pain is described as being worse
on the 'outside' of the hip and is particularly bad at night when she lies on the right hand side.
On examination there is a full range of movement in the hip including internal and external rotation.
Deep palpation of the lateral aspect of the right hip joint recreates the pain.
An x-ray of the right hip is reported as follows:

Right hip: Minor narrowing of the joint space otherwise normal appearance

What is the most likely diagnosis?

Fibromyalgia
Lumbar nerve root compression
Osteoarthritis
Greater trochanteric pain syndrome
Meralgia paraesthetica

Greater trochanteric pain syndrome is now the preferred term for trochanteric bursitis.

Whilst the x-ray shows joint space narrowing this is not an uncommon finding. Osteoarthritis would
also be less likely given the palpable nature of the pain and relatively short duration of symptoms.

Discuss and give feedback

Hip pain in adults

External media

Hip Examination

Oxford Medical Education - YouTube0

Question 39 of 134

A 31-year-old woman presents as her fingers intermittently turn white and become painful. She
describes the fingers first turning white, then blue and finally red. This is generally worse in the winter
months but it is present all year round. Wearing gloves does not help. Clinical examination of her
hands, other joints and skin is unremarkable. Which one of the following treatments may be
beneficial?

Amitriptyline
Aspirin
Pregabalin
Propranolol
Nifedipine
Question 39 of 134

A 31-year-old woman presents as her fingers intermittently turn white and become painful. She
describes the fingers first turning white, then blue and finally red. This is generally worse in the winter
months but it is present all year round. Wearing gloves does not help. Clinical examination of her
hands, other joints and skin is unremarkable. Which one of the following treatments may be
beneficial?

Amitriptyline
Aspirin
Pregabalin
Propranolol
Nifedipine

This lady has Raynaud's disease.

Discuss and give feedback

Raynaud's

External links

Arthritis Research Council (ARC)

ARC Raynaud's Patient Info

Question 40 of 134

A 79-year-old man presents with a history of lower back pain and right hip pain. Blood tests reveal the
following:

Calcium 2.20 mmol/l

Phosphate 0.8 mmol/l
ALP 890 u/L

What is the most likely diagnosis?

Primary hyperparathyroidism
Chronic kidney disease
Osteomalacia
Osteoporosis
Paget's disease
Question 40 of 134
A 79-year-old man presents with a history of lower back pain and right hip pain. Blood tests reveal the
following:

Calcium 2.20 mmol/l

Phosphate 0.8 mmol/l
ALP 890 u/L
What is the most likely diagnosis?

Primary hyperparathyroidism
Chronic kidney disease
Osteomalacia
Osteoporosis
Paget's disease

Paget's disease - old man, bone pain, raised ALP

The normal calcium and phosphate combined with a raised alkaline phosphate points to a
diagnosis of Paget's.
Discuss and give feedback

Paget's disease of the bone

Paget's disease is a disease of increased but uncontrolled bone turnover. It is thought to be primarily a
disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic
activity. Paget's disease is common (UK prevalence 5%) but symptomatic in only 1 in 20 patients
Predisposing factors:
increasing age
male sex
northern latitude
family history
Clinical features - only 5% of patients are symptomatic:
bone pain (e.g. pelvis, lumbar spine, femur)
classical, untreated features: bowing of tibia, bossing of skull
raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal
skull x-ray: thickened vault, osteoporosis circumscripta.
Indications for treatment include: bone pain, skull or long bone deformity, fracture, periarticular
Paget's.

bisphosphonate (either oral risedronate or IV zoledronate)

calcitonin is less commonly used now

Complications:

deafness (cranial nerve entrapment)

bone sarcoma (1% if affected for > 10 years)

fractures

skull thickening

high-output cardiac failure

© Image used on license from Radiopaedia

The radiograph demonstrates marked thickening of the calvarium. There are also ill-defined sclerotic
and lucent areas throughout. These features are consistent with Paget's disease.
 © Image used on license from Radiopaedia

Pelvic x-ray from an elderly man with Paget's disease. There is a smooth cortical expansion of the left
hemipelvic bones with diffuse increased bone density and coarsening of trabeculae.
 © Image used on license from Radiopaedia

Isotope bone scan from a patient with Paget's disease showing a typical distribution in the spine,
asymmetrical pelvic disease and proximal long bones.

*usually normal in this condition but hypercalcaemia may occur with prolonged immobilisation
Question 41 of 134

A 25-year-old man presents with back pain. Which one of the following may suggest a diagnosis of
ankylosing spondylitis?

Rapid onset
Gets worse following exercise
Bone tenderness
Pain at night
Improves with rest
Question 41 of 134

A 25-year-old man presents with back pain. Which one of the following may suggest a diagnosis of
ankylosing spondylitis?

Rapid onset
Gets worse following exercise
Bone tenderness
Pain at night
Improves with rest

Discuss and give feedback

Ankylosing spondylitis: features

External links

Arthritis Reasearch Council

Ankylosing Spondylitis Patient Info

Question 42 of 134

You are the ST1 working in the rheumatology out-patient clinic. Your next patient is a 25-year-old
man who was diagnosed with ankylosing spondylitis (AS) 12 months ago. Despite regular
physiotherapy and trials of two different non-steroidal anti-inflammatory drugs (NSAIDs) he remains
symptomatic and asks you about the potential benefits of TNF-inhibitor therapy. You should tell him
that TNF-inhibitors will improve all of the following except:

Quality of life
Radiological progression
Spinal mobility
Extra-articular features
Early morning stiffness
Question 42 of 134

You are the ST1 working in the rheumatology out-patient clinic. Your next patient is a 25-year-old
man who was diagnosed with ankylosing spondylitis (AS) 12 months ago. Despite regular
physiotherapy and trials of two different non-steroidal anti-inflammatory drugs (NSAIDs) he remains
symptomatic and asks you about the potential benefits of TNF-inhibitor therapy. You should tell him
that TNF-inhibitors will improve all of the following except:

Quality of life
Radiological progression
Spinal mobility
Extra-articular features
Early morning stiffness

Radiographic damage in AS is quantified by the number of syndesmophytes, squaring, erosions and

sclerosis developing at vertebral corners. Quantified radiographic damage has been shown to correlate
well with spinal mobility and overall physical function. However, unlike rheumatoid arthritis and
psoriatic arthritis, where TNF-inhibitors have demonstrated significant effect on progression of
structural damage, the evidence to date is that the radiographic progression of AS is unaltered with the
use of these agents. The only therapy showing promise for a disease modifying effect in this regard so
far has been sustained use of NSAIDs.

Discuss and give feedback

Ankylosing spondylitis: investigation and management

External links

NICE

2016 TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis

European League Against Rheumatism (EULAR)

2010 Ankylosing spondylitis guidelines

Question 43 of 134

A 32-year-old woman presents with a facial rash that appears to be worse in summer. She has also
noticed intermittent swelling of the small joints of her hands and describes suffering from Raynaud's
syndrome for 5 years.
Given the likely diagnosis which of these auto-antibodies is most likely to be positive?

Anti-dsDNA
Anti-nuclear cytoplasmic antibody
Anti-nuclear antibody
Anti-Sm
Anti-Ro
Question 43 of 134

A 32-year-old woman presents with a facial rash that appears to be worse in summer. She has also
noticed intermittent swelling of the small joints of her hands and describes suffering from Raynaud's
syndrome for 5 years.
Given the likely diagnosis which of these auto-antibodies is most likely to be positive?

Anti-dsDNA
Anti-nuclear cytoplasmic antibody
Anti-nuclear antibody
Anti-Sm
Anti-Ro

This lady presents with a photosensitive rash, Raynaud's syndrome and small joint arthritis - giving a
likely diagnosis of systemic lupus erythematosus (SLE).
-nuclear (ANA) antibody is the most likely antibody to be present. Approximately 95% of
people with SLE have a positive ANA, however it is not very specific.
-Sm are the most specific antibodies for SLE, but only around 35% of patients with SLE will be
positive. Anti-dsDNA antibodies are positive in around 70% of SLE cases.
-Ro antibodies are present in 15% of patients with SLE, but are more frequently associated with
Sjörgren's syndrome.
-nuclear cytoplasmic antibodies are not associated with SLE. They are associated with
inflammatory bowel disease and vasculitis such as Wegener's granulomatosis.

Discuss and give feedback

SLE: investigations

External media

Systemic lupus erythematosus (SLE) - causes, symptoms, diagnosis & pathology

Osmosis - YouTube
Question 44 of 134

Perinuclear antineutrophil cytoplasmic antibodies (pANCA) are most strongly associated with
which condition?

Goodpasture's syndrome
Churg-Strauss syndrome
Polyarteritis nodosa
Granulomatosis with polyangiitis
Autoimmune hepatitis
Question 44 of 134

Perinuclear antineutrophil cytoplasmic antibodies (pANCA) are most strongly associated with which
condition?

Goodpasture's syndrome
Churg-Strauss syndrome
Polyarteritis nodosa
Granulomatosis with polyangiitis
Autoimmune hepatitis

cANCA = granulomatosis with polyangiitis; pANCA = Churg-Strauss + others

Discuss and give feedback

ANCA

There are two main types of anti-neutrophil cytoplasmic antibodies (ANCA) - cytoplasmic (cANCA)
and perinuclear (pANCA)
For the exam, remember:

cANCA - granulomatosis with polyangiitis (Wegener's granulomatosis)

pANCA - Churg-Strauss syndrome + others (see below)

cANCA

most common target serine proteinase 3 (PR3)

some correlation between cANCA levels and disease activity

granulomatosis with polyangiitis, positive in > 90%

microscopic polyangiitis, positive in 40%

pANCA

most common target is myeloperoxidase (MPO)

cannot use level of pANCA to monitor disease activity

associated with immune crescentic glomerulonephritis (positive in c. 80% of patients)

microscopic polyangiitis, positive in 50-75%

Churg-Strauss syndrome, positive in 60%

primary sclerosing cholangitis, positive in 60-80%

granulomatosis with polyangiitis, positive in 25%

Other causes of positive ANCA (usually pANCA):

inflammatory bowel disease (UC > Crohn's)

connective tissue disorders: RA, SLE, Sjogren's

autoimmune hepatitis
Question 45 of 134

A 54-year-old woman who is obese comes to the Emergency department complaining of pain at the
back of her right knee and swelling of the right calf, which she tells you came on all of a sudden. She
is awaiting a knee replacement for osteoarthritis of the right knee. Routine blood testing reveals that
the D-dimer is in the normal range.

Which of the following is the most likely diagnosis?

Deep vein thrombosis

Ruptured popliteal cyst
Pseudogout
Ruptured calf muscle
Septic arthritis
Question 45 of 134

A 54-year-old woman who is obese comes to the Emergency department complaining of pain at the
back of her right knee and swelling of the right calf, which she tells you came on all of a sudden. She
is awaiting a knee replacement for osteoarthritis of the right knee. Routine blood testing reveals that
the D-dimer is in the normal range.

Which of the following is the most likely diagnosis?

Deep vein thrombosis

Ruptured popliteal cyst
Pseudogout
Ruptured calf muscle
Septic arthritis

Sudden onset of pain, particularly when this is associated first with symptoms behind the knee, and
calf swelling, is very suspicious of an underlying ruptured popliteal cyst. The fact she is awaiting a
right total knee replacement also suggests significant osteoarthritis of the knee, which predisposes to
the condition. Physiotherapy and analgesia are the mainstay of therapy for the condition. Patients may
complain of posterior knee and calf pain for a number of weeks after the original incident.

act that pain began behind the knee, and that the D-dimer is normal, counts against a diagnosis
of deep vein thrombosis. Pseudogout is primarily associated with anterior knee pain and swelling, as is
septic arthritis. A ruptured calf muscle is more likely to present with pain in the body of the calf itself,
rather than pain behind the knee.

Discuss and give feedback

Popliteal fossa
Question 46 of 134

The presence of anti-cyclic citrullinated peptide antibody is suggestive of which one of the
following conditions?

Systemic lupus erythematous

Rheumatoid arthritis
Type 1 diabetes mellitus
Addison's disease
Dermatomyositis
Question 46 of 134

The presence of anti-cyclic citrullinated peptide antibody is suggestive of which one of the
following conditions?

Systemic lupus erythematous

Rheumatoid arthritis
Type 1 diabetes mellitus
Addison's disease
Dermatomyositis

Anti-cyclic citrullinated peptide antibodies are associated with rheumatoid arthritis

Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of
rheumatoid arthritis. It may therefore play a key role in the future of rheumatoid arthritis, allowing
early detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity similar to
rheumatoid factor (70-80%, see below) with a much higher specificity of 90-95%.

Discuss and give feedback

Rheumatoid arthritis: antibodies

Question 47 of 134

A 35-year-old gentleman has attended his GP due to joint pains and reported skin changes.
On examination, you note a brownish/bluish pigment to his ears. On closer inspection, you also note a
similar discolouration of his sclera bilaterally. His past history includes a prior knee joint replacement.
A specialist urine sample is sent away, which ultimately shows elevated levels of homogentisic acid.
What is the most likely unifying diagnosis?

Osteogenesis imperfecta
Alkaptonuria
Porphyria cutanea tarda
Wilson disease
Phenylketonuria
Question 47 of 134

A 35-year-old gentleman has attended his GP due to joint pains and reported skin changes.
On examination, you note a brownish/bluish pigment to his ears. On closer inspection, you also note a
similar discolouration of his sclera bilaterally. His past history includes a prior knee joint replacement.
A specialist urine sample is sent away, which ultimately shows elevated levels of homogentisic acid.
What is the most likely unifying diagnosis?

Osteogenesis imperfecta
Alkaptonuria
Porphyria cutanea tarda
Wilson disease
Phenylketonuria

Alkaptonuria is an autosomal recessive disorder that is a result of a deficiency of homogentisic acid

dioxygenase leading to elevated levels of homogentisic acid (HGA). HGA then polymerises and forms
a pigment that is deposited in connective tissue throughout the body (ochronosis). Clinically features
include: brown/bluish pigment of the ear cartilage or sclera, arthropathy, renal stones, cardiac valve
involvement and coronary calcification.

d with elevated HGA. Porphyria

cutanea tarda, Wilson disease and phenylketonuria do not cause cartilage discolouration nor elevated
HGA.

Discuss and give feedback

Alkaptonuria
Question 48 of 134

A 27-year-old woman presents with painful genital ulceration. She has had recurrent attacks for the
past four years. Oral aciclovir has had little effect on the duration of her symptoms. She has also
noticed for the past year almost weekly attacks of mouth ulcers which again are slow to heal. Her only
past medical history of note is being treated for thrombophlebitis two years ago. What is the most
likely diagnosis?

Behcet's syndrome
Polyarteritis nodosa
Systemic lupus erythematosus
Sarcoidosis
Herpes simplex virus type 2
Question 48 of 134

A 27-year-old woman presents with painful genital ulceration. She has had recurrent attacks for the
past four years. Oral aciclovir has had little effect on the duration of her symptoms. She has also
noticed for the past year almost weekly attacks of mouth ulcers which again are slow to heal. Her only
past medical history of note is being treated for thrombophlebitis two years ago. What is the most
likely diagnosis?

Behcet's syndrome
Polyarteritis nodosa
Systemic lupus erythematosus
Sarcoidosis
Herpes simplex virus type 2

Discuss and give feedback

Behcet's syndrome

External media

Bechet's syndrome

Osmosis - YouTube
Question 49 of 134

A 56-year-old lady is referred to rheumatology clinic due to severe Raynaud's phenomenon associated
with arthralgia of the fingers. On examination you note shiny and tight skin of the fingers with a
number of telangiectasia on the upper torso and face. She is also currently awaiting a gastroscopy to
investigate heartburn. Which one of the following antibodies is most specific for the underlying
condition?

Anti-Jo 1antiobodies
Rheumatoid factor
Anti-Scl-70 antibodies
Anti-centromere antibodies
Anti-nuclear factor
Question 49 of 134

A 56-year-old lady is referred to rheumatology clinic due to severe Raynaud's phenomenon associated
with arthralgia of the fingers. On examination you note shiny and tight skin of the fingers with a
number of telangiectasia on the upper torso and face. She is also currently awaiting a gastroscopy to
investigate heartburn. Which one of the following antibodies is most specific for the underlying
condition?

Anti-Jo 1antiobodies
Rheumatoid factor
Anti-Scl-70 antibodies
Anti-centromere antibodies
Anti-nuclear factor

Limited (central) systemic sclerosis = anti-centromere antibodies

This lady has some features of CREST syndrome. Although ANA is positive in 90% of patients with
systemic sclerosis, anti-centromere antibodies are the most specific test for limited cutaneous systemic
sclerosis

Discuss and give feedback

Systemic sclerosis
Question 50 of 134

Which one of the following statements concerning discoid lupus is correct?

Commonly progresses to SLE

Causes non-scarring alopecia
Characterised by follicular keratin plugs
Is rarely photosensitive
Typically presents in older males
Question 50 of 134

Which one of the following statements concerning discoid lupus is correct?

Commonly progresses to SLE

Causes non-scarring alopecia
Characterised by follicular keratin plugs
Is rarely photosensitive
Typically presents in older males

Discoid lupus erythematosus is characterised by follicular keratin plugs

Discuss and give feedback

Discoid lupus erythematous

External links

DermNet NZ

Discoid lupus erythematosus

Question 51 of 134

A 31-year-old female with a history of SLE gives birth following a 39 week pregnancy. The newborn
is noted to be bradycardic. Which one of the following autoantibodies are associated with
congenital heart block?

Anti-Ro
Anti-Sm
Anti-RNP
Anti-dsDNA
Anti-Jo 1
Question 51 of 134

A 31-year-old female with a history of SLE gives birth following a 39 week pregnancy. The newborn
is noted to be bradycardic. Which one of the following autoantibodies are associated with
congenital heart block?

Anti-Ro
Anti-Sm
Anti-RNP
Anti-dsDNA
Anti-Jo 1

SLE - antibodies associated with congenital heart block = anti-Ro

Discuss and give feedback

SLE: pregnancy

External links

American College of Rheumatology

Systemic Lupus Erythematosus diagnostic criteria

External media

Systemic lupus erythematosus (SLE) - causes, symptoms, diagnosis & pathology

Osmosis - YouTube
Question 52 of 134

A 45-year-old woman with a history of primary Sjogren's syndrome is reviewed in clinic. Her main
problem is a dry mouth, which unfortunately has not responded to artificial saliva. Which one of the
following medications is most likely to be beneficial?

Rivastigmine
Neostigmine
Clonidine
Atropine
Pilocarpine
Question 52 of 134

A 45-year-old woman with a history of primary Sjogren's syndrome is reviewed in clinic. Her main
problem is a dry mouth, which unfortunately has not responded to artificial saliva. Which one of the
following medications is most likely to be beneficial?

Rivastigmine
Neostigmine
Clonidine
Atropine
Pilocarpine

Discuss and give feedback

Sjogren's syndrome
Question 53 of 134

A 45-year-old woman is referred to rheumatology outpatients with a 4 month history of joint pains,
myalgia and generalised lethargy. An autoantibody screen reveals she is ANA positive and anti-
ribonucleoprotein positive. The creatine kinase is elevated at 525. What is the most likely diagnosis?

Systemic lupus erythematous

Mixed connective tissue disease
Polymyositis
Dermatomyositis
CREST syndrome
Question 53 of 134

A 45-year-old woman is referred to rheumatology outpatients with a 4 month history of joint pains,
myalgia and generalised lethargy. An autoantibody screen reveals she is ANA positive and anti-
ribonucleoprotein positive. The creatine kinase is elevated at 525. What is the most likely diagnosis?

Systemic lupus erythematous

Mixed connective tissue disease
Polymyositis
Dermatomyositis
CREST syndrome

Anti-ribonuclear protein (anti-RNP) = mixed connective tissue disease

Discuss and give feedback

Mixed connective tissue disease

Question 54 of 134

A 57-year-old man with a history of ischaemic heart disease presents with an hot, erythematous and
painful left 1st metatarsophalangeal joint. The attack settles following a course of non-steroidal anti-
inflammatories. He currently takes aspirin 75 mg od for secondary prevention of ischaemic heart
disease. What should happen regarding his medication?

Switch aspirin to clopidogrel

Continue aspirin at current dose
Increase aspirin dose to 300mg od
Switch aspirin to dipyridamole
Stop aspirin
Question 54 of 134
A 57-year-old man with a history of ischaemic heart disease presents with an hot, erythematous and
painful left 1st metatarsophalangeal joint. The attack settles following a course of non-steroidal anti-
inflammatories. He currently takes aspirin 75 mg od for secondary prevention of ischaemic heart
disease. What should happen regarding his medication?

Switch aspirin to clopidogrel

Continue aspirin at current dose
Increase aspirin dose to 300mg od
Switch aspirin to dipyridamole
Stop aspirin

Aspirin in a dose of 75-150mg is not thought to have a significant effect on plasma urate levels -
please see the British Society for Rheumatology guidelines for more details.

Aspirin in low doses (75-150mg/day) has insignificant effects on the plasma urate, and should be
used as required for cardiovascular prophylaxis (B). However, aspirin in analgesic doses (600-
2400mg/day) interferes with uric acid excretion and should be avoided (B).

Discuss and give feedback

Gout: drug causes

External links
RCP Clinical Medicine
Crystal arthritis: contemporary approaches to diseases of antiquity
British Society for Rheumatology
2007 gout guidelines
Question 55 of 134

Osteopetrosis is due to a defect in:

Osteoclast function
PTH receptors
Osteoblast function
Calcium resorption in proximal tubule
Calcium absorption
Question 55 of 134

Osteopetrosis is due to a defect in:

Osteoclast function
PTH receptors
Osteoblast function
Calcium resorption in proximal tubule
Calcium absorption

Discuss and give feedback

Osteopetrosis
Question 56 of 134

Each one of the following is seen in reactive arthritis, except:

Urethritis
Keratoderma blenorrhagica
Conjunctivitis
Aseptic meningoencephalitis
Circinate balanitis
Question 56 of 134

Each one of the following is seen in reactive arthritis, except:

Urethritis
Keratoderma blenorrhagica
Conjunctivitis
Aseptic meningoencephalitis
Circinate balanitis

Discuss and give feedback

Reactive arthritis: features

External links

DermNet NZ

Reactive arthritis
Question 57 of 134

A 54-year-old man with a history of type 2 diabetes mellitus presents with a history of right shoulder
pain. On examination there is limited movement of the right shoulder in all directions. What is the
most likely diagnosis?

Adhesive capsulitis
Dermatomyositis
Avascular necrosis
Lhermitte's syndrome
Diabetic amyotrophy
Question 57 of 134

A 54-year-old man with a history of type 2 diabetes mellitus presents with a history of right shoulder
pain. On examination there is limited movement of the right shoulder in all directions. What is the
most likely diagnosis?

Adhesive capsulitis
Dermatomyositis
Avascular necrosis
Lhermitte's syndrome
Diabetic amyotrophy

Diabetic amyotrophy affects the lower limbs

Discuss and give feedback

Adhesive capsulitis

External links

Patient.info

Frozen shoulder review

Question 58 of 134

A 54-year-old woman who has had two Colle's fractures in the past three years has a DEXA scan:

T-score
L2-4 -1.4
Femoral neck -2.7

What does the scan show?

Osteoporosis in both the vertebrae and femoral neck

Osteoporosis in vertebrae, osteopaenia in femoral neck
Osteopaenia in both the vertebrae and femoral neck
Osteopaenia in vertebrae, osteoporosis in femoral neck
Normal bone density in vertebrae, osteoporosis in femoral nec
Question 58 of 134

A 54-year-old woman who has had two Colle's fractures in the past three years has a DEXA scan:

T-score
L2-4 -1.4
Femoral neck -2.7

What does the scan show?

Osteoporosis in both the vertebrae and femoral neck

Osteoporosis in vertebrae, osteopaenia in femoral neck
Osteopaenia in both the vertebrae and femoral neck
Osteopaenia in vertebrae, osteoporosis in femoral neck
Normal bone density in vertebrae, osteoporosis in femoral neck

Discuss and give feedback

Osteoporosis: DEXA scan

Question 59 of 134

An 28-year-old man is investigated for recurrent lower back pain. A diagnosis of ankylosing
spondylitis is suspected. Which one of the following investigations is most useful?

ESR
X-ray of the sacro-iliac joints
HLA-B27 testing
X-ray of the thoracic spine
CT of the lumbar spine
Question 59 of 134

An 28-year-old man is investigated for recurrent lower back pain. A diagnosis of ankylosing
spondylitis is suspected. Which one of the following investigations is most useful?

ESR
X-ray of the sacro-iliac joints
HLA-B27 testing
X-ray of the thoracic spine
CT of the lumbar spine

X-ray of the sacro-iliac joints is the most useful investigation for diagnosis and monitoring, but
changes may not be seen for many years after the onset of symptoms.

Discuss and give feedback

Ankylosing spondylitis: investigation and management

External links

NICE

2016 TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis

European League Against Rheumatism (EULAR)

2010 Ankylosing spondylitis guidelines

Question 60 of 134

Which one of the following conditions is least associated with HLA-B27?

Reiter's syndrome
Psoriatic arthritis
Ankylosing spondylitis
Crohn's disease
Sacroiliitis
Question 60 of 134

Which one of the following conditions is least associated with HLA-B27?

Reiter's syndrome
Psoriatic arthritis
Ankylosing spondylitis
Crohn's disease
Sacroiliitis

There is an indirect association between HLA-B27 and Crohn's as some patients may develop
enteropathic arthritis, but this is the least common association of the above

Discuss and give feedback

Seronegative spondyloarthropathies
Question 61 of 134

You are doing the annual review of a 50-year-old woman who has rheumatoid arthritis. Which one of
the following complications is most likely to occur as a result of her disease?

Chronic lymphocytic leukaemia

Hypertension
Colorectal cancer
Type 2 diabetes mellitus
Ischaemic heart disease
Question 61 of 134

You are doing the annual review of a 50-year-old woman who has rheumatoid arthritis. Which one of
the following complications is most likely to occur as a result of her disease?

Chronic lymphocytic leukaemia

Hypertension
Colorectal cancer
Type 2 diabetes mellitus
Ischaemic heart disease

Rheumatoid arthritis: patients have an increased risk of IHD

Discuss and give feedback

Rheumatoid arthritis: complications

Question 62 of 134

A 54-year-old male presents with weakness of his upper arms. On examination he is found to have a
macular rash over his back and the extensor aspects of his upper arms. He is a heavy smoker and his
sodium is 121 mmol/l. What is the most likely underlying diagnosis?

Addison's disease
Polymyositis
Overlap syndrome
Dermatomyositis
Hypothyroidism
Question 62 of 134

A 54-year-old male presents with weakness of his upper arms. On examination he is found to have a
macular rash over his back and the extensor aspects of his upper arms. He is a heavy smoker and his
sodium is 121 mmol/l. What is the most likely underlying diagnosis?

Addison's disease
Polymyositis
Overlap syndrome
Dermatomyositis
Hypothyroidism

This man may have an underlying small cell lung cancer causing Syndrome of Inappropriate
Antidiuretic Hormone Secretion.

Discuss and give feedback

Dermatomyositis
Question 63 of 134

An 86-year-old woman presented to the emergency department complaining of a 2-day history of

difficulty weight bearing and pain in the right knee. She is known to have atrial fibrillation, for which
she is currently anticoagulated with warfarin. Her INR 2 weeks ago was seen to be 4.4, and she
subsequently had her warfarin dose adjusted. On examination, you note that her right knee is red, hot
and tender with a fluctuant effusion. What is the next most appropriate step?

Intravenous flucloxacillin
5mg oral vitamin K
Commence colchicine
Aspirate the joint
Discharge the patient with advice to rest, ice, compress and elevate the leg.
Question 63 of 134

An 86-year-old woman presented to the emergency department complaining of a 2-day history of

difficulty weight bearing and pain in the right knee. She is known to have atrial fibrillation, for which
she is currently anticoagulated with warfarin. Her INR 2 weeks ago was seen to be 4.4, and she
subsequently had her warfarin dose adjusted. On examination, you note that her right knee is red, hot
and tender with a fluctuant effusion. What is the next most appropriate step?

Intravenous flucloxacillin
5mg oral vitamin K
Commence colchicine
Aspirate the joint
Discharge the patient with advice to rest, ice, compress and elevate the leg.

The red, hot, tender joint is an important presentation in acute rheumatology. The three classic
differentials for this presentation are septic arthritis, gout and pseudogout. In this lady, in view of the
previously high INR, joint haematoma is also an important consideration. It is not possible to
differentiate these conditions clinically, so joint aspiration is the most important next step. Culture will
enable a positive diagnosis of septic arthritis, whilst microscopy and gross appearance the diagnosis of
crystal arthropathy.

IV antibiotics. However, this should be done after joint aspiration so that more targetted therapy can
be performed subsequently.
-risk nature of joint aspiration and the
fact that her previous INR was only 4.4 with a subsequent reduction in dose. Colchicine is a useful
medication in the acute management of gout, but the diagnosis is yet to be established. Discharging the
patient at this point is premature.
Discuss and give feedback

Septic arthritis

External links

Patient.info

Septic arthritis review

Question 64 of 134

Which of the following findings is not typical in a patient with antiphospholipid syndrome?

Prolonged APTT
Thrombocytosis
Recurrent venous thrombosis
Recurrent arterial thrombosis
Livedo reticularis
Question 64 of 134

Which of the following findings is not typical in a patient with antiphospholipid syndrome?

Prolonged APTT
Thrombocytosis
Recurrent venous thrombosis
Recurrent arterial thrombosis
Livedo reticularis

Antiphospholipid syndrome: arterial/venous thrombosis, miscarriage, livedo reticularis

Thrombocytopenia is associated with antiphospholipid syndrome.

Discuss and give feedback

Antiphospholipid syndrome

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous

and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder
or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)
A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in
the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with
phospholipids involved in the coagulation cascade

Features:

venous/arterial thrombosis

recurrent fetal loss

livedo reticularis

thrombocytopenia

prolonged APTT

other features: pre-eclampsia, pulmonary hypertension

Associations other than SLE:

other autoimmune disorders

lymphoproliferative disorders

phenothiazines (rare)

Management - based on BCSH guidelines:

initial venous thromboembolic events: evidence currently supports use of warfarin with a target
INR of 2-3 for 6 months

recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin
then increase target INR to 3-4

arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

External links

British Society of Haematology

Antiphospholipid syndrome guidelines

DermIS

Pictures of livedo reticularis

Question 65 of 134

A 55-year-old woman presents with a four week history of shoulder pain. There has been no obvious
precipitating injury and no previous experience. The pain is worse on movement and there is a grating
sensation if she moves the arm too quickly. She also gets pain at night, particularly when she lies on
the affected shoulder. On examination there is no obvious erythema or swelling. Passive abduction is
painful between between 60 and 120 degrees. She is unable to abduct the arm herself past 70-80
degrees. Flexion and extension are preserved. What is the most likely diagnosis?

Adhesive capsulitis (frozen shoulder)

Supraspinatus tendonitis
Acromioclavicular joint injury
Glenohumeral arthritis
Superior labral lesion
Question 65 of 134

A 55-year-old woman presents with a four week history of shoulder pain. There has been no obvious
precipitating injury and no previous experience. The pain is worse on movement and there is a grating
sensation if she moves the arm too quickly. She also gets pain at night, particularly when she lies on
the affected shoulder. On examination there is no obvious erythema or swelling. Passive abduction is
painful between between 60 and 120 degrees. She is unable to abduct the arm herself past 70-80
degrees. Flexion and extension are preserved. What is the most likely diagnosis?

Adhesive capsulitis (frozen shoulder)

Supraspinatus tendonitis
Acromioclavicular joint injury
Glenohumeral arthritis
Superior labral lesion

This patient has a classic 'painful arc' which is a sign of shoulder impingement, most commonly
secondary to supraspinatus tendonitis.

Discuss and give feedback

Rotator cuff muscles

Question 66 of 134

Which one of the following is least recognised in polyarteritis nodosa?

Cytoplasmic-antineutrophil cytoplasmic antibodies

Hypertension
Mononeuritis multiplex
Pyrexia
Renal failure
Question 66 of 134

Which one of the following is least recognised in polyarteritis nodosa?

Cytoplasmic-antineutrophil cytoplasmic antibodies

Hypertension
Mononeuritis multiplex
Pyrexia
Renal failure

Perinuclear-antineutrophil cytoplasmic antibodies are found in around 20% of patients.

Discuss and give feedback

Polyarteritis nodosa
Question 67 of 134

A 51-year-old male presents with an acute onset of swelling and pain in his right knee. Aspiration
shows negatively birefringent crystals with no organisms seen. His pain fails to settle with NSAIDs.
What is the most appropriate next step in his management?

Repeat joint aspiration and intra-articular depomederone

Allopurinol
IV flucloxacillin
Diuretics
Low dose methotrexate
Question 67 of 134

A 51-year-old male presents with an acute onset of swelling and pain in his right knee. Aspiration
shows negatively birefringent crystals with no organisms seen. His pain fails to settle with NSAIDs.
What is the most appropriate next step in his management?

Repeat joint aspiration and intra-articular depomederone

Allopurinol
IV flucloxacillin
Diuretics
Low dose methotrexate

Discuss and give feedback

Gout: management

External links

Genetics home reference

Lesch Nyhan Syndrome

Clinical Knowledge Summaries

Gout guidelines
Question 68 of 134

Which of the following is least likely to be associated with ankylosing spondylitis?

Apical fibrosis
Achilles tendonitis
Amyloidosis
Achalasia
Heart block
Question 68 of 134

Which of the following is least likely to be associated with ankylosing spondylitis?

Apical fibrosis
Achilles tendonitis
Amyloidosis
Achalasia
Heart block

Ankylosing spondylitis features - the 'A's

Apical fibrosis

Anterior uveitis

Aortic regurgitation

Achilles tendonitis

AV node block

Amyloidosis

Achalasia is not a recognised association of ankylosing spondylitis

Discuss and give feedback

Ankylosing spondylitis: features

External links

Arthritis Reasearch Council

Ankylosing Spondylitis Patient Info

Question 69 of 134

A 54-year-old man presents to the Emergency Department with a 2 day history of an swollen, painful
left knee. Aspirated joint fluid shows calcium pyrophosphate crystals. Which of the following blood
tests is most useful in revealing an underlying cause?

Transferrin saturation
ACTH
ANA
Serum ferritin
LDH
Question 69 of 134

A 54-year-old man presents to the Emergency Department with a 2 day history of an swollen, painful
left knee. Aspirated joint fluid shows calcium pyrophosphate crystals. Which of the following blood
tests is most useful in revealing an underlying cause?

Transferrin saturation
ACTH
ANA
Serum ferritin
LDH

This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate

haemochromatosis, a recognised cause of pseudogout
evel is also seen in haemochromatosis but can be raised in a variety of infective and
inflammatory processes, including pseudogout, as part of an acute phase response

Discuss and give feedback

Pseudogout

External links

RCP Clinical Medicine

Crystal arthritis: contemporary approaches to diseases of antiquity

Question 70 of 134

A 71-year-old male undergoes an ultrasound scan for an acutely painful right knee associated with
swelling. An ultrasound scan conforms the presence of an effusion and states the 'double contour' sign
was observed. What is the most likely diagnosis?

Chondrocalcinosis
Gout
Septic arthritis
Meniscus tear
Osteoarthritis
Question 70 of 134
A 71-year-old male undergoes an ultrasound scan for an acutely painful right knee associated with
swelling. An ultrasound scan conforms the presence of an effusion and states the 'double contour' sign
was observed. What is the most likely diagnosis?

Chondrocalcinosis
Gout
Septic arthritis
Meniscus tear
Osteoarthritis

Gout is one of the commonest forms of inflammatory arthritis. The prevalence appears to be rapidly
increasing worldwide. It is mediated by the crystallization of uric acid within the joints. Urate crystals
are deposited predominantly in the superficial portions of the articular cartilage. These characteristic
cartilaginous deposits are not readily demonstrated with conventional diagnostic imaging including CT
or MRI.
iagnostic
clues. However, disadvantages include :lack of specificity (bone scan, MRI), considerable cost
(MRI) and the inability to assess early soft tissue changes such as effusion, early erosions, synovial
hypertrophy and hypervascularity or small tophi (roentgenography). Typical well-defined, punched
out, periarticular erosions with overhanging edges are not seen radiographically until 6-12 yrs after the
initial acute attack. The most reliable method of diagnosis is invasive needle aspiration and
identification of crystals on polarizing microscopy. However, many physicians do not perform
synovial fluid analysis, and therapy is often initiated with an assumed diagnosis.
-contour sign a hyperechoic, irregular band over
the superficial margin of the joint cartilage, produced by deposition of monosodium urate crystals on
the surface of the hyaline cartilage, which increases the interface of the cartilage surface, reaching a
thickness similar to the subchondral bone.

hyaline cartilage, parallel to the bony cortex, as a hyperechoic, irregular line embedded in the
anechoic-appearing hyaline cartilage, with a normal hyaline cartilage surface. Chondrocalcinosis can
thus be readily distinguished from gout.

Discuss and give feedback

Gout: features
External media

Gout - causes, symptoms, diagnosis, treatment, pathology

Osmosis - YouTube
Question 71 of 134

A 66-year-old female with COPD and a background of multiple previous courses of steroids presents
to her GP for a routine bloods screen. She also has hypertension and angina. Her blood results are as
follows:

25-OH Vitamin D 16 nmol/l (>50)

Adjusted calcium 2.34 mmol/l

Her dietary intake of calcium is good. Which answer is most appropriate in view of her past
medical history and vitamin D levels?

Give calcium and vitamin D combined

Reassurance
Repeat in 1 year and if vitamin D <10 commence treatment
Commence oral bisphosphonate
Oral vitamin D loading then maintenance
Question 71 of 134
A 66-year-old female with COPD and a background of multiple previous courses of steroids presents
to her GP for a routine bloods screen. She also has hypertension and angina. Her blood results are as
follows:

25-OH Vitamin D 16 nmol/l (>50)

Adjusted calcium 2.34 mmol/l

Her dietary intake of calcium is good. Which answer is most appropriate in view of her past
medical history and vitamin D levels?

Give calcium and vitamin D combined

Reassurance
Repeat in 1 year and if vitamin D <10 commence treatment
Commence oral bisphosphonate
Oral vitamin D loading then maintenance
This patient has vitamin D deficiency and thus the correct answer is to load with vitamin D and then
continue on maintenance. In patients with good calcium intake and normal serum calcium, giving oral
calcium may actually be detrimental. This is due to evidence suggesting adverse cardiovascular
outcomes, which is thought to be related to accelerated tissue and vascular calcification. Thus given
her background of angina, this should be avoided.
Measurement of serum 25-OH vitamin D is the best way of estimating vitamin D status.

Optimal: > 75nmol/l

Adequate: 50-75nmol/l
Insufficiency: 30-49nmol/l
Deficiency: < 30nmol/l
Serum 25OHD < 30 nmol/l: treatment recommended
Serum 25OHD 30-50 nmol/l: treatment is advised in patients with: fragility fracture,
osteoporosis, symptoms suggestive of vitamin D deficiency, reduced exposure to sunlight,
raised PTH, conditions associated with malabsorption
Serum 25OHD > 50 nmol/l: provide reassurance and give advice on maintaining adequate
vitamin D levels through safe sunlight exposure and diet.
Reference: 1. National Osteoporosis Society (2013). Vitamin D and Bone Health: A Practical Clinical
Guideline for Patient Management.

Discuss and give feedback

Vitamin D supplementation

External links
Chief Medical Officer 2016 Vitamin D guidance
NICE 2014 Vitamin D recommendations
Question 72 of 134

A 47-year-old female is referred to the rheumatology clinic due to cold fingers. Which connective
tissue disease is most strongly associated with Raynaud's phenomenon?

Systemic lupus erythematous

Rheumatoid arthritis
Systemic sclerosis
Sjogren's syndrome
Polyarteritis nodosa
Question 72 of 134

A 47-year-old female is referred to the rheumatology clinic due to cold fingers. Which connective
tissue disease is most strongly associated with Raynaud's phenomenon?

Systemic lupus erythematous

Rheumatoid arthritis
Systemic sclerosis
Sjogren's syndrome
Polyarteritis nodosa

Raynaud's phenomenon is associated with all the above conditions but is most strongly linked to
systemic sclerosis. Around 2% of women and 6% of men with Raynaud's phenomenon develop
systemic sclerosis

Discuss and give feedback

Raynaud's

External links

Arthritis Research Council (ARC)

ARC Raynaud's Patient Info

Question 73 of 134

Which one of the following is the most common ocular manifestation of rheumatoid arthritis?

Scleritis
Episcleritis
Keratoconjunctivitis sicca
Corneal ulceration
Keratitis
Question 73 of 134

Which one of the following is the most common ocular manifestation of rheumatoid arthritis?

Scleritis
Episcleritis
Keratoconjunctivitis sicca
Corneal ulceration
Keratitis

Keratoconjunctivitis sicca is characterised by dry, burning and gritty eyes caused by decreased
tear production.

Discuss and give feedback

Rheumatoid arthritis: ocular manifestations

Question 74 of 134

Which one of the following drugs is least likely to cause gout?

Lithium
Bendrofluazide
Alcohol
Pyrazinamide
Furosemide
Question 74 of 134

Which one of the following drugs is least likely to cause gout?

Lithium
Bendrofluazide
Alcohol
Pyrazinamide
Furosemide

Lithium was actually used to treat gout in the 19th century

Discuss and give feedback

Gout: drug causes

External links

RCP Clinical Medicine

Crystal arthritis: contemporary approaches to diseases of antiquity

British Society for Rheumatology

2007 gout guidelines

External media

Gout - causes, symptoms, diagnosis, treatment, pathology

Question 75 of 134

A 39-year-old woman with a history of rheumatoid arthritis presents with a two day history of a red
right eye. There is no itch or pain. Pupils are 3mm, equal and reactive to light. Visual acuity is 6/5 in
both eyes. What is the most likely diagnosis?

Keratoconjunctivitis sicca
Scleritis
Glaucoma
Episcleritis
Anterior uveitis
Question 75 of 134

A 39-year-old woman with a history of rheumatoid arthritis presents with a two day history of a red
right eye. There is no itch or pain. Pupils are 3mm, equal and reactive to light. Visual acuity is 6/5 in
both eyes. What is the most likely diagnosis?

Keratoconjunctivitis sicca
Scleritis
Glaucoma
Episcleritis
Anterior uveitis

Scleritis is painful, episcleritis is not painful

Discuss and give feedback

Rheumatoid arthritis: ocular manifestations

Question 76 of 134

Which one of the following is most useful in the management of Familial Mediterranean Fever?

Prednisolone
Erythromycin
Cyclophosphamide
Colchicine
Benzylpenicillin
Question 76 of 134

Which one of the following is most useful in the management of Familial Mediterranean Fever?

Prednisolone
Erythromycin
Cyclophosphamide
Colchicine
Benzylpenicillin

Discuss and give feedback

Familial Mediterranean Fever

External links

DermNet NZ

Erysieloid
Question 77 of 134

A 64-year-old female is referred to rheumatology out-patients by her GP with a history of arthritis in

both hands. Which one of the following x-ray findings would most favour a diagnosis of
rheumatoid arthritis over other possible causes?

Loss of joint space

Periarticular osteopenia
Subchondral sclerosis
Osteophytes
Subchondral cysts
Question 77 of 134

A 64-year-old female is referred to rheumatology out-patients by her GP with a history of arthritis in

both hands. Which one of the following x-ray findings would most favour a diagnosis of
rheumatoid arthritis over other possible causes?

Loss of joint space

Periarticular osteopenia
Subchondral sclerosis
Osteophytes
Subchondral cysts

Periarticular osteopenia and osteoporosis would point towards a diagnosis of rheumatoid arthritis
(RA). Loss of joint space is common in both RA and osteoarthritis

Discuss and give feedback

Rheumatoid arthritis: x-ray changes

Question 78 of 134

A 33-year-old man who is suspected of having ankylosing spondylitis has a lumbar spine x-ray.
Which one of the following features is most likely to be present?

Wedge shaped discs

Sclerosis
'Rugger-Jersey' spine
Osteophytes
Subchondral cysts
Question 78 of 134

A 33-year-old man who is suspected of having ankylosing spondylitis has a lumbar spine x-ray.
Which one of the following features is most likely to be present?

Wedge shaped discs

Sclerosis
'Rugger-Jersey' spine
Osteophytes
Subchondral cysts

Ankylosing spondylitis - x-ray findings: subchondral erosions, sclerosis

and squaring of lumbar vertebrae

Discuss and give feedback

Ankylosing spondylitis: features

External links

Arthritis Reasearch Council

Ankylosing Spondylitis Patient Info

Question 79 of 134

A 40-year-old woman complains of a permanent 'funny-bone' sensation in her right elbow. This is
accompanied by tingling in the little and ring finger. Her symptoms are worse when the elbow is bent
for prolonged periods. What is the most likely diagnosis?

Cubital tunnel syndrome

Lateral epicondylitis
Medial epicondylitis
Median nerve entrapment syndrome
Radial tunnel syndrome
Question 79 of 134

A 40-year-old woman complains of a permanent 'funny-bone' sensation in her right elbow. This is
accompanied by tingling in the little and ring finger. Her symptoms are worse when the elbow is bent
for prolonged periods. What is the most likely diagnosis?

Cubital tunnel syndrome

Lateral epicondylitis
Medial epicondylitis
Median nerve entrapment syndrome
Radial tunnel syndrome

Discuss and give feedback

Elbow pain
Question 80 of 134

A 41-year-old man presents with persistent fatigue for the past 8 months. Which one of the following
features is least consistent with a diagnosis of chronic fatigue syndrome?

Dizziness
Painful lymph nodes without enlargement
Having a busy day improves the symptoms
Palpitations
Headaches
Question 80 of 134

A 41-year-old man presents with persistent fatigue for the past 8 months. Which one of the following
features is least consistent with a diagnosis of chronic fatigue syndrome?

Dizziness
Painful lymph nodes without enlargement
Having a busy day improves the symptoms
Palpitations
Headaches

Physical or mental exertion usually makes the symptoms worse.

Discuss and give feedback

Chronic fatigue syndrome

External links

NICE

2007 Chronic fatigue syndrome guidelines

Question 81 of 134

Which one of the following is least associated with Behcet's syndrome?

Mouth ulcers
Genital ulcers
Conjunctivitis
Deep vein thrombosis
Aseptic meningitis
Question 81 of 134

Which one of the following is least associated with Behcet's syndrome?

Mouth ulcers
Genital ulcers
Conjunctivitis
Deep vein thrombosis
Aseptic meningitis

Oral ulcers + genital ulcers + anterior uveitis = Behcet's

Mouth ulcers, genital ulcers, deep vein thrombosis and aseptic meningitis are all recognised features of
Behcet's syndrome

Ocular involvement is the most feared complication of Behcet's syndrome. Conjunctivitis is seen
rarely and is much less common than anterior uveitis. Other ocular problems seen include retinal
vasculitis, iridocyclitis and chorioretinitis

Discuss and give feedback

Behcet's syndrome

External media

Bechet's syndrome

Osmosis - YouTube
Question 82 of 134

A 44-year-old female with a history of Raynaud's phenomenon is reviewed in the rheumatology clinic.
She is currently being investigated for dysphagia. On examination she is noted to have tight, shiny
skin over her fingers. Which one of the following complications is she most likely to develop?

Early onset dementia

Erythema nodosum
Malabsorption
Constrictive pericarditis
Erosive joint disease
Question 82 of 134

A 44-year-old female with a history of Raynaud's phenomenon is reviewed in the rheumatology clinic.
She is currently being investigated for dysphagia. On examination she is noted to have tight, shiny
skin over her fingers. Which one of the following complications is she most likely to develop?

Early onset dementia

Erythema nodosum
Malabsorption
Constrictive pericarditis
Erosive joint disease

This patient is likely to have CREST syndrome, a subtype of limited cutaneous systemic sclerosis.
Malabsorption can develop in these patients secondary to bacterial overgrowth of the sclerosed small
intestine

Whilst diffuse systemic sclerosis is associated with more severe and rapid internal organ involvement
it is also seen in the limited form.

Discuss and give feedback

Systemic sclerosis
Question 83 of 134

Which one of the following features is least typical of polymyalgia rheumatica?

Elevated creatinine kinase

Low-grade fever
Morning stiffness in proximal limb muscles
Polyarthralgia
Anorexia
Question 83 of 134

Which one of the following features is least typical of polymyalgia rheumatica?

Elevated creatinine kinase

Low-grade fever
Morning stiffness in proximal limb muscles
Polyarthralgia
Anorexia

Discuss and give feedback

Polymyalgia rheumatica

External links

Clinical Knowledge Summaries

Polymyalgia rheumatica guidelines

British Society for Rheumatology

BSR and BHPR guidelines for the management of polymyalgia rheumatica

Question 84 of 134

A 61-year-old man is noted to have thickened patches of skin over his knuckles and extensor surfaces
consistent with Gottron's papules. His creatinine kinase levels are also elevated. A diagnosis of
dermatomyositis is suspected. Which one of the following types of autoantibody is most specific
for this condition?

Anti-scl-70 antibodies
Anti-Jo-1 antibodies
Anti-nuclear antibodies
Anti-Mi-2 antibodies
Anti-centromere bodies
Question 84 of 134

A 61-year-old man is noted to have thickened patches of skin over his knuckles and extensor surfaces
consistent with Gottron's papules. His creatinine kinase levels are also elevated. A diagnosis of
dermatomyositis is suspected. Which one of the following types of autoantibody is most specific
for this condition?

Anti-scl-70 antibodies
Anti-Jo-1 antibodies
Anti-nuclear antibodies
Anti-Mi-2 antibodies
Anti-centromere bodies

Dermatomyositis antibodies: ANA most common, anti-Mi-2 most specific

Discuss and give feedback

Dermatomyositis: investigations and management

Question 85 of 134

Which one of the following statements regarding ankylosing spondylitis is correct?

Schober's test assesses reduced chest expansion

HLA-B27 is positive in 50% of patients
Achilles tendonitis is a recognised association
It is equally common in men and women
The typical age of presentation is between 40-50 years
Question 85 of 134

Which one of the following statements regarding ankylosing spondylitis is correct?

Schober's test assesses reduced chest expansion

HLA-B27 is positive in 50% of patients
Achilles tendonitis is a recognised association
It is equally common in men and women
The typical age of presentation is between 40-50 years

HLA-B27 is positive in 90% of patients.

Discuss and give feedback

Ankylosing spondylitis: features

External links

Arthritis Reasearch Council

Ankylosing Spondylitis Patient Info

Question 86 of 134

A 54-year-old man is recovering following his first episode of gout. The pain and inflammation settled
4 days ago. He has no risk factors for the development of gout and there is no evidence of gouty tophi
on examination. What is the most suitable point to start uric acid lowering therapy?

Immediately
If more than 6 episodes of gout in a 1 year period
If one further attack of gout in the next 12 months
4 weeks after the initial attack of gout has settled
If more than 4 episodes of gout in a 1 year period
Question 86 of 134

A 54-year-old man is recovering following his first episode of gout. The pain and inflammation settled
4 days ago. He has no risk factors for the development of gout and there is no evidence of gouty tophi
on examination. What is the most suitable point to start uric acid lowering therapy?

Immediately
If more than 6 episodes of gout in a 1 year period
If one further attack of gout in the next 12 months
4 weeks after the initial attack of gout has settled
If more than 4 episodes of gout in a 1 year period

Gout: start allopurinol if >= 2 attacks in 12 month period

Discuss and give feedback

Gout: management

External links

Genetics home reference

Lesch Nyhan Syndrome

Clinical Knowledge Summaries

Gout guidelines
Question 87 of 134

Which one of the following conditions has polygenic inheritance?

Bartter's syndrome
Huntington disease
Ankylosing spondylitis
Fragile X syndrome
Von Willebrand's disease
Question 87 of 134

Which one of the following conditions has polygenic inheritance?

Bartter's syndrome
Huntington disease
Ankylosing spondylitis
Fragile X syndrome
Von Willebrand's disease

Discuss and give feedback

Ankylosing spondylitis: investigation and management

External links

NICE

2016 TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis

European League Against Rheumatism (EULAR)

2010 Ankylosing spondylitis guidelines

Question 88 of 134

A 47-year-old female presents with elbow pain. She has just spent the weekend painting the house. On
examination there is localised pain around the lateral epicondyle and a diagnosis of lateral
epicondylitis is suspected. Which one of the following movements would characteristically worsen
the pain?

Resisted thumb flexion

Thumb extension
Flexion of the elbow
Pronation of the forearm with the elbow flexed
Resisted wrist extension with the elbow extended
Question 88 of 134

A 47-year-old female presents with elbow pain. She has just spent the weekend painting the house. On
examination there is localised pain around the lateral epicondyle and a diagnosis of lateral
epicondylitis is suspected. Which one of the following movements would characteristically worsen
the pain?

Resisted thumb flexion

Thumb extension
Flexion of the elbow
Pronation of the forearm with the elbow flexed
Resisted wrist extension with the elbow extended

Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow extended

Discuss and give feedback

Lateral epicondylitis

External links

Clinical Knowledge Summaries

Tennis elbow
Question 89 of 134

Approximately what percentage of patients with psoriasis develop an associated arthropathy?

0.5%
30-40%
4-5%
1%
10-20%
Question 89 of 134

Approximately what percentage of patients with psoriasis develop an associated arthropathy?

0.5%
30-40%
4-5%
1%
10-20%

Discuss and give feedback

Psoriatic arthropathy

External links

Annals of the Rheumatic Diseases

Relative incidence of polyarthritis vs. oligoarthritis

Question 90 of 134

You review a 48-year-old woman who is taking methotrexate for rheumatoid arthritis. Concurrent
prescription of which other medication should be avoided?

Erythromycin
Trimethoprim
Sumatriptan
Lansoprazole
Sodium valproate
Question 90 of 134

You review a 48-year-old woman who is taking methotrexate for rheumatoid arthritis. Concurrent
prescription of which other medication should be avoided?

Erythromycin
Trimethoprim
Sumatriptan
Lansoprazole
Sodium valproate

There is an increased risk of haematological toxicity when trimethoprim is prescribed alongside

methotrexate.

Discuss and give feedback

Methotrexate

External links

British Society for Rheumatology

Quick reference guideline for monitoring of disease modifying anti-rheumatic drug (DMARD) therapy

National Patient Safety Agency

Improving compliance with oral methotrexate guidelines

Question 91 of 134

A 68-year-old presents with a painful swollen left knee which has failed to settle after a weeks rest.
There is no history of trauma. On examination he has a moderate sized effusion. A plain radiograph is
reported as follows:

Some loss of joint space

Linear calcification of the articular cartilage

What is the most likely diagnosis?

Pseudogout
Rheumatoid arthritis
Sarcoidosis
Gout
Osteoarthritis
Question 91 of 134

A 68-year-old presents with a painful swollen left knee which has failed to settle after a weeks rest.
There is no history of trauma. On examination he has a moderate sized effusion. A plain radiograph is
reported as follows:

Some loss of joint space

Linear calcification of the articular cartilage

What is the most likely diagnosis?

Pseudogout
Rheumatoid arthritis
Sarcoidosis
Gout
Osteoarthritis

This x-ray describes chondrocalcinosis. Non-specific changes such as loss of joint space are common
in this age group and pseudogout itself may cause osteoarthritic-like changes.

Discuss and give feedback

Pseudogout

External links

RCP Clinical Medicine

Crystal arthritis: contemporary approaches to diseases of antiquity

Question 92 of 134

A 69-year-old man presents with an acute episode of gout on his left first metatarsal-phalangeal joint.
What is the most likely underlying mechanism?

Sedentary lifestyle
Decreased renal excretion of uric acid
Increased endogenous production of uric acid
Starvation
Too much protein in diet
Question 92 of 134

A 69-year-old man presents with an acute episode of gout on his left first metatarsal-phalangeal joint.
What is the most likely underlying mechanism?

Sedentary lifestyle
Decreased renal excretion of uric acid
Increased endogenous production of uric acid
Starvation
Too much protein in diet

The vast majority of gout is due to decreased renal excretion of uric acid

Decreased renal excretion of uric acid is thought to account for 90% of cases of primary gout.
Secondary risk factors such as alcohol intake and medications should also be investigated

Discuss and give feedback

Gout: predisposing factors

External links

RCP Clinical Medicine

Crystal arthritis: contemporary approaches to diseases of antiquity

Question 93 of 134

A 50-year-old man with no past medical history is investigated for ongoing back pain. He is found to
have a vertebral collapse secondary to osteoporosis. What is the most appropriate test to determine
the cause of his osteoporosis?

Thyroid function tests

Prostate specific antigen
Oestrogen level
Prolactin level
Testosterone level
Question 93 of 134

A 50-year-old man with no past medical history is investigated for ongoing back pain. He is found to
have a vertebral collapse secondary to osteoporosis. What is the most appropriate test to determine
the cause of his osteoporosis?

Thyroid function tests

Prostate specific antigen
Oestrogen level
Prolactin level
Testosterone level

Osteoporosis in a man - check testosterone

Whilst thyrotoxicosis is a known cause of osteoporosis, testosterone deficiency is much more

likely in a middle-aged male.

Discuss and give feedback

Osteoporosis: causes

External links

Postgraduate Medical Journal

Review of osteoporosis
Question 94 of 134

A 54-year-old farm worker presents for review. She has recently been diagnosed with osteoarthritis of
the hand but has no other past medical history of note. Despite regular paracetamol she is still
experiencing considerable pain, especially around the base of both thumbs. What is the most suitable
next management step?

Add oral diclofenac + lansoprazole

Switch paracetamol for co-codamol 8/500
Add topical ibuprofen
Add oral ibuprofen
Add oral glucosamine
Question 94 of 134

A 54-year-old farm worker presents for review. She has recently been diagnosed with osteoarthritis of
the hand but has no other past medical history of note. Despite regular paracetamol she is still
experiencing considerable pain, especially around the base of both thumbs. What is the most suitable
next management step?

Add oral diclofenac + lansoprazole

Switch paracetamol for co-codamol 8/500
Add topical ibuprofen
Add oral ibuprofen
Add oral glucosamine

Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line.

The 2008 NICE guidelines suggest the use of paracetamol and topical NSAIDs first-line

Discuss and give feedback

Osteoarthritis: management

External links

NICE

2014 osteoarthritis guidelines

Question 95 of 134

A 24-year-old female is investigated for intermittent pain and swelling of the metacarpal phalangeal
joints for the past 3 months. An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid
factor is positive and a diagnosis of rheumatoid arthritis is made. What is the most appropriate
management to slow disease progression?

Infliximab
Rituximab
Sulfasalazine
Methotrexate + sulfasalazine + short-course of prednisolone
Diclofenac
Question 95 of 134

A 24-year-old female is investigated for intermittent pain and swelling of the metacarpal phalangeal
joints for the past 3 months. An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid
factor is positive and a diagnosis of rheumatoid arthritis is made. What is the most appropriate
management to slow disease progression?

Infliximab
Rituximab
Sulfasalazine
Methotrexate + sulfasalazine + short-course of prednisolone
Diclofenac

The 2009 NICE guidelines recommend that patients with newly diagnosed active RA start a
combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term
glucocorticoids). Women of child-bearing age should be given effective contraception for the duration
of treatment and for 3 months after methotrexate has been stopped.

Discuss and give feedback

Rheumatoid arthritis: management

External links

NICE

2009 Rheumatoid guidelines

Question 96 of 134

A 76-year-old gentleman is seen in Rheumatology clinic for a painful left first metatarsophalangeal
joint. He has a past medical history of chronic kidney disease stage 4, heart failure and poorly
controlled type 2 diabetes.

His GP suspects an acute flare-up of gout and would like to commence treatment. What is the most
appropriate medication to initiate?

Naproxen
Prednisolone
Colchicine
Allopurinol
Ibuprofen
Question 96 of 134

A 76-year-old gentleman is seen in Rheumatology clinic for a painful left first metatarsophalangeal
joint. He has a past medical history of chronic kidney disease stage 4, heart failure and poorly
controlled type 2 diabetes.
His GP suspects an acute flare-up of gout and would like to commence treatment. What is the most
appropriate medication to initiate?
Naproxen
Prednisolone
Colchicine
Allopurinol
Ibuprofen

The best medication for this patient would be colchicine titrated to his renal function. BNF
recommends reducing the dose or increasing the dosage interval if eGFR 10-50ml/minute/1.73m²;
avoid if eGFR less than 10mL/minute/1.73m².

aindicated due to his chronic kidney disease, prednisolone would worsen his
already poorly controlled diabetes, and allopurinol would not be indicated for an acute flare.

Discuss and give feedback

Gout: management
External links
Genetics home reference
Lesch Nyhan Syndrome
Clinical Knowledge Summaries 00
Gout guidelines
Question 97 of 134

A 29-year-old with adult onset Still's comes to the rheumatology clinic for review. She still has
significant symptoms including joint pains and a persistent skin rash despite methotrexate and
etanercept. Examination reveals a macular erythematous rash and active synovitis. CRP is elevated at
95 mg/l.
Which of the following is the most appropriate next intervention?

Denosumab
Mepolizumab
Rituximab
Tocilizumab
Anakinra
Question 97 of 134

A 29-year-old with adult onset Still's comes to the rheumatology clinic for review. She still has
significant symptoms including joint pains and a persistent skin rash despite methotrexate and
etanercept. Examination reveals a macular erythematous rash and active synovitis. CRP is elevated at
95 mg/l.
Which of the following is the most appropriate next intervention?

Denosumab
Mepolizumab
Rituximab
Tocilizumab
Anakinra

The evidence is very strong to support the use of IL-1 inhibition for adult onset Still's disease. A
review of published data estimated the overall remission rate at over 80%, and complete remission rate
at approximately 66%. Anakinra competitively inhibits the action of IL-1 by binding to the IL-1
receptor and plasma levels correlate well with IL-1 in synovial fluid and presence of synovitis.

Denosumab is a RANK ligand inhibitor used in the treatment of osteoporosis. Mepolizumab is used
in the treatment of severe asthma with elevated eosinophils. There is some evidence to support the use
of tocilizumab, an anti-IL6 monoclonal antibody in adult onset Still's, but there is stronger data to
support a role for tocilizumab in the treatment of rheumatoid arthritis. Rituximab is usually instigated
in patients who fail to respond to anakinra.

https://www.evidence.nhs.uk/formulary/bnf/current/10-musculoskeletal-and-joint-diseases/101-drugs-
used-in-rheumatic-diseases-and-gout/1013-drugs-that-suppress-the-rheumatic-disease-
process/cytokine-modulators/anakinra

Discuss and give feedback

Still's disease in adults

Question 98 of 134

A 40-year-old woman who is known to have systemic lupus erythematosus is reviewed with an
exacerbation of wrist pain. Which one of the following is the most useful marker for monitoring
disease activity?

C-reactive protein
C2 levels
Anti-nuclear antibody titres
Anti-dsDNA titres
Anti-Sm titres
Question 98 of 134

A 40-year-old woman who is known to have systemic lupus erythematosus is reviewed with an
exacerbation of wrist pain. Which one of the following is the most useful marker for monitoring
disease activity?

C-reactive protein
C2 levels
Anti-nuclear antibody titres
Anti-dsDNA titres
Anti-Sm titres

Discuss and give feedback

SLE: investigations
Question 99 of 134

Which one of the following is not associated with carpal tunnel syndrome?

Tinel's sign
Compression of the median nerve
Wasting of the hypothenar eminence
Flexion of the wrist reproduces symptoms
Weakness of thumb abduction
Question 99 of 134

Which one of the following is not associated with carpal tunnel syndrome?

Tinel's sign
Compression of the median nerve
Wasting of the hypothenar eminence
Flexion of the wrist reproduces symptoms
Weakness of thumb abduction

Discuss and give feedback

Carpal tunnel syndrome

External media

Carpal tunnel syndrome

Osmosis - YouTube
Question 100 of 134

A 34-year-old kitchen worker presents with a two week history of pain in her right wrist. She has
recently emigrated from Ghana and has no past medical history of note. On examination she is tender
over the base of her right thumb and also over the radial styloid process. Ulnar deviation of the wrist
recreates the pain. What is the most likely diagnosis?

Rheumatoid arthritis
Osteoarthritis of the carpometacarpal joint
De Quervain's tenosynovitis
Carpal tunnel syndrome
Systemic lupus erythematosus
Question 100 of 134

A 34-year-old kitchen worker presents with a two week history of pain in her right wrist. She has
recently emigrated from Ghana and has no past medical history of note. On examination she is tender
over the base of her right thumb and also over the radial styloid process. Ulnar deviation of the wrist
recreates the pain. What is the most likely diagnosis?

Rheumatoid arthritis
Osteoarthritis of the carpometacarpal joint
De Quervain's tenosynovitis
Carpal tunnel syndrome
Systemic lupus erythematosus

Discuss and give feedback

De Quervain's tenosynovitis
Question 101 of 134

A 52-year-old Afro-Caribbean female with a known past medical history of sarcoidosis attends her GP
for increased frequency of urination and polydipsia. Her GP decides to do some blood tests which are
as follows:

Hb 132 g/l
Platelets 250 * 109/l
WBC 6.6 * 109/l

Na+ 139 mmol/l

K+ 4.4 mmol/l
Urea 4.8 mmol/l
Creatinine 79 µmol/l

Adjusted calcium 2.93mmol/l

What is the most likely mechanism of hypercalcaemia?

Primary hyperparathyroidism
Secondary hyperparathyroidism
Paget's disease
PTHrP release
Increased activation of vitamin D
Question 101 of 134

A 52-year-old Afro-Caribbean female with a known past medical history of sarcoidosis attends her GP
for increased frequency of urination and polydipsia. Her GP decides to do some blood tests which are
as follows:

Hb 132 g/l
Platelets 250 * 109/l
WBC 6.6 * 109/l

Na+ 139 mmol/l

K+ 4.4 mmol/l
Urea 4.8 mmol/l
Creatinine 79 µmol/l

Adjusted calcium 2.93mmol/l

What is the most likely mechanism of hypercalcaemia?

Primary hyperparathyroidism
Secondary hyperparathyroidism
Paget's disease
PTHrP release
Increased activation of vitamin D

Sarcoidosis mainly causes hypercalcaemia through forming increased concentrations of calcitriol, the

the sarcoid macrophages.

dism is mainly associated with parathyroid adenomas/hyperplasia. As a rule,

secondary hyperparathyroidism and Paget's do not cause hypercalcaemia. PTHrP release is associated
with malignancies such as squamous cell lung cancers.

Discuss and give feedback

Sarcoidosis
Question 102 of 134

A 54-year-old man is diagnosed as having gout. You are discussing ways to help prevent future
attacks. Which one of the following is most likely to precipitate an attack of gout?

Chocolate
Brazil nuts
Eggs
Sardines
Smoking
Question 102 of 134

A 54-year-old man is diagnosed as having gout. You are discussing ways to help prevent future
attacks. Which one of the following is most likely to precipitate an attack of gout?

Chocolate
Brazil nuts
Eggs
Sardines
Smoking

Foods to avoid include those high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines)
and yeast products

Discuss and give feedback

Gout: management

External links

Genetics home reference

Lesch Nyhan Syndrome

Clinical Knowledge Summaries

Gout guidelines
Question 103 of 134

A 45-year-old man presents with a painful, swollen and red left middle toe. There is no history of
trauma and his symptoms have been present for around a week. Which one of the following
conditions is most associated with this presentation?

Diabetes mellitus
Systemic sclerosis
Rheumatoid arthritis
Bisphosphonate use
Psoriatic arthritis
Question 103 of 134

A 45-year-old man presents with a painful, swollen and red left middle toe. There is no history of
trauma and his symptoms have been present for around a week. Which one of the following
conditions is most associated with this presentation?

Diabetes mellitus
Systemic sclerosis
Rheumatoid arthritis
Bisphosphonate use
Psoriatic arthritis

A 'sausage-shaped' digit is a classical description of dactylitis. It would be unusual for gout to affect
the middle toe, the vast majority of cases occur in the first metatarsophalangeal joint.

d erythema go against a diagnosis of septic

arthritis (e.g. linked to diabetes).

Discuss and give feedback

Dactylitis
Question 104 of 134

A 54-year-old lady presents with one-month history of worsening right groin pain. The pain is worse
on walking and she has developed a limp. She has a background of systemic lupus erythematosus and
is on long-term hydroxychloroquine with a recent course of prednisolone for an acute flare. On
examination, the patient has pain and reduced range of movement particularly on internal rotation of
the right hip.

Which of the following is the most sensitive investigation to confirm the likely diagnosis?

Pelvic x-ray
MRI right hip
CT hip
Anti-phospholipid antibodies
Right hip aspiration and microscopy
Question 104 of 134

A 54-year-old lady presents with one-month history of worsening right groin pain. The pain is worse
on walking and she has developed a limp. She has a background of systemic lupus erythematosus and
is on long-term hydroxychloroquine with a recent course of prednisolone for an acute flare. On
examination, the patient has pain and reduced range of movement particularly on internal rotation of
the right hip.

Which of the following is the most sensitive investigation to confirm the likely diagnosis?

Pelvic x-ray
MRI right hip
CT hip
Anti-phospholipid antibodies
Right hip aspiration and microscopy

This patient has avascular necrosis of her right femoral head due to both her history of systemic lupus
erythematosus and recent steroid use. The most sensitive investigation is MRI scanning. X-rays may
show increased density of the femoral head in advanced cases. In practice, x-rays would usually be
done first-line.

Explanations for other options:

1. In practice, pelvic x-rays would usually be done first-line but they may be normal in early
cases of avascular necrosis.

3. CT scan of the hip is not as sensitive as MRI scanning.

4. Antiphospholipid antibodies are a possible cause of avascular necrosis but would not
confirm the diagnosis.

5. Hip aspiration and microscopy would not be useful in diagnosing avascular necrosis. It is
helpful in cases of possible septic arthritis, gout or pseudogout, none of which are suggested by
this history.
Discuss and give feedback

Avascular necrosis

Avascular necrosis (AVN) may be defined as death of bone tissue secondary to loss of the blood
supply. This leads to bone destruction and loss of joint function. It most commonly affects the
epiphysis of long bones such as the femur.

Causes

long-term steroid use

chemotherapy

alcohol excess

trauma

Features

initially asymptomatic

pain in the affected joint

Investigation:

plain x-ray findings may be normal initially

MRI is the investigation of choice. It is more sensitive than radionuclide bone scanning
Question 105 of 134

A 27-year-old woman is referred to orthopaedics. Three years she had surgery and chemotherapy for
thyroid cancer. Follow up scans to date have shown no evidence of any disease recurrence. For the
past two months she has been experiencing gradually increasing pain in her right hip which is worse
on exercising. On examination passive movement of the hip is painful in all directions, especially
internal rotation. An x-ray ordered by her GP has been reported as normal. What is the most likely
diagnosis?

Trochanteric bursitis
Avascular necrosis of the femoral head
Primary hyperparathyroidism
Metastatic deposits
Hypoparathyroidism
Question 105 of 134
A 27-year-old woman is referred to orthopaedics. Three years she had surgery and chemotherapy for
thyroid cancer. Follow up scans to date have shown no evidence of any disease recurrence. For the
past two months she has been experiencing gradually increasing pain in her right hip which is worse
on exercising. On examination passive movement of the hip is painful in all directions, especially
internal rotation. An x-ray ordered by her GP has been reported as normal. What is the most likely
diagnosis?

Trochanteric bursitis
Avascular necrosis of the femoral head
Primary hyperparathyroidism
Metastatic deposits
Hypoparathyroidism

Initial x-rays are often normal in patients with avascular necrosis, but it would be unlikely that
metastatic deposits significant enough to cause pain would not be shown.
Discuss and give feedback

Avascular necrosis
Avascular necrosis (AVN) may be defined as death of bone tissue secondary to loss of the blood
supply. This leads to bone destruction and loss of joint function. It most commonly affects the
epiphysis of long bones such as the femur.
Causes:
-term steroid use

Features:

affected joint

Investigation
plain x-ray findings may be normal initially.
MRI is the investigation of choice. It is more sensitive than radionuclide bone scanning.
Question 106 of 134

A 73-year-old man presents pain in his right thigh. This has been getting progressively worse for the
past 9 months despite being otherwise well. An x-ray is reported as follows:

X-ray right Radiolucency of subarticular region suggestive of osteolysis. Some areas of patchy
femur sclerosis

Bloods tests show:

Calcium 2.38 mmol/l

Phosphate 0.85 mmol/l
Alkaline phosphatase 544 u/L
Prostate specific antigen 4.4 ng/ml

What is the most appropriate action?

Vitamin D supplementation
Check serum testosterone
Referral to an orthopaedic surgeon
Referral to a urologist
IV bisphosphonates
Question 106 of 134

A 73-year-old man presents pain in his right thigh. This has been getting progressively worse for the
past 9 months despite being otherwise well. An x-ray is reported as follows:

X-ray right Radiolucency of subarticular region suggestive of osteolysis. Some areas of patchy
femur sclerosis

Bloods tests show

Calcium 2.38 mmol/l

Phosphate 0.85 mmol/l
Alkaline phosphatase 544 u/L
Prostate specific antigen 4.4 ng/ml

What is the most appropriate action?

Vitamin D supplementation
Check serum testosterone
Referral to an orthopaedic surgeon
Referral to a urologist
IV bisphosphonates

This patient has Paget's disease as evidenced by an isolated rise in ALP and characteristic x-ray
changes. As he has bone pain he should be treated with bisphosphonates. A PSA of 4.4 ng/ml is
probably normal in a 73-year-old man and is certainly not consistent with metastatic prostate cancer.

Discuss and give feedback

Paget's disease of the bone

Paget's disease is a disease of increased but uncontrolled bone turnover. It is thought to be primarily a
disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic
activity. Paget's disease is common (UK prevalence 5%) but symptomatic in only 1 in 20 patients.
Predisposing factors

increasing age

male sex

northern latitude

family history

Clinical features - only 5% of patients are symptomatic:

bone pain (e.g. pelvis, lumbar spine, femur)

classical, untreated features: bowing of tibia, bossing of skull

raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal

skull x-ray: thickened vault, osteoporosis circumscripta

Indications for treatment include: bone pain, skull or long bone deformity, fracture, periarticular
Paget's.

bisphosphonate (either oral risedronate or IV zoledronate)

calcitonin is less commonly used now

Complications

deafness (cranial nerve entrapment)

bone sarcoma (1% if affected for > 10 years)

fractures

skull thickening

high-output cardiac failure

 © Image used on license from Radiopaedia

The radiograph demonstrates marked thickening of the calvarium. There are also ill-defined sclerotic
and lucent areas throughout. These features are consistent with Paget's disease.
 © Image used on license from Radiopaedia

Pelvic x-ray from an elderly man with Paget's disease. There is a smooth cortical expansion of the left
hemipelvic bones with diffuse increased bone density and coarsening of trabeculae.
 © Image used on license from Radiopaedia

Isotope bone scan from a patient with Paget's disease showing a typical distribution in the spine,
asymmetrical pelvic disease and proximal long bones.

*usually normal in this condition but hypercalcaemia may occur with prolonged immobilisation
Question 107 of 134

A 25-year-old man presents with a painful, swollen left knee. He returned 4 weeks ago from a holiday
in Spain. There is no history of trauma and he has had no knee problems previously. On examination
he has a swollen, warm left knee with a full range of movement. His ankle joints are also painful to
move but there is no swelling. On the soles of both feet you notice a waxy yellow rash. What is the
most likely diagnosis?

Rheumatoid arthritis
Psoriatic arthritis
Gout
Reactive arthritis
Gonococcal arthritis
Question 107 of 134

A 25-year-old man presents with a painful, swollen left knee. He returned 4 weeks ago from a holiday
in Spain. There is no history of trauma and he has had no knee problems previously. On examination
he has a swollen, warm left knee with a full range of movement. His ankle joints are also painful to
move but there is no swelling. On the soles of both feet you notice a waxy yellow rash. What is the
most likely diagnosis?

Rheumatoid arthritis
Psoriatic arthritis
Gout
Reactive arthritis
Gonococcal arthritis

The rash on the soles is keratoderma blenorrhagica. His reactive arthritis may be secondary to either
gastrointestinal infection or Chlamydia.

Discuss and give feedback

Reactive arthritis: features

External links

DermNet NZ

Reactive arthritis
Question 108 of 134

A 24-year-old man is investigated for chronic back pain. Which one of the following would most
suggest a diagnosis of ankylosing spondylitis?

Reduced lateral flexion of the lumbar spine

Pain gets worse during the day
Accentuated lumbar lordosis
Pain on straight leg raising
Loss of thoracic kyphosis
Question 108 of 134

A 24-year-old man is investigated for chronic back pain. Which one of the following would most
suggest a diagnosis of ankylosing spondylitis?

Reduced lateral flexion of the lumbar spine

Pain gets worse during the day
Accentuated lumbar lordosis
Pain on straight leg raising
Loss of thoracic kyphosis

Reduced lateral flexion of the lumbar spine is one of the earliest signs of ankylosing spondylitis.
There tends to be a loss of lumbar lordosis and an accentuated thoracic kyphosis in patients with
ankylosing spondylitis

Discuss and give feedback

Ankylosing spondylitis: features

External links

Arthritis Research Council

Ankylosing Spondylitis Patient Info

Question 109 of 134

A 45-year-old man who is known to have haemochromatosis presents with a swollen and painful right
knee. An x-ray shows no fracture but extensive chondrocalcinosis. Given the likely diagnosis, which
one of the following is most likely to present in the joint fluid?

Raised hyaluronic acid levels

Monosodium urate crystals
Bipyramidal oxalate crystals
Negatively birefringent calcium carbonate crystals
Positively birefringent rhomboid-shaped crystals
Question 109 of 134

A 45-year-old man who is known to have haemochromatosis presents with a swollen and painful right
knee. An x-ray shows no fracture but extensive chondrocalcinosis. Given the likely diagnosis, which
one of the following is most likely to present in the joint fluid?

Raised hyaluronic acid levels

Monosodium urate crystals
Bipyramidal oxalate crystals
Negatively birefringent calcium carbonate crystals
Positively birefringent rhomboid-shaped crystals

Pseudogout - positively birefringent rhomboid shaped crystals

Discuss and give feedback

Pseudogout

External links

RCP Clinical Medicine

Crystal arthritis: contemporary approaches to diseases of antiquity

Question 110 of 134

A 28-year-old woman with rheumatoid arthritis asks for advice about conception. Which one of the
following statements is true?

Methotrexate may be continued during pregnancy as long as the woman takes folic acid
5mg daily
NSAIDs should be avoided in the first and second trimester
Woman with rheumatoid should be encouraged to conceive as soon as possible (ideally
within 1 year) after diagnosis to minimise the risk of complications
TNF-
Hydroxychloroquine is considered safe during pregnancy
Question 110 of 134

A 28-year-old woman with rheumatoid arthritis asks for advice about conception. Which one of the
following statements is true?

Methotrexate may be continued during pregnancy as long as the woman takes folic acid
5mg daily
NSAIDs should be avoided in the first and second trimester
Woman with rheumatoid should be encouraged to conceive as soon as possible (ideally
within 1 year) after diagnosis to minimise the risk of complications
TNF-
Hydroxychloroquine is considered safe during pregnancy

Discuss and give feedback

Rheumatoid arthritis: pregnancy

Question 111 of 134

Which of the following statements is true regarding psoriatic arthropathy?

Skin disease always precedes joint disease

Approximately one-third of patients with psoriasis eventually develop arthropathy
The mainstay of management is analgesia, physiotherapy and joint replacement
Males and females are equally affected
Arthritis mutilans is the most common subtype
Question 111 of 134

Which of the following statements is true regarding psoriatic arthropathy?

Skin disease always precedes joint disease

Approximately one-third of patients with psoriasis eventually develop arthropathy
The mainstay of management is analgesia, physiotherapy and joint replacement
Males and females are equally affected
Arthritis mutilans is the most common subtype

Males and females are affected equally by psoriatic arthritis.

Discuss and give feedback

Psoriatic arthropathy

External links

Annals of the Rheumatic Diseases

Relative incidence of polyarthritis vs. oligoarthritis

Question 112 of 134

Which one of the following is most recognised as a risk factor for developing osteoporosis?

Osteogenesis imperfecta
Marfan's syndrome
Myotonic dystrophy
Duchenne muscular dystrophy
Ehler-Danlos syndrome
Question 112 of 134

Which one of the following is most recognised as a risk factor for developing osteoporosis?

Osteogenesis imperfecta
Marfan's syndrome
Myotonic dystrophy
Duchenne muscular dystrophy
Ehler-Danlos syndrome

Discuss and give feedback

Osteoporosis: causes

External links

Postgraduate Medical Journal

Review of osteoporosis
Question 113 of 134

A 71-year-old man presents with an erythematous, swollen first metatarsophalangeal joint on the left
foot. This is causing him considerable pain and he is having difficulty walking. He has never had any
previous similar episodes. His past medical history includes atrial fibrillation and type 2 diabetes
mellitus and his current medications are warfarin, metformin and simvastatin. What is the most
appropriate treatment of this episode?

Intra-articular corticosteroid
Colchicine
Ibuprofen
Diclofenac
Prednisolone
Question 113 of 134

A 71-year-old man presents with an erythematous, swollen first metatarsophalangeal joint on the left
foot. This is causing him considerable pain and he is having difficulty walking. He has never had any
previous similar episodes. His past medical history includes atrial fibrillation and type 2 diabetes
mellitus and his current medications are warfarin, metformin and simvastatin. What is the most
appropriate treatment of this episode?

Intra-articular corticosteroid
Colchicine
Ibuprofen
Diclofenac
Prednisolone

NSAIDs should be avoided in elderly patients taking warfarin due to the risk of a life-threatening
gastrointestinal haemorrhage. Oral steroids are an option but would upset his diabetic control.

attractive

Discuss and give feedback

Gout: management

External links

Genetics home reference

Lesch Nyhan Syndrome

Clinical Knowledge Summaries

Gout guidelines
Question 114 of 134

A 33-year-old female presents 6 weeks after the birth of her first child with a two-week history of
polyarthralgia, fever and a skin rash. First-line investigations show:

ESR 45 mm/hour

What is the most likely diagnosis?

Polymorphic eruption of pregnancy

Systemic lupus erythematous
Rheumatoid arthritis
Reactive arthritis
Pseudogout
Question 114 of 134

A 33-year-old female presents 6 weeks after the birth of her first child with a two-week history of
polyarthralgia, fever and a skin rash. First-line investigations show:

ESR 45 mm/hour

What is the most likely diagnosis?

Polymorphic eruption of pregnancy

Systemic lupus erythematous
Rheumatoid arthritis
Reactive arthritis
Pseudogout

Unlike many autoimmune diseases systemic lupus erythematous (SLE) often becomes worse during
pregnancy and the puerperium

Discuss and give feedback

SLE: pregnancy

External links

American College of Rheumatology

Systemic Lupus Erythematosus diagnostic criteria

Question 115 of 134

A 57-year-old woman with a history of polymyalgia rheumatica has been taking prednisolone 10 mg
for the past 5 months. A DEXA scan is reported as follows:

L2 T-score -1.6 SD
Femoral neck T-score -1.7 SD

What is the most suitable management?

No treatment
Vitamin D + calcium supplementation + repeat DEXA scan in 6 months
Vitamin D + calcium supplementation
Vitamin D + calcium supplementation + hormone replacement therapy
Vitamin D + calcium supplementation + oral bisphosphonate
Question 115 of 134

A 57-year-old woman with a history of polymyalgia rheumatica has been taking prednisolone 10 mg
for the past 5 months. A DEXA scan is reported as follows:

L2 T-score -1.6 SD
Femoral neck T-score -1.7 SD

What is the most suitable management?

No treatment
Vitamin D + calcium supplementation + repeat DEXA scan in 6 months
Vitamin D + calcium supplementation
Vitamin D + calcium supplementation + hormone replacement therapy
Vitamin D + calcium supplementation + oral bisphosphonate

This patient has been taking 10mg of prednisolone for the past 5 months and hence should be assessed
for bone protection. The T score of less than -1.5 SD is an indication for a bisphosphonate. This should
be co-prescribed with calcium + vitamin D.

Discuss and give feedback

Osteoporosis: glucocorticoid-induced

External links

Clinical Knowledge Summaries

Osteoporosis guidelines
Question 116 of 134

A 66-year-old female presents with pain at the base of her left thumb. She has no past medical history
of note. On examination there is diffuse tenderness and swelling of her left first carpometacarpal joint.
What is the most likely diagnosis?

Osteoarthritis
De Quervain's tenosynovitis
Gout
Rheumatoid arthritis
Primary hyperparathyroidism
Question 116 of 134

A 66-year-old female presents with pain at the base of her left thumb. She has no past medical history
of note. On examination there is diffuse tenderness and swelling of her left first carpometacarpal joint.
What is the most likely diagnosis?

Osteoarthritis
De Quervain's tenosynovitis
Gout
Rheumatoid arthritis
Primary hyperparathyroidism

The trapeziometacarpal joint (base of thumb) is the most common site of hand osteoarthritis.

Discuss and give feedback

Osteoarthritis: management

External links

NICE

2014 osteoarthritis guidelines

Question 117 of 134

A 66-year-old female is on long-term prednisolone therapy for polymyalgia rheumatica. What is

the most appropriate protection against osteoporosis?

Hormone replacement therapy

Calcitonin
Oral bisphosphonate
Calcium and vitamin D
Hip-protectors
Question 117 of 134

A 66-year-old female is on long-term prednisolone therapy for polymyalgia rheumatica. What is the
most appropriate protection against osteoporosis?

Hormone replacement therapy

Calcitonin
Oral bisphosphonate
Calcium and vitamin D
Hip-protectors

Oral bisphosphonate therapy is recommended for patients older than 65 years who have taken, or who
are likely to remain on oral corticosteroids for more than 3 months

Discuss and give feedback

Bisphosphonates

External links

BNF

Bisphosphonates

Clinical Knowledge Summaries

Osteoporosis - prevention of fragility fractures

Question 118 of 134

Which one of the following is most likely to indicate an underlying connective tissue disorder in
a patient with Raynaud's phenomenon?

Chilblains
Bilateral symptoms
Female patient
Onset at 18 years old
Recurrent miscarriages
Question 118 of 134

Which one of the following is most likely to indicate an underlying connective tissue disorder in
a patient with Raynaud's phenomenon?

Chilblains
Bilateral symptoms
Female patient
Onset at 18 years old
Recurrent miscarriages

Raynaud's disease (i.e. primary) presents in young women with bilateral symptoms

A history of recurrent miscarriages could indicate systemic lupus erythematous or anti-phospholipid

syndrome. Chilblains (pernio) are itchy, painful purple swellings which occur on the fingers and toes
after exposure to the cold. They are occasionally associated with underlying connective tissue disease
but this is rare

Discuss and give feedback

Raynaud's

External links

Arthritis Research Council (ARC)

ARC Raynaud's Patient Info

Question 119 of 134

A 33-year-old female is admitted to the Emergency Department due to right-sided weakness. She has a
past history of deep vein thrombosis following the birth of her daughter. The only other past history of
note is two miscarriages. A CT head confirms an ischaemic stroke in the left middle cerebral artery
territory. What is the likely finding on echocardiography?

Normal
Dilated cardiomyopathy
Bicuspid aortic valve
Atrial septal defect
Ventricular septal defect
Question 119 of 134

A 33-year-old female is admitted to the Emergency Department due to right-sided weakness. She has a
past history of deep vein thrombosis following the birth of her daughter. The only other past history of
note is two miscarriages. A CT head confirms an ischaemic stroke in the left middle cerebral artery
territory. What is the likely finding on echocardiography?

Normal
Dilated cardiomyopathy
Bicuspid aortic valve
Atrial septal defect
Ventricular septal defect

This is a typical MRCP question. On first sight this question appears to be pointing towards a
paradoxical embolus. However, given the history of miscarriages and DVT a diagnosis of
antiphospholipid syndrome is more likely.

Discuss and give feedback

Antiphospholipid syndrome

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous

and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder
or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)

A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in
the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with
phospholipids involved in the coagulation cascade

Features

recurrent fetal loss

livedo reticularis

thrombocytopenia

prolonged APTT

other features: pre-eclampsia, pulmonary hypertension

 Associations other than SLE:

lymphoproliferative disorders

phenothiazines (rare)

Management - based on BCSH guidelines

initial venous thromboembolic events: evidence currently supports use of warfarin with a target
INR of 2-3 for 6 months

recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin
then increase target INR to 3-4

arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

External links

British Society of Hematology

Antiphospholipid syndrome guidelines

DermIS

Pictures of livedo reticularis

Question 120 of 134

A 35-year-old woman who has severe Raynaud's disease is reviewed in clinic. Three months ago she
was started on nifedipine. Unfortunately this has had a minimal effect on her symptoms and has
resulted in ankle oedema. What is the most appropriate next step in management?

Aspirin
Sympathectomy
Intravenous prostacyclin
Methotrexate
Intravenous infliximab
Question 120 of 134

A 35-year-old woman who has severe Raynaud's disease is reviewed in clinic. Three months ago she
was started on nifedipine. Unfortunately this has had a minimal effect on her symptoms and has
resulted in ankle oedema. What is the most appropriate next step in management?

Aspirin
Sympathectomy
Intravenous prostacyclin
Methotrexate
Intravenous infliximab

Discuss and give feedback

Raynaud's

External links

Arthritis Research Council (ARC)

ARC Raynaud's Patient Info

Question 121 of 134

A 63-year-old man presents to the Emergency Department with a 2 day history of a painful and
swollen left knee joint. Aspiration reveals positively birefringent crystals and no organisms are seen.
Which of the following conditions are not recognised causes of the underlying condition?

Haemochromatosis
Low magnesium
High phosphate
Acromegaly
Hyperparathyroidism
Question 121 of 134

A 63-year-old man presents to the Emergency Department with a 2 day history of a painful and
swollen left knee joint. Aspiration reveals positively birefringent crystals and no organisms are seen.
Which of the following conditions are not recognised causes of the underlying condition?

Haemochromatosis
Low magnesium
High phosphate
Acromegaly
Hyperparathyroidism

Discuss and give feedback

Pseudogout

External links

RCP Clinical Medicine

Crystal arthritis: contemporary approaches to diseases of antiquity

Question 122 of 134

A 23-year-old female presents with a painful ankle following an inversion injury whilst playing tennis.
Which one of the following findings is least relevant when deciding whether an x-ray is needed?

Swelling immediately after the injury and now

Pain in the malleolar zone
Tenderness at the medial malleolar zone
Tenderness at the lateral malleolar zone
Cannot walk 4 steps immediately after the injury and now
Question 122 of 134

A 23-year-old female presents with a painful ankle following an inversion injury whilst playing tennis.
Which one of the following findings is least relevant when deciding whether an x-ray is needed?

Swelling immediately after the injury and now

Pain in the malleolar zone
Tenderness at the medial malleolar zone
Tenderness at the lateral malleolar zone
Cannot walk 4 steps immediately after the injury and now

Discuss and give feedback

Ankle injury: Ottawa rules

External links

MDCalc

Ottawa rules
Question 123 of 134

A 28-year-old man is diagnosed with having ankylosing spondylitis. He presented with a six month
history of back pain. On examination there is reduced lateral flexion of the spine but no evidence of
any other complications. Which one of the following is he most likely to offered as first-line
treatment?

Exercise regime + NSAIDs

Exercise regime + infliximab
Physiotherapy + sulfasalazine
Physiotherapy + etanercept
Exercise regime + paracetamol
Question 123 of 134

A 28-year-old man is diagnosed with having ankylosing spondylitis. He presented with a six month
history of back pain. On examination there is reduced lateral flexion of the spine but no evidence of
any other complications. Which one of the following is he most likely to offered as first-line
treatment?

Exercise regime + NSAIDs

Exercise regime + infliximab
Physiotherapy + sulfasalazine
Physiotherapy + etanercept
Exercise regime + paracetamol

The anti-TNF drugs are currently only used for patients with severe ankylosing spondylitis which has
failed to respond to NSAIDs.

Discuss and give feedback

Ankylosing spondylitis: investigation and management

External links

NICE

2016 TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis

European League Against Rheumatism (EULAR)

2010 Ankylosing spondylitis guidelines

Question 124 of 134

Which one of the following is most consistently associated with a poor prognosis in rheumatoid
arthritis?

Anti-CCP antibodies
HLA DR2 allele
Rapid onset
Being a smoker
Female sex
Question 124 of 134

Which one of the following is most consistently associated with a poor prognosis in rheumatoid
arthritis?

Anti-CCP antibodies
HLA DR2 allele
Rapid onset
Being a smoker
Female sex

See below for further information on the effect of gender on prognosis.

Discuss and give feedback

Rheumatoid arthritis: prognostic features

External links

NICE

2009 Rheumatoid guidelines

Question 125 of 134

You review a 40-year-old mechanic who presents with joint pains. For the past two months he has
noticed intermittent pain, stiffness and swelling of the joints in his hands and feet. The stiffness tends
to improve during the day but the pain tends to get worse. He has also noticed stiffness in his back but
cannot remember any aggravating injury. You order some blood tests (taken during an acute attack)
which are reported as follows:

Rheumatoid factor Negative

Anti-cyclic citrullinated peptide antibody Positive
Uric acid 0.3 mmol/l (0.18 - 0.48)
ESR 41 mm/hr

What is the most likely diagnosis?

Reactive arthritis
Ankylosing spondylitis
Gout
Osteoarthritis
Rheumatoid arthritis
Question 125 of 134

You review a 40-year-old mechanic who presents with joint pains. For the past two months he has
noticed intermittent pain, stiffness and swelling of the joints in his hands and feet. The stiffness tends
to improve during the day but the pain tends to get worse. He has also noticed stiffness in his back but
cannot remember any aggravating injury. You order some blood tests (taken during an acute attack)
which are reported as follows:

Rheumatoid factor Negative

Anti-cyclic citrullinated peptide antibody Positive
Uric acid 0.3 mmol/l (0.18 - 0.48)
ESR 41 mm/hr

What is the most likely diagnosis?

Reactive arthritis
Ankylosing spondylitis
Gout
Osteoarthritis
Rheumatoid arthritis

-cyclic citrullinated peptide antibodies are associated with rheumatoid arthritis

-cyclic citrullinated peptide antibody is highly specific for rheumatoid arthritis.

Discuss and give feedback

Rheumatoid arthritis: antibodies

Question 126 of 134

A 30-year-old female who is known to have antiphospholipid syndrome is diagnosed as having a deep
vein thrombosis. This is her first thrombotic event. How should her anticoagulation be managed?

Life-long low-dose aspirin

6 months warfarin, target INR 2 - 3
Life-long warfarin, target INR 3 - 4
Life-long warfarin, target INR 2 - 3
6 months warfarin, target INR 2 - 3 followed by life-long low-dose aspirin and clopidogrel
Question 126 of 134

A 30-year-old female who is known to have antiphospholipid syndrome is diagnosed as having a deep
vein thrombosis. This is her first thrombotic event. How should her anticoagulation be managed?

Life-long low-dose aspirin

6 months warfarin, target INR 2 - 3
Life-long warfarin, target INR 3 - 4
Life-long warfarin, target INR 2 - 3
6 months warfarin, target INR 2 - 3 followed by life-long low-dose aspirin and clopidogrel

This is a tough question and some textbooks may contradict this answer, suggesting either lifelong
warfarin or a target INR of 3-4. Please see the link to the BCSH guidelines. There is also a recent
review in JAMA 2006; 295(9): 1050-7

Discuss and give feedback

Antiphospholipid syndrome

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous

and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder
or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)

A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in
the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with
phospholipids involved in the coagulation cascade

Features

venous/arterial thrombosis

recurrent fetal loss

livedo reticularis

thrombocytopenia

prolonged APTT

other features: pre-eclampsia, pulmonary hypertension

Associations other than SLE:

other autoimmune disorders

lymphoproliferative disorders

phenothiazines (rare)

Management based on BCSH guidelines:

initial venous thromboembolic events: evidence currently supports use of warfarin with a target
INR of 2-3 for 6 months

recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin
then increase target INR to 3-4

arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

External links

British Society of Haematology

Antiphospholipid syndrome guidelines

DermIS

Pictures of livedo reticularis

Question 127 of 134

A 20-year-old woman is reviewed in the rheumatology clinic. She has been referred due to a three
month history of arthralgia, lethargy, muscle pains and Raynaud's phenomenon. On examination she is
noted to have slightly swollen hands but no significant synovitis. A number of blood tests are ordered:

Hb 12.9 g/dl
Platelets 282 * 109/l
WBC 6.2 * 109/l

Rheumatoid factor Negative

ANA Positive
Anti-dsDNA antibodies Negative
CRP 25 mg/l
ESR 39 mm/hr
Creatine kinase 675 ng/mL (50-200)

Given the likely diagnosis, which other antibodies are most likely to be present?

Anti-Scl-70
Anti-centromere
Anti-Jo
Anti-RO
Anti-RNP
Question 127 of 134

A 20-year-old woman is reviewed in the rheumatology clinic. She has been referred due to a three
month history of arthralgia, lethargy, muscle pains and Raynaud's phenomenon. On examination she is
noted to have slightly swollen hands but no significant synovitis. A number of blood tests are ordered:

Hb 12.9 g/dl
Platelets 282 * 109/l
WBC 6.2 * 109/l

Rheumatoid factor Negative

ANA Positive
Anti-dsDNA antibodies Negative
CRP 25 mg/l
ESR 39 mm/hr
Creatine kinase 675 ng/mL (50-200)

Given the likely diagnosis, which other antibodies are most likely to be present?

Anti-Scl-70
Anti-centromere
Anti-Jo
Anti-RO
Anti-RNP

Anti-ribonuclear protein (anti-RNP) = mixed connective tissue disease

This patient has typical features of mixed connective tissue disease (e.g. arthralgia, myositis and
Raynaud's). To confirm the diagnosis anti-RNP antibodies need to be detected.

Discuss and give feedback

Mixed connective tissue disease

Question 128 of 134

A 62-year-old man with lung cancer is suspected of having dermatomyositis. Which one of the
following antibodies is most likely to be positive?

Anti-nuclear antibodies
Anti-centromere bodies
Anti-scl-70 antibodies
Anti-Jo-1 antibodies
Anti-Mi-2 antibodies
Question 128 of 134

A 62-year-old man with lung cancer is suspected of having dermatomyositis. Which one of the
following antibodies is most likely to be positive?

Anti-nuclear antibodies
Anti-centromere bodies
Anti-scl-70 antibodies
Anti-Jo-1 antibodies
Anti-Mi-2 antibodies

Dermatomyositis antibodies: ANA most common, anti-Mi-2 most specific

Discuss and give feedback

Dermatomyositis: investigations and management

Question 129 of 134

A 50-year-old woman complains of pain in her right elbow. This has been present for the past four
weeks and is maximal around 4-5cm distal from the lateral aspect of the elbow joint. The pain is made
worse by extending the elbow and pronating the forearm. What is the most likely diagnosis?

Lateral epicondylitis
Radial tunnel syndrome
De Quervain's tenosynovitis
Cubital tunnel syndrome
Medial epicondylitis
Question 129 of 134

A 50-year-old woman complains of pain in her right elbow. This has been present for the past four
weeks and is maximal around 4-5cm distal from the lateral aspect of the elbow joint. The pain is made
worse by extending the elbow and pronating the forearm. What is the most likely diagnosis?

Lateral epicondylitis
Radial tunnel syndrome
De Quervain's tenosynovitis
Cubital tunnel syndrome
Medial epicondylitis

Discuss and give feedback

Elbow pain
Question 130 of 134

Which one of the following antibodies is most specific for systemic lupus erythematous?

Anti-neutrophil cytoplasmic antibodies

Anti-nuclear antibodies
Anti-Sm antibodies
Anti-RNP antibodies
Anti-cardiolipin antibodies
Question 130 of 134

Which one of the following antibodies is most specific for systemic lupus erythematous?

Anti-neutrophil cytoplasmic antibodies

Anti-nuclear antibodies
Anti-Sm antibodies
Anti-RNP antibodies
Anti-cardiolipin antibodies

SLE: ANA is 99% sensitive - anti-Sm & anti-dsDNA are 99% specific

Discuss and give feedback

SLE: investigations
Question 131 of 134

Which one of the following is most recognised as a potential complication in a patient with
ankylosing spondylitis?

Heart block
Aortic stenosis
Achalasia
Diabetes mellitus
Bronchiectasis
Question 131 of 134

Which one of the following is most recognised as a potential complication in a patient with
ankylosing spondylitis?

Heart block
Aortic stenosis
Achalasia
Diabetes mellitus
Bronchiectasis

Ankylosing spondylitis features - the 'A's

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis

Discuss and give feedback

Ankylosing spondylitis: features

External links
Arthritis Reasearch Council
Ankylosing Spondylitis Patient Info
Question 132 of 134

A 58-year-old woman with a history of left hip osteoarthritis presents for review. She is currently
taking co-codamol 30/500 for pain on a regular basis but this is unfortunately not controlling her
symptoms. There is no past medical history of note, in particular no asthma or gastrointestinal
problems. What is the most suitable next step in management?

Switch to regular oral tramadol

Add topical ibuprofen
Add oral diclofenac + proton pump inhibitor
Add oral etoricoxib
Add oral diclofenac
Question 132 of 134

A 58-year-old woman with a history of left hip osteoarthritis presents for review. She is currently
taking co-codamol 30/500 for pain on a regular basis but this is unfortunately not controlling her
symptoms. There is no past medical history of note, in particular no asthma or gastrointestinal
problems. What is the most suitable next step in management?

Switch to regular oral tramadol

Add topical ibuprofen
Add oral diclofenac + proton pump inhibitor
Add oral etoricoxib
Add oral diclofenac

NICE recommend co-prescribing a PPI with NSAIDs in all patients with osteoarthritis

Topical NSAIDs are only indicated for osteoarthritis of the knee or hand.

Discuss and give feedback

Osteoarthritis: management

External links

NICE

2014 osteoarthritis guidelines

Question 133 of 134

Which one of the following is least associated with the development of gout?

Psoriasis
Lesch-Nyhan syndrome
Lymphoma
Lithium toxicity
Renal failure
Question 133 of 134

Which one of the following is least associated with the development of gout?

Psoriasis
Lesch-Nyhan syndrome
Lymphoma
Lithium toxicity
Renal failure

Discuss and give feedback

Gout: predisposing factors

External links

RCP Clinical Medicine

Crystal arthritis: contemporary approaches to diseases of antiquity

Question 134 of 134

A 44-year-old woman is seen in the rheumatology clinic. She has been referred with Raynaud's
phenomenon. During the review of systems she mentions that her GP is organising an endoscopy to
investigate dyspepsia. On examination she is noted to have tight, shiny skin over her fingers. Which
one of the following complications is she most likely to develop?

Bronchiectasis
Angiodysplasia
Arterial hypertension
Chronic kidney disease
Pulmonary hypertension
Question 134 of 134

A 44-year-old woman is seen in the rheumatology clinic. She has been referred with Raynaud's
phenomenon. During the review of systems she mentions that her GP is organising an endoscopy to
investigate dyspepsia. On examination she is noted to have tight, shiny skin over her fingers. Which
one of the following complications is she most likely to develop?

Bronchiectasis
Angiodysplasia
Arterial hypertension
Chronic kidney disease
Pulmonary hypertension

This patient is likely to have CREST syndrome. Unfortunately pulmonary hypertension is one of the
more common late complications seen in such patients.

Discuss and give feedback

Systemic sclerosis