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50 Marks

1. A 40-year-old man comes to the office because of pain in his right knee
the past three days. The patient denies fever, vomiting, or dysuria. He
no history of trauma but admits to prior episodes of pain, especially
binge drinking. It usually occurs in the knee, ankle, or big toe and is
relieved somewhat by ibuprofen. He takes no medications and has no
allergies. He has a 25-pack-year smoking history and drinks about half
case of beer when hanging out with friends. His mother developed the
same symptoms at the age of 50. On examination, the right knee
swollen, red, and tender to palpation and has a limited range of
You decide to aspirate the knee joint.
Which of the following is most consistent with his diagnosis?
A) Positively birefringent, rhomboid-shaped crystals and 200 white
B) Bipyramidal crystals and 2,000 white cells/mL
C) Negatively birefringent, rhomboid-shaped crystals and 20,000 white
D) Cloudy and watery fluid with weakly positive birefringent crystals
and 20,000 white cells/L
E) Watery fluid with strongly negative birefringent crystals and 20,000
white cells/l
2. A 63 year old male presents to his GP with an acutely painful right toe,
following a drinking binge. On examination the toe is swollen,
erythematous with red and shiny overlying skin, and is extremely
tender to touch. The patient is currently taking furosemide, atenolol,

ramipril and aspirin.

Which of the following would be the most useful investigation to obtain
a diagnosis?
a) Serum uric acid
b) Plain radiograph
c) Synovial fluid aspirate
d) Full blood count
e) Blood cultures
3. A 39-year-old Polish man comes to the clinic for painful calves after
walking long distances and for discoloration of the fingers with changes
in temperature. He says his symptoms started two months ago, and he
gets no relief from the ibuprofen. He has previously been healthy. He
currently smokes a pack a day and drinks socially. He has no history of
drug abuse. On physical examination, his blood pressure is 140/90 mm
Hg, heart rate is 68/min, and he is afebrile. Examination of the hands
reveals distal digital ischemia and trophic changes in the nails of both
hands. Radial pulses are absent bilaterally, but all other pulses are
present. His right calf shows evidence of a superficial thrombophlebitis.
Laboratory studies show: white cell count 9,600/mm3, hematocrit
38.6%, MCV 89 m3, ESR 40 mm/h, and C-ANCA as negative. The
rheumatoid factor and ANA are negative.
Which of the following should be done next for this patient?
A. Heparin
B. Prednisone
C. Arterial bypass
D. Cyclophosphamide
E. Abstention from tobacco
4. 41-year-old woman suffers from dysphagia, crops of red skin spots,
and painful blue hands when exposed to cold. She is started on
monotherapy for latent tuberculosis but immediately develops a malar
Which of the following antibody tests could be positive in this woman?
A. Anti-scl 70
B. Anti-centromere
C. Anti-microsomal

D. Anti-smooth muscle
E. Anti-Ro
5. A 32 year old white woman presents to the emergency department
with sudden onset of a painful right knee. The pain is associated with
fever, chills and immobility of the knee. She is sexually active. A knee
joint aspiration reveals the following:
Turbid, yellowish-red fluid. WBC=105,000 with N90 L10, Glucose=10
mg/dL, Protein=150 mg/dL. A gram stain of the fluid reveals the
You would give this patient:
A. A 10 day course of Doxycycline
B. A course of IV Ceftriaxone with an optional 10 day course of
C. A 10 day course of Bactrim
D. Oral NSAID's and a heating pack
E. Intraarticular steroid shot with p.o. steroids and or colchicines
6. A 70-year-old man complains of fever and pain in his left knee. Several
days previously, he suffered an abrasion of his knee while working in
his garage.
The knee is red, warm, and swollen. An arthocentesis is performed,
shows 200,000 leukocytes/L and a glucose of 20 mg/dL. No crystals
are noted.
Which of the following is the most important next step?
A. Gram stain and culture of joint fluid
B. Urethral culture
C. Uric acid level
D. Antinuclear antibody
E. Antineutrophil cytoplasmic antibody
7. A 57-year-old man comes to the emergency department because of
excruciating pain in his right big toe. He describes the pain as so
severe that it woke him from a deep sleep. He has no chronic medical
conditions, does not take any medications, and denies any similar
episodes in the past. He admits to a few drinking binges over the
past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is
130/90 mm Hg, and pulse is 80/min. Examination shows an

erythematous, warm, swollen, and exquisitely tender right great toe.

The skin overlying the first metatarsophalangeal joint is dark red,
tense, and shiny. Synovial fluid analysis reveals negatively birefringent,
needle-shaped crystals within polymorphonuclear leukocytes (PMNs).
Laboratory studies show:
Uric acid..15 mg/dL
Calcium.9 mg/dL
Which of the following is the most appropriate pharmacotherapy?
A. Allopurinol
B. Ceftriaxone
C. Indomethacin
D. Probenecid
E. Sulfinpyrazone
8. A 45-year-old man has noted pain in his right knee for several years.
There is no joint swelling. As he moves about during the day, the pain
The underlying disease process is probably which of the following?
A. Osteoarthritis
B. Osteochondroma
C. Osteomalacia
D. Osteopetrosis
E. Osteoporosis
9. A 35-year old woman who was two months postpartum presented with
a four-week history of joint pain, skin rash and fever. The ESR was 40
mm / hour.
What is the most likely diagnosis?
A. Reactive arthritis
B. Rheumatoid arthritis
C. Sarcoidosis
D. Systemic lupus erythematosus
E. Viral arthritis
Which of the following statements regarding systemic lupus
erythematosis (SLE) is correct?

A. When disease is active the levels of complements C3 and C4 are

B. When evidence of mild nephritis is present, a renal biopsy is
C. There is a female preponderance of 8:1.
D. First manifestation of the disease may be idiopathic
thrombocytopenia purpura.
E. There is neurological involvement in about 10% of cases.
An otherwise healthy middle-aged man with no prior medical
history has had increasing back pain and right hip pain for the past 10
years. The pain is worse at the end of the day. He has bony
enlargement of the distal interphalangeal joints. A radiograph of the
spine reveals the presence of prominent osteophytes involving the
vertebral bodies. There is sclerosis with narrowing of the joint space at
the right acetabulum seen on a radiograph of the pelvis.
Which of the following pathologic processes is most likely to be taking
place in this patient?
A. Gout
B. Lyme disease
C. Osteoarthritis
D. Osteomyelitis
E. Rheumatoid arthritis
A 63-year-old male presents with severe pain in his left wrist. The
wrist is swollen, tender to touch and red. Aspiration reveals fine needle
shaped yellow birenfringent crystals.
Which treatment is unlikely to help this patient?
A. Colchicine
B. Indomethacin
C. Allopurinol
D. Corticosteroids
E. All of the Above
A 22 year old woman with known hereditary angioneurotic
oedema (HAO) presents with a recurrent fever, arthralgia and a rash on
the face and the upper chest. Despite treatment for her HAO, she has
always been troubled by recurrent attacks and has required adrenaline
on several occasions. Her C4 levels have been persistently reduced

secondary to HAO.
What is the most likely cause for her current symptoms?

Drug rash
Psoriasis with arthropathy
Systemic Lupus Erythematosus
Viral illness


Only Aspirin can:


Reduce fever
Irreversibly inhibit its target enzymes
C .Prevent episodes of gouty arthritis with long term use
Reduce the risk of colon cancer
Selectively inhibit CoX-2 enzymes

Indomethacine is preferred over Colchicine for Acute Attack of
Gout because it is:

Less likely to cause Gastrointestinal bleeding

Less likely to cause Diarrhea
Less likely to cause Acute Renal Failure
More likely to reduce inflammation
More likely to prevent further Acuter attacks

A 35-year-old man asks for advice regarding seasonal eye itching
and runny nose. Recurrent conjunctivitis in this patient is most likely
caused by which of the following mechanisms of disease?

Bacterial infection
Chemical toxicity
Viral infection

An 8-year-old boy presents with periorbital edema and throbbing
headaches. His parents report that the boy had a strep throat 2
weeks ago. Urinalysis shows 3+ hematuria. A renal biopsy shows
hypercellular glomeruli, and electron microscopic examination of
glomeruli discloses subepithelial humps. Which of the following best
explains the pathogenesis of glomerulonephritis in this patient?
A. Antineutrophil cytoplasmic autoantibodies


Deposition of circulating immune complexes

Directly cytotoxic IgG and IgM antibodies
IgE-mediated mast cell degranulation
T cellmediated delayed hypersensitivity reaction.

40-year-old man complains of having yellow skin and sclerae,
abdominal tenderness, and dark urine. Physical examination reveals
jaundice and mild hepatomegaly. Laboratory studies demonstrate
elevated serum bilirubin (3.1 mg/dL), decreased serum albumin (2.5
g/dL), and prolonged prothrombin time (17 seconds). Serologic tests
reveal antibodies to hepatitis B core antigen (IgG anti-HBcAg). The
serum is also positive for HBsAg and HBeAg.
Which of the following glycoproteins serves as the principal cell surface
receptor for viral antigens on B lymphocytes in this patient?

HLA class I molecules
HLA class II molecules
Membrane immunoglobulin

What glycoprotein on virally infected hepatocytes provides a
target for cell-mediated cytotoxicity in the patient described in
Question 18?

Class I HLA molecules
Class II HLA molecules

A 21-year-old woman presents with a 3-month history of malaise,
joint pain, weight loss, and sporadic fever. The patient appears
agitated. Her temperature is 38C (101F). Other physical findings
include malar rash, erythematous pink plaques with telangiectatic
vessels, oral ulcers, and nonblanching purpuric papules on her legs.
Laboratory studies show elevated levels of blood urea nitrogen and
creatinine. Antibodies directed to which of the following antigens would
be expected in the serum of this patient?

C-ANCA (anti-proteinase-3)
Double-stranded DNA
P-ANCA (anti-myeloperoxidase)
Rheumatoid factor
Scl-70 (anti-topoisomerase I)

Serum levels of complement proteins may be reduced during the
active phase of disease in the patient described in Question 20 due to
which of the following mechanisms of disease?

Binding of complement to immune complexes

Decreased complement protein biosynthesis
Defective activation of the complement cascade
Increased urinary excretion of immunoglobulins
Stimulation of the acute phase response

A 45-year-old woman complains of severe headaches and
difficulty swallowing. Over the past 6 months, she has noticed small,
red lesions around her mouth as well as thickening of her skin. The
patient has stone facies on physical examination. Which of the
following antigens is the most common and most specific target of
autoantibody in patients with this disease?

C-ANCA (anti-proteinase-3)
Double-stranded DNA
P-ANCA (anti-myeloperoxidase)
Scl-70 (anti-topoisomerase I)

During the physical examination of a 22-year-old man, a purified
protein derivative isolated from Mycobacterium tuberculosis is injected
into the skin. Three days later, the injection site appears raised and
indurated. Which of the following glycoproteins was directly involved in
antigen presentation during the initiation phase of delayed
hypersensitivity in this patient?\

Class I HLA molecules
Class II HLA molecules

A 54-year-old woman is involved in an automobile accident and
requires a blood transfusion. Five hours later, she becomes febrile and
has severe back pain. Laboratory studies show evidence of
intravascular hemolysis. It is discovered that type A Rh+ blood was
given by mistake to this type B Rh+ patient. Which of the following
best explains the development of intravascular hemolysis in this
A. Antibody-dependent cellular cytotoxicity
B. Antibody-mediated complement fi xation

C. Delayed-type hypersensitivity
D. Immune complex disease
Immediate hypersensitivity
A 52-year-old woman with a history of systemic hypertension
and chronic renal failure undergoes kidney transplantation, but the
graft fails to produce urine. A renal biopsy is diagnosed as hyperacute
transplant rejection. Graft rejection in this patient is caused primarily
by which of the following mediators of immunity and inflammation?
A. Cytotoxic T lymphocytes
B. Helper T lymphocytes
C. Mononuclear phagocytes
D. Natural killer cells
Preformed antibodies
A 31-year-old man with AIDS complains of difficulty swallowing.
Examination of his oral cavity demonstrates whitish membranes
covering much of his tongue and palate. Endoscopy also reveals
several whitish, ulcerated lesions in the esophagus. These pathologic
findings are fundamentally caused by loss of which of the following
immune cells in this patient?
A. B lymphocytes
B. Helper T lymphocytes
C. Killer T lymphocytes
D. Monocytes/macrophages
Natural killer (NK) cells
A 20-year-old woman with a history of asthma and allergies
undergoes skin testing to identify potential allergens in her
environment. A positive skin reaction to ragweed in this patient would
be mediated by which of the following classes of immunoglobulin?
A. IgA
B. IgD
C. IgE
D. IgG


A 53-year-old woman complains of progressive weight loss,
nervousness, and sweating (patient shown in the image). Physical
examination reveals tachycardia and exophthalmos. Her thyroid is
diffusely enlarged and warm on palpation. Serum levels of thyroidstimulating hormone (TSH) are low, and levels of thyroid hormones (T3
and T4) are markedly elevated. Which of the following mechanisms of

disease best explains the pathogenesis of this patients thyroid

A. Antibody-dependent cellular cytotoxicity
B. Cytopathic autoantibodies
C. Delayed-type hypersensitivity
D. Immediate hypersensitivity
Immune complex disease
A 20-year-old gardener presents to his family physician for
treatment of what he describes as poison ivy. The patients hands
and arms appear red and are covered with oozing blisters and crusts.
Which of the following best describes the pathogenesis of these skin
A. Cytotoxic antibody production
B. Delayed-type hypersensitivity
C. Deposition of antigluten antibodies
D. Deposition of circulating immune complexes
IgE-mediated mast cell degranulation
A 50-year-old man complains of fever, weight loss, abdominal
pain, and bloody urine. Physical examination reveals red-purple
discoloration of the skin. Serologic findings are inconclusive, but a
positive P-ANCA test suggests an autoimmune disease. Biopsy of
lesional skin discloses fibrinoid necrosis of a small muscular artery
(shown in the image). Which of the following immune responses best
explains the pathogenesis of inflammation and necrotizing vasculitis in
this patient?
A. Antibody-dependent cellular cytotoxicity
B. Cytopathic autoantibodies
C. Delayed-type hypersensitivity
D. Immediate hypersensitivity
Immune complex disease
You have been treating a 42-year-old woman with mild
rheumatoid arthritis for 4 years with ibuprofen. She has returned to
your office and complains that the pain in her wrists is worse and 800
mg/day of ibuprofen does not give relief. You elect to try etanercept for
her RA and send her off for a chest X-Ray. You caution your patient that
a serious adverse effect of the drug is:
A. GI bleeding
B. Hallucinations
C. Infections

D. Anemia
Excessive tear production
Following a kidney transplant, a 24-year-old male patient is
placed on cyclosporine but after 48 hours complains of serious nausea
and diarrhea and has a sudden increase in transaminases. You switch
him to tacrolimus but the nausea persists and he complains of getting
dizzy and has dyspnea. Which of the following immunosuppressive
agents would be an alternate drug in this scenario?
A. Mycophenolate mofetil
B. Etanercept
C. Tocilizumab
D. Colchicine
A 70-year-old man suffers a myocardial infarction (MI). He is
admitted to the cardiac intensive care unit and is given aspirin and a blocker. A catheterization procedure is scheduled. The patients wife,
who is a pharmacy technician, wants to know why the patient is being
given aspirin and not another nonsteroidal anti-inflammatory drug
(NSAID). What is the best answer to this question?
A. Aspirin inhibits both COX-1 and COX-2
B. Aspirin irreversibly binds to COX-1 and COX-2
C. Aspirin is a weak acid
D. Aspirin is excreted by the kidneys
Aspirin has much greater antithrombotic activity