Multiple Choice Questions MCQ

Question 73# Print Question

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?

A. Immediately

B. If more than 6 episodes of gout in a 1 year period

C. If one further attack of gout in the next 12 months

D. 4 weeks after the initial attack of gout has settled

E. If more than 4 episodes of gout in a 1 year period

Question 71# 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?
A. Anti-scl-70 antibodies
B. Anti-Jo-1 antibodies
C. Anti-nuclear antibodies
D. Anti-Mi-2 antibodies
E. Anti-centromere bodies
Correct Answer D: Dermatomyositis antibodies: ANA most common, anti-Mi-2 most specific. Dermatomyositis: investigations and management: Investigations: Elevated creatine kinase EMG Muscle biopsy ANA positive in 60% Anti-Jo-1 antibodies are not commonly seen in dermatomyositis - they are more common in polymyositis where they are seen in a pattern of disease associated with lung involvement, Raynaud's and fever Anti-Mi-2 antibodies are highly specific for dermatomyositis, but are only seen in around 25% of patients Management: Prednisolone

Question 72# Which one of the following statements regarding ankylosing spondylitis is correct?
A. Schober's test assesses reduced chest expansion
B. HLA-B27 is positive in 50% of patients
C. Achilles tendonitis is a recognized association
D. It affects men twice as commonly as women
E. The typical age of presentation is between 40-50 years
Correct Answer C: HLA-B27 is positive in 90% of patients. Ankylosing spondylitis: features: Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 5:1) aged 20-30 years old. Features: Typically a young man who presents with lower back pain and stiffness of insidious onset Stiffness is usually worse in the morning and improves with exercise The patient may experience pain at night which improves on getting up Clinical examination: Reduced lateral flexion Reduced forward flexion - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible Reduced chest expansion Other features - the 'A's: Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis And cauda equina syndrome Peripheral arthritis (25%, more common if female)

Question 74# Which one of the following conditions has polygenic inheritance?
A. Bartter's syndrome
B. Huntington disease
C. Ankylosing spondylitis
D. Fragile X syndrome
E. Von Willebrand's disease
Correct Answer C: Ankylosing spondylitis: investigation and management: Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 5:1) aged 20-30 years old. Investigation: Inflammatory markers (ESR, CRP) are typically raised although normal levels do not exclude ankylosing spondylitis. HLA-B27 is of little use in making the diagnosis as it is positive in: 90% of patients with ankylosing spondylitis 10% of normal patients Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis. Radiographs may be normal early in disease, later changes include: Sacroilitis: subchondral erosions, sclerosis Squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) Chest x-ray: apical fibrosis Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints. Management: Early diagnosis is now more important following the advent of anti-TNF therapy: Encourage regular exercise such as swimming NSAIDs Physiotherapy The disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement TNF-alpha blockers such as etanercept and adalimumab are increasingly used. This approach for severe ankylosing spondylitis was supported by NICE in 2008

Question 75# A 47-year-old female presents with elbow pain. She has just spent the weekend painting the house. On examination there is localized pain around the lateral epicondyle and a diagnosis of lateral epicondylitis is suspected. Which one of the following movements would characteristically worsen the pain?
A. Resisted thumb flexion
B. Thumb extension
C. Flexion of the elbow
D. Pronation of the forearm with the elbow flexed
E. Resisted wrist extension with the elbow extended
Correct Answer E: Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow extended. Lateral epicondylitis: Lateral epicondylitis typically follows unaccustomed activity such as house painting or playing tennis ('tennis elbow'). It is most common in people aged 45-55 years and typically affects the dominant arm. Features: Pain and tenderness localized to the lateral epicondyle Pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended Episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks Management options: Advice on avoiding muscle overload Simple analgesia Steroid injection Physiotherapy

Question 73# 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?
A. Immediately
B. If more than 6 episodes of gout in a 1 year period
C. If one further attack of gout in the next 12 months
D. 4 weeks after the initial attack of gout has settled
E. If more than 4 episodes of gout in a 1 year period
Correct Answer C: Gout: start allopurinol if >= 2 attacks in 12 month period . Gout: management: Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 μmol/l). Acute management: NSAIDs Intra-articular steroid injection Colchicine has a slower onset of action. The main side-effect is diarrhoea If the patient is already taking allopurinol it should be continued Allopurinol prophylaxis - see indications below: Allopurinol should not be started until 2 weeks after an acute attack has settled as it may precipitate a further attack if started too early Initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 300 μmol/l NSAID or colchicine cover should be used when starting allopurinol Indications for allopurinol: Recurrent attacks - the British Society for Rheumatology recommend 'In uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attacks occur within 1 year' Tophi Renal disease Uric acid renal stones Prophylaxis if on cytotoxics or diuretics Lifestyle modifications: Reduce alcohol intake and avoid during an acute attack Lose weight if obese Avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products Patients with Lesch-Nyhan syndrome often take allopurinol for life.

Your-Doctor Multiple Choice Questions (MCQ)

Your-Doctor
Multiple Choice Questions (MCQ)