What am I
Best Next
The cure
Picture Perfect
Screen and protect
100
50F presents with inflammatory arthritis and 1 hour of morning stiffness. She has swelling and tenderness involving the MCP, PIP, and DIP joints of the thumb and second and third fingers, along with swelling of several toes. Rheumatoid factor is negative, and she has small psoriatic plaques on the scalp. What is the most likely diagnosis?
Psoriatic arthritis.
100
56 F with polyarticular tophaceous gout (hands, feet, knees). Previously developed a rash with allopurinol. CKD (Cr 1.8, eGFR 31), uric acid 10.1 mg/dL. On prednisone taper.
Febuxostat.
100
43F with fibromyalgia has persistent widespread pain and poor sleep despite exercise and cognitive behavioral therapy. She is on escitalopram for depression. What is the next best treatment?
Pregabalin.
100
A young woman with type 1 diabetes has chronic diarrhea and the pruritic rash shown.
Dermatitis herpetiformis (DH)
100
51 F with RA × 2 years on methotrexate + tofacitinib.
Which vaccine is contraindicated?
Live vaccine. MMR
200
23M has recurrent episodes of fever, severe abdominal pain, rash, and monoarthritis lasting 2–3 days since childhood. He has a family history of similar episodes, and urinalysis shows mild proteinuria. What is the diagnosis
Familial Mediterranean Fever (FMF)
200
35 F. Ankylosing spondylitis. Persistent inflammatory back pain and morning stiffness >1 hour despite 3 NSAIDs and physical therapy. Bilateral sacroiliitis on X-ray. What is the next best treatment?
Etanercept (TNF inhibitor).
200
23yr M has recurrent painful oral ulcers and genital ulcers that heal with scarring. He has no ocular, neurologic, or vascular involvement. What is the first-line treatment for his mucocutaneous disease?
Behçet syndrome; colchicine.
200
This painful pretibial rash is characteristic of what condition?
Erythema nodosum.
200
30 F with SLE × 12 years, history of lupus nephritis now in remission. Disease quiescent for 5 years on hydroxychloroquine and azathioprine.
What health risk should be routinely assessed in this patient?
Cardiovascular disease.
300
A 32-year-old woman has galactorrhea, irregular menses, fatigue, constipation, weight gain, and a prolactin level of 68 ng/mL. What is the most likely diagnosis?
Primary hypothyroidism.
300
67F with fatigue,dry cough, sinus congestion, and painless red eyes for several weeks. CT chest: multiple cavitary lung lesions. Exam: palpable purpura. Lab:elevated creatinine, hematuria with dysmorphic red blood cells and red blood cell casts, and proteinuria. What is the best test to confirm it?
Granulomatosis with polyangiitis (GPA); kidney biopsy. Pauci-immune necrotizing crescent glomerulonephritis.
300
68 M. Mild pain and marked swelling of the left knee. Several months ago, he traveled and developed an expanding erythematous rash with fever and arthralgias that resolved without treatment. First-line treatment?
Lyme arthritis; doxycycline.
300
A 40-year-old woman develops arthralgia and the rash shown after intense sun exposure. She takes hydrochlorothiazide. What is the most likely diagnosis?
Subacute cutaneous lupus erythematosus (SCLE).
300
65 M with 4 months of proximal muscle weakness, Gottron papules, heliotrope/shawl rash, CK 4500, 15-lb weight loss.
What should be done next?
Malignancy screening (begin with age-appropriate cancer screening, e.g., colonoscopy).
400
A 52-year-old man has chronic pain in the hands, ankles, and toes. The hand radiograph is shown. What is the most likely diagnosis?
Chronic tophaceous gout.
400
A 74F with osteoporosis treated with teriparatide for 2 years. What should be done next?
Discontinue teriparatide anabolic and start an antiresorptive agent (e.g., alendronate).
400
A 34-year-old woman is 28 weeks pregnant with gestational diabetes. Despite diet and exercise, fasting glucose is 105–115 mg/dL and 2-hour postprandial glucose is 130–140 mg/dL. What is the best next step?
Initiate basal and prandial insulin.
400
A 43-year-old man has weight loss, nausea, weakness, and the skin finding shown. What is the most likely diagnosis?
Primary adrenal insufficiency (Addison disease).
400
A 20-year-old transgender man started testosterone therapy 3 months ago. Which laboratory test should be monitored to screen for the most common treatment-related complication?
Hematocrit (screening for erythrocytosis).
500
63F:fatigue & leg rash(4 days). She started hydrochlorothiazide 2 weeks ago for hypertension. The rash is palpable.
Hypersensitivity vasculitis (cutaneous small-vessel/leukocytoclastic vasculitis).
500
62 M with acute polyarticular gout (right knee, left ankle, forefoot). Joint aspiration: Gram stain and culture negative. CKD stage 3a, kidney transplant on tacrolimus, heart failure, recent PE on LMWH. No response to prednisone.
Anakinra.
500
A 52-year-old man with diffuse systemic sclerosis develops progressive dyspnea, bibasilar crackles, ground-glass opacities on HRCT, and reduced FVC/DLCO. What is the best treatment?
Mycophenolate mofetil is the mainstay of treatment for systemic sclerosis–associated interstitial lung disease (SSc-ILD)
500
24M with asymmetric oligoarthritis (R knee, R ankle, R wrist) 3 weeks after diarrhea. Name the palm rash.
Keratoderma blennorrhagicum (psoriasiform palmoplantar rash) in Reactive arthritis
500
36F with well-controlled RA on leflunomide, hydroxychloroquine, and certolizumab is planning pregnancy. Which medication must be discontinued before conception?
Leflunomide