MCQ's in Rheumatology

 Contributor:

Dr. Gary Meenagh
Rheumatology Reg.

January 2006

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(1)   A 37 year old female teacher presents with a 2 week history of small joint pain and stiffness in her hands and feet.

Which of the differential diagnoses listed is the least likely explanation for her symptoms?

(a) Rheumatoid arthritis
(b) Viral arthritis
(c) Fibromyalgia
(d) Connective tissue disease
(e) Psoriatic arthritis
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(2)   A 67 year old male presents with his first episode of knee pain and swelling together with the following x-ray.

Which of the following investigations is the next investigation indicated diagnostically?

(a) Thyroid function tests
(b) Serum urate
(c) Knee aspiration
(d) Serum iron
(e) Skeletal survey
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(3)   A patient with small airway involvement secondary to her rheumatoid disease attends clinic complaining of progressive shortness of breath.

The most clinically relevant parameter on standard pulmonary function testing is:

(a) High FEF25-75
(b) Reduction in DLCO
(c) Reduction in lung volumes
(d) Increased FEV1/FVC ratio
(e) None of the above
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(4)   The following pelvic x-ray displays radiographic features of which of the following rheumatic disorders?

(a) Rheumatoid arthritis
(b) Paget's disease
(c) Osteonecrosis
(d) Osteoarthritis
(e) None of the above
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(5)   Which of the following is not included in the American College of Rheumatology (ACR) diagnostic criteria for SLE?
(a) Thrombocytopenia
(b) Elevated ANA antibody titre
(c) Psychosis
(d) Alopecia
(e) Photosensitivity
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(6)   A disproportionate rise in CRP compared to the ESR is typically found in which of the following clinical situations?
(a) Polymyalgia rheumatica
(b) Sepsis in a patient with SLE
(c) Active vasculitis
(d) Cerebral lupus
(e) Psoriatic arthritis
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(7)   Which of the following types of joint involvement is not seen in psoriatic arthritis?
(a) Symmetrical small joint arthropathy
(b) Jaccoud's arthropathy
(c) Sacroiliitis
(d) Monoarthritis
(e) DIP joint arthropathy
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(8)   In septic arthritis which one of the following pairings is most commonly found in hospital practice?
(a) Ankle joint and Staph Aureus
(b) Knee joint and MRSA
(c) Wrist joint and Beta haemolytic streptococci
(d) Knee joint and Staph Aureus
(e) Hip joint and Staph Aureus
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(9)   Which of the following is not a recognised risk factor for osteoporosis?
(a) Early menarche
(b) Smoking
(c) Low dietary calcium intake
(d) Sedentary lifestyle
(e) Slender body habitus
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(10)   All of the following are rheumatic manifestations of malignancy with the exception of which one?
(a) Hypertrophic pulmonary osteoarthropathy (HPOA)
(b) Gout
(c) Degenerative joint change
(d) Dermatomyositis
(e) Cryoglobulinaemia
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Question
number		Answers are:
(1)(c) Fibromyalgia

Inflammatory arthropathies and connective tissue disease can all present in this fashion. In fibromyalgia whilst patients commonly describe 'joint swelling' often this is merely a sensation rather than apparent physical swelling.

(2)(c) Knee aspiration

The x-ray clearly shows chondrocalcinosis which is meniscal calcification. Whilst this condition can be linked with underlying pathology eg. thyroid disease, haemochromatosis etc., it is imperative to demonstrate the presence of calcium pyrophosphate crystals on plane polarising microscopy. These are classically rhomboid crystals (rather than needle-shaped as found in gout).

(3)(a) High FEF25-75

The earliest finding on pulmonary function testing in patients with small airways involvement in RA is elevation in FEF 25-75. Reduction in DLCO is seen in patients with pulmonary fibrosis which may be due to the condition itself or the treatment (eg. Methotrexate).

(4)(d) Osteoarthritis

The x-ray shows medial joint space narrowing, bony sclerosis and marginal osteophytosis - all classical features of osteoarthritis.

(5)(d) Alopecia

Whilst alopecia is a frequent symptom in SLE, it is strangely not included in the ACR criteria for the disease.

(6)(b) Sepsis in a patient with SLE

A disproportionately high CRP is indicative of sepsis. The ESR and CRP may not reflect the degree of disease activity in some clinical scenarios eg. Psoriatic arthritis and cerebral vasculitis. Often the CRP will rise and fall before the ESR as an inflammatory condition settles.

(7)(b) Jaccoud's arthropathy

Jaccoud's arthropathy is the eponymous name given to the non-erosive arthropathy seen in SLE - typically deforming but non-erosive, and involving the small joints of the hands.

(8)(d) Knee joint and Staph Aureus

The knee joint is the commonest joint to be involved in a septic episode and the most common organism is Staphylococcus.

(9)(a) Early menarche

Any condition which leads to a shortening of the exposure to oestrogens will increase risk of developing osteoporosis. A late onset of menarche will therefore be more relevant than an early one.

(10)(c) Degenerative joint change

Degenerative arthropathy is not linked with an underlying malignancy. Gout is common in patients with a lymphoproliferative state. Dermatomyosistis and cryoglobulinaemia can be associated with malignancy in a proportion of patients and should always be excluded when a patient presents with these diagnoses. HPOA is often diagnosed coincidentally when patients have a hand and wrist x-ray for an 'arthritic complaint'.

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