Welcome to your Gp neelima internal medicine-rhuematology 13-02-17

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A 69-year-old smoker and drinker has a two months history of difficulty raising his arms, ascending stairs, and a dry mouth. He has proximal weakness of all four limbs with absent tendon reflexes. CXR shows a right pleural effusion. What is the most likely diagnosis?

A 73-year-old female is diagnosed with giant cell arteritis and is treated with Prednisolone 60 mg per day. What is the most appropriate treatment for the prevention of steroid induced osteoporosis?

A 31-year-old male presents with a week history of a painful right leg. Past medical history reveals that he had erythema nodosum and recurrent oral and scrotal ulceration. Examination reveals a diffusely swollen left leg. What is the most likely cause of his swollen leg?

A 43-year-old has six month old dyspepsia and a 3 year history of Raynaud´s phenomenon. On examination she had telangiectasia. Her investigations reveal an ESR of 40 mm/hr and positive anticentromere antibodies. Which of the following is a typical late complication of this disorder?

A male aged 52 years has a six-week history of general malaise and a 2 day history of a right foot drop, left ulnar nerve palsy and a widespread purpuric rash. He also complained of arthralgia but no clinical evidence of inflammatory joint disease was present. Investigations showed
ESR 100 mm/hr (0-20)
ANCA Negative
ANA Negative
Rheumatoid factor strongly positive
C3 0.8 g/L (0.75-1.6)
C4 0.02 g/L (0.14-0.5)
Urine dipstick Blood + +, No protein
An echocardiogram was normal and two sets of blood cultures were negative. What is the most likely diagnosis?


A 44 year old male attends you for an insurance medical and is in good health. Examination was normal but investigations reveal that he has a serum urate concentration of 0.55 mmol/ L (0.25-0.45). Which management is most appropriate in this patient?

A 45 year old male presents 2 weeks after you see him for infectious diarrhea caused by C. Jejuni. He has now developed unilateral lower limb weakness and bilateral distal parasthesia and decreased ankle tendon reflex. The most likely diagnosis is

An elderly man complains of lower back pain. X-ray reveals decreased joint space and osteophytes. The most appropriate diagnosis is

A 55 year old male presents with acute onset on painful great right toe. It is swollen, red and tender. This is his first episode. You decide to order a serum uric acid and 24 hour urine for uric acid. You would then prescribe which of the following?

Which of the following is a pro-inflammatory cytokine?

A 41-year-old with rheumatoid arthritis treated with a potentially remittive agent has a low oxygen saturation on routine oximetry prior to upper gastrointestinal endoscopy for severe dyspepsia. Further studies reveal elevated carboxymethemoglobin. The remittive agent she is receiving is probably

The appearance of pseudofractures on radiographs is associated with

A 27 year old woman complains of fatigue, stiffness, and a diffuse aching in her neck, shoulders, and back for several months. She is not sleeping well. A physical examination is unremarkable except for tenderness over the upper trapezius, second costochondral junctions, lateral epicondyles, and medial knees. A CBC, erythrocyte sedimentation rate, and rheumatoid factor are unremarkable. The most appropriate management at this time is

A 16-year-old has five day old swollen knee and a low-grade fever. She had pain while urinating and vaginal discharge two weeks ago, which she thought to be an yeast infection. Her knee is aspirated and the cell count shows 40,000 WBCs and 10 RBCs. Cultures are pending. The most appropriate treatment would be

A 34-year-old woman presents with a history of progressive stiffness of her fingers and cold intolerance of her hands and feet. Which one of the following is LEAST likely to be associated with her condition?

A 60 year old woman presents with complains of "feeling tired." She also complains of frequent one sided throbbing headaches. Physical examination reveals tenderness over both temples. Investigations show elevated erythrocyte sedimentation rate. This patient if not treated aggressively can develop which one of the following?

A 20 year old Japanese woman presents with sudden left upper extremity hemiparesis and blindness in the left eye. Examination demonstrates absent pulses in both arms and bruits in the carotid arteries. Her ESR is 100 mm/hr. The most likely diagnosis is

True statement regarding the use of alendronate (Fosamax) for the treatment of osteoporosis in men is

A 43 year old woman complains of fatigue and chronic joint pain as well as morning stiffness, which lasts approximately an hour. Physical examination reveals nontender, rubbery nodules on her elbows. Biopsy of synovium from her knee joint is shown in a photomicrograph below. The most abundant cells in the inflammatory infiltrate are which of the following?

Clinical sign that is described by pain on dorsiflexion is which one of the following?

A 33 year old man of Middle Eastern origin presented with uveitis, genital ulcers, and recurrent oral ulcers. Joint pain in the knees and ankles was also present. Investigations were positive for HLA-B51. The most likely diagnosis is

Drug that can be administered to pregnant women with active rheumatoid arthritis with relative safety if necessary is which of the following?

A 25 year old woman presents with fever, weight loss, and malaise. Examination reveals a "butterfly" rash and rashes over sunlight exposed. The autoantibodies that would strengthen the diagnosis of systemic lupus erythematosus are

Roentegram studies of the spine in a 38 year old woman reveal no abnormalities. A follow up radiographic evaluation is performed approximately three months later and sacroiliitis is detected. The most likely diagnosis is

A 34 year old female factory worker uses a stapling gun every day in her right hand. After several months she notices pain and some numbness in her right thumb and index finger. What is the most likely cause of her discomfort?

A prisoner of age 40 years was exercising vigorously in his prison cell, lifting weights, when he suddenly felt weakness, malaise, and muscle pain. He has never experienced this before, although he has been working out for many years. He was found to have an elevated creatinine phosphokinase level and no red blood cells in the urine. The treatment of choice is which one of the following?

What is a major distinguishing characteristic of the urinalysis in patients with acute rhabdomyolysis?

A 45 year old dialysis patient presents with arthritis of the distal and proximal interphalangeal joints of the hands that is secondary to the deposition of pyramidal shaped positively birefringent crystals. After NSAID therapy he recovers without complication. The most likely diagnosis is

A 54 year old male has reddening and itching of his skin. Examination shows erythematous areas covered by a silvery scale on the extensor surfaces of his elbow and knees. Pain in his hands and knees is also present. Joint involvement in this condition is pathologically similar to that in which condition?

A 47 year old woman has a feeling of sand in her eyes and reports difficulty swallowing such foods as crackers or toast. Biopsy of an enlarged salivary gland reveals lymphocytic infiltration. There is hyperplasia of the ductal linings and signs of fibrosis and hyalinization of the acini. The pair of tests that would likely reveal positive results in this patient includes

 Rheumatoid factor and anti-SS-A antibody

A 28-year-old man presents with fever, urethritis and arthralgia. He is found to have a swollen ankle with a pustular rash on the dorsal aspect of his foot.

A 74-year-old lady presents with pain and swelling of the left wrist. Three weeks ago she received an intra-articular steroid injection into the wrist as treatment of chronic pain which was felt to be due to osteoarthritis. On examination, the joint is erythematous, swollen and tender. Results reveal:

White cell count 12.5 x 103/L
LDH concentration 400 U/L
Rheumatoid Factor 34 U/L

X-ray of wrist revealed a bony destruction of the joint and wrist aspiration revealed only a dry tap. What is the most diagnosis?

A 49-year-old undergoes bone densitometry which shows bone mass decreased more than 2 standard deviations below the mean for her age in her left femoral head, wrist, and lumbar vertebral region. Six months later, the amount of bone loss is seen to be increased by repeat densitometry examination. Which serum laboratory test abnormality is associated?

A 21-year-old lady presents has typical erythema nodosum. She has a low grade fever and bilateral ankle arthritis. No history of travel abroad present and no medication taken. Which of the following would be the most appropriate investigation for this patient?

A 44 year old female notices that she develops tingling and numbness over the palmar surface of her thumb, index, and middle fingers after working several hours at her computer workstation making a document. She also reports that pain in the same area often occurs at night as well. Her symptoms account for which pathological finding?

A female aged 36 years, who was two months postpartum, presented with complains of joint pain, skin rash and fever. On investigation ESR was found to be 40 mm/hour (0-20). What is the most likely diagnosis?

A 72-year-old with chronic renal impairment and atrial fibrillation for which he takes warfarin, presents with an acutely tender and red left big toe.
Investigations reveal:

Serum Creatinine 200 micromol/l (50-100)
Serum Urate 0.51 mmol/l (0.12-0.42)

Which of the following is the most appropriate treatment for this man´s presentation?

Congenital Heart block in a Neonate given birth by a mother maybe due to which antibody in the mother´s serum?

A 39-year-old lady presents to clinic complaining of an 18 month history of dorsoradial wrist pain. She is a keen tennis player. On examination she has tenderness localized to the dorsoradial aspect of the wrist and passive motion of the thumb causes crepitus in the same region. Finkelstein´s test is positive. What is the likely diagnosis?

A 24-year-old non-smoker lady has left knee joint pain along 10 week old weight loss. With good appetite, she had occasional loose motions twice daily over this time. She neither smokes nor takes any medicines but takes modest quantities of alcohol. Family history of Hypothyroidism is +ve. Examination reveals a swollen, tender left knee joint with a small effusion. Which of the following likely diagnosis?

A 29-year-old man presented with acute stiffness and swelling of his knee and ankles, and a painful rash on his legs. ESR was 87 mm in the first hour (0-15). Chest X-ray showed hilar lymphadenopathy. What is the likely outcome?

A 22 year old boy has acute fever, malaise and pain in and just below the left knee. There has not been any injury. Which physical finding is most consistent with acute osteomyelitis?

The radiographic feature that is most consistent with osteoarthritis of the knee is

A 48 year woman has had rheumatoid arthritis for 8 years. Her hands now show moderate ulnar deviation of the fingers and she says her wrists and knees also hurt. She says, "I had several drop attacks during the past 3 months." She characterizes these attacks as episodes of weakness and loss of feeling in her legs for several minutes. During one of these episodes, she became incontinent. On physical examination she has facial plethora and swollen and painful metacarpophalangeal and knee joints, bilaterally. The rest of the examination is normal. The most likely cause of her "drop attacks" is

All of the following features are commonly present in osteoarthritis EXCEPT

A 51-year-old woman with a long history of rheumatoid arthritis is taking nonsteroidal anti-inflammatory drugs. Which one of the following is associated with her illness?

A 69 year old man developed a violaceous discoloration around the eyes and a violet erythema over the knuckles that spared the skin over the phalanges. He complained of arthralgia several months later and noted difficulty rising from a chair. The most common and specific serologic marker found in this disease is which of the following?

A 39 year old cab driver presents with excruciating pain in his hands. He has a 30-pack-year history of cigarette smoking, has hypercholesterolemia, has not been compliant with medications. He admits to drinking in excess "fairly often." Physical examination is remarkable for severe ulcerations on the fingertips and atrophic nail changes. The 4th digit on the left hand is gangrenous at the tip. The most likely diagnosis is

A 39 year old man is brought to the emergency room with multiple arm and leg fractures following a minor fall. Examination reveals a slight weakness of facial muscles on the left. Blood investigations show a mild anemia. X-ray studies demonstrate a generalized bony widening with partial obliteration of marrow spaces. The patient´s condition is most likely due to abnormal functioning of which of the following type of cell?

Which one of the following is the most common site of gout attacks?

A 51 year old woman presents with enlarged knuckles and large subcutaneous nodules hear her elbow. Her proximal interphalangeal joints (PIP) are hyperextended and her distal interphalangeal joints (DIP) are flexed. The nodules when biopsied would show which of the following histological appearance?

Modality of therapy that can be very helpful in restoring some of the abilities necessary for the routine activities of daily living in patients with rheumatoid arthritis is

A 35 year old woman has recent onset of systemic lupus erythematosus. She has polyarthralgias, episodic mild skin rashes, and occasional pleurisy. What is the best initial treatment?

A 55 year old woman who is taking procainamide for her cardiac condition develops arthralgias, rash, myalgias, and a pleural effusion eight months later. She was found to have a fever of 101°. The anti-body titers that would be positive in this particular condition include

A 74 year old male presents with high output cardiac failure. Further examination demonstrates hypercalcemia, elevated alkaline phosphatase, and a disabling weakness secondary to left pelvic bone pain. The most likely diagnosis is

A 31 year old woman has dry eyes, dryness of the mouth, and increased epistaxis. Examination showed xerostomia, keratoconjunctivitis sicca, and dryness of the nasal mucosa. She was found to have positive titers of anti-SSB antibody. Useful diagnostic test in this condition is

Antibody studies given below suggest which one of the following disease?

Anti-ribonucleoprotein (anti-RNP) high titer
Rheumatoid factor (RF) low titer
Anti-single stranded DNA (anti-ssDNA) low titer
Anti-double-stranded DNA (anti-dsDNA) not detected
Anti-Smith antigen (anti-Sm) not detected
Antia Scl-70 not detected

A 52-year-old female has rheumatoid arthritis. She states that she is allergic to Penicillin and Co-Trimoxazole. Therefore, which of the following drugs is contraindicated?

An 86-year-old woman presented with bilateral osteoarthritis of the knees. She had no history of previous gastrointestinal disease. Which of the following is the most appropriate initial treatment for her?

A 56-year-old is recently commenced on leflunomide for sero-negative rheumatoid arthritis. Prior to the drug, her AST was 33 U/L and her ALT was 40 U/L which are now increased to 59 U/L and 72 U/L respectively. Her FBC is normal. Alkaline phosphatase=100 U/L and Bilirubin=12 µmol/L. What is the most appropriate management option?

A 47 year old man has a history of pain in his left knee for several years. No joint swelling is present. The pain decreases as he moves about during the day. The disease process involved is probably which one of the following?

A man aged 71 years underwent an elective surgery for inguinal hernia. He developed acute monoarthritis of his right ankle on the second postoperative day. He was using a diuretic for hypertension. His temperature was 38°C on examination. Which one of the following is the most likely diagnosis?

A 25 year old female returns to the office a follow-up visit. She was last seen 2 weeks ago because of a facial rash that worsens with sun exposure. She complains of joint pain today. She says, "It just hurts everywhere, sometimes my knees hurt, and sometimes it´s my elbows or my ankles. And I have been feeling tired all the time. I just don´t have any energy." She denies any joint swelling. Urinalysis shows 3+ proteins. You consider the diagnosis systemic lupus erythematosus and plan additional diagnostic testing. If she has systemic lupus erythematosus, studies are most likely to show

A man develops swelling in his knee. Swelling is red warm on examination. An arthrocentesis is performed and comes back showing rhomboid positively bifringent crystals. What is the most appropriate treatment?

A 74 year old female presents with a pain in her hips and shoulders bilaterally for 1 month, accompanied by marked stiffness in the morning. In addition, she reports a 4lb weight loss and fatigue. She denies fever, chills, sweats, nausea, vomiting, swallowing disturbances, or changes in bowel habits. She specifically denies any visual symptoms of headache. Her physical examination is unremarkable, except for changes suggestive of osteoarthritis in the knees and hands. Laboratory testing reveals a hemoglobin level of 11.8 g/dL. (N 13.0-16.0), a hematocrit of 36% (N 40-45), and an erythrocyte sedimentation rate of 84 mm/hr

A 71 year old woman suffered a lumbar vertebral fracture 3 years ago. At that time she had a dual energy X-ray absorptiometry (DEXA) scan, with a T score of -2.6, and was placed on alendronate (Fosamax), calcium, and vitamin D. She recently quit smoking. Her BMI is 21. A DEXA scan today shows her bone mineral density to be -2.1. Most appropriate in the management of this patient is

Which is not associated with HLA-B27?

A 73-year-old afebrile man has acutely painful right knee that is hot and swollen. His white cell count is 12.8 x109/L (4-11 x109) and a knee X-ray shows reduced joint space and calcification of the articular cartilage. Culture of aspirated fluid revealed no growth. Diagnose:

The first line therapy for mild to moderately severe psoriasis confined to the elbows and knees is

A 78 year old man with a previous history of prostate cancer has a lumbar spine films suggesting osteopenia. Subsequent bone density studies show a T score of 2-2.7. The appropriate therapy would be

A positive flexion abduction external rotation (FABER) test that elicits posterior pain indicates involvement of which of the following joints?

Which of the following is NOT true?

Which one of the following is NOT characteristic of limited systemic scleroderma?

The test most appropriate for the diagnosis of dermatomyositis is

A 38 year old female presents with complaint of bone pain. X-rays are taken and a diagnosis of osteosarcoma is made. The most likely appearance of the affected bone on X- ray is

A 27 year old woman presents with a history of recent digital ulcerations, small nodules on her digits and around her knees that occasionally drain white material, and a sensation that she cannot fully open her mouth. Whenever she gets cold her hands turn blue and get painful. She also likely has noted which one of the following symptoms?

A patient mentions that after many years without teeth problems, she has recently developed severe caries. According to her she has had pain and swelling in her hands and knees for many years. More specifically, she finds that her MOP joints and wrists are warm and tender, and are most painful in the morning. The test that would most likely reveal the definitive diagnosis for this patient is

A woman aged 42 years presents with a history of white cyanotic appearing digits when she is exposed to cold which is promptly relieved by heat with a resultant hyperemia. Her pulses are normal and she has chronic nail and skin changes. This clinical condition is known as

A 44 year old man presents with an acute attack of severe first right toe pain. No fever, trauma, or other medical problems are present. On aspiration of the joint fluid what would the physician see under a polarizing microscope?

What is the most effective treatment for gout in a patient allergic to cochicine?

A 21 year old woman presents to her physician after noticing blurred vision attacks. On physical examination absent pulses in the regions of the aortic arch and the arms are revealed. The most likely diagnosis is

A 32 year old female presents to her physician because of weakness, discomfort, and coldness in both arms that are exacerbated when she does overhead work or tries to carry anything. She has had generalized fatigue for several months and has lost about 15 pounds. Which of the following finding would be present on the physical examination?

A 55 year old male has a swollen, extremely painful right knee. He has a history of a few similar episodes over the last five years, involving either knees or ankles. He also has low grade fever. Synovial fluid aspiration reveals no crystals or bacteria but a white count of 35,000. Chondrocalcinosis is revealed on knee radiography. The treatment of choice in this patient is

A 56 year old man has arthritic pain in his first metatarsophalangeal joint. Serum analysis demonstrates a uric acid level of 8.3 mg/dl. Arthrocentesis reveals the presence of tophi. The statement LEAST likely appropriate to this man´s disorder is

Common vertebral column finding in ankylosing spondylitis is

Which one of the following is NOT commonly associated with rheumatoid arthritis?

During auscultation of the heart of a 30 year old male a faint murmur consistent with aortic regurgitation is heard. Musculoskeletal system examination shows decreased range of motion of the hips bilaterally and of the spine in rotation and forward bending. No scoliosis is seen. Eyes and mouth exam is unremarkable. His skin is smooth and dry. The doctor thinks of a spondyloarthropathy. Which test would best differentiate this patient´s disease from the other spondyloarthropathies?

A 60-year-old female has shoulder pain for the last 3 months after treatment of a fractured radius that involved casting of the wrist and elbow and use of an arm sling for 8 weeks. It is severe at night. Stiffness and difficulty moving the affected shoulder exists. Exam reveals limited active and passive range of motion of the shoulder, and arthrography demonstrates decreased capacity of the joint space. Which of the following is the most likely diagnosis?

Which of the following most accurately describes the mechanism of action of the bisphosphonates?

A middle aged man has had increasing back pain and right hip pain for the past 10 years. The pain is worse at the end of the day. He has bony enlargement of the distal interphalangeal joints. He is otherwise healthy with no prior medical history. Presence of prominent osteophytes involving the vertebral bodies is seen on the spine radiograph. Radiograph of the pelvis shows sclerosis with narrowing of the joint space at the right acetabulum seen. Which of the following pathologic processed is most likely to be taking place in this patient?

A 51 year old lady presents with dry eyes, a dry mouth, an erythematous rash and polyarthralgia.
Investigations show:

Anti-Ro/SSA antibodies strongly positive
Rheumatoid factor Positive
IgG 45 g/L (<15)
IgM Normal
IgA Normal
Kappa/lambda ratio Normal

Which of the following is the most likely diagnosis?

A lady of 38 years of age presents to you with a feeling of being tired all the time. Out of the following, which clinical finding is consistent with chronic fatigue syndrome?

A 38 year old woman has a history of weakness, diplopia and fatigue. Rheumatoid arthritis had been recently diagnosed in her. On examination there was bilateral ptosis and weakness of abduction of both eyes and mild proximal weakness of the arms and legs but sensation and reflexes were normal. Which of the following is the most likely diagnosis?

A 33 year old woman comes to you with a history of the gradual onset of pain and tenderness in the wrists and hands for 3 months. She also complains of 1 hour of morning stiffness, she denies rash, fever, or skin changes. On physical examination she has symmetric swelling of the proximal interphalangeal joints and metacarpophalangeal joints. Movement at these joints is painful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, and chest films are unremarkable. Her CBC is normal, but the erythrocyte sedimentation rate is elevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclear antibody (ANA) test is negative. The most likely diagnosis is

A 75 year old black female has moderately severe pain due to osteoarthritis. She is also on medication for a seizure disorder. When choosing medications to management her chronic pain, which one of the following should be used with caution because of her history of seizures?

A patient with long standing rheumatoid arthritis, who has been taking medications for it, develops tinnitus. The most likely cause is

A 55-year-old alcoholic male presents to the emergency room complaining of severe pain and swelling of his right toe. He denies any recent trauma, urogenital infections, diarrhea, rashes, or sexual activity. There is no family history of arthritis. This pain usually occurs after binge drinking and subsides with Nonsteroidal anti-inflammatory drugs. What is the most likely diagnosis in this patient?

A 77 year old Asian woman comes to your office with a history of the gradual onset of localized low back pain for 6 weeks. The pain is increased with walking or standing and relives by sitting and lying. Pushing a shopping cart dramatically relieves the pain. Which one of the following is the most likely diagnosis?

A 36-year-old woman falls from a ladder and sustains a severe comminuted fracture of her distal humerus with intra-articular extension. Several days after surgery, she develops acute pain, swelling, and redness of the involved elbow, as well as fever and chills. The likeliest cause is: