RHEUMATOLOGY MCQS

Q. APPROACH TO A PATIENT WITH CT DISEASE?? (ORAL)

1) Clinically  history-exam(articular & extra)
2) Auto Ab detection.
3) ESR-CRP.
4) Radiology.
 ESR  USED FOR FOLLOW UP & NOT THE DIAGNOSIS / CAUSES OF HIGH ESR???
 1RY SCLEROSING CHOLANGITIS  ANCA +VE

SLE
 ARTHRITIS  M/C presentation(not the skin)
 DRUGS CAUSING SLE  add: phenothiazines-OCP-grisiofulvein
 M/C CARDIAC  pericarditis
 BLOOD  pancytopenia
 PSYCHOSIS IN SLE  disease itself or steroid therapy.
 LUPUS NEPHRITIS  biopsy reveals??? silver wire.
 ANA IS THE MOST SENSITIVE BUT…..anti DNA is the most specific
 P.17: OTHER INDICATIONS OF PULSE STEROIDS.

POLYMYOSITIS
 Associated with HLA B8 & HLA D3
 Should exclude before diagnosing Duchenne & Baker. (untreatable)

VASCULITIS
 PAN  use pulse steroidin case of RPGN(add to TTT)
 TAKAYASAU'S  bruit over left subclavian & CCA
DD OF ARTHRITIS
1) COLLAGEN D.  SLE- sero-ve- OA- Rh. fever – HSP - still's – Kawasaki – RA.
2) METABOLIC  gout & pseudogout
3) INFECTIONS  viral-TB-septic-lyme disease???
4) LYME:
 CA  Boriella Burgdorfi(spirochetes)-
 MOT  tics after safari or camping
 Cl./P  M-P rash / Arthralgia  bilateral – symmetrical - knee joint.
 TTT  doxycycline & amoxicillin.
5) REACTIVE
6) MISCELLANEOUS: malignancy-sickle cell-hemophilia-chondro malacia -trauma-
hemarthrosis

 RHEUMATOID  more extra articular with RF +ve patients.

 PSORIATIC ARTHRITIS  erythmato-squamus rash on extensor aspects of limbs.
 KCS  ass. with pernicious anaemia.

PHYSIOTHERAPY IN OF AS???
1) NECK  orthosis.
2) CHEST  breathing exercise.
3) LUMBAR & SACROILIAC  swimming.
4) KYPHOSIS  orthosis. (thoracolumbar jacket)
AS: associated with bilateral fibrocavitary diseases in lung(case of AS + progressive dyspnea)

SCLERODERMA
 CAUSES OF CYANOSIS???  IPF(central)- Raynauds (peripheral)
 CLUBBING & PSEUDO-CLUBBING.
 M/C OF DEATH  Cardiac causes.
 INVEST.  add NAIL FOLD CAPILLOROSCOPE(early diagnosis of Raynauds)
 TTT  Most. Imp. Is to warn the patient to wear gloves & socks in cold weather
USES OF COLICHICINE
1) GOUT & PSEUDOGOUT
2) BEHCET
3) FMF
4) LIVER???
5) SCLERODERMA
6) PSEUDO-PSEUDO GOUT

CHONDRO-CALCINOSIS:
 Common in patients with PREVIOUS HISTORY OF OA (PREVIOUS JOINT DISEASE)
 ADD COLICHICINE in TTT for prophylaxis

PSUDO-PSEUDO-GOUT:
 CAUSES MILWAUKEE SHOULDER(destruction & Hgic effusion)
 CCC. in ESRD

OSTEO-ARTHRITIS:
 Affects the whole joint. (MCQ)
 1 event  matrix loss.
st
(MCQ)

SEPTIC ARTHROPATHY:
 Joint aspirate   Glucose & proteins in
 Common in  Osteoarthritis.
 M/C site  hip.

OSTEOPOROSIS:
 CAUSES ADD  Malignancy-coeliac enteropathy-anorexia nervosa-pregrancy
 1ST SYMPTOM  FRACTURE(very important-MCQ)
 INVEST.  DEXA SCAN: > 2.5 SD IS DIAGNOSTIC  2 TYPES:
a) Z-score  compare to normal person of the same age
b) T-score  compare to normal young adult
 It's measured in grams hydroxyl appetite/cm2
 TTT.  SERM (RALOXIFIEN) IS A NON- CARCINOGENIC HRT.
 GIT MCQs
DISEASES OF SALIVARY GLANDS:
 Anorexia ; bulemia nervosa lead to salivary gland Swelling due to purgatives
 Xerostomia: oral breathing, polyuria ; polydepsia

OTHER OESPH DISEASES:

1) CAUSTIC OESP INJURY: KOH, delay endoscopy, never induce emesis, precancerous
2) PLUMMER VINSON:
 middle age female.
 dysphagia, iron; vit B12 def anaemia, splenomegaly in a
 precancerous
3) ZENKER'S DIVERTICULUM:
 Etiology  protrusion of post pharynreal wall (cricopharyngeus ms non-relaxing)
 C/O  double phase swallowing.
 Aspiration  not related to swallowin.g(MCQ)
 Invest  avoid endoscopy(dangerous)(MCQ)
 TTT  diverticulectomy-myotomy

 BISMUTH  black stools ; masks melena.

 TTT OF ACUTE HEMATEMESIS ; MELENA  packed RBC's ; Colloid transf. (repeated MCQ)
 VARIANTS OF ACUTE GASTRITIS  eosinophilic-allergic-lymphocytic-granulomatous-
reactive (gastric antral telangectasia)In investigations: blood urea only without creatinine.

PYLORIC STENOSIS
 urinary pH < 5.
 metabolic alkalosis  tetany, dehydration ; pre-RF
M ALAB S O R PT IO N :
 GIARDIA  ccc. by  IgA.
 HYPOTHYROIDISM  malabsorption
 GLUTEN:
a) Milk intolerance.
b) Other investigations  T3-T4 ; BS.
c) Causes Cancer oesphagus.
d) causes of subtotal villous atrophy: Whipple - gastrinoma -hypo- globulin -
tropical sprue.
 TROPICAL SPRUE  milk intolerance + steatorrhea +  Fat sol. Vitamins. ADEK.
 BLIND LOOP  steatorrhea +  Fat sol Vitamins. ADEK.
 WHIPPLE  HLA B27
 INVEST. OF MALABSORPTION:
a) FECAL FAT  gold standard(1st step)
b) BIOPSY  most definitive.
c) DON'T FORGET  PT; INR ( vit K)

TUMORS IN GIT (MCQ)

1) CANCER OESOPH.  gluten enteropathy is 1 of the causes

2) CANCER STOMACH  Menetrier $ is a RF. (repeated MCQ)

 LARGE MUCOSAL FOLDS IN STOMACH (MCQ LAST YEAR ; LANGE)

 PROTEIN LOSING ENTEROPATHY.

3) GASTRINOMA  liver metastasis is a common.

4) VIPOMAS  SECRETORY DIARRHEA  doesn't resolve by fasting

5) M/C 1RY MALIG. TUMOR OF SI  adenocarcinoma  bleeding / rectum  iron def.

6) 1RY INTESTINAL LYMPHOMA  ttt by ABS in early stages…. occurs on top of Coeliac D.-
Crohn's- HIV.

7) TUMORS OF THE DISTAL PART OF SI  lipoma ; cacinoid

8) CANCER COLON:  M/C GIT carcinoma  palpable per rectum

 9) CARCINOID:
 M/C ENDOCRINAL TUMORS OF GIT.
 SITE  appendix.
 Intestinal ischemia is common - Granuloma in liver
 1 LINE OF INVEST.  (HIAA)
ST

 1 LINE OF TTT  Octreotide.( Acromegaly-insulinoma-ruptured varices)

ST

10) FAMILIAL Polyposis: no clubbing / Intussusceptions / Dysentry.

11) TUMORS IN BILIARY SYSTEMS

1) CHOLANGIOSARCOMA:
 Cause  GB stones; ulcerative colitis.
 Cl./P  abd. Pain; obst jaundice -ALP > 3X
 TTT  palliative

2) CARCINOMA OF THE GB:

 Adenocarcinoma
 Usually uncurable at presentation-obst. Jaundice

INFLAMMATORY BOWEL DISEASE

1) ULCERATIVE COLITIS:
 2ry milk intolerance.
 Sulphasalazine  DOESN"T  RISK FOR CANCER OR PREVENT INTESTINAL OBST.

2) CROHN'S:  2ry milk intolerance or subacute intestinal obstruction-Strictures.

3) COMPLICATIONS OF IBD:
a) toxic megacolon  can occur in crohn's
b) mouth ulcer  “Aphthus Ulcer”
c) in crohn's  biliary ; renal stones are common
d) CBC  Megaloblastic An???VIT B12 def. (T. ileum affection)

 DIVERTICULITIS:
 # NSAIDS.
 Complications  paralytic ileus ; septicemia-abscess
 TTT  1st line is DIETRY FIBERS. (MCQ)
  PSEUDO-MEMBRANOUS COLITIS
 CAUSES  CLINDAMYCIN ; CEPHALO SP.
 INVEST.  CL. DIFICILE TOXIN IN STOOL
 TTT.  VANCOMYCINE + MDTRONIDAZOLE.

GALL BLADDER:
1) CBD diameter  should be < 8mm-
2) M/C GB stones  cholesterol.
3) IMAGING
a) PLAIN X-RAY  usually radiolucent.
b) US  most imp.….. size of stone ; intra-hepatic biliary dilatation  indication to:
c) ERCP  extrahepatic biliary obstn
 TTT OF ACUTE CHOLYSYSTITIS  AMPICILLIN ISN'T USED NOW
 1RY SCLEROSING CHOLANGITIS  MAINLY INTRAHEPATIC(MCQ)

PANCREAS
 CYSTIC FIBROSIS:-sever steatorrhea-glaucose intolerance-peptic ulcer-the pathology is:
widespread obstn in pancreatic ductules
 ACUTE PANCREATITIS:
a) M. avium is a cause in HIV patients.
b) Prayer's postion
c) on auscultation:  bowel sounds(paralytic ileus)

 CHRONIC PANCREATITIS:
 NO  OF s. AMYLASE. (only in acute)_
 Stones aren't a cause??????? (not sure of this….found in LANGE)

 RENAL FAILURE  false in amylase. (MCQ)

 PANCREATIC DIVISM  chronic pancreatitis
 INTESTINAL TB  mainly ileocaecal - perianal fistulas-granulomatous hepatitis-pain
without alternation in bowel habits
 MALIGNANT ASCITIS  sister Mary Joseph nodules in umbilicus.
 FUNCTIONAL GIT DISORDERS  somatoform disorders(MCQ)
 LIVER MCQS
HISTOLOGY & LIVER INVEST.
 HEPATIC ARTERY SUPPLIES 25% of the cardiac output ; 50% of the total hepatic O2 supply
 ALT  early diagnostic / but AST  early prognostic
 1ST TEST LIVER DISEASE TRANSAMINASES
 P.8: GT  only liver enzyme affected by enzyme inducers(MCQ)
  IGG  chronic hepatitis while  IgA  alcoholics ; liver cirrhosis

VIRAL HEPATITIS
 IGA  responsible for the be - bridging in liver cirrhosis(CLINICAL PATHOLOGY)
 HAV  the highest cholestasis
 HBV  usually in the prodroma there's polyarthritis
 CARRIER  no enzyme elevation
 CHRONIC HEPATITIS   enzymes.
 PROLONGED JAUNDICE   Gilbert-relapse:  SGPT
 HSV, YELLOW FEVER  sever necrosis +  liver enzymes
 MONONUCLEOSIS DISEASES??  IMN-CMV-TOXOPLASMOSIS-EBV…..
 JAUNDICE  Chronic hepatitis(direct) ... AIHA. (indirect)

C IR R HO S IS
 CHRONIC ACTIVE HEPATITIS  INTERFACE HEPATITIS(MCQ)
 H. HAEMOCHROMATOSIS  HLA A3(MCQ)
 WILSON  causes FANCONI $
 MALLORY HYALINE  WILSON – PBC -alcoholic-NASH
 1RY BILIARY CIRRHOSIS  mainly intrahepatic.
HEPATIC ENCEPHALOPATHY
 CHRONIC LIVER DISEASE  WORSE THAN ACUTE…WHY??? Due to affection of:
ASTROCYTES(ischemia)_OLIGODENTROCYTES(decreases the nerve conduction)
 BUT IN ACUTE  no pathological changes
 1ST AID  Enema + FLAGYL
 DD OF ENCEPHALOPATHY  hypoglycemic coma (remember DD of DELIRIUM???)
 …SO THE 1ST AID  IV Dextrose 10%

 FULMINATE HEPATITIS
 Acute fatty liver of pregnancy - REYE's –TETRACYCLINE.

 all cause mitochondrial damage(MCQ)

 THERE"S NO  HSM – ascitis - low albumin(ACUTE)(MCQ)

PORTAL HTN:
 IN POST-SINUSOIDAL  ADD 1) IVC obstn (in BEHCET)...
2) Cardiac causes???TVD-RVF-constrictive pericarditis
 PATIENT WITH LCF…BLEEDING??
1) Bleeding tendency. (due to low coagulation factors)
2) Peptic ulcer.
3) Rupture varices.
 BA SWALLOW SHOWS  worm like filling defects
 COMPLICATIONS  add hepatorenal $

HCC
 HEPATIC BRUIT  MAAMON's sign
 ONLY CURATIVE TTT  Transplantation.
 SURGICAL RESECTION IF  good GC - (no decompensation)

FATTY LIVER  PEM(MAINLY KWO)

 M/C CAUSE OF NASH  DM(repeated MCQ)
 INVESTIGATIONS  CT is better than Sonar
JAUNDICE:
 I. BILIRUBIN Causes  constipation-neonatal jaundice-cholestasis…
 INTRA-HEPATIC  add 1ry biliary cirrhosis(MCQ)
 EXTRA-HEPATIC  add cystic fibrosis
 GILBERT  defect in Z-Y receptors(MCQ)
 JAUNDICE + LEUCOCYTOSIS  SBP (the 1st to think of)

DRUG INDUCED
 ENZYME   phentoin-carbamazepine-rifampicine_i
 ENZYME (-)  barbatirates

 ZONE 3  the most affected.

 OCP ON LIVER  cholestasis(stones)-adenoma-budd chiari-
 DRUGS CAUSING FIBROSIS ;CIRRHOSIS  methotrexate-

 VIT A-GRANULOMAS  allopurinol-amiodarone-acetaaminophen is toxic through it's active

metabolite >>> antidote ... N-acetyl cystein(MCQ)

OTHERS
 ADD TO POSTOPERATIVE JAUNDICE: accidental ligation of bile duct-synthetic valve-infection.
 BUDD-CHIARI  all liver is congested except >>> caudate lobe
 TRANSPLANTATION  Add to indications: cryptogenic cirrhosis - HCC- intrapulmonary
shunts-1ry ; 2ry biliary cirrhosis, cholangiosarcoma(MCQ)
add to#  disseminated malignancy
 PREGNANCY   ALP-clotting factors(budd chiari)-stones(Lecture)
 ADD TO EMERGENCIES  acute fulminating hepatitis