Sush Unity-RHEUMATOLOGY 1700 PDF

RHEUMATOLOGY-System
Wise 1700-by Sush and Team. 2016

Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Dear Plabber,

• This first ever System Wise 1700 document was created thanks to 3 months of daily hard work by the

PLAB Skype group ‘Unity’ which was brought together by Dr Susmita Chowdhury.

The team members were:

& Susmita (Lead/most ignorant as she is working full time in public health for 13 years)
& Asad (Invaluable in IT and all types of support/the heart of the group)
& Manu (Volunteered to solve more questions/pathologist/amazing genuine person)
& Saima (Most concise clear notes/ photographic memory)
& Zohaib (Great research/a surgeon)
& Savia (Great research/multi-tasker with two little ones)
& Shanu (Very helpful after her March exam for those appearing in June)
& Mona (Great contributor in discussions)
& Manisha (Gyne/great discussion contributor)
& Sitara (Good discussion contributor)
& Samreena (Stayed a shorter time but great)

& Sami (Contributed the most early on but too brilliant for the group/still great friends)

& Komal (Knowledgeable sweet supportive girl)

• The main purpose was to break down the 1700 Q Bank System wise.

• We did our own reliable research for the options (OHCM/Patient info etc.) and concluded these keys
below on skype. This can save you 100s of hours of research. But I suggest you also do your own.

• 90% of the document consists of Unity research. We also added information from other circulating
documents and they are referenced as Dr Khalid/Dr Rabia (and her Team).

• However, several keys may be ‘incorrect’ and so please use your own judgment as we take no
responsibility. I suggest cross checking with Dr Khalid’s latest keys (a few of which are still debatable).
Finally decide on your own key.

• Sorry if some members failed to make their answers thorough. The highlights are mostly as per what
the team members wanted to highlight. Blank tables to be ignored.

• Note that some 1700 Questions are missing from here (when members did not do their share).
Questions may not be in order due to merging of documents and there is excess information than
required. Read as much as needed.

• This has been circulated by our team as a generous contribution to the Plabbers’ success and must

not be ‘sold’.

Good luck and best wishes: Sush and Team

1
RHEUMATOLOGY-System Wise 1700-by Sush and Team. 2016

Q: 430 A 45yo woman complains of pain in her hands precipitated by exposure to the
cold weather. She is breathless on walking. When she is eating, she can feel
food suddenly sticking to the gullet. It seems to be in the middle of the
esophagus but she can’t localize exactly where it sticks. It is usually relieved
with a drink of water. Choose the single most likely cause of dysphagia from
the options?
a. Esophageal carcinoma
b. Systemic sclerosis
c. SLE
d. Pharyngeal carcinoma
e. Globus hystericus

Clincher(s) Pain in hand (cold weather), SOB, Dysphagia
A Only local signs possible- difficulty swallowing liquids
B Correct answer
C SLE has Raynaud Phenomenon but no Dysphagia
D Only local signs possible
E Patient feel like having a lump in throat, when in fact they don’t. Exm – normal
KEY B CREST
Additional
Information

Systemic sclerosis (SS) is thickening of the skin caused by accumulation of
2

collagen, and by injuries to the smallest arteries. It is classified into 2 types-
Limited cutaneous SS (70%) and Diffuse cutaneous SS (30%) according to
extent of skin involvement.
• Limited SS:
! Skin involvement limited to face, hands and feet
! CREST Syndrome:
∼ Calcinosis (subcutaneous tissues)
∼ Raynaud’s phenomenon- cardinal sign, early and very
common presentation.
∼ Esophageal dysmotility
∼ Sclerodactyly
∼ Telangiectasia
! Pulmonary hypertension: s/s >> SOB, fatigue, non- productive
cough, dizzy, chest pain, palpitations, peripheral oedema,
• Diffuse SS:
! Diffuse skin involvement (whole body in severe cases) and
organ fibrosis: lung, cardiac and renal dz.

3

4

Reference OHCM 554
Dr Khalid/Rabia

Q: 449 A young pt is complaining of vertigo whenever she moves sideways on the bed
5

while lying supine. What would be the most appropriate next step?
a. Head roll test
b. Reassure
c. Advice on posture-vertibo basilar artery insufficiency- no neck extension
d. Carotid Doppler- amorasis fugax-
e. CT

Clincher(s) Complains of vertigo when move sideways on bed
A Correct answer
B
C
D
E
KEY A Dx " BPPV # most common cause of vertigo
Additional Vertigo is a symptom, rather than a condition itself. It's the sensation that you,
Information or the environment around you, is moving or spinning.
This feeling may be barely noticeable, or it may be so severe that you find it
difficult to keep your balance and do everyday tasks.
Attacks of vertigo can develop suddenly and last for a few seconds, or they
may last much longer. If you have severe vertigo, your symptoms may be
constant and last for several days, making normal life very difficult.
Other symptoms associated with vertigo may include:
• loss of balance – which can make it difficult to stand or walk
• feeling sick or being sick
• dizziness

Vertigo is commonly caused by a problem with the way balance works in the
inner ear, although it can also be caused by problems in certain parts of the
brain.
Causes of vertigo may include:
• benign paroxysmal positional vertigo (BPPV) – where certain head
movements trigger vertigo
• migraines – severe headaches
• labyrinthitis – an inner ear infection
• vestibular neuronitis – inflammation of the vestibular nerve, which runs into
the inner ear and sends messages to the brain that help to control
balance
Depending on the condition causing vertigo, you may experience additional
symptoms, such as a high temperature, ringing in your ears (tinnitus) and
hearing loss.

6

Reference
7

Dr Khalid/Rabia KEY- A
Dx? Benign Paroxysmal Positional Vertigo (BPPV)- Most common cause of
vertigo. Vertigo triggered by change in head position. Might be accompanied
by nausea and nystagmus. Less commonly, vomiting and syncope.
Diagnosis: Dix-Hallpike and Head roll test.
Management: Epley and Semont Maneuver.

Q:1141 A 45yo female looking pale has bluish discoloration of hands whenever she
goes out in the cold. She has also noticed some reddish spots on her body. She
has symmetrical peripheral arthropathy for the last yr. What is the most
probable dx?
a. RA
b. Osteosarcoma
c. Limited systemic sclerosis
d. Diffuse systemic sclerosis
e. Chondrosarcoma

Clincher(s) Discolouration of hands,reddish spots,peripheral arthropathy symmetrical
A Age 40-50.
Joint pain,stiffness mainly in morning,swelling warmth and redness
• tiredness and a lack of energy

• a high temperature (fever)
• sweating
• a poor appetite
• weight loss
The inflammation associated with rheumatoid arthritis can also sometimes

cause problems affecting other areas of the body, including dry eyes if the eyes
are affected and chest pain if the heart or lungs are affected.
Symmetrical arthropathy occurs with out reynauds phenomenon

B It affects mainly the metaphysis,the growing end of bones
The three areas most often affected by osteosarcoma are:
• The lower thigh bone nearest to the knee (distal femur)

• The upper shin bone nearest to the knee (proximal tibia)
• The upper arm bone nearest to the shoulder (proximal humerus
There are 5 types of osteosarcoma----

Osteoblastic type
8

Chondroblastic
Telengiectactic
Fibroblastic and small cell osteosarcoma
The tumor is solid, hard, irregular ("fir-tree," "moth-eaten", or "sun-burst"
appearance on X-ray examination) due to the tumor spicules of calcified bone
radiating in right angles. These right angles form what is known as Codman's
triangle, which is characteristic but not diagnostic of osteosarcoma.
Surrounding tissues are infiltrated.
C
picture of scleroderma
Localised scleroderma and systemic
Systemic is divided to limited and diffuse form ;
Limited cutaneous systemic sclerosis:
• a milder form that only affects skin on the hands, lower arms, feet,
lower legs and face, although it can eventually affect the lungs and
digestive system too
• often starts as Raynaud's phenomenon (a circulation problem where
fingers and toes turn white in the cold)
• other typical symptoms include thickening of the skin over the hands,
feet and face, red spots on the skin, hard lumps under the
skin, heartburn and problems swallowing (dysphagia)
• tends to get gradually worse over time, although it's generally less
severe than diffuse systemic sclerosis and can often be controlled with
treatment
• Limited means that the skin involvement is limited to the hands
(although the face and neck may also be involved).
• Diffuse is when skin tightening also occurs above the wrists (or
elbows, see below).
• Systemic Sclerosis sine Scleroderma is when there is internal organ
9

fibrosis, but no skin tightening
D Diffuse systemic sclerosis:
• is more likely to affect internal organs

• skin changes can affect the whole body
• other symptoms can include weight loss, fatigue and joint pain and
stiffness
• symptoms come on suddenly and get worse quickly over the first few
years, but then the condition normally settles and the skin may
gradually improve
In some cases of systemic sclerosis, organs such as the heart, lungs or kidneys
are affected. This can cause a range of potentially serious problems, such as
shortness of breath, high blood pressure and pulmonary hypertension (high
blood pressure in the lungs).

E Most common sites are pelvis and shoulder
Symptoms :
• Back or thigh pain

• Sciatica
• Bladder Symptoms
• Unilateral edema

KEY c
Additional it's a disease of connective tissue disease like as RA, SLE. so arthritis here and
Information symmetrical arthritis. two
variety of Systemic sclerosis. LCSS- Involvement distal to the knee and

elbows with CREST syndrome,
DCSS- involvement proximal to knee and elbows with renal involvement

(scleroderma renal crisis ).
presence of telangiectasia and Raynaud pheno indicates LCSS.in RA, arthritis

present but not raynauds
pheno. Raynaud's also present in SLE.
scleroderma
10

Common presenting symptoms are Raynaud's phenomenon, skin hardening
in hands or face,
and oesophageal symptoms.
types of SSC
Limited scleroderma >>> Generally a milder disease, with less skin

involvement, slow onset and
slow progression.
70% of SSc cases.
Affects only the face, forearms and lower legs up to the knee.
The older term for limited scleroderma is CREST syndrome (= Calcinosis,

Raynaud's disease,
(O)Esophageal dysmotility, Sclerodactyly, Telangiectasia).
Diffuse scleroderma >>> Usually a more rapid onset, with skin thickening and
Raynaud's
phenomenon occurring together or within a short interval
30% of SSc cases ,, Involves also the upper arms, thighs or trunk
- Formerly known as the CREST Syndrome
- C: Calcinosis
- R: Raynaud’s Phenomenon
E: Esophageal and Gut dysmotility
- S: Sclerodactyly
- T: Telangiectasias (Reddish Spots)

Reference Nhs and rabia
Dr Khalid/Rabia

Q:1142 60yo female has pain and stiffness in her right hip joint. Pain is not severe in
the
11

morning but
increases as the day progresses. She has noticed some nodules in her hands.
Inv: Hgb=low. What
is the most probable dx?
a. RA
b. Osteoarthritis
c. Gout
d. Pseudogout
e. Multiple myeloma

Clincher(s) Pain increases as day progresses with nodules on hand
A Pain more in morning with joint stiffness
B Pain increases as day progresses,or after exercise
C Gout:
>>>Monosodium urate
>>>Acute Monoarthritis
>>>Negative birefringence, Needle shape crystals, and Negative Gr stain and

culture.
MC involved joint in Gout is the first toe (metatarsophalangeal

joint)>>>podaGra>>>this joint is close to the Ground.

D Pseudogout:
>>>Calcium Pyro-Phosphate
>>>Acute Monoarthritis (both Gaut and Pseudogout are Acute and Mono-
arthritis)
>>>Positive birefringence and Rhomboid/Rectangular crystals.
MC involved joint in Pseudogout is the knee. On X-ray look for CalciumPPD

crystals in joint menisci or articular cartilage>>>ChondroCalcinosis

E Multiple myeloma is a neoplasm of the bone marrow plasma cells. The peak
Calcium elevated ,Renal failure,Anaemia,Bone lesions , (CRAB)
Remember it's incidence is patients aged 60-70 years.
Clinical features
12

· bone disease: bone pain, osteoporosis + pathological fractures (typically
vertebral), osteolytic lesions
· lethargy
· infection
· hypercalcaemia
· renal failure
· other features: amyloidosis e.g. Macroglossia, carpal tunnel syndrome;
neuropathy; hyperviscosity
pneumonic CRAB:
normocytic and normochromic anaemia
Diagnosis is based on:
· monoclonal proteins (usually IgG or IgA) in the serum and urine (Bence
Jones proteins)
· increased plasma cells in the bone marrow
· bone lesions on the skeletal survey ,hypercalcaemia in myeloma

KEY B
Additional reason : A diagnosis of OA can be made clinically without investigations if a
Information person:
· Is aged 45 years or over; and
· Has activity-related joint pain; and
· Has either no morning joint-related stiffness or morning stiffness that lasts

no longer than 30 minutes. osteoarthritis
Symptoms
Joint pain that is exacerbated by exercise and relieved by rest. Rest and night
pain can occur in advanced disease. Knee pain due to OA is usually bilateral
and felt in and around the knee. Hip pain due to OA is felt in the groin and
anterior or lateral thigh. Hip OA pain can also be referred to the knee and, in
males, to the testicle on the affected side. Joint stiffness in the morning or
13

after rest.
Signs
Pain and Reduced range of joint movement. Joint swelling/synovitis

(warmth, effusion, synovial thickening).
Bony swelling and deformity due to osteophytes
Commonest joint condition
- Usually monoarthritis
- Usually affects females 50 years and above
- Commonly affects the weight-bearing joints e.g, Hip and knee joints.
(Notice the joint involved)
- Pain on movement and worsening towards the end of the day
- Bouchard’s nodes and Heberden’s nodes are usually present.
- Investigations
- X-ray
- Treatment
-Advise exercise and activity, and physiotherapy
- Paracetamol
- Topical NSAIDs
- Intra-articular steroids
- Low-dose of tricyclic antidepressants for pain at night
- Weight reduction
- Joint replacement in end-stage Osteoarthritis

Reference Nhs ,rabia
Dr Khalid/Rabia

14

Q:1143 A 30yo female has chronic diarrhea, mouth ulcers and skin tags. She complains
of visual prbs, low back pain and morning stiffness. Inv: ESR and CRP=raised,
Hgb=10 mg/dl. What is the most probable dx?
a. SLE
b. Reactive Arthritis
c. Gout
d. Pseudogout
e. Seronegative arthritis

Clincher(s) Diarhoea,visual ,back pain,and inv.
A Main symptoms are fatigue,joint pain,rashescalled malar rash or butterfly rash
• a fever (high temperature)

• swollen lymph glands (small glands found throughout your body,
including in your neck, armpits and groin)
• recurring mouth ulcers
• hair loss (alopecia)
• high blood pressure (hypertension)
• headaches and migraines
• stomach (abdominal) pain
• chest pain
• depression
• dry eyes
• memory loss
• seizures (fits)
• problems thinking clearly and difficulty telling the difference between
reality and imagination (psychosis)
• shortness of breath
• Raynaud's phenomenon
Diagnosis by:
Blood tests ESR
ANTI NULEAR ANTIBODY
ANTI DNA ANTIBODY
TREATMENT:
Nsaids
hydroxychloroquine
B Large joints,uveitis,and Git symptoms

C GOUT PSEUDOGOUT
1. Smaller joints 1. Large joints
2. Intense pain 2. Moderate pain
3. Joint inflamed 3. Joint swollen
4. Hyperuricemia 4. Chondrocalcinosis
5. Uric acid crystals 5. Calcium pyrophosphate crystals
15

6. Rod shaped crystals 6. Rectangular shaped crystals
7. Negatively bisfringent

7. Positive bisfringence
D
E There is a high incidence of HLA-B27 but negative rheumatoid factor tests.
Diseases belonging to the seronegative spondyloarthropathies' group include

ankylosing spondylitis, Reiter's syndrome, enteropathic arthritis, psoriatic
arthritis, Behçet's disease and juvenile idiopathic arthritis.
Presentation
• The mean age at onset is 20 to 40 years. Spondyloarthropathies may

sometimes be relatively mild and many patients do not seek medical
advice.
• Inflammatory back pain: lumbar or dorsal pain at night or stiffness in
the morning.
• Sacroiliitis: buttock pain; pain alternating between the two buttocks is
more specific.
• Peripheral arthritis: mainly affects the lower limbs and is often but not
always asymmetrical.
• Enthesitis.
• Dactylitis: inflammation involving a whole finger or toe with
tendovaginitis and arthritis (sausage digit).
• Non-gonococcal urethritis or cervicitis, or acute diarrhoea one month
or less before the onset of arthritis.
• Psoriasis, balanitis or inflammatory bowel disease.
• Anterior uveitis.
• Family history of spondyloarthropathy

KEY B
Additional reason : the symptoms fits ( GIT or urinary tract symptoms >> diarrhea + law
Information back pain + visual
problems >> uveitis + lab >> anemia and inreased ESR & CRP )
Reactive arthritis or Reiter's syndrome >>> is a form of seronegative

spondyloarthritis clinically associated with inflammatory back pain, GIT
symptoms . The presence of large joint oligoarthritis, urogenital tract
infection and uveitis characterises Reiter's syndrome as a clinical
subtype of reactive arthritis.
Presentation
· develops 2-4 weeks after a genitourinary or gastrointestinal infection.
16

· The onset is most often acute, with malaise, fatigue, and fever.
· An asymmetrical, predominantly lower extremity, Low back pain often

occurs.
· The complete Reiter's triad of urethritis, conjunctivitis, and arthritis may

occur.
· Skin ,nails and mucous membranes (mouth ulcers) may all be affected.
· Eyes: uveitis, episcleritis, keratitis, and corneal ulcerations.
· Gastrointestinal: abdominal pain and diarrhoea
Investigations :
**Once arthritis is observed, microbial tests and blood or synovial fluid

cultures are negative,
and only serum antibodies are detected.
· ESR and CRP are usually very high.
· FBC: normocytic normochromic anaemia
· HLA-B27 is positive
Management
· In the acute phase, rest affected joints, aspirate synovial effusions.
· Physiotherapy.
· Non-steroidal anti-inflammatory drugs (NSAIDs).
· Corticosteroids
Antibiotics to treat an identified causative organism

Reference nhs
Dr Khalid/Rabia rabia

Q:1146 A 60yo lady with a hx of HTN and suffering from RA since the last 10y now
presents with hot swollen and tender knee joint. What inv would you do for
her?
17

a. XR
b. C&S of joint aspirate
c. US
d. MRI
e. CT

Clincher(s) RA since 10 years,hot swollen tender knee joint
A s
B We should know the cause of inflammation like septic arthritis need to be
ruled out
C
D
E
KEY B
Additional reason : septic arthritis is the most important diagnosis to exclude as, if left
Information untreated, the sequelae include permanent joint damage, impairment of
function and even death
DDx of hot swollen tender joint
Infection:
· Septic arthritis >> acute onset , monoarthritis, mostly knee in adults and
hip in
children , plus constitutional symptoms ( fever , malaise)
· Neisseria gonorrhoeae
· Lyme disease >> erythema migrans
Rheumatoid arthritis >>> insidious onset ,polyarthritis
Crystal arthropathies - gout and pseudogout >>> acute onset , monoarthritis

mostly, 70% of
attacks first occur in the big toe in gout
Reactive arthritis (now considered synonymous with Reiter's syndrome).

>>> polyarthritis , Hx
of gastrointestinal or genitourinary infection
Trauma >>> Hx of trauma
18

History of Rubor, Erythema and swelling in a single joint is Septic Arthritis
until proven otherwise.
- Therefore the investigation of choice would be C/S of joint aspirate.
- Rest of the investigations do not help in making the diagnosis or exclusion

of septic arthritis.

Reference
Dr Khalid/Rabia

Q:952(derma) 952. A 67yo builder presents witha persistent nodular lesion on upper
part of pinna with some telangiectasia around the lesion. What is the dx?
a. Basal cell
b. Squamous cell
c. Keratocanthoma
d. Actinic keratosis
e. Bowens diseas

Clincher(s) Builder(exposed to sun),nodular rash on pinna
A presentation of basal cell CA is over sun exposed areas, lesions small pearly
white and raised with telangiectasia.rodent ulcer has an indurated edge and
ulcerated centre.
types:
Nodular=Solitary, shiny, red nodule with large telangiectatic vessels.Commonly
on the face.

B · The lesion caused by SCC is often asymptomatic
· Ulcer or reddish skin plaque that is slow growing
· Intermittent bleeding from the tumor, especially on the lip
· The clinical appearance is highly variable
· Usually the tumor presents as an ulcerated lesion with hard, raised edges
· The tumor may be in the form of a hard plaque or a papule,
C · Typically, rapid growth over a few weeks to months, followed by a slow
spontaneous resolution over 4-6 months (but may take up to one year).
· Most occur on sun-exposed areas - eg, the face, neck, and dorsum of hands
and forearms.
· They are usually solitary and begin as firm, round, skin-coloured or reddish
papules that rapidly progress to dome-shaped nodules with a smooth shiny
surface. A central crater of ulceration may develop, or a keratin plug that may
project like a horn.
D Premalignant state- leads to Ca
19

E Bowen's disease is typically a red-looking patch of skin that has an irregular
outline. It tends to look crusty or scaly. Sometimes the patch of Bowen's
disease can become cracked or ulcerated and can bleed. Patches can slowly
enlarge.
KEY A (anything on face is Basal Cell ca until proven otherwise)
Additional
Information
Bowen,s disease
Basal cell carcinoma
20

Reference Various websites
Dr Khalid/Rabia Basal cell Carcinoma:
Superficial=
Often multiple, usually on the upper trunk and shoulders,
Erythematous well-demarcated scaly plaques.
Morphoeic=Also known as sclerosing or infiltrative BCC.Usually
found in mid-facial sites.More aggressive and have poorly defined
borders
Pigmented=Brown, blue or greyish lesion.Nodular or superficial
histology.Seen more often in individuals with dark skin.
Basosquamous
Mixed BCC and squamous cell carcinoma (SCC)
Treatment : Surgery : mohs micrographic surgery
Curettage and cautery/electrodesiccation.
Not recommended for recurrent,
large, morphoeic tumours or tumours on the face
Cryotherapy/cryosurgery .
Cryotherapy is well established for treating
small low
-
risk lesions, including superficial BCCs.Histology is
not available
unless an incisional biopsy is taken first.
Imiquimod 5% cream:
Topical Imiquimod appears to be effective in the
treatment of primary small superficial BCCs
Radiotherapy.
The best indications for radiotherapy are BCC with
incomplete excision, r
ecurrent BCC, nodular BCC of the head and neck
under 2 cm and BCC with invasion of bone or cartilag

Q:957 A 61yo man who had stroke 2y ago is on aspirin. He has RA but suffers from
pain and can’t tolerate it. He is taking senna for constipation. What is the best
med to relieve his pain?
a. DMARDs
b. Ibuprofen
c. Co-codamol- cause constipation
d. Paracetamol- osteoarthritis

Only for osteoarthritis: paracetmol,
21

Clincher(s)
A Disease-modifying anti-rheumatic drugs (DMARDs) act by altering the
underlying disease rather than treating symptoms. They're not painkillers, but
they'll reduce pain, swelling and stiffness over a period of weeks or months by
slowing down the disease and its effects on the joints. Read more about the
following conventional DMARDs:
• ciclosporin
• cyclophosphamide
• gold injections
• hydroxychloroquine
• leflunomide
• methotrexate
• mycophenolate
• sulfasalazine.
- See more at: http://www.arthritisresearchuk.org/arthritis-
information/drugs/dmards.aspx#sthash.LfSJZfrr.dpuf

B NSAIDS are good for symptom relief , recommended are Ibuprofen,
naproxen,diclofena

C weak opiates are rarely effective , ( another contraindication is constipation)
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia

Q: 610 A 62yo man with rheumatoid arthritis struck his hand against a door. He
subsequently found
that although he could extend the interphalangeal joint of his right thumb, the
MCP joint of the
thumb remained flex. What is the single most likely tendon to have been
damaged?
a. Extensor carpi ulnaris
b. Extensor digitorum
c. Extensor indicis
d. Extensor pollicis brevis
e. Extensor pollicis longus

Clincher(s)
A
22

B
C
D
E Extensor pollicis longus extends the terminal phalanx of the thumb.
KEY d. Extensor pollicis brevis

Additional the extensor pollicis brevis both extends and abducts the thumb[1] at
Information the carpometacarpal andmetacarpophalangeal joints.[2]
Reference wikipedia
Dr Khalid/Rabia Remember pollicis is for thumb. Extensir pollicis brevis is inserted at the base of proximal
phalanx of thumb . Extensor pollucis longus at the interphalangeal joint of thumb. As he is unable
to extend MCP joint so brevus tendon is ruptured.
( Make it simple.. from longus remember it would be long and go more distal to get inserted at
the IP joint. And brevis ends short at MCP joint)

Q: 647 A 35yo woman undergoing tx for TB presents with malar rash, photosensitivity
and hematuria.
What is the single most likely positive antibody?
a. Anti Ds DNA
b. Anti Sm
c. Anti Histone
d. Anti La
e. Anti centromere

Clincher(s) 35 year olod, tb treatment, rash photosentivity hematuria.
A sle
B Sle (antinuclear antibodies-98%)
C Drug induced lupus
D Shojrens syndrome
E Limited systemic sclerosis
KEY c. anti histone antibodies
Additional Drug induced lupus. Skin, lung, renal, cns affected. Disease remits if drug
Information stopped.

Drug-induced lupus erythematosus (DIL or DILE) is an autoimmune disorder
(similar to systemic lupus erythematosus [SLE]) caused by chronic use of certain
drugs. These drugs cause an autoimmune response (the body attacks its own
cells) producing symptoms similar to those of SLE. There are 38 known
medications to cause DIL but there are three that report the highest number of
cases: hydralazine, procainamide, andisoniazid.[1] While the criteria for diagnosing
DIL has not been thoroughly established, symptoms of DIL typically present
as muscle pain and joint pain. Generally, the symptoms recede after discontinuing
use of the drugs.[2]
23

igns and symptoms of drug-induced lupus erythematosus include the following:
• Joint pain (Arthralgia) and muscle pain (myalgia)

• Fatigue
• Inflammation of the sac around the heart (pericarditis) and the sac around the
lungs (pleuritis)
• Anti-histone antibodies in 95% of cases
These signs and symptoms are not side effects of the drugs taken which occur
during short term use. DIL occurs over long-term and chronic use of the
medications listed below. While these symptoms are similar to those of systemic
lupus erythematosus, they are generally not as severe unless they are ignored
which leads to more harsh symptoms, and in some reported cases, death.
Treatment[edit]
It is important to recognize early that these drugs are causing DIL like symptoms
and discontinue use of the drug. Symptoms of drug-induced lupus erythematosus
generally disappear days to weeks after medication use is discontinued. Non-
steroidal anti-inflammatory drugs (NSAIDs) will quicken the healing
process. Corticosteroids may be used if more severe symptoms of DIL are present.

Reference Ohcm 556 and wikipedia
Dr Khalid/Rabia Drug induced lupus.
Most common causes
• procainamide
• hydralazine
Less common causes

• isoniazid
• minocycline
phenytoin

Q:459 A 56yo man has symptoms of sleep apnea and daytime headaches
and somnolence. Spirometry shows a decreased tidal volume and vital
capacity. What is the single most appropriate dx
a. Ankylosing spondylitis
b. Churg-strauss syndrome
c. Good pasture syndrome
d. Motor neuron disease
e. Progressive massive fibrosis
f. Spinal cord compression

Clincher(s) Sleep apnea, day time somnolence and headache, Dec tidal volume and
24

capacity.
A Hx of low back pain with sacroiliac joint involvement and typically involve
young males.
B It present with triad of vasculitis, easonophilia and asthma.
C Assciated with lung and kidney involvement. Anti GBM antibodies present at
glomerular membrane.
E Progressive massive fibrosis also known as complicated form of coal workers
pneumoconiosis.
Symptoms:
Shortness of breath, Chronic cough, Black sputum, Lung dysfunction
Pulmonary hypertension, Heart problems
F Symptoms suggestive of cord compression are back pain, a dermatome of
increased sensation, paralysis of limbs below the level of compression,
decreased sensation below the level of compression, urinary and fecal
incontinence and/or urinary retention. Lhermitte's sign (intermittent
shooting electrical sensation) when bending the head and hyperreflexia may
be present.
KEY D
Additional Motor neurone disease is a rare condition that progressively damages parts of
Information the nervous system. This leads to muscle weakness, often with visible wasting.

Respiratory-onset disease:
In extremely rare cases, motor neurone disease starts by affecting the lungs,
rather than affecting them at the end of the condition. This is called
respiratory-onset disease.
In some cases the initial symptoms are obvious, such as breathing difficulties
and shortness of breath.
In other cases the symptoms are less noticeable, such as waking up frequently
during the night because the brain is temporarily starved of oxygen when lying
down. This can make the person feel very tired and unrefreshed the next
morning, sometimes
Shortness of breath may be particularly troublesome at night. Some people find
it difficult to breathe when they're lying down. Others may wake up in the night
because of breathlessness.

Reference
Dr Khalid/Rabia Involvement of respiratory muscles in Motor Neuron Disease is associated
with poor respiration causing sleep apnoea

Q:496 A 45yo woman has been dx with Giant Cell A and is being treated
with steroids. What is the other drug that can be added to this?
25

a. ACEi
b. Beta blockers
c. Aspirin
d. Interferons
e. IVIG

Clincher(s) Second Drug choice for GCA along with steroid
A
B
C
D
E No role of immunoglobulins here.
KEY C
Additional GCA is uncommon and mainly affects people over the age of 60. It rarely
Information affects people aged under 50. Women are more commonly affected than men.
The cause is not known.
The common symptoms of giant cell arteritis are headache, tenderness over
one or both sides of the forehead, and feeling unwell. Other symptoms that
may occur include pain in your jaw muscles when you chew which eases when
you rest the jaw muscles, and visual loss

The headache can be one-sided, or on both sides. Typically, it is mainly towards
the front and sides of the head.

Dx: ESR is done initially but temporal biopsy is for diagnosis as ESR is raised in
many other inflammatory condition.

In addition to a steroid tablet, a low daily dose of aspirin is usually advised. 75
mg daily is the usual dose. The low dose of aspirin helps to prevent heart
attacks and strokes. (As mentioned above, there is an increased risk of
developing a heart attack or stroke if you have GCA).

PPI is advised when taking steroids and aspirin because of increase chance of
developing gastric ulcer. Bisphosphonates also required to prevent
osteoporosis.
Reference Patient info
Dr Khalid/Rabia

Q: 940 A young woman fell and hit her knee. Exam: valgus test +ve. What ligament
was most probably injured?
a. Ant cruciate (Ant drawer test positive)
b. Medial collateral (valgus +)
c. Lateral collateral (Varus +)
26

d. Post cruciate (post drawer test +)
e. Meniscus

Clincher(s)
A
B Medial collateral. [The valgus stress test involves placing the leg into
extension, with one hand placed as a pivot on the knee. With the other hand
placed upon the foot applying an abducting force, an attempt is then made to
force the leg at the knee into valgus. If the knee is seen to open up on the
medial side, this is indicative of medial collateral ligament damage].

C
D
E
KEY B
Additional The posterior cruciate ligament (or PCL) is one of the four major ligaments of
Information the knee. It connects the posterior intercondylar area of the tibia to the medial
condyle of the femur. This configuration allows the PCL to resist forces pushing
the tibia posteriorly relative to the femur.
The PCL is an intracapsular ligament along with the anterior cruciate ligament
(ACL) because it lies deep within the knee joint. They are both isolated from
the fluid-filled synovial cavity, with the synovial membrane wrapped around
them. The PCL gets its name by attaching to the posterior portion of the tibia.
Function
Although each PCL is a unified unit, they are described as separate

anterolateral and posteromedial sections based off where each section's
attachment site and function.[7] During knee joint movement, the PCL rotates
[6][8]
such that the anterolateral section stretches in knee flexion but not in
knee extension and the posteromedial bundle stretches in extension rather
than flexion.[4][9]
The function of the PCL is to prevent the femur from sliding off the anterior
edge of the tibia and to prevent the tibia from displacing posterior to the
femur. The posterior cruciate ligament is located within the knee. Ligaments
are sturdy bands of tissues that connect bones. Similar to the anterior cruciate
ligament, the PCL connects the femur to the tibia.
Injury
Common causes of injuries are direct blows to the flexed knee, such as the
knee hitting the dashboard in a car accident or falling hard on the knee, both
instances displacing the tibia posterior to the femur.
27

There are four different grades of classification in which medical doctor’s
classify a PCL injury: Grade I, the PCL has a slight tear. Grade II, the PCL
ligament is minimally torn and becomes loose. Grade III, the PCL is torn
completely and the knee can now be categorized as unstable. Grade IV, the
ligament is damaged along with another ligament housed in the knee (i.e.
ACL). With these grades of PCL injuries, there are different treatments
available for such injuries

Examine the medial and lateral collateral ligaments with the knee flexed
20°–30° (to relax the posterior capsule and the cruciate ligaments); one hand
lifts the ankle, the other stabilizes the knee. Stress the knee by abducting the
ankle while pushing the knee medially with the hand behind the knee (tests
the medial ligament with a valgus stress force). Reverse the pressures to give
adducting force to test lateral ligament (ie varus stress). If these ligaments
are torn the knee joint opens more widely when the relevant ligament is
tested (compare knees against each other, as general laxity may be present).
The Valgus stress test is a test for ligament damage. It involves placing the leg
into extension, with one hand placed as a pivot on the knee. With the other
hand placed upon the foot applying an abducting force, an attempt is then
made to force the leg at the knee into valgus. If the knee is seen to open up on
the medial side, this is indicative of medial collateral ligament damage and
may also indicate capsular or cruciate ligament laxity.
There are two versions of this test, valgus at 0 degrees and valgus at 30
degrees. When performing the test at 30 degrees, the MCL is the primary
stabilizer; the joint capusle is also tested. When tested at 0 degrees, the MCL,
medial joint capsule, and anterior and posterior cruciate ligaments are
stressed.

Reference Ohcs and wikipedia
Dr Khalid/Rabia

Q: 951 A 68yo man presents with muscle weakness. He is not able to climb stairs. He
also complains of mild breathlessness. He says that he sometimes feels
difficulty in swallowing food. Labs: ALP=216, AST=49, ALT=43, CK=417, ESR=16.
What is the most likely dx?
a. Polymyosis (CK raised)- weakness
b. Polymyalgia rheumatic- weakness (CK =N)
c. Muscular dystrophy
d. Esophageal carcinoma
e. Osteoarthritis
28

Clincher(s)
A
B Onset is subacute < 2weeks, crp is normal
C Muscular wasting is the key feature, children
D
E
KEY A
Additional Signs and symptoms
Information
The hallmark of polymyositis is weakness and/or loss of muscle mass in the
proximal musculature, as well as flexion of the neck and torso.[1] These
symptoms can be associated with marked pain in these areas as well. The hip
extensors are often severely affected, leading to particular difficulty in
ascending stairs and rising from a seated position. The skin involvement of
dermatomyositis is absent in polymyositis. Dysphagia (difficulty swallowing) or
other problems with esophageal motility occur in as many as 1/3 of patients.
Low grade fever and peripheral adenopathy may be present. Foot drop in one
or both feet can be a symptom of advanced polymyositis and inclusion body
myositis. The systemic involvement of polymyositis includes interstitial lung
disease and cardiac disease, such as heart failure and conduction
abnormalities.[2]
Polymyositis tends to become evident in adulthood, presenting with bilateral

proximal muscle weakness often noted in the upper legs due to early fatigue
while walking. Sometimes the weakness presents itself as an inability to rise
from a seated position without help or an inability to raise one's arms above
one's head. The weakness is generally progressive, accompanied by
lymphocytic inflammation (mainly cytotoxic T cells).
Associated Illnesses
Polymyositis and the associated inflammatory myopathies have an associated

increased risk of malignancy.[3] The features they found associated with an
increased risk of cancer was older age, age greater than 45, male sex,
dysphagia, cutaneous necrosis, cutaneous vasculitis, rapid onset of myositis
(<4 weeks), elevated CK, higher ESR, higher CRP levels. Several factors were
associated with lower-than-average risk, including the presence of ILD,
arthritis/arthralgia, Raynaud's syndrome, or anti-Jo-1 antibody.[3] The
malignancies that are associated are nasopharyngeal cancer, lung cancer, non-
hodgkins lymphoma & bladder cancer amongst others.[4]
Cardiac involvement manifests itself typically as heart failure, and is present in

up to 77% of patients.[2] Interstitial lung disease is found in up to 65% of
patients with polymyositis, as defined by HRCT or restrictive ventilatory
defects compatible with ILD.[5]
29

Causes
Polymyositis is an inflammatory myopathy mediated by cytotoxic T cells with

an as yet unknown autoantigen, while dermatomyositis is a humorally
mediated angiopathy resulting in myositis and a typical dermatitis.[6] The cause
of polymyositis is unknown and may involve viruses and autoimmune factors.
Cancer may trigger polymyositis and dermatomyositis, possibly through an
immune reaction against cancer that also attacks a component of muscles.[7]
Diagnosis
Diagnosis is fourfold, history and physical examination, elevation of creatine

kinase, electromyograph (EMG) alteration, and a positive muscle biopsy.[8]
The hallmark clinical features of polymyositis is proximal muscle weakness,

with less important findings being muscle pain and dysphagia. Cardiac and
pulmonary findings will be present in approximately 25% of cases of patients
with polymyositis.
Sporadic inclusion body myositis (sIBM): IBM is often confused with

(misdiagnosed as) polymyositis or dermatomyositis that does not respond to
treatment is likely IBM. sIBM comes on over months to years; polymyositis
comes on over weeks to months. Polymyositis tends to respond well to
treatment, at least initially; IBM does not.
Treatment
The first line treatment for polymyositis is corticosteroids. Specialized exercise

therapy may supplement treatment to enhance quality of life.

Reference
Dr Khalid/Rabia

Q: 662 A 35yo woman has butterfly rash on her face and she suffers symmetrical joint
pains on knee and elbow, ESR is raised. What is the most discriminative inv for
dx?
a. Anti DNA antibodies
b. Anti Jo1 antibodies
c. Anti nuclear antibodies
d. Anti centromere antibodies
e. Anti la antibodies

Clincher(s) 35yo, woman, butterfly rash on her face, symmetrical joint pains on knee
and elbow, ESR raised
30

A Most specific for SLE
B antibodies to Jo-1 correlate with disease activity in the polymyositis and
dermatomyositis spectrum, especially with the presence of pulmonary
interstitial disease. antibodies to Jo-1 are found less often in SLE and mixed
connective tissue disorders
C Increased ANF (Anti nuclear factor) is always present in
• SLE (80-90% - note that uraemia may render the result negative> most
commonly seen but not most specific)
• systemic sclerosis (80%)
• Sjogren's syndrome (60%)
• polymyositis/dermatomyositis (30%)
• Still's disease (30%)
Also seen in:
• autoimmune chronic active hepatitis
• primary biliary cirrhosis
• infections, infective endocarditis
• fibrosing alveolitis
• drug reactions
Occasionally a positive ANF is found in normal elderly people.
D Anti-centromere antibody is found in:
• 70% of patients with CREST syndrome
• 20% with systemic sclerosis
E anti la antibody to an extractable nuclear antigen. This is associated with SLE
and primary Sjogren's syndrome.
KEY: A SLE is a chronic, multisystem, inflammatory connective tissue disorder of
autoimmune origin. It is non-organ specific and characterized by vasculitis.
31

32

Additional
Information

Reference GPNotebook, OHCM pg: 557
Dr Khalid/Rabia a. Anti DNA antibodies
in diagnostic critera for SLE,we have four antibody.Among them most specific
is anti double stranded DNA antibody.So answer is a.
Immunology
· 99% are ANA positive
· 20% are rheumatoid factor positive
· anti-dsDNA: highly specific (> 99%), but less sensitive (70%)
· anti-Smith: most specific (> 99%), sensitivity (30%)
· also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
Monitoring
· ESR: during active disease the CRP is characteristically normal - a raised CRP
may indicate underlying infection
· complement levels (C3, C4) are low during active disease (formation of
complexes leads to consumption of complement)
33

· anti-dsDNA titres can be used for disease monitoring (but note not present in
all patients)

Q: 712 A 60yo man has had spontaneous painful swelling of his right knee for 3days.
5days prv he had an inguinal hernia repaired as a day case. He takes
bendroflumethiazide 2.5mg daily. He is apyrexial. What is the single most
appropriate diagnostic inv?
a. Blood culture
b. CRP
c. D-dimer
d. XR knee
e. Serum uric acid

Clincher(s) Spontaneous swelling of right knee, h/o of surgery, on bendroflumethiazide
A
B C-reactive protein raised in inflammation
C elevated levels of D-dimers occur in most critically ill patients with severe
infection, trauma, or inflammatory disorders, DVT, DIC etc
D Radiographs show only soft-tissue swelling in the early stages. Later, well-
defined ‘punched out’ erosions are seen in juxta-articular bone
E
KEY: E Serum Uric Acid
Thiazide diuretics causes hyperuicemia which can precipitate acute attack of
gout
Additional
Information
Reference
Dr Khalid/Rabia There is a suspicion of gout for which serum uric acid needs to be checked. The
patient takes a thiazide diuretic which predisposes to gout.

Q: 719 A 70yo man presented with muscle weakness and inability to climb the stairs.
Inv: CPK (creatinine phosphokinase) raised, ESR 15. What is the most likely dx?
a. Polymyositis
b. Polymyalgia rheumatic
c. Reactive arthritis
d. RS (reiter’s syndrome)
e. Duchenne’s MD

Clincher(s)
A
B Polymyalgia rheumatica presents with shoulder girlde ache, morning stiffness.
CPK not raised
C h/o of tx of sexually tx infection or gastroenteritis; increased ESR and CRP
D
34

E Duchene will not present at the age of 70 yrs it presents in childhood.
KEY: A Polymyositosis
Proximal muscle weakness and raised CPK points towards polymyositis
The myositis of polymyositis and dermatomyositis results in:

• muscle tenderness
• proximal, symmetrical muscle weakness
• may present as difficulty rising from a chair or climbing stairs
In severe cases there may be:
• dysphagia
• dysphonia
• respiratory failure
Additional
Information
Reference Samsons notes, GPNotebook
Dr Khalid/Rabia Proximal muscle weakness raised CPK point towards the diagnosis. Anti Jo
antibodies are raised in polymyositis. Polymyalgia rheumatica presents with
shoulder girlde ache, morning stiffness. Duchene will not present at the age of
70 yrs it presents in childhood.

Q: 832 An 80yo woman suffering from RA presents with severe epigastric pain and
vomiting. She also complains of shoulder tip pain. What is the single most
discriminatory inv?
a. US Abdomen
b. Sigmoidoscopy
c. Colonscopy
d. Barium meal
e. Upper GI endoscopy
f. Erect CXR

Clincher(s) 80yo, woman, RA, severe epigastric pain and vomiting, shoulder tip pain
A
B
C
D
E
KEY The key is F. Erect CXR.

Dr. Khalid >> Elderly patient with RA is usually on NSAIDs which may lead to
perforated peptic ulcer which presents as severe epigastric pain, vomiting
and shoulder tip pain. Diagnosis is made by seeing free gas shadow under the
diaphragm on erect CXR

35

Additional
Information
Reference GPNotebook
Dr. Rabia key : f
reason : acute abdomen + diaphragmatic irritation >>>> gut perforation mostly
peptic ulcer because of RA drugs
Indications of plain abdominal x-ray
Renal colic:
• A 'KUB' picture is requested. This is a large film that is designed to take in the
kidneys, ureters and bladder.
• About 90% of renal stones are radio-opaque. Uric acid stones may be missed.
• False positives may occur from phleboliths that are most common in the
pelvic veins. False negatives may arise, especially if stones are small.
• Calcification may represent gallstones but only a minority of gallstones are
radio-opaque. Gallstones become more frequent with age and are often
asymptomatic.[4]
• Doctors in A&E tend to be poor at identifying stones on plain films but, if
urinalysis is negative, the diagnosis is unlikely to be renal colic.
Intestinal obstruction:
• Erect and supine films are used to confirm the diagnosis.
• Obstruction of the small bowel shows a ladder-like series of small bowel
loops but this also occurs with an obstruction of the proximal colon. Fluid
levels in the bowel can be seen in upright views.
• Distended loops may be absent if obstruction is at the upper jejunum.
• Obstruction of the large bowel is more gradual in onset than small bowel
obstruction. The colon is in the more peripheral part of the film and distension
may be very marked.
• Fluid levels will also be seen in paralytic ileus when bowel sounds will be
reduced or absent rather than loud and tinkling as in obstruction.
• In an erect film, a fluid level in the stomach is normal as may be a level in the
caecum. Multiple fluid levels and distension of the bowel are abnormal.
Perforation of the intestine:
• If the bowel has been perforated and a significant amount of gas has been
released it will show as a translucency under the diaphragm on an erect film.
• Gas will also be found under the diaphragm for some time after laparotomy
or laparoscopy.
Appendicitis
• An appendicolith may be apparent in an inflamed appendix in 15% of cases
but as a diagnostic point in the management of appendicitis, the plain X-ray is
36

of very limited value.[6]
• It may be of value in infants.
Intussusception:
• Intussusception occurs in adults and children.
• A plain abdominal X-ray may show some characteristic gas patterns.[8]
• A sensitivity and specificity of 90% adds to this rather difficult diagnosis but
ultrasound is vastly superior.[9]
• Detection of swallowed foreign bodies:
• Plain X-ray will detect the presence of radiopaque foreign bodies.
• A plain abdominal X-ray will show 90% of cases of 'body packing' (internal
concealment of drugs to avoid detection) but there will be false positives in
3%.

Q: 849 A 28yo man is inv for recurrent lower back pain. A dx of AS is suspected. Which
of the following inv is most useful?
a. ESR
b. XR sacro-iliac joints
c. HLA B27
d. XR thoracic spine
e. CT lumbar spine

Clincher(s)
A
B
C
D
E
KEY: B XR sacro-iliac joints.

x-ray sacroiliac joint shows fusion of both SI joints and thin, symmetrical
syndesmophytes bridging the intervertebral disc spaces
Additional
Information
Reference OHCM PG: 552
37

Dr Khalid/Rabia

Tests: Diagnosis is clinical, supported by imaging (MRI is most sensitive and
better at detecting early disease). Sacroiliitis is the earliest X-ray feature, but
may appear late.
In later stages, calcification of ligaments with ankylosis lead to a ‘bamboo
spine’ appearance.
Also: FBC (normocytic anaemia), ESR, CRP, HLA B27+ve (not diagnostic)
Treatment: Exercise, NSAIDs, TNF blockers etanercept, adalimumab and
golimumab are indicated in severe active AS if NSAIDS fail

Q: 864 A pt with terminal cancer is being treated with chemo develops tingling and
numbness of the fingertips of both arms. What is the single most likely cause
of the symptoms?
a. Bone mets to cervical vertebrae
b. Post-chemo neuropathy
c. Hyponatremia
d. Hypocalcemia

Clincher(s)
A Make bones weaker and cause them to break which can lead to
hypercalcaemia. spinal metastasis may cause pain, instability, neurological
injuries with loss of control urinary and rectal sphincter up to paraplegia.
However 60% asymptomatic
B
38

C

KEY The key is B. Post-chemo neuropathy.

Peripheral neuropathy results from some type of damage to the peripheral
nerves. Certain chemotherapy drugs can cause peripheral neuropathy such
as vinca alkaloids (vincristine), cisplatin, paclitaxel, and the podophyllotoxins
(etoposide and tenoposide). Other drugs used to treat cancer such as
thalidomide and interferon also can cause peripheral neuropathy.

Individuals at greatest risk of peripheral neuropathy associated with
chemotherapy are those with preexisting peripheral neuropathy from
conditions such as:
•Diabetes
•Alcoholism
•Severe malnutrition
•Previous chemotherapy

Symptoms of peripheral neuropathy:
•Numbness, tingling (feeling of pins and needles) of hands and/or feet
•Burning of hands and/or feet
•Numbness around mouth
•Constipation
39

•Loss of sensation to touch
•Loss of positional sense (knowing where a body part is without looking).
•Weakness and leg cramping or any pain in hands and/or feet
•Difficulty picking things up or buttoning clothes
Additional
Information
Reference http://chemocare.com/chemotherapy/side-effects/numbness-tingling.aspx
GPNotebook
Dr Khalid/Rabia

Q: 185 A 32yo previously healthy woman has developed pain and swelling of both
knees and ankles with nodular rash over her shins. As part of the inv a CXR has
been performed. What is the single
most likely CXR appearance?
a. Apical granuloma
b. Bilateral hilar lymphadenopathy
c. Lobar consolidation
d. Pleural effusion
e. Reticular shadowing in the bases

Clincher(s)
A Apical granuloma: apical granuloma modified granulation tissue containing
elements of chronic inflammation located adjacent to the root apex of a tooth
with infected necrotic pulp.

B bilateral hilar lymphadenopathy is pathognomonic for sarcoidosis.
The condition is Lofgren’s syndrome. It is the triad of i) erythema nodosum ii)
bilateral hilar lymphadenopathy and iii) arthralgia.
C Lobar consolidation: pneumonia

D
E
KEY The key is B. bilateral hilar lymphadenopathy.
Additional
Information Sarcoidosis:
Presentation: Lungs are in involved in more than 90% cases of sarcoidosis.
There is interstitial lung disease. The painful skin lesion is erythema nodosum.
Also look for Lupus pernio (chronic raised hardened, often purple lesion) may
be seen on the face.
40

Lofgren syndrome is often a part of sarcoidosis. The triad is i) Erythema
nodosum ii) Bilateral hilar lymphadenopathy iii) Arthralgia
Sarcoidosis is a multisystem disease and can involve any system/organ

Tests: ESR is often raised. Serum ACE enzyme levels are raised in 60% of times
Plain CXR may show bilateral hilar or paratracheal lymphadenopathy. High
resolution CT should be done. There will be restricitve pattern of disease on
pulmonary function tests.
Screening: HRCT (high resolution CT)
Transbronchial biopsy can demonstrate the presence of non-caseating
granulomata, giving a more accurate diagnosis: Defnitiive.
Bronchioalveolar lavage may also be done

Reference
Dr Khalid/Rabia

Q: 444 A 15yo boy presents with a limp and pain in the knee. Exam: leg is externally
rotated and 2cm shorter. There is limitation of flexion, abduction and medial
rotation. As the hip is flexed external rotation is increased. Choose the most
likely dx?
a. Juvenile rheumatoid arthritis
b. Osgood-schlatter disease
c. Reactive arthritis
d. Slipped femoral epiphysis
e. Transient synovitis of the hip

Clincher(s)
A Juvenile rheumatoid arthritis (JRA), often referred to by doctors today
as juvenile idiopathic arthritis (JIA), is a type of arthritis that causes joint
inflammation and stiffness for more than six weeks in a child aged 16 or
younger.

The most common symptoms of juvenile arthritis are joint swelling,
pain, and stiffness that doesn't go away. Usually it affects the knees,
hands, and feet, and it's worse in the morning or after a nap. Other
signs include: Limping in the morning because of a stiff knee.

B Osgood Schlatter disease- Inflammation of the patellar ligament at the tibial
tuberosity. Painful lump just below the knee, often seen in young adolescents.
Risk factors- overuse (especially in sports involving running, jumping and quick
changes of direction) & adolescent growth spurts.
C Reactive arthritis or Reiter's syndrome- Autoimmune reaction to an infection
somewhere else in the body. Triad- arthritis, uveitis, urethritis\cervicitis
41

D Slipped femoral epiphysis- Fracture through the growth plate (physis), which
results in slippage of the overlying end of the femur (epiphysis). Symptoms
include gradual, progressive onset of thigh or knee pain with a painful limp.
Hip motion will be limited, particularly internal rotation. Slipped so shprter.
Seen in teenagers (growing time), after minor trauma in obese children. Rx-
reduction and fixation

E Transient synovitis is a self-limiting condition in which there is aninflammation of
the inner lining (the synovium) of the capsule of the hip joint.
Transient synovitis causes pain in the hip, thigh, groin or knee on the affected
side.[4] There may be a limp (or abnormal crawling in infants) with or without pain.
The condition is nearly always limited to one side.[4] The pain and limp can range
from mild to severe.

KEY D
Additional
Information
Reference
Dr Khalid/Rabia

Q: 1635
A 32yo woman has had a febrile illness and swelling of the small
joints of her hands, feet, wrists and knees for two days. She has a
maculopapular rash and a few palpable, small cervical lymph nodes.
She was previously well. There is no history of relevant travel
outside the UK. She has two young children. What is the SINGLE
most likely dx?
a. Psoriasis.
b. Reactive arthritis.
c. Rheumatoid arthritis.
d. Sarcoidosis.
e. SLE

Clincher(s) Swelling of the small joints, maculopapular rash, febrile illness.
A There should be other signs like skin and nail manifestations.
B Fever and cervical lymphadenopathy suggest reactive arthritis.
C There is no fever and there should be long history.
D No fever
E There is butterfly rash
KEY E-SLE (will present with GIT problems) (whether C? to post)
42

Additional
Information
43

Reference
Dr Khalid/Rabia

44

Q: 1654 A 51yo woman complains of difficulty swallowing and also reddish dots on her
skin. A pic of her hand is seen. What is the most appropriate term for the
condition you would expect to see?
a. Sclerodactyly
b. RA
c. Swan neck deformity
d. Polydactyly
e. Ulnar deformity

Clincher(s) Dysphagia and reddish dots on skin.
A Signs given here a suggestive for limited cutaneous systemic sclerosis. The red
dots are telangiectasia. Other sign is sclerodactyly(swollen tight digits)
B There is Z deformity,
C This occur in Rheumatoid Arthritis
D Congenital extra digits/fingers.
E This also occurs in RA.
KEY A- Sclerodactyly.
45

Additional
Information

Reference
Dr Khalid/Rabia

Q: 1669 A pt has fine nail pitting, small yellow-brown areas of discoloration in the
nailbed involving the nails on both hands. These findings are commonly
associated with?
a.Yellow nail syndrome
b. Leukonychia
c. Onychomycosis
d. Lichen planus
e. Pellagra
f. Thallium toxicity
46

g. Contact dermatitis
h. Zinc deficiency
i. Hypoalbuminemia
j. Psoriasis

Clincher(s) Nail pitting and bilateral yellow brown areas of discoloration on nail bed.
A Yellow nail syndrome is triad of nail discoloration and dystrophy, lymph
oedema, and chronic respiratory disorders.
B Leukonychia is condition of white nail.
C Onchylosis is loss nail from nail bed.
D Tongue lesions in which there is white patchy lesion.
E Deficiency of niacin, dementia, diarrhoea and dermatitis.
KEY J- Psoriasis.
Additional
Information

Reference
Dr Khalid/Rabia

47

Q: 868 A 35yo male who recently had an appendicectomy has got severe
pain in his right big toe. Joint is red and swollen. He consumes 30
units of alcohol/week. What is the most probable dx?
a. Rhabdomyosarcoma
b. Osteoarthritis
c. gout
d. Pseudogout

Clincher(s) Alcohol excess, appendiectomy and single joint pain
A Not association
B Not association with clinical picture.
C Precipitated post operatively/surgery and trauma, increased by alcohol,
D
E It is usually spontaneous and not associated with alcohol.
KEY C
48

Additional
Information

Reference
Dr Khalid/Rabia

Q:869 A 25yo male who recently noticed change in his shoe size, he is also
constipated, has a preference to hot weather, his skin is dry, has
severe pain in wrist joint. Joint is red and swollen. What is the most
probable dx?
a. Chondro-sarcoma
b. Lipo-sarcoma
c. Gout.
49

d. Pseudogout
e. Ankylosing spondylitis

Clincher(s)
A
B
C
D
E
KEY D- Pseudogout.
Additional
Information

Reference
Dr Khalid/Rabia

50

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RHEUMATOLOGY-System

Wise 1700-by Sush and Team. 2016

• tiredness and a lack of energy

The inflammation associated with rheumatoid arthritis can also sometimes

Symmetrical arthropathy occurs with out reynauds phenomenon

The three areas most often affected by osteosarcoma are:

• The lower thigh bone nearest to the knee (distal femur)

There are 5 types of osteosarcoma----

Limited cutaneous systemic sclerosis:

(although the face and neck may also be involved).

elbows, see below).

• Systemic Sclerosis sine Scleroderma is when there is internal organ

D Diffuse systemic sclerosis:

• is more likely to affect internal organs

• Back or thigh pain

variety of Systemic sclerosis. LCSS- Involvement distal to the knee and

DCSS- involvement proximal to knee and elbows with renal involvement

presence of telangiectasia and Raynaud pheno indicates LCSS.in RA, arthritis

pheno. Raynaud's also present in SLE.

and oesophageal symptoms.

Limited scleroderma >>> Generally a milder disease, with less skin

70% of SSc cases.

The older term for limited scleroderma is CREST syndrome (= Calcinosis,

(O)Esophageal dysmotility, Sclerodactyly, Telangiectasia).

phenomenon occurring together or within a short interval

- Formerly known as the CREST Syndrome

E: Esophageal and Gut dysmotility

- T: Telangiectasias (Reddish Spots)

>>>Negative birefringence, Needle shape crystals, and Negative Gr stain and

MC involved joint in Gout is the first toe (metatarsophalangeal

>>>Positive birefringence and Rhomboid/Rectangular crystals.

MC involved joint in Pseudogout is the knee. On X-ray look for CalciumPPD

Calcium elevated ,Renal failure,Anaemia,Bone lesions , (CRAB)

Remember it's incidence is patients aged 60-70 years.

· other features: amyloidosis e.g. Macroglossia, carpal tunnel syndrome;

normocytic and normochromic anaemia

Diagnosis is based on:

· increased plasma cells in the bone marrow

· bone lesions on the skeletal survey ,hypercalcaemia in myeloma

· Is aged 45 years or over; and

· Has activity-related joint pain; and

· Has either no morning joint-related stiffness or morning stiffness that lasts

Pain and Reduced range of joint movement. Joint swelling/synovitis

Bony swelling and deformity due to osteophytes

Commonest joint condition

- Usually affects females 50 years and above

- Pain on movement and worsening towards the end of the day

- Bouchard’s nodes and Heberden’s nodes are usually present.

-Advise exercise and activity, and physiotherapy

- Low-dose of tricyclic antidepressants for pain at night

- Joint replacement in end-stage Osteoarthritis

• a fever (high temperature)

Diseases belonging to the seronegative spondyloarthropathies' group include

• The mean age at onset is 20 to 40 years. Spondyloarthropathies may

Reactive arthritis or Reiter's syndrome >>> is a form of seronegative

subtype of reactive arthritis.

· develops 2-4 weeks after a genitourinary or gastrointestinal infection.

· An asymmetrical, predominantly lower extremity, Low back pain often

· The complete Reiter's triad of urethritis, conjunctivitis, and arthritis may

· Eyes: uveitis, episcleritis, keratitis, and corneal ulcerations.

· Gastrointestinal: abdominal pain and diarrhoea

**Once arthritis is observed, microbial tests and blood or synovial fluid

and only serum antibodies are detected.