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Medicines
Quick Answer
Obscure
100
A 66-year-old woman is evaluated for a 10-year history of pain in the hands and knees. She has tried occupational therapy, with minimal benefit; she is enrolled in a weight loss program. She has hypertension and chronic kidney disease. Current medications are lisinopril and amlodipine.
On physical examination, Heberden and Bouchard nodes are present and there is carpometacarpal joint tenderness. The medial joint line of each knee is tender to palpation. There is bony enlargement of the medial knees, with crepitus on range of motion.
Laboratory evaluation shows a serum creatinine level of 2.2 mg/dL (194.5 μmol/L) and an estimated glomerular filtration rate of 45 mL/min/1.73 m2.
Which of the following is the most appropriate treatment? (Read answer options)
Topical diclofenac
Topical lidocaine
Topical capsaicin
Hydrocodone
Meloxicam
100
A 73-year-old woman is hospitalized for progressive dyspnea. Six months ago, she developed chronic sinusitis and nose bleeds. Four months ago, a persistent dry chronic cough developed, followed by myalgia and distal paresthesia. She has lost 13.6 kg (30 lb).
On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is 148/96 mm Hg, pulse rate is 104/min, respiration rate is 24/min, and oxygen saturation is 94% with the patient breathing ambient air. Dry crackles are heard at the lung bases. There is loss of sensation to light touch in the left foot. Numerous small palpable red-purple lesions are present on the lower legs.
Laboratory studies:
Erythrocyte sedimentation rate : 120 mm/h
Creatinine : 1.7 mg/dL (150.3 μmol/L)
ANCA: Positive
Antiproteinase-3 antibodies: Positive
Urinalysis: 3+ blood; 2+ protein; 20-30 dysmorphic erythrocytes/hpf; 5-10 leukocytes/hpf
Chest radiograph shows peripheral pulmonary parenchymal opacities. Chest CT scan shows multiple opacities and nodules throughout both lungs.
Kidney biopsy results are pending.
High-dose glucocorticoids are started.
Which of the following will most likely be the appropriate additional treatment?
Rituximab
MTX
Azathioprine
Mycophenolate
100
A 33-year-old woman is evaluated for a 1-month history of pain in the hands. She also has stiffness in the hands upon arising in the morning that lasts 90 minutes. She otherwise has been well. She reports no tingling or numbness in the fingers; changes in the color of the digits; or rash, oral ulcers, or alopecia. Her vaccinations are up to date. She works in her home as a computer software engineer, is not sexually active, has no contact with children, and has not traveled.
On physical examination, vital signs are normal. Examination of the hands reveals bilateral polyarticular joint swelling and tenderness involving the metacarpophalangeal joints.
Which of the following is the most likely cause of this patient's joint pain?
RA
Reactive arthritis
Ankylosing spondy
Erosive OA
100
A 39-year-old woman is evaluated for newly discovered neutropenia. She has a 10-year history of severe, difficult-to-control rheumatoid arthritis. She has no sicca symptoms. Current medications are prednisone, methotrexate, folic acid, and adalimumab.
On physical examination, vital signs are normal. There are rheumatoid nodules over the olecranon processes. The spleen tip is palpable. Joint examination reveals ulnar deviation, subluxation at the metacarpophalangeal joints, reduced range of motion at the wrists, and bilateral swelling of the wrists and left ankle.
Which of the following is the most likely diagnosis?
Felty syndrome
SLE
Sjogren
AA Amyloidosis
200
A 50-year-old woman is evaluated for a 2-year history of pain affecting the knee joints. The pain is associated with walking or standing and occurs 1 to 2 days per week. She has tried acetaminophen with minimal benefit; she is enrolled in a weight loss program. She prefers a home-based self-management treatment option.
On physical examination, vital signs are normal. BMI is 33. There is mild tenderness to palpation of knee medial joint lines bilaterally. Knee joints are not warm or swollen and have normal range of motion. No other joints are involved.
Which of the following is the most appropriate treatment?
Tai chi
High impact aerobic exercise
Transcutaneous electrical stimulation
Vegan diet
200
A 62-year-old man is evaluated in the hospital for an arthrocentesis-confirmed diagnosis of acute polyarticular gout involving the right knee, left ankle, and forefoot. Joint fluid Gram stain and culture were negative. He was hospitalized 4 days ago with heart failure complicated by pulmonary embolism. He has a history of recurrent acute gout. The first night of his hospital stay, he developed polyarticular gout that has not responded to appropriate prednisone doses. He also has hypertension, hyperlipidemia, type 2 diabetes mellitus, and stage G3a chronic kidney disease; he underwent kidney transplantation 10 years ago. Current medications include low-molecular-weight heparin, metoprolol, losartan, furosemide, insulin glargine, and tacrolimus.
The right knee, left ankle, and forefoot are swollen, tender, and warm.
Which of the following is the most appropriate treatment?
Anakinra
Colchicine
Intra-articular triamcinolone
Naproxen
200
A 26-year-old woman is evaluated for a 3-month history of increasing left hip pain that is worse with prolonged standing. Systemic lupus erythematosus was diagnosed 5 years ago, characterized by small joint arthralgia, malar rash, cytopenias, and Raynaud phenomenon. At diagnosis she required high-dose prednisone, hydroxychloroquine, and azathioprine therapy. Prednisone dosage was tapered over 6 months. Periodic flares have been treated with increased dosages of prednisone. Current medications are hydroxychloroquine, azathioprine, and low-dose prednisone.
On physical examination, internal rotation and full flexion of the left hip are limited and elicit pain. The remainder of the examination is normal.
Complete blood count, erythrocyte sedimentation rate, and serum complement levels are normal. Anti–double-stranded DNA antibody titer is low and has been unchanged for 6 months.
Radiograph of the left hip is normal.
Which of the following is the most appropriate management?
MRI hip
Azathioprine -> Mycophenolate
PT
Increase prednisone
200
A 24-year-old man is evaluated for fever of 6 weeks' duration. He also has joint pain, myalgia, and occasional sore throat. The fever begins in the early evening and resolves by morning. His most recent temperature in the evening was 39.5 °C (103.1 °F). The fever is accompanied by a salmon-pink macular rash on the trunk and arms, which resolves with the fever. He has no history of travel. Current medication is acetaminophen.
On physical examination, temperature is 37.5 °C (99.6°F). The remaining vital signs are normal. There is bilateral cervical lymphadenopathy. A friction rub is heard bilaterally at the lung bases. Abdomen is tender without guarding. The knees have effusions. Cardiac examination is normal.
Laboratory studies:
Erythrocyte sedimentation rate : 125 mm/h
Leukocyte count : 22,000/μL (22 × 109/L)
Hemoglobin : 11.5 g/dL (115 g/L)
Ferritin : 5200 ng/mL (5200 μg/L)
Blood cultures are pending.
A chest CT scan shows small pleural effusions bilaterally with moderate pleural thickening. An abdominal CT scan shows a small amount of ascitic fluid with evidence of peritoneal thickening.
Which of the following is the most likely diagnosis?
Adult onset Still's disease
SLE
IE
Familial Med fever
300
A 35-year-old woman is evaluated in the emergency department for sudden vision loss in the left eye. Two years ago, she had developed intermittent fever, myalgia, and chronic fatigue. She reports recent postprandial abdominal pain and effort-related left arm pain.
On physical examination, blood pressure is 160/100 mm Hg in the left arm and 130/80 mm Hg in the right arm. Pulse rate is 88/min. Radial pulse in the left arm is absent; left-sided subclavian bruit is present.
Laboratory studies reveal an erythrocyte sedimentation rate of 76 mm/h and a blood hemoglobin level of 9.2 g/dL (92 g/L).
Magnetic resonance angiogram of the chest and abdomen shows focal luminal narrowing in several areas, including the ascending aorta, left subclavian artery, superior mesenteric artery, and right renal artery.
Which of the following is the most likely diagnosis?
Takayasu arteritis
PAN
GCA
Cryoglobulinemic vasculitis
300
A 52-year-old woman is evaluated at a follow-up visit. Dermatomyositis was diagnosed 4 weeks ago; she was positive for anti–Mi-2 antibodies. Prednisone has improved heliotrope and photosensitive rashes and proximal muscle weakness. She is currently asymptomatic. Current medication is prednisone, 60 mg/d. She is participating in physical therapy.
On physical examination, vital signs are normal. There is no rash. Muscle strength is normal.
Serum creatine kinase level is 200 U/L, decreased from 520 U/L 1 month ago.
Results of screening colonoscopy, mammography, and cervical cancer screening are all normal.
Which of the following is the most appropriate treatment?
MTX
Rituximab
Hydroxychloroquine
Continue current med
300
A 58-year-old woman is evaluated for brief episodes of pain, swelling, and redness in the right wrist for 4 days. During the past 2 years, she has had similar episodes in her left wrist and left third metacarpophalangeal joint, which resolved without treatment.
On physical examination, vital signs are normal. Joint examination reveals swelling, warmth, and redness of the left wrist and redness and bony enlargement of the left third metacarpophalangeal joint. Other joints are normal.
Laboratory studies show normal complete blood count, comprehensive metabolic panel, and serum calcium, magnesium, and thyroid-stimulating hormone levels.
Radiographs of wrist and metacarpophalangeal joints are shown.
Synovial fluid from the left wrist shows a leukocyte count of 30,000/μL (30 × 109/L) with 90% neutrophils; polarizing microscopy shows numerous positively birefringent rhomboid crystals within neutrophils. Synovial fluid Gram stain and culture are negative.
Which of the following is the most appropriate laboratory study to perform next?
6%AAntinuclear antibodies
Ferritin
ANA
ESR
RF
300
1 year of pain with limited ROM in 85 yo. Diagnosis?
Basic calcium phosphate-associated arthritis
Adhesive capsulitis
Calcium pyrophosphate deposition disease
Rheumatoid arthritis
400
A 42-year-old woman is evaluated for 3 months of pain and swelling in her hands and multiple other joints, as well as morning stiffness lasting more than 1 hour. She has increasing difficulty with daily activities, such as walking and making the bed. She has no other symptoms or medical problems and takes no medication.
On physical examination, vital signs are normal. She has swelling and tenderness of the second and third proximal interphalangeal joints bilaterally, right second and left third metacarpophalangeal joints, left wrist, and bilateral ankles.
Laboratory studies:
C-reactive protein : 6.4 mg/dL (64 mg/L)
Rheumatoid factor: Positive
Antinuclear antibodies: 1:80 (≥1:160 positive)
Anti–cyclic citrullinated peptide antibodies: Positive
Which of the following is the most likely diagnosis?
Not worth 400 points.. RA
Parvovirus
Chikungunya
SLE
400
A 58-year-old man is evaluated at a follow-up visit. He has had rheumatoid arthritis for 5 years. Increasing morning stiffness, fatigue, increasing joint pain, and swelling of small hand joints have developed in the past 6 months. His disease activity score shows moderate activity. He also has coronary artery disease, COPD, and a history of diverticulitis. Current medications are aspirin, lisinopril, metoprolol, a tiotropium inhaler, methotrexate, and sulfasalazine.
On physical examination, blood pressure is 136/84 mm Hg. BMI is 29. Multiple metacarpophalangeal joints are tender to palpation, and there is active synovitis.
Result of an interferon-gamma release assay is negative.
Hand radiographs show joint-space narrowing and three new erosions.
Which of the following is the most appropriate treatment?
Adalimumab
Abatacept
Anakinra
Tocilizumab
Tofacitinib
400
A 47-year-old woman is evaluated for a 3-year history of pain in all of her muscles and joints. She is a commercial truck driver. Her sleep is poor, and she awakens unrefreshed. She completes a fibromyalgia diagnostic questionnaire and meets the criteria for fibromyalgia. She has anxiety and depression, with a history of opioid use disorder. She takes no medications.
On physical examination, vital signs are normal. Physical examination findings are limited to widespread muscle tenderness with normal strength.
Laboratory evaluation reveals an erythrocyte sedimentation rate of 19 mm/h, a blood C-reactive protein level of 0.3 mg/dL (3 mg/L), and a thyroid-stimulating hormone level of 1.6 μU/mL (1.6 mU/L).
Low-impact aerobic exercise is recommended.
Which of the following is the most appropriate additional treatment?
Duloxetine
Pregabalin
Amitriptyline
Diclofenac
Tramadol
400
4 months rash over hands and face, weight loss, proximal muscle weakness. CK 4500. Most appropriate test to perform next?
Colonoscopy
Muscle biopsy
ANA
PFT