Rheumatology UQU 2012

Rheumatology
 Rheumatology UQU 2012
1. An elderly lady presented with chronic knee pain bilaterally that increases with activity & decreases with
rest, The most likely diagnosis is:
a) Osteoarthritis
b) Rheumatoid arthritis
c) Septic arthritis

2. the initial non pharmacological management in osteoarthritis is :

a) strengths of quadriceps muscle

3. An old woman complaining of hip pain that increases by walking and is peaks by the end of the day and
keeps her awake at night, also morning stiffness:
a) Osteoporosis
b) Osteoarthritis
c) Rh. Arthritis

4. Old pt with bilateral knee swelling, pain, normal ESR:

a) Gout
b) Osteoarthritis
c) RA

5. What is the initial management for a middle age patient newly diagnosed knee osteoarthritis.
a) Intra-articular corticosteroid.
b) Reduce weight
c) Exercise.
d) Strengthening of quadriceps muscle.

6. The useful exercise for osteoarthritis in old age to maintain muscle and bone:
a) Low resistance and high repetion weight training
b) Conditioning and low repetion weight training
c) Walking and weight exercise

7. male patient present with swollen erythema , tender of left knee and right wrist , patient give history of
international travel before 2 month , aspiration of joint ravel , gram –ve diplococcic , what is most likely
organism?
a) Neisseria gonorrhea
b) staphcoccus
c) streptococcus

8. Triad of heart block, Uveitis and sacroileitis, diagnosis:

a) Ankylosing Spondylitis
b) lumbar stenosis
c) multiple myeloma

9. Patient have of urethritis now com with left knee, urethral swap positive puss cell but –ve for N.M,
chlymedia
a) RA
b) Reiter's disease
c) Gonococcal
 Rheumatology UQU 2012
10. Patient with Rheumatoid Arthritis he did an X-Ray for his fingers and show permanent lesion that may lead
to permanent dysfunction, what is the underlying process?
a) substance the secreted by synovial

11. Which of following favor diagnosis of SLE?

a) joint deformity
b) lung cavitations
c) sever raynaud phenomenon
d) cystoid body in retina

12. Patient with Rheumatoid arthritis on hand X-Ray there is swelling what you will do for him
a) NSAID
b) Injection steroid
c) positive pressure ventilation

13. True about dermatomyositis :

a) associated with inflammatory bowl dz
b) indicate underlying malignancy
c) present as distal muscle weakness

14. Psuedogout:
a) Phosphate
b) Calcium
c) Florida
d) calcium pyrophosphate

15. Patient complaints of abdominal pain and joint pains, the abdominal pain is colicky in character, and
accompanied by nausea, vomiting and diarrhea. There is blood and mucus in the stools. The pain in joints
involved in the ankles and knees, ,, ,, on examination there is purpura appear on the legs and buttocks ,,,
a) Meningococcal Infections
b) Rocky Mountain Spotted Fever
c) Systemic Lupus Erythematous
d) Henoch sconlein purpura

16. long scenario, bone mineral density ,having T score - 3.5,, so diagnosis is
a) Osteopenia
b) Osteoporosis
c) Normal
d) Rickets disease

17. patient with HTN and use medication for that , come complain of pain and swelling of big toe (MTJ) on light
of recent complain which of following drug must be change:
a) Thiazide
 side effect of Thiazide is gout

18. Elderly came with sudden loss of vision in right eye with headache، investigation show high CRP and high
ESR, what is the diagnosis
a) Temporal arteritis
 Rheumatology UQU 2012
19. old female pt with osteoporosis what is exogenous cause
a) age
b) Decreased vitamin D

20. Patient with cervical spondylitis came with atrophy in Hypothenar muscle and decreased sensation in ulnar
nerve distribution. Studies showed alertness in ulnar nerve function in elbow..to ur action is :
a) Physiotherapy
b) Cubital tunel decompression
c) Bla bla bla

21. Polymyalgia Rheumatica case with elevated ESR , other feature :

a) proximal muscle weakness
b) proximal muscle tenderness
 N.B. in polymyalgia Rhematica pain occurs on movement with normal strengths of the muscles.

22. Patient came with osteoarthritis & swelling in distal interphalangeal joint, what is the name of this swelling?
a) Bouchard nodes
b) Heberden's nodes

23. Patient is known case of cervical spondylolysis , presented by parasthesis of the little finger , with atrophy
of the hypothenar muscles , EMG showed Ulnar tunnel compression of the ulnar nerve, what is your action
now:
a) Steroid injection
b) CT scan of the spine
c) Ulnar nerve decompression

24. regarding Boutonniere deformity which one is true

a) Flexion of PIP &hyperextension of DIP.
b) Flexion of PIP & flexion of DIP
c) Extension of PIP & flexion of DIP.
d) Extension of PIP & extension of DIP

25. patient has history of parotid and salivary gland enlargement complains of dry eye .mouth and skin, lab
results HLA-B8 and DR3 ANA positive, rheumatoid factor positive, what is the course of treatment
a) physostigmin
b) eye drops with saliva replacement
c) NSAID
d) plenty of oral fluid

26. Young patient with red, tender, swollen big left toe 1st metatarsal, tender swollen foot and tender whole
left leg. His temperature 38, what is the diagnosis?
a) Cellulitis
b) Vasculitis
c) Gout Arthritis

27. Pt elderly , with unilateral headache , chronic shoulder and limb pain ,positive Rheumatoid factor ,and +ve
ANA ttt\:
a) aspirin
b) indomethacin
c) corticosteroid
 Rheumatology UQU 2012
28. patient with recurrent inflammatory arthritis (migratory) and in past she had mouth ulcers now c/o
abdominal pain what is the diagnosis
a) Read about causes of migratory arthritis

29. Acute Gout management :

a) Allopurinol
b) NSAID
c) Paracetamol
d) Gold salt

30. best investigation for Giant Cell Arteritis

a) Biopsy from temperal arteritis

31. Patient with rheumatoid arthritis came to you and asking about the most effective way to decrease joint
disability in the future, your advice will be:
a) Cold application over joint will reduce the morning stiffness symptoms
b) Disease modifying antirheumatic drugs are sufficient alone

32. Treatment of acute gouty arthritis

a) Allopurinol
b) Indometathin
c) Pencillamin
d) Steroid

33. osteoporosis depend on

a) age
b) stage
c) Gender

34. Rheumatoid Arthritis:

a) Destruction in articular cartilage
b) M=F

c) No nodules

d) Any synovial joint
e) HLA DR4
 Explanation:
a  is true plus destruction of bones
b is false the M:F is 1:3
c  is false Nodules are present in elbows & lungs
d is false because it doesn't affect the dorsal &
lumbar spines
e  is true but it also affects HLA DR1

35. 30 years old male with hx of pain and swelling of the right knee, synovial fluid aspiration showed yellow color
opaque appearance, variable viscosity. WBC = 150,000 , 80% neutrophil, poor mucin clot, Dx is :
a) Goutism Arthritis
b) Meniscal tear
c) RA
d) SA ( septic arthritis )
e) Pseudogout arthritis
 Explanation: WBC>50,000 with poly predominance>75% is suspicious for bacterial infection
 Rheumatology UQU 2012
36. An 80 year old lady presented to your office with a 6 month history of stiffness in her hand, bilaterally. This
stiffness gets worse in the morning and quickly subsides as the patient begins ge daily activities. She has no
other significant medical problems. On examination the patient has bilateral bony swellings at the margins of
the distal interphalangeal joints on the (2nd-5th) digits. No other abnormalities were found on the physical
examination. These swellings represent :
a) Heberden’s nodes
b) Bouchar’s nodes

c) Synovial thickenings
d) Subcutaneous nodules
e) Sesamoids
 Explanation: the history suggests osteoarthritis which has both heberden’s nodes and bouchard’s ,depending on
the location the names of the nodes differ heberden’s nodes are at the DIPJ while bouchard’s nodes are at the
PIPJ. Reference: Saunders’pocket essentials of Clinical medicine (parveen KUMAR)

37. Rheumatoid arthritis distal interphalengial nodules :

a) Hebrerden's nodes
 Heberden's nodes are at the DIP while Bouchard's nodes are at PIP.

38. Triad of heart block, Uveitis and sacroileitis, Dx:

a) Ankylosing Spondylitis
b) lumbar stenosis
c) multiple myeloma

39. Pseud-gout is
a) CACO3
b) CACL3
 Gout : Deposition of Monosodium Urate Monohydrate [ MSUM ] –ve of birefringent, needle shape
 Psudogout : Deposition of Calcium Pyrophosphates Dehydrate [ CPPD ] crystal, +ve birefringent, rhomboid
shape, [ CACO3 ]

40. Juvenile RA treatment :

a) Aspirin
b) Steroid
c) Penicillamine
d) Hydrocloroquin
 Both are correct

41. Man with pain and swelling of first metatarso-phalyngeal joint. Dx:
a) Gout “also called Podagra”

42. Patient present with SLE, The least drug has side effect:
a) Methotrexate
b) name of other chemotherapy

43. Regarding Allopurinol:

a) is a uricouric agent
b) decrease the development of uric acid stones
c) useful in acute attack of gout
 Allopurinol is used to treat Hyperuricemia along with its complications [ chronic gout & kidney stones ]
 Rheumatology UQU 2012
44. Which of the following is a disease improving drug for RA :
a) NSAID
b) Hydroxychloroquine
 Disease Modifying Anti-Rheumatic Drugs (DMARDs) :
 Chloroquine & Hydroxychloroquine
 Cyclosporin A
 D-penicillamine
 Gold salts
 Infliximab
 Methotrexate (MTX)
 Sulfasalazine (SSZ)

45. 27 years old male has symmetric oligoarthritis , involving knee and elbow , painful oral ulcer for 10 years ,
came with form of arthritis and abdominal pain. Dx is:
a) Behjets disease
b) SLE
c) Reactive arthritis
d) UC
e) Wipple’s disease
 Explanation: The diagnosis of Behçet disease was clarified by an international study group (ISG) .This group
developed ISG criteria, which currently are used to define the illness. At least 3 episodes of oral ulceration must
occur in a 12-month period. They must be observed by a physician or the patient and may be herpetiform or
aphthous in nature.
 At least 2 of the following must occur:
1) recurrent, painful genital ulcers that heal with scarring;
2) ophthalmic lesions, including anterior or posterior uveitis, hypopyon, or retinal vasculitis;
3) skin lesions, including erythema nodosum, pseudofolliculitis, or papulopustular lesions (may also include atypical
acne)
4) pathergy, which is defined as a sterile erythematous papule larger than 2 mm in size appearing 48 hours after
skin pricks with a sharp, sterile needle (a dull needle may be used as a control).
5) Neurologic manifestations: The mortality rate is up to 41% in patients with CNS disease. This tends to be an
unusual late manifestation 1-7 years after disease onset: Headache - 50% , Meningoencephalitis - 28% , Seizures
- 13% , Cranial nerve abnormalities - 16% , Cerebellar ataxia , Extrapyramidal signs, Pseudobulbar palsy ,
Hemiplegia or paralysi , Personality changes ,Incontinence ,Dementia (no more than 10% of patients, in which
progression is not unusual)
6) Vasculopathy: Behçet disease is a cause of aneurysms of the pulmonary tree that may be fatal. DVT has been
described in about 10% of patients, and superficial thrombophlebitis occurred in 24% of patients in the same
study. Noninflammatory vascular lesions include arterial and venous occlusions, varices, and aneurysms.
7) Arthritis: Arthritis and arthralgias occur in any pattern in as many as 60% of patients. A predilection exists for the
lower extremities, especially the knee. Ankles, wrist, and elbows can also be primarily involved. The arthritis
usually is not deforming or chronic and may be the presenting symptom and rarely involves erosions. The
arthritis is inflammatory, with warmth, redness, and swelling around the affected joint.Back pain due to
sacroiliitis may occur.
8) Gastrointestinal manifestations : Symptoms suggestive of IBD, Diarrhea or gastrointestinal bleeding ,Ulcerative
lesions (described in almost any part of the gastrointestinal tract) , Flatulence ,Abdominal pain, Vomiting and
Dysphagia.
9) Other manifestations : Cardiac lesions include arrhythmias, pericarditis, vasculitis of the coronary arteries,
endomyocardial fibrosis, and granulomas in the endocardium. , Epididymitis , Glomerulonephritis
Lymphadenopathy , Myositis, Polychondritis
 Rheumatology UQU 2012
46. Child with positive Gower sign which is most diagnostic test :
a) muscle biopsy
 Gowers' sign indicates weakness of the proximal muscle of the lower limb. seen in Duchenne muscular
dystrophy & myotonic dystrophy [ hereditary diseases ]

47. Patient is 74 yrs old female complaining of pain and stiffness in the hip and shoulder girdle muscles. She is
also experiencing low grade fever and has depression. O/E: no muscle weakness detected.
Investigation of choice is :
a) RF
b) Muscle CK
c) ESR
 Typical presentation of Polymyalgia rheumatic

48. Female pt diagnosed as Polymyalgia Rheumatica, what you will find in clinical picture to support this
diagnosis :
a) osteophyte in joint radiograph
b) tenderness of proximal muscle
c) weakness of proximal muscle
d) Very high ESR
 Polymyalgia Rheumatica is a syndrome with pain or stiffness, usually in the neck, shoulders, and hips, caused
by an inflammatory condition of blood vessels. Predisposes to temporal arteritis
 Usually treated with oral Prednisone

49. Dermatomyositis came with the following symptoms:

a) Proximal muscle weakness
b) Proximal muscle tenderness
 Dermatomyositis (DM) is a connective-tissue disease that is characterized by inflammation of the muscles and
the skin. While DM most frequently affects the skin and muscles, it is a systemic disorder that may also affect
the joints, the esophagus, the lungs, and, less commonly, the heart

50. 14y girl with athralgia and photosensitivity and malar flush and protinurea , so diagnosis is :
a) RA
b) Lupus Nephritis
c) UTI

51. Most important point to predict a prognosis of SLE patient :

a) degree of renal involvement
b) sex of the patient
c) leucocyte count
 Rheumatology UQU 2012
52. Which of following favor diagnosis of SLE?
a) joint deformity
b) lung cavitations
c) severe Raynaud's phenomenon
d) cytoid body in retina

53. Which drug causes SLE like syndrome:

a) Hydralazine
b) Propranolol
c) Amoxicillin
 High risk:
1) Procainamide (antiarrhythmic)
2) Hydralazine (antihypertensive)
 Moderate to low risk:
1) Infliximab (anti-TNF-α)
2) Isoniazid (antibiotic)
3) Minocycline (antibiotic)
4) Pyrazinamide (antibiotic)
5) Quinidine (antiarrhythmic)
6) D-Penicillamine (anti-inflammatory)
7) Carbamazepine (anticonvulsant)
8) Oxcarbazepine (anticonvulsant)
9) Phenytoin (anticonvulsant)
10) Propafenone (antiarrhythmic)

54. In patient with rheumatoid arthritis:

a) Cold app. over joint is good
b) Bed rest is the best
c) Exercise will decrease post inflammatory contractures
 Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and
organs, but mainly joints. It involves an inflammation of the capsule around the joints (synovium)
 Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more
than an hour. Gentle movements may relieve symptoms in early stages of the disease

55. Gouty arthritis negative pirfringes crystal what is the mechanism :

a) deposition of uric acid crystal in synovial fluid due to over saturation
 Gout (also known as Podagra when it involves the big toe) is a medical condition characterized by recurrent
attacks of acute inflammatory arthritis — a red, tender, hot, swollen joint. The metatarsal-phalangeal joint at
the base of the big toe is the most commonly affected (50% of cases). However, it may also present as tophi,
kidney stones or urate nephropathy
 Mechanism : disorder of purine metabolism, and occurs when its final metabolite, uric acid, crystallizes in the
form of monosodium urate, precipitating in joints, on tendons, and in the surrounding tissues

56. Patient was presented by back pain relieved by ambulation, what is the best initial treatment:
a) Steroid injection in the back.
b) Back bracing.
c) Physical therapy “initial treatment”
 Rheumatology UQU 2012
57. Old pts with history of bilateral pain and crepitations of both knee for years now come with acute RT knee
swelling , on examination you find that there is edema over dorsum and tibia of RT leg, what is the best
investigation for this condition?
a) Right limb venogram

58. Patient have urethritis now come with left knee pain , urethral swap positive puss cell but negative for
chlymedia, what is the diagnosis?
a) RA
b) Reiter's arthritis
c) Gonococcal
 Reiter's arthritis : characteristic triad of symptoms: an inflammatory arthritis of large joints, inflammation of
the eyes in the form of conjunctivitis or uveitis, and urethritis in men or cervicitis in women

59. Diet supplement for osteoarthritis

a) Ginger

60. Female with sudden blindness of right eye, no pain in the eye, there is temporal tenderness when combing
hair, what is the management?
a) eye drop steroid
b) oral steroid
c) IV steroids
 Giant-cell arteritis (temporal arteritis) : inflammatory disease of blood vessels most commonly involving large
and medium arteries of the head, predominately the branches of the external carotid artery. It is a form of
vasculitis.
 Treatment: Corticosteroids, typically high-dose prednisone (40–60 mg), must be started as soon as the
diagnosis is suspected (even before the diagnosis is confirmed by biopsy) to prevent irreversible blindness
secondary to ophthalmic artery occlusion. Steroids do not prevent the diagnosis from later being confirmed by
biopsy, although certain changes in the histology may be observed towards the end of the first week of
treatment and are more difficult to identify after a couple of months. The dose of prednisone is lowered after
2–4 weeks, and slowly tapered over 9–12 months. Oral steroids are at least as effective as intravenous
steroids, except in the treatment of acute visual loss where intravenous steroids appear to be better

61. 40 years old male come to you complaining of sudden joint swelling, no history of trauma, no history of
chronic disease, what is the investigation you will ask?
a) CBC for WBCs
b) ESR
c) MRI of knee joint
d) Rheumatoid factor

62. Patient with oral ulcer, genital ulcer and arthritis, what is the diagnosis?
a) Behçet's disease
b) syphilis
c) herpes simplex
 Behçet's disease: rare immune-mediated systemic vasculitis, described as triple-symptom complex of
recurrent oral aphthous ulcers, genital ulcers, and uveitis. As a systemic disease, it can also involve visceral
organs and joints
 Rheumatology UQU 2012
63. Patient with history of 5 years HTN on thiazide, came to ER midnight screaming holding his left foot, O/E pt
a febrile, Lt foot tender erythema, swollen big toe most tender and painful, no other joint involvement
a) cellulitis
b) Gouty arthritis
c) septic arthritis
 one of the Thiazide side effect is Hyperuricemia which predisposes to Gout

64. Joint aspirate, Gram stain reveal gram negative diplococci (N. gonorrhea), what is the treatment?
a) Ceftriaxone IM or cefepime PO one dose

65. Commonest organisms in Septic arthritis:

a) Staphylococcus aureus
b) Streptococci
c) N. gonorrhea

66. Child with back pain that wake pt from sleep , So diagnosis (incomplete Q)
a) lumber kyphosis
b) Osteoarthritis
c) Juvenile Rheumatoid Arthritis [ JRA ]
d) Scoliosis
 JRA or Juvenile Idiopathic Arthritis (JIA) is the most common form of persistent arthritis in children. JIA may be
transient and self-limited or chronic. It differs significantly from arthritis seen in adults. The disease commonly
occurs in children from the ages of 7 to 12

67. Patient with pain in sacroiliac joint, with morning stiffness, X-ray of sacroiliac joint, all will be found EXCEPT:
a) RF negative
b) Subcutaneous nodules
c) male > female
 explanation: This inflammatory joint disease characterized by persistently –ve test for RF
 It develops in men before age of 40 with HLA B27.It causes synovial and extra synovial inflammation involving
the capsule , periarticularperiosteum, cartilage and subchondral bone. Large central joints are particularly
involved such as( sacroiliac, symphysis pubis & intervertebral joints)
Resolution of inflammation leads to
extensive fibrosis and joint fusion, but no subcutaneous nodules since it's not a seropositive disease

68. Allopurinol, one is true:

a) Effective in acute attack of gout.
b) decreases the chance of uric acid stone formation in kidneys

c) Salisylates antagonize its action


 Explanation: Indication of Allopurinol: Prevention of attacks of gouty arthritis uric acid nephropathy. [but not
in acute attack]

69. old pt c/o bilateral knee pain with mild joint enlargement ESR and CRP normal dx :
a) Osteoarthritis
b) Rheumatoid arthritis
c) Gout
d) Osteoporosis