A
B
C
D
100
A 72-year-old man is evaluated for a 15-year history of pain and stiffness in the knees. He can walk only 50 yards before needing to stop because of the knee pain. He has tried exercises and physical therapy without relief. Intra-articular glucocorticoids provide minimal relief. He has no other medical problems. Current medications are maximum dosages of celecoxib, duloxetine, and acetaminophen.
On physical examination, the medial joint line of each knee is tender to palpation. He has crepitus with movement.
Which of the following is the most appropriate treatment?
Total knee replacement
Arthroscopic knee surgery
Chondroitin sulfate and glucosamine
Intra-articular hyaluronic acid injection
Intra-articular platelet-rich plasma injection
100
A 56-year-old woman is evaluated for a 2-year history of osteoarthritis involving the fingers, bases of the thumbs, hips, and knees. She has tried physical and aquatic therapy with minimal benefit, and she is enrolled in a weight loss program. She has no other medical problems and takes no medications.
On physical examination, vital signs are normal. BMI is 29. Heberden and Bouchard nodes and squaring of the bilateral first carpometacarpal joints are present. The first carpometacarpal joints and medial joint line of both knees are tender to palpation. There is pain in the anterior left groin on internal rotation of the hip. There is bony enlargement of the knees, with crepitus on range of motion.
Which of the following is the most appropriate treatment?
Piroxicam
Acetaminophen
Duloxetine
Gabapentin
Tramadol
100
A 62-year-old woman is evaluated for joint pain. She has a 10-year history of psoriasis and a 3-year history of arthritis. Her psoriasis has been controlled with adalimumab, but joint symptoms persist. She has stiffness in the affected joints for less than 30 minutes every morning, and pain increases with activity. There is no dactylitis. Current medication is adalimumab.
On physical examination, there are small psoriatic plaques on the left elbow and right knee. She has bony enlargement, without swelling, of most distal and proximal interphalangeal joints of the hands. The left knee has a small effusion. The remainder of the examination is normal.
Radiographs of the hands show joint-space narrowing and osteophytes at the distal and proximal interphalangeal joints of both hands. Radiographs of the knees show medial joint-space narrowing and subchondral sclerosis of the left medial compartment.
Which of the following is the most likely cause of this patient's joint pain?
Osteoarthritis
Chronic gout
Psoriatic arthritis
Rheumatoid arthritis
100
A 52-year-old man is evaluated for treatment of interstitial lung disease. Over the last 6 months, he developed a nonproductive cough and dyspnea on exertion. He has a 3-year history of diffuse cutaneous systemic sclerosis and gastroesophageal reflux disease. Current medication is pantoprazole.
On physical examination, respiration rate is 18/min and oxygen saturation is 97% with the patient breathing ambient air. On a 6-minute walk test, oxygen saturation drops to 90%. Crackles are heard at both lung bases. Heart sounds are normal. Skin changes consistent with diffuse cutaneous systemic sclerosis are present.
A high-resolution CT scan shows ground-glass changes in the lower lung fields.
Pulmonary function tests show an FVC of 75% of predicted and a DLCO of 65% of predicted.
Which of the following is the most appropriate treatment?
Mycophenolate mofetil
Hydroxychloroquine
Methotrexate
Nintedanib
200
A 53-year-old man is evaluated in the emergency department for abdominal pain. Four weeks ago, fatigue and malaise developed, followed 1 week later by a rash. Two weeks ago, he began tripping over his left foot. Three days ago, he developed abdominal pain after a meal; abdominal pain is now constant.
On physical examination, temperature is 38.0 °C (100.4 °F), and blood pressure is 154/96 mm Hg; other vital signs are normal. The abdomen is soft and nontender. Muscle strength at dorsiflexion of the left ankle is 3/5. Erythematous nodules are present on the lower legs. The remainder of the examination is normal.
Laboratory studies:
Hemoglobin
8.7 g/dL (87 g/L)
C-reactive protein
13.8 mg/dL (138 mg/L)
Creatinine
1.7 mg/dL (150.3 μmol/L)
Urinalysis
Normal
Hepatitis C virus serology
Negative
HIV testing
Negative
Chest radiograph is normal.
Which of the following is most likely to establish the diagnosis?
Magnetic resonance angiography of abdomen
ANCA panel
Hepatitis A virus serology
Kidney biopsy
200
A 65-year-old man is evaluated for “pain everywhere.” Two months ago, he developed neck and upper back pain, fatigue, and malaise. Over the next few weeks, stiffness and achiness developed in the shoulders and upper arms. He has no headaches, visual changes, or jaw discomfort. He takes no medications.
On physical examination, vital signs are normal. There is no scalp tenderness. Temporal artery pulses are normal. There are no swollen or tender joints. Discomfort limits range of shoulder motion bilaterally and causes difficulty with standing from a seated position. Extremity strength and reflexes are normal.
Laboratory evaluation shows a normal complete blood count, normal serum thyroid-stimulating hormone level, and blood C-reactive protein level of 6.8 mg/dL (68 mg/L).
Which of the following is the most appropriate management?
Prednisone, 15 mg/d
Measurement of rheumatoid factor, antinuclear antibodies, and ANCA
Prednisone, 60 mg/dD
Pregabalin
200
A 40-year-old woman is evaluated for a 9-month history of Raynaud phenomenon. She reports no difficulty swallowing, dyspnea on exertion, or hand stiffness. She has recently developed gastroesophageal reflux disease.
On physical examination, vital signs are normal. The skin between the distal and proximal interphalangeal joints of the fingers is difficult to tent. Three telangiectasias on the right hand and four on the left are noted. She also has two small telangiectasias on the face and one on the inside bottom lip. No digital pitting is seen.
Laboratory evaluation reveals a positive antinuclear antibody titer (1:320) and positive anticentromere antibody titer (1:160).
Which of the following is the most likely diagnosis?
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
Eosinophilic fasciitis
Mixed connective tissue disease
200
An 18-year-old woman is evaluated for fever, chills, and malaise that developed 5 days after her last menstrual period. The following day, she developed arthralgia that first involved the left wrist and then the right knee; the left fifth toe became exquisitely painful and diffusely swollen, with limited range of motion. She is sexually active with one male partner. Her only medication is a combined oral contraceptive.
On physical examination, temperature is 38.1 °C (100.6 °F). Her feet and left hand are shown.
Which of the following is the most likely diagnosis?
Disseminated gonococcal infection
Hepatitis B virus infection
HIV-associated arthritis
Lyme arthritis
Systemic lupus erythematosus
300
A 45-year-old man is evaluated 2 weeks after an emergency department visit for gouty olecranon bursitis. Naproxen was initiated at 500 mg twice daily; after clinical improvement, the dosage was tapered. He has a 5-year history of acute gout that occurs three times a year. He also has a history of kidney stones. Current medication is naproxen, 250 mg twice daily.
There is left olecranon bursal thickening without redness, warmth, or fluid. Tophi are present bilaterally in the first metatarsophalangeal joints without swelling, redness, or warmth.
Kidney function is normal. Serum urate level is 10.5 mg/dL (0.62 mmol/L).
Which of the following is the most appropriate additional treatment?
Allopurinol
Colchicine
Febuxostat
Probenecid
300
A 63-year-old man is evaluated for an 8-week history of a spreading rash on the feet and legs, fatigue, and arthralgia.
On physical examination, vital signs are normal. The rash is shown. Some lesions are palpable. He cannot extend his left wrist. Findings on pulmonary, cardiac, and gastrointestinal examinations are unremarkable. There are no swollen or tender joints.
Laboratory studies:
Erythrocyte sedimentation rate
110 mm/h
Alanine aminotransferase
93 U/L
Aspartate aminotransferase
89 U/L
C3 complement
113 mg/dL (1130 mg/L)
C4 complement
Not detected
Creatinine
2.1 mg/dL (185.6 μmol/L)
Rheumatoid factor
118 U/mL (118 kU/L)
Anti–cyclic citrullinated peptide antibodies
Not detected
Urinalysis
2+ blood; 2+ protein; dysmorphic erythrocytes; no casts
Which of the following is the most likely diagnosis?
Cryoglobulinemic vasculitis
Hypersensitivity vasculitis
Polyarteritis nodosa
Rheumatoid vasculitis
300
A 60-year-old woman is evaluated for achiness and fatigue. She reports dry mouth, irritated eyes, and discoloration of fingers after exposure to cold temperature that rapidly responds to rewarming.
On physical examination, vital signs are normal. Parotid glands are enlarged, and salivary pooling is decreased. There is no lymphadenopathy. All appendicular joints have preserved range of motion without discomfort.
Laboratory evaluation reveals erythrocyte sedimentation rate of 77 mm/h, a blood C-reactive protein level of 0.23 mg/dL (2.3 mg/L), and a rheumatoid factor level of 202 U/mL (202 kU/L).
Which of the following is the most appropriate diagnostic test to perform next?
Anti-Ro/SSA antibodies
ANCA
Anti–cyclic citrullinated peptide antibodies
Cryoglobulins
300
A 50-year-old woman is evaluated for a 6-month history of progressive difficulty getting out of a chair and raising her arms above her head. She has a 10-year history of Raynaud phenomenon and gastroesophageal reflux. Current medications are omeprazole and acetaminophen.
On physical examination, vital signs are normal. Fingers are puffy bilaterally, without digital ulcers or skin thickening. Neurologic examination shows bilateral proximal muscle weakness; distal muscle strength in upper and lower extremities is normal bilaterally. The remainder of the examination is normal.
Laboratory studies:
Complete blood count
Normal
C3 complement
Normal
C4 complement
Normal
Creatine kinase
2000 U/L
Antinuclear antibodies
Strongly positive
Anti–U1-ribonucleoprotein antibodies
Positive
Anti-Ro/SSA antibodies
Negative
Anti-La/SSB antibodies
Negative
Anti–Smith antibodies
Negative
Anti–double-stranded DNA antibodies
Negative
Urinalysis
Normal
Which of the following is the most likely diagnosis?
Mixed connective tissue disease
BRheumatoid arthritis
Systemic lupus erythematosus
Undifferentiated connective tissue disease
400
A 35-year-old man is evaluated for a 3-day history of abrupt polyarticular joint pain in both hands. His 5-year-old daughter recently had a low-grade fever and malaise with 1 day of frequent loose stools; 2 days later she had an erythematous rash over her cheeks.
On physical examination, vital signs are normal. Joint examination shows tenderness of the right second, third, and fourth proximal interphalangeal joints; tenderness of the right second and third metacarpophalangeal joints; tenderness of the left second and third proximal interphalangeal joints; and tenderness of the left second and third metacarpophalangeal joints.
Results of serologic tests are pending.
Which of the following is the most appropriate treatment?
Diclofenac
Etanercept
Hydroxychloroquine
Methotrexate
400
A 36-year-old woman is evaluated for preconception counseling. She has a 3-year history of rheumatoid arthritis well controlled with leflunomide, hydroxychloroquine, and certolizumab. Her most recent disease activity score showed remission. In the past, attempts to discontinue her medications have been unsuccessful because of recurrent active disease.
On physical examination, vital signs are normal. BMI is 24. Range of motion is normal, and joints are not warm or swollen.
Which of the following is the most appropriate preconception management?
Discontinue leflunomide
Discontinue all drugs
Discontinue certolizumab
Discontinue hydroxychloroquine
No changes are needed
400
A 70-year-old woman is evaluated for a 5-year history of tophaceous gout in both hands. Previous treatment with allopurinol resulted in rash. Over the past year, maximum-dose febuxostat has decreased serum urate levels to 9.5 mg/dL (0.56 mmol/L). She also has hypertension and stage G3b chronic kidney disease. Current medications are febuxostat and losartan.
Radiograph of the right hand obtained before initiation of febuxostat therapy is shown.
Which of the following is the most appropriate treatment?
Stop febuxostat and start pegloticase
Add hydroxychloroquine
Add probenecid
No treatment changes
400
An 82-year-old man is seen in follow-up for inclusion body myositis. A prednisone taper over the past 4 months was completed without clinical improvement.
On physical examination, vital signs are normal. There is weakness in the shoulders, forearms, hand grip, hip girdle, and knee extensors that is unchanged from previous examinations.
Serum creatine kinase level is 370 U/L, minimally decreased from 4 months ago.
Which of the following is the most appropriate treatment?
Initiate physical therapy
Add cyclophosphamide
Add intravenous immune globulin
Add methotrexate
Restart prednisone