MRCP Part Rheumatology Best of five Dr Hakim Assalahi 2014 MRCP Part Rheumatology Best of five By Dr Hakim Assalahi MRCP Part Rheumatology Best of five EDITED BY Dr Hakim Assalahi 1st Edition 2014 https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi Copyright © 2014 Contrary to Copyright Act of 1976, any part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the permission of the publisher.) This is what we learned in our religion that does not have a monopoly of science.( For more updated information and effective participation, you can join the group here: https://www.facebook.com/groups/628388877218259/ Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi PREFACE This is the first edition of MRCP Part Rheumatology best of five that I have had the honor of working on MRCP Part Rheumatology best of five is a part of a huge work include all sections of internal medicine Endocrinology, Gastroenterology, Cardiology, Infectious Diseases and GUM, Respiratory medicine, Rheumatology, Dermatology, Nephrology, Psychiatry, Ophthalmology, Neurology, Clinical hematology, Clinical Pharmacology, Therapeutics and Toxicology and oncology, Geriatric medicine and Clinical sciences witch include Cell, molecular and membrane biology, Clinical anatomy, Clinical biochemistry and metabolism, Clinical physiology, Genetics, Statistics, epidemiology and evidence-based medicine and Immunology The care of patients is a privilege As physicians, we owe it to our patients to be intelligent, contemporary, and curious Continuing education takes many forms; many of us enjoy the intellectual stimulation and active learning challenge of the question-answer format It is in that spirit that I offer the 1st edition of the MRCP Part Rheumatology best of five to students, house staff, and practitioners I hope that from it you will learn, read, investigate, and question The questions and answers are particularly conducive to collaboration and discussion with colleagues This edition contains over 183 questions that, whenever possible, utilize realistic patient scenarios including radiographic or pathologic images Similarly, the answers attempt to explain the correct or best choice “We are here to add what we can to life, not to get what we can from life.” We hope this addition to your life stimulates your mind, challenges your thinking, and translates to your patients I would like to thank all my friends and members of my group that participate effectively in producing this work It is truly inspirational to remind ourselves why we love medicine broadly, and internal medicine specifically Of course, none of this would be possible without the loving support of our families, for which we are truly thankful They were patient and encouraging, as we transformed (often not quietly) a mountain of page proofs into this book https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi Rheumatology A 65 year old woman is recovering in hospital following a knee replacement She is known to have a history of alcohol excess and has had previously a duodenal ulcer for which she is on omeprazole What would you prescribe for prophylaxsis for a DVT while she is post op.? A B C D E Warfarin Subcutaneous low molecular weight heparin IV Heparin Nil due to risk of bleeding Aspirin LMWH should be used for all prophylaxsis of DVTs due to its efficacy, ease of administration and it does not require monitoring unlike IV heparin Although it can not be as easily reversed as heparin Rheumatology A 64 year old gentleman who is known to drink alcohol excessively presents with a red, hot swollen ankle What investigation should be performed for a definitive diagnosis? A B C D E Ankle X-ray Joint aspiration and culture Joint aspiration and microscopy Blood culture Urate levels The most likely diagnosis here is gout due to the history and known alcohol excess Joint aspiration and microscopy may show negatively birefringent crystal which are needle-shaped Serum urate levels are useful however they can be low in acute attacks of gout https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi Rheumatology An 80 year old male presents with a painful hip and knee He is known to have a peptic ulcer and is on omeprazole He has limited internal rotation of the hip What analgesia you prescribe initially? A B C D E Regular paracetamol NSAIDs Mild opiates Knee replacement Cortisol injection This gentleman is most likely to be suffering from osteoarthritis Paracetamol should be used in this case according to the analgesic ladder NSAIDs are not appropriate in this case due to the peptic ulcer disease Rheumatology An 19 year old male presents with back pain and morning stiffness It is relieved with exercise An X-ray was performed of his lumbar spine and showed obliteration of the sacroiliac junction What treatment is the most appropriate? A B C D E NSAIDs Bedrest Cortisol injection Opiates Paracetamol The most likely diagnsois is ankylosing spondylitis NSAIDs and regular physiotherapy are the most useful in the management od this patient Bed rest and cotisol injections are not useful https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi Rheumatology A 68 year old female has had pain in her left knee for numerous years She is now waking up in the middle of the night with the pain and her knee is giving way and she has fallen several times The knee is unstable on examination There is evidence of Herberdens and Bouchards nodes on the hands How would you manage this patient? A B C D E Referral for joint replacement Paracetamol NSAIDs Physiotherapy Cortisol injection This patient clearly has severe osteoarthritis of the knee with significant symptoms and instability A knee replacement is thus indicated Rheumatology A year old girl is complaining of pain in her thigh and hip On examination she is tender on palpation of the thigh Her bloods show elevated inflammatory markers An ultrasound and x-ray of the hip and femur is normal What is the most likely diagnosis? A B C D E Perthes disease Osteomyelitis Hip fracture Septic arthritis Bone Tumour The most likely is osteomyelitis as the pain is in the thigh It is unlikely to be a fracture or bone tumour due to the normal x-ray However osteomyelitis does not show up on the x-ray initially and then later it can show haziness and loss of density of the bone, then followed by subperiosteal reaction and sequestrum Septic arthritis is unlikely as the joint is normal Perthes disease is osteochondritis of the epiphysis of the femoral head and there would normally be x-ray findings with the earliest being https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi widening of the joint space, followed by loss of the nuclear femoral head with patchy density It does not cause raised inflammatory markers Rheumatology A 13 year old boy is complaining of left hip pain On examination, internal rotation of the hip is very limited What is the most likely diagnosis? A B C D E Perthes disease Ewings Sarcoma Slipped upper femoral epiphysis Non-Accidental Injury Juvenile Idiopathic Arthritis Slipped upper femoral epiphysis is the most likely diagnosis It normally affects children between 10 and 16 It is associated with obesity and hypogonadism There is limited internal rotation and adduction of the hip Perthes disease is osteochondritis of the femoral head and typically affects a younger age group those between and 11 On examination unlike SUFE there is limited movement in all directions The history and clinical findings are not indicative of the other diagnoses Rheumatology A year old girl is generally unwell and pyrexial She is also unable to weight bear due to hip pain Her inflammatory markers are markedly raised An X-ray shows a widened joint space What is the most likely diagnosis? A B C D E Non-accidental injury Septic arthritis Perthes disease Slipped upper femoral epiphysis Osteomyelitis https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi The most likely diagnosis here is septic arthritis due to the history and raised inflammatory markers An early feature on x-ray is a widened joint space Osteomyelitis is less likely due to the pain being in the joint, the sudden onset and how unwell the patient is The other diagnosis not cause the patient to be pyrexial or unwell Perthes disease is osteochondritis of the femoral head, affecting children aged between and 11 years It presents with pain in the hip or knee and causes a limp Rheumatology A year old boy is complaining of hip and groin pain On examination he walks with a limp and there is limited restriction of all movements of the joint An x-ray reveals flattening of the femoral head What is the most likely diagnosis? A B C D E Septic Arthritis Osteomyelitis Ewings Sarcoma Perthes disease Slipped upper femoral epiphysis Perthes disease is the most likely diagnosis due to the history, the restriction of all hip joint movements and the x-ray findings It begins with widened joint space and then reduced density and flattened femoral head and the further deformity The patient is too well for this to be a septic arthritis SUFE affects older children and predominantly internal rotation and adduction Rheumatology A 32 year old female presents with painful wrists and hands Her wrists and hands are very stiff in the morning and only loosen off after hours On examination there is active synovitis in both wrists and over several PIPs and MCPs What test is useful in aiding the diagnosis? A Rheumatoid Factor B X-ray if hands and wrists C Urate levels https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi D Anti dsDNA E Inflammatory markers The history is very indicative of Rheumatoid arthritis and Rheumatoid factor is positive in about three quarters of all patients X-rays are useful in monitoring for erosions as the disease progresses and in guiding therapy however is unlikely to show significant changes indicative of RA at this early stage Rheumatology A 55 year old female presents with knee pain She has problems for sometime with pain in her DIPs and the base of her thumb On examination there is pain on the medial aspect of the knee joint and there is evidence of Bouchard and Herberdens nodes She is tiff in the morning however the pain worsens in the evening and after movement She has a family history of osteoarthritis What investigation will give the definitive diagnosis? A B C D E Synovial membrane biopsy Rheumatoid Factor X-ray of knee Inflammatory markers X-ray of hands This woman most likely has nodal generalised osteoarthritis This is a subset which leads to multiple joint involvement of OA, which can be severe and sudden onset, predominantly the knee hips and hands with Bouchard and Heberdens nodes It is thought to be an autoimmune disease and a synovial membrane biopsy would show immune complex deposition Rheumatology A 45 year old woman with a 10 year history of Rheumatoid Arthritis develops suddenly a painful, hot, swollen, tender knee with very restricted movement How would you investigate? A Joint fluid aspiration for crystal examination B Joint fluid aspirate for microscopy and culture https://www.facebook.com/groups/628388877218259/ MRCP Part Rheumatology Best of five By Dr Hakim Assalahi D Type diabetes mellitus E Autonomic Neuropathy The most likely diagnosis is haemachromatosis with the history of liver dysfunction, diabetes, arthralgia and increased skin pigmentation The signs and symptoms are secondary to abnormal iron deposition in the organs Wilsons disease presents with liver dysfunction and neurological features SLE does not lead to increased pigmentation or Diabetes Mellitus Type diabetes mellitus and autonomic neuropathy would not account for all the features Rheumatology A 35 year old female presents with pyrexia, fatigue and joints pains affecting the wrists and hands She also has a facial malar rash-year-old woman She has an elevated ESR You suspect she has SLE What anti-nuclear antibody titre level would confirm a likely diagnosis of SLE? A B C D E 1:400 1:40 1:16 1:1600 1:4 A titre of 1:1600 would provide likely confirmation as in low titres can be seen in normal individuals of level of