Rheumatology - 2021 January OSCE

Question 1

The 38-year-old woman came to rheumatologist complaining of pain and swelling of her hands, feet, and knees. The first symptoms appeared 2 years ago. She used NSAIDs periodically, but effect is insufficient. 
In the last few months, symptoms are deteriorating, she feels chronically tired, has low grade fever (37.2 - 37.5* C), 3 hour-duration morning stiffness of joints. The joints of the hands began to deform, the strength of the hands decreased, it became difficult to do normal household chores, to bend the knees, to sit down, to put on shoes. 
Life history: Other diseases, allergies are denied. 
Obj .: Temperature 36.9* C, skin without rash. Vital organs by examination - nothing special. 
The image of the hand joints is shown in the photo:

1.	What statement about joint changes in the hand are correct? (1 p.)

Accepted Answer

Swelling of the II-V PIP joints of the hands is observed on both hands

Answer

Subcutaneous nodules, typical for gout, are visible in the II-V PIP joints of the hands

Answer

Examination of the hands - without pathological changes

Answer

Deformations of the II -IV DIP joints of the hands, which are typical for osteoarthritis

Question 2

The 38-year-old woman came to rheumatologist complaining of pain and swelling of her hands, feet, and knees. The first symptoms appeared 2 years ago. She used NSAIDs periodically, but effect is insufficient. 
In the last few months, symptoms are deteriorating, she feels chronically tired, has low grade fever (37.2 - 37.5* C), 3 hour-duration morning stiffness of joints. The joints of the hands began to deform, the strength of the hands decreased, it became difficult to do normal household chores, to bend the knees, to sit down, to put on shoes. 
Life history: Other diseases, allergies are denied. 
Obj .: Temperature 36.9* C, skin without rash. Vital organs by examination - nothing special. 
The image of the hand joints is shown in the photo:

2.	Which stament about the preliminary diagnosis is correct? (1p.)

Accepted Answer

Chronic symmetrical polyarthritis – possible systemic connective tissue disease, or rheumatoid arthritis

Answer

Chronic asymmetric oligoarthritis – typical for seronegative spondyloarthropathy

Answer

The disease presents with episodes of recurrent arthritis flare – typical for crystalline arthropathy

Answer

The disease manifests itself only in arthralgia, without symptoms of arthritis, most probable diagnosis - osteoarthritis

Question 3

The 38-year-old woman came to rheumatologist complaining of pain and swelling of her hands, feet, and knees. The first symptoms appeared 2 years ago. She used NSAIDs periodically, but effect is insufficient. 
In the last few months, symptoms are deteriorating, she feels chronically tired, has low grade fever (37.2 - 37.5* C), 3 hour-duration morning stiffness of joints. The joints of the hands began to deform, the strength of the hands decreased, it became difficult to do normal household chores, to bend the knees, to sit down, to put on shoes. 
Life history: Other diseases, allergies are denied. 
Obj .: Temperature 36.9* C, skin without rash. Vital organs by examination - nothing special. 
The image of the hand joints is shown in the photo:

3.	What tests will you recommend for this patient to clarify the diagnosis? (select one or more – 3 p.)

Accepted Answer

a.	CRP and / or ESR

Accepted Answer

b.	ANA, anti dsDNA

Accepted Answer

d.	Ultrasound of sore joints

Accepted Answer

f.	RF, anti CCP

Accepted Answer

g.	General blood test

Accepted Answer

i.	Linear radiographs of hands and feet

Answer

c.	Blood and urine calcium and ionized calcium levels

Answer

e.	CT of sore joints

Answer

h.	Culture of the knee joint fluid

Answer

j.	Pelvic radiograph

Question 4

4.	The patient underwent a radiograph pf the feet.
What changes are observed on this X-ray? (1p.)

Accepted Answer

Erosions of the V right metatarsal head of the right foot and IV left foot, periarticular osteoporosis, joint space narrowing in right V and left IV-V MTP joints. The lesions are typical for erosive arthritis

Answer

Narrowing of the joint spaces of the IV-V MTF joints on both sides, subchondral sclerosis, cysts, osteophytes. The changes are typical for osteoarthritis

Answer

Punched-out lesion, soft tissue shadow in the right I MTP joint. The changes are typical for gout

Answer

Feet radiograph without changes. Normal

Question 5

5.	Correct statement about the treatment of this patient is: (1p.)

Accepted Answer

Continue to take NSAIDs , low-dose prednisolone up to 10 mg daily can be added until the final diagnosis is clear

Answer

In the absence of contraindications, the first-line treatment is biological therapy with TNF inhibitors

Answer

Physiotherapy procedures should be given first, in the absence of an effect – medical treatment

Answer

Pulse glucocorticoid therapy should be considered at this time, followed by further pathogenetic therapy

Answer

It is currently advisable to administer NSAIDs and start with Alopurinol 100 mg

Question 6

6.	After 4 months, the patient arrives for a follow-up consultation. After treatment, the condition greatly improved, no fever, the swelling of the hands and feet disappeared, but the swelling of the right knee remained. 
The patient underwent a right knee puncture. 60 ml of liquid was obtained.
 Joint fluid: 
●	Yellowish, cloudy
●	Viscosity decreased
●	Leu 6240 x10 ^ 6 / l (normal 0-200 x10 ^ 6 / l)
●	Ery 10 x10 ^ 6 / l (normal 0-25 x10 ^ 9 / l)
●	Neutrophils make up to 60 percent (normal up to 25%) Glucose decreased
●	Protein 35 g / l (normal <30g / l)
●	No crystals were found

Choose the correct statements: (select one or more- 1p.)

Accepted Answer

The punctate is inflammatory

Accepted Answer

Glucocorticoids can be injected into the right knee joint

Answer

The punctate is septic, it is necessary to take a culture of synovial fluid and administer the antibiotic intravenously

Answer

The punctate is inflammatory, typical for gout

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Rheumatology - 2021 January OSCE

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