It's Never Lupus
Skin Deep
IgG and JPG
Oscar the Gouch
Dis Knee Is On Fire
100
A 31-year-old woman with systemic lupus erythematosus is evaluated in clinic. Her symptoms are controlled on prednisone and hydroxychloroquine.
Vital signs are stable. Exam is unchanged from prior other than some lower extremity edema.
Labs show:
Decreased C3/C4 (previously normal)
Creatinine 1.3 (from 0.7)
UA with 2+ protein, 1+ RBC (previously trace RBCs)
Urine protein:creatinine ratio 1200 (from 300)
Other than renal function tests, what blood test correlates most specifically with her clinical change?
anti-double stranded DNA
100
What condition is responsible for these nail findings?
Psoriasis
100
A 40-year-old woman presents with chronic painful color changes in her fingers exacerbated by cold weather. She also reports a 3-month history of pain and swelling in her MCP joints. History is also significant for dry eyes and dry mouth of 5 years' duration as well as recent onset of diffusely puffy hands and increasing fatigue. She reports no gastrointestinal symptoms, including gastroesophageal reflux disease. She takes no medications.
Exam is notable for edematous, cool fingers and scattered palmar telangiectasias.
Other than ANA, what rheumatologic antibody is most likely positive in this patient?
anti-U1 RNP (Mixed Connective Tissue Disease)
100
List 2 indications for urate lowering therapy in the management of gout
Stones (uric acid stones refractory to initial intervention)
Tophi (and structural joint damage)
Attacks (frequent or disabling flares, usually 2+/year)
Renal insufficiency (CrCl < 60)
100
We must be swift as
the coursing river
With all the force
of a great typhoon
With all the strength
of a raging fire...
Mysterious as the dark side of the moon
200
A 49yo woman presents for evaluation of a rash on her back and shoulders. It began 2 years ago as a red scaly rash, with recurrence every 2-3 months since then.
What is the most likely diagnosis?
Subacute cutaneous lupus erythematosus
200
A 36-yo M with ulcerative colitis presents for evaluation of non-healing ulcers of his ostomy site. He was diagnosed with ulcerative colitis 15 years ago and underwent total colectomy 1 year-ago without any complications. He has tried usual wound-care remedies including frequent bandage changes without relief. What is the treatment for the skin care findings below?
Topical glucocorticoids (pyoderma gangrenosum)
200
A 51-year old man presents with finger pain.
What is the most likely diagnosis?
Psoriatic arthritis
200
A 50 year old woman presents with knee pain.
What findings on arthrocentesis are specific for her disease?
positively birefringent CPP crystals
200
Every turn I take, every trail I track
Every path I make, every road leads back
To the place I know, where I cannot go, where I long to be
See the line where the sky meets the sea? It calls me
And no one knows, how far it goes
300
What is the term for this finding, a cutaneous manifestation of sarcoidosis?
lupus pernio
300
A 24-year-old woman is seen for 1-week of tender nodules over the legs and pain and stiffness in the ankles. She also notes a nonproductive cough of 3 days' duration.
On physical examination, her vitals are stable. There are four 3-cm erythematous tender nodules on the left anterior lower leg and three on the right. Swelling of both ankles with tenderness at the right Achilles tendon insertion into the calcaneus is noted; no other joints are swollen. Cardiopulmonary examination is normal.
She has elevated inflammatory markers and her CXR is notable for bilateral hilar lymphadenopathy.
What is this syndrome called?
Lofgren's syndrome (95% specific for sarcoidosis)
300
A 71yo man presents with chronic stiffness, decreased range of motion, and pain of the neck, mid-back, and lower back.
He has no history of falls or injuries. The stiffness and pain do not improve with activity and are not noticeably worse in bed or with inactivity. Acetaminophen provides minimal relief. He has no other medical problems.
On physical examination, vital signs and BMI are normal. Skin examination is normal. Bony hypertrophy of the second through fifth distal interphalangeal joints and the second and fifth proximal interphalangeal joints is present. Marked reduction in thoracic lateral bending and reduction of spinal flexion and extension are noted.
The following imaging is obtained of the lumbar spine:
What is the most likely diagnosis?
Diffuse idiopathic skeletal hyperostosis
300
A patient with inflammatory bowel disease and gout is being started on urate-lowering therapy with allopurinol.
What medication should his PCP make sure the patient is NOT on prior to starting this new therapy?
azathioprine (also interacts with 6-MP, ampicillin, alkylating agents)
300
Unbelievable sights,
Indescribable feeling
Soaring, tumbling, freewheeling
Through an endless diamond sky
400
A 28yo woman presents with a 1-day history of progressive shortness of breath, cough, and hemoptysis. She reports a fever but no chills. She has a 2-year history of systemic lupus erythematosus.
On physical examination, temperature is 38.9 °C (102.0 °F), blood pressure is 100/60 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. Oxygen saturation is 88% on ambient air.
Exam significant for malar rash and MTP/PIP swelling, as well as diffuse crackles on long auscultation.
Laboratory studies:
Which is the most likely explanation of her presentation?
Diffuse Alveolar Hemorrhage
400
A 29-year-old man is evaluated for a 6-month history of recurrent painful oral and genital ulcers that last 1 to 2 weeks and then resolve, as well as waxing and waning knee, ankle, and wrist pain during this time. He is an IV-drug user and has noticed that he also develops pustules at his injection sites. Medical history had been unremarkable until the onset of these symptoms, and he takes no medications.
What is the diagnosis?
Behçet Syndrome
400
A previously healthy 21yo woman presents with 3 weeks of painful lower extremity nodules and rash, diffuse joint tenderness and swelling. She also reports low-grade fever and weight loss. Medications include famotidine and minocycline.
Temperature 38.2, vital signs otherwise stable.
Exam notable for swelling in wrist, knees, ankles, scattered nodules, and livedo reticularis in her lower extremities.
Labs show:
ANA positive in 1:320 titer
Anti-ds DNA negative
Anti-smith negative
Anti-U1 RNP negative
Anti-histone negative
ANCA positive but anti-MPO negative
UA normal
What is the most appropriate next step in MANAGEMENT?
discontinue minocycline
400
A patient presents with severe gout and debilitating tophi refractory to several urate-lowering agents. His rheumatologist has decided to start him on pegloticase.
What condition must be screened for prior to starting medications in this class?
G6PD deficiency
400
Under the sea
Under the sea
Darling it's better
Down where it's wetter, Take it from me
