Raynaund's phenomenon [vasospasm of small vessels causing color changes in fingers and toes] is frequently seen in SLE. It occurs in up to 20-30% of SLE patients and is often associated with other autoimmune diseases.

Incorrect Options-

• Joint deformity- More commonly associated with RA.
• Lung cavitations- More likely associated with TB, fungal infections, or vasculitis.
• Cystoid body in the retina- Linked to metabolic disorders like Tay-Sachs disease or lysosomal storage disease.

NSAIDs are typically the first-line management for mild pain and inflammation in rheumatoid arthritis [RA]. They help in reducing pain, stiffness, and mild joint swelling, making them appropriate when the disease is not causing severe joint damage.

Incorrect Options-

• Injection steroid- Used in more severe inflammation or localized joint swelling.
• Positive pressure ventilation- Used in respiratory issues.
• Negative pressure ventilation- Not relevant

Pseudo-gout is caused by the accumulation of calcium pyrophosphate crystals in the joints. These crystals deposit in the cartilage, leading to inflammation and pain which mimics gout but without uric acid involvement. Pseudo-gout often affects the knees and wrists.

Incorrect Options-

• Phosphate- Involved in kidney stones, not in gout and pseudo-gout.
• Fluoride- Accumulates in bones and teeth, but does not commonly cause joint inflammation.
• Calcium-  Involved in the formation of crystals in pseudo-gout but only when in combination with pyrophosphate.

Henoch-Schonlein-purpura [HSP] is a type of vasculitis [inflammation of blood vessels] that commonly affects children but can also occur in adults.

The classic features include-

Abdominal pain [often colicky with, nausea, vomititng, sometimes blood with mucus in stool],Joint pain [particularly ankles and knees], A purpuric rash [often appearing on thighs and buttocks]. 

Incorrect Options-

• Meningococcal infections- Can cause purpuric rash, severe fever, neck stifness, altered mental statuse, and septic shock.
• Rocky mountain spooted fever- Rash [starting or wrists and ankle], muscle ache, and history of tick exposure.
• SLE- Can cause joint apin and rash, it typically presents with butterfly- shaped rash.

Thiazide diuretics→ reduced renal excretion and increased reabsorption of uric acid→ hyperuricemia→urate crystal deposition⇒ Gout.

Temporal arteritis is a condition where the blood vessels in the head become inflamed. This can cause headaches, sudden vision loss, and high levels of inflammation markers like CRP and ESR. Early diagnosis is critical to prevent permanent vision loss.

Temporal arteritis, also known as giant cell arteritis, is a serious condition involving inflammation of the blood vessels, primarily in the temples. The correct treatment is corticosteroids which are essential for managing this condition. These medications rapidly reduce inflammation and prevent complications such as vision loss, which can occur if the condition is left untreated.

Incorrect Options-

• NSAIDs [eg., ibuprofen] may alleviate pain but are not effective in controlling the underlying inflammation or preventing complications.
• Beta-blockers are used for managing conditions related to heart or hypertension.
• Methotrexate can be used as an adjunct in patients who cannot tolerate steroids or need a steroid-sparing agent but is not a primary treatment.

Vitamin D deficiency is an external [exogenous] factor because it's related to diet and sun exposure. Without enough vitamin D, the body can't absorb calcium properly, leading to weaker bones and osteoporosis.

• Incorrect Options-
• Age- internal process
• Vitamin C deficiency- not a main cause of osteoporosis.
• Sex- internal biological factor

Physiotherapy is the best initial management as the patient has a known case of cervical spondylitis and is now suffering from ulnar nerve symptoms. It helps restore strength, improve flexibility, and manage pain.

EMG confirms ulnar nerve compression, causing paresis and muscle atrophy. Surgery to decompress the nerve is the definitive treatment to relieve pressure and restore function. 

Incorrect Option-

• Steroids give temporary relief but don't fix compression.
• A CT scan is not needed for the decision.
• Radial nerve compression will not manifest the following features.

Polymyalgia rheumatica causes pain and stiffness, especially in the shoulders, neck, hips, and thighs but muscle strength remains the same.

Incorrect Options-

• Muscle weakness isn't a feature.
• It doesn't affect distal muscles.

Heberden's nodes are bony swelling that forms on the distal interphalangeal [DIP] joints, a common feature of osteoarthritis.

Incorrect Options-

• Bouchard's nodes -occur on proximal interphalangeal [PIP] joints.
• Cellulitis- This is a bacterial skin infection.
• Lymphangitis- Its infection of lymphatic vessels.

The history suggests osteoarthritis which can present as Heberden’s nodes or Bouchard’s nodes. The names of the nodes differ according to the location Heberden’s nodes are at the DIPJ while Bouchard’s nodes are at the PIPJ.

Reference: Saunders’pocket essentials of Clinical medicine (ParveenKUMAR)

Boutonniere deformity is when the middle joint [PIP] is flexed while the [DIP] is hyperextended.

The presentation of a red, swollen, tender big toe along with inflammation spreading to the foot and leg and fever suggests cellulitis, which is a bacterial skin infection.

Causative organism- Streptococcus pyogenes [group A Streptococcus], Staphylococcus aureus.

This patient likely has Sjogren's syndrome, an autoimmune condition which is characterized by dryness of eyes, mouth, and skin.

The treatment primarily focuses on symptom relief-

• Eye drops artificial tears for dry eyes.
• Saliva replacements or sialogogues to manage dry mouth.

Incorrect Option-

• Physostigmine- Used in myasthenia gravis.
• NSAIDs- don't address dryness.
• Plenty of fluid- helpful but not sufficient for severe dryness.

This presentation suggests giant cell arteritis, especially with the symptoms of unilateral headache and systemic symptoms. Chronic pain in the shoulders and limbs also indicates polymyalgia rheumatica. Both conditions are treated effectively with corticosteroids, which reduce inflammation and prevent complications like vision loss.

Recurrent migratory arthritis, mouth ulcers, and abdominal pain strongly suggest IBD, such as Crohn's disease or ulcerative colitis.

Incorrect Options-

• Gout- Acute arthritis in one joint not migratory.
• RF-  Unlikely without a history of streptococcus infection.

NSAIDs [ibuprofen, naproxen] are the first-line treatment for acute gout attacks. They help reduce inflammation and relieve pain quickly.

Incorrect options-

• Allopurinol- This is used for long-term management, not acute attack.
• Paracetamol- Not as effective as NSAIDs.
• Gold salt- Not used in modern treatment, and is reserved for other conditions like RA.

Indomethacin [an NSAID] is the first-line management for acute gouty arthritis, as it effectively reduces inflammation and pain during flare-ups

Gold salt is the least relevant option and is not used in managing gout, whether acute or chronic.

A temporal artery biopsy is the gold standard for diagnosing Giant Cell Arteritis [GCA]. It allows direct examination of the artery to look for inflammation, which helps in confirming the diagnosis.

Biopsy findings- mononuclear cell infiltration, multinucleated giant cells, a fragment of the internal elastic lamina, and narrowing of the lumen.

Incorrect Options-

• Biopsy from bone marrow is used for blood disorders.
• Lumbar puncture is used for suspected neurological conditions like meningitis.
• CBC may show elevated levels but can't confirm GCA.
•  

The most effective way to prevent joint disability in rheumatoid arthritis is early and consistent treatment with DMARDs, like methotrexate. These drugs slow the progression of the disease, reduce inflammation, and prevent joint damage over time.

Incorrect Options-

• Cold application temporarily reduces stiffness and pain but doesn't stop damage to joints.
• Heat packs may relieve symptoms but do not prevent joint disability.
• None of the above is incorrect

Age is a key factor in the development of osteoporosis. As we age, bone density naturally decreases, making bones more fragile and prone to fractures.

Aspirin is generally the least likely to cause significant side effects among the options. It is commonly used for managing pain and inflammation in SLE and is well tolerated in low doses.

• Yellow opaque fluid with variable viscosity indicated infection.
• A WBC count of 1,50,000 per cubic millimeter points toward an infectious process.
• 80% neutrophils are indicative of an acute inflammatory response.
• Pure mucin clot suggests that the infection has caused significant joint damage.

Steroids [such as prednisone] are commonly used to manage inflammation and reduce symptoms in JIA, especially during flare-ups.

Incorrect Options-

• Aspirin- It was used in the past but is generally avoided now in children due to the increased risk of Reye's syndrome.
• Penicillamine- Used in RA.
• Hydroxychloroquine- Primarily used for lupus.

Gout is the most likely diagnosis, especially when it affects the first metatarsophalangeal joint, which is the classic site for podagra [ a term specifically used for gout affecting the big toe].

In RA chronic inflammation leads to destruction of articular cartilage and erosion of underlying bone, causing joint deformity and disability over time.

Incorrect Option-

•  M: F is 1:3
•  Nodules are present in elbows & lungs
•  it doesn't affect lumbar spines

• Pseudogout: Deposition of Calcium Pyrophosphates Dehydrate crystal, +ve birefringent, rhomboid shape, (CACO3)
• Gout: Deposition of Monosodium Urate Monohydrate, –ve of birefringent, needle shape.

Polymyalgia rheumatica is a syndrome with pain or stiffness of muscles, usually in the neck, shoulders, and hips, caused by an inflammatory condition of blood vessels. Predisposes to temporal arteritis. Usually treated with oral Prednisone.

Lupus nephritis is a common and serious complication of SLE characterized by kidney inflammation, which can result in proteinuria, edema, and hypertension.

Disease Modifying Anti-Rheumatic Drugs (DMARDs): Chloroquine & Hydroxychloroquine, Cyclosporin A, D-penicillamine, Gold salts, Infliximab, Methotrexate (MTX), Sulfasalazine (SSZ).

• High risk:

1. Procainamide (antiarrhythmic), 2. Hydralazine (antihypertensive)

• Moderate to low risk:

1. Infliximab (anti-TNF-), 2. Isoniazid (antibiotic), 3. Minocycline (antibiotic), 4. Pyrazinamide (antibiotic), 5. Quinidine (antiarrhythmic), 6. D-Penicillamine (anti-inflammatory), 7. Carbamazepine (anticonvulsant), 8. Oxcarbazepine (anticonvulsant), 9. Phenytoin (anticonvulsant), 10. Propafenone (antiarrhythmic).

Renal involvement is one of the most significant factors that influence a patient's prognosis with SLE. Kidney damage particularly lupus nephritis, can lead to severe complications.

Physical therapy is the first-line management for spinal stenosis because it helps improve flexibility, strength, and posture, which can relieve pain and improve mobility. 

Spinal stenosis leads to the narrowing of the spinal canal, leading to nerve compression. This often results in back pain that is relieved by walking or ambulation as the posture of a spinal canal opens up due to posture change.

Ginger has anti-inflammatory properties that can help reduce pain and stiffness in people with osteoarthritis. It can be taken in supplement form or used fresh in cooking.

In rheumatoid arthritis the immune system mistakenly attacks the joints, causing inflammation. Anti-inflammatory cytokines like TNF-alpha and IL -1 play a key role by promoting inflammation, which damages the synovial membrane. Over time this leads to joint destruction, swelling, and pain.

According to ISG criteria, used to define the illness. At least 3 episodes of oral ulceration must occur in 12 months. A physician or the patient must observe them and maybe herpetiform or aphthous.

 At least 2 of the following must occur-

1) recurrent, painful genital ulcers that heal with scarring; 2) ophthalmic lesions, including anterior or posterior uveitis, hypopyon, or retinal vasculitis; 3) skin lesions,  4) pathergy, which is defined as a sterile erythematous papule larger than 2 mm in size appearing 48 hours after the skin pricks with a sharp, sterile needle (a dull needle may be used as a control). 5) Neurologic manifestations, Headache, Meningoencephalitis, Seizures, Cranial nerve abnormalities 6) Vasculopathy-DVT, thrombophlebitis, Noninflammatory vascular lesions including arterial and venous occlusions, varices, and aneurysms 7) Arthritis, 8) Gastrointestinal manifestations: Symptoms suggestive of IBD, Diarrhea or gastrointestinal bleeding, ulcerative lesions, Flatulence, Abdominal pain, Vomiting, and Dysphagia, 9) Other manifestations: Cardiac lesions include arrhythmias, pericarditis, vasculitis of the coronary arteries, endomyocardial fibrosis, granulomas in the endocardium, Epididymitis, Glomerulonephritis, Lymphadenopathy, Myositis, Polychondritis.

The patient's symptoms are suggestive of polymyalgia rheumatica, a condition often seen in older adults. PMR is characterized by inflammation, and CRP is a blood test that helps measure the level of inflammation in the body.

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but mainly joints. It involves an inflammation of the capsule around the joints (synovium). Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Gentle movements may relieve symptoms in the early stages of the disease.

Gout (also known as Podagra when it involves the big toe) is a medical condition characterized by recurrent attacks of acute inflammatory arthritis — a red, tender, hot, swollen joint. The metatarsalphalangeal joint at the base of the big toe is the most commonly affected (50% of cases). However, it may also present as tophi, kidney stones, or urate nephropathy.

• Mechanism - A disorder of purine metabolism, that occurs when its final metabolite, uric acid crystallizes in the form of monosodium urate, precipitating in joints, on tendons, and in the surrounding tissues.

The presence of acute swelling and edema in the lower limb could indicate a venous problem such as DVT, or venous insufficiency. A lumbar venogram is used to visualize the veins and provides an assessment for abnormalities like thrombosis or venous obstruction.

The symptoms are suggestive of an acute inflammatory condition like gout or pseudo-gout, both of which can cause acute joint swelling. ESR is a general marker of inflammation and can help identify inflammatory arthritis or systemic conditions causing joint swelling.

Giant-cell arteritis (temporal arteritis): inflammatory disease of blood vessels most commonly involving large and medium arteries of the head, predominately the branches of the external carotid artery. It is a form of vasculitis.

• Treatment:
• Corticosteroids, typically high-dose prednisone (40–60 mg), must be started as soon as the diagnosis is suspected (even before the diagnosis is confirmed by biopsy) to prevent irreversible blindness secondary to ophthalmic artery occlusion.
• Steroids do not prevent the diagnosis from later being confirmed by biopsy, although certain changes in the histology may be observed towards the end of the first week of treatment and are more difficult to identify after a couple of months.
• The dose of prednisone is lowered after 2–4 weeks and slowly tapered over 9–12 months. Oral steroids are at least as effective as intravenous steroids, except in the treatment of acute visual loss where intravenous steroids appear to be better.

Behçet's disease: rare immune-mediated systemic vasculitis, described as a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis. As a systemic disease, it can also involve visceral organs and joints.

One of the side effects of thiazides is Hyperuricemia which predisposes to Gout.

Neisseria gonorrhoeae is the causative agent of gonococcal arthritis, and the treatment of choice is ceftriaxone, a broad-spectrum third-generation cephalosporin.

• This inflammatory joint disease is characterized by persistent – ve tests for RF.
• It develops in men before the age of 40 with HLA B27.
• It causes synovial and extra-synovial inflammation involving the capsule, periarticular periosteum, cartilage, and subchondral bone.
• Large central joints are particularly involved such as (sacroiliac, symphysis pubis & intervertebral joints). Resolution of inflammation leads to extensive fibrosis and joint fusion, but no subcutaneous nodules since it's not a seropositive disease.

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

Allopurinol is used to treat Hyperuricemia along with its complications “chronic gout & kidney stones”.

Arthrocentesis is the process of widrawing fluid from a joint using a needle. In case of a painful knee swelling with a positive ballotment test,it is the next best step to confirm diagnosis [eg- septic artritis ,gout] etc., and obtain fluid for analysis.

Staphylococcus aureus is the most common cause of septic artritis in adults and children. It is a gram-positive bacterium that can spread through the blood stream or direct inoculation [eg., surgery,injury]. It typically presents with fever, joint pain, and limited movement.

• Young female, with a joint problem, high ESR, Proteinuria, and a positive VDRL (which is false positive in SLE).
• A blood culture is not needed (the patient is afebrile, and inflammatory features in the joint aren’t so intense.
• A.S.O. titer is also not top on your list although post streptococcus. Glomerulonephritis is possible but not top on the list since it is more common in the pediatric age group.

So the answer would be double-stranded DNA which is one of the serology criteria in SLE.

Ulnar nerve entrapment, often occuring at the elbow [cubital tunnel syndrome], involves compression of the ulnar nerve. Cubital fossa release [surgical decompresssion] is the recommended intervention for severe or persistent cases when conservative treatments like- rest, splinting, or physical therapy fail.

In Cushing's syndrome, high cortisol levels weaken bones by increasing bone loss and reducing bone formation. Combined with age-related bone thinning, this makes fractures from minor falls more likely.

Incorrect Options-

• Hyperparathyroidim can cause osteoporosis but isn't directly linked with Cushing's syndrome.
• Osteomyelitis is a bone infection which presents as pain, swelling and fever.
• Osteomalacia presents as softening of bones due to vitamin D defciency.

Loss of extensor tendon continuity at the DIPJ causes the joint to rest in an abnormally flexed position, the classic mechanism of injury in a finger held rigidly in extension or nearly full extension.

Felty’s syndrome: triad of RA, neutropenia, and splenomegaly.

Steroids are the most preferable treatment for giant cell arteritis. They quicly reduce inflammation and prevent serious complications like vision loss, which is a major concern in GCA.

Incorrect Options-

• Insulin is used to manage diabetes, not inflammation.
• Antibiotics are used to treat infection, and GCA is not an infection.
• Anti-inflammatory drugs are useful in minor inflammation but not strong enough for GCA.

Low resistance exercises, like light weight training with more repetitions, improve muscle endurance and mainatin bone strength. This helps combat age-related muscle loss [sarcopenia] and osteoporosis.

This initial treatment helps in reducing swelling and pain in acute muscle injuries.

Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the deep surface of the deltoid muscle.

• Subacromial bursitis often presents with a constellation of symptoms called impingement syndrome. Pain along the front and side of the shoulder is the most common symptom and may cause weakness and stiffness. If the pain resolves and weakness persists other causes should be evaluated such as a tear of the rotator cuff or a neurological problem arising from the neck or entrapment of the suprascapular nerve. The onset of pain may be sudden or gradual and may or may not be related to trauma. Impingement may be brought on by sports activities, such as overhead throwing sports and swimming, or overhead work such as painting, carpentry, or plumbing. Activities that involve repetitive overhead activity, or directly in front, may cause shoulder pain. Direct upward pressure on the shoulder, such as leaning on an elbow may increase pain. Night-time pain, especially sleeping on the affected shoulder, is often reported.
• Localized redness or swelling are less common and suggest an infected subacromial bursa. The patient actively abducts the arm and a painful arc occurs between 80° and 120°. Shoulder arthritis can be one of three types of arthritis in the glenohumeral joint of the shoulder The main symptom of shoulder arthritis is pain; this is due to the grinding of the bones against each other because of the lack of cartilage. Pain usually occurs in the front of the shoulder and is worse with motion.

People with shoulder arthritis will also experience moderate to severe weakness, stiffness developing over many years, and the inability to sleep on the affected shoulder. Diagnosis is simple; usually, the doctor can tell if you have shoulder arthritis by your symptoms, but he she will most likely also take an X-ray or MRI.

The needle-like crystals with negative birefringence confirm gout,  caused by uric acid buildup. Indomethacin is the first-line treatment to quickly reduce pain and inflammation during an acute gout attack.

The symptoms described particularly pain and difficulty in raising the arm, are consistent with sub-acromial bursitis. This condition occurs when the bursa under the acromion process becomes inflamed, often due to repetitive overhead motions, as expected in a carpenter.

These symptoms point to myasthenia gravis, an autoimmune disease where antibodies attack acetylcholine receptors at the neuromuscular junction. This disrupts nerve signals to muscles leading to the above-mentioned symptoms.

The symptoms described are highly suggestive of gout, a condition caused by the primary component of uric acid crystals in the joints. Monosodium urate crystals are the primarycomponent of these deposits, leading to pain, swelling, and inflammation seen in gout attacks.

The symptoms described, particularly the excruciating pain in the big toe joint, are classic for gout. Gout is a type of inflammatory arthritis caused by the build-up of uric acid crystals, primarily sodium urate crystals, in the joints.

The combination of symptoms - acute painful swelling, redness, tenderness, and fever are highly suggestive of septic arthritis, which is an infection within a joint. In this case, the first metatarsophalangeal joint is affected.

The anterior surface of the wrist is the location of the median nerve, which is crucial for thumb movement and sensation. A deep laceration in this area can injure the medican nerve leading to a condition called '' ape hand deformity''. In this condition, the patient loses the ability to oppose the thumb to other fingers, making tasks like picking up small objects difficult.

Median nerve injury leads to the inability to oppose the thumb to other fingers.

Acute rheumatic fever is a complication of respiratory infections. Post-streptococcal glomerulonephritis is a complication of either strep throat or streptococcal skin infection.

The diagnosis of Rheumatic fever can be made when two of the major Modified Jones criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection: elevated or rising Antistreptolysin ‘ASO’ titer or DNAase.

Methotrexate, corticosteroid, and hydroxychloroquin have comparatively more sideeffect.

• Primary prevention for preventing initial infection with group A streptococcus] is a short-term term typically 10 days of antibiotics.
• Secondary prevention [preventing recurrent rheumatic fever, usually 5 years or 10 years depending on the presence of carditis.

The most likely diagnosis for an elderly patient presenting with chronic knee pain bilaterally, which increases with activity and decreases with rest, is osteoarthritis.

OA is a degenerative joint disease that commonly affects weight-bearing joints like the hips.

The pain pattern described is typical of OA - it tends to worsen with activity and improve with rest, and can also cause morning stiffness.

OA  is a degenerative joint disease that commonly affects the weight-bearing joints like the knee. Bilateral knee involvement and normal ESR are consistent with OA.

• Quadriceps muscle strengthening helps to improve knee stability and reduce pain.
• It is a non-pharmacological, conservative approach that can be started early in the disease course.

• Walking is a low-impact exercise that helps improve cardiovascular health, increase bone density, and strengthen muscles.
• Weight exercise is a low resistance high repetition weight training that is beneficial for building muscle strength and maintaining bone health.

• Gram-negative diplococci is a characterstic feature of Neisseria species.
• Gonorrhea is a sexually transmitted infection that can cause arthritis, particularly in young adults.
• A history of international travel increases the likelihood of exposure to Neisseria gonorrhea.

• AS is a chronic inflammatory disease that primarily affects the spine, but can also involve other organs.
• The triad of heart block, uveitis, and sacroiliitis is known as ''ocular-spinal-cardiac syndrome'' and is a classic manifestation of AS.

Reiter's arthritis: a characteristic triad of symptoms: inflammatory arthritis of large joints, inflammation of the eyes in the form of conjunctivitis or uveitis, and urethritis in men or cervicitis in women.

In RA, the synovium, lining the joints becomes inflamed and produces excessive amounts of inflammatory substances including cytokines and enzymes that damage the cartilage and bone leading to permanent changes and dysfunction.

Pulmonary involvement in AS can lead to various lung complications, including upper lung fibrosis. This is due to chronic inflammation and scarring of lung tissue.

Allopurinol is a xanthine oxidase inhibitor that reduces uric acid production in the body. This helps to lower uric acid levels in the blood and prevent gout attacks.

• Photosensitivity, malar rash and, joint pain are common symptoms of SLR.
• RBCs in the urine indicate kidney involvement, a frequent complication of SLE, often referred to as lupus nephritis.

Explanation: RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction. MEDICATIONS: Disease-modifying antirheumatic drugs (DMARDs): These drugs are the first drugs usually tried in patients with RA. They are prescribed in addition to rest, strengthening exercises, and anti-inflammatory drugs.