11.) A 21 y.o. man complains of having morning pains in his back for the last three months. The pain
can be relieved during the day and after physical exercises. Physical
examination revealed reduced mobility in the lumbar part of his spine, increase of muscle tonus
in the lumbar area and sluch during moving. X-ray pattern of spine
revealed bilateral sclerotic changes in the sacrolumbal part. What test will be the most necessary
for confirming a diagnosis?
A. HLA-B27
B. ESR
C. Rheumatoid factor
D. Uric acid in blood plasma
E. Antinuclear antibodies
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.
12.) A 40 y.o. patient with rheumatic heart disease complains of anorexia, weakness and loss of
weight, breathlessness and swelling of feet. The patient had tooth extraction one month ago. On
examination: t0- 390C, Ps- 100/min. Auscultation: diastolic murmur in the mitral area. Petechial
lesion around the clavicle; spleen was palpable.
A. Subacute bacteria endocarditis
B. Recurrence of rheumatic fever
C. Thrombocytopenia purpura
D. Mitral stenosis
E. Aortic stenosis
EXPLANATION:-Sub acute bacterial endocarditis (also called endocarditis lenta) is a type of endocarditis (more specifically, infective endocarditis). Sub acute bacterial endocarditis can be considered a form of type III hypersensitivity.It is usually caused by a form of streptococci viridans bacteria that normally live in the mouth (Streptococcus mutans - is a facultatively anaerobic, gram-positive coccus (round bacterium) commonly found in the human oral cavity and is a significant contributor to tooth decay ). Sub acute bacterial endocarditis gradually causes such symptoms as fatigue, mild fever, a moderately fast heart rate, weight loss, sweating, and a low red blood cell count.Diagnosis of sub acute bacterial endocarditis can be done by collecting three blood culture specimens over a 24-hour period for analysis, also it can usually be indicated by the existence of:
• Osler's nodes.
• Roth's spots
• Nail clubbing
Note:-. Sub-acute bacterial endocarditis connected to IV drugs users ,hepatitis,tonsillitis, tooth extraction,etc.
13.) A 41 y.o. woman complains of weakness, fatigue, fever up to 380C, rash on the face skin, pain in
the wrists and the elbows. On physical examination: erythematous rash on the cheeks with
"butterfly"look, the wrists and elbow joints are involved symmetrically, swollen, sensitive,
friction rub over the lungs, the heart sounds are weak, regular, HR-
88/min, BP- 160/95 mm Hg. Hematology shows anemia, leucopenia, lymphopenia; on
urinalysis: proteinuria, leukocyturia, casts. What is the main mechanism of disease
development?
A. Production of antibodies to double stranded DNA
B. Production of myocytes antibodies
C. Production of antibodies to endothelial cells
D. Production of myosin antibodies
E. Production of antimitochondrial antibodies
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
14.) A 19 y.o. girl admitted to the hospital complained of pain in the knee and fever of 38, 60C. She
is ill for 2 weeks after acute tonsillitis. On exam, hyperemia and swelling of both knees,
temperature is 37, 40C, HR- 94/min, BP- 120/80 mm Hg, and heart border is displaced to the
left; S1 is weak, systolic murmur is present. Total blood count shows the following: Hb- 120 g/L,
WBC- 9, 8 · 109/L, ESR of 30 mm/L. ECG findings: the rhythm is regular, PQ = 0,24 sec.What
is a causative agent of the disease?
A. Beta-hemolytic streptococci
B. Viral-bacterial association
C. Autoimmune disorder
D. Staphylococci
E. Ricchetsia
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.If joints involve then migratory pain occurs.
15.) A 54 y.o. woman has been ill with osteomyelitis of femoral bone for over 20 years. During the
last month there appeared and have been steadily increasing edemata of lower extremities. Urine
analysis revealed: proteinuria - 6,6 g/l. Blood analysis: disproteinemia in form of
hypoalbuminemia, raise of α2- and γ- globulines, ESR- 50 mm/h. What is the most probable
diagnosis?
A. Secondary renal amyloidosis
B. Acute glomerulonephritis
C. Myelomatosis
D. Chronic glomerulonephritis
E. Systematic lupus erythematosus
EXPLANATION:- Patient has history of chronic disease( osteomyelitis of femoral bone) and in urine increase level of protien and increase of α2- and γ-globulins.One common sign of kidney amyloidosis is the presence of abnormally high levels of protein in the urine, a condition known as proteinuria. Healthy kidneys prevent protein from entering the urine, so the presence of protein may be a sign that the kidneys aren't working properly.
16.) A 58 y.o. patient complains of weakness, leg edemata, dyspnea, anorexia. He has been suffering
from chronic bronchitis for many years. During the last 5 years he has been noting intensified
discharge of sputum that is often purulent. Objectively: RR- 80/min, AP- 120/80 mm Hg.
Disseminated edemata, skin is dry and pale, low turgor. In urine:
intense proteinuria, cylindruria. Specify the most probable pathological process in kidneys:
A. Renal amyloidosis
B. Chronic glomerulonephritis
C. Chronic pyelonephritis
D. Interstitial nephritis
E. Acute glomerulonephritis
EXPLANATION:-Patient has history of chronic disease( chronic bronchitis for many years) and in urine increase level of protien and increase of α2- and γ-globulins.One common sign of kidney amyloidosis is the presence of abnormally high levels of protein in the urine, a condition known as proteinuria. Healthy kidneys prevent protein from entering the urine, so the presence of protein may be a sign that the kidneys aren't working properly.
17.) A 30 y.o. man complains of intense pain, reddening of skin, edema in the ankle-joint area, fever
up to 390_. There was acute onset of the illness. In the past there were similar attacks lasting 5-6
days without residual changes in the joint. The skin over the joint is hyperemic without definite
borders and without infiltrative bank on the periphery. What is the most likely diagnosis?
A. Gout
B. Infectional arthritis
C. Rheumatoid arthritis
D. Erysipelatous inflammation
E. Osteoarthritis
EXPLANATION:- Gout is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot, and swollen joint.It mainly affect middle age male(30-45 yr) more than women. Other joints, such as the heels, knees, wrists and fingers, may also be affected. Joint pain usually begins over 2–4 hours and during the night.Gout is characterized by sudden, severe attacks of pain, redness and tenderness in joints, often the metatarsal-phalangeal joint at the base of the big toe (podagra) affected most often, similar attacks occurs for 5-6 days without residual changes in joints.
The signs and symptoms of gout almost always occur suddenly — often at night — and without warning. They include:
• Intense joint pain. Gout usually affects the large joint of your big toe, but it can occur in your feet, ankles, knees, hands and wrists. The pain is likely to be most severe within the first four to 12 hours after it begins.
• Lingering discomfort. After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints.
• Inflammation and redness. The affected joint or joints become swollen, tender, warm and red.
• Limited range of motion. Decreased joint mobility may occur as gout progresses.
18.) A 34 year old woman fell ill 3 months ago after cold exposure. She complained of pain in her
hand and knee joints, morning stiffness and fever up to 38oC. Interphalangeal,
metacarpophalangeal and knee joints are swollen, hot, with reduced ranges of motions; ESR of
45mm/h, CRP (+++), Vaaler-Rouse test of 1:128.What group of medicines would you
recommend the patient?
A. Nonsteroidal anti-inflammatory drugs
B. Cephalosporines
C. Tetracyclines
D. Sulfonamides
E. Fluorchinolones
EXPLANATION:- First line of drug to management in this case is Non steroidal anti-inflammatory drugs.
19.) A 32 year old patient complains about pain in small joints of her hands, paresthesia at the tips of
fingers, weakness, difficult diglutition. She has been suffering from this for 13 years. Objectively: face amimia, shortening of nail bones, skin indurations in the area of shoulder girdle are present. Roentgenological examination of lungs revealed basal pneumosclerosis. Fibrogastroscopy revealed esophagus constriction in its cardial part. Blood count: leukocytes - 9, 8 · 109/l, ESR – 22 mm/h, γ-globulin - 22%.What is the most probable diagnosis?
A. Systemic scleroderma
B. Systemic lupus erythematosus
C. Rheumatoid arthritis
D. Dermatomyositis
E. Myxedema
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 (basilar lower pneumosclerosis), and gastrointestinal tract.
20.) A 25 year old patient had pharyngitis 2 weeks ago. Now he complains about body temperature
rise up to 38oC, general weakness, dyspnea during walking, swelling and shifting pain in the
articulations. Objectively: cyanosis of lips, rhythmic pulse of poor volume - 100 bpm. Left
cardiac border deviates outwards from the mediaclavicular line by 1 cm. The first heart sound is
weakened on the apex, auscultation revealed systolic souffle. What is the most probable
aetiological factor that caused this pathological process?
A. β-haemolytic streptococcus
B. Staphylococcus
C. Pneumococcus
D. Virus
E. Fungi
EXPLATION:-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),pharyngitis .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
Part 3 to be continued.....
