krok 2 (Rheumatology) with explanation part 3

Correct answer for all Question is A

21.) A 13 year old girl was admitted to the cardiological department because of pain in the muscles

and joints. Examination of her face revealed an edematic erythema in form of butterfly in the

region of nose bridge and cheeks. What is the most probable diagnosis?

A. Systemic lupus erythematosus

B. Rheumatism

C. Dermatomyositis

D. Rheumatoid arthritis

E. Periarteritis nodosa

EXPLANATION:- Systemic lupus erythematous 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

22.) A 38 year old female patient complains about body stiffness in the morning, especially in the

articulations of her upper and lower limbs, that disappears 30-60 minutes later after active

movements. She has also arthritis of metacarpophalangeal and proximal phalangeal articulations,

subfebrile temperature. ESR- 45 mm/h. Roentgenography revealed osteoporosis and erosion of

articular surface of small hand and foot articulations. What is the most probable diagnosis?

A. Rheumatoid arthritis

B. Psoriatic arthropathy

C. Osteoarthrosis deformans

D. Systemic lupus erythematosus

E. Reactive polyarthritis

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

23.) A 30 year old man complains of intense pain, reddening of skin, edema in the ankle-joint area,

fever up to 39oC. There was an 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 and

ill-defined, without infiltrative bank on the periphery. What is the most likely diagnosis?

A. Gout

B. Infectious 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.

24.) A 52 year old patient complains about headache, weakness of his upper left extremity.

Neurological symptoms become more intense during physical stress of the left extremity.

Pulsation on the arteries of the left extremity is sharply dampened but it remains unchanged on

the carotid arteries. What is the most probable diagnosis?

A. Occlusion of the left subclavicular artery, steal syndrome

B. Thoracal outlet syndrome

C. Raynaud’s syndrome

D. Takayasu’s disease

E. Occlusion of brachiocephalic trunk

 25.) A 47-year-old obese man complained of periodic attacks of acute arthritis in the st left

tarsophalangeal joint. Lab exam revealed increased serum rate of uric acid. What is the

diagnosis?

A. Gout arthritis

B. Reiter’s disease

C. Rheumatoid arthritis

D. Rheumatic arthritis

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.

Note: increase serum uric acid indicate gout.

,

26.) A 33-year-old man with a history of rheumatic fever complains of fever up to 38 − 39oC

abdominal pain, dyspnea, tachycardia. Heart borders are displaced to the left by 2 cm, systolic

and diastolic murmurs above aorta, BP of 160/30 mm Hg. Petechial rash occurs after

measurement of blood pressure. Liver is enlarged by 3 cm, spleen is palpable. Urine is brown-

yellow. What is the most likely diagnosis?

A. Infectious endocarditis

B. Rheumatic fever

C. Acute hepatitis

D. Acute nephritis

E. Aortic regurgitation

EXPLANATION:-Subacute bacterial endocarditis (also called endocarditis lenta) is a type of endocarditis (more specifically, infective endocarditis). Subacute 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 (Associated with tooth infectioins after extraction ), mitis, sanguis or milleri).Diagnosis of subacute 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

It can be congenital heart disease, it can be characterized by long term fever,malaise,weakness ,excessive sweat too,low diastolic pressure,high pulse,distant heart murmur( most common for congenital one) . subacute bacterial endocarditis connected to IV drugs users ,hepatitis,tonsilitis tooth extraction,etc.

27.) 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

28.) 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.

29.) A 30-year-old patient presented with body temperature rise up to 38, 5oC, pain in the small

articulations of hands; face edemata and erythema. In blood: RBCs - 2, 6 · 1012/l; Hb- 98 г/л;

WBCs - 2 · 109/l; ESR - 58 mm/h. In the urine: protein - 3,1 g/l; RBCs - 10-15 in the vision

field. What disease can be suspected in this case?

A. Systemic lupus erythematosus

B. Sepsis

C. Systemic scleroderma

D. Periarteritis nodosa

E. Acute glomerulonephritis

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

30.) 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.

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