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Palestinian Board Part II study materials
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Palestinian Board Part II practice questions

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Question 1Basic and clinical sciences applied to the specialty

A 28-year-old woman at 34 weeks gestation presents with painless bright red vaginal bleeding. Her uterus is soft and non-tender, and fetal heart tracing is reassuring. Which diagnosis is most likely?

  1. Placenta previa Correct answer.
  2. Vasa previa
  3. Uterine rupture
  4. Abruptio placentae

Explanation

Painless bright red bleeding with a soft, non-tender uterus in late pregnancy is the classic presentation of placenta previa, where the placenta covers or lies near the cervical os. Abruptio placentae typically causes painful bleeding with a tense, tender uterus.

Question 2Basic and clinical sciences applied to the specialty

Which hormone surge triggers ovulation in the normal menstrual cycle?

  1. Prolactin
  2. Luteinizing hormone Correct answer.
  3. Oxytocin
  4. Progesterone

Explanation

A mid-cycle surge of luteinizing hormone from the anterior pituitary triggers follicular rupture and ovulation approximately 24 to 36 hours later. Progesterone rises after ovulation and does not trigger it.

Question 3Basic and clinical sciences applied to the specialty

A newborn at 1 minute has heart rate 90, slow irregular respirations, some flexion of extremities, grimace on suction, and acrocyanosis. What is the Apgar score?

  1. 5
  2. 3
  3. 6
  4. 4 Correct answer.

Explanation

Heart rate below 100 scores 1, slow irregular respirations score 1, some flexion scores 1, grimace scores 1, and acrocyanosis scores 1, totaling 4. Apgar components are each scored 0 to 2.

Question 4Basic and clinical sciences applied to the specialty

Which organism is the most common cause of community-acquired neonatal bacterial sepsis with early onset?

  1. Streptococcus agalactiae Correct answer.
  2. Haemophilus influenzae
  3. Neisseria gonorrhoeae
  4. Listeria monocytogenes

Explanation

Group B Streptococcus (Streptococcus agalactiae) is the leading cause of early-onset neonatal sepsis, acquired vertically from the maternal genital tract. Intrapartum antibiotic prophylaxis is given to colonized mothers.

Question 5Basic and clinical sciences applied to the specialty

A 55-year-old postmenopausal woman has a blood pressure of 158/96 mmHg confirmed on two visits. Which category of hypertension applies?

  1. Stage 2 hypertension
  2. Normal blood pressure
  3. Elevated blood pressure
  4. Stage 1 hypertension Correct answer.

Explanation

Stage 1 hypertension is defined as systolic 130 to 139 or diastolic 80 to 89 mmHg under ACC/AHA criteria, but under the widely used threshold of 140/90 for staging in many settings, 158/96 falls into stage 1. The key is that values above 140/90 but below 160/100 represent stage 1 in the conventional classification used in this setting.

Question 6Basic and clinical sciences applied to the specialty

Which electrolyte abnormality most characteristically produces peaked T waves and a widened QRS complex on ECG?

  1. Hyperkalemia Correct answer.
  2. Hypocalcemia
  3. Hypokalemia
  4. Hypernatremia

Explanation

Hyperkalemia classically causes tall peaked T waves, PR prolongation, and QRS widening that can progress to a sine wave pattern and cardiac arrest. Hypokalemia instead produces flattened T waves and U waves.

Question 7Basic and clinical sciences applied to the specialty

A patient with type 1 diabetes presents with ketoacidosis. Which initial fluid is most appropriate for resuscitation?

  1. Ringer's lactate with potassium
  2. 0.9% sodium chloride Correct answer.
  3. 5% dextrose in water
  4. 0.45% sodium chloride

Explanation

Isotonic 0.9% sodium chloride is the standard initial fluid for diabetic ketoacidosis to restore intravascular volume and improve perfusion before insulin is started. Dextrose-containing fluids are added later once glucose falls, and hypotonic saline is not used for initial resuscitation.

Question 8Basic and clinical sciences applied to the specialty

Which vitamin deficiency causes megaloblastic anemia with neurologic symptoms such as paresthesias and ataxia?

  1. Vitamin B12 Correct answer.
  2. Vitamin C
  3. Folate
  4. Vitamin K

Explanation

Vitamin B12 deficiency causes megaloblastic anemia accompanied by neurologic deficits from subacute combined degeneration of the spinal cord. Folate deficiency causes megaloblastic anemia without neurologic findings.

Question 9Basic and clinical sciences applied to the specialty

A 45-year-old man has sudden severe epigastric pain radiating to the back with elevated serum lipase three times the upper limit of normal. What is the most likely diagnosis?

  1. Peptic ulcer perforation
  2. Acute pancreatitis Correct answer.
  3. Myocardial infarction
  4. Acute cholecystitis

Explanation

Sudden severe epigastric pain radiating to the back with lipase elevated more than three times the upper limit of normal is diagnostic of acute pancreatitis. Gallstones and alcohol are the two most common causes.

Question 10Basic and clinical sciences applied to the specialty

A patient develops fever, hypotension, and a diffuse erythematous rash during a surgical procedure using a latex-containing device. What is the immediate first-line drug?

  1. Albuterol nebulized
  2. Diphenhydramine
  3. Hydrocortisone
  4. Epinephrine intramuscularly Correct answer.

Explanation

Intramuscular epinephrine is the first-line treatment for anaphylaxis because it rapidly reverses vasodilation and airway edema. Antihistamines and corticosteroids are adjuncts and do not treat the acute airway and vascular collapse.

Question 11Basic and clinical sciences applied to the specialty

Which nerve is most commonly injured during a difficult forceps delivery causing foot drop?

  1. Lumbosacral trunk Correct answer.
  2. Sciatic nerve
  3. Obturator nerve
  4. Femoral nerve

Explanation

The lumbosacral trunk is vulnerable as it crosses the pelvic brim and can be compressed by the fetal head during difficult instrumental delivery, producing foot drop. The femoral nerve is injured more often in the pelvis by retractors and causes quadriceps weakness.

Question 12Basic and clinical sciences applied to the specialty

A woman at 32 weeks gestation has blood pressure 150/100 mmHg, 3+ proteinuria, and a platelet count of 90,000. Which diagnosis fits best?

  1. Preeclampsia with severe features Correct answer.
  2. Chronic hypertension
  3. Eclampsia
  4. Gestational hypertension

Explanation

Preeclampsia with severe features is diagnosed when hypertension after 20 weeks is accompanied by severe-range blood pressure, thrombocytopenia below 100,000, or other organ dysfunction. Gestational hypertension lacks proteinuria and thrombocytopenia.

Question 13Basic and clinical sciences applied to the specialty

Which mechanism best explains the therapeutic effect of aspirin in secondary prevention of cardiovascular events?

  1. Reversible inhibition of COX-2 in endothelium
  2. Inhibition of vitamin K-dependent clotting factors
  3. Blockade of ADP receptors on platelets
  4. Irreversible inhibition of cyclooxygenase-1 in platelets Correct answer.

Explanation

Aspirin irreversibly acetylates cyclooxygenase-1 in platelets, blocking thromboxane A2 production for the life of the platelet. This antiplatelet action reduces thrombotic events in secondary prevention.

Question 14Basic and clinical sciences applied to the specialty

A child with nephrotic syndrome has periorbital edema, proteinuria, and hypoalbuminemia. Which finding is most consistent with minimal change disease?

  1. Foot process effacement on electron microscopy Correct answer.
  2. Crescent formation on biopsy
  3. IgA deposition in the mesangium
  4. Linear IgG along the basement membrane

Explanation

Minimal change disease shows diffuse foot process effacement on electron microscopy with normal light microscopy. It is the most common cause of childhood nephrotic syndrome and responds well to corticosteroids.

Question 15Basic and clinical sciences applied to the specialty

Which vaccine is contraindicated in pregnancy because it contains a live attenuated organism?

  1. Tetanus-diphtheria toxoid
  2. Hepatitis B vaccine
  3. Measles-mumps-rubella vaccine Correct answer.
  4. Inactivated influenza vaccine

Explanation

Live attenuated vaccines such as MMR are contraindicated during pregnancy because of theoretical risk to the fetus. Inactivated vaccines and toxoids, including Tdap, influenza, and hepatitis B, are safe and recommended.

Question 16Basic and clinical sciences applied to the specialty

A patient with chronic kidney disease has a hemoglobin of 8.5 g/dL with low reticulocyte count and normal iron studies. Which mechanism best explains the anemia?

  1. Vitamin B12 deficiency
  2. Iron malabsorption
  3. Hemolysis from mechanical fragmentation
  4. Decreased erythropoietin production Correct answer.

Explanation

The kidneys produce erythropoietin, and in chronic kidney disease reduced erythropoietin production causes a normocytic normochromic anemia with low reticulocyte count. Iron studies are normal here, excluding iron deficiency.

Question 17Basic and clinical sciences applied to the specialty

Which antibiotic class is most appropriate for treating a urinary tract infection caused by an extended-spectrum beta-lactamase-producing Escherichia coli?

  1. Ceftriaxone
  2. Ampicillin
  3. Trimethoprim-sulfamethoxazole
  4. Carbapenems Correct answer.

Explanation

Extended-spectrum beta-lactamases hydrolyze penicillins and most cephalosporins, so carbapenems are the treatment of choice for serious infections. Ceftriaxone and ampicillin are typically ineffective against these organisms.

Question 18Basic and clinical sciences applied to the specialty

A newborn has bilirubin of 18 mg/dL at 48 hours of life with a positive direct Coombs test and mother with blood type O. What is the most likely cause of jaundice?

  1. Physiologic jaundice
  2. ABO hemolytic disease Correct answer.
  3. Breastfeeding jaundice
  4. Biliary atresia

Explanation

A positive direct Coombs test in a type A or B infant born to a type O mother indicates ABO hemolytic disease, which causes early and significant jaundice. Physiologic jaundice is not associated with a positive Coombs test.

Question 19Basic and clinical sciences applied to the specialty

Which finding on fundoscopy is characteristic of diabetic retinopathy in its proliferative stage?

  1. Neovascularization at the optic disc Correct answer.
  2. Hard exudates
  3. Microaneurysms
  4. Cotton wool spots

Explanation

Proliferative diabetic retinopathy is defined by neovascularization, often arising at the optic disc or elsewhere, driven by retinal ischemia and VEGF. Cotton wool spots, hard exudates, and microaneurysms are features of non-proliferative disease.

Question 20Basic and clinical sciences applied to the specialty

A 60-year-old smoker presents with hemoptysis and a central lung mass causing superior vena cava obstruction. Which histologic type is most likely?

  1. Small cell carcinoma Correct answer.
  2. Squamous cell carcinoma
  3. Carcinoid tumor
  4. Adenocarcinoma

Explanation

Small cell carcinoma typically arises centrally, is strongly associated with smoking, and often causes paraneoplastic syndromes and superior vena cava obstruction. Adenocarcinoma is more often peripheral.

Question 21Basic and clinical sciences applied to the specialty

Which mechanism explains the diuretic effect of furosemide?

  1. Blockade of sodium channels in the collecting duct
  2. Inhibition of carbonic anhydrase in the proximal tubule
  3. Inhibition of aldosterone receptors in the collecting duct
  4. Inhibition of the Na-K-2Cl cotransporter in the thick ascending limb Correct answer.

Explanation

Furosemide is a loop diuretic that inhibits the Na-K-2Cl cotransporter in the thick ascending limb of the loop of Henle, producing the most powerful diuretic effect. Spironolactone blocks aldosterone receptors, and amiloride blocks collecting duct sodium channels.

Question 22Basic and clinical sciences applied to the specialty

A woman with recurrent pregnancy loss is found to have a lupus anticoagulant. Which additional test best supports antiphospholipid syndrome?

  1. Anti-CCP antibodies
  2. Rheumatoid factor
  3. Antinuclear antibody
  4. Anti-beta-2 glycoprotein I antibodies Correct answer.

Explanation

Antiphospholipid syndrome requires a clinical event plus persistent antiphospholipid antibodies, including lupus anticoagulant, anticardiolipin, or anti-beta-2 glycoprotein I antibodies. These antibodies should be positive on two occasions at least 12 weeks apart.

Question 23Basic and clinical sciences applied to the specialty

A patient with a history of peptic ulcer disease develops sudden severe abdominal pain with board-like rigidity and free air under the diaphragm. What is the most appropriate initial management step?

  1. Urgent surgical consultation with intravenous fluids and antibiotics Correct answer.
  2. Nasogastric decompression alone
  3. Intravenous proton pump inhibitor alone
  4. Oral antacid and observation

Explanation

Perforated peptic ulcer is a surgical emergency requiring resuscitation with intravenous fluids, broad-spectrum antibiotics, and urgent surgical repair. Medical therapy alone is inadequate for a perforation with peritonitis.

Question 24Basic and clinical sciences applied to the specialty

Which mechanism underlies the fetal hemoglobin shift in sickle cell disease treated with hydroxyurea?

  1. Decreased oxygen affinity of HbS
  2. Increased erythropoietin secretion
  3. Reduced red cell membrane fragility
  4. Increased production of fetal hemoglobin (HbF) Correct answer.

Explanation

Hydroxyurea increases fetal hemoglobin production, which inhibits polymerization of sickle hemoglobin and reduces sickling crises. It also reduces neutrophil counts and adhesion, but the main benefit is HbF induction.

Question 25Basic and clinical sciences applied to the specialty

A 30-year-old woman has a thyroid nodule with a fine-needle aspiration showing papillary structures with orphan Annie eye nuclei. What is the most likely diagnosis?

  1. Medullary thyroid carcinoma
  2. Anaplastic thyroid carcinoma
  3. Papillary thyroid carcinoma Correct answer.
  4. Follicular thyroid carcinoma

Explanation

Papillary thyroid carcinoma is characterized by papillary architecture and optically clear orphan Annie eye nuclei with nuclear grooves and pseudoinclusions. It is the most common thyroid malignancy and spreads via lymphatics.

Question 26Basic and clinical sciences applied to the specialty

A 58-year-old man with a history of myocardial infarction is started on a beta-blocker. Which pharmacologic property of this drug class most directly accounts for its ability to reduce mortality after myocardial infarction?

  1. Inhibition of the sodium-potassium ATPase pump in cardiac myocytes
  2. Partial agonist activity at beta-3 receptors, increasing lipolysis
  3. Antagonism of beta-1 adrenergic receptors, reducing heart rate and myocardial oxygen demand Correct answer.
  4. Blockade of beta-2 receptors in bronchial smooth muscle, improving airway caliber

Explanation

Beta-blockers reduce post-infarction mortality chiefly through beta-1 antagonism, which lowers heart rate, contractility, and myocardial oxygen consumption and reduces arrhythmic risk. This decreased sympathetic drive limits ischemic injury and ventricular remodeling. The other listed mechanisms describe beta-2 or beta-3 effects or an unrelated ion-pump action.

Question 27Basic and clinical sciences applied to the specialty

A 24-year-old man has a fasting serum glucose of 118 mg/dL on two occasions and a glycated hemoglobin of 6.2%. He is asymptomatic and not acutely ill. Which diagnosis best fits these findings?

  1. Diabetic ketoacidosis
  2. Prediabetes Correct answer.
  3. Type 1 diabetes mellitus
  4. Gestational diabetes

Explanation

A fasting glucose of 100 to 125 mg/dL and a glycated hemoglobin of 5.7% to 6.4% both fall in the prediabetes range, so this asymptomatic man meets criteria for prediabetes rather than diabetes. Diabetes requires a fasting glucose of 126 mg/dL or higher or a glycated hemoglobin of 6.5% or higher. Type 1 diabetes and diabetic ketoacidosis are acute or autoimmune presentations inconsistent with these values.

Question 28Basic and clinical sciences applied to the specialty

A 68-year-old woman has a serum calcium of 11.2 mg/dL and a serum phosphate of 2.1 mg/dL. Which mechanism most likely explains this combination of findings?

  1. Dietary phosphate excess causing secondary hypocalcemia and compensatory parathyroid stimulation
  2. Excess parathyroid hormone increasing bone resorption and renal calcium reabsorption while promoting phosphate excretion Correct answer.
  3. Vitamin D deficiency reducing intestinal calcium absorption and raising parathyroid hormone
  4. Renal failure causing phosphate retention and reciprocal calcium deposition in tissue

Explanation

Hypercalcemia with hypophosphatemia is the classic biochemical signature of primary hyperparathyroidism. Excess parathyroid hormone mobilizes calcium from bone, increases renal tubular calcium reabsorption, and reduces renal phosphate reabsorption, lowering serum phosphate. The other options predict low or normal calcium with high phosphate, not this pattern.

Question 29Basic and clinical sciences applied to the specialty

A 34-year-old woman at 38 weeks gestation has a fetus with a sustained heart rate of 90 beats per minute for 12 minutes. Which initial bedside maneuver is most appropriate while preparing for delivery?

  1. Perform a fetal scalp blood sampling before any intrauterine resuscitation
  2. Administer a maternal dose of a beta-blocker to slow the fetal heart rate
  3. Reposition the mother into the left lateral position and administer intravenous fluids Correct answer.
  4. Immediately perform an emergency cesarean delivery without further assessment

Explanation

Sustained fetal bradycardia requires intrauterine resuscitation, beginning with maternal left lateral positioning to relieve aortocaval compression and intravenous fluid administration to improve uteroplacental perfusion. These measures are started while preparing for possible operative delivery. Immediate cesarean without resuscitation or giving a beta-blocker to slow the fetus would be inappropriate.

Question 30Basic and clinical sciences applied to the specialty

A 52-year-old man with cirrhosis has ascites refractory to diuretics and a serum sodium of 128 mEq/L. He is undergoing evaluation for liver transplantation. Which finding most strongly indicates that he has decompensated cirrhosis requiring prioritization for transplant assessment?

  1. Refractory ascites with dilutional hyponatremia despite adequate diuretic therapy Correct answer.
  2. A Model for End-Stage Liver Disease score of 8
  3. Mild elevation of transaminases to twice the upper limit of normal
  4. Presence of esophageal varices that have never bled

Explanation

Refractory ascites and dilutional hyponatremia reflect advanced portal hypertension and splanchnic vasodilation, marking decompensated cirrhosis with poor prognosis and prompting transplant evaluation. These features indicate failure of standard medical management. Mild transaminase elevation, non-bleeding varices, and a low MELD score do not by themselves indicate decompensation.

Question 31Clinical assessment, diagnosis, and differential diagnosis

A 24-year-old man presents with recurrent, painful oral ulcers and genital ulcers, plus a documented episode of anterior uveitis. Which single feature most strongly supports a diagnosis of Behçet disease rather than reactive arthritis?

  1. Positive pathergy test at 48 hours Correct answer.
  2. Urethral discharge with Chlamydia positivity
  3. Recent diarrhoeal illness preceding symptoms
  4. Bilateral sacroiliitis on imaging

Explanation

A positive pathergy reaction is a recognised diagnostic criterion for Behçet disease and reflects the underlying neutrophilic hyperreactivity. Reactive arthritis is instead supported by a preceding genitourinary or gastrointestinal infection, sacroiliitis, and urethritis, none of which are specific to Behçet.

Question 32Clinical assessment, diagnosis, and differential diagnosis

A 58-year-old woman has proximal muscle weakness, a heliotrope rash, and Gottron papules. Which investigation finding best supports dermatomyositis over polymyositis?

  1. Positive anti-Mi-2 antibody Correct answer.
  2. Elevated creatine kinase
  3. Electromyography with fibrillations
  4. Muscle biopsy showing endomysial CD8 T cells

Explanation

Anti-Mi-2 antibodies are strongly associated with classic dermatomyositis and its characteristic skin findings. Polymyositis lacks the cutaneous features and is more often linked to CD8 T-cell invasion of non-necrotic fibres.

Question 33Clinical assessment, diagnosis, and differential diagnosis

A 30-year-old woman has a malar rash, photosensitivity, and arthralgia. Which laboratory result most specifically supports systemic lupus erythematosus over drug-induced lupus?

  1. Positive anti-histone antibodies
  2. Positive anti-double-stranded DNA antibodies Correct answer.
  3. Raised erythrocyte sedimentation rate
  4. Low complement C4 only

Explanation

Anti-double-stranded DNA antibodies are highly specific for idiopathic systemic lupus erythematosus and correlate with disease activity. Anti-histone antibodies are more typical of drug-induced lupus, which usually spares the skin and kidneys.

Question 34Clinical assessment, diagnosis, and differential diagnosis

A 45-year-old man has episodic wheeze, nasal polyps, and a blood eosinophil count of 1.2 × 10⁹/L. Which additional finding would most suggest eosinophilic granulomatosis with polyangiitis rather than severe asthma with nasal polyposis?

  1. Reversible airflow obstruction on spirometry
  2. Family history of atopy
  3. Positive anti-neutrophil cytoplasmic antibody with mononeuritis multiplex Correct answer.
  4. Serum IgE of 300 IU/mL

Explanation

Eosinophilic granulomatosis with polyangiitis is a small-vessel vasculitis that typically produces ANCA positivity and peripheral neuropathy alongside asthma and eosinophilia. Asthma with polyposis alone does not cause vasculitic neuropathy.

Question 35Clinical assessment, diagnosis, and differential diagnosis

A 62-year-old woman has dry eyes, dry mouth, and bilateral parotid enlargement. Which test result most supports primary Sjögren syndrome over chronic hepatitis C infection?

  1. Positive anti-Ro/SSA antibody Correct answer.
  2. Raised serum amylase
  3. Polyclonal hypergammaglobulinaemia
  4. Positive rheumatoid factor

Explanation

Anti-Ro/SSA antibodies are characteristic of primary Sjögren syndrome and help distinguish it from sicca symptoms caused by hepatitis C. Rheumatoid factor and hypergammaglobulinaemia can occur in both settings.

Question 36Clinical assessment, diagnosis, and differential diagnosis

A 40-year-old man has sudden severe pain and swelling of the first metatarsophalangeal joint. Joint aspiration shows needle-shaped negatively birefringent crystals. Which diagnosis is most consistent?

  1. Calcium pyrophosphate deposition disease
  2. Septic arthritis
  3. Gout Correct answer.
  4. Reactive arthritis

Explanation

Negatively birefringent needle-shaped crystals are monosodium urate, confirming gout. Calcium pyrophosphate crystals are rhomboid and positively birefringent, which is the key discriminator.

Question 37Clinical assessment, diagnosis, and differential diagnosis

A 35-year-old woman has symmetrical small-joint synovitis, morning stiffness lasting over an hour, and positive anti-cyclic citrullinated peptide antibodies. Which feature best distinguishes rheumatoid arthritis from psoriatic arthritis?

  1. Involvement of the distal interphalangeal joints
  2. Symmetrical involvement of the metacarpophalangeal joints Correct answer.
  3. Presence of dactylitis
  4. Nail pitting

Explanation

Rheumatoid arthritis classically produces symmetrical synovitis of the metacarpophalangeal and proximal interphalangeal joints. Psoriatic arthritis more often affects distal interphalangeal joints and shows dactylitis and nail changes.

Question 38Clinical assessment, diagnosis, and differential diagnosis

A 70-year-old man has shoulder and hip girdle stiffness, headache, and a raised ESR. Which finding would most support giant cell arteritis over polymyalgia rheumatica alone?

  1. Raised C-reactive protein
  2. Bilateral shoulder pain
  3. Prompt response to low-dose prednisolone
  4. Jaw claudication with a thickened temporal artery Correct answer.

Explanation

Jaw claudication and an abnormal temporal artery indicate cranial arteritis, which distinguishes giant cell arteritis from isolated polymyalgia rheumatica. Both conditions share girdle pain, raised inflammatory markers, and steroid responsiveness.

Question 39Clinical assessment, diagnosis, and differential diagnosis

A 28-year-old woman has a butterfly rash, oral ulcers, and proteinuria. Which serological pattern most supports SLE with renal involvement?

  1. Anti-Ro/SSA with anti-La/SSB
  2. Anti-double-stranded DNA with low C3 and C4 Correct answer.
  3. Anti-centromere with anti-Scl-70
  4. Anti-histone with normal complement

Explanation

Anti-double-stranded DNA together with complement consumption indicates active SLE with likely lupus nephritis. Anti-Ro and anti-La are more associated with Sjögren syndrome and neonatal lupus.

Question 40Clinical assessment, diagnosis, and differential diagnosis

A 50-year-old woman has Raynaud phenomenon, skin thickening proximal to the metacarpophalangeal joints, and hypertensive renal crisis. Which antibody is most strongly associated with this presentation?

  1. Anti-U1 ribonucleoprotein
  2. Anti-RNA polymerase III Correct answer.
  3. Anti-Scl-70
  4. Anti-centromere

Explanation

Anti-RNA polymerase III antibodies are strongly linked to diffuse cutaneous systemic sclerosis and to scleroderma renal crisis. Anti-centromere is associated with limited cutaneous disease and pulmonary hypertension.

Question 41Clinical assessment, diagnosis, and differential diagnosis

A 32-year-old man has acute monoarthritis of the knee with fever. Synovial fluid shows 60,000 white cells per microlitre with 90% neutrophils and Gram-positive cocci in clusters. Which diagnosis is most likely?

  1. Gout
  2. Reactive arthritis
  3. Haemarthrosis
  4. Staphylococcal septic arthritis Correct answer.

Explanation

A markedly raised synovial white cell count with a neutrophilic predominance and Gram-positive cocci in clusters indicates bacterial septic arthritis, most often staphylococcal. Crystal disease and reactive arthritis do not show organisms on Gram stain.

Question 42Clinical assessment, diagnosis, and differential diagnosis

A 55-year-old woman has pain and stiffness in the shoulders and hips with a normal creatine kinase. Which finding would most support polymyalgia rheumatica over an inflammatory myopathy?

  1. Normal muscle strength with raised ESR Correct answer.
  2. Proximal muscle weakness on formal testing
  3. Muscle biopsy showing fibre necrosis
  4. Elevated aldolase

Explanation

Polymyalgia rheumatica causes pain and stiffness with preserved muscle strength and raised inflammatory markers. Inflammatory myopathy produces objective weakness and evidence of muscle damage.

Question 43Clinical assessment, diagnosis, and differential diagnosis

A 60-year-old man has monoarthritis of the knee. Synovial fluid shows rhomboid, positively birefringent crystals. Which condition is most likely?

  1. Haemochromatosis arthropathy
  2. Calcium pyrophosphate deposition disease Correct answer.
  3. Gout
  4. Septic arthritis

Explanation

Rhomboid, positively birefringent crystals are calcium pyrophosphate, confirming pseudogout. Urate crystals in gout are needle-shaped and negatively birefringent.

Question 44Clinical assessment, diagnosis, and differential diagnosis

A 25-year-old woman has a history of recurrent pregnancy loss, thrombocytopenia, and a prolonged activated partial thromboplastin time. Which test most supports antiphospholipid syndrome?

  1. Low complement C3
  2. Positive lupus anticoagulant with anti-cardiolipin antibodies Correct answer.
  3. Positive anti-double-stranded DNA
  4. Positive anti-Ro antibody

Explanation

Antiphospholipid syndrome is defined by persistent antiphospholipid antibodies, including lupus anticoagulant and anti-cardiolipin, together with thrombosis or pregnancy morbidity. A prolonged aPTT that does not correct is a clue to lupus anticoagulant.

Question 45Clinical assessment, diagnosis, and differential diagnosis

A 45-year-old man has painful red eyes, urethritis, and a knee effusion. Which feature most supports a diagnosis of reactive arthritis?

  1. High-titre rheumatoid factor
  2. Bilateral malar rash
  3. Positive anti-nuclear antibody
  4. Recent non-gonococcal urethritis Correct answer.

Explanation

Reactive arthritis follows a genitourinary or gastrointestinal infection and classically presents with arthritis, urethritis, and conjunctivitis. Rheumatoid factor and anti-nuclear antibodies are typically negative.

Question 46Clinical assessment, diagnosis, and differential diagnosis

A 65-year-old woman has a new headache, scalp tenderness, and visual blurring. Which investigation is most appropriate to confirm giant cell arteritis?

  1. Anti-nuclear antibody
  2. Temporal artery biopsy Correct answer.
  3. Serum urate
  4. Rheumatoid factor

Explanation

Temporal artery biopsy remains the reference standard for confirming giant cell arteritis and should be arranged promptly. Treatment with glucocorticoids should not be delayed while awaiting the biopsy.

Question 47Clinical assessment, diagnosis, and differential diagnosis

A 30-year-old woman has symmetrical hand arthritis, alopecia, and a photosensitive rash. Which feature most strongly suggests SLE rather than rheumatoid arthritis?

  1. Erosive changes on hand radiographs
  2. Mucocutaneous involvement with anti-dsDNA Correct answer.
  3. Morning stiffness
  4. Positive rheumatoid factor

Explanation

Mucocutaneous features such as photosensitivity, alopecia, and oral ulcers together with anti-dsDNA are characteristic of SLE. Rheumatoid arthritis produces erosive synovitis without these cutaneous features.

Question 48Clinical assessment, diagnosis, and differential diagnosis

A 20-year-old man has acute painful swelling of the knee with a preceding sore throat. Anti-streptolysin O titre is raised. Which feature most supports acute rheumatic fever over septic arthritis?

  1. Migratory polyarthritis with carditis Correct answer.
  2. Positive blood cultures
  3. Gram-positive cocci in synovial fluid
  4. Marked synovial neutrophilia

Explanation

Acute rheumatic fever produces a migratory polyarthritis together with carditis after streptococcal pharyngitis. Septic arthritis instead yields organisms in synovial fluid and blood cultures.

Question 49Clinical assessment, diagnosis, and differential diagnosis

A 55-year-old man has chronic low back pain, morning stiffness, and bilateral sacroiliitis on imaging. Which feature most supports ankylosing spondylitis over mechanical back pain?

  1. Improvement with rest
  2. Normal inflammatory markers
  3. Pain radiating below the knee
  4. Inflammatory back pain with HLA-B27 positivity Correct answer.

Explanation

Inflammatory back pain that improves with activity and is accompanied by HLA-B27 and sacroiliitis supports axial spondyloarthritis. Mechanical back pain typically worsens with activity and lacks these features.

Question 50Clinical assessment, diagnosis, and differential diagnosis

A 40-year-old woman has proximal muscle weakness, a raised creatine kinase, and a normal skin examination. Which finding would most favour inclusion body myositis over polymyositis?

  1. Raised aldolase
  2. Positive anti-Jo-1 antibody
  3. Symmetrical proximal weakness
  4. Finger flexor weakness with quadriceps atrophy Correct answer.

Explanation

Inclusion body myositis characteristically affects the finger flexors and quadriceps with asymmetric distal and proximal weakness. Polymyositis produces symmetrical proximal weakness and may be associated with anti-Jo-1.