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    Prof. of Hepatology & Gastroenterology, Cairo University.

    Consultant of Hepatology,Gastroenterology and Endoscopy

    Management Positions: •

    Chief of Hepatology unit El Manial University Hospital (1994-1998).

    • Chief of Gastroentero ICU in Cairo university hospital (1997-2000)

    • President of the board of AlfaScope GI Specialized center (2004-2014).

    • Head of Endoscopy Unit in Cairo University Hospitals (2005-2010).       

     

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    استاذ الكبد و الجهاز الهضمى بكلية الطب جامعة القاهرة

    استشارى الكبد و الجهاز الهضمى و المناظير

    دكتوراه امراض الكبد و الجهاز الهضمى من كلية الطب جامعة القاهرة

    الرئيس السابق لقسم الامراض الباطنية بكلية الطب جامعة ٦ اكتوبر

    الرئيس السابق لوحدة مناظير الجهاز الهضمى و مركز الكبد و الرعاية المركزة بقصر العينى

     

    إقرأ المزيد

     

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Monday, Nov 20th

Last update10:09:06 AM

        

Rheumatology

Rheumatology

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Rheumatology

 

Enumerate:

1. Causes of gout.

2. Joint deformities in rheumatoid arthritis.

3. Cardiovascular manifestations in rheumatoid arthritis.

4. Respiratory manifestations in rheumatoid arthritis.

5. Neurological manifestations in rheumatoid arthritis.

6. Renal manifestations in rheumatoid arthritis.

7. Complications of NSAIDs.

8. Complications of corticosteroids.

9. Criteria for diagnosis of rheumatoid arthritis.

10. Precipitating factors for acute gouty arthritis.

11. Indications for allopurinol in gout.

12. Uses of chloroquin.

13. Renal complications due to hyperuricemia.

14. Four causes of polyarthritis. (3 marks)

 

 

Differentiate between:

1. Rheumatic and rheumatoid arthritis.

2. Rheumatoid arthritis and gouty arthritis.

3. Acute & chronic gouty arthritis.

 

Give a short account on:

1. Aetiology of gout.

2. Clinical features of gout.

3. Clinical picture of chronic gouty arthritis. (10 marks)

3. Treatment of gout.

4. Treatment of acute gouty arthritis.

5. Treatment of acute gouty arthritis. (3 marks)

4. Joint affection in rheumatoid arthritis.

5. Extra-articular manifestations in rheumatoid arthritis.

6. Variants of rheumatoid arthritis.

7. Sero-negative arthritidis.

8. Rheumatoid factors.

9. Investigations for rheumatoid arthritis.

10. Treatment of rheumatoid arthritis.

11. Clinical (6 marks) & laboratory diagnostic criteria (4 marks) of SLE.

11. Treatment of SLE. (2 marks)

12. How could you differentiate between various types of polyarthritis? Describe the treatment of one of them.

13. Define the meaning of: (10 marks)

          - Osteomalacia.

          - Osteoporosis.

          - Osteitis fibrosa cystica.

Give one example of a disease associated with each of these types of bone disease.

Describe the clinical & laboratory features of one of these diseases.

14. The renal manifestations of lupus nephritis (3 marks), How would you manage a case of diffuse proliferative  lupus nephritis? (4 marks)

15. Causes, clinical picture, investigations and treatment of osteoarthritis. (10 marks)

16. Clinical picture and investigations of rheumatoid arthritis. (7 marks)

17. Differential diagnosis of polyarthritis. (7 marks)

18. Causes and management of osteoporosis. (7 marks)

 

Causes of polyarthritis:

1. Rheumatoid arthritis & its variants.

2. Rheumatic fever.

3. Collagen diseases.

4. Seronegative arthritidis.

5. Primary generalized osteoarthritis.

6. Chronic polyarticular gout.

7. Pyrophosphate arthropathy (pseudo gout).

8. Arthritis associated with systemic diseases as:

- Hemophilia.

- Sarcoidosis.

- Leukemia.

- Myxedema.

 

Causes of monoarthritis:

1. Traumatic arthritis.

2. Hemarthrosis.

3. Septic & tuberculous arthritis.

4. Rheumatic fever.

5. Acute gouty arthritis.

6. Osteoarthritis.

7. Neuropathic arthritis (Charcot’s joint).

8. Causes of polyarthritis in its initial phase.


Case 1:

A male patient aged 40 years complains of pain, redness and swelling of the metatarsophalyngeal joint of the big toe of few hours duration.

1. What is your diagnosis? (2 marks)

2. What are the investigations you like to do? (5 marks)

3. Mention the various disease states that may result in such a condition. (5 marks)

4. What are the short and the long term lines of therapy? (8 marks)

          (Details of drugs needed)

 

Case 2:

A 50 year-old executive after attending a cocktail party awoke in the morning with acute pain in the right big toe. The patient did not have any previous history of a similar episode. The toe was hot, acutely tender and the patient was unable to stand on that foot.

1. What are the causes of monoarthritis?

2. Which one of the following is the most probable diagnosis?

a. Behcet’s disease.

b. Acute pyogenic arthritis.

c. Ankylosing spondylitis.

d. Acute gouty arthritis.

e. Reiter’s syndrome.

3. Which of the following is/are most likely to be found in this patient?

a. Increased serum uric acid.

b. Decreased serum complement level.

c. Increased serum ASO titer.

d. Bilateral lumbosacral arthritis by X-ray.

e. Positive blood culture for gonococci.

4. What are the possible complications of this illness?

5. What are the precipitating factors of such an attack?

6. What are the drugs that would relief the patient’s pain?

 

Case 3:

A 35 year-old woman complains of weight loss and frequent, greasy, foul-smelling stools. She had a history of repeated attacks of Raynaud’s phenomenon. On examination she was observed to have a thickened, stretched skin on her hands, which looks as if fixed to the underlying structures

1. What is the most likely diagnosis?

2. What are the esophageal manifestations in this disease?

3. What is the pathogenesis of the stool changes?
Case 4:

Forty year-old housewife has been complaining of joint pains in both hands intermittently for five years. She states that all the joints in her hands feel stiff in the morning but the stiffness gradually disappears as the day progresses. On examination, the joints of her both hands were swollen and subcutaneous nodules were felt at the finger joints. Her past history was completely negative.

 

1. Enumerate causes of polyarthritis.

2. What is the most diagnostic investigation to be done?

3. What are the possible deformities that she may develop?

4. What are the non-articular manifestations that she may have?

5. What are modified Dukett-Jone’s criteria for diagnosis of rheumatic fever?

6. What are The American College Of Rheumatology criteria for diagnosis of rheumatoid arthritis?

7. Does negative rheumatoid factor excludes the diagnosis of rheumatoid arthritis?

8. What are the causes of false positive rheumatoid factor?

9.  What are the articular complications that she may have?

10. What are the drugs that will relieve her pains? What are their adverse effects?

11. What are the drugs that will slow the progress of the disease? What are their adverse effects?

12. A long-term renal complication of her illness may be:

a. Recurrent kidney stones.

b. Renal amyloidosis.

c. Kimmelstiel-Wilson's kidney.

 

Case 5:

A 65 year-old woman who had a 12 years history of symmetrical polyarthritis was admitted to the hospital. Physical examination revealed splenomegaly together with the joint affection and rheumatoid factor titer of 1:4000.

 

1. The most likely diagnosis is:

a. Sjogren’s syndrome.

b. Ankylosing spondylitis.

c. Caplan’s disease.

d. Still’s disease.

e. Felty’s disease.

2. What is the expected CBC of the patient?

 


Case 6:

A 30 year old female went to the doctor complaining of joint and muscle pains for nearly one year. No joint swelling or tenderness were found and the temperature was found to be 37.4ºC.

Investigations revealed:

- CBC: normal.

- Rheumatoid factor: negative.

- ASO: 150 units/dl.

 

1. What are the causes of arthralgia?

Two months later, the patient experienced an acute stitching pain in the chest, which lasted for hours. Next day, she went to the doctor, who did not found any abnormal findings by examination.

2. What are the possibilities of this pain?

Three months later, the patient began to notice marked loss of her hair during combing and after showering, so she went to a dermatologist, who prescribed for her some lotions and vitamins and asked for the following investigations:

- Urine: showed mild proteinuria.

- CBC: was found to be normal.

- ESR: was 100 after one hour.

3. Put three possibilities for diagnosis of the patient.

Few months later, she faced very stressful situation in her life, and began to complain of repeated headaches, so she went to a near by pharmacist to measure her blood pressure, which was found to be 160/100. The pharmacist told her that she is hypertensive and gave her Hydralazine to control her blood pressure.

4. Is it justifiable to consider this patient hypertensive?

5. Do you think that her blood pressure is the cause of her headaches?

Few days later, the patient developed marked redness of her face and swelling together with tenderness of her finger joints.

6. What are the investigations to be done for the patient?

7. What are the possible renal complications that the patient may develop?

8. How to treat the patient?

One year later during routine examination, a grade 3/6 presystolic murmur was heard at the apex.

9. What is the explanation of this murmur?

Few months later she developed left side hemiplegia, with difficulty in speaking, deviation of the tongue to the left side and deviation of the mouth to the right side. No other cranial nerve affections were found.

10. What are the possible causes of this hemiplegia? What is its level?

 

Case 7:

A 30 year-old man complained of difficulty in breathing for the past six months. He did not have any history of cough or expectoration. There was no history of any cardiac illness in the past. Four years age he started to have low back pain especially in the mornings, and for approximately 3 months he is having difficulty in bending forwards or backwards.

On examination, blood pressure was 160/60 mm Hg, pulse 90/min and regular.

Examination of the chest revealed restrictive mobility but was otherwise normal. Cardiac examination revealed a short diastolic murmur. Examination of the spine revealed tenderness at the right sacroiliac area. Laboratory data were all normal except elevated ESR. ECG was normal.

1. The probable diagnosis of this patient’s illness is:

a. Rheumatoid arthritis.

b. Reiter’s disease.

c. Ankylosing spondylitis.

2. The diastolic murmur heard in the heart is probably due to:

a. Aortic regurgitation

b. Mitral stenosis

c. Pulmonary regurgitation

3. X- ray of the spine most probably will show:

a. Decreased density of all the vertebral bodies.

b. Bamboo spine.

c. Cervical spondylosis

4. This disease belongs to a group which includes the following except:

          a. Behcet’s disease.

          b. Reactive arthritis.

          d. Enteropathic arthritis.

          e. Psoriatic arthritis.

5. What are the common features of this group?

Case 8:

A 20 year old female presented with joint pain, alopecia and edema of the lower limbs of few weeks duration. She was pale and hypertensive. Her serum creatinine was 1.9 mg/dl.

1. What is the likely diagnosis? (2 marks)

2. What are the investigations you would ask for? (7 marks)

3. Describe the lines of therapy. (6 marks)


Questions 1 through 3

1. You evaluate a 38-year-old man who complainsof muscle weakness. Her appearance is remarkablefor a periorbital heliotrope rash withedema and erythema on his upper chest, neck,and face . Which of the following isthe most likely diagnosis?

 

(A) polymyositis

(B) dermatomyositis

(C) spinocerebellar degeneration

(D) vasculitis

(E) rheumatoid arthritis

 

2. Which of the following examination findings

would this patient most likely have?

(A) proximal muscle weakness

(B) distal muscle weakness

(C) ataxic gait

(D) hyperactive deep tendon reflexes

(E) inflamed small joints

 

3. Which of the following blood parameters is

likely to be elevated?

(A) serum creatinine

(B) serum potassium

(C) serum sodium

(D) rheumatoid factor

(E) creatinine phosphokinase

Answers:

 

1. (B)2. (A)3. (E)

 

Explanations 1 through 3

The heliotrope, purple periorbital rash is seenwith dermatomyositis and may even precedethe muscle involvement. On examination, thesepatients will usually show proximal muscleweakness and may complain of difficulty gettingup from a chair, climbing stairs, and raisingthe arms over the head. Ataxia may be presentwith cerebellar lesions. Deep tendon reflexesshould be normal and there is no joint inflammation.Polymyalgia rheumatica generallyoccurs in older people but is not associated withmuscle weakness. Spinocerebellar degeneration,vasculitis, and rheumatoid arthritis are notassociated with this rash. Creatine phosphokinaseis usually markedly elevated and musclebiopsy will confirm the diagnosis. Serum creatinine,sodium, and potassium should benormal, and the rheumatoid factor should notbe elevated.


Rheumatology

 

1) Which of the following is not associated with active SLE:

A.   High serum level of ANA

B.   Low serum level of complement

C.   High serum level of C-reactive protein

D.   High serum level of anti-ds DNA

E.    High ESR

 

2) Exacerbations of SLE is produced by:

A.   Rifampicin

B.   Oral contraceptives

C.   Carbamazepine

D.   Reserpine

E.    Neomercazole

 

3) Rheumatoid factor in SLE is positive in:

A.   20% cases

B.   35% cases

C.   50% cases

D.   70% cases

E.    60% cases

 

4) ANF in SLE is positive in approximately:

A.    60% cases

B.     70% cases

C.     80% cases

D.    95% cases

E.     100% cases

 

5) Lupus nephritis is treated by all except:

A.   Interferon

B.   Glucocorticoids

C.   Azathioprine

D.   Cyclophosphamide

E.    Mycophenolate

 

6) Mixed connective tissue disease (MCTD) is a combination of SLE, scleroderma, rheumatoid arthritis and

A.    Sjogren's syndrome

B.     Polymyositis

C.     My asthenia gravis

D.    Osteoarthritis

E.     Eosinophilic fasciitis

 

7) Rose-Waaler test is positive in rheumatoid arthritis in:

A.   30%  cases

B.   45% cases

C.   70% cases

D.   90% cases

E.    60% cases

 

8) Rheumatoid nodules are characterized by all except:

A.    Big

B.     Tender

C.     Fixed to skin

D.    Ulcerate

E.     Associated with positive rheumatoid factor

 

9) Still's disease does not give rise to:

A.    Positive Rose-Waaler test

B.     Splenomegaly

C.     Lymphadenopathy

D.    Maculopathy rash

E.     Fever

 

10) Which is not a disease-modifying antirheumatic drug:

A.    Hydroxychloroquine sulphate

B.     Azathioprine

C.     Sulphasalazine

D.    Naproxen

E.     Methotrexate

 

11) Felty's syndrome is not associated with:

A.    Age of onset 20-25 yrs

B.     Vasculitis

C.     Lymphadenopathy

D.    Thrombocytopenia

E.     Splenomegaly

 

12) All are extra-articular manifestations of rheumatoid arthritis except:

A.    Fibrosing alveolitis

B.     Pericarditis

C.     Mononeuritis multiplex

D.    Ulcerative colitis

E.     Sjögren's Syndrome

 

13) Drug-induced SLE is not commonly associated with:

A.    Polyarthritis

B.     Pulmonary infiltrates

C.     Renal involvement

D.    Polyserositis

E.     Skin rash

 

14) Which is not an extra-articular manifestation of ankylosing spondylitis

A.    Acute pulmonary fibrosis

B.     Aortic incompetence

C.     Amyloidosis

D.    Raynaud's phenomenon

E.     Uveitis

 

15) The most effective prophylaxis adopted in gout by:

A.    Allopurinol

B.     Benzbromarone

C.     Pronbenecid

D.    Colchicine

E.     Diclofenac

 

16) Terminal interphalangeal joint is classically involved in:

A.    Rheumatoid arthritis

B.     Reactive arthritis

C.     Behcet's syndrome

D.    Psoriatic arthropathy

E.     Pseudogout

 

17) Behcet's syndrome is not associated with:

A.    Meningoencephalitis

B.     Genital ulceration

C.     Thrombophlebitis

D.    Urethritis

E.     Iridocyclitis

 

18) Heberden's node is seen in:

A.    Osteoarthritis

B.     Progressive systemic sclerosis

C.     Dermatomyositis

D.    Gout

E.     Polyarteritis

 

19) Multiple myeloma is associated with all of the following except:

A.    Bone pain

B.     Hypercalcaemia

C.     High alkaline phosphatase

D.    Bone marrow failure

E.     Anemia

 

20) Drug of choice for relieving pain in osteoartheritis is:

A.    Corticosteroids.

B.     Ibuprofan

C.     Paracetamol.

D.    Diclofenac

E.     Penicillamine

 

21) Hypertrophic osteoarthropathy is most commonly due to:

A.    Mesothelioma of pleura

B.     COPD

C.     Bronchogenic carcinoma

D.    Fibrosing afveolitis

E.     Tuberculosis

 

22) Example of autoimmune arthritis is:

A.    Rheumatoid arthritis

B.     Haemophilic arthritis

C.     Psoriatic arthritis

D.    Osteoarthritis

E.     Reiter’s syndrome

 

23) Regarding drug-induced SLE which is false:

A.    Nephritis is rare

B.     Hydralazine and procainamide are most common causes

C.     Anti-histone antibodies are present

D.    Central nervous system involvement is common

E.     Serositis is coma

 

24) A 20-years woman has repeated attacks of myalgia, non-deforming arthralgia, pericarditis and pleural effusion for few years. The laboratory screening test should be

A.    Rose-Waaler agglutination test

B.     Antinuclear antibodies

C.     CD4 lymphocyte count

D.    ASO titre

E.     ANCA

 

25) In rheumatoid arthritis,' rheumatoid factor is formed against:

A.    IgG

B.     IgA

C.     IgM

D.    IgD

E.     IgE

 

26) Penicillamine and cochicine both are used in treatment of:

A.    Rheumatoid arthritis

B.     Systemic lupus erythematosus

C.     Progressive systemic

D.    Wilson's disease sclerosis

E.     Gout

 

27) Hydroxychloroquine toxicity does not produce:

A.    Maculopathy

B.     Corneal deposits

C.     Optic atrophy

D.    Cataract

E.     Dermatitis

 

28) Recurrent anterior uveitis is most characteristic of:

A.    Behcet's syndrome

B.     Rheumatoid arthritis

C.     Systemic lupus

D.    Sjogren's syndrome erythematosus

E.     Temporal arteritis

 

29) Still's disease is classically associated with all except:

A.    Sacroiliitis

B.     Maculo-papular rash

C.     Negative Rose-Waaler test

D.    Involvement of metacarpophalangeal joints

E.     Splenomegaly

 

30) Arthritis mutilans' is characteristic of:

A.    Psoriasis

B.     Reiter's syndrome

C.     Behcet's syndrome

D.    Sjogren's syndrome

E.     Rheumatoid arthritis

 

31) Brucella arthritis commonly affects:

A.    Knee joint

B.     Joints of hands

C.     Spine

D.    Metatarsophalangeal joint

E.     Hip joint

 

32) Which of the following usually presents as monoarthropathy:

A.   SLE

B.   Rheumatoid arthritis

C.   Gout

D.   Sjogren's syndrome

E.    Osteoarthritis

 

 

Answer key :

1.     C

2.     B

3.     A

4.     D

5.     A

6.     B

7.     C

8.     B

9.     A

10.                        D

11.                        A

12.                        D

13.                        C

14.                        D

15.                        A

16.                        D

17.                        D

18.                        A

19.                        C

20.                        C

21.                        C

22.                        A

23.                        D

24.                        B

25.                        A

26.                        C

27.                        D

28.                        A

29.                        A

30.                        A

31.                        C

32.                        C

 

 

Rheumatology

 

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 المعلومات الواردة في مختلف صفحات موقع د.سامح لبيب على الإنترنت هي معلومات صادرة عنه لأغراض تعليمية-خدميه. وتلك المعلومات محمية بموجب قوانين  حماية المصنفات الأدبية والفنية واتفاقيات دولية أخرى وبمقتضى القوانين الوطنية الخاصة بحقوق التأليف والحقوق المرتبطة بها. ويجوز استعراض أجزاء من المعلومات الواردة في الموقع أو نسخها أو ترجمتها لأغراض البحث أو لإجراء دراسة شخصية ولكن ليس لبيعها أو استخدامها لأغراض تجارية.

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