Gp neelima internal medicine-rhuematology kit 213-02-17 Welcome to your Gp neelima internal medicine-rhuematology kit 213-02-17 Name Business Email Phone Number A 30 year old woman has migratory arthritis of her ankles and wrists and a vesiculopustular skin eruption. She is afebrile. Physical examination reveals tenosynovitis of her wrists. The most likely diagnosis is Gonococcal arthritis Reiter´s syndrome Rheumatoid arthritis Meningococcemia Systemic lupus erythematosus Hint Which one of the following drugs is contraindicated in acute gouty arthritis? Indomethacin Colchicine Glucocorticoids Allopurinol All of the above drugs are indicated. Hint A 25 year old Turkish man has had recurrent genital and oral ulcers for several years as well as waxing and waning joint pains. On examination, he was found to have cutaneous vasculitis and inflammation in the posterior chamber of the eyes on slit-lamp exam. X-rays reveal erosive changes of the hip and knee joints. The most likely diagnosis is Sarcoidosis Reiter´s syndrome Polymyositis Polymyalgia rheumatica Behcet´s disease Hint A 33 year old man presents to a physician because of a painful, swollen knee for several weeks. The patient reports having had several episodes of painful urination prior to the onset of his knee pain. Physical examination reveals an edematous knee, and bilateral conjunctival injection with mucopurulent discharge. The synovial fluid if aspirated from his knee would most closely resemble synovial fluid aspirated from a joint in a patient with which disease? Gout Gram-negative bacillary arthritis Osteochondritis dissecans Pigmented villonodular tenosynovitis Rheumatoid arthritis Hint A 16 year old Mexican boy presents with pain and deformity of his right hand and forearm. Radiograph of the hand and forearm demonstrates erosion of the terminal phalanges and marked metaphyseal resorption of the ulna and radius. The boy also has chronic renal failure but has not been treated with dialysis. These problems are caused by excessive secretion of which of the following hormones? Aldosterone Calcitonin Parathyroid hormone Renin Vitamin D Hint A 62 year old woman presents with progressive tightening and hardening of the skin on her arms and face that has recently caused disfigurement and caused her difficulty in performing manual activities. You suspect an autoimmune disorder and order an antinuclear antibody panel. The results show antitopoisomerase I and no anticentromere antibodies. If the patient is left untreated, her disease will most likely do which do which of the following? Convert to a dermatologic malignancy Progress to involve other skin surfaces Progress to potentially fatal systemic fibrosis Remit completely Stabilize, with residual dermal fibrosis Hint A 48-year-old woman with rheumatoid arthritis is found to have thrombocytosis (platelet count of 700,000) on a routine blood exam? What statement regarding her is correct? Her arthritis is active. She is likely to develop thrombi. She should be put on anticoagulation. She probably has a myeloproliferative disorder. Hint An old woman presents to her physician that eyes and mouth are always dry. She also complains of sore, aching joints, which she says have limited her ability to perform her daily activities. Aspiration of joint fluid would most likely reveal which of the following? Calcium pyrophosphate crystals Excessive cartilage loss and reactive bone formation Monosodium urate crystals Non proliferative synovitis with many neutrophils and gram negative diplococci Proliferative synovitis with many lymphocytes macrophages, and plasma cells Hint A 62 year old woman presents with fatigue, morning stiffness for over 30 minutes, inability to comb her hair because of arm weakness, and inability to get up from a chair without assistance. These symptoms have developed gradually over several months. Examination revealed proximal muscle weakness. Investigation show the ESR to be 70 mm/hr. Rheumatoid factor is negative and creatinine kinase level is negative. The correct diagnosis is Polymyositis Giant cell arteritis Polymyalgia rheumatica Rheumatoid arthritis Fibromyalgia syndrome Hint A 42 year old woman complains of numbness and tingling in her thumb and index fingers which gets worse just prior to menstruation. Physical finding likely to be positive is her is which of the following? Shober´s test Schirmer´s test Cervical compression test Phalen´s test Finkelstein´s test Hint Which of the following is NOT useful in the management of Paget´s disease? Salmon calcitonin. Human calcitonin. Eitidrinate disodium. Pamidronate disodium. Naproxen sodium. Hint Which test is most appropriate for the diagnosis of osteoarthritis? Gram stain and culture of synovial fluid. Examination of synovial fluid for presence of urate crystals. Radiographic evaluation with clinical examination. Serum muscle enzyme measurement. Arteriogram. Hint Which of the following test is most appropriate for the diagnosis of gout? Gram stain and culture of synovial fluid. Examination of synovial fluid for presence of urate crystals. Radiographic evaluation with clinical examination. Serum muscle enzyme measurement. Arteriogram Hint Which one of the following is associated with psoriatic arthritis? Bamboo spine Chondrocalcinosis DIP sclerosis Juxta-articular demineralization Pencil in cup erosions Hint Symptom that is more common in individuals with inflammatory arthritis of the back than in people with mechanical low back pain is which one of the following? Morning stiffness Radiation of pain to the leg Numbness of the toes History of trauma Absence of family history Hint A condition that is usually NOT associated with an elevated creatine phosphokinase level is which one of the following? Acute myocardial infarction Dermatomyositis Renal failure Acute trauma Polymyalgia rheumatica Hint A 19 year old boy presents with acute onset of a hot, painful, swollen knee. Which one of the following test should be performed first? Urinalysis Lumbar puncture Arthrocentesis Chest radiograph Tuberculin skin test Hint A 19 year old boy presents with acute onset of a hot, painful, swollen knee. Which one of the following test should be performed first? Urinalysis Lumbar puncture Arthrocentesis Chest radiograph Tuberculin skin test Hint A 23 year old woman presents with low grade fever, abdominal pain, and malaise. Examination showed pallor with no signs of lymphadeopathy, murmur, or abdominal findings. Lab data revealed lymphopenia and a creatinine level greater than 4.0. Slight alopecia was also noted. The most likely diagnosis is Hodgkin´s disease Sarcoidosis Systemic lupus erythematosus Chronic fatigue syndrome Tuberculosis Hint A 21-year-old male has chronic low back pain for the past 8 months. It begins frequently at night, radiates down the thighs along pronounced stiffness and moderate limitation of back motion. Tenderness is +ve. No GIT/GUT symptoms exist. A diastolic murmur along the left sternal border exists. ESR and RF are negative. His x-ray film is shown below. Which of the following is the next best step in management? Intra-articular corticosteroid injection Low-dose oxycodone Methotrexate Nonsteroidal anti-inflammatory drugs Oral prednisone Hint A 76-year-old with hyperosmolar non-Ketotic hyperglycemia has a red, hot and swollen knee. Which of the following is most useful in the diagnosis of the swollen knee joint? C-ANCA CRP Orthopedic referral for joint washout Joint Aspiration Rheumatoid factor Hint A 25-year-old promising athlete is diagnosed with chronic fatigue syndrome. Which of the following treatments is indicated? Group therapy Prednisolone Seroxat Graded exercise therapy Thyroxine Hint A 25-year-old male has been receiving sulphasalazine for six months as treatment for Reiter´s disease. His most recent series of blood tests were normal. Three weeks Two month Three months Seven months One year Hint A 31-year-old woman presents with Raynaud´s phenomenon. Which one of the following clinical features suggests an underlying connective tissue disease? Involvement of toes One previous miscarriage in early pregnancy Symmetrical involvement of fingers Pernio Symptoms developed as a teenager Hint A 60-year-old has increasing back and leg pain for several years. X-Rays reveal bony sclerosis of the sacroiliac, lower vertebral and upper tibial regions with cortical thickening and radiolucent areas. He has greater difficulty hearing on the left. He has orthopnea and pedal edema. Blood tests reveal an elevated serum alkaline phosphatase. What is the most likely pathologic process that explains these findings? Paget´s disease of bone Decreased bone mass Metastatic adenocarcinoma Renal failure with renal osteodystrophy Vitamin D deficiency Hint A man aged 25 years has a three months history of arthralgia, mouth ulceration and eye irritation. On examination he did not have fever but had some ulceration of the mouth, bilaterally swollen wrists and effusions, with reduced range of movements of both knees. Scrotal ulcer was present on external genitilia. His investigations showed: White cell count 12 x 109/l (4-11 x 109) C-reactive protein 120 mg/l (<10) Rheumatoid factor Negative What is the most likely diagnosis? Inflammatory bowel disease Psoriatic arthritis Behcet´s syndrome Reiter´s syndrome Sjogren´s syndrome Hint A 55 year old presents to you with pain and stiffness in both hands and knees of 6 months duration. You suspect rheumatoid arthritis. The physical examination finding that is most distinctive with a diagnosis is Unilateral joint tenderness/effusions Maculopapular rash Joint stiffness worse in the morning Iridocyclitis Hepatosplenomegaly Hint A 19 year old girl presents with pain and swelling of her right knee and no other symptoms. Joint effusion is revealed on investigation. She has been sexually active since she was 15 and is seeing a gynecologist for follow-up of cervical dysplasia. Rheumatoid factor was negative. The most likely diagnosis is Osteoarthritis Gouty arthritis Pseudogout Systemic lupus erythematosus Gonococcal arthritis Hint A woman who is positive for ANA presents with ankle edema, arthralgia, protein in her urine and a butterfly rash on her face. What is the most likely diagnosis? Lupus Scleroderma Multiple sclerosis Rheumatoid arthritis Hint Guillain-Barre syndrome is not associated with Proximal muscle weakness Areflexia Treatment with antibiotics Infection with C. jejuni Hint A 69-year-old woman complained of pain at the base of her right thumb. There was tenderness and swelling of the right first carpo-metacarpal joint. Avascular necrosis of the scaphoid De Quervain´s tenosynovitis Psoriatic arthritis Osteoarthritis Rheumatoid Hint An 86-year-old patient with recurrent falls has a fracture of the distal ulna. Which of the following statements is/are correct? Bone fractures attributable to vitamin D deficiency are due to bone density. Low Vitamin D levels are not associated with muscle weakness The toxic levels of vitamin D occur at approximately twice the therapeutic dose Vitamin D deficiency in the elderly is rare Vitamin D replacement reduces the incidence of fractures in the elderly Hint A 43-year-old female has dermatomyositis. Which one of the following autoantibodies is seen in the highest frequency in dermatomyositis? Anti-neutrophil cytoplasmic antibodies Anti-jo-1 antibodies Rheumatoid Factor Anti-dsDNA antibodies Anti-Ro antibodies Hint The diagnostic test of choice for the diagnosis of myasthenia gravis is EEG Tensilon test MRI of brain SCF analysis Hint A 69 year old presents with an acutely red and swollen right great toe without history of trauma. The most useful finding for making a diagnosis is this patient is which of the following? Persistent elevation of serum uric acid Good response to colchicines trial Radiograph showing joint erosion in the first metatarsophalangeal (MTP) joint An associated right ankle effusion Painless elbow nodule Hint A 32 year old woman presents to a physician with nonspecific complaints of fatigue, malaise, low grade fever, and arthralgias. Screening serum chemistries demonstrate elevated blood urea nitrogen (BUN). The urine is positive for proteinuria. The most likely diagnosis would be established by testing of which one of the following? Anticentromeric antibody Anti-double stranded DNA antibody Antimitochondrial antibody Anti-thyroid stimulating hormone (TSH) receptor antibody Rheumatoid tactor Hint A 54 year old female has a long standing history of morning stiffness of her joints, anemia, and bilateral symmetric arthritis of her hands and feet. Physician examination shows ulnar deviation of her fingers and subcutaneous nodules. She is being treated with corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). The cardiac complication that may arise in this clinical setting is Constrictive Pericarditis Dilated cardiomyopathy Hypersensitivity myocarditis Hypertrophic cardiomyopathy Restrictive cardiomyopathy Hint The x-ray below shows the hip joint of a 66 year old female. If aspiration of the joint fluid had been performed, the most accurate description of the aspirated fluid would be Clear fluid with high protein content and no significant numbers of inflammatory cells Clear fluid with high protein content; neutrophils and mononuclear cells; and culture positive for mycobacteria Clear fluid with high protein content; neutrophils and mononuclear cells; no bacteria and no crystals Purulent fluid with large numbers of neutrophils and culture positive for bacteria Purulent fluid with large numbers of neutrophils and needle-shaped crystals Hint A 55 year old female wakes up one morning with a painful warm pinna and episcleritis. She has a remote history of inflammation of her nose that was attributed to trauma. She is at increased risk for which one of the following? Tracheobronchial inflammation. Lung cancer. Otitis media. Sinusitis. Temporal arteritis. Hint A perimenopausal woman has a bony swelling in the distal in the distal interpharyngeal joint on physical examination. No inflammation is apparent. The proximal interphalangeal joint, hands, and wrists are not involved, and the patient is asymptomatic. What process is related to these findings? Autoantibody formation Bacterial infection Crystal deposition Joint trauma Viral infection Hint A 22 year old bisexual male has a 4 week history of intermittent diarrhea, urethral discharge, and pain in the right knee and left second toe. On examination he has several oral ulcers, a clear urethral discharge, a scaly popular rash on palms and soles, onycholysis, sausage like swelling of the left second toe, and heat and swelling of the right knee. The results of Gram stains and cultures of urethral discharge are negative. No rheumatoid factor is present. Which of the following is the most likely diagnosis? Gonococcal arthritis Reiter´s syndrome Behcet disease Psoriatic arthritis Acquired immune deficiency syndrome Hint A woman aged 45 years presents with complains of dry mouth and dry eyes. The physician suspects a diagnosis of Sjögren´s syndrome. Antibodies found at the highest frequency in Sjögren´s syndrome are which of the following? Anti-neutrophil cytoplasmic antibodies Anti-RNA antibodies Anti-dsDNA antibodies Anti-Ro antibodies Anti-Jo-I antibodies Hint A 36 year old female presents with a gritty sensation in her eyes, dry mouth, and early morning stiffness in her hands, mists, knees, and feet. Investigations would probably show which one of the following? A positive rheumatoid factor. Low C3 levels. An elevated uric acid. Anti-Jo-1 antibodies. Eosinophilia. Hint Which of the following is NOT an immunologic abnormality in systemic lupus erythematosis? Production of pathogenic subsets of autoantibodies and immune complexes is sustained. The mononuclear phagocyte system is unable to process immune complexes normally. Idiotype antiidiotype networks fail to suppress hyperactivated T- and B-cells. T-lymphocytes are skewed to suppressor functions. Tolerance mechanisms that normally eliminate or inactivate strongly autoreactive T- and B- lymphocytes are impaired. Hint A 52 year old man complains of bone pain. Lab data show a normal calcium and phosphate level but alkaline phosphatase levels are elevated. Urinalysis reveals an elevated level of hydroxyproline and roentengram studies demonstrate dense, enlarged bones. Osteocalcin level is increased. The most likely diagnosis is Pott´s disease Osteogenic sarcoma Fibrogenesis imperfect ossium Hyperparathyroidism Paget´s disease Hint Which of the following is a manifestation of rheumatoid arthritis? Bamboo spine Chondrocalcinosis DIP sclerosis Juxta-articular demineralization Pencil-in-cup erosions Hint A 57 year old man presents to the ER with an acutely swollen, painful, and red right great toe for first time. Serum uric acid level is elevated and has monosodium urate crystals in synovial fluid aspirated from his toe. He responds well to oral indomethacin. Which one of the following forms a part of an appropriate discharge plan? Daily oral colchicine and a return appointment for a 24 hour urine collection in three weeks. Daily oral allopurinol. Daily oral allopurinol and a return appointment for a 24- hour urine collection in three weeks. Low purine diet and follow up as needed. Oral penicillamine. Hint FALSE statement regarding systemic lupus erythematosis is which one of the following? It is increased in monozygotic as compared to dizygotic twins. It is increased in women during childbearing years. The relative risk of developing it s increases as the number of susceptibility genes increases. Ultraviolet light produces disease flares. Drug induced and spontaneous diseases have the same clinical and autoantibody picture. Hint Which of the following condition is NOT frequently associated with the HLA-B27 antigen? Ankylosing spondylitis. Ulcerative colitis. Psoriatic arthritis. Iritis. Scleroderma. Hint A 26 year old woman presents with severe arthritis that is acute in onset, fever, and a tender rash on both her lower extremities. Her CXR was normal and nodular, tender, erythematous lesions were noted on the anterior surface of both her legs. The most likely diagnosis is Rheumatoid arthritis Heertfortd´s syndrome Loeffgren´s syndrome Lyme disease Erythema multiforme Hint A 48-year-old male went for an insurance medical examination. He was entirely asymptomatic, but his serum urate concentration was noted to be 0.5 mmol/L (0.23 - 0.46). What is the most appropriate management for this patient? Allopurinol Lifestyle intervention Colchicine Ibuprofen Probenecid Hint Tennis elbow is associated with? Pain on pressure over the medical epicondyle Pain on supination Pain on adduction of the thumb against resistance Pain on wrist extension against resistance Pain on extension of the elbow Hint A teenager treated for sexually transmitted disease three months ago has a large effusion in the right knee. Synovial fluid analysis revealed a white cell count of 16 x 103/l but culture was negative. Which one of the following organisms is the most likely cause? Chlamydia Trachomatis Herpes Simplex Treponema Pallidum Neisseria Gonorrhea Trichomonas Vaginalis Hint A 73-year-old female has tenderness and bony swelling over the base of first metacarpal and wasting of right thenar eminence. Labs show: ESR 30mm/1st hour, CRP normal, Rheumatoid factor 60IU/L. X-ray shows loss of joint space with articular sclerosis and osteophytes of the first carpo-metacarpal joint. Diagnosis is: Osteoporosis Gouty arthritis Paget´s disease of bone Osteoarthritis Rheumatoid arthritis Hint Which of the following regarding Infliximab is most true? It is antibody to TNF-α Is authorized for the treatment of severe ulcerative colitis Is a polyclonal antibody It prevents relapse of Crohn´s disease in patients who are in remission Must not be used in combination with methotrexate due to increased toxicity Hint A 66-year-old male has inadequate pain relief for his hip osteoarthritis. He takes Paracetamol and codeine 30mg four times daily but has found little benefit. What is the most likely explanation for the lack of efficacy here? Inadequate dose of Codeine Fast acetylator status Ipratropium accelerates the metabolism of codeine Impaired absorption of Codeine Interaction of Paracetamol with Codeine Hint A 23-year-old boy with known hereditary angioneurotic edema presents with a recurrent fever, arthralgia and a rash on the face and the upper chest. Despite treatment, he has recurrent attacks and required adrenaline on several occasions. His C4 levels have been persistently reduced secondary to this. What is the most likely cause for his current symptoms? Systemic lupus erythematosus (SLE) Dermatomyositis Erythema Multiforme Psoriasis with arthropathy Viral illness Hint A man in his 20´s begins to note lower back pain and stiffness that is persistent and diminishes with activity. During his 30´s he also develops shoulder and hip arthritis, and in his 40´s he is troubled by decreased mobility of lumbar spine. No other medical problems are present. These findings typically point to which of the following? Calcium pyrophosphate dehydrate deposition disease Lyme disease Ankylosing spondylitis Osteoarthritis Rheumatoid arthritis Hint A 37 year old woman has a history of joint pain and stiffness of hands and feet for six months. Synovitis of distal interphalangeal joints of left index finger and right ring finger along with right wrist and ankle joints is present on examination. Her ESR was 35 mm/hr (0-10). This pattern of joint involvement is most likely to be present in which condition? Osteoarthritis Reactive arthritis Rheumatoid arthritis Psoriatic arthritis Systemic lupus erythematosus Hint A 66 year old male complains of bone pain especially in his spine. Lytic lesions in the vertebrae and skull were revealed on X-ray. The patient had been anemic and hypercalcemic in the past. Which of the following is least likely to be present in this patient? Macroglobulinemia Bence Jones proteins Decreased resistance to infection Infiltration of flat bones by plasma cells Monoclonal gammopathy Hint A 55 year old man presents with extreme pain and swelling of the left middle finger. He suffered a small puncture wound to the volar aspect of the finger at the level of the distal flexor crease four days ago. Passive extension of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints severely aggravates his symptoms. The most likely diagnosis is Pulp space infection Cellulitis Mid-palmar space infection Septic arthritis distal interphalangeal (DIP) joint Septic tenosynovitis Hint A 42 year old woman presents with painful swelling of the joints of her fingers, excessive fatigue and a malar rash. She is most likely suffering from Psoriasis Pseudogout Rheumatoid arthritis Systemic lupus erythematosus (SLE) Serum sickness Hint A 40-year old smoker with rheumatoid arthritis has increasing shortness of breath with a progressive fall in the FEV1. The residual volume is increased by two liters but diffusion is normal. Diagnose: Caplan´s syndrome Chronic obstructive pulmonary disease Organizing pneumonia Bronchiolitis obliterans Rheumatoid associated lung fibrosis Hint A 53-year-old man with chronic alcohol abuse has gouty tophi. He is commenced on allopurinol but develops severe joint pains two days later. On examination he has a temperature of 39°C, and erythematous swelling of his hands, knees and ankles. Investigations reveal: Urate 0.55 mmol/L (0.23-0.46) C-reactive protein 150 mg/L (<10) Which of the following is the most likely cause for his presentation? Acute pyrophosphate arthropathy Acute rheumatoid arthritis Allopurinol allergy Alcohol ingestion Treatment with allopurinol Hint What is the most effective treatment for osteoporosis? Exercise Analgesics Vitamins Bisphosphonates Hint What would be radiographic feature of osteoarthritis of the knee joint? Marginal erosions Loss of articular cartilage with narrowing of the radiologic joint space Juxta-articular osteopenia (demineralization) Osteonecrosis (avascular necrosis) of the medial femoral condyle High riding patella (patella alta) Hint A post menopausal woman comes to you to discuss hormone replacement therapy (HRT). A history of migraine and a strong family history of osteoporosis are present. An appropriate choice would be Offer combination oral estrogen-progesterone HRT Offer progesterone only Offer oral estrogen only Offer biphosphonate only Hint A 30 year old individual with a human leukocyte antigen type of HLA-B27 will be at risk for the development of which one of the following diseases? Reiter´s syndrome Psoriatic arthritis Arthritis associated with gastrointestinal defects Rheumatoid arthritis Osteoarthritis Hint A 37-year old woman with glucose-6-phosphate dehydrogenase deficiency has rheumatoid arthritis. Which one of the following medications should NOT be prescribed for her? Hydroxychloroquine Azathioprine Ibuprofen Prednisone Penicillamine Hint Which of the following observation does NOT support an immunological basis for the development of rheumatic fever? The short latency between streptococcal infection and the development of rheumatic fever. Antistreptococcal antibodies, which cross-react with cardiac tissue, are present in sera. High titers of streptococcal extracellular and somatic antigens in sera. Exaggerated cellular reactivity to streptococcal cell membrane antigens. Increased frequency of class II histocompatibility antigens in sera. Hint A 22 year old registered nurse comes to the employee health clinic because she says, "I´m too tired to work." She has had increasing fatigue, malaise and anorexia during the past several days. Investigations show: ALT 1160 U/L, PT 13 sec, Bilirubin 1.8 mg/dL, HBsAg positive She is instructed to rest at home and return in 3 days if no new symptoms develop. Two days later she calls to say that she has now developed an urticarial rash and swelling of the joints of her fingers. What is the most correct statement about her condition at this time? The arthritis and rash are unrelated to her liver disease The arthritis and rash are the result of an associated immune complex disorder It is unlikely that her blood is infectious She has a 50% risk for developing chronic liver disease She should be given hepatitis B immune globulin Hint The disease that most predisposes an individual to the development of secondary amyloidosis is Inflammatory bowel disease Rheumatoid arthritis Scleroderma Tuberculosis Bronchiectasis Hint All of the following have a role in the management of acute gout, EXCEPT Allopurinol Corticosteroids Colchicine Indomethacin Ibuprofen Hint Which of the following should NOT be a treatment of a patient with rheumatoid arthritis and myasthenia gravis? Penicillamine. Intramuscular gold injections. Azathioprine. Methotrexate. Steroids. Hint A 56 year old man´s examination shows unusual bluish black pigmentation over his face and fingers. His urine sample turned black on adding sodium hydroxide. Spinal films revealed intervertebral disk spaces showing greater radiodensity than the adjacent vertebrae. The most likely diagnosis is Ochronosis Porphyria cutanea tarda Systemic lupus erythematosus Pellagra Sturge Weber syndrome Hint What is the most important aspect of the management of septic arthritis of the hip? Elevation. Immobilization. IV antibiotics. Serial aspiration. Irrigation and debridement. Hint Which one of the following is commonly seen in osteoarthritis? Bamboo spine Chondrocalcinosis DIP sclerosis Pencil-in-cup erosions Overhanging erosions Hint A 45 year old woman has difficulty swallowing, calcifying subcutaneous lesions, and diminished circulation to the fingers. Her fingers have thickened skin and are extended in an inflexible position. What autoantibodies are likely to be present in this patient? Anti-centromere antibody Anti-histone antibody Anti-SS-A Anti-SS-B Rheumatoid factor Hint A 52 year old man has generalized "stiffness" lasting a few hours each morning. He has a recent 10 lb weight loss and a past medical history of duodenal ulcers. On exam, his temperature is 38.1°C (100.5°F), lymphadenopathy and mild splenomegaly. Subcutaneous "nodules" are palpable over selected bony prominences. Which would be recommended for the treatment his acute pain? Acetaminophen Celecoxib Indomethacin Methotrexate Sulfasalazine Hint A 66-year-old man with chronic thigh pain slips and hits his left thigh to the ground, followed by a "snap." He also has decreased hearing in both ears and a 2/6 midsystolic crescendo-decrescendo murmur. X-ray of the left femur shows a midshaft fracture as well as an expanded, deformed cortical contour. X-ray of the right shows an expanded, bowed femur. A bone scan shows focal areas of intense uptake in both thighs. Laboratory data are: Sodium 149 mEq/L Potassium 4.8 mEq/L Chloride 105 mEq/L Bicarbonate 24 mEq/L Urea nitrogen: 13 mg/dL Creatinine: 1.0 mg/dL Calcium: 9.2 mg /dL Phosphate: 2.9 mg/dL AST: 32 IUL ALT: 25 IUL Alkaline phosphatase: 400 IUL GOT: 15 IUL (normal: 9-50 IU/L) ESR: 18 mm/hour Other than referral to orthopedic surgery, what therapy should be offered to this patient? Calcium supplementation Bisphosphonates Doxorubicin High-dose corticosteroids Hydrochlorothiazide Hint A 73-year-old man presents with painful lumps in his feet and is diagnosed with gout. Following initial treatment with non-steroidal anti-inflammatory agents, he is started on Allopurinol. How does this work? Inhibition of microtubule assembly Inhibits Xanthine oxidase irreversibly Inhibits cyclooxygenase II Inhibition of renal reuptake of uric acid Inhibits Xanthine oxidase reversibly Hint A 41-year-old has Raynaud´s phenomenon, dyspepsia and arthralgias. along sclerodactyly and synovitis of the small joints of the hands. ESR =41 mm/hr (<10) but Rf and ANA are both negative. Which of the following is most likely to develop? Malabsorption Anterior uveitis Butterfly rash Erosive joint disease Erythema nodosum Hint A 29-year-old has a 3 month history of arthralgia along swelling of the distal interphalangeal joints of the middle and ring fingers of the hand and wrist on the right plus a swollen left ankle. She had no medical history of note. Her ESR=41 mm/hr. Diagnose: Acute exacerbation of osteoarthritis Rheumatoid arthritis Sjogren´s syndrome Psoriatic arthropathy Systemic lupus erythematous Hint A lady aged 67 presented with complain of pain at the base of her right thumb. Tenderness and swelling of right first carpometacarpal joint was present on examination. Which one of the following is the most likely diagnosis? Avascular necrosis of the scaphoid Osteoarthritis de Quervain´s tenosynovitis Psoriatic arthritis Rheumatoid arthritis Hint : A 17 years old girl presents with a history of polyarthralgia and marked early morning stiffness for 3 months. Her symptoms are relieved by Diclofenac but she is becoming increasingly concerned about her symptoms which appear to be progressing. She is otherwise healthy apart from a history of acne which is well controlled on Minocycline. Her mother has severe rheumatoid arthritis. Investigations: ESR 50 mm/hr (0-20) CRP 100 mg/L (<10) Rheumatoid factor Negative ANA Strongly positive (1: 1600) Anti-dsDNA antibodies Negative IgG 25 g/L (<15) What is the most likely cause? Systemic Lupus Erythematosus Fibromyalgia Rheumatoid arthritis Drug-induced SLE Hint A 52-years-old woman presented with a two week history of malaise and lower limb joint pain, associated with a vasculitic rash over her shins, thighs and buttocks. Investigations revealed: Haemoglobin 9.8 g/dL (11.5-16.5) Platelet count 275 x109 /L (150-400 x109) Serum creatinine concentration 452 µmol/L (60-110) Antinuclear antibodies Negative Antineutrophil cytoplasmic antibodies Negative Antiglomerular basement membrane antibodies Negative Dipstix urinalysis Blood +++ Protein + What is the most likely diagnosis? Amyloidosis Hemolytic uremic syndrome Membranous nephropathy Myeloma Henoch-Schonlein nephritis Hint A 52 year old male has a history of lethargy, polydipsia, polyuria and pain and stiffness of the hands. Evidence of an arthropathy affecting the second and third metacarpophalangeal (MCP) joints is present on his both hands and X-ray of these sites reveal the evidence of degenerative disease. Hepatomegaly of 5cm is also found in this patient. What is your likely diagnosis? Gout Osteoarthritis Pyrophosphate arthropathy Haemochromatosis Rheumatoid arthritis with amyloidosis Hint A 72 year old woman returns to the office because of aching and weakness her arms to the point where she cannot lift her arm to brush her hair. No muscle tenderness or other evidence of joint disease is present in both arms. The aching improves when she takes the prescribed nonsteroidal anti-inflammatory drug (NSAID). She also describes tenderness over the right parietal area of her scalp. Physical examination of the scalp shows no lesions. The most appropriate next step is Increases the dose of the NSAID Order determination of serum rheumatoid factor Order x-ray films of the cervical spine Order determination of erythrocyte sedimentation rate Refer her for psychiatric counseling Hint The least likely cause of avascular necrosis is Sickle cell disease Septic arthritis Steroid use Constrictive dressings Post-traumatic fracture Hint A 66 year old woman is concerned about osteoporosis. The study of choice for determining whether or not she has osteoporosis is A quantititative CT scan of the hip and spine Dual energy X-ray absorptiometry (DEXA) of the hip and spine Plain radiographs of the hip and spine Ultrasonography of the heel A DEXA scan of the middle phalanx of the non-dominant hand Hint A 55-year-old female undergoes a DEXA scan which reveals a bone mineral density (BMD) T score of -2.55 at the hip and lumbar spine. Cushing´s Disease Acromegaly Delayed menopause Hypothyroidism Obesity Hint Which of the following statements is true regarding neck of femur fracture? Internal rotation of the affected limb is a common clinical finding In the young displaced fractures should be reduced and fixed urgently Mortality for elderly patients is >80% at one year Non-union is not a complication Hint A 63-year-old lady is suffering from pain and stiffness of her shoulders and difficulty getting out of a chair. Which of the following would support a diagnosis of Polymyalgia rheumatica? Hypothermia Muscle tenderness Proximal muscle weakness Pelvic girdle stiffness Weight gain Hint A 66 years old hypertensive female has been treated with hydrochlorothiazide, 25 mg/day; atenolol (Tenormin), 100 mg/day; and Hydralazine (Apresoline), 50 mg 4 times/day for several years. Her blood pressure has been well controlled on this regimen. She has experienced malaise, along with diffuse joint pains that involve symmetric sites in the fingers, hands, elbows, and knees over the past 3 months. A pleural friction rub is noted on examination. Laboratory testing shows that the patient has mild anemia and leucopenia, with a negative rheumatoid factor and a positive antinuclear antibody (ANA) titer of 1:640. What is the most appropriate initial treatment? Discontinue the Hydralazine Discontinue the thiazide diuretic and switch to a loop diuretic such as furosemide (Lasix) Begin treatment with prednisone, 40 mg/day orally Treat with hydroxychloroquine (Plaquenil), 400 mg/day Obtain renal function studies and anticipate that a renal biopsy will be needed Hint A woman with lupus suddenly develops a fever and notes that her urine is dark in color. Analysis of her urine reveals the presence of red cells. She has had some joint aching and been feeling unwell for a few days. Her malar rash is about the same as usual for her. The feature that suggests she is experiencing an exacerbation of her disease is C3 and C4 are both normal C3 is low and C4 is normal CH5, C3 and C4 is normal C3 and C4 are low Hint A 73-year-old male with adenocarcinoma of the lung presents with proximal muscle weakness and an elevated creatine phosphokinase level in his serum. The likeliest diagnosis is Myasthenia gravis. Inclusion body myositis. Guillain-Barre syndrome. A paraneoplastic syndrome. Pressure effects of the cancer on the sympathetic chain. Hint A 46-year-old construction worker has to work alone at a heavy job that usually requires a two-man crew because his partner is ill. Next day, he wakes up with diffuse pain and stiffness. Which one of the following tests is most likely to be abnormal? Hemoglobin Antinuclear antibody Electrocardiogram Chest radiograph Creatine phosphokinase Hint A 33-year-old woman complains of severe joint pain in her elbow and knee joints. An arthocentesis test is performed. WBC count is shown to be 4,000 cells /microliter in the synovial fluid, yet no bacteria can be cultured. Which one of the following findings would be diagnostic for the presence of rheumatoid arthritis? T-cells specific for myelin basic protein Autoantibody directed at myelin basic protein Autoantibody directed at type I collagen Autoantibody directed at serum immunoglobulins T-cells specific for serum immunoglobulins Hint An 82 year old man has onset low back pain. X-ray of the lower back and pelvis shows sclerotic changes in the lower vertebrae and in focal areas throughout the pelvis. The radiologist´s report states that the sclerotic changes may represent osteoarthritis; however, a neoplastic process cannot be excluded. The most cost effective method in the initial work-up of this patient is Bone marrow aspirate and biopsy Digital rectal exam Prostate-specific antigen Radionuclide bone scan Serum alkaline phosphatase Hint A 54 year old woman develops symptoms consistent with left knee arthritis. Physical examination demonstrates a large effusion over the joint, which is aspirated for analysis. Fluid analysis reveals needle shaped negatively birefringent crystals. Which of the following is the most likely diagnosis? Gout. Pseudogout. Apatite disease. Rheumatoid arthritis. None of the above. Hint Time's up Submit a Comment Cancel replyYour email address will not be published. Required fields are marked *Comment * Name * Email * Website Save my name, email, and website in this browser for the next time I comment.
