RHEUMATOLOGY  Questions  1   2     

A 50 year old woman presents with dry eyes, a dry mouth, an erythematous rash and polyarthralgia. Investigations: ANA strongly positive (1:1600), anti-Ro/SSA antibodies strongly positive, rheumatoid factor positive, IgG markedly elevated at 45 g/l (normal - <15 g/l), IgM and IgA levels are normal and the kappa/lambda ratio is normal. What is the most likely diagnosis?

  1. Hyperviscosity syndrome

  2. Myeloma associated vasculitis

  3. Primary Sjogren's Syndrome

  4. Rheumatoid arthritis with secondary Sjogren's Syndrome

  5. Systemic Lupus Erythematosus


A 72 year old man presents with an acutely painful right knee. On examination, he had a temperature of 37°C with a hot, swollen right knee. Of releavance amongst his investigations, was his white cell count which was 12.6 x109/l and a knee X-ray revealed reduced joint space and calcification of the articular cartilage. Culture of aspirated fluid revealed no growth. What is the most likely diagnosis?

  1. gout

  2. psoriatic monoarthropathy

  3. pseudogout

  4. rheumatoid arthiritis

  5. septic arthritis



Which of the following is a pro-inflammatory cytokine?

  1. C-reactive protein

  2. IL-4

  3. IL-10

  4. Serum amyloid precursor protein

  5. tumour Necrosis factor - alpha


A 40 year old man presents with acute monoarthritis of the right knee. Gout is confirmed following joint aspiration and examination of the fluid under polarised light microscopy. He underwent endoscopy 3 weeks earlier because of dyspepsia and this confirmed a duodenal ulcer. Which of the following would be the best initial treatment for him?

  1. allopurinol

  2. indomethacin alone

  3. indomethacin and lansoprazole

  4. indomethacin and misoprostol

  5. intraarticular corticosteroid injection


A 45 year old male attends for an insurance medical and is in good health. Examination was normal but investigations reveal that he has a serum urate concentration of 0.55 mmol/l (NR 0.25-0.45). Which of the following is the most appropriate management for this patient?

  1. lifestyle advice

  2. start allopurinol

  3. start colchicine

  4. start diclofenac

  5. start prednisolone


A 25-year-old student presents to casualty with a systemic illness. She appears unwell, with a swinging fever, 3kg weight loss over 2 months, generalised myalgia, polyarthralgia affecting wrists, knees, ankles, elbows and metacarpophalangeal joints, and a sore throat. Investigations demonstrate normochromic normocytic anaemia 9.8g/l, ESR 81 mm in the first hour, CRP 31g/l, serum ferritin 1756mg/dl, RF negative, ANA negative, ENA negative, ASO titre <200iu. What is the most likely diagnosis?

  1. seronegative rheumatoid arthritis

  2. adult onset Still's disease

  3. systemic lupus erythematosus

  4. polymyositis

  5. rheumatic fever


A 70-year-old retired sea captain develops weakness of the shoulders and hips over a 4 month period. He has also noticed weak finger flexors with normal strength in straightening them. He has had some difficulty swallowing liquids. There is no past medical history, apart from a sexually transmitted disease picked up in the South Pacific some forty years before. This was treated with antibiotics and he is not sure of the diagnosis. He smokes a pipe and drinks 1 or 2 tots of rum at the weekend. A creatinine kinase level comes back at 120. Which investigation is most likely to give a definite diagnosis?

  1. Anti Jo 1 antibody titres

  2. CT scan of the chest

  3. EMG

  4. Muscle biopsy with electron microscopy

  5. 24 hour urine collection for myoglobin


A 70-year-old man from Lancashire has noted increasing back and leg pain for several years. X-rays reveal bony sclerosis of the sacroiliac, lower vertebral, and upper tibial regions with cortical thickening, but without mass effect or significant bony destruction.

He also says his hat does not fit him anymore. He has greater difficulty hearing on the left. He has orthopnea and pedal edema.

Blood tests reveal an elevated serum alkaline phosphatase.

The most likely pathologic process that explains these findings is?
  1. decreased bone mass

  2. metastatic adenocarcinoma

  3. Paget's disease of bone

  4. renal failure with renal osteodystrophy

  5. vitamin D deficiency


A 68-year-old woman complained of pain at the base of her right thumb. There was tenderness and swelling of the right first carpo-metacarpal joint.

What is the most likely diagnosis?

  1. avascular necrosis of the scaphoid

  2. de Quervain's tenosynovitis

  3. osteoarthritis

  4. psoriatic arthritis

  5. rheumatoid arthritis


A 75-year-old man has persistent back pain for several months that is unrelated to physical activity. He has lost 12 kg in weight during this time.

Laboratory findings include a White cell count of 6.7 x 109/L with a differential of 70 segs, 8 bands, 2 metamyelocytes, 15 lymphocytes, 5 monocytes, and 2 nucleated RBCs/100 WBCs. Haemoglobin is 11.2 g/dL, Haematocrit 33.3%, MCV 88 fL, and platelet count 89 x 109/L.

The Biochemistry shows a sodium concentration of 144 mmol/L, potassium 4.5 mmol/L, chloride 100 mmol/L, bicarbonate of 26 mmol/L, urea 14 mmol/L, creatinine 90 µmol/L, and a glucose of 5.4 mmol/L.

A CT scan of the spine reveals scattered 0.4 to 1.2 cm bright lesions in the vertebral bodies.

Which of the following additional laboratory test findings is he most likely to have?
  1. Blood culture positive for Neisseria gonorrheae

  2. Parathyroid hormone, intact, of 100 pg/mL (normal < 65)

  3. Positive serology for Borrelia burgdorferi

  4. Serum calcium of 1.4 mmol/L

  5. Serum prostate specific antigen of 35 microgram/L


A 45-year-old woman notices that she develops tingling and numbness over the palmar surface of her thumb, index, and middle fingers after several hours at her computer workstation doing word processing. Pain in the same area often occurs at night as well.

Which of the following pathologic findings accounts for her symptoms?

  1. gout

  2. hyperthrophic osteoarthropathy

  3. localised tenosynovitis

  4. rheumatoid arthritis

  5. toxic peripheral neuropathy


A 70 year old man complains of pain and stiffness in both his shoulders. He has lost 1 stone in last 8 weeks and complains of feeling lethargic with loss of appetite. Investigations revealed a very high ESR (100 mm/hr), normochromic normocytic anaemia and a positive rheumatoid factor. The most likely diagnosis is:

  1. polyarteritis nodosa

  2. polymyalgia rheumatica

  3. polymyositis

  4. rheumatoid arthritis

  5. SLE


A 25 year old lady gives birth to a baby with complete heart block who subsequently requires pacemaker insertion. Which of the following antibodies is most likely to be detected in the maternal serum?

  1. Anti-dsDNA antibodies

  2. Anti-endomysial antibodies

  3. Anti-Ro/SSA antibodies

  4. Anti-SCL70 antibodies

  5. Rheumatoid factor


A female presents with headache, lethargy and weight loss. Which of the following would make the diagnosis of giant cell arteritis unlikely?

  1. A normal ESR

  2. Bilateral headache

  3. Non-tender temporal arteries

  4. Papilloedema on fundoscopy

  5. The patient is 50 years old


A study has been designed to investigate whether a certain drug plus physiotherapy treatment is better than drug treatment alone in the management of rheumatoid arthritis. After randomizing the patients a small proportion of the drug plus physiotherapy group decide to drop out of the study or omit some treatment sessions specified in the research protocol. What is the correct way of analysing the subsequent data?

  1. Assume the patients have withdrawn their consent

  2. Exclude these patients from all analysis

  3. Extend the trial recruitment to make up the numbers

  4. Include these patient outcomes in the drug plus physiotherapy group

  5. Interview the patients and report their group separately


A man in his 20's begins to note persistent lower back pain and stiffness that diminishes with activity. In his 30's he also develops hip and shoulder arthritis, and in his 40's he is bothered by decreased lumbar spine mobility. He has no other major medical problems.

These findings are most typical for which of the following?

  1. Ankylosing spondylitis

  2. Calcium pyrophosphate dihydrate deposition disease

  3. Lyme disease

  4. Osteoarthritis

  5. rheumatoid arthritis


A 40 year-old woman presents with a year history of Raynaud’s phenomenon, dyspepsia and arthralgias. On examination she has sclerodactyly and synovitis of the small joints of the hands. Her ESR is 40 mm/hr (<10) but Rheumatoid factor and Antinuclear Antibody are both negative.

Which one of the following is most likely to develop as a further complication of this disorder?

  1. anterior uveitis

  2. butterfly rash

  3. erosive joint disease

  4. erythema nodosum

  5. malabsorption


Which ONE of the following diagnoses is associated with acute Iritis?

  1. keratoconus

  2. Lyme disease

  3. osteogenesis imperfecta

  4. psoriatic arthritis

  5. Refsum's disease


Which of the following drugs is most likely to cause systemic lupus-like syndrome?

  1. baclofen

  2. isoniazid

  3. methotrexate

  4. procainamide

  5. sulphasalazine


Which one of the following drugs works by inhibiting the tumour necrosis factor?

  1. cyclosporin

  2. infliximab

  3. methotrexate

  4. montelukast

  5. sulphasalazine





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