Rheum Diagnosing
A 42-year-old woman presents with chronic widespread musculoskeletal pain for the past 6 months. She reports extreme fatigue, non-restorative sleep, and difficulty concentrating throughout the day. Physical exam reveals tenderness in multiple soft-tissue areas 12/18 points, including the trapezius, lateral epicondyle, hips, and knees. Her CBC, ESR, TSH, and metabolic panel are all normal.
Which of the following is the most likely diagnosis?
A. Polymyalgia rheumatica
B. Fibromyalgia
C. Rheumatoid arthritis
D. Systemic lupus erythematosus
B. Fibromyalgia
A 58-year-old man presents to the emergency department with sudden onset of severe pain, redness, and swelling in his right big toe. He reports that the pain began overnight and is so intense that he cannot tolerate the bedsheet touching the area. He recently increased his alcohol intake and started a thiazide diuretic for hypertension.
Physical exam shows marked erythema, warmth, and tenderness over the 1st MTP joint. X-ray shows punched-out erosions with sclerotic, overhanging margins.
Arthrocentesis is performed.
Which of the following synovial fluid findings confirms the diagnosis?
A. Positively birefringent, rhomboid-shaped crystals
B. Negatively birefringent, needle-shaped crystals
C. Cloudy fluid with > 100,000 WBC and predominantly neutrophils
D. Calcium hydroxyapatite deposits
Correct answer: B. Negatively birefringent, needle-shaped crystals.
A 48-year-old woman presents with chronic dry eyes, difficulty swallowing dry foods, and persistent dry mouth requiring frequent sips of water. The physical exam shows dry oral mucosa, multiple dental caries, and bilateral parotid enlargement.
Which of the following diagnostic tests is considered the criterion standard for confirming Sjögren syndrome?
A. Schirmer test
B. Rose Bengal corneal staining
C. Anti-Ro/SSA antibody testing
D. Minor salivary gland (lip) biopsy
Correct answer: D. Minor salivary gland (lip) biopsy.
A 15-year-old boy has been coming to the clinic with progressive left knee pain for the past two months. The pain is worse at night and has recently begun to interfere with daily activities. He also reports swelling around the knee. On exam, there is a firm, tender mass over the distal femur and decreased range of motion.
X-ray of the distal femur shows a mixed sclerotic and lytic lesion with a sunburst or hair on end appearance and an elevated periosteum forming a Codman triangle. Lab testing reveals an elevated alkaline phosphatase level.
Which of the following is the most likely diagnosis?
A. Osteoid osteoma
B. Chondrosarcoma
C. Osteosarcoma
D. Giant cell tumor of bone
Correct answer: C. Osteosarcoma.
Which of the following is the most common cause of malignant bone tumors?
A. Osteosarcoma
B. Chondrosarcoma
C. Ewing Sarcoma
D. Metastatic bone disease
Correct answer: D. Metastatic bone disease.
A 67-year-old postmenopausal woman presents for evaluation after noticing progressive height loss and mild mid-back pain. She has no history of trauma. Her medical history is significant for long-term proton pump inhibitor use and chronic smoking. She has a BMI of 18.5 and reports low dairy intake.
Physical exam reveals thoracic kyphosis. Laboratory studies show normal calcium, phosphate, and PTH levels. A DEXA scan reveals low bone mineral density with a T-score of –2.7 at the lumbar spine.
A. Paget disease of bone
B. Osteoporosis
C. Osteomalacia
D. Hyperparathyroidism
Correct answer: B. Osteoporosis
75-year-old woman presents with acute pain, swelling, and warmth in her right wrist and left knee. Arthrocentesis from the knee shows positively birefringent, rhomboid-shaped crystals. She has involvement of two joints.
Which of the following is the most appropriate treatment?
A. Intra-articular corticosteroid injections after joint aspiration
B Colchicine only
C. Oral NSAIDs only
D. IL-1 inhibitor (Anakinra)
Correct answer: B. Intra-articular corticosteroid injections after joint aspiration.
Which of the following autoantibodies is NOT associated with dermatomyositis?
A. Anti–Jo-1
B. Anti–Mi-2
C. ANA
D. Anti–dsDNA
Correct answer: D. Anti–dsDNA.
A 28-year-old woman presents with progressive knee pain and swelling for three months. The pain is worse with activity and has begun to limit her ability to bear weight. Physical exam shows mild warmth and decreased range of motion of the right knee.
An X-ray of the distal femur is obtained.
Which of the following radiographic findings is most characteristic of this condition?
A. A well-defined, lucent lesion with stippled calcifications in the metaphysis
B. A pedunculated bony projection continuous with the cortex and medullary canal
C. A destructive, lytic epiphyseal lesion with a “soap-bubble” appearance
D. A small radiolucent nidus surrounded by dense reactive bone
Correct answer: C. A destructive, lytic epiphyseal lesion with a “soap-bubble” appearance.
A 14-year-old Caucasian boy presents with progressively worsening pain in his right thigh accompanied by fever and malaise. The physical exam shows localized swelling and tenderness over the mid-femur. Labs reveal leukocytosis, an elevated ESR, and a markedly increased LDH level.
X-ray shows a diaphyseal lytic lesion with an onion-skin periosteal reaction and a Codman triangle. Biopsy reveals small round blue cells consistent with Ewing sarcoma.
Which of the following is the most appropriate management?
A. Immediate limb amputation
B. Radiation therapy alone
C. Combination chemotherapy followed by limb-sparing surgical resection
D. Oral bisphosphonates and observation
Correct answer: C. Combination chemotherapy followed by limb-sparing surgical resection.
A 43-year-old man presents with progressive pain and swelling in several fingers over the past 6 months. He notes that entire fingers “swell up like sausages.” He has a history of a chronic rash on his elbows that forms erythematous plaques with thick silvery-white scales. Exam shows dactylitis, tenderness at tendon insertions (enthesitis), and nail pitting.
X-ray of the hands demonstrates erosion of the distal phalanx with a “pencil-in-cup” deformity.
Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis
B. Psoriatic arthritis
C. Osteoarthritis
D. Reactive arthritis
Correct answer: B. Psoriatic arthritis.
What is the first-line treatment for classic Polyarteritis Nodosa (PAN)?
A. NSAIDs
B. Glucocorticoids
C. Cyclophosphamide alone
D. Plasmapheresis only
Correct answer: B. Glucocorticoids.
Which of the following pathologic findings is most characteristic of polymyositis?
A. CD8+ T-cell–mediated inflammation of the endomysium
B. CD4+ T-cell infiltration around the perimysium
C. B-cell deposition along the dermal–epidermal junction
D. Noncaseating granulomas within the muscle fascia
Correct answer: A. CD8+ T-cell–mediated inflammation of the endomysium.
A 16-year-old boy is brought to the clinic because of a firm, painless lump on the lateral aspect of his knee noticed over the past several months. He denies trauma, systemic symptoms, or functional limitations. On exam, a non-tender, immobile bony mass is palpated near the proximal tibia at the site of tendon insertion.
Plain radiographs show which of the following?
A. A pedunculated bony outgrowth with continuity of the cortex and medullary canal
B. A lytic lesion with a “sunburst” periosteal reaction
C. A radiolucent nidus surrounded by dense reactive bone
D. A soap-bubble, expansile osteolytic lesion in the epiphysis
Correct Answer is A. A pedunculated bony outgrowth with continuity of the cortex and medullary canal
A 32-year-old woman presents with increasing pain in her right hand over the past several months. She denies trauma. X-ray of the hand shows a well-defined, lucent intramedullary lesion with stippled calcifications in the proximal phalanx. There is no soft-tissue extension, but the lesion is symptomatic.
Which of the following is the most appropriate management?
A. Observation with routine radiographic follow-up
B. Intralesional curettage with bone grafting
C. Wide surgical resection
D. Radiation therapy
Correct answer: B. Intralesional curettage with bone grafting.
A 29-year-old woman presents with a history of one unprovoked DVT and two consecutive second-trimester pregnancy losses. She reports intermittent episodes of mottled purple discoloration on her legs. Physical exam reveals livedo reticularis.
Coagulation studies show a prolonged PTT that does not correct with mixing studies.
Which of the following laboratory findings would support the diagnosis of antiphospholipid syndrome?
A. Anti–double-stranded DNA antibodies
B. Anti–Scl-70 antibodies
C. Anti–β2 glycoprotein I antibodies
D. Anti-centromere antibodies
Correct answer: C. Anti–β2 glycoprotein I antibodies
A 68-year-old woman presents with a 3-month history of worsening pain and stiffness in her shoulders, neck, and hips. She reports difficulty getting out of bed in the morning due to stiffness lasting over an hour. She denies headaches, jaw pain, or visual symptoms. Exam shows decreased active and passive range of motion in the shoulders and hips, but normal muscle strength.
Lab results show:
ESR: 78 mm/hr (elevated)
CRP: elevated
CK: normal
Which of the following is the most appropriate initial treatment?
A. High-dose prednisone
B. Low-dose corticosteroids
C. Methotrexate monotherapy
D. IV methylprednisolone
Correct answer: B. Low-dose corticosteroids.
A 42-year-old woman presents with several months of hand pain and morning stiffness lasting more than an hour. She reports difficulty opening jars and typing. On physical examination, her wrists and MCP joints are swollen and tender. The joints feel soft with a “boggy” consistency. You also notice ulnar deviation of the fingers and deformities in which the PIP joints are hyperextended and the DIP joints are flexed.
Which of the following physical exam findings is most characteristic of rheumatoid arthritis?
A. Heberden and Bouchard nodes of the DIP joints
B. Tender, soft “boggy” symmetric synovitis of MCP/PIP joints
C. Isolated swelling of DIP joints with pitting edema
D. Dactylitis (“sausage digits”)
B Tender, soft “boggy” symmetric synovitis of MCP/PIP joints
A 52-year-old white man presents with slowly worsening hip pain that is most severe at night. He also reports a feeling of fullness in the upper thigh. Physical exam shows localized tenderness over the proximal femur.
X-ray of the proximal femur reveals a lytic lesion with punctate, “popcorn-like,” and rings-and-arcs calcificationswithin the medullary cavity. MRI confirms an expansile cartilage-based mass.
Which of the following diagnoses is most consistent with these radiographic findings?
A. Osteosarcoma
B. Chondrosarcoma
C. Ewing sarcoma
D. Giant cell tumor of bone
Correct answer: B. Chondrosarcoma.
A 68-year-old man is evaluated for progressive right hip pain. He has no recent trauma. Physical exam reveals an antalgic gait and mild bowing of the right femur. Laboratory studies show a significantly elevated alkaline phosphatase level with normal calcium, phosphate, and PTH. X-ray of the femur shows thickened cortical bone with coarse trabeculae and a cotton wool appearance.
Which of the following is the most appropriate treatment?
A. Oral bisphosphonate therapy
B. Calcium channel blockers
C. Long-term corticosteroids
D. Observation only, regardless of symptoms
Correct answer: A. Oral bisphosphonate therapy.
In limited systemic sclerosis, the acronym CREST is used to describe the characteristic clinical features. Which of the following correctly represents the components of CREST syndrome?
A. Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasias
B. Contractures, Renal failure, Edema, Synovitis, Tendon rupture
C. Cyanosis, Respiratory fibrosis, Esophagitis, Skin tightening, Thrombocytopenia
D. Calcinosis, Rheumatoid nodules, Eosinophilia, Sclerodactyly, Tricuspid regurgitation
Correct answer: A. Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasias.
A 26-year-old woman presents with 3 months of fatigue, joint pain in her hands, and a facial rash that worsens with sun exposure. She also reports intermittent low-grade fevers and painless ulcers on the inside of her mouth. Examination shows a malar rash that spares the nasolabial folds and mild MCP joint swelling.
Laboratory studies reveal leukopenia, thrombocytopenia, and low complement levels (C3, C4). Urinalysis shows mild proteinuria. ANA is positive.
Which of the following findings would NOT be expected in a patient with systemic lupus erythematosus?
A. Anti–double-stranded DNA antibodies
B. Low complement levels during disease flares
C. Photosensitive rash over sun-exposed areas
D. Elevated creatine kinase due to muscle fiber destruction
Correct answer: D. Elevated creatine kinase due to muscle fiber destruction.
A 58-year-old man presents with fatigue, joint pain, and low-grade fevers for several months. He denies photosensitivity, oral ulcers, alopecia, or neurologic symptoms. He has been taking procainamide for ventricular arrhythmias. Laboratory studies show a positive ANA, normal complement levels, and negative anti–double-stranded DNA antibodies.
Which of the following laboratory findings is most characteristic of drug-induced lupus?
A. Anti–double-stranded DNA antibodies
B. Anti-Smith antibodies
C. Low complement levels (C3, C4)
D. Anti-histone antibodies
Correct answer: D. Anti-histone antibodies
A 72-year-old man undergoes imaging after developing progressive left tibial pain. Laboratory testing shows an isolated elevation in alkaline phosphatase with normal calcium, phosphate, and PTH.
X-ray of the tibia reveals an area of flame-shaped (blade of grass) lucency transitioning into regions of sclerotic, thickened cortical bone with coarse trabecular markings.
Which of the following diagnoses is most consistent with these radiographic findings?
A. Osteoporosis
B. Osteosarcoma
C. Paget disease of the bone
D. Osteochondritis
C. Paget disease of the bone
A 13-year-old Caucasian boy presents with worsening pain and swelling of his left thigh for the past month. His parents report that he has also had intermittent fevers, fatigue, and decreased appetite. Physical exam shows localized warmth and tenderness over the mid-femur.
Laboratory testing reveals an elevated ESR, leukocytosis, and an increased LDH level.
X-ray of the femur demonstrates a diaphyseal lesion with an onion-skin periosteal reaction, a moth-eaten pattern of bone destruction, and a Codman triangle.
Which of the following is the most likely diagnosis?
A. Osteosarcoma
B. Chondrosarcoma
C. Ewing sarcoma
D. Osteoid osteoma
C. Ewing sarcoma