Morning Rounds \u00b7 [YOUR TOPIC]<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n\/* \u2500\u2500 All styles are namespaced to #mrq01 so they don't\n bleed into the WordPress theme around this HTML block \u2500\u2500 *\/\n#mrq01 *,#mrq01 *::before,#mrq01 *::after{box-sizing:border-box;margin:0;padding:0}\n#mrq01{\n \/* \u2500\u2500 Colour palette \u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\n To change the accent colour, replace #8B3D20 (dark terracotta)\n in these three lines and the conic-gradient in showScore() JS *\/\n --ter:#8B3D20;\n --ter-light:#B85A38;\n --ter-pale:#FDF0EB;\n --ter-dark:#6B2D14;\n \/* \u2500\u2500 Leave these alone \u2500\u2500 *\/\n 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.mr-band-s{background:var(--ter-pale);color:var(--ter)}\n#mrq01 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--ter);color:var(--ter);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#mrq01 .mr-retry:hover{background:var(--ter);color:#FFFDF9}\n@media(max-width:480px){#mrq01 .mr-title{font-size:1.4rem}#mrq01 .mr-num{font-size:1.7rem}#mrq01 .mr-stem{font-size:0.9rem}#mrq01 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n<\/head>\n<body>\n\n\n<div id=\"mrq01-img1\" style=\"display:none\">\n <figure class=\"mr-img-wrap\">\n \n <svg viewBox=\"0 0 520 200\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:520px;display:block;margin:0 auto\">\n <rect x=\"0\" y=\"0\" width=\"250\" height=\"200\" rx=\"8\" fill=\"#0a0a1a\"\/>\n <rect x=\"270\" y=\"0\" width=\"250\" height=\"200\" rx=\"8\" fill=\"#0a0a1a\"\/>\n <text x=\"125\" y=\"18\" text-anchor=\"middle\" fill=\"#aaaaaa\" font-size=\"10\" font-family=\"Georgia,serif\">GOUT \u00b7 MSU<\/text>\n <text x=\"395\" y=\"18\" text-anchor=\"middle\" fill=\"#aaaaaa\" font-size=\"10\" font-family=\"Georgia,serif\">PSEUDOGOUT \u00b7 CPPD<\/text>\n <text x=\"125\" y=\"190\" text-anchor=\"middle\" fill=\"#666666\" font-size=\"9\">← slow axis →<\/text>\n <text x=\"395\" y=\"190\" text-anchor=\"middle\" fill=\"#666666\" font-size=\"9\">← slow axis →<\/text>\n <line x1=\"38\" y1=\"80\" x2=\"202\" y2=\"88\" stroke=\"#F0C040\" stroke-width=\"5\" stroke-linecap=\"round\" opacity=\"0.95\"\/>\n <line x1=\"52\" y1=\"108\" x2=\"192\" y2=\"114\" stroke=\"#F0C040\" stroke-width=\"3.5\" stroke-linecap=\"round\" opacity=\"0.82\"\/>\n <line x1=\"62\" y1=\"132\" x2=\"178\" y2=\"138\" stroke=\"#D4A020\" stroke-width=\"3\" stroke-linecap=\"round\" opacity=\"0.7\"\/>\n <line x1=\"156\" y1=\"46\" x2=\"161\" y2=\"155\" stroke=\"#5090E8\" stroke-width=\"3\" stroke-linecap=\"round\" opacity=\"0.65\"\/>\n <text x=\"120\" y=\"66\" text-anchor=\"middle\" fill=\"#F0C040\" font-size=\"9\" font-family=\"Georgia,serif\">yellow (parallel)<\/text>\n <text x=\"176\" y=\"150\" text-anchor=\"middle\" fill=\"#6888D0\" font-size=\"8.5\" font-family=\"Georgia,serif\">blue (perp)<\/text>\n <text x=\"125\" y=\"175\" text-anchor=\"middle\" fill=\"#888888\" font-size=\"8\" font-family=\"Georgia,serif\" font-style=\"italic\">Negative birefringence<\/text>\n <polygon points=\"318,76 360,64 382,92 340,104\" fill=\"none\" stroke=\"#5090E8\" stroke-width=\"3\" opacity=\"0.9\"\/>\n <polygon points=\"354,102 400,92 416,118 370,128\" fill=\"none\" stroke=\"#5090E8\" stroke-width=\"2.5\" opacity=\"0.8\"\/>\n <polygon points=\"294,118 330,110 346,132 310,140\" fill=\"none\" stroke=\"#6898DC\" stroke-width=\"2\" opacity=\"0.7\"\/>\n <polygon points=\"402,54 432,78 422,102 392,78\" fill=\"none\" stroke=\"#D4A828\" stroke-width=\"2.5\" opacity=\"0.6\"\/>\n <text x=\"395\" y=\"158\" text-anchor=\"middle\" fill=\"#5090E8\" font-size=\"9\" font-family=\"Georgia,serif\">blue (parallel)<\/text>\n <text x=\"395\" y=\"175\" text-anchor=\"middle\" fill=\"#888888\" font-size=\"8\" font-family=\"Georgia,serif\" font-style=\"italic\">Weakly positive birefringence<\/text>\n <\/svg>\n <figcaption>\n \n Polarised light microscopy with red compensator. MSU (gout): needle-shaped,\n <strong>negatively birefringent<\/strong> \u2014 yellow when parallel to the slow axis.\n CPPD (pseudogout): rhomboid, <strong>weakly positively birefringent<\/strong> \u2014 blue when parallel.\n <\/figcaption>\n <\/figure>\n<\/div>\n\n\n\n<div id=\"mrq01\">\n\n \n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Daily Clinical Quiz<\/div>\n <div class=\"mr-title\">\n Rheumatology<br><em>Clinical Reasoning<\/em>\n \n \n <\/div>\n <div class=\"mr-subtitle\">Five cases · Read carefully · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n \n <div class=\"mr-sentinel\" id=\"mrq01-sentinel\"><\/div>\n\n \n <div class=\"mr-progress\" id=\"mrq01-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"mrq01-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n\n \n <div id=\"mrq01-cases\"><\/div>\n\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"mrq01-submit\">Submit for Debrief<\/button>\n <\/div>\n\n \n <div class=\"mr-score\" id=\"mrq01-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"mrq01-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"mrq01-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"mrq01-net\"><\/div>\n <div class=\"mr-verdict\" id=\"mrq01-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"mrq01-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"mrq01-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"mrq01-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"mrq01-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n\n <\/div>\n<\/div>\n\n\n<script>\n(function () {\n 'use strict';\n\n \/* \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n NAMESPACE \u2014 one string that prefixes every element id.\n If you ever put two quizzes on the same page, change\n 'mrq01' to 'mrq02' in one of them (and update every\n id=\"mrq01-...\" in the HTML above to match).\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 *\/\n var NS = 'mrq01';\n var TOTAL = 5;\n var MAX = 20; \/* TOTAL \u00d7 4 \u2014 update if you ever change TOTAL *\/\n var LTRS = ['A','B','C','D'];\n\n\n \/* \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n \u2605 EDIT HERE \u2605 \u2014 THE QUESTION BANK\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n\n QS is an array of 5 question objects.\n Each object has these fields:\n\n id \u2014 question number 1\u20135. Keep in order. Don't skip.\n\n tag \u2014 short topic label shown above the stem in small caps.\n Examples: 'Cardiology', 'Pharmacology', 'ECG Interpretation'\n\n stem \u2014 the question text. Use HTML tags inside the string:\n <strong>bold<\/strong> for key clinical facts\n <em>italic<\/em> for emphasis\n > for > (greater-than sign)\n < for < (less-than sign)\n μ for \u03bc (micro symbol)\n ≥ for \u2265 (greater-than-or-equal)\n × for \u00d7 (multiplication)\n – for \u2013 (en-dash)\n & for & (ampersand)\n\n correct \u2014 the EXACT text of the correct option.\n Must match one of the entries in opts, character for character.\n The quiz uses string matching, not index \u2014 so it still works\n correctly after the options are reshuffled on every load.\n\n opts \u2014 array of exactly 4 answer strings.\n Put the correct answer anywhere; order doesn't matter\n because the quiz shuffles them on every load.\n Same HTML entity rules as stem apply.\n\n exp \u2014 explanation shown after the user answers.\n This is your teaching point. Aim for 3\u20135 sentences.\n Use <strong> for key facts. Use <em> for emphasis.\n Same HTML entity rules as stem apply.\n\n imgId \u2014 set to 'mrq01-img1' to show the image from the hidden div\n above in this question's Debrief section.\n Set to null (no quotes) to show no image.\n Only one image slot exists (mrq01-img1).\n Only set this on ONE question; it makes no sense on all five.\n\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 *\/\n var QS = [\n\n \/* \u2500\u2500 Question 1 \u2500\u2500 *\/\n {\n id: 1,\n tag: 'Crystal Arthropathy',\n stem: 'A <strong>68-year-old man<\/strong> presents with a 12-hour history of an acutely swollen, erythematous, exquisitely tender <strong>first metatarsophalangeal joint<\/strong>. He has been on hydrochlorothiazide for five years. Synovial fluid is examined under polarised light with a red compensator. Which finding confirms the diagnosis?',\n correct: 'Needle-shaped crystals appearing yellow when aligned parallel to the slow axis',\n opts: [\n 'Needle-shaped crystals appearing yellow when aligned parallel to the slow axis',\n 'Rhomboid crystals appearing blue when aligned parallel to the slow axis',\n 'Needle-shaped crystals appearing blue when aligned parallel to the slow axis',\n 'Rhomboid crystals appearing yellow when aligned parallel to the slow axis'\n ],\n exp: 'Monosodium urate (MSU) crystals are <strong>needle-shaped<\/strong> and <strong>negatively birefringent<\/strong> \u2014 yellow when the long axis lies <em>parallel<\/em> to the compensator slow axis, blue when perpendicular. CPPD crystals (pseudogout) are <strong>rhomboid<\/strong> and <strong>weakly positively birefringent<\/strong> \u2014 blue parallel, yellow perpendicular. Hydrochlorothiazide reduces renal uric acid excretion and is a classic pharmacological precipitant of gout.',\n imgId: 'mrq01-img1' \/* \u2190 shows the microscopy SVG in this debrief *\/\n },\n\n \/* \u2500\u2500 Question 2 \u2500\u2500 *\/\n {\n id: 2,\n tag: 'RA \u2014 Treatment Escalation',\n stem: 'A <strong>44-year-old woman<\/strong> has had symmetric polyarthritis of MCP and PIP joints for nine months. She has been on <strong>methotrexate 20 mg\/week<\/strong> for four months. Current assessment: morning stiffness 90 min, DAS28-CRP 5.4, anti-CCP 3× upper limit of normal, CRP 28 mg\/L. What is the most appropriate next step?',\n correct: 'Add a TNF inhibitor to methotrexate',\n opts: [\n 'Add a TNF inhibitor to methotrexate',\n 'Switch methotrexate to leflunomide',\n 'Add hydroxychloroquine and sulfasalazine (triple therapy)',\n 'Increase methotrexate to 25 mg\/week and reassess in 3 months'\n ],\n exp: 'Per <strong>EULAR 2022<\/strong>: if a cDMARD at adequate dose and duration fails <em>and<\/em> poor prognostic markers are present (high anti-CCP, elevated CRP, high DAS28), a <strong>biologic DMARD should be added<\/strong>. A TNF inhibitor combined with methotrexate is the preferred first biologic strategy. Dose-escalating methotrexate beyond 20 mg\/week is not appropriate once poor-prognosis markers are established; switching within cDMARDs loses critical time.',\n imgId: null \/* \u2190 no image for this question *\/\n },\n\n \/* \u2500\u2500 Question 3 \u2500\u2500 *\/\n {\n id: 3,\n tag: 'SLE — Lupus Nephritis',\n stem: 'A <strong>27-year-old woman<\/strong> with known SLE presents with proteinuria 2.8 g\/day and haematuria. Creatinine has risen from 72 to 118 μmol\/L over 8 weeks. Anti-dsDNA markedly elevated; C3 and C4 both <em>low<\/em>. Renal biopsy shows endocapillary proliferation in >50% of glomeruli with subendothelial immune deposits. What is the ISN\/RPS class and what does the complement pattern signify?',\n correct: 'Class IV; low C3\/C4 reflects classical pathway consumption by immune complexes',\n opts: [\n 'Class IV; low C3\/C4 reflects classical pathway consumption by immune complexes',\n 'Class III; hypocomplementaemia is a non-specific acute-phase response',\n 'Class V; low complement confirms immune-mediated membranous disease',\n 'Class II; low complement indicates mesangial lupus with activity'\n ],\n exp: '<strong>ISN\/RPS Class IV<\/strong> (diffuse proliferative lupus nephritis) involves >50% of glomeruli and carries the worst renal prognosis. Low <strong>C3 and C4<\/strong> reflect activation of the <strong>classical complement pathway<\/strong> by immune complexes with resultant consumption — complement levels mirror disease activity. Induction therapy: mycophenolate mofetil 2–3 g\/day or IV cyclophosphamide (Euro-Lupus protocol) with high-dose corticosteroids.',\n imgId: null\n },\n\n \/* \u2500\u2500 Question 4 \u2500\u2500 *\/\n {\n id: 4,\n tag: 'Giant Cell Arteritis',\n stem: 'A <strong>74-year-old woman<\/strong> presents with a 4-week history of right temporal headache and jaw claudication. ESR 108 mm\/hr, CRP 62 mg\/L. She reports <strong>two episodes of transient visual blurring<\/strong> in the right eye over the past week. What is the correct immediate management?',\n correct: 'Start prednisolone 60 mg\/day immediately; arrange temporal artery biopsy within 2 weeks',\n opts: [\n 'Start prednisolone 60 mg\/day immediately; arrange temporal artery biopsy within 2 weeks',\n 'Arrange urgent temporal artery biopsy before starting any treatment',\n 'Start low-dose aspirin and await biopsy result before committing to steroids',\n 'Order PET-CT to confirm large vessel involvement before treatment'\n ],\n exp: 'In GCA with <strong>visual symptoms<\/strong>, high-dose prednisolone must be started <em>immediately without waiting for biopsy<\/em>. The risk is <strong>anterior ischaemic optic neuropathy<\/strong>, which can progress to permanent blindness within hours of a warning episode. <strong>Biopsy accuracy is preserved for 2–4 weeks<\/strong> after steroid initiation. Delaying treatment to obtain histology is the most consequential clinical error in GCA management.',\n imgId: null\n },\n\n \/* \u2500\u2500 Question 5 \u2500\u2500 *\/\n {\n id: 5,\n tag: 'Axial Spondyloarthritis',\n stem: 'A <strong>31-year-old HLA-B27 positive man<\/strong> has had low back pain for 20 months. Pain wakes him in the second half of the night, is accompanied by 75 minutes of morning stiffness, and <em>improves with exercise but not with rest<\/em>. Onset was insidious before age 40. Pelvic X-ray shows bilateral grade II sacroiliitis. Which one correctly characterises the pain pattern?',\n correct: 'ASAS inflammatory back pain criteria — he satisfies all five features',\n opts: [\n 'ASAS inflammatory back pain criteria — he satisfies all five features',\n 'Modified New York criteria — bilateral grade II sacroiliitis with one clinical feature',\n 'BASDAI ≥4 indicating high disease activity requiring biologic therapy',\n 'Calin criteria — he meets only 4 of the 5 required features'\n ],\n exp: 'The <strong>ASAS criteria for inflammatory back pain<\/strong> require ≥4 of 5 features: age of onset <40; insidious onset; improvement with exercise; <em>no improvement with rest<\/em>; nocturnal pain improving on getting up. This patient satisfies <strong>all five<\/strong>. BASDAI measures disease activity and is not a diagnostic criterion. The question asks specifically about characterising the back pain pattern, which the ASAS criteria address.',\n imgId: null\n }\n\n ];\n \/* \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n END OF QUESTION BANK \u2014 do not edit below this line\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 *\/\n\n\n \/* \u2500\u2500 Internal state \u2014 nothing to edit \u2500\u2500 *\/\n var answers = {};\n var answered = 0;\n var shuffled = {};\n var done = false;\n\n \/* \u2500\u2500 DOM helpers \u2500\u2500 *\/\n function byId(id) { return document.getElementById(id); }\n function gid(suffix) { return byId(NS + '-' + suffix); }\n\n \/* \u2500\u2500 Fisher-Yates shuffle (pure ES5) \u2500\u2500 *\/\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, tmp;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n }\n return a;\n }\n\n \/* \u2500\u2500 Count answers of a given value ('c' or 'w') \u2500\u2500 *\/\n function countVal(val) {\n var k, n = 0;\n for (k in answers) {\n if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n }\n return n;\n }\n\n \/* \u2500\u2500 Build the five progress pips \u2500\u2500 *\/\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n \/* connecting line between pips (not before the first) *\/\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n \/* pip circle *\/\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n \/* \u2500\u2500 Build all case cards from the QS array \u2500\u2500 *\/\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n\n \/* reset state *\/\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts); \/* shuffle options fresh each load *\/\n shuffled[q.id] = opts; \/* store shuffled order for later use *\/\n\n \/* \u2500\u2500 outer card \u2500\u2500 *\/\n card = document.createElement('div');\n card.className = 'mr-case';\n\n \/* \u2500\u2500 top section: big number + tag + stem \u2500\u2500 *\/\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? '0' + q.id : String(q.id);\n\n meta = document.createElement('div');\n meta.className = 'mr-meta';\n\n tag = document.createElement('div');\n tag.className = 'mr-tag';\n tag.innerHTML = q.tag; \/* innerHTML so — etc. render *\/\n\n stem = document.createElement('div');\n stem.className = 'mr-stem';\n stem.innerHTML = q.stem;\n\n meta.appendChild(tag);\n meta.appendChild(stem);\n top.appendChild(numDiv);\n top.appendChild(meta);\n card.appendChild(top);\n\n \/* \u2500\u2500 divider line \u2500\u2500 *\/\n rule = document.createElement('div');\n rule.className = 'mr-rule';\n card.appendChild(rule);\n\n \/* \u2500\u2500 answer options \u2500\u2500 *\/\n optsDiv = document.createElement('div');\n optsDiv.className = 'mr-opts';\n\n for (j = 0; j < opts.length; j++) {\n optEl = document.createElement('div');\n optEl.className = 'mr-opt';\n optEl.id = NS + '-o' + q.id + '-' + j;\n optEl.setAttribute('role', 'button');\n optEl.setAttribute('tabindex', '0');\n\n ltrSpan = document.createElement('span');\n ltrSpan.className = 'mr-ltr';\n ltrSpan.textContent = LTRS[j];\n\n txtSpan = document.createElement('span');\n txtSpan.className = 'mr-opt-text';\n txtSpan.innerHTML = opts[j];\n\n optEl.appendChild(ltrSpan);\n optEl.appendChild(txtSpan);\n optsDiv.appendChild(optEl);\n\n \/* IIFE to capture correct qid and oi for each click listener *\/\n (function (qid, oi) {\n optEl.addEventListener('click', function () { pick(qid, oi); });\n }(q.id, j));\n }\n card.appendChild(optsDiv);\n\n \/* \u2500\u2500 explanation (hidden until the user answers) \u2500\u2500 *\/\n expDiv = document.createElement('div');\n expDiv.className = 'mr-exp';\n expDiv.id = NS + '-exp' + q.id;\n\n lbl = document.createElement('div');\n lbl.className = 'mr-exp-lbl';\n lbl.textContent = 'Debrief';\n\n txt = document.createElement('div');\n txt.className = 'mr-exp-text';\n txt.innerHTML = q.exp;\n\n expDiv.appendChild(lbl);\n expDiv.appendChild(txt);\n\n \/* inject image if this question has one *\/\n if (q.imgId) {\n imgSrc = byId(q.imgId);\n if (imgSrc) {\n imgDiv = document.createElement('div');\n imgDiv.innerHTML = imgSrc.innerHTML; \/* clone HTML from hidden div *\/\n expDiv.appendChild(imgDiv);\n }\n }\n\n card.appendChild(expDiv);\n cont.appendChild(card);\n }\n }\n\n \/* \u2500\u2500 Handle a user clicking an option \u2500\u2500 *\/\n function pick(qid, oi) {\n var q, opts, i, el, correct;\n\n if (answers[qid] !== undefined || done) return; \/* ignore if already answered *\/\n\n \/* find the question object *\/\n q = null;\n for (i = 0; i < QS.length; i++) {\n if (QS[i].id === qid) { q = QS[i]; break; }\n }\n if (!q) return;\n\n opts = shuffled[qid];\n correct = (opts[oi] === q.correct); \/* string comparison *\/\n answers[qid] = correct ? 'c' : 'w';\n answered++;\n\n \/* style all four options *\/\n for (i = 0; i < opts.length; i++) {\n el = byId(NS + '-o' + qid + '-' + i);\n if (opts[i] === q.correct) {\n el.className = 'mr-opt correct locked';\n } else if (i === oi) {\n el.className = 'mr-opt wrong locked';\n } else {\n el.className = 'mr-opt dimmed locked';\n }\n }\n\n \/* reveal explanation *\/\n byId(NS + '-exp' + qid).style.display = 'block';\n\n \/* colour the progress pip *\/\n byId(NS + '-pip' + qid).className = 'mr-pip ' + (correct ? 'correct' : 'wrong');\n\n \/* colour the connecting line that leads TO this pip *\/\n if (qid > 1) {\n var pl = gid('pl' + qid);\n if (pl) pl.className = 'mr-pip-line done';\n }\n }\n\n \/* \u2500\u2500 Show the score panel after Submit is clicked \u2500\u2500 *\/\n function showScore() {\n var c, w, s, net, pct, disp, verdicts, vi, sc;\n if (done) return;\n done = true;\n\n c = countVal('c');\n w = countVal('w');\n s = TOTAL - answered;\n net = (c * 4) - w;\n pct = Math.max(0, Math.round((net \/ MAX) * 100));\n disp = Math.min(100, Math.max(0, pct));\n\n \/* fill the donut ring \u2014 colour matches --ter *\/\n gid('ring').style.background =\n 'conic-gradient(#8B3D20 ' + disp + '%, #E8DDD8 0%)';\n\n gid('pct').textContent = pct + '%';\n gid('net').textContent = 'Net Score: ' + net + ' \/ ' + MAX;\n\n \/* pick verdict by correct count *\/\n verdicts = [\n [5, 'Perfect round. Exceptional clinical reasoning.'],\n [4, 'Strong \\u2014 one nuance to revisit.'],\n [3, 'Solid base \\u2014 consolidate the finer distinctions.'],\n [2, 'Halfway there \\u2014 review the missed cases carefully.'],\n [0, 'These cases repay close reading. Come back tomorrow.']\n ];\n gid('verdict').textContent = verdicts[4][1]; \/* default: lowest *\/\n for (vi = 0; vi < verdicts.length; vi++) {\n if (c >= verdicts[vi][0]) {\n gid('verdict').textContent = verdicts[vi][1];\n break;\n }\n }\n\n \/* unicode escapes so no multi-byte literals in source *\/\n gid('ct-c').textContent = '\\u2705 ' + c + ' Correct';\n gid('ct-w').textContent = '\\u274C ' + w + ' Wrong';\n gid('ct-s').textContent = '\\u23ED ' + s + ' Skipped';\n\n sc = gid('score');\n sc.style.display = 'block';\n sc.scrollIntoView({ behavior: 'smooth', block: 'center' });\n }\n\n \/* \u2500\u2500 Sticky progress bar via IntersectionObserver \u2500\u2500\n When the sentinel div (just below the header) leaves the\n viewport, the fixed progress bar appears. When the sentinel\n comes back into view (user scrolled back up), bar disappears. *\/\n function initObserver() {\n var sentinel = gid('sentinel'), bar = gid('progress');\n if (!sentinel || !bar || !window.IntersectionObserver) return;\n new IntersectionObserver(function (entries) {\n if (!entries[0].isIntersecting) {\n bar.className = 'mr-progress visible';\n } else {\n bar.className = 'mr-progress';\n }\n }, { threshold: 0 }).observe(sentinel);\n }\n\n \/* \u2500\u2500 Bootstrap \u2500\u2500 *\/\n function init() {\n gid('submit').addEventListener('click', showScore);\n gid('retry').addEventListener('click', function () {\n build();\n window.scrollTo(0, 0);\n });\n initObserver();\n build();\n }\n\n if (document.readyState === 'loading') {\n document.addEventListener('DOMContentLoaded', init);\n } else {\n init();\n }\n\n}());\n<\/script>\n<\/body>\n<\/html>\n\n\n","protected":false},"excerpt":{"rendered":"<p>GOUT \u00b7 MSU PSEUDOGOUT \u00b7 CPPD ← slow axis → ← slow axis → yellow (parallel) blue (perp) Negative birefringence blue (parallel) Weakly positive birefringence Polarised light microscopy with red compensator. MSU (gout): needle-shaped, negatively birefringent \u2014 yellow when parallel to the slow axis. CPPD (pseudogout): rhomboid, weakly positively birefringent \u2014 blue when parallel. Morning… <\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[24],"tags":[],"class_list":["post-36651","post","type-post","status-publish","format-standard","hentry","category-neet-pg"],"yoast_head":"\n<title>Rheumatology Clinical - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/2026\/04\/21\/rheumatology-clinical\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Rheumatology Clinical - atsixty\" \/>\n<meta property=\"og:description\" content=\"GOUT \u00b7 MSU PSEUDOGOUT \u00b7 CPPD ← slow axis → ← slow axis → yellow (parallel) blue (perp) Negative birefringence blue (parallel) Weakly positive birefringence Polarised light microscopy with red compensator. MSU (gout): needle-shaped, negatively birefringent \u2014 yellow when parallel to the slow axis. CPPD (pseudogout): rhomboid, weakly positively birefringent \u2014 blue when parallel. 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MSU (gout): needle-shaped, negatively birefringent \u2014 yellow when parallel to the slow axis. CPPD (pseudogout): rhomboid, weakly positively birefringent \u2014 blue when parallel. 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.mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#mrq01 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#mrq01 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#mrq01 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#mrq01 .mr-band-s{background:var(--ter-pale);color:var(--ter)}\n#mrq01 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--ter);color:var(--ter);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#mrq01 .mr-retry:hover{background:var(--ter);color:#FFFDF9}\n@media(max-width:480px){#mrq01 .mr-title{font-size:1.4rem}#mrq01 .mr-num{font-size:1.7rem}#mrq01 .mr-stem{font-size:0.9rem}#mrq01 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n<\/head>\n<body>\n\n\n<div id=\"mrq01-img1\" style=\"display:none\">\n <figure class=\"mr-img-wrap\">\n \n <svg viewBox=\"0 0 520 200\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:520px;display:block;margin:0 auto\">\n <rect x=\"0\" y=\"0\" width=\"250\" height=\"200\" rx=\"8\" fill=\"#0a0a1a\"\/>\n <rect x=\"270\" y=\"0\" width=\"250\" height=\"200\" rx=\"8\" fill=\"#0a0a1a\"\/>\n <text x=\"125\" y=\"18\" text-anchor=\"middle\" fill=\"#aaaaaa\" font-size=\"10\" font-family=\"Georgia,serif\">GOUT \u00b7 MSU<\/text>\n <text x=\"395\" y=\"18\" text-anchor=\"middle\" fill=\"#aaaaaa\" font-size=\"10\" font-family=\"Georgia,serif\">PSEUDOGOUT \u00b7 CPPD<\/text>\n <text x=\"125\" y=\"190\" text-anchor=\"middle\" fill=\"#666666\" font-size=\"9\">← slow axis →<\/text>\n <text x=\"395\" y=\"190\" text-anchor=\"middle\" fill=\"#666666\" font-size=\"9\">← slow axis →<\/text>\n <line x1=\"38\" y1=\"80\" x2=\"202\" y2=\"88\" stroke=\"#F0C040\" stroke-width=\"5\" stroke-linecap=\"round\" opacity=\"0.95\"\/>\n <line x1=\"52\" y1=\"108\" x2=\"192\" y2=\"114\" stroke=\"#F0C040\" stroke-width=\"3.5\" stroke-linecap=\"round\" opacity=\"0.82\"\/>\n <line x1=\"62\" y1=\"132\" x2=\"178\" y2=\"138\" stroke=\"#D4A020\" stroke-width=\"3\" stroke-linecap=\"round\" opacity=\"0.7\"\/>\n <line x1=\"156\" y1=\"46\" x2=\"161\" y2=\"155\" stroke=\"#5090E8\" stroke-width=\"3\" stroke-linecap=\"round\" opacity=\"0.65\"\/>\n <text x=\"120\" y=\"66\" text-anchor=\"middle\" fill=\"#F0C040\" font-size=\"9\" font-family=\"Georgia,serif\">yellow (parallel)<\/text>\n <text x=\"176\" y=\"150\" text-anchor=\"middle\" fill=\"#6888D0\" font-size=\"8.5\" font-family=\"Georgia,serif\">blue (perp)<\/text>\n <text x=\"125\" y=\"175\" text-anchor=\"middle\" fill=\"#888888\" font-size=\"8\" font-family=\"Georgia,serif\" font-style=\"italic\">Negative birefringence<\/text>\n <polygon points=\"318,76 360,64 382,92 340,104\" fill=\"none\" stroke=\"#5090E8\" stroke-width=\"3\" opacity=\"0.9\"\/>\n <polygon points=\"354,102 400,92 416,118 370,128\" fill=\"none\" stroke=\"#5090E8\" stroke-width=\"2.5\" opacity=\"0.8\"\/>\n <polygon points=\"294,118 330,110 346,132 310,140\" fill=\"none\" stroke=\"#6898DC\" stroke-width=\"2\" opacity=\"0.7\"\/>\n <polygon points=\"402,54 432,78 422,102 392,78\" fill=\"none\" stroke=\"#D4A828\" stroke-width=\"2.5\" opacity=\"0.6\"\/>\n <text x=\"395\" y=\"158\" text-anchor=\"middle\" fill=\"#5090E8\" font-size=\"9\" font-family=\"Georgia,serif\">blue (parallel)<\/text>\n <text x=\"395\" y=\"175\" text-anchor=\"middle\" fill=\"#888888\" font-size=\"8\" font-family=\"Georgia,serif\" font-style=\"italic\">Weakly positive birefringence<\/text>\n <\/svg>\n <figcaption>\n \n Polarised light microscopy with red compensator. MSU (gout): needle-shaped,\n <strong>negatively birefringent<\/strong> \u2014 yellow when parallel to the slow axis.\n CPPD (pseudogout): rhomboid, <strong>weakly positively birefringent<\/strong> \u2014 blue when parallel.\n <\/figcaption>\n <\/figure>\n<\/div>\n\n\n\n<div id=\"mrq01\">\n\n \n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Daily Clinical Quiz<\/div>\n <div class=\"mr-title\">\n Rheumatology<br><em>Clinical Reasoning<\/em>\n \n \n <\/div>\n <div class=\"mr-subtitle\">Five cases · Read carefully · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n \n <div class=\"mr-sentinel\" id=\"mrq01-sentinel\"><\/div>\n\n \n <div class=\"mr-progress\" id=\"mrq01-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"mrq01-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n\n \n <div id=\"mrq01-cases\"><\/div>\n\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"mrq01-submit\">Submit for Debrief<\/button>\n <\/div>\n\n \n <div class=\"mr-score\" id=\"mrq01-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"mrq01-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"mrq01-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"mrq01-net\"><\/div>\n <div class=\"mr-verdict\" id=\"mrq01-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"mrq01-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"mrq01-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"mrq01-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"mrq01-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n\n <\/div>\n<\/div>\n\n\n<script>\n(function () {\n 'use strict';\n\n \/* \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n NAMESPACE \u2014 one string that prefixes every element id.\n If you ever put two quizzes on the same page, change\n 'mrq01' to 'mrq02' in one of them (and update every\n id=\"mrq01-...\" in the HTML above to match).\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 *\/\n var NS = 'mrq01';\n var TOTAL = 5;\n var MAX = 20; \/* TOTAL \u00d7 4 \u2014 update if you ever change TOTAL *\/\n var LTRS = ['A','B','C','D'];\n\n\n \/* \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n \u2605 EDIT HERE \u2605 \u2014 THE QUESTION BANK\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n\n QS is an array of 5 question objects.\n Each object has these fields:\n\n id \u2014 question number 1\u20135. Keep in order. Don't skip.\n\n tag \u2014 short topic label shown above the stem in small caps.\n Examples: 'Cardiology', 'Pharmacology', 'ECG Interpretation'\n\n stem \u2014 the question text. Use HTML tags inside the string:\n <strong>bold<\/strong> for key clinical facts\n <em>italic<\/em> for emphasis\n > for > (greater-than sign)\n < for < (less-than sign)\n μ for \u03bc (micro symbol)\n ≥ for \u2265 (greater-than-or-equal)\n × for \u00d7 (multiplication)\n – for \u2013 (en-dash)\n & for & (ampersand)\n\n correct \u2014 the EXACT text of the correct option.\n Must match one of the entries in opts, character for character.\n The quiz uses string matching, not index \u2014 so it still works\n correctly after the options are reshuffled on every load.\n\n opts \u2014 array of exactly 4 answer strings.\n Put the correct answer anywhere; order doesn't matter\n because the quiz shuffles them on every load.\n Same HTML entity rules as stem apply.\n\n exp \u2014 explanation shown after the user answers.\n This is your teaching point. Aim for 3\u20135 sentences.\n Use <strong> for key facts. Use <em> for emphasis.\n Same HTML entity rules as stem apply.\n\n imgId \u2014 set to 'mrq01-img1' to show the image from the hidden div\n above in this question's Debrief section.\n Set to null (no quotes) to show no image.\n Only one image slot exists (mrq01-img1).\n Only set this on ONE question; it makes no sense on all five.\n\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 *\/\n var QS = [\n\n \/* \u2500\u2500 Question 1 \u2500\u2500 *\/\n {\n id: 1,\n tag: 'Crystal Arthropathy',\n stem: 'A <strong>68-year-old man<\/strong> presents with a 12-hour history of an acutely swollen, erythematous, exquisitely tender <strong>first metatarsophalangeal joint<\/strong>. He has been on hydrochlorothiazide for five years. Synovial fluid is examined under polarised light with a red compensator. Which finding confirms the diagnosis?',\n correct: 'Needle-shaped crystals appearing yellow when aligned parallel to the slow axis',\n opts: [\n 'Needle-shaped crystals appearing yellow when aligned parallel to the slow axis',\n 'Rhomboid crystals appearing blue when aligned parallel to the slow axis',\n 'Needle-shaped crystals appearing blue when aligned parallel to the slow axis',\n 'Rhomboid crystals appearing yellow when aligned parallel to the slow axis'\n ],\n exp: 'Monosodium urate (MSU) crystals are <strong>needle-shaped<\/strong> and <strong>negatively birefringent<\/strong> \u2014 yellow when the long axis lies <em>parallel<\/em> to the compensator slow axis, blue when perpendicular. CPPD crystals (pseudogout) are <strong>rhomboid<\/strong> and <strong>weakly positively birefringent<\/strong> \u2014 blue parallel, yellow perpendicular. Hydrochlorothiazide reduces renal uric acid excretion and is a classic pharmacological precipitant of gout.',\n imgId: 'mrq01-img1' \/* \u2190 shows the microscopy SVG in this debrief *\/\n },\n\n \/* \u2500\u2500 Question 2 \u2500\u2500 *\/\n {\n id: 2,\n tag: 'RA \u2014 Treatment Escalation',\n stem: 'A <strong>44-year-old woman<\/strong> has had symmetric polyarthritis of MCP and PIP joints for nine months. She has been on <strong>methotrexate 20 mg\/week<\/strong> for four months. Current assessment: morning stiffness 90 min, DAS28-CRP 5.4, anti-CCP 3× upper limit of normal, CRP 28 mg\/L. What is the most appropriate next step?',\n correct: 'Add a TNF inhibitor to methotrexate',\n opts: [\n 'Add a TNF inhibitor to methotrexate',\n 'Switch methotrexate to leflunomide',\n 'Add hydroxychloroquine and sulfasalazine (triple therapy)',\n 'Increase methotrexate to 25 mg\/week and reassess in 3 months'\n ],\n exp: 'Per <strong>EULAR 2022<\/strong>: if a cDMARD at adequate dose and duration fails <em>and<\/em> poor prognostic markers are present (high anti-CCP, elevated CRP, high DAS28), a <strong>biologic DMARD should be added<\/strong>. A TNF inhibitor combined with methotrexate is the preferred first biologic strategy. Dose-escalating methotrexate beyond 20 mg\/week is not appropriate once poor-prognosis markers are established; switching within cDMARDs loses critical time.',\n imgId: null \/* \u2190 no image for this question *\/\n },\n\n \/* \u2500\u2500 Question 3 \u2500\u2500 *\/\n {\n id: 3,\n tag: 'SLE — Lupus Nephritis',\n stem: 'A <strong>27-year-old woman<\/strong> with known SLE presents with proteinuria 2.8 g\/day and haematuria. Creatinine has risen from 72 to 118 μmol\/L over 8 weeks. Anti-dsDNA markedly elevated; C3 and C4 both <em>low<\/em>. Renal biopsy shows endocapillary proliferation in >50% of glomeruli with subendothelial immune deposits. What is the ISN\/RPS class and what does the complement pattern signify?',\n correct: 'Class IV; low C3\/C4 reflects classical pathway consumption by immune complexes',\n opts: [\n 'Class IV; low C3\/C4 reflects classical pathway consumption by immune complexes',\n 'Class III; hypocomplementaemia is a non-specific acute-phase response',\n 'Class V; low complement confirms immune-mediated membranous disease',\n 'Class II; low complement indicates mesangial lupus with activity'\n ],\n exp: '<strong>ISN\/RPS Class IV<\/strong> (diffuse proliferative lupus nephritis) involves >50% of glomeruli and carries the worst renal prognosis. Low <strong>C3 and C4<\/strong> reflect activation of the <strong>classical complement pathway<\/strong> by immune complexes with resultant consumption — complement levels mirror disease activity. Induction therapy: mycophenolate mofetil 2–3 g\/day or IV cyclophosphamide (Euro-Lupus protocol) with high-dose corticosteroids.',\n imgId: null\n },\n\n \/* \u2500\u2500 Question 4 \u2500\u2500 *\/\n {\n id: 4,\n tag: 'Giant Cell Arteritis',\n stem: 'A <strong>74-year-old woman<\/strong> presents with a 4-week history of right temporal headache and jaw claudication. ESR 108 mm\/hr, CRP 62 mg\/L. She reports <strong>two episodes of transient visual blurring<\/strong> in the right eye over the past week. What is the correct immediate management?',\n correct: 'Start prednisolone 60 mg\/day immediately; arrange temporal artery biopsy within 2 weeks',\n opts: [\n 'Start prednisolone 60 mg\/day immediately; arrange temporal artery biopsy within 2 weeks',\n 'Arrange urgent temporal artery biopsy before starting any treatment',\n 'Start low-dose aspirin and await biopsy result before committing to steroids',\n 'Order PET-CT to confirm large vessel involvement before treatment'\n ],\n exp: 'In GCA with <strong>visual symptoms<\/strong>, high-dose prednisolone must be started <em>immediately without waiting for biopsy<\/em>. The risk is <strong>anterior ischaemic optic neuropathy<\/strong>, which can progress to permanent blindness within hours of a warning episode. <strong>Biopsy accuracy is preserved for 2–4 weeks<\/strong> after steroid initiation. Delaying treatment to obtain histology is the most consequential clinical error in GCA management.',\n imgId: null\n },\n\n \/* \u2500\u2500 Question 5 \u2500\u2500 *\/\n {\n id: 5,\n tag: 'Axial Spondyloarthritis',\n stem: 'A <strong>31-year-old HLA-B27 positive man<\/strong> has had low back pain for 20 months. Pain wakes him in the second half of the night, is accompanied by 75 minutes of morning stiffness, and <em>improves with exercise but not with rest<\/em>. Onset was insidious before age 40. Pelvic X-ray shows bilateral grade II sacroiliitis. Which one correctly characterises the pain pattern?',\n correct: 'ASAS inflammatory back pain criteria — he satisfies all five features',\n opts: [\n 'ASAS inflammatory back pain criteria — he satisfies all five features',\n 'Modified New York criteria — bilateral grade II sacroiliitis with one clinical feature',\n 'BASDAI ≥4 indicating high disease activity requiring biologic therapy',\n 'Calin criteria — he meets only 4 of the 5 required features'\n ],\n exp: 'The <strong>ASAS criteria for inflammatory back pain<\/strong> require ≥4 of 5 features: age of onset <40; insidious onset; improvement with exercise; <em>no improvement with rest<\/em>; nocturnal pain improving on getting up. This patient satisfies <strong>all five<\/strong>. BASDAI measures disease activity and is not a diagnostic criterion. The question asks specifically about characterising the back pain pattern, which the ASAS criteria address.',\n imgId: null\n }\n\n ];\n \/* \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n END OF QUESTION BANK \u2014 do not edit below this line\n \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 *\/\n\n\n \/* \u2500\u2500 Internal state \u2014 nothing to edit \u2500\u2500 *\/\n var answers = {};\n var answered = 0;\n var shuffled = {};\n var done = false;\n\n \/* \u2500\u2500 DOM helpers \u2500\u2500 *\/\n function byId(id) { return document.getElementById(id); }\n function gid(suffix) { return byId(NS + '-' + suffix); }\n\n \/* \u2500\u2500 Fisher-Yates shuffle (pure ES5) \u2500\u2500 *\/\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, tmp;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n }\n return a;\n }\n\n \/* \u2500\u2500 Count answers of a given value ('c' or 'w') \u2500\u2500 *\/\n function countVal(val) {\n var k, n = 0;\n for (k in answers) {\n if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n }\n return n;\n }\n\n \/* \u2500\u2500 Build the five progress pips \u2500\u2500 *\/\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n \/* connecting line between pips (not before the first) *\/\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n \/* pip circle *\/\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n \/* \u2500\u2500 Build all case cards from the QS array \u2500\u2500 *\/\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n\n \/* reset state *\/\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts); \/* shuffle options fresh each load *\/\n shuffled[q.id] = opts; \/* store shuffled order for later use *\/\n\n \/* \u2500\u2500 outer card \u2500\u2500 *\/\n card = document.createElement('div');\n card.className = 'mr-case';\n\n \/* \u2500\u2500 top section: big number + tag + stem \u2500\u2500 *\/\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? '0' + q.id : String(q.id);\n\n meta = document.createElement('div');\n meta.className = 'mr-meta';\n\n tag = document.createElement('div');\n tag.className = 'mr-tag';\n tag.innerHTML = q.tag; \/* innerHTML so — etc. render *\/\n\n stem = document.createElement('div');\n stem.className = 'mr-stem';\n stem.innerHTML = q.stem;\n\n meta.appendChild(tag);\n meta.appendChild(stem);\n top.appendChild(numDiv);\n top.appendChild(meta);\n card.appendChild(top);\n\n \/* \u2500\u2500 divider line \u2500\u2500 *\/\n rule = document.createElement('div');\n rule.className = 'mr-rule';\n card.appendChild(rule);\n\n \/* \u2500\u2500 answer options \u2500\u2500 *\/\n optsDiv = document.createElement('div');\n optsDiv.className = 'mr-opts';\n\n for (j = 0; j < opts.length; j++) {\n optEl = document.createElement('div');\n optEl.className = 'mr-opt';\n optEl.id = NS + '-o' + q.id + '-' + j;\n optEl.setAttribute('role', 'button');\n optEl.setAttribute('tabindex', '0');\n\n ltrSpan = document.createElement('span');\n ltrSpan.className = 'mr-ltr';\n ltrSpan.textContent = LTRS[j];\n\n txtSpan = document.createElement('span');\n txtSpan.className = 'mr-opt-text';\n txtSpan.innerHTML = opts[j];\n\n optEl.appendChild(ltrSpan);\n optEl.appendChild(txtSpan);\n optsDiv.appendChild(optEl);\n\n \/* IIFE to capture correct qid and oi for each click listener *\/\n (function (qid, oi) {\n optEl.addEventListener('click', function () { pick(qid, oi); });\n }(q.id, j));\n }\n card.appendChild(optsDiv);\n\n \/* \u2500\u2500 explanation (hidden until the user answers) \u2500\u2500 *\/\n expDiv = document.createElement('div');\n expDiv.className = 'mr-exp';\n expDiv.id = NS + '-exp' + q.id;\n\n lbl = document.createElement('div');\n lbl.className = 'mr-exp-lbl';\n lbl.textContent = 'Debrief';\n\n txt = document.createElement('div');\n txt.className = 'mr-exp-text';\n txt.innerHTML = q.exp;\n\n expDiv.appendChild(lbl);\n expDiv.appendChild(txt);\n\n \/* inject image if this question has one *\/\n if (q.imgId) {\n imgSrc = byId(q.imgId);\n if (imgSrc) {\n imgDiv = document.createElement('div');\n imgDiv.innerHTML = imgSrc.innerHTML; \/* clone HTML from hidden div *\/\n expDiv.appendChild(imgDiv);\n }\n }\n\n card.appendChild(expDiv);\n cont.appendChild(card);\n }\n }\n\n \/* \u2500\u2500 Handle a user clicking an option \u2500\u2500 *\/\n function pick(qid, oi) {\n var q, opts, i, el, correct;\n\n if (answers[qid] !== undefined || done) return; \/* ignore if already answered *\/\n\n \/* find the question object *\/\n q = null;\n for (i = 0; i < QS.length; i++) {\n if (QS[i].id === qid) { q = QS[i]; break; }\n }\n if (!q) return;\n\n opts = shuffled[qid];\n correct = (opts[oi] === q.correct); \/* string comparison *\/\n answers[qid] = correct ? 'c' : 'w';\n answered++;\n\n \/* style all four options *\/\n for (i = 0; i < opts.length; i++) {\n el = byId(NS + '-o' + qid + '-' + i);\n if (opts[i] === q.correct) {\n el.className = 'mr-opt correct locked';\n } else if (i === oi) {\n el.className = 'mr-opt wrong locked';\n } else {\n el.className = 'mr-opt dimmed locked';\n }\n }\n\n \/* reveal explanation *\/\n byId(NS + '-exp' + qid).style.display = 'block';\n\n \/* colour the progress pip *\/\n byId(NS + '-pip' + qid).className = 'mr-pip ' + (correct ? 'correct' : 'wrong');\n\n \/* colour the connecting line that leads TO this pip *\/\n if (qid > 1) {\n var pl = gid('pl' + qid);\n if (pl) pl.className = 'mr-pip-line done';\n }\n }\n\n \/* \u2500\u2500 Show the score panel after Submit is clicked \u2500\u2500 *\/\n function showScore() {\n var c, w, s, net, pct, disp, verdicts, vi, sc;\n if (done) return;\n done = true;\n\n c = countVal('c');\n w = countVal('w');\n s = TOTAL - answered;\n net = (c * 4) - w;\n pct = Math.max(0, Math.round((net \/ MAX) * 100));\n disp = Math.min(100, Math.max(0, pct));\n\n \/* fill the donut ring \u2014 colour matches --ter *\/\n gid('ring').style.background =\n 'conic-gradient(#8B3D20 ' + disp + '%, #E8DDD8 0%)';\n\n gid('pct').textContent = pct + '%';\n gid('net').textContent = 'Net Score: ' + net + ' \/ ' + MAX;\n\n \/* pick verdict by correct count *\/\n verdicts = [\n [5, 'Perfect round. Exceptional clinical reasoning.'],\n [4, 'Strong \\u2014 one nuance to revisit.'],\n [3, 'Solid base \\u2014 consolidate the finer distinctions.'],\n [2, 'Halfway there \\u2014 review the missed cases carefully.'],\n [0, 'These cases repay close reading. Come back tomorrow.']\n ];\n gid('verdict').textContent = verdicts[4][1]; \/* default: lowest *\/\n for (vi = 0; vi < verdicts.length; vi++) {\n if (c >= verdicts[vi][0]) {\n gid('verdict').textContent = verdicts[vi][1];\n break;\n }\n }\n\n \/* unicode escapes so no multi-byte literals in source *\/\n gid('ct-c').textContent = '\\u2705 ' + c + ' Correct';\n gid('ct-w').textContent = '\\u274C ' + w + ' Wrong';\n gid('ct-s').textContent = '\\u23ED ' + s + ' Skipped';\n\n sc = gid('score');\n sc.style.display = 'block';\n sc.scrollIntoView({ behavior: 'smooth', block: 'center' });\n }\n\n \/* \u2500\u2500 Sticky progress bar via IntersectionObserver \u2500\u2500\n When the sentinel div (just below the header) leaves the\n viewport, the fixed progress bar appears. When the sentinel\n comes back into view (user scrolled back up), bar disappears. *\/\n function initObserver() {\n var sentinel = gid('sentinel'), bar = gid('progress');\n if (!sentinel || !bar || !window.IntersectionObserver) return;\n new IntersectionObserver(function (entries) {\n if (!entries[0].isIntersecting) {\n bar.className = 'mr-progress visible';\n } else {\n bar.className = 'mr-progress';\n }\n }, { threshold: 0 }).observe(sentinel);\n }\n\n \/* \u2500\u2500 Bootstrap \u2500\u2500 *\/\n function init() {\n gid('submit').addEventListener('click', showScore);\n gid('retry').addEventListener('click', function () {\n build();\n window.scrollTo(0, 0);\n });\n initObserver();\n build();\n }\n\n if (document.readyState === 'loading') {\n document.addEventListener('DOMContentLoaded', init);\n } else {\n init();\n }\n\n}());\n<\/script>\n<\/body>\n<\/html>\n\n\n","protected":false},"excerpt":{"rendered":"<p>GOUT \u00b7 MSU PSEUDOGOUT \u00b7 CPPD ← slow axis → ← slow axis → yellow (parallel) blue (perp) Negative birefringence blue (parallel) Weakly positive birefringence Polarised light microscopy with red compensator. MSU (gout): needle-shaped, negatively birefringent \u2014 yellow when parallel to the slow axis. CPPD (pseudogout): rhomboid, weakly positively birefringent \u2014 blue when parallel. Morning… <\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[24],"tags":[],"class_list":["post-36651","post","type-post","status-publish","format-standard","hentry","category-neet-pg"],"yoast_head":"\n<title>Rheumatology Clinical - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/2026\/04\/21\/rheumatology-clinical\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Rheumatology Clinical - atsixty\" \/>\n<meta property=\"og:description\" content=\"GOUT \u00b7 MSU PSEUDOGOUT \u00b7 CPPD ← slow axis → ← slow axis → yellow (parallel) blue (perp) Negative birefringence blue (parallel) Weakly positive birefringence Polarised light microscopy with red compensator. MSU (gout): needle-shaped, negatively birefringent \u2014 yellow when parallel to the slow axis. CPPD (pseudogout): rhomboid, weakly positively birefringent \u2014 blue when parallel. 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