KROK 2 Therapy Rheumatology BASES WITH HIGHLIGHTS AND EXPLANATIONS

The bellow material is aimed to improve the study and understanding of the Krok 2 Therapy Rheumatology with the use of highlights for relevant key works, links to rlevant study materials, reference images and explanations to individual questions aimed at making remembrance of questions easier and also understanding of new questions for the upcoming Step 2 exam.

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Correct answer for all Question is A
1.)  A 30 y.o. female with rheumatoid arthritis of five years  duration  complains of pain in the first three fingers of her right hand over past 6 weeks. The pain seems especially severe at night often awakening her from sleep. The most likely cause is?
A. Carpal tunnel syndrome
B. Atlanto-axial sublaxation of cervical spine
C. Sensory peripheral neuropathy
D. Rheumatoid vasculitis
E. Rheumatoid arthritis without complication
EXP:- 
Carpal tunnel syndrome is a Compression of the median nerve as it travels through the wrist at the carpal tunnel. The main symptoms are pain, numbness, and tingling, in the thumb, index finger, middle finger, and the thumb side of the ring fingers.Symptoms typically start gradually and during the night and often awakening from sleep. It is one of the  most complication of RA.
Others complication of RA are;adverse effect of medications,felty syndrome,bakers cysts, Atlanto- axial sublaxation.
 2.) A 17 y.o. patient complains of acute pain in the knee joint and t0– 38oC. He was ill with angina 3 weeks ago. Objectively: deformation and swelling of the knee joints with skin hyperemia.
Small movement causes an acute pain in the joints.
Which diagnose is the most correct?
A. Rheumatic fever, polyarthritis
B. Systemic lupus eritematodes
C. Reactive polyarthritis
D. Infectious-allergic polyarthritis
E. Rheumarthritis
EXP:
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.
3.) A patient, aged 40, has been ill during approximately 8 years, complains of pain in the lumbar part of the spine on physical excertion, in cervical and thoracal part (especially when coughing), pain in the hip and knee joints on the right. On examination: the body is fixed in the forward inclination with head down, gluteal muscles atrophy. Spine roentgenography: ribs osteoporosis, longitudinal ligament ossification. What is the most likely diagnosis? 
A. Ankylosing spondyloarthritis
B. Tuberculous spondylitis
C. Psoriatic spondyloarthropatia
D. Spondyloarthropatia on the background of Reiter’s disease
E. Spread osteochondrosis of the vertebral column
EXP:- 
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  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.
4.) A 18 y.o. male patient complains of pain in knee and ankle joints, temperature elevation to 39, 50C.He had a respiratory disease 1,5 week ago. On examination: temperature- 38, 50C, swollen knee and ankle joints, pulse- 106 bpm, rhythmic, AP- 90/60 mm Hg, heart borders without changes, sounds are weakened, soft systolic apical murmur. What indicator is connected with possible etiology of the process?
A. Antistreptolysine-0
B. 1-antitrypsine
C. Creatinkinase
D. Rheumatic factor
E. Seromucoid
EXP:- 
The antistreptolysin O (ASO) titer test is a blood test that checks for a strep infection. Patient has respiratory disease 1.5 week ago. Pain in knee and ankles elevated temperature thus suspect of step infection that is associated with rheumatic fever. ASO titer test measures antibodies produced by our body in response to a toxin known as streptolysin O. Streptolysin O is a toxin produced by group A Streptococcus (GAS) bacteria.
5.) A man, aged 30, complains of intense pain, reddening of skin, edema in the ankle-joint area,
fever up to 390_. Sudden 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
EXP:- 
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.
6.) A 40 y.o. woman is ill with rheumatic disease with composite mitral disease with prevalence of
the stenosis of left venous foramen.Complains of palpitation, fatigability,
progressing dyspnea, attacks of dyspnea and hemoptysis. Now she cannot be engaged even in the
easy activities.
What tactics is the most expedient?
A. Mitral comissurotomia
B. Conduction of current bicilinoprophilaxis
C. Prescription of anticoagulants
D. Prescription of venous vasodilatators
E.
EXP:- 
Mitral commissurotomy is an open-heart surgery that repairs a mitral valve that is narrowed from mitral valve stenosis.Patient has rheumatic disease and mostly affected valve is mitral valve with stenosis.
7.)  A patient has complained of great weakness for 6 years. He fell seriously ill, the illness is
accompanied by body temperature rise, indisposition, pain in joints and along the legs muscles.
Objectively: violet-bluish erythema around eyes and over knee joints. HR- 120/min, heart sounds
are weak. Blood count: leukocytes- 12 ∗  109/L, ESR- 40 mm/h. What is the most probable
diagnosis?
A. Dermatomyositis
B. Systemic lupus erythematosus
C. Rheumathoid arthritis
D. Atopic dermatitis
E. Reactive polyarthritis
EXP:- 
Dermatomyositis(DM) is a  rare connective-tissue disease  which is an idiopathic , autoimmune and chronic inflammatory mostly involved skin and muscles. It’s  a systemic disorders  that can also  affect the joints, the oesophagus, the lungs, the kidney ,the heart ,etc. It’s more common in elderly  people (over 40 yrs).In children most often appears between 5 and 15 years. Female to male ratio is 2:1. Black more affected. For more dermatomyositis
8.) A 54 y.o. patient has been suffering from osteomyelitis of femoral bone for over 20 years. In the
last month there appeared and gradually progressed edemata of lower extremities. Urine
analysis: proteinuria – 6,6 g/L. Blood analysis: disproteinemia in form of hypoalbuminemia,
increase of α2- andγ-globulins, ESR- 50 mm/h. What is the most probable diagnosis?
A. Secondary renal amyloidosis
B. Acute glomerulonephritis
C. Myelomatosis
D. Chronic glomerulonephritis
E. Systemic lupus erythematosus
EXP:- 
Patient has history of chronic disease and in urine increase level of protien and increase of α2- andγ-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.
9.)  A 31 y.o. patient has been suffering from systemic scleroderma for 14 years.
She has been treated in hospital many times. She complains of occasional dull pain in the heart
region, palpitation, dyspnea, headache, eye-lid edemata, weight loss and deformation of
extremities joints. What organ affection worsens the disease prognosis?
A. Kidneys
B. Heart
C. Lungs
D. Gastrointestinal tract
E. Skin and joints
EXP:- 
Most affect organ is  kidney because the patient has complains of eye- lid edema .'” scleroderma renal crisis”  has been used to characterized the renal involvement in scleroderma ,in which malignant hypertension  occurs over a days to week and is associated with acute renal failure ( rapid rise in creatinine and protein). Best drug to treat in this case is ACE inhibitors. In this case patient develop eye lid edema which is the result of protein loss because of renal failure.
10.) A 60 y.o. patient complains of pain in interphalangeal joints of hand that gets worse during
working. Objectively: distal and proximal joints of the II-IV fingers are defigured, with
Heberden’s and Bouchard’s nodes, painful, stiff. X-ray picture of joints: joint spaces are
constricted, there are marginal osteophytes, subchondral sclerosis. What is the most probable
diagnosis?
A. Osteoarthritis
B. Reiter’s disease
C. Ankylosing spondylitis
D. Rheumatic arthritis
E. Psoriatic arthritis
EXP:- 
Osteoarthritis sometimes called degenerative joint disease or degenerative arthritis, osteoarthritis (OA) is the most common chronic condition of the joints . OA can affect any joint, but it occurs most often in knees, hips, lower back and neck, small joints of the fingers and the bases of the thumb and big toe.In OA, the cartilage breaks down, causing pain, swelling and problems moving the joint. As OA worsens over time, bones may break down and develop growths called spurs.In the final stages of OA, the cartilage wears away and bone rubs against bone leading to joint damage and more pain.It is most common in people older than 60. Common risk factors include increasing age, obesity, previous joint injury, overuse of the joint, weak thigh muscles, and genes.
Note:Heberden’s and Bouchard’s node are a sign of osteoarthritis and are caused by formation of osteophytes (calcific spurs) of the articular (joint) cartilage in response to repeated trauma at the joint.
 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
EXP:- 
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
EXP:- 
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 anaerobicgram-positivecoccus (round bacterium) commonly found in the humanoral 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
EXP:- 
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
EXP:- 
Rheumatic fever is caused by group A streptococcus Beta hemolyticus. It is an inflammatory disease that can involve the heartjoints  ( 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
EXP:- 
Patient has history of chronic disease( osteomyelitis of femoral bone) and in urine increase level of protien and increase of  α2- andγ-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
EXP:- 
Patient has history of chronic disease( chronic bronchitis for many years) and in urine increase level of protien and increase of  α2- andγ-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

EXP:- 
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

EXP:- 
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 diglutitionShe 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
EXP:- 
Systemic scleroderma, also called diffuse scleroderma or systemicsclerosis, 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 (CalcinosisRaynaud’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 kidneysheartlungs (basilar  lower  pneumosclerosis), and gastrointestinal tract.

Note: face amimia, masked face, face like fish mouth associates with Systemic scleroderma,

20.) A 25 year old patient had pharyngitis 2 weeks ago. Now he complains about body temperature
rise up to38oC, 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

EXP:- 
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
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

EXP:- 
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

EXP:- 
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
EXP:- 
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
EXP:- 
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
EXP:- 
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

EXP:- 

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
EXP:- 
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
EXP:- 
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
EXP:- 
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 (CalcinosisRaynaud’s phenomenonEsophageal 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 kidneysheartlungs, and gastrointestinal tract.

31.) A 32-year-old male patient has beensuffering 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
EXP:- 
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.
32.) A 35-year-old patient has been admitted to a hospital for pain in the left sternoclavicular and
knee joints, lumbar area. The disease has an acute character and is accompanied by fever up to
38oC. Objectively: the left sternoclavicular and knee joints are swollen and painful. In blood:
WBCs – 9, 5 · 109/l, ESR – 40 mm/h, CRP – 1,5 millimole/l, fibrinogen – 4,8 g/l, uric acid – 0,28
millimole/l. Examination of the urethra scrapings reveals chlamydia. What is the most likely
diagnosis?
A. Reiter’s syndrome
B. Rheumatic arthritis
C. Gout
D. Bechterew’s disease
E. Rheumatoid arthritis
EXP:- 
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)
33.) A 32-year-old patient has a 3-year history of asthma attacks, that can be hardly stopped with
berotec. Over a few last months he has experienced pain in the joints and sensitivity disorder of
legs and feet skin. Ps – 80/min, AP – 210/100 mm Hg. In blood: eosinophilia at the rate of 15%.
What disease can be suspected in this case?
A. Periarteritis nodosa
B. Systemic lupus erythematosus
C. Systemic scleroderma
D. Dermatomyositis
E. Wegener’s disease
34.) 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
EXP:- 
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 (CalcinosisRaynaud’s phenomenonEsophageal 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 kidneysheartlungs, and gastrointestinal tract.

 

35.) 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
EXP:- 
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
36.) 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
EXP:- 
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.
37.) 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
EXP:- 
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 (CalcinosisRaynaud’s phenomenonEsophageal 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 kidneysheartlungs, and gastrointestinal tract.
38.) A 10-year-old girl was admitted to a hospital with carditis presentations. It is known from the
anamnesis that two weeks ago she had exacerbation of chronic tonsillitis. What is the most likely
etiological factor in this case?
A. Streptococcus
B. Staphylococcus
C. Pneumococcus
D. Klebsiella
E. Proteus
EXP:- 
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.
39.) 5 weeks after hypothermia a 22-year-old patient developed fever, weakness, muscle pain,
inability to move independently. Objectively: tenderness, induration of shoulder and shin
muscles, restricted active movements, erythema on the anterior surface of chest. There is a
periorbital edema with heliotropic erythema. Gottron’s sign is present. What study is required to
verify the diagnosis?
A. Muscle biopsy
B. Aminotransferase activity
C. Pneumoarthrography
D. ASO titre
E. Rheumatoid factor
EXP:- 
Heliotropic erythema. Gottron’s sign specific sign for dermatomyositis .Gold standard for diagnosis of it is muscle biopsy.
 40.) 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
EXP:- 
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  worse and constant.  Heberden’s(DIP) and Bouchard’s nodes(PIP).
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
EXP:- 
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 (CalcinosisRaynaud’s phenomenonEsophageal 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 kidneysheartlungs, 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
EXP:- 
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
EXP:- 
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
EXP:- 
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

butterflyface rash

 

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
EXP:- 
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
EXP:- 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
EXP:- 
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
EXP:- 
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
EXP:- 
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
EXP:- 
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
EXP:- 
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
EXP:-  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
EXP:- 
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
EXP:- 
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
EXP:- 
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 (CalcinosisRaynaud’s phenomenonEsophageal 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 kidneysheartlungs, 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
EXP:- 
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
EXP:- 
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
EXP:- 
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
EXP:- 
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 (CalcinosisRaynaud’s phenomenonEsophageal 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 kidneysheartlungs, 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

 

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

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