Discussion in 'MRCP Forum' started by Guest, Sep 21, 2005.

  1. Guest

    Guest Guest

    A 70-year-old woman presents to your office for evaluation of arthritis in the right hip. She has had arthritis for 5 years, as well as progressive pain on weight-bearing and limitation of ambulation. A recent hip radiograph showed marked joint space narrowing, marginal osteophytes, and subchondral cysts. Compared with radiographs 1 year ago, the changes are somewhat more advanced.
    During the last 2 months, she has also experienced a dull aching pain in the right hip at night that interferes with her sleep. This differs from her previous hip pain and is unrelieved by an increase in the dose of naproxen to 500 mg twice daily. She has been afebrile, and her general health has been good. Recent routine laboratory studies, including a complete blood count, are normal.
    On physical examination, the right hip has 30 degrees of flexion contracture and l0 degrees of total rotation. There is marked pain on motion.
    What would you do next?

    (A) Order MRI of right hip.

    (B) Order CT of abdomen and pelvis.

    (C) Refer to rheumatologist for further medical management.

    (D) Refer to invasive radiologist for fluoroscopic aspiration of synovial fluid from hip.

    (E) Refer to orthopedic surgeon for total hip replacement.
  2. Guest

    Guest Guest

    A 39-year-old housewife with systemic lupus erythematosus who has been receiving long-term glucocorticoid therapy presents to the emergency department with substernal chest pain, which she has had for the past several hours. The pain is not positional or pleuritic. History shows that her father died of a myocardial infarction when he was 54 years old. Physical examination does not show chest wall tenderness. Lung fields are clear on auscultation. On cardiac examination, she is tachycardic. Previous laboratory tests have not shown antiphospholipid antibodies. Electrocardiogram shows some T-wave changes in anterior leads.
    Initial treatment includes a liquid antacid, which has no effect on her pain.
    What test should be done next in this patient?

    (A) Creatine kinase MB band and troponin

    (B) V/Q scan

    (C) Echocardiography

    (D) Esophageal manometry

    (E) High-resolution chest CT
  3. Guest

    Guest Guest

    A 55-year-old woman is referred by her sports medicine physician for evaluation of abnormal test results. She plays tennis, and during the past year she has had many musculo-skeletal problems, including right shoulder pain, which responded to rest and a local glucocorticoid injection. She also had low back pain, epicondylitis of the right elbow, heel pain, and left knee pain. Because of these multiple problems an arthritis panel of tests was ordered. Abnormalities included a positive rheumatoid factor 43 IU, antinuclear antibodies 1/160 (speckled), and erythrocyte sedimentation rate 60 mm/h.
    She has felt well except for musculoskeletal symptoms, which have resolved. There has been no recent weight loss and no other symptoms, except for hot flushes since cessation of menses 6 months ago and recurrent conjunctivitis. She drinks 3 or 4 liters of bottled water daily and takes a variety of vitamins and minerals. For 5 months, she has taken an estrogen/progesterone preparation for hormone replacement therapy.
    On physical examination, she appears to be a healthy, muscular woman. There are no abnormalities, except moderate conjunctival injection and mild parotid enlargement bilaterally. The buccal mucosa is dry, but there is no pharyngeal erythema. The joints show no swelling, tenderness, or limitation of motion.
    What is the most likely cause of her laboratory abnormalities?

    (A) Rheumatoid arthritis

    (B) Systemic lupus erythematosus

    (C) Primary keratoconjunctivitis sicca (Sjِgren’s syndrome)

    (D) Adverse reaction to hormone replacement therapy
  4. Guest

    Guest Guest

    A 54-year-old white woman presents to your office with back pain that began 2 days ago when she was bending over cleaning her bathtub. She felt something stretch in her back, and she was seized with severe pain, which is now radiating down the back of her right leg. It is made worse by sneezing or coughing. On physical examination, there is loss of lumbar lordosis. Sensation and strength in the legs are intact. The straight leg-raising test is positive on the right.
    After prescribing an analgesic for her pain, which one of the following should be done for this patient?

    (A) Magnetic resonance imaging of the spine in the lumbar region

    (B) Radiographs of the lumbar region of the spine

    (C) Bed rest at home

    (D) Referral to physical therapy for lumbar traction

    (E) Continued activity as tolerated
  5. Guest

    Guest Guest

    A 36-year-old white woman with a 6-year history of systemic lupus erythematosus presents to your office with pain radiating down her left anterior thigh. She says this pain occurs both during the day and the night. She describes the pain as deep and says it is worse with walking. She had a total abdominal hysterectomy at 32 years of age. For the past 5 years, the patient has had lupus nephritis, which has required treatment with prednisone for most of this time in doses ranging between 10 and 40 mg daily. On physical examination, there are no sensory or motor deficits in the leg. She walks with a slight limp, and internal rotation of the left hip in flexion is painful.
    Which one of the following studies would now be appro-priate to diagnose this woman’s condition?

    (A) Dual energy x-ray absorptiometry (DXA)

    (B) Technetium pyrophosphate bone scan

    (C) Plain radiograph of the left femur

    (D) CT of the pelvis

    (E) MRI of both hips
  6. Guest

    Guest Guest

    A 39-year-old white man presents because of a 3-year history of worsening polyarticular pain. When he wakes, he has 3 hours or more of morning stiffness in his hands and wrists. His knees, ankles, and shoulders are somewhat less stiff, and he has a 6-month history of low back stiffness that lasts all day. For the last 2 years he has had nearly daily attacks of painless, watery, nonbloody diarrhea (six to eight episodes a day) that occasionally wakes him from sleep. There is no mucus or pus in the stools, but there is a foul smell and an oily quality to the toilet water after he defecates. He has lost 4.5 kg (10 lb) since the onset of his illness. Imaging studies of the upper gastrointestinal tract, endoscopy, and analysis of the stools for ova and parasites have been unrevealing in the past.
    Physical examination reveals synovitis of the wrists and knees. There is no tenderness noted over the Achilles tendon, sacroiliac joints, or tendinous insertions.
    What is the most likely diagnosis?

    (A) Lactose intolerance

    (B) Irritable bowel syndrome with fibromyalgia

    (C) Inflammatory bowel disease

    (D) Bacterial infectious diarrhea

    (E) Celiac disease
  7. Guest

    Guest Guest

    A 65-year-old man presents with diffuse bilateral pain in the upper and lower extremities and morning stiffness for 1 hour. He also has progressive fatigue. Since retirement from his job as a building contractor 3 years ago and simultaneous cessation of smoking, his chronic obstructive pulmonary disease has been stable and well controlled by inhaled glucocorticoid and b-agonist medications.
    On physical examination, the anterior-posterior diameter of his chest has increased. On auscultation, expiration is prolonged, and there are a few scattered wheezes but no rales. Heart sounds are distant. The liver span is not increased. The extremities show mild pedal and pretibial edema. There is tenderness over the distal radius and tibia. There are moderate effusions in both knees. The fingers show clubbing. Reflexes are normal, and there are no neurologic deficits or muscle weakness.
    Laboratory studies
    Hematocrit 40%
    Erythrocyte sedimentation rate 60 mm/h
    Creatine kinase 90 U/L
    Synovial fluid from knee 800 leukocytes/µL
    Mononuclear cells90%
    Radiographs of knees Normal
    Which of the following steps would most likely lead to a diagnosis accounting for his pain and joint swelling?
    (A) Chest radiography

    (B) Rheumatoid factor assay

    (C) Therapeutic trial of prednisone, 10 mg/d

    (D) Serum and urine protein electrophoresis

    (E) Thyroid-stimulating hormone level
  8. Guest

    Guest Guest

    A 36-year-old woman presents to your office with moderate pain and stiffness in her proximal interphalangeal and metacarpophalangeal joints. The symptoms began 3 weeks ago after a mild febrile illness. The patient works in a daycare facility for preschool children and has contracted numerous upper respiratory infections in the past year, especially during the winter months. Ibuprofen has alleviated the discomfort slightly. She has had no change in bowel habits, and she has no back pain, psoriasis, or rashes, but she does think that her hair is thinning slightly. There is no family history of arthritis.
    On physical examination, she has a temperature of 37.7 °C (100 °F), slight erythema of the posterior pharynx, a few small soft cervical lymph nodes, slight soft tissue swelling of the proximal interphalangeal joints bilaterally, and tenderness to compression of both the metacarpophalangeal and metatarsophalangeal joints.
    Which of the following studies is likely to lead to the correct diagnosis?

    (A) Rheumatoid factor

    (B) Fluorescent antinuclear antibodies

    (C) Antibodies to parvovirus B19

    (D) Antibodies to Borrelia burgdorferi

    (E) Radiogr
  9. Guest

    Guest Guest

    A 54-year-old white woman has pain in the metacarpophalangeal (MCP) joints of both hands and both knees. Radio-graphs show destructive changes in the MCP joints of both hands and changes consistent with osteoarthritis of both knees. There is calcification of the menisci bilaterally, with a small effusion. The transferrin saturation level is 60%, and the ferritin level is 454 µg/mL.
    Which one of the following tests is most appropriate for this patient?

    (A) Genetic testing for mutation of the HFE gene

    (B) Measurement of urinary excretion of iron following administration of desferrioxamine

    (C) Liver biopsy

    (D) MRI of the liver

    (E) Arthrocentesis of the knee and examination of the synovial fluid by polarized light microscopy
  10. Guest

    Guest Guest

    A 65-year-old man presents to your office because he develops numbness and tingling in his thumb and index finger at night. The sensation goes away when he shakes his hand briefly. He also has had severe pain and limitation of motion in both shoulders for the past year. He has end-stage renal disease and has been receiving hemodialysis for the past 13 years.
    What is the most effective way of controlling this patient’s rheumatologic problems?

    (A) Daily hemodialysis on a dialyzer containing a high-flux cuprophane membrane

    (B) Peritoneal dialysis

    (C) Renal transplantation

    (D) Plasmapheresis three times weekly for 3 months

    (E) Nocturnal splints for forearms and hands
  11. Guest

    Guest Guest

    A 27-year-old woman presents to your office because she had a spontaneous abortion 6 weeks after becoming pregnant for the first time.
    Laboratory studies
    Anticardiolipin antibodies
    IgG Normal
    IgM Low positive
    IgA Normal
    Sensitive partial thromboplastin time 22 seconds (normal)
    Modified Russell viper venom time 25 seconds (normal)
    What therapy would be appropriate for this patient during her next pregnancy?

    (A) Warfarin

    (B) Heparin, prophylactic dose

    (C) Heparin, therapeutic dose

    (D) Prednisone, 20 mg twice daily

    (E) No treatment
  12. Guest

    Guest Guest

    A 24-year-old white man presents to the emergency department with a swollen right calf. The calf has been swollen for 1 day. He had a deep venous thrombosis of the opposite leg when he was 17 years old, for which he took warfarin for 3 months. His father also had a deep venous thrombosis, but he is currently in good health. Physical examination shows a tender, warm, swollen right calf with a positive Homan’s sign. Doppler studies confirm a deep venous thrombosis.
    The most likely risk factor for hypercoagulability in this patient is:

    (A) Antiphospholipid antibodies

    (B) Occult malignancy

    (C) Paroxysmal nocturnal hemoglobinuria

    (D) Factor V Leiden mutation

    (E) Homocysteinemia
  13. Guest

    Guest Guest

    A 70-year-old man with polymyositis (confirmed by muscle biopsy) presents to your office because of persistent weakness and difficulty getting out of a chair. He has taken prednisone 60 mg daily for the last 3 months. There has been improvement in overall strength. On physical examination, there is no heliotrope rash (purple discoloration on the eyelids) or Gottron’s papules (erythematosus scales over the metacarpophalangeal and proximal interphalangeal joints). The proximal muscles are slightly weak. Reflexes are intact.
    Creatine kinase level
    4300 U/L (3 months ago when the diagnosis was first made)
    2100 U/L (2 months ago)
    2000 U/L (1 month ago)
    2300 U/L (today)
    Your next step should be:

    (A) Increase prednisone to 100 mg.

    (B) Change prednisone to 40 mg every other day.

    (C) Reduce prednisone to 20 mg.

    (D) Add methotrexate.

    (E) Start intravenous immunoglobu
  14. Guest

    Guest Guest

    A 65-year-old retired woman presents with the onset of a new rash. She smokes 2 packs of cigarettes per day. She has mild hypertension, which is treated with a diuretic. On physical examination there she has a purplish diffuse rash of the eyelids and Gottron’s papules (scaling plaques over the proximal interphalangeal and metacarpophalangeal joints). Muscle strength testing is normal.
    Laboratory studies
    Creatine kinase level Normal
    Aldolase Normal
    Chest radiography Mild cardiomegaly
    Which test(s) should be done next?
    (A) Muscle biopsy

    (B) Mammogram, Pap smear, chest CT

    (C) Electromyography

    (D) Anti-Jo1

    (E) Antinuclear antibodies
  15. Guest

    Guest Guest

    A 19-year-old male college student presents to your office because of an acute upper respiratory infection, which he has had for 10 days. His major initial symptom was a sore throat, but he has subsequently developed arthralgias. He also has some abdominal pain, which he describes as cramps. On physical examination, there are raised red lesions about18 to12 inch in diameter on his legs and buttocks.
    Laboratory studies
    Antinuclear antibody titer 1:20
    C4 Normal
    Liver function tests Normal
    Urinalysis Proteinuria (2+)
    Erythrocytes: 10 to 20/high- power field
    What is the most likely diagnosis in this patient?

    (A) Crohn’s disease with associated vasculitis

    (B) Essential mixed cryoglobulinemia

    (C) Henoch-Schِnlein purpura

    (D) Systemic lupus erythematosus

    (E) Polyarteritis nodosa
  16. Guest

    Guest Guest

    A 73-year-old man presents to your office because of the onset of bilateral shoulder and upper arm pain, which began about 3 months ago. He has also subsequently developed generalized aching, including pain in the thighs and buttocks, which he attributes to exercising on his stationary bicycle. His symptoms are worse in the morning and after periods of prolonged sitting in his automobile or in the theater. He has also felt increased fatigue and has lost 2.3 kg (5 lb) during the last 3 months. Two months ago, his right shoulder was injected by an orthopedic surgeon and all of his symptoms were much improved for about 1 week. Shoulder radiographs were ordered subsequently, and these were normal, except for narrowing and osteophyte formation at the acromioclavicular joints. Naproxen, 1000 mg/d, has provided only minimal relief. On physical examination, there is no joint swelling or limitation, but some pain is elicited on shoulder and hip rotation. There is no muscle weakness, tenderness, or atrophy. The results of the general physical examination are unremarkable.
    Laboratory studies

    Hemoglobin 12.4 g/dL
    Hematocrit 38%
    Leukocyte count 6800/µL
    Erythrocyte sedimentation rate 30 mm/h
    Alkaline phosphatase 140 U/L
    Bilirubin Normal
    Alanine aminotransferase Normal
    Urinalysis Normal
    Fecal occult blood test Negative

    What is the most likely cause of his symptoms?
    (A) Generalized osteoarthritis

    (B) Fibromyalgia syndrome

    (C) Polymyalgia rheumatica

    (D) Rheumatoid arthritis

    (E) Hepatitis B virus infection-associated rheumatic -syndrome
  17. Guest

    Guest Guest

    A 24-year-old black woman with a 5-year history of systemic lupus erythematosus (SLE) presents with weakness in both legs for 36 hours. She woke in the morning with the pain, and it has grown steadily worse since then. She has had some difficulty urinating during the past few hours. She played a vigorous game of basketball the day before her weakness started, but she was not injured during the game. She has had moderate SLE, which has been controlled with hydroxychloroquine, and she has not had any neurologic problems. Occasional short courses of prednisone have been required to control symptoms during flares.
    On physical examination, she has definite weakness of the hip flexors and knee extensors, but she is able to stand and walk. Range of motion in the spine is normal, and there is no local tenderness. Sensation is intact. Rectal examination reveals diminished sphincter tone. Deep tendon reflexes are intact, and there are three beats of clonus at the left ankle.
    Which one of the following studies is the most appropriate at this time?

    (A) MRI of the spine

    (B) CT of the spine

    (C) Radiographs of the spine

    (D) Analysis of the cerebrospinal fluid

    (E) Measurement of the antiphospholipid antibody level
  18. Guest

    Guest Guest

    A 36-year-old man presents to your office with diffuse joint pain, which began about 3 weeks ago. He describes several of his joints as hot, red, and swollen. During the last 3 months, he has had fevers up to 38 °C (101 °F), fatigue, and a 10-kg (22-lb) weight loss. Diarrhea has occurred at least three times daily for the last 4 weeks, and he is often awakened by the urge to defecate. He has difficulty falling asleep and wakes repeatedly because of the joint pain. This sleep pattern has been refractory to over-the-counter sedatives.
    On physical examination, he has difficulty walking to the examination table; he has a wide-based gait and walks on the outer edges of his feet. There is tenderness of the plantar fasciae and Achilles tendons. His feet are swollen with moderate metatarsophalangeal joint tenderness. The left knee is warm with a large effusion. The right ankle is tender and has a decreased range of motion. The left wrist and right second and fourth metacarpophalangeal joints are tender and red and have a decreased range of motion. Full motion is maintained in the spine. A papulosquamous and pustular eruption is present on the palms and soles, and there is onychodystrophy and yellowing of multiple toenails. Painless cervical, axillary, and inguinal adenopathy is present.
    Laboratory studies
    Hemoglobin 9.7 g/dL
    Leukocyte count 4700/µL
    Polymorphonuclear 75%
    Lymphocytes 18%
    Monocytes 4%
    Eosinophils 3%
    Twenty-five milliliters of cloudy fluid is aspirated from the left knee. The cell count shows 18,500 leukocyte/µL, with 75% polymorphonuclear neutrophil leukocytes. Gram’s stain and routine cultures are negative.

    Which one of the following studies should be ordered next?

    (A) HLA-B27

    (B) Colonoscopy

    (C) HIV screening test

    (D) Skin biopsy of palm lesion

    (E) Lymph node biopsy
  19. Guest

    Guest Guest

    A 40-year-old woman presents to your office because of a recurrent rheumatologic syndrome, which she has had for the past 2 years. She is currently asymptomatic, but pain typically begins in the second and third proximal inter-phalangeal joints of her right hand, extends to her left wrist, and occasionally develops in her knees. Within hours, the joints become mildly swollen, red, and tender. During the next day, symptoms usually subside in reverse order of their appearance. She is completely asymptomatic between attacks, but the interval appears to be decreasing. In the past 2 months, she has had these symptoms every 9 to 13 days. She takes acetaminophen, 500 mg every 6 hours, during episodes. She has no allergies and has had no other illnesses or surgery. Her menses occur regularly. Her family history is notable for gout in her father and grandfather.
    The physical examination is normal, and she has no joint tenderness, swelling, or limitation of motion.
    Which of the following is the most likely diagnosis?

    (A) Gout

    (B) Arthritis secondary to parvovirus B19 infection

    (C) Palindromic rheumatism

    (D) Pseudogout

    (E) Rheumatic fever
  20. Guest

    Guest Guest

    A 22-year-old man, who abuses intravenous drugs, presents to the emergency department with painful fingers and an inability to lift his feet. On physical examination, many of his fingers have tender erythematous slightly necrotic areas, some with frank demarcation. On neurologic examination, he has bilateral foot drop.
    What types of infections, in addition to hepatitis B, might be associated with vasculitis in this patient?

    (A) Hepatitis C virus infection and HIV

    (B) Chlamydia

    (C) Hepatitis C virus infection

    (D) Hepatitis C virus and gonococcal infection

    (E) Hepatitis C virus infection and syphilis
  21. Guest

    Guest Guest

    A 36-year-old male patient with a 16-year history of ankylosing spondylitis brings in his 15-year-old son for evaluation of 3 weeks’ low back pain. The son thinks the pain started after he did a new exercise in gym class. Your patient, his father, and his 50-year-old brother have HLA-B27 and severe ankylosing spondylitis; your patient is concerned that his son may have it as well.
    The patient’s son has 5 to 10 minutes of stiffness in his lower back when he wakes in the morning and has no significant stiffness later in the day after periods of rest (for example, after sitting in class or in the car on his 20-minute drive to and from school). He does not have remarkable improvement after exercise or stretching and in fact thinks exercise makes the pain worse. There is no groin or buttock pain. He has no history of urethritis, uveitis, oral ulcers, peripheral arthritis, prolonged diarrhea, or colitis. He recounts an episode of bilateral conjunctivitis about 8 years ago, but he cannot recall any rash on his palms, soles, or penis. On physical examination, there is full range of motion of the cervical, thoracic, and lumbar regions of the spine, and there is no evidence of peripheral arthritis. The skin, mucus membranes, heart, and lungs are normal.
    What management option should be done next?
    (A) Test for HLA-B27.

    (B) Perform MRI of the sacroiliac joint.

    (C) Prescribe heat, stretching exercises, and nonsteroidal anti-inflammatory drugs.

    (D) Start a 6-month course of doxycycline.

    (E) Refer to an ophthalmologist.
  22. Guest

    Guest Guest

    37-year-old man with rheumatoid arthritis presents to your office with increasing fatigue and continuous nausea that developed several days after discontinuing treatment with methotrexate. Two weeks ago, methotrexate was discontinued when he entered a clinical trial and began taking a cytokine antagonist. The nodules in his olecranon bursae enlarged during the time he was taking methotrexate. He had been treated with methotrexate (17.5 mg/week) for 6 years. His arthritis improved during this time but he noted that his rheumatoid nodules had increased in size and number. In addition, he is taking naproxen (1500 mg/d), hydroxychloroquine (400 mg/d), and folic acid (1 mg/d).
    His history is remarkable for an attack of iritis as a teenager, which subsided after treatment with glucocorticoid eye drops, and 3 years of intravenous drug use during his late 20s. He smokes one pack of cigarettes each day, but does not drink alcohol.
    On physical examination, his metacarpophalangeal and proximal interphalangeal joints are mildly swollen and tender. There are nodules on the olecranon bursae and on second fingers. Abdominal examination is normal, except for mild percussion tenderness over the liver.
    Laboratory studies
    Hemoglobin level 11.4 g/dL
    Leukocyte count (predominance of neutrophils) 12,000/µL
    Erythrocyte sedimentation rate 32 mm/h
    Serum creatinine Normal
    Serum albumin 3.1 gm/dL
    Serum alkaline phosphatase 214 U/L
    Serum aspartate aminotransferase 143 U/L
    Serum alanine aminotransferase 86 U/L
    Total bilirubin Normal
    HIV-1 Negative
    Hepatitis A Negative
    Hepatitis B Negative
    Hepatitis C Positive
    Polymerase chain reaction 100,000 viral particles
    Which of the following applies most appropriately to this patient?

    (A) Rheumatoid nodules usually become smaller during methotrexate therapy, regardless of whether joints improve.

    (B) Cessation of methotrexate therapy in patients with hepatitis C virus infection can precipitate a flare of liver disease.

    (C) Naproxen should be discontinued and replaced with sulindac.

    (D) It would be appropriate to restart the methotrexate at less than 12.5 mg daily.

    (E) Tripling the daily dose of folic acid should reduce the abnormal liver enzymes to a normal or high normal level.
  23. Guest

    Guest Guest

    A 73-year-old man presents to your office because he has not felt well for some time. He does not smoke cigarettes. His major symptom is profound morning stiffness, especially in the shoulders and hips. On physical examination, results of the head, eyes, ears, nose, and throat examination, including the retina, are normal. Muscle strength is normal. The joint examination shows mild crepitus of the knees, but no frank synovitis. Laboratory studies show a hematocrit level of 27%, an erythrocyte sedimentation rate of 120 mm/h, and a negative rheumatoid factor.
    What would you do next for this patient?

    (A) Temporal artery biopsy

    (B) Prednisone, 15 mg/d

    (C) Chest radiography

    (D) Ibuprofen, 800 mg three times daily

    (E) Celecoxib, 200 mg twice daily
  24. Guest

    Guest Guest

    A 68-year-old woman presents to your office with pain in the radial aspect of the right wrist, which is aggravated when she uses her hand, particularly when she is pruning shrubs in her garden or weaving on her loom. She has had only minimal relief from naproxen (l g/d for 3 weeks).
    On physical examination, there is tenderness at the base of the right thumb, with limited excursion and crepitus. Pain is not increased by ulnar deviation of the wrist when the thumb is enclosed in her fist.
    A radiograph of the right hand shows narrowing and erosion of the first carpometacarpal joint.
    What further treatment should be initiated for this patient?

    (A) Permanent discontinuation of activities causing pain

    (B) Rofecoxib, 25 mg/d

    (C) Referral to hand surgeon for consideration of arthroplasty or fusion of the carpometacarpal joint

    (D) Referral to rheumatologist for glucocorticoid injection of carpometacarpal joint

    (E) Exercise by squeezing a rubber ball several times daily

    Rheumatology Item 30

    A 74-year-old woman presents to your office because of pain in her left hip. The patient has difficulty sleeping on her left side at night, and when asked to point to the pain, she localizes it to the lateral aspect of her hip. She has a history of peptic ulcer disease and peripheral edema. She is taking furosemide, 40 mg daily as needed. On physical examination, the patient weighs 81.6 kg (180 lb) and is 163 cm (64 in) tall. There is tenderness over the lateral aspect of the left hip.
    Which of the following management options would you choose?

    (A) Plain radiograph of left hip

    (B) Celecoxib, 200 mg/d

    (C) Referral to physical therapy for modalities and aquatic exercises

    (D) Naproxen, 500 mg twice daily

    (E) Local injection of the affected area with depot glucocorticoids
  25. Guest

    Guest Guest

    An obese 56-year-old white man is referred to you for further management from the emergency department 1 week after developing severe pain in his left great toe. A diagnosis of gout was made. The patient is now asymptomatic, but he describes the episode as the worst pain of his life. He has had four or five such episodes in the last 5 years, and each one is more painful than the last. The patient was given medication that relieved his pain in the emergency department, but he does not know the name of it.
    His history is remarkable for mild hypertension, which has been well controlled with hydrochlorothiazide, 25 mg/d, for the about past 2 years. Tests from the emergency department show an elevated uric acid level (9.9 mg/dL) and mild renal dysfunction (serum creatinine level: 1.9 mg/dL; blood urea nitrogen: 25 mg/dL). A 24-hour urine collection contained 1200 mg of uric acid.
    What is the most appropriate treatment for this patient?

    (A) Short-term nonsteroidal anti-inflammatory drugs as needed

    (B) Allopurinol

    (C) Probenecid

    (D) Colchicine

    (E) Prednisone as needed for acute attacks
  26. Guest

    Guest Guest

    A 60-year-old man presents to your office because of severe rheumatoid arthritis. He developed persistently active progressive rheumatoid arthritis when he was 47 years old. He was treated for the next 10 years with prednisone (15 to 20 mg/d), full doses of nonsteroidal anti-inflammatory drugs, a full course of parenteral gold, and, subsequently, D-penicillamine. After developing a severe skin reaction to D-penicillamine, it was discontinued. The only medication he takes now is prednisone (7.5 mg/d). At the age of 57 years, he developed severe back pain and spasms after lifting a suitcase. Radiographs of his back showed severe osteopenia and compression fractures of the fourth and fifth lumbar vertebrae. Radiographs showed widespread loss of the joint spaces and advanced erosion. Prednisone was reduced to 10 mg daily.
    He spends most of his time confined to a chair or bed. With effort he can feed himself and brush his teeth, but he needs assistance from his wife for bathing and using the toilet.
    On physical examination, he appears cushingoid and has multiple large ecchymoses on his arms. The wrists and MCP joints of both hands are ankylosed. The MCP joints of both hands are fused in 70 degrees of flexion. The last three finger extensor tendons of both hands are ruptured. The knees have severe flexion contractures and shoulder motion is markedly restricted. No soft tissue swelling is present in any joints. He has severe atrophy of the skin and muscles. His hemoglobin level is 10.2 g/dL. The erythrocyte sedimentation rate is normal, and the rheumatoid factor is 1:185. Kidney and liver function tests are normal.
    In addition to prescribing supplemental calcium, vitamin D, and a bone-protective agent such as alendronate, which of the following would be the most appropriate therapy at this time?
    (A) Start methotrexate, 7.5 mg/week.

    (B) Start cyclosporine, 2.5 mg/kg.

    (C) Taper prednisone to 5 mg/d or less.

    (D) Refer for reconstructive hand surgery.

    (E) Start leflunomide, 20 mg/d.
  27. Guest

    Guest Guest

    A 21-year-old previously healthy woman presents to your office with generalized arthralgia and fever, which she has had for the past 2 weeks. One of her friends has had Lyme disease, and she is concerned that she may have it also. She lives in a wooded area and removed a tick from her arm about 2 months ago. Her hands, wrists, and ankles are the most symptomatic joints, and she has morning stiffness for about a half hour. There is no past history of joint pain. She takes famotidine intermittently for heartburn and dyspepsia. For 2 years, she has taken minocycline for acne, which is currently under good control. One year ago, she had acute sinusitis during an episode of seasonal allergic rhinitis.
    Physical examination reveals a temperature of 38.2 °C (100.7 °F). There is no rash, but the extremities have a mottled, reticulated erythema. Most of her joints are tender and painful with motion, and there is soft tissue swelling in both wrists and all of the proximal interphalangeal joints.
    Laboratory studies
    Hematocrit 38%
    Leukocyte count 7400/µL
    Erythrocyte sedimentation rate 48 mm/h
    Serum alanine aminotransferase (ALT) 89 U/L
    Serum aspartate aminotransferase (AST) 94 U/L
    Antinuclear antibodies (ANA) Positive 1:1280
    Anti-dsDNA Negative
    Antineutrophil cytoplasmic antibodies (ANCA) Positive p-ANCA 1:640
    Antihistone antibodies Negative
    Borrelia burgdorferi antibodies (ELISA) Negative
    Urinalysis Normal
    Which of the following is the most likely diagnosis?

    (A) Wegener’s granulomatosis

    (B) Systemic lupus erythematosus

    (C) Hepatitis C virus infection

    (D) Drug-induced lupus

    (E) Lyme disease

    Rheumatology Item 34

    A 55-year-old man presents to your office because he has become progressively sick over the past few weeks. His symptoms include fatigue and general malaise. The symptoms began after mowing his lawn for the first time in 9 months. He has now developed pain in his hands. On physical examination, there is no Raynaud’s phenomenon, but the skin over his forearms is thickened, with areas that have an orange-peel-like quality. The hands are spared from the skin thickening, and there are no nailfold capillary changes. Laboratory studies show a hematocrit level of 35%, a leukocyte count of 9200/µL, and a platelet count of 345,000/µL.
    Which one of the following tests is most likely to lead to the correct diagnosis?

    (A) Punch biopsy of the skin

    (B) Antiscleroderma 70 antibody

    (C) Anticentromere antibody

    (D) Creatine kinase (CK)

    (E) Differential count of leukocytes
  28. Guest

    Guest Guest

    50-year-old man with diabetes mellitus, which he has had since childhood, presents to your office for a routine follow-up visit. He has had mild renal failure, retinopathy, and neuropathy for several years, and his diabetes is well controlled with insulin. He mentions that his right foot has been somewhat swollen recently, but it has not been painful. He gives you a radiograph ordered yesterday by his podiatrist (shown below). Physical examination reveals moderate swelling and slight warmth in the tarsal and metatarsal areas of the right foot but no tenderness or erythema. The pedal pulses are palpable, and there are no ulcerations.
    Laboratory studies

    Hematocrit 37%
    Leukocyte count 6800/µL
    Serum glucose 180 mg/dL
    Serum creatinine l.9 mg/dL
    Serum uric acid 9.2 mg/dL
    Erythrocyte sedimentation rate 36 mm/h

    See the picture
    What is the cause of his foot swelling?

    (A) Gout

    (B) Osteomyelitis

    (C) Neuroarthropathy (Charcot joint)

    (D) Septic arthritis

    (E) Avascular necrosis
  29. Guest

    Guest Guest

    dr tamer

    if u have the model answer kindly post them
  30. Guest

    Guest Guest

    where are the answers of these questions?
    cant we haav that too
  31. Guest

    Guest Guest

    hi i just noticed u r from cairo
    i m pakistani but currently in cairo too
    will u like to help me out if u know any academies for preparation of mrcp1 in cairo
    looking forward to ur help regards
  32. Guest

    Guest Guest

    hi tamer........u r from cairo gr8.........i m in cairo n a pakistani national...........i want some help
    can u plz tell me abt any academies in cairo running prep classes for mrcp1
    n i want to do some job in medicine to fulfill mrcp2 requirement.........where i can get info or job that is recognized for mrcp n is there any test or criteria to b fulfilled for job here..........i m not gud at arabic too
    plz help me out
    i dont kno where to go for guidance
  33. Guest

    Guest Guest

    where are the answers for the questions ??
    can i have it ?
    with explanation too. thanks.

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