SNAPP Questions Unit 4 Flashcards Preview

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Which of the following signs would be consistent with an actual arthritis diagnosis as opposed to periarticular pain?

Decreased range of motion
Pain is worse with active motion


Periarticular pain refers to pain arising from structures around the joint such as tendons or bursae. It can be distinguished from true arthritis by the lack of effusion, the presence of point tenderness over the area of inflammation, and joint pain made worse with active motion. There could be decreased range of motion and deformity in either case so neither A nor C is a good answer. Finally, pain worse with active motion is not consistent with arthritis and is more associated with periarticular pain so would not be sign used in diagnosing arthritis.


Staph Aureus is placed on a slide and incubated with a patient's serum. After washing, a fluorescently-labeled antibody is incubated with the samples. Some samples are fluorescent after a second wash; what is this assay proving the presence of?

Presence of staph aureus in the patient's serum
Patient antibody to staph aureus
Patient antibody to the fluorescently labeled antibody
Immune complexes of staph aureus and patient antibody

patient antibody to staph aureus

INDIRECT IMMUNOFLORESCENCE TELLS ABOUT PRESENCE OF ANTIBODY olliPlate known antigen/liliAdd patient serum/liliAdd a florescent antibody to the patient's antibody/li/ol


Which of the following is consistent with a positive synovial fluid analysis for rheumatoid arthritis?

>2000 WBC/ul
200-2000 WBC/ul, 25% neutrophils and type 1 fluid
Positive crystal exam
Elevated complement and serum glucose

>2000 WBC/ul

2000 WBC/ul with predominantly neutrophils. Complement and glucose levels are usually LOW in RA. B. would be correct for osteoarthritis: 200-2000 WBC/ul with 25% neutrophils (negative crystals and normal glucose)/p


Initial recognition of MSU crystals is done by:

B cells
T cells
Toll-like receptors


Toll like receptors 2 and 4 recognize MSU crystals. This triggers an innate immune response by activation of mast cells and monocytes via cytokines TNFa, IL6, IL8. The inflammatory response to MSU crystals depends on IgG binding to MSU crystals, subsequent activation of complement and neutrophil chemotaxis. /p Phagocytosis of MSU crystals by neutrophils causes neutrophil lysis and release of proteolytic enzymes into the extracellular space. This is part of why gouty attacks are self-limited in nature.


Abnormal pyrophosphate (PPi) metabolism is found in CPDD and osteoarthritis. Which of the following is true of PPi levels in the synovial fluid of CPDD and osteoarthritis?

PPi levels are elevated in both CPDD and osteoarthritis
PPi levels are decreased in both CPDD and osteoarthritis
PPi levels are decreased in CPDD and elevated in osteoarthritis
PPi levels are elevated in CPDD and decreased in osteoarthritis

PPi levels are elevated in both CPDD and osteoarthritis

Synovial PPi levels are elevated in both CPDD and osteoarthritis. The PPi then bind to the calcium forming CPDD crystals in the mid-zonal cartilage layers around the chondrocytes. Where as MSU crystals precipitate spontaneously in the synovial fluid, CPDD crystals are released into synovial fluids via shedding from the cartilage itself


What effect would inhibition of COX-1 have on hemostasis?

Increased binding of vWF to damaged endothelium
Decreased amounts of thromboxane A2
Increased release of alpha granules
Decreased binding of glycoprotein Ib to vWF

Decreased amounts of thromboxane A2

COX-1 converts arachidonic acid to prostaglandin H2, which in turn is converted to thromboxane A2 by thomboxane synthetase. Thromboxane A2, along with other agonists, is released, acting to amplify platelet activation.

A is not correct because vWF binds to endothelium before COX-1 is activated and regardless, this action would INCREASE platelet aggregation.

An increase in release of alpha granules would not be caused by COX-1 either and this would also INCREASE platelet aggregation.

Finally, even though D would lead to decreased platelet activation (like inhibition of COX-1), this happens before COX-1 activation, so inhibiting COX-1 would not affect this.


The major cell type found in the Pannus of RA is:

T cells and macrophages
Dendritic cells

T cells and macrophages

Major cells in a Pannus are MEMORY T CELLS and macrophages Minor cells in Pannus: Fibroblasts, plasma cells, endothelium, DCs /p Major cells in Synovial fluid of RA: neutrophils/p


What is unique about elite controllers?

They make effective antibodies for HIV
Their T cells are more diverse
Their T cells are more aggressive
Their T cells have more TCRs and thus rendered more effective at recognizing the antigen presented on the MHC

T cells are more diverse

HLA-B57 has been associated with resistance to HIV infection. These individuals produce a wider variety of CTL's targeted against HIV. Elite controllers have T cells that HAVE been infected with HIV, but greater CTL diversity means more efficacious killing of infected T cells. These people will retain normal immune function for a long time, but probably not forever as infected T cells are being destroyed.


People with bombay blood make antibodies against which carbohydrates complexes?


A,B, and O all have a gene that allows it to make the H antigen in which they hang their other antigens (an A antigen, a B antigen, or in the case of O, nothing). Bombay type does not even have the gene that makes the H antigen, so therefore all of these types of blood seem foreign to it. Bombay blood individuals can only receive other bombay blood. In their case, the saying that O is the universal donor is a misnomer because they are unable to even receive O blood.


Which of the following is a feature of osteoarthritis?

Frequent joint inflammation
Increased joint mobility
Radiographic osteophytes
Systemic involvement

radiographic osteophytes

A common feature of osteoarthritis is hypertrophic bony spurs or (osteophytes). In osteoarthritis there is INFREQUENT joint inflammation because it is usually not considered an inflammatory type of arthritis. There is DECREASED joint mobility from the destruction of the cartilage and the hypertrophy of the contiguous bone. In osteoarthritis, there is no systemic involvement.


Which joint is most classically affected during an acute gouty arthritic attack?

The first DIP
The first MCP
The elbow joint
The first MTP

first MTP

The MTP (metatarsophalangeal) of the great toe. This is called podagra and is by far the most common joint for gout to occur. Other commonly affected areas include the insteps, ankles, heels, knees, wrists, fingers and elbows.


Early pathologic findings of rheumatoid arthritis include which of the following?

Destruction of articular cartilage, bone and periarticular structures
An increase in synovial lining cells (type a, macrophages, type b, fibroblast-like)
Growth of new blood vessels and focal aggregates of CD4 and B cells
Inflammation of the synovium

Inflammation of the synovium

RA begins with inflammation of synovium (early on mono-nuclear cells predominate). Mild inflammation, microvascular injury, edema. Later: Increased type A and B cells in synovium, fibroblast proliferation New blood vessels Focal aggregates of CD4 and B cells Continued microvascular injury Pannus forms under the influence of cytokines Primarily neutrophil response/p


Takayasu's Artheritis affects which sized vessels?



Large vessel vasculitis includes Giant Cell arteritis and Takayasu's. Giant Cell arteritis is related to HLA-DR4, suggesting its antigen driven. Medium size vessels: Polyarteritis Nodosa and Kawasaki's disease Small vessles: Wegener's (cANCAs), Microscopic polyangiitis (pANCAs), and Churg-Straus (p-ANCAs) /p VASCULITIS INVOLVES PLATELET ACTIVATING FACTOR which is permissive for immune complex deposition in vessels.


Mucocutaneous bleeding is an indication of:

primary hemostasis defect
secondary hemostasis defect
fibrolytic disorders
a local vascular defect

primary hemostasis defect

deep muscle bleeding=secondary


Fifteen years after following off of a roof and shattering his left ankle, a patient presents to you with worsening pain and stiffness in the left ankle. Upon examination, his ankle has lost all range of motion. You suspect that his joint was trying to protect itself from the ongoing disease process and fused. What do you call this fixation?

None of the above


Ankylosis is the fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Spondylitis refers to inflammation of specifically the sacroiliac joint and synchondrosis is also a union like ankylosis, but it is a natural union (not from a disease process). It is the union of two bones formed by cartilage seen in the pubic symphysis or costosternal joints.


In Reverse Passive Agglutination:

Latex beads coated with antigen are crosslinked by bacterial antigens
Latex beads coated with antigen are crosslinked by bacterial antibodies
Latex beads coated with antibody are crosslinked by bacterial antigens
Latex beads coated with antibody are crosslinked by bacterial antibodies

Latex beads coated with antibody are crosslinked by bacterial antigens

Reverse passive agglutination: olliCoat latex beads separately with known antigen/liliAdd patient serum/liliIf bacteria in CSF, bacterial ANTIGENS will crosslink the latex beads


A 35 year-old Caucasian male comes to the ED complaining of pain in his ankles that seems to have started pretty abruptly, with his right ankle having more pain than the left. On exam, you see that in addition to inflammation in his ankles, he has dactylitis (sausage digits) in his toes, as well as signs of conjunctivitis. He also informs you that he has had diarrhea for about the last 2 weeks, along with some pain and dysuria. Based on this history and exam, which of the following is the most likely diagnosis?

Rhematoid arthritis
Reactive arthritis
Ankylosing spondylitis
Psoriatic arthritis

reactive arthritis

Reactive arthritis is correct--characterized by asymmetric peripheral arthritis affecting lower extremities (knees and ankles most commonly), male: female ratio of 5-10:1, dactylitis in 20-50% of patients, and a history of diarrhea for 2-4 weeks. Patients can also present with inflammatory back pain symptoms, inflammatory eye disease (also present in some AS patients). Step 1 Gem: Reiter's Disease is a triad of reactive arthritis, uveitis and conjunctivitis that can occur as the result of sexually transmitted diseases as well asl GI pathogens. Patients with Reithers quot;can't see, can't pee, can't climb a tree.quot; Sexually transmitted arthritis... who knew?


Which of the following mother/fetus combinations is a likely set up for erythroblastosis fetalis? (Assume that the mother only has two children total)

RhD(-) mother, first baby RhD(+), second baby RhD (+)
RhD(-) mother, first baby RhD(+), second baby RhD(-)
RhD(-) mother, first baby RhD(-), second baby RhD(-)
RhD(-) mother, first baby RhD(-), second baby RhD(+)

RhD(-) mother, first baby RhD(-), second baby RhD(+)

HLA genes are expressed co-dominately. You receive one allele from each parent per HLA type and both of these alleles are expressed equally.p The HLA genes are located on chromosome 6 so A is incorrect. /pp HLA A and B code for MHC class I and HLA-DR codes for MHC class II so B is incorrect. HLA DR is the most important for considering rejection in transplantation cases so C is incorrect


Which of the following statements is most correct regarding the major histocompatibility antigen that is strongly associated with spondlyoarthropathies?

90% of patients are positive for HLA-B27
90% of patients who are HLA-B27 will get the disease
HLA-B27 is necessary for the disease
HLA-B27 is sufficient for the disease

90% of patients are positive for HLA-B27

Over 90% of Caucasian AS patients are HLA- B27 positive, but only 1-2% of HLA-B27 positive people ever get AS in their lifetime. Remember that although this is the strongest association between a Class I HLA and disease, it is neither necessary nor sufficient for causing disease. /p Only 7% of the general population have the HLA B27 gene


If an individual has a HLA-B27 genotype but does not have any first degree relatives with Anklosing Spondylitis, what are his chances of getting it?



2% if HLA-B27 and no family history. If you are HLA-B27 and also have a first degree relative with AS then 20% chance. 90% of ppl with AS have HLA-B27 but only a small percentage of people with this genotype get the disease. /p Predominant cytokine in AS is TNFa /p Rats with genotype do NOT get disease if kept in sterile environment indicating that disease onset requires BOTH environmental trigger and a suseptible host.


You place a bacterial specimen on slide, and add a patient's serum. You then add a fluoro-labeled anti-human IgG antibody, incubate, and the wash the specimen When you look at your experiment under the microscope, you observe flourescence. From your test, which of the following conclusions is MOST correct?

IgG is present, because the secondary antibody is bound to it
Bacterial antigen is present, because the secondary antibody is bound to it
IgG is absent, because the secondary antibody is bound to the bacteria
Bacterial antigen is absent, because the secondary antibody is bound to the IgG

IgG is present, because the secondary antibody is bound to it

This experiment is describing an INDIRECT immunoflourescence test, which tests for the presence of an antibody in the patient's serum. A direct immunofluorescence test is used to detect the presence of an ANTIGEN, by adding a flourescent antibody directly to it./


Approximately how many people in the world become infected with HIV every year?

3 million, mostly adults
3 million, mostly kids
30 million, mostly adults
30 million, mostly kids

3 million, mostly adults

Worldwide, approximately 2.7 million people became infected with HIV. Of these, 2.3 million were adults, and 430,000 were kids under age 15. The indicence of HIV infection is speculted to be underestimated by as much as 40%. In 2008, there were approximately 33.4 million people worldwide living with HIV. /p AIDS diagnosis means that an HIV positive individual EITHER develops symptoms of opportunistic infections or Kaposi


Which of the following best describes a ligament?

Connect muscle to bone
Active drivers of joint motion
Composed of bundles of parallel type 1 collagen
Connect muscle to muscle

Composed of bundles of parallel type 1 collagen

Ligaments are made of type 1 collagen and connect bone to bone. They prevent inappropriate motion at joint (hinge joints are bordered by collateral ligaments to limit flexion/extension). Tendons are the active drivers of motion.


65% of people who are 'elite controllers' have HLA-B57 and:

Retain high numbers of CD8 cells even after HIV infection
Have greater numbers and diversity of CTLs against HIV peptides
Do not have CCR5 and are immune to HIV infection
Make antibody to HIV-1 and HIV-2

Have greater numbers and diversity of CTLs against HIV peptides

HLA-B57 = more CTL and they are more diverse against HIV peptides. 65% of elite controllers have HLA-B57 (this allele also causes DTH reaction to one of the treatments for AIDS and genotyping is now required before receiving that treatment) /p Elite controllers = harbor HIV but retain normal immune function for many years.


A 65 year old female patient presents to your clinic with complaints of a unilateral headache, visual loss and scalp tenderness. Which of the following additional symptoms might you also expect, given this information?

Jaw claudication
Rash on the buttocks and legs
Thrombosis of peripheral veins

Jaw claudication

Giant Cell arteritis = most common arteritis affecting med and large arteries, usually branches off the carotid. Affects elderly females. Temporal arteries originating from aortic arch/p Unilateral headache, jaw claudication, vision loss (occlusion of opthalmic artery may cause irreversible blindness), scalp tenderness Disruption of internal elastic lamina Treat with high dose steroids.


Which type of pathophysiologic process is rheumatoid arthritis considered?

All of the above


RA is a classic example of inflammatory arthritis. It is causes by an autoimmune disease that creates inflammation in the joint.


Asymptomatic hyperuricemia is defined as which of the following?

Abrupt pain, with warm/red swelling of joints in the morning or overnight
An MSU serum level above 7 mg/dl but without gouty arthritis, tophi or uric acid nephrolithiasis
Attacks that spontaneously resolve within 3-10 days
No symptoms in between acute gout attacks

An MSU serum level above 7 mg/dl but without gouty arthritis, tophi or uric acid nephrolithiasis

Asymptomatic hyperuricemia is defined as 7 mg/ul MSU in serum but no symptoms or signs of gout, tophi or uric acid nephrolithiasis. Acute gouty arthritis is characterized by attacks that occur in morning/overnight and include painful, red, hot swelling. These attacks are self-limiting and resolve in 3-10 days. /p Intercritical gout describes the asymptomatic period between gouty attacks /p Chronic tophaceous gout results from the development of MSU deposits over time


Which of the following is NOT a part of the clinical triad of Reiter's syndrome?



Reiter's Triad includes conjunctivitis, urethritis, arthritis (REACTIVE ARTHRITIS). Can't see, can't pee, can't climb a tree! Caused by either sexually transmitted infections such as chlamydia or enteric bacterial infection. HLA-B27 Theory: misfolding of HLA receptor that occurs while it is still being processed in the endoplasmic reticulum triggers a cellular stress response


A 50 year old basket weaver presents to your clinic complaining of pain in her fingers. After receiving his history, which of the following features indicate that osteoarthritis is the most likely diagnosis?

The pain is worse during exercise and improves with rest
The pain is present in the first couple hours of the morning
He experiences frequent afternoon fatigue
He describes the pain in his MCPs and PIPs, but reports no pain the DIPs

The pain is worse during exercise and improves with rest

Osteoarthritis has classically pain with use with improvement during rest. The other answers are commonly seen in rheumatoid arthritis.


Which of the following is true regarding gout disease?

It is an auto-immune process
It is usually polyarticular
It lacks systemic symptoms
It causes crystal deposition in joints

It causes crystal deposition in joints

Gout is a disease process in which there is a build up of monosodium urate. This can precipitate out and causes crystals in the joint space. Gout is a metabolic process that creates inflammation; however it is NOT an auto-immune process. Gout can affect more than one joint and be polyarticular, however it is more likely seen as a monoarticular disease (potentially oligoarticular, but usually not polyarticular). Gout can have systemic symptoms associated with it.