Welcome to your Gp neelima internal medicine-rhuematology kit 213-02-17

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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



Which one of the following drugs is contraindicated in acute gouty arthritis?



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



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?



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?



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?



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?



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?



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



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?



Which of the following is NOT useful in the management of Paget´s disease?



Which test is most appropriate for the diagnosis of osteoarthritis?



Which of the following test is most appropriate for the diagnosis of gout?



Which one of the following is associated with psoriatic arthritis?



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?



A condition that is usually NOT associated with an elevated creatine phosphokinase level is which one of the following?



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?



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?



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



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?



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?



A 25-year-old promising athlete is diagnosed with chronic fatigue syndrome. Which of the following treatments is indicated?



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.



A 31-year-old woman presents with Raynaud´s phenomenon. Which one of the following clinical features suggests an underlying connective tissue disease?



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?



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?



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



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



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?



Guillain-Barre syndrome is not associated with



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.



An 86-year-old patient with recurrent falls has a fracture of the distal ulna. Which of the following statements is/are correct?



A 43-year-old female has dermatomyositis. Which one of the following autoantibodies is seen in the highest frequency in dermatomyositis?



The diagnostic test of choice for the diagnosis of myasthenia gravis is



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?



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?



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



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



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?



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?



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?



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?



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?



Which of the following is NOT an immunologic abnormality in systemic lupus erythematosis?



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



Which of the following is a manifestation of rheumatoid arthritis?



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?



FALSE statement regarding systemic lupus erythematosis is which one of the following?



Which of the following condition is NOT frequently associated with the HLA-B27 antigen?



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



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?



Tennis elbow is associated with?



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?



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:



Which of the following regarding Infliximab is most true?



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?



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?



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?



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?



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?



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



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



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:




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?


 



What is the most effective treatment for osteoporosis?



What would be radiographic feature of osteoarthritis of the knee joint?



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



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?



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?



Which of the following observation does NOT support an immunological basis for the development of rheumatic fever?



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 disease that most predisposes an individual to the development of secondary amyloidosis is



All of the following have a role in the management of acute gout, EXCEPT



Which of the following should NOT be a treatment of a patient with rheumatoid arthritis and myasthenia gravis?



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



What is the most important aspect of the management of septic arthritis of the hip?



Which one of the following is commonly seen in osteoarthritis?



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?



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?



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?



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?



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?



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:



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?












: 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?



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?



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?



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



The least likely cause of avascular necrosis is



A 66 year old woman is concerned about osteoporosis. The study of choice for determining whether or not she has osteoporosis is



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.



Which of the following statements is true regarding neck of femur fracture?



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?



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?



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



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



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?



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?



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



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?



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