krok 2 (Rheumatology) with explanation part 3

Correct answer for all Question is A
41.) A 28-year-old female patient with a six-year history of Raynaud’s syndrome has recently

developed pain in the small joints of hands, difficult movement of food down the esophagus.

What kind of disease can you think of in this case?

A. Systemic scleroderma

B. Periarteritis nodosa

C. Rheumatoid arthritis

D. Systemic lupus erythematosus

E. Pseudotrichiniasis

EXPLANATION:-Systemic scleroderma, also called diffuse scleroderma or systemic sclerosis, is an autoimmune disease of the connective tissue. It is characterized by thickening of the skin caused by accumulation of collagen, and by injuries to small arteries.

CREST syndrome (Calcinosis, Raynaud's phenomenon, Esophageal dysfunction, Sclerodactyly, and Telangiectasia) is associated with limited scleroderma.There are two forms of scleroderma: localized and systemic. The localized (limited) form affects the skin of only the face, hands, and feet. The systemic (diffuse) form involves those and, in addition, may progress to visceral organs, including the kidneys, heart, lungs, and gastrointestinal tract.

42.) A 60-year-old patient complains of recurrent pain in the proximal interphalangeal and wrist

joints, their periodic swelling and reddening that have been observed for 4 years. X-ray picture

represents changes in form of osteoporosis, joint space narrowing and single usuras. What is the

most likely diagnosis?

A. Rheumatoid arthritis

B. Osteoarthritis

C. Gout

D. Pseudogout

E. Multiple myeloma

EXPLANATION;-Rheumatoid arthritis(RA) a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles.Female affected more than male. MCPs and PIPs involved but not DIPs. Characterized by morning stiffness more than 1hr, pain gradually reliefs after exercis , ulnar deviation, Boutonierre deformity ,Swan neck deformity ,rheumatoid nodules backers cysts also present.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
• Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

43.) A 36-year-old female patient complains of intense pain in the knee joints and neck. In the

morning she experiences pain in the interscapular region and leg joints; pain subsides after

warm-up gymnastics. The patient is overnourished, there is a clicking sound in the knees when

squatting, the knees are somewhat disfigured, painful on palpation. Blood test results: ESR- 18

mm/h, WBC- 8, 0·109/l. Radiography reveals subchondral sclerosis in the left knee. What is the

basis of this pathology?

A. Degenerative processes in cartilage

B. Autoimmune process in the synovium

C. Deposition of urates (tophi) in the articular tissues

D. Beta-haemolytic streptococcus

E. Hemarthrosis

EXPLANATION;-Rheumatoid arthritis(RA) a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles.Female affected more than male. MCPs and PIPs involved but not DIPs. Characterized by morning stiffness more than 1hr, pain gradually reliefs after exercis , ulnar deviation, Boutonierre deformity ,Swan neck deformity ,rheumatoid nodules backers cysts also present.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
• Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

44.) After a holiday in the Crimea, a 36-yearold female patient presents with severe pain in the elbow

joints, dyspnea and weakness. The body temperature is of 37, 6oC, the skin is pale, there is

erythema of cheeks and nose, lower lip ulceration. Visual inspection reveals no changes in the

joints, the right elbow movement is limited. There is murmur and pleural friction in the lungs

below the right angle of the scapula. Cardiac sounds are muffled, there is tachycardia, gallop

rhythm, Ps- 114/min. AP- 100/60. What is the most likely diagnosis?

A. SLE

B. Rheumatic heart disease

C. Rheumatoid arthritis

D. Infectious allergic myocarditis

E. Dry pleurisy

EXPLANATION:-is an autoimmune   systemic disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body.

American College of Rheumatology (ACR) established  .A person has SLE if any 4 out of 11 symptoms are present simultaneously or serially on two separate occasions.

 • Malar rash (rash on cheeks- BUTTERFLY RASH)

 • Discoid rash (red, scaly patches on skin that cause scarring).

 • Serositis: Pleurisy (inflammation of the membrane around the lungs) or pericarditis (inflammation of the membrane around the heart).

 • Oral ulcers (includes oral or nasopharyngeal ulcers).

 • Arthritis: nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion.

 • Photosensitivity (exposure to ultraviolet light causes rash, or other symptoms of SLE flareups).

 • Blood—hematologic disorder—hemolytic anemia (low red blood cell count), leukopenia (white blood cell count<4000/µl), lymphopenia (<1500/µl), or low platelet count (<100000/µl) in the absence of offending drug. Hypocomplementemia is also seen, due to either consumption of C3 and C4 by immune complex-induced inflammation or to congenitally complement deficiency, which may predispose to SLE.

 • Renal disorder: More than 0.5 g per day protein in urine or cellular casts seen in urine under a microscope.

 • Antinuclear antibody test positive.

 • Immunologic disorder: Positive anti-Smith, anti-ds DNA, antiphospholipid antibody . Presence of anti-ss DNA in 70% of cases(most common in SLE).

 • Neurologic disorder: Seizures or psychosis.

Note: Libman–Sacks endocarditis associated with SLE

45.)A 60-year-old female patient complains of recurrent pain in the proximal interphalangeal and

wrist joints, their periodic swelling and reddening that have been observed for 4 years. X-ray

picture represents changes in form of osteoporosis, joint space narrowing and single usuras.

What is the most likely diagnosis?

A. Rheumatoid arthritis

B. Osteoarthritis

C. Gout

D. Pseudogout

E. Multiple myeloma

EXPLANATION;-Rheumatoid arthritis(RA) a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles.Female affected more than male. MCPs and PIPs involved but not DIPs. Characterized by morning stiffness more than 1hr, pain gradually reliefs after exercis , ulnar deviation, Boutonierre deformity ,Swan neck deformity ,rheumatoid nodules backers cysts also present.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
• Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

46.) A 39-year-old male patient complains of moderate pain and weakness in the shoulder, back and

pelvic girdle muscles, that has been progressing for the last 3 weeks; great difficulty in getting

out of bed, going up and down the stairs, shaving. Dermatomyositis has been suspected. Blood

test results: Hb- 114 g/l, WBC- 10, 8 · 109/l, eosinophils - 9%, ESR -22 mm/h, C-reactive

protein - (++). The alteration in the following laboratory value wil be of decisive diagnostic

significance:

A. Creatine phosphokinase

B. Ceruloplasmin

C. Sialic acids

D. dsDNA antibodies

E. Gamma-globulins

Explanation :read more dermatomyositis

47.) A 26-year-old male patient complains of pain in the right knee, which is getting worse in the

morning. Two weeks before, he consulted an urologist about prostatitis. Objectively:

conjunctivitis is present. There is also periarticular edema of the knee joint, redness of the

overlying skin. Rheumatoid factor was not detected. Until further diagnosis is specified, it would

be reasonable to start treatment with the following antibiotic:

A. Tetracyclines

B. Cephalosporins

C. Penicillins

D. Aminoglycosides

E. Lincosamides

EXPLANATION: Also known as reactive arthritis, autoimmune condition that develop to an infection in another part of body usually genitourinary and gastrointestinal infection. Mostly caused by chlamydia, e coli, campylobacter etc

Traid - Conjunctivitis, Arthritis, Non gonococcal urethritis

Treatment - tetracycline (chlamydia)

48.) Examination of a 35-year-old patient with rheumatism revealed that the right heart border was 1

cm displaced outwards from the right parasternal line, the upper border was on the level with

inferior margin of the 1st rib, the left border was 1 cm in from the left midclavicular line.

Auscultation revealed atrial fibrillation, loud apical first sound, diastolic shock above the

pulmonary artery. Echocardiocopy revealed abnormal pattern of the mitral valve motion. What

heart disease is characterized by these symptoms?

A. Mitral stenosis

B. Mitral valve prolapse

C. Mitral valve insufficiency

D. Aortic stenosis

E. Tricuspid valve insufficiency

EXPLANATION: patient has history of rheumatism and must common complication of rheumatism is mitral stenosis > arotic stenosis> tricuspic vulve> pulmonary vulve (rare)

49.) A 36-year-old female patient complains of intense pain in the knee joints and neck. In the

morning she experiences pain in the interscapular region and leg joints; pain subsides after

warm-up gymnastics. The patient is overnourished, there is a clicking sound in the knees when

squatting, the knees are somewhat disfigured, painful on palpation. Blood test results: ESR- 18

mm/h, WBC-8,0·109/l. Radiography reveals subchondral sclerosis in the left knee. What is the

basis of this pathology?

A. Degenerative processes in cartilage

B. Autoimmune process in the synovium

C. Deposition of urates (tophi) in the articular tissues

D. Beta-haemolytic streptococcus

E. Hemarthrosis

EXPLANATION;- Patients has features of Rheumatoid arthritis(RA) a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles.Female affected more than male. MCPs and PIPs involved but not DIPs. Characterized by morning stiffness more than 1hr, pain gradually reliefs after exercis , ulnar deviation, Boutonierre deformity ,Swan neck deformity ,rheumatoid nodules backers cysts also present.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
• Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

50.) After a holiday in the Crimea, a 36-year old female patient presents with severe pain in the

elbow joints, dyspnea and weakness. The body temperature is of 37,6oC, the skin is pale, there is

erythema of cheeks and nose, lower lip ulceration. Visual inspection reveals no changes in the

joints, the right elbow movement is limited. There is murmur and pleural friction in the lungs

below the right angle of the scapula. Cardiac sounds are muffled, there is tachycardia, gallop

rhythm, Ps- 114/min. AP- 100/60. What is the most likely diagnosis?

A. SLE

B. Rheumatic heart disease

C. Rheumatoid arthritis

D. Infectious allergic myocarditis

E. Dry pleurisy

EXPLANATION:-is an autoimmune   systemic disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body.

American College of Rheumatology (ACR) established  .A person has SLE if any 4 out of 11 symptoms are present simultaneously or serially on two separate occasions.

 • Malar rash (rash on cheeks- BUTTERFLY RASH)

 • Discoid rash (red, scaly patches on skin that cause scarring).

 • Serositis: Pleurisy (inflammation of the membrane around the lungs) or pericarditis (inflammation of the membrane around the heart).

 • Oral ulcers (includes oral or nasopharyngeal ulcers).

 • Arthritis: nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion.

 • Photosensitivity (exposure to ultraviolet light causes rash, or other symptoms of SLE flareups).

 • Blood—hematologic disorder—hemolytic anemia (low red blood cell count), leukopenia (white blood cell count<4000/µl), lymphopenia (<1500/µl), or low platelet count (<100000/µl) in the absence of offending drug. Hypocomplementemia is also seen, due to either consumption of C3 and C4 by immune complex-induced inflammation or to congenitally complement deficiency, which may predispose to SLE.

 • Renal disorder: More than 0.5 g per day protein in urine or cellular casts seen in urine under a microscope.

 • Antinuclear antibody test positive.

 • Immunologic disorder: Positive anti-Smith, anti-ds DNA, antiphospholipid antibody . Presence of anti-ss DNA in 70% of cases(most common in SLE).

 • Neurologic disorder: Seizures or psychosis.

Note: Libman–Sacks endocarditis associated with SLE

51.) A 60-year-old female patient complains of recurrent pain in the proximal interphalangeal and

wrist joints, their periodic swelling and reddening that have been observed for 4 years. X-ray

picture represents changes in form of osteoporosis, joint space narrowing and single usuras.

What is the most likely diagnosis?

A. Rheumatoid arthritis

B. Osteoarthritis

C. Gout

D. Pseudogout

E. Multiple myeloma

EXPLANATION;-Rheumatoid arthritis(RA) a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles.Female affected more than male. MCPs and PIPs involved but not DIPs. Characterized by morning stiffness more than 1hr, pain gradually reliefs after exercis , ulnar deviation, Boutonierre deformity ,Swan neck deformity ,rheumatoid nodules backers cysts also present.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
• Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

52.) A 26-year-old female patient has an 11-year history of rheumatism. Four years ago she suffered

2 rheumatic attacks. Over the last 6 months there have been paroxysms of atrial fibrillation every

2-3 months. What option of antiarrhythmic therapy or tactics should be proposed?

A. Prophylactic administration of cordarone

B. Immediate hospitalization

C. Defibrillation

D. Lidocaine administration

E. Heparin administration

EXPLANATION: cordarone is amiodarone which is antiarrythmic medicine.

53.) An 11-year-old boy complains of general weakness, fever up to 38,2oC, pain and swelling of the

knee joints, feeling of irregular heartbeat. 3 weeks ago, the child had quinsy. Knee joints are

swollen, the overlying skin and skin of the knee region is reddened, local temperature is

increased, movements are limited. Heart sounds are muffled, extrasystole is present, auscultation

reveals apical systolic murmur that is not conducted to the left inguinal region. ESR is 38 mm/h.

CRP is 2+, antistreptolysin O titre - 400. What is the most likely diagnosis?

A. Acute rheumatic fever

B. Vegetative dysfunction

C. Non-rheumatic carditis

D. Juvenile rheumatoid arthritis

E. Reactive arthritis

EXPLANATION: Rheumatic fever is caused by group A streptococcus Beta hemolyticus. It is an inflammatory disease that can involve the heart, joints  ( polyarthritis ), skin, and brain. Rheumatic fever may occur following an infection of the throat ( angina) .The underlying mechanism is believed to involve the production of antibodies against a person's own tissues.Treating people who have strep throat with antibiotics, such as penicillin, decreases the risk of developing rheumatic fever.

54.) A 60-year-old male patient, who works as a construction worker, complains of pain in the right

hip and knee joints, that is getting worse on exertion. These presentations have been observed for

the last 5 years. Objectively: the patient is overnourished. Right knee joint is moderately

deformed. Examination of other organs and systems revealed no pathology. Blood tet results:

WBCs - 8,2·109/l, ESR - 15 mm/h. Uric acid - 0,35 mmol/l. What is the most likely diagnosis?

A. Deforming osteoarthritis

B. Reactive arthritis

C. Gout

D. Rheumatoid arthritis

E. Reiter’s disease

EXPLANATION:-Osteoarthritis is a type of joint disease that results from breakdown of joint cartilage and underlying bone . ON xray joint space narrow .The most common symptoms are joint pain and stiffness. Initially, symptoms may occur only following exercise, but over time may become constant.  Heberden’s(DIP) and Bouchard’s nodes(PIP).,

55.) A 28-year-old female patient with a six-year history of Raynaud’s syndrome has recently

developed pain in the small joints of hands, difficult movement of food down the esophagus.

What kind of disease canyouthinkofinthiscase?

A. Systemic scleroderma

B. Periarteritis nodosa

C. Rheumatoid arthritis

D. Systemic lupus erythematosus

E. Pseudotrichiniasis

EXPLANATION:-Systemic scleroderma, also called diffuse scleroderma or systemic sclerosis, is an autoimmune disease of the connective tissue. It is characterized by thickening of the skin caused by accumulation of collagen, and by injuries to small arteries.

CREST syndrome (Calcinosis, Raynaud's phenomenon, Esophageal dysfunction, Sclerodactyly, and Telangiectasia) is associated with limited scleroderma.There are two forms of scleroderma: localized and systemic. The localized (limited) form affects the skin of only the face, hands, and feet. The systemic (diffuse) form involves those and, in addition, may progress to visceral organs, including the kidneys, heart, lungs, and gastrointestinal tract.

56.) A 60-year-old patient complains of recurrent pain in the proximal interphalangeal and wrist

joints, their periodic swelling and reddening that have been observed for 4 years. X-ray picture

represents changes in form of osteoporosis, joint space narrowing and single usuras. What is the

most likely diagnosis?

A. Rheumatoid arthritis

B. Osteoarthritis

C. Gout

D. Pseudogout

E. Multiple myeloma

EXPLANATION;-Rheumatoid arthritis(RA) a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles.Female affected more than male. MCPs and PIPs involved but not DIPs. Characterized by morning stiffness more than 1hr, pain gradually reliefs after exercis , ulnar deviation, Boutonierre deformity ,Swan neck deformity ,rheumatoid nodules backers cysts also present.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
• Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

57.) A 35-year-old patient complains about pain and morning stiffness of hand joints and

temporomandibular joints that lasts over 30 minutes. She has had these symptoms for 2 years.

Objectively: edema of proximal interphalangeal digital joints and limited motions of joints. What

examination should be administered?

A. Roentgenography of hands

B. Complete blood count

C. Rose-Waaler reaction

D. Immunogram

E. Proteinogram

EXPLANATION: Patient diagnosed as rheumaroid arthritis so best diagnosis for RA is  roentgenography of hands.Rheumatoid arthritis(RA) a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles.Female affected more than male. MCPs and PIPs involved but not DIPs. Characterized by morning stiffness more than 1hr, pain gradually reliefs after exercis , ulnar deviation, Boutonierre deformity ,Swan neck deformity ,rheumatoid nodules backers cysts also present.

Factors that may increase your risk of rheumatoid arthritis include:

• Your sex. Women are more likely than men to develop rheumatoid arthritis.
• Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.
• Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.
• Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity.
• Environmental exposures. Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.
• Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.

The following are the revised criteria of American Rheumatology Association (ARA), for diagnosing RA:

"MORNING  Always Helps to See Nature Fresh and RADIANT"

•   MORNING - Morning stiffness of >1 hour duration
•   Always - Arthritis of  atleast three areas ( PIP, MCP, MTP, WRIST etc.)
•   Helps -  Hand arthritis
•   See* - Symmetrical arthritis
•   Nature - Nodules as observed by physician
•   Fresh -  rheumatoid Factor &
•   RADIANT - Radiological changes

58.) A 32-year-old male patient has been suffering from pain in the sacrum and coxofemoral joints,

painfulness and stiffness in the lumbar spine for a year. ESR-56 mm/h. Roentgenography

revealed symptoms of bilateral sacroileitis. The patient is the carrier of HLA B27 antigen. What

is the most likely diagnosis?

A. Ankylosing spondylitis

B. Coxarthrosis

C. Rheumatoid arthritis

D. Reiter’s disease

E. Spondylosis

EXPLANATION:-Ankylosing spondylitis is an inflammatory disease that, over time, can cause some of the vertebrae of  spine to fuse. This fusing makes the spine less flexible and can result in a hunched-forward posture. It affects men (over 38 yr) more than women. Early signs and symptoms of ankylosing spondylitis might include pain and stiffness in  lower back and hips, especially in the morning and after periods of inactivity. Neck pain and fatigue also are common.It is associated with  HLA- B27 gene. (MRI), and X-ray studies of the spine, which show characteristic spinal changes and inflammation of the sacroiliac joint, combined with a genetic marker blood test are the major diagnostic tools. Schober's test is a useful clinical measure of flexion of the lumbar spine performed during the physical examination. X-ray showing bamboo spine in a person with ankylosing spondylitis because of longititudinal ligament ossification.

59.) A 58-year-old patient complains about sensation of numbness, sudden paleness of II-IV fingers,

muscle rigidness, intermittent pulse. The patient presents also with polyarthralgia, dysphagia,

constipations. The patient’s face is masklike, solid edema of hands is present. The heart is

enlarged; auscultation revealed dry rales in lungs. In blood: ESR- 20 mm/h, crude protein - 85/l,

γ-globulines - 25%. What is the most likely diagnosis?

A. Systemic scleroderma

B. Dermatomyositis

C. Rheumatoid arthritis

D. Systemic lupus erythematosus

E. Raynaud’s disease

EXPLANATION:-Systemic scleroderma, also called diffuse scleroderma or systemic sclerosis, is an autoimmune disease of the connective tissue. It is characterized by thickening of the skin caused by accumulation of collagen, and by injuries to small arteries.

CREST syndrome (Calcinosis, Raynaud's phenomenon, Esophageal dysfunction, Sclerodactyly, and Telangiectasia) is associated with limited scleroderma.There are two forms of scleroderma: localized and systemic. The localized (limited) form affects the skin of only the face, hands, and feet. The systemic (diffuse) form involves those and, in addition, may progress to visceral organs, including the kidneys, heart, lungs, and gastrointestinal tract.

60.) A 12-year-old child had three attacks of acute rheumatic fever accompanied by carditis.

Examination revealed the symptoms of chronic tonsillitis, mitral insufficiency, carious teeth.

What is the optimal method of secondary prophylaxis?

A. Year-round bicillin prophylaxis till the age of 25

B. Course of cardiotrophic drugs twice a year

C. Year-round bicillin prophylaxis for 3 years

D. Tonsillectomy

E. Oral cavity sanitation

EXPLANATION: bacillin 5 is given for acute rheumatic fever secondary propylaxis till age of 25 year.