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Mcqs in Rheumatology Inflammatory Arthritis Ms Word
Mcqs in Rheumatology Inflammatory Arthritis Ms Word
Inflammatory arthritis
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Question 1
A 70 year old man with rheumatoid arthritis is in pre-op clinic prior to an
elective total knee replacement in 6 weeks time. His current medication
includes Methotrexate and Etanercept. The orthopaedic FY2 doctor contacts
you for advice.
You should advise the FY2 doctor to
1.
2.
3.
4.
5.
Question 2
A 30 year old lady with rheumatoid arthritis attends follow up appointment 8
weeks after the birth of her first child. She stopped hydroxychloroquine 8
weeks ago, concerned about using it whilst breast feeding. She intends to
breast feed for four more months. She has a swollen right knee. There is no
history of trauma. 50 ml viscous, straw colored synovial fluid was drained, and
the knee was injected with 80 mg methylprednisolone.
Which of the following statements is the best management for her arthritis?
1. Avoid hydroxychloroquine while breast feeding
2. Avoid hydroxychloroquine when breast feeding, and start oral
corticosteroids
3. Restart hydroxychloroquine
4. Give oral NSAIDs
5. Start methotrexate
Question 3
A 45-year old woman presents with a 2 month history of joint pains and early
morning stiffness. She does not smoke and takes alcohol in moderation. On
examination, you find swelling and tenderness of both wrists, and of the index
and middle finger metacarpo-phalangeal joints bilaterally.
Investigations:
Hb 11.5 g/dL (low), MCV 80 fL, WCC 6.2 x10 9/L, urea 7 mmol/L, creatinine 92
mol/L,
ALT 25 iu/L, ANA negative, ANCA negative, rheumatoid factor
positive. Chest x-ray is normal.
Which of the following is the most appropriate initial management plan for this
patient?
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1.
2.
3.
Corticosteroids
Methotrexate and sulphasalazine
Methotrexate, sulphasalazine and
hydroxychloroquine
4.
Methotrexate, hydroxychloroquine and
corticosteroids
5.
Methotrexate and corticosteroids
Question 4
A 55 year old male smoker with active rheumatoid arthritis for 6 years, who
has failed combination therapy with methotrexate 25 mg weekly, sulfasalazine
1 gm BD, and hydroxychloroquine 200mg BD, was commenced on
Etanercept six months ago. While on etanercept (50 mg/week) and
methotrexate (7.5mg/week), he developed ST elevation anterior myocardial
infarction. He had thrombolytic therapy, and appropriate secondary preventive
measures. Since discharge, he is feeling well, but gets short of breath on
walking uphill. General physical examination reveals bilateral pedal oedema
(mild), and is otherwise unremarkable. A FBC, UEC, urine dipstick, and LFT
are normal.
Which of the following tests would you do next to decide whether to stop
etanercept treatment?
1.
2.
3.
4.
5.
Coronary angiogram
ECG
Echocardiogram
Stress echocardiogram
Thallium scan
Question 5
A 24 year old child minder with rheumatoid arthritis for three years is on
Methotrexate 20 mg weekly, and Leflunomide 10 mg OD. She was
commenced on 15 mg prednisolone OD 2 weeks ago for flare of RA. One of
the children she is looking after has developed chicken pox. She has not had
chicken pox in the past, and blood tests prior to starting methotrexate showed
that she did not have IgG antibodies to varicella.
Which of the following is the correct approach for her in this situation?
1.
2.
3.
4.
5.
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Question 6
A 36 year old female with a 5 year history of rheumatoid arthritis on
methotrexate 15mg/week attends for annual review. Her DAS 28 score is
1.95, and she has not had any articular symptoms in the last 12 months. She
must travel to mid-Africa for some important business, and has been advised
to take yellow fever vaccine for this. She is quite keen to take the vaccine, and
asks you what to do about the methotrexate.
How many months before the vaccination should she discontinue the
methotrexate?
1. 2 weeks
2. 1 month
3. 2 months
4. 3 months
5. 6 months
Question 7
A 67 year old male presents to the Rheumatology department with a 5 week
history of pain and swelling of the wrists and dorsum of the hands. He has
pronounced early morning stiffness. On examination he has swelling,
warmth, tenderness of MCPJs, PIPJs, and wrists. He has pitting oedema of
dorsum of both hands, and feet. Lab investigations reveal a CRP-82 mg/l,
ESR-100 mm/hr. He is ANA, rheumatoid factor, and anti-CCP negative. Urine
dipstick is unremarkable.
X ray hands showed narrowing of joint spaces in 5th proximal and distal
Interphalangeal joints, no erosive changes.
Which of the following is the best initial treatment option for him?
1.
2.
3.
4.
5.
Question 8
A 22 year old fit and well man presents to his GP with a 2 day history of left
ankle pain and swelling. He has no history of trauma and is generally well in
himself. He had diarrhoea for 2 days while on holiday in Egypt 3 weeks ago.
On examination T - 37.2 oC, HR-86/min regular, BP -126/82 mm Hg. General
and systemic examination was unremarkable. Musculoskeletal examination
reveals a tender, swollen left ankle.
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Question 9
A 25 year old woman presents to the medical admissions unit with a 2 week
history of swollen ankles, and a rash on her legs. On examination she has
bilateral ankle effusions and erythematous tender nodules on her shins.
Which investigation is most useful to aid your diagnosis?
1.
2.
3.
4.
5.
Borrelia serology
C reactive protein
Chest radiograph
Rheumatoid factor
Serum ACE level
Question 10
A 63 year old woman with rheumatoid arthritis is seen for review after
commencing leflunomide 20mg od, 6 weeks ago. She previously discontinued
Methotrexate and Sulfasalazine due to side effects. For the past 10 days she
had noticed an increasingly itchy rash appearing over her trunk and limbs. On
examination she had discrete blanching erythematous papules over her
abdomen and limbs.
What is the most appropriate next step in management?
1.
2.
3.
4.
5.
Stop leflunomide
Stop leflunomide, prescribe cholestyramine 8mg tds
Stop leflunomide, prescribe cholestyramine 8g tds
Stop leflunomide, prescribe cetirizine 10mg od
Stop leflunomide, prescribe prednisolone 10mg od
Question 11
A 30 year old man returned from a six week holiday in Thailand. He presented
with dysuria, conjunctivitis and painful swollen joints. His general practitioner
performed the following blood tests
Rheumatoid factor- Negative
ANA- Negative
CRP 35 mg/L
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ESR 60 mm/hr
In view of the likely diagnosis, which of the following features will you
specifically look for?
1.
2.
3.
4.
5.
Circinate balanitis
Calcinosis
Dermographism
Heliotrope rash
Pathergy
Question 12
A thirty-sixty year old man presents with seronegative inflammatory arthritis
(anti-CCP, and rheumatoid factor negative) predominantly affecting the knees,
and the DIPJs. There is no past or family history of psoriasis.
Which of the following is true about psoriatic arthritis?
1. Site of psoriasis involvement increases the risk of psoriatic arthritis
2. Nail pitting, and onycholysis do not associate with arthritis
3. Over 60% psoriasis patients develop inflammatory arthritis
4. Psoriatic arthritis may precede skin involvement in 15-30% cases
5. Severity of skin involvement increases the risk of psoriatic arthritis
Question 13
A 36 year old man is seen in A& E with a swollen right ankle for three weeks.
He denies any trauma. He has bloody diarrhoea with abdominal pain for past
two months. On examination he has right ankle synovitis, is able to weight
bear, and move the joint with little difficulty. Sigmoidoscopic biopsy confirms a
diagnosis of ulcerative colitis.
Which one of the following is incorrect regarding ulcerative colitis associated
arthropathy?
1.
2.
3.
4.
5.
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Answers
Q1.
4. Stop Etanercept 10 days before surgery, continue
methotrexate
Although the BSR guidelines suggest that the decision to treat with anti-TNF
agents in the peri-operative period should be balanced between the risk of
infection, and disease flare, most clinicians would be comfortable with
suggesting that anti-TNF agents be withdrawn 3-5 half lives before the
operative procedure.
Q2.
3. Restart hydroxychloroquine
Steroids are quick acting and are appropriate initial management for RA.
However, other disease-modifying agents take longer to have an effect. NICE
guidelines (CG79 February 2009) recommends combination DMARDs plus
short course corticosteroid. Hence amongst the options available, oral
glucocorticoids, methotrexate and hydroxychloroquine is the most appropriate
choice.
Q4.
3. Echocardiogram
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4. 3 months
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Q8.
2. Klebsiella pneumonia
3.Chest radiograph
This is a drug reaction to leflunomide. Due to the long half life, leflunomide
requires a washout with cholestyramine. The dose is 8g tds for 11 days.
Q11.
1. Circinate balanitis
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Ulcerative colitis (UC) predominantly affects the colon and rectum. Arthritis is
the commonest extra intestinal feature. Other extra-intestinal features are
erythema nodosum, pyoderma gangrenosum, episcleritis, iritis, sclerosing
cholangitis and thrombosis. pANCA is positive in 60% and does not correlate
with disease activity. Anti-saccharomyces cerevisiae mannan antibodies are
negative in ulcerative colitis.
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