RHEMATOLOGY FINAL EXAM QUESTIONS WITH VERIFIED SOLUTIONS 100% CORRECT 2024 NEW UPDATE, Exams of Nursing

Download RHEMATOLOGY FINAL EXAM QUESTIONS WITH VERIFIED SOLUTIONS 100% CORRECT 2024 NEW UPDATE and more Exams Nursing in PDF only on Docsity! RHEMATOLOGY FINAL EXAM QUESTIONS WITH VERIFIED SOLUTIONS 100% CORRECT 2024 NEW UPDATE 1. When compared with patients with rheumatoid arthritis (RA) who do not have anti- cyclic citrullinated protein (CCP) antibodies, patients with RA who have anti-CCP antibodies: a. Are less likely to develop extra-articular manifestations of RA (e.g., vasculitis) b. are less likely to have history of smoking c. Develop fewer subchondral bone erosions on imaging over their disease course. d. have higher prevalence of shared epitope (HLADRB1) risk allels e. Have lower scores for physical disability 2- Which of the following conditions is nearly twice as common in patients with diffuse cutaneous systemic sclerosis than in limited cutaneous systemic sclerosis? a. Esophageal involvement b. Pulmonary arterial hypertension c. Pulmonary fibrosis d. Raynaud phenomenon e. Skin involvement 03- All of the following agents have been shown to have disease modifying antirheumatic drug (DMAD) efficacy in patients with rheumatoid arthritis EXCEPT: a. Infliximab b. Leflunomide c. Methotrexate d. Naproxen e. Rituximab 04- A patient with primary Sjogren syndrome that was diagnosed 6 years ago and treated with tear replacement for symptomatic relief notes continued parotid swelling for the last 3 months. She has also noted enlarging posterior cervical lymph nodes. Evaluation shows leukopenia and low C4 complement levels. What is the most likely diagnosis? a. Amyloidosis b. Chronic pancreatitis c. HIV d. Lymphoma e. Secondary Sjogren syndrome 05- Which of the following is the most common extra-articular manifestation of ankylosing spondylitis? a. Anterior uveitis b. Aortic insufficiency c. Inflammatory bowel disease d. Pulmonary fibrosis e. Third-degree heart block 06- Lung biopsy has the greatest diagnostic yield in which of the following vasculitis syndrome? a. Cryoglobulinemic vasculitis b. Cutaneous vasculitis c. Granulomatosis with polyangiitis d. IgA vasculitis (Henoch-Schonlein) e. Polyarteritis nodosa 07- All of the following have been implicated in the proposed pathogenesis of sarcoidosis EXCEPT: a. Exposure to mold b. Genetic susceptibility c. Immune response to mycobacterial proteins d. Infection with Propionibacterium acnes e. Malignant expansion of helper T cells 08- Which of the following statements regarding osteoarthritis is true? a. During the diagnostic workup of a suspected osteoarthritis joint, MRI is warranted to evaluate for any other causes. b. Loss of cartilage causes pain due to direct stimulation of pain receptors in joint cartilage itself. c. Osteoarthritis is the second most common cause of arthritis, behind rheumatoid arthritis. 16- All of the following conditions occur in association with Behcet syndrome EXCEPT: a. Arthritis b. Deep venous thrombosis c. Folliculitis d. Genital ulcers e. Scleritis 17- Which of the following disorders is associated with relapsing polychondritis? a. Giant cell arteritis b. Granulomatosis with polyangiitis (formerly Wegener disease) c. Rheumatoid arthritis d. Psoriasis e. B and C 18- Which of the following statements regarding pulmonary sarcoidosis is true? a. Lung involvement is the second most common manifestation of sarcoidosis, behind only cutaneous involvement. b. Obstructive disease is a rare manifestation of pulmonary sarcoidosis patients. c. pulmonary hypertension never responds to therapy in sarcoidosis patients d. Pulmonary infiltrates in sarcoidosis tend to be predominantly an upper lobe process. e. The presence of cough should prompt evaluation for a cause other than pulmonary sarcoidosis. 19- Which of the following finding is typically seen in patients with fibromyalgia? a. elevated C-reactive protein b. elevated thyroid stimulating hormone c. erosions of the metacarpophalangeal joints on radiographs d. Positive anti-nuclear antibody e. Skin roll tenderness on physical examination 20- Which of the following skin lesions is associated with Lyme disease? a. Erythema marginatum b. Erythema infectiosum c. Erythema migrans d. Erythema multiforme e. Erythema nodosum 21- A 50-year-old white woman presents with aching and stiffness in the trunk, hip, and shoulders. There is widespread muscle pain after mild exertion. Symptoms are worse in the morning and improve during the day. They are also worsened by stress. The patient is always tired and exhausted. She has trouble sleeping at night. On examination, joints are normal. ESR is normal, and Lyme antibody and HIV test are negative. The patient has multiple tender points to palpation on physical examination. She asks about the best treatment option for her condition. After telling her it is still under investigation, which is the most accurate next statement? a. Tricyclic antidepressants have proven to be the single most effective medication for the disorder. b. Given the fact that lack of restorative sleep has been determined to exacerbate the condition, the use of sleep-inducing medications such as zolpidem has been instrumental in the treatment. c. Low urinary cortisol in these patients has been noted; hence beginning long term, low dose prednisone has been effective in relieving symptoms. d. Chronic opiates are the first line of treatment for this debilitating condition. e. A multidisciplinary approach is most effective including treatment of any depression, physical therapy, an exercise program, support group attendance, and possibly the use of acetaminophen, gabapentin or similar medications as needed. 22- A 44-year-old woman presents with diffuse myalgias and excessive fatigue. She has morning stiffness and pain of all her joints, especially her wrists, elbows, shoulders, hips, knees, and neck. She does not sleep well at night. Her symptoms have been progressing for over four years. On physical examination, the patient has 13 tender points at the elbows, knees, shoulders, and hips. Which of the following is the most likely diagnosis? a. Polymyalgia rheumatica b. Rheumatoid arthritis c. Fibromyalgia syndrome d. Polymyositis e. Scleroderma 23- A 30-year-old woman presents to an internal medicine clinic for evaluation of joint pain and swelling of about 2 years duration accompanied by morning stiffness. She denies any back or neck pain. Symptoms have primarily affected her lower extremities. She notes intermittent swelling in her Achilles tendon, ankles, and knees. She denies any psoriasis or family history of skin disease. She denies any Achilles enthesitis, left ankle synovitis, and dactylitis of the third and fourth fingers of her right hand. Imaging of her sacroiliac joints with MRI shows no erosions or bone marrow edema. Laboratory testing shows an elevated C- reactive protein, negative rheumatoid factor, and negative anti-cyclic citrullinated protein antibodies. Which of the following is the most likely diagnosis? A. Ankylosing spondylitis B. Peripheral spondylarthritis C. Psoriatic arthritis D. Reactive arthritis E. Rheumatoid arthritis 24- A 57-year-old woman with depression and chronic migraine headache reports several years of dry mouth and dry eyes, her primary complaint is that she can no longer eat her favorite crackers, although she does report photosensitivity and eye burning on further questioning. She has no other associated symptoms. Examination shows dry, erythematous sticky oral mucosa. All of the following tests are likely to be positive in this patient EXCEPT: a. La/SS-B antibody b. Ro/SS-A antibody c. Schirmer test d. Scl-70 antibody e. Sialometry 25- All of the following arteries are commonly affected in Takayasu arteritis EXCEPT: a. Abdominal aorta b. Cerebral arteries c. Common carotid artery d. Renal artery e. Subclavian artery c. Soft tissue swelling d. Subchondral erosions e. Symmetric joint space loss 33- Most of the manifestations of acute rheumatic fever present approximately 3 weeks after the precipitating group A streptococcal infection. Which manifestation may present several months after the precipitating infection? a. Chorea b. Erythema marginatum c. Fever d. Polyarthritis e. Subcutaneous nodules 34- A 60-year-old, mildly obese woman presents complaining of bilateral medial right knee pain that occurs with prolonged standing. The pain does not occur with sitting or climbing stairs but seems to be worse with other activity and at the end of the day. The patient denies morning stiffness. Examination of the knees reveals no deformity, but there are small effusions. Some mild pain and crepitus are produced with palpation of the medial aspect of the knees. Which of the following is the most likely diagnosis? a. Psoriatic arthritis b. Rheumatoid arthritis c. Osteoarthritis d. Chondromalacia patellae e. Gouty arthritis 35- A 34-year-old woman has a 15-year history of Crohn’s disease . She presents to your office with the acute onset of right ankle and left knee pain. She recalls a worsening of her gastrointestinal symptoms a few days before the joint symptoms developed. Radiographs of the knee and ankle demonstrate soft tissue swelling and small effusions but no bone destruction. Which of the following statements is true? a. The patient requires high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) b. The patient is experiencing the most common extraintestinal manifestation of inflammatory bowel disease c. The patient is not HLA-B27 positive d. The patient will go on to develop bone erosion and destruction of the knee and ankle e. Controlling the intestinal symptoms will eliminate the knee and ankle arthritis 36- A 28-year-old woman presents with her third episode of left lower extremity deep venous thrombosis. She has a history of two second trimester miscarriages in the past. Laboratory data reveal an elevated activated partial thromboplastin time (PTT) that is not corrected by dilution with normal plasma and an abnormal dilute Russell’s viper venom. Which of the following is the most likely diagnosis? a. Libman-Sacks disease b. Antiphospholipid syndrome c. Takayasu’s arteritis d. Livedo reticularis e. Sjögren’s syndrome 37- A 49-year-old man presents with painful, recurring episodes of swelling in his left great toe. He takes 25 mg of hydrochlorothiazide daily for blood pressure control but otherwise is in good health. On physical examination, the patient is afebrile, but his great toe is warm, swollen, erythematous, and exquisitely tender to palpation. He has several subcutaneous nodules in his pinna. Which of the following is the most likely diagnosis? a. Calcium phosphate deposition disease b. Osteoarthritis of the great toe c. Monosodium urate deposition disease d. Calcium pyrophosphate dihydrate deposition disease e. Calcium oxalate deposition disease 38- A 31-year-old man presents with fever and arthralgias for one day. He complains of diffuse abdominal pain and inability to move his left foot due to weakness. He also states he has had hematuria for several hours. On physical examination, the patient has a temperature of 38.4°C (101.2°F). He has diffuse abdominal tenderness on palpation but has no rebound tenderness. Testicular exam reveals marked tenderness of the testes but no urethral discharge. Neurologic examination reveals a left footdrop . Which of the following is the most likely diagnosis? a. Polyarteritis nodosa b. Whipple’s disease c. Behçet’s syndrome d. Osteonecrosis 39- A 40-year-old woman complains of pain and swelling in both wrists and ankles for 7 weeks. She has several months of fatigue. Morning stiffness impairs her activities for approximately 2 hours. OTC naproxen provides temporary relief. On examination, the metacarpophalangeal (MCP) joints and wrists are warm and tender; there is slight tenderness to pressure over the ankles and metatarsophalangeal (MTP) joints as well. All other joints are normal. There is no alopecia, photosensitivity, kidney disease, or rash . Which of the following is correct? a. The clinical picture suggests early rheumatoid arthritis (RA), and a rheumatoid factor and anticyclic citrullinated peptide (antiCCP) should be obtained. b. An aggressive search for occult malignancy is indicated. c. Lack of systemic symptoms suggests osteoarthritis. d. The prodrome of lethargy suggests chronic fatigue syndrome (CFS). e. X-rays of the hand are likely to show joint space narrowing and erosion. 40- A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. She has a few telangiectasias over the chest but no erythema of the face or extensor surfaces. There is slight thickening of the skin over the hands, arms, and torso. What is the best diagnostic workup? a. BUN and creatinine b. Antinuclear, anti-Scl-70, and anticentromere antibodies c. Creatine kinase (CK) and antisynthetase antibodies (such as anti-Jo-1) d. Rheumatoid factor and anti-CCP antibodies e. Reproduction of symptoms and findings by immersion of hands in cold water 41- A 65-year-old man develops the onset of severe right knee pain over 24 hours . The knee is red, swollen, and tender. The patient does not have fever or systemic symptoms; he has never had severe joint pain before. Plain film of the knee shows linear calcification of the articular cartilage without destructive change. Definitive diagnosis is best made by which of the following? a. Rheumatoid factor b. ANA c. Arthrocentesis and identification of positively birefringent rhomboid crystals d. Serum uric acid e. Serum calcium b. Antineutrophil cytoplasmic antibody (ANCA) c. Gram stain and culture of joint fluid d. Uric acid level e. Urethral culture 49- A 40-year-old man complains of acute onset of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension. On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities. Which of the following is the best next step in management? a. Begin allopurinol if uric acid level is elevated. b. Obtain ankle x-ray to rule out fracture. c. Perform arthrocentesis. d. Begin colchicine and broad-spectrum antibiotics. e. Apply a splint or removable cast. 50- A 22-year-old man develops the insidious onset of low back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, rash, or nail changes. On examination, the patient has loss of mobility with respect to lumbar flexion and extension. He has a kyphotic posture. Which test or group of tests would be most supportive of your suspected diagnosis? a. A positive rheumatoid factor, anti-CCP, and an elevated C-reactive protein level. b. MRI of the lumbosacral spine showing spinal compression fractures associated with bony destruction. c. Lumbosacral x-rays showing vertebral joint space narrowing and osteophyte formation at various levels. d. An elevated sedimentation rate, a mild anemia on CBC, positive HLA-B27 in blood and sclerosis of the sacroiliac joints on plain films of the back. e. A colonoscopy with biopsy results consistent with Crohn disease. 51- A 75-year-old man complains of headache. On one occasion he transiently lost vision in his right eye. He also complains of aching in the shoulders and neck, particularly in the morning. There are no focal neurologic findings. Carotid pulses are normal without bruits. Laboratory data show a mild anemia. Erythrocyte sedimentation rate (ESR) is 85 . Which of the following is the best approach to management? a. Schedule temporal artery biopsy and begin corticosteroids based on biopsy results and clinical course. b. Start aspirin and defer any invasive studies unless further symptoms develop. c. Follow ESR and consider further studies if it remains elevated. d. Schedule carotid angiography. e. Begin glucocorticoid therapy and arrange for temporal artery biopsy. 52- A 35-year-old woman complains of aching all over. She sleeps poorly and all her muscles and joints hurt. Her symptoms have progressed over several years. She reports she is desperate because pain and weakness often cause her to drop things. Physical examination shows multiple points of tenderness over the neck, shoulders, elbows, and wrists. There is no joint swelling or deformity. A complete blood count and erythrocyte sedimentation rate are normal. Rheumatoid factor is negative. Which of the following is the best therapeutic option in this patient? a. Graded aerobic exercise b. Prednisone c. Weekly Methotrexate Hydroxychloroquine e. A nonsteroidal anti-inflammatory drug 53- A 28-year-old woman presents to her primary care physician with a 3-month history of fatigue. Her past medical history includes severe acne. She has had 3 uncomplicated vaginal deliveries and has healthy children aged 5, 3, and 2 years. Questioning reveals that she develops an erythematous rash upon minimal sun exposure, and has heavy menstrual periods despite being on oral contraceptives for the past 2 years. For the past 6 months, she has taken minocycline for acne. Physical examination reveals small joint effusions and tenderness to palpation of the knees bilaterally. Lab testing reveals a normocytic anemia, thrombocytopenia, mild hyper-bilirubinemia, and a marked elevation in her ANA titer. Which of the following statements best characterizes this patient’s illness? a. Her anemia is due to bone marrow suppression from chronic disease. b. Her anemia is due to iron deficiency. c. Minocycline should be discontinued. d. Anti-histone antibodies are likely to be negative. e. The likelihood of this patient developing venous thromboembolism is comparable to the general population. 54- A 53-year-old man presents with arthritis, cough, hemoptysis, and bloody nasal discharge. Urinalysis reveals 4+ proteinuria, RBCs, and RBC casts. Chest x-ray shows several bilateral cavitary nodules. CT scan of chest is reproduced below. ANCA is positive in a cytoplasmic pattern. Antiproteinase 3 (PR3) antibodies are present, but antimyeloperoxidase (MPO) antibodies are absent. Which of the following is the most likely diagnosis? a. Behçet syndrome b. Sarcoidosis c. Granulomatosis with polyangiitis (Wegener granulomatosis) d. Henoch-Schönlein purpura e. Classic polyarteritis nodosa 55- A 17-month-old boy has a history of multiple fractures due to “brittle bones .” The child is short in stature and has a deformed skull. Physical examination is normal except for the finding of blue scleras. Which of the following is the most likely diagnosis? a. Osteoporosis b. Osteomalacia c. Achondroplasia d. Osteitis deformans e. Osteogenesis imperfect 56- A 25-year-old man presents with morning back pain and stiffness and tenderness over the sacroiliac joints. The patient denies any previous history of eye or genitourinary problems. On physical examination, there is diminished chest expansion with breathing. Which of the following is the most likely diagnosis? a. Sjögren’s syndrome b. Ankylosing spondylitis c. Systemic lupus erythematosus d. Reiter’s syndrome e. Rheumatoid arthritis 57- A 28-year-old law student complains of blanching and cyanosis of her fingertips in cold weather and in times of emotional stress. She complains that her fingers become numb and painful during these episodes. She has a six-month history of dysphagia and arthralgias. She d. Thrombocytopenia e. Cutaneous vasculitis 64- A 32-year-old female is seen in the emergency department for acute shortness of breath. A helical CT shows no evidence of pulmonary embolus, but inciden¬tal note is made of dilatation of the ascending aorta to 4.3 cm. All the following are associated with this finding EXCEPT: a. Systemic lupus erythematosus b. Rheumatoid arthritis c. Giant cell arteritis d. Takayasu’s arteritis e. Syphilis 65- A 46-year-old woman with SLE presents with episodic swelling of her ears and nose. On physical examination, her nose is swollen and tender to palpation. Her ears are not acutely inflamed but are atrophic and deformed. This patient is at increased risk for which of the following conditions? a. Asphyxiation b. Myocarditis c. Bacteremia d. Embolus e. Blindness 66- A 24-year-old man with a two-year history of ankylosing spondylitis presents for his regularly scheduled appointment. An electrocardiogram reveals first-degree heart block. Which of the following heart sounds is most likely to be audible in this patient? a. Pericardial friction rub b. Diastolic rumbling murmur c. Systolic murmur that radiates to the carotid artery d. Midsystolic click with systolic murmur e. Holosystolic murmur that radiates to the axilla f. Diastolic murmur with an opening snap 67- Which of the following laboratory findings is most consistent with poststreptococcal glomerulonephritis? a. Positive antinuclear antibody titers b. Positive blood cultures c. Positive cryoglobulin titers d. Elevated ASO titers 68- A 24-year-old woman is newly diagnosed with systemic lupus erythematosus. Which of the following organ system complications is she most likely to have over the course of her lifetime? a. Renal b. Cutaneous c. Cardiopulmonary d. Hematologic e. Musculoskeletal 69- A 76-year-old man complains of a 1-year history of low back and buttock pain that worsens with walking and is relieved by sitting or bending forward. He has hypertension and takes hydrochlorothiazide but has otherwise been healthy. There is no history of back trauma, fever, or weight loss. On examination, the patient has a slightly stooped posture, pain on lumbar extension, and has a slightly wide based gait. Pedal pulses are normal and there are no femoral bruits. Examination of peripheral joints and skin is normal. What is the most likely cause for this patient’s back and buttock pain? a. Herniated nucleus pulposus b. Atherosclerotic peripheral vascular disease c. Facet joint arthritis d. Lumbar spinal stenosis e. Prostate cancer 70- A 30-year-old quadriplegic man presents to the emergency room with fever, dyspnea, and cough. He has a chronic indwelling Foley catheter. Recurrent urinary tract infections have been a problem for a number of years. He has been on therapy to suppress the urinary tract infections. On examination, the patient has a temperature of 38°C (100.4°F), HR 88, and BP 126/76. Mild wheezing is audible over both lungs. A diffuse erythematous rash is noted. The chest x-ray shows diffuse alveolar infiltrates. The CBC reveals a WBC of 13,500, with 50% segmented cells, 30% lymphocytes, and 20% eosinophils. Which of the following is the most likely diagnosis? a. Acute exacerbation of COPD b. Drug reaction to one of his medications c. Health care-related pneumonia d. Sepsis with acute respiratory distress syndrome (ARDS) secondary to urinary tract infection e. Lymphocytic interstitial pneumonitis 72- Patients with antiphospholipid syndrome will often falsely test positive for which of the following infectious diseases? a. Syphilis b. Schistosomiasis c. Malaria d. Hepatitis C e. Human immunodeficiency virus (HIV) 73- A 28-year-old woman has been told she has rheumatic heart disease, specifically mitral stenosis. Which of the following murmurs is most likely present? a. Diastolic rumble at apex of the heart b. Late-peaking systolic murmur at right upper sternal border c. Holosystolic murmur at apex d. Early diastolic decrescendo at right upper sternal border 74- A 60-year-old woman complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On examination, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. Which of the following best describes the pathophysiology of the condition? a. Previous exposure to group A streptococcal organisms have stimulated an autoimmune response that leads to cross-reactivity between host and organism with tissue destruction and reduced tear and saliva production. c. Rheumatoid arthritis d. Systemic lupus erythematosus e. Osteoarthritis f. Pseudogout 80- A 72-year-old man develops severe pain and swelling in both knees, shortly after undergoing an abdominal hernia repair surgery. Physical examination shows warmth and swelling of both knees with large effusions. Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly positive birefringent crystals in the synovial fluid. Gram stain is negative. Which of the following is the most likely diagnosis? a. Reactive arthritis b. Septic arthritis c. Calcium oxalate deposition disease d. Pseudogout e. Gout 81. Rheumatic fever develops due to an autoimmune process. Which of the following mechanisms of autoimmunity is primarily responsible for the development of rheumatic fever? A. Intrinsic cytokine imbalance b. Endocrine abnormalities c. Increased T-cell help due to cytokine stimulation d. Increased B-cell function e. Molecular mimicry 82- Acute onset of unilateral elbow swelling, warmth, and tenderness and cervical discharge in a 25-year-old woman a. Pseudogout b. Rheumatoid arthritis c. Gout d. Gonococcal arthritis e. Systemic Lupus Erythematosus f. Osteoarthritis 83- Symmetric bilateral ulnar deviation of both hands in a 42-year-old woman a. Pseudogout b. Rheumatoid arthritis c. Gout d. Gonococcal arthritis e. Systemic Lupus Erythematosus f. Osteoarthritis Rheumatoid arthritis gives the ulnar deviation of the fingers 83- Painful, swollen metatarsophalangeal great toe (unilateral) with redness and warmth after eating steak and shrimp dinner in a 45-year-old man. a. Pseudogout b. Rheumatoid arthritis c. Gout d. Gonococcal arthritis e. Systemic Lupus Erythematosus f. Osteoarthritis Gouty arthritis often affects the first metatarsophalangeal joint and can be precipitated by various food or alcohol. 84- A 17-year-old sexually active adolescent male presents with a 5- day history of fever, chills, and persistent left ankle pain and swelling. On physical examination, maculopapular and pustular skin lesions are noted on the trunk and extremities. He denies any symptoms of Genitourinary tract infection. Synovial fluid analysis is most likely to show which of the following? a. WBCs 500/mm3 with 25% polymorphonuclear leukocytes b. WBCs 48000/mm3 with 80% lymphocytes c. RBCs 100 000/mm3, WBCs 1000/mm3 d. WBCs 75000/mm3 with 95% polymorphonuclear leukocytes 85- a 65-year-old man with a history of chronic hypertension, diabetes mellitus, and degenerative joint disease presents with acute onset of severe pain of the metatarsophalangeal (MTP) joint and swelling of the left first toe. Physical examination show exquisite tenderness of the joint, with swelling, warmth, and erythema. The patient has no history of trauma or other significant medical problems. Synovial fluid analysis and aspiration is most likely to show which of the following? a. Hemorrhagic fluid b. Gram-negative organisms c. Rhomboidal, positively birefringent crystals d. Noninflammatory fluid e. Needle-shaped, negatively birefringent crystals 86- Which of the following patients is most likely to be a candidate for bone mineral density screening? a. A 35-year-old asthmatic woman who took prednisone 40 mg/d for a 2-week course 1 week ago b. A 65-year-old, thin, white woman who smokes and is 15 years postmenopausal c. A healthy 75-year-old white man who is sedentary d. A 60-year-old overweight African American woman e. A 40-year-old white woman who exercises daily and still menstruates. 87- Which of the following diagnostic tests is most likely to give the diagnosis for the Gonococcal arthritis? a. Culture of joint fluid b. Crystal analysis of joint fluid c. Blood culture d. Cervical culture 88- A 23-year-old woman is evaluated by her primary care physician because she is concerned that she may have systemic lupus erythematosus after hearing a public health announcement on the radio. She has no significant past medical history, and her only medication is occasional ibuprofen. She is not sexually active and works in a grocery store. She reports that she has had intermittent oral ulcers and right knee pain. Physical examination shows no evidence of alopecia, skin rash, or joint swelling/inflammation. Her blood work shows that she has a positive antinuclear antibody (ANA) at a titer of 1:40, but no other abnormalities. Which of the following statements is true? 95- A 72-year-old man complains of painful joints in his hips and knees, which you have diagnosed as osteoarthritis. Which of the following is the best agent to prescribe for this patient? a. Oral prednisone b. Acetaminophen c. Intra-articular prednisone d. Naproxen sodium e. Celecoxib 96- During which of the following periods in woman’s life is the most bone mass accumulated? a. Ages 15-25 b. Ages 25-35 c. Ages 35-45 d. Ages 45-55 97- A 64-year-old woman presents with 6 weeks of fatigue, dyspnea, and night sweats. She has lost 11 lb. She has no history of trauma, has never had surgery, and takes no medications. Chest x-ray reveals a large right-sided pleural effusion. Thoracentesis yields pleural fluid that appears milky. Pleural fluid triglyceride level is 500 mg/dL. Which of the following disorders is most likely in this patient? a. Pneumonia b. Lymphoma c. Congestive heart failure d. Pulmonary embolism e. Systemic lupus erythematosus 98- A 53-year-old male with septic shock develops acute renal failure with a serum creatinine of 565.76 mkmol/L. Which of the following is a specific indication to initiate dialysis? a. Hematocrit falls to Slt;30%. b. Urine output falls to Slt;10 mL/h. c. Pericardial friction rub develops d. BUN rises to 75 mg/dL. 99- A 19-year-old man was seen at the university student health clinic a week ago complaining of pharyngitis, and now returns because he has noted discoloration of his urine. He is noted to have elevated blood pressure (178/110 mm Hg), and urinalysis reveals red blood cell (RBC) casts, dysmorphic RBCs, and 1+ proteinuria. Which of the following is the most likely diagnosis? a. SLE b. Amyloidosis c. HIV nephropathy d. Poststreptococcal glomerulonephritis 100- A 19-year-old recent immigrant from Ethiopia comes to your clinic to establish primary care. She currently feels well. Her past medical history is notable for a recent admission to the hospital for new-onset atrial fibrillation. As a child in Ethiopia, she developed an illness that caused uncontrolled flailing of her limbs and tongue lasting approximately 1 month. She also has had three episodes of migratory large-joint arthritis during her adolescence that resolved with pills that she received from the pharmacy. She is currently taking metoprolol and warfarin and has no known drug allergies. Physical examination reveals an irregularly irregular heart beat with normal blood pressure. Her point of maximal impulse (PMI) is most prominent at the midclavicular line and is normal in size. An early diastolic rumble and 3/6 holosystolic murmur are heard at the apex. A soft early diastolic murmur is also heard at the left third intercostal space. You refer her to a cardiologist for evaluation of valve replacement and echocardiography. What other intervention might you consider at this time? a. Monthly penicillin G injections b. Daily doxycycline c. Daily aspirin d. Low-dose corticosteroids e. Penicillin G injections as needed for all sore throats Nayana question paper 1) A 32-year-old woman presents to the clinic with right thumb and wrist pain that has worsened over several weeks. She has pain when she pinches her thumb against her other fingers. Her only other history is that she is a new mother with an 8-week- old infant at home. On physical examination, she has mild swelling and tenderness over the radial styloid process, and pain is elicited whenshe places her thumb in her palm and grasps it with her fingers. A Phalen maneuver is negative. Which condition is most likely? A. Carpal tunnel syndrome B. De Quervain tenosynovitis C. Gouty arthritis of the first metacarpophalangeal joint D. Palmar fasciitis E. Rheumatoid arthritis 2) A 58-year-old woman presents complaining of right shoulder pain. She does not recall any prior injury but notes that she feels that the shoulder has been getting progressively stiffer over the last several months. She previously had several episodes of bursitis of the right shoulder that were treated successfully with nonsteroidal anti- inflammatory drugs and corticosteroid injections. The patient’s past medical history is also significant for diabetes mellitus, for which she takes metformin and glyburide. On physical examination, the right shoulder is not warm or red but is tender to touch. Passive and active range of motion are limited in flexion, extension, and abduction. A right shoulder radiogram shows osteopenia without evidence of joint erosion or osteophytes. What is the most likely diagnosis? a. Adhesive capsulitis b. Avascular necrosis c. Bicipital tendinitis d. D. Osteoarthritis e. E. Rotator cuff tear 3) All of the following can cause bursitis except? a) Bacterial infection b) Gout c) Rheumatoid arthritis d) Overuse e) fibromyalgia tender and swollen; the earlobe appears minimally swollen but is neither red nor tender. Which of the following is the most likely explanation for this finding? A. Behçet syndrome B. Cogan syndrome C. Hemoglobinopathy D. Recurrent trauma E. Relapsing polychondritis 13) A 64-year-old woman is evaluated for weakness.She has had several weeks of difficulty brushing her teeth and combing her hair. She has also noted a rash on her face.Examination is notable for a heliotrope rash and proximal muscle weakness. Serum creatinine kinase is elevated, and she is diagnosed with dermatomyositis. After evaluation by a rheumatologist, she is found to have anti-Jo-1 antibodies. She is also likely to have which of the followingadditional findings? A. Ankylosing spondylitis B. Inflammatory bowel disease C. Interstitial lung disease D. Primary biliary cirrhosis E. Psoriasis 14) All of the following therapeutic agents are used in the treatment of polymyositis EXCEPT: A. Azathioprine B. Mycophenolate Mofetil C. Prednisone D. Rituximab E. Secukinumab 15) A 58-year-old man presents to the clinic for a routine follow-up visit. He notes he has been dropping things more frequently and is having trouble rising from a seated position. He also notes some trouble swallowing and needing to swallow multiple times for one bite of food.On physical examination he has 4/5 strength in his kneeextensors, 3/5 strength in his finger flexors, and atrophy in the medial thighs and forearms. On laboratory studies, his creatinine kinase is two times the upper limit of normal. You decide to pursue a muscle biopsy. What findings are likely to be noted on the muscle biopsy by light microscopy? A. Multifocal necrotic and regenerating muscle fibers with a paucity of inflammation B. Perifascicular muscle atrophy C. Perivascular inflammatory cell infiltrate with no endomysial inflammation D. Rimmed vacuoles and inclusions E. Type 2 muscle fiber atrophy 16) Which of the following is required for the diagnosis of Behçet syndrome? A. Large vessel vasculitis B. Pathergy test C. Recurrent oral ulceration D. Recurrent genital ulceration E. Uveitis 17) All of the following conditions occur in association with Behçet syndrome EXCEPT: A. Arthritis B. Deep venous thrombosis C. Folliculitis D. Genital ulcers E. Scleritis 18) Lung biopsy has the greatest diagnostic yield in which of the following vasculitic syndromes? A. Cryoglobulinemic vasculitis B. Cutaneous vasculitis C. Granulomatosis with polyangiitis (Wegener) D. IgA vasculitis (Henoch-Schönlein) E. Polyarteritis nodosa 19) You are seeing in follow-up a 46-year-old man who, 6 months ago, presented to the hospital acutely with hemoptysis, diffuse nodular pulmonary infiltrates, and glomerulonephritis. Workup revealed a positive serologic study for antibodies against cytoplasmic antineutrophil cytoplasmic antibodies (ANCA), and he was eventually diagnosed with granulomatosis with polyangiitis. Treatment was initiated with high-dose glucocorticoids and daily cyclophosphamide with excellent clinical response. You are ready today to have the patient transition from induction therapy with cyclophosphamide to maintenance therapy with azathioprine. What blood test should you check before starting azathioprine? A. ANCA titers B. Cryoglobulins C. CYP3A4 genotyping D. Glucose-6-phosphate dehydrogenase enzyme levels E. Thiopurine methyltransferase enzyme activity 20) A 54-year-old man is evaluated for cutaneous vasculitis and peripheral nephropathy. Because of concomitant renal dysfunction, he undergoes kidney biopsy that shows glomerulonephritis. Cryoglobulins are demonstrated in the peripheral blood. Which of the following laboratorystudies should be sent to determine the etiology? A. Hepatitis B surface antigen B. Antineutrophil cytoplasmic antibody C. Hepatitis C polymerase chain reaction D. HIV antibody E. Rheumatoid factor 21) A 40-year-old male presents to the emergency department with 2 days of low- volume hemoptysis. He reports that he has been coughing up 2–5 tablespoons of blood each day. He does report mild chest pain, lowgrade fevers, and weight loss. In addition, he has had about 1 year of severe upper respiratory symptoms including frequent epistaxis and purulent discharge treated with several courses of antibiotics. Aside from mild hyperlipidemia, he is otherwise healthy. His only medications are daily aspirin and lovastatin. On physical examination he has a saddle nose deformity. His vital signs are normal and his lungs areclear. A CT of the chest shows multiple 1- to 2- cm cavitating nodules, and urinalysis shows red blood cells. Which of the following tests offers the highest diagnostic yield tomake the appropriate diagnosis? A. Deep skin biopsy B. Percutaneous kidney biopsy C. Pulmonary angiogram D. Surgical lung biopsy E. Upper airway biopsy 22) A 55-year-old man presents to the emergency department with weight loss, fever, testicular pain, and a new rash on his legs. On physical examination, he has abdominal tenderness and raised nonblanching erythematous lesions on his legs. Laboratory studies show an elevated erythrocyte sedimentation rate and C-reactive protein as well as a positive hepatitis B surface antigen. He undergoes a surgical skin biopsy. The biopsy is most likely to show: A. Fibrinoid necrosis of small- and medium-sized arteries B. Interface dermatitis C. Leukocytoclastic vasculitis with IgA deposition on immunofluorescence D. Noncaseating granulomas E. Septal panniculitis 23) Which cardiac valvular lesion is most common in patients with ankylosing spondylitis? A. Aortic regurgitation B. Mitral regurgitation C. Mitral stenosis D. Pulmonic stenosis E. Tricuspid regurgitation 24) All of the following help distinguish psoriatic arthritis from other joint disorders EXCEPT: A. Dactylitis B. Enthesitis C. Nail pitting D. Presence of diarrhea E. Shortening of digits A. Are less likely to develop extra-articular manifestations of RA (e.g., vasculitis) B. Are less likely to have a history of smoking C. Develop fewer subchondral bone erosions on imaging over their disease course D. Have a higher prevalence of shared epitope (HLADRB1) risk alleles E. Have lower scores for physical disability 35) A 27-year-old woman is admitted to the intensive care unit after recent delivery of a full-term infant 3 days prior. The patient was found to have right hemiparesis and a blue left hand. Physical examination is also notable for livedo reticularis. Her laboratories were notable for a white blood cell count of 10.2/μL, hematocrit of 35%, and platelet count of 13,000/μL. Her blood urea nitrogen is 36 mg/dL, and her creatinine is 2.3 mg/dL. Although this pregnancy was uneventful, the three prior pregnancies resulted in early losses. A peripheral smear shows no evidence of schistocytes. Which of the following laboratory studies will best confirm the underlying etiology of her presentation? A. Anticardiolipin antibody panel B. Antinuclear antibody C. Doppler examination of her left arm arterial tree D. Echocardiography E. MRI of her brain 36) All of the following statements regarding antiphospholipid antibodies are true EXCEPT: a. Antiphospholipid antibodies are generally directed against negatively charged phospholipids including cardiolipin, phosphocholine, and phosphatidylserine. b. Patients who are positive for the lupus anticoagulant will have an elevated activated partial thromboplastin time in vitro. c. Patients with antiphospholipid antibodies may test false positive for syphilis. d. The majority of patients with systemic lupus erythematosus and antiphospholipid antibodies develop clinical manifestations of antiphospholipid syndrome 37) All of the following are predisposing factors for systemic lupus erythematosus EXCEPT: A. C1 esterase inhibitor deficiency B. Female sex C. HLA-DR alleles D. Smoking E. Ultraviolet light 38) Which of the following findings is typically seen in patients with fibromyalgia? A. Elevated C-reactive protein B. Elevated thyroid-stimulating hormone C. Erosions of the metacarpophalangeal joints on radiographs D. Positive anti-nuclear antibody E. Skin roll tenderness on physical examination 39) Which of the following joints is often spared by osteoarthritis? A. Cervical spine B. Distal interphalangeal joint C. Hip D. Proximal interphalangeal joint E. Wrist 40) Which of the following statements regarding pulmonary sarcoidosis is true? a. Lung involvement is the second most common manifestation of sarcoidosis, behind only cutaneous involvement. B. Obstructive disease is a rare manifestation of pulmonary sarcoidosis. C. Pulmonary hypertension never responds to therapy in sarcoidosis patients. D. Pulmonary infiltrates in sarcoidosis tend to be predominantly an upper lobe process. E. The presence of cough should prompt evaluation for a cause other than pulmonary sarcoidosis. Case questions(2 Marks each) 1. A 45-year-old African American woman with systemic lupus erythematosus (SLE) presents to the emergency department with complaints of headache and fatigue. Her prior manifestations of SLE have been arthralgias, hemolytic anemia, malar rash, and mouth ulcers, and she is known to have high titers of antibodies to doublestranded DNA. She currently is taking prednisone, 5 mg daily, and hydroxychloroquine, 200 mg daily. On presentation, she is found to have a blood pressure of 190/110 with a heart rate of 98 beats/min. A urinalysis shows 25 red blood cells (RBCs) per high-powered field with 2+ proteinuria. No RBC casts are identified. Her blood urea nitrogen is 88 mg/dL, and creatinine is 2.6 mg/dL (baseline 0.8 mg/dL). She has not previously had renal disease related to SLE and is not taking nonsteroidal anti-inflammatory drugs. She denies any recent illness, decreased oral intake, or diarrhea. a. How can you explain onset of new symptoms,signs and test results? b. What is the most appropriate next step in the management of this patient? Answer: a. Explanation of onset of new symptoms,signs and test results: • This patient is presenting with acute lupus nephritis with evidence of hematuria, proteinuria, and an acute rise in creatinine. • It is important to assess for other potentially reversible causes of acute renal insufficiency, but this patient is not otherwise acutely ill and is taking no medications that would cause renal failure. • The urinalysis shows evidence of active nephritis with hematuria and proteinuria. • Even in the absence of red blood cell casts, therapy should not be withheld to await biopsy results in someone with a known diagnosis of SLE with consistent clinical presentation and urinary findings. • This patient also has other risk factors known to predict the development of lupus nephritis, including high titers of antidsDNA and African American race. b. Most appropriate step in management of this patient is : Begin high-dose systemic glucocorticoids. (IV methylprednisolone, 1000 mg daily for three doses, followed by oral prednisone, 1 mg/kg daily) and mycophenolate mofetil, 2 g daily. 2. A 19-year-old recent immigrant from Ethiopia comes to your clinic to establish primary care. She currently feels well. Her past medical history is notable for a recent admission to the hospital for new-onset atrial fibrillation. As a child in Ethiopia, she developed an illness that caused uncontrolled flailing of her limbs and tongue lasting approximately 1 month. She also has had three episodes of migratory large-joint arthritis during her adolescence that resolved with pills that she received from the pharmacy. She is currently taking metoprolol and warfarin and has no known drug allergies. Physical examination reveals an irregularly irregular heart beat with normal blood pressure. Her point of maximal impulse is most prominent at the midclavicular line and is normal in size. An early diastolic rumble and 3/6 holosystolic murmur are heard at the apex. A soft early diastolic murmur is also heard at the left third intercostal space. You refer her to a cardiologist for evaluation of valve replacement and echocardiography. a. What is the diagnosis of this patient and what are the clinical features supporting the diagnosis? b. What other intervention might you consider at this time? Answer: a. Diagnosis of the patient? • This patient has a history suggestive of recurrent bouts of acute rheumatic fever (ARF) ,since she is of ethiopian origin and there is also evidence of mitral regurgitation, mitral stenosis, and aortic regurgitation on physical examination. • This and the presence of atrial fibrillation imply severe rheumatic heart disease. • Risk factors for this condition include poverty and crowded living conditions. b. Interventions: • Daily aspirin is the treatment of choice for the migratory large-joint arthritis and fever that are common manifestations of ARF. • Secondary prophylaxis with either daily oral penicillin or, preferably, monthly IM injections is considered the best method to prevent further episodes of ARF and, therefore, prevent further valvular damage. 3. A 30-year-old woman presents to an internal medicine clinic for evaluation of joint pain and swelling of about 2 years duration accompanied by morning stiffness. She denies any back or neck pain. Symptoms have primarily affected her lower extremities. She notes intermittent swelling in her Achilles tendons, ankles, and knees. She denies any psoriasis or family history of skin disease. She denies any gastrointestinal symptoms or preceding • Laboratory findings are nonspecific with elevations in the erythrocyte sedimentation rate and the white blood cell count. b. Treatment • For oral ulcerations, topical steroids or sucralfate solution are first-line therapy for mild isolated ulcerations. Colchicine has also been used to prevent mucocutaneous relapse. For severe mucocutaneous lesions, systemic corticosteroids, azathioprine, interferon-alfa, colchicine can be used. • For ocular disease, azathioprine is widely used as the initial agent. For severe eye disease , either cyclosporine or infliximab may be used in combination with azathioprine and corticosteroids. 6. You are seeing a 19-year-old woman today in consultation for recurrent fevers. She reports several years of fevers, occurring on average every 2–3 months. These episodes are unpredictable, although she thinks they may occur in times of psychological stress. Each febrile episode lasts 2–3 days. She also has recurrent episodes of abdominal pain. Repeated blood cultures have been negative, even during acute febrile episodes. Similarly, abdominal CT scans have shown no obvious etiology for her pain. During one episode, she underwent an exploratory laparotomy, which showed peritoneal adhesions and a sterile neutrophilic peritoneal exudate. She also notes that when she exercises, she develops intense muscle pains that last for days. An extensive serologic search for autoantibodies returned negative, including anti-nuclear antibodies. a. Which of the following is the most likely diagnosis? b. What is the appropriate treatment for this disease? Answer: a. The most likely diagnosis is familial Mediterranean fever.It is the prototype of a group of inherited diseases that are characterized by recurrent episodes of fever with serosal, synovial, or cutaneous inflammation. Attacks are often unpredictable, although some patients relate them to physical exertion. b. Treatment for familial Mediterranean fever: Colchicine is primarily effective as a prophylactic treatment for the FMF attacks. It is recommended in all patients regardless of the frequency and intensity of attacks. 7. A 42-year-old woman is seen in her primary care doctor’s office complaining of diffuse pains and fatigue. She has a difficult time localizing the pain to any particular joint or location, but she reports it affects her upper and lower extremities, neck, and hips. It is described as achy and 10 out of 10 in intensity. She feels that her joints are stiff but does not notice that it is worse in the morning. The pain has been present for the last 6 months and is increasing in intensity. She has tried both over-thecounter ibuprofen and acetaminophen without significant relief. The patient feels as if the pain is interfering with her ability to get restful sleep and is making it difficult for her to concentrate. She has missed multiple days of work as a waitress and fears that she will lose her job. There is a medical history of depression and obesity. The patient is currently taking venlafaxine sustained release 150 mg daily. She has a family history of rheumatoid arthritis in her mother. She smokes one pack of cigarettes daily. On physical examination, vital signs are normal. Body mass index is 36 kg/m2 . Joint examination demonstrates no erythema, swelling, or effusions. There is diffuse pain with palpation at the insertion points of the suboccipital muscles, at the midpoint of the upper border of the trapezius muscle, along the second costochondral junction, at the lateral epicondyles, and along the medial fat pad of the knees. a. What is the cause of the patient’s diffuse pain syndrome? b. How to manage this patient? Answer: a. This patient presents with a characteristic history for fibromyalgia, a diffuse pain syndrome associated with increased sensitivity to evoked pain. The underlying pathophysiology of pain in fibromyalgia is related to altered pain processing in the central nervous system. The most common presenting complaint is diffuse pain that is difficult to localize. Pain is both above and below the waist and affects the extremities as well as the axial skeleton. However, it does not localize to a specific joint. The pain is noted to be severe in intensity and difficult to ignore and interferes with daily functioning. b. Management is by both medications and self care strategies: The focus of treatment should not be on eliminating pain but improving function and quality of life. Medications : Pain releivers, Tricyclic antidepressants, Anti seizure drugs can be sometimes effective Therapy- physical therapy, occupational therapy and counseling 8. A 36-year-old woman presents to your office with diffuse pain throughout her body associated with fatigue, insomnia, and difficulty concentrating. She finds the pain difficult to localize but reports that it is 7–8 out of 10 in intensity and not relieved by nonsteroidal antiinflammatory medications. She has a long-standing history of generalized anxiety disorder and is treated with sertraline 100 mg daily as well as clonazepam 1 mg twice daily. On examination, she has pain with palpation at several musculoskeletal sites. Her laboratory examination demonstrates a normal complete blood count, basic metabolic panel, erythrocyte sedimentation rate, and rheumatoid factor. You diagnose her with fibromyalgia. a. What is the mechanism of this disease? b. What is the best treatment plan for this lady? Answer: a. The pathophysiology of fibromyalgia is influenced by abnormal pain signaling, genetic predispositions, abnormal neuroendocrine and autonomic system activity, environmental triggers, and sleep disturbances. The pathogenesis of fibromyalgia is not well understood, and the diagnosis remains clinical in practice. The enhanced pain sensitivity and persistence of widespread pain in people with fibromyalgia may be caused by changes in the central processing of sensory input and deficiencies in endogenous pain inhibition. b. Treatment: • Treatment for fibromyalgia should include a combination of nonpharmacologic and pharmacologic approaches. • Patient education regarding the disease is important to provide a framework for understanding symptoms. • The focus of treatment should not be on eliminating pain but improving function and quality of life. • Physical conditioning is an important part of improving function and should include a multifaceted exercise program with aerobic exercise, strength training, and exercises that incorporate relaxation techniques. • Cognitive behavioral therapy can be useful in improving sleep disturbance and also for decreasing illness behaviors. • Pharmacologic therapy in fibromyalgia is targeted at the afferent and efferent pain pathways. The two most common categories of medications for fibromyalgia are antidepressants and anticonvulsants. • Amitriptyline, duloxetine, and milnacipran have all been used with some efficacy in fibromyalgia. The anticonvulsants that are predominantly used include gabapentin and pregabalin 9. A 32-year-old woman is seen in the clinic with a complaint of left knee pain. She enjoys running long distances and is currently training for a marathon. She is running on average 30–40 miles weekly. She currently is experiencing an aching pain on the lateral aspect of her left knee. There is a burning sensation that also continues up the lateral aspect of her thigh. She denies any injury to her knee, and she has not felt that it was hot or swollen. She is otherwise healthy and takes no medications other than herbal supplements. Physical examination of the knee reveals point tenderness over the lateral femoral condyle that is worse with flexing the knee. The patient is asked to lie on her right side with her right knee and hip flexed at 90 degrees. Her left leg is extended at the hip and slowly lowered into adduction behind the bottom leg, reproducing the patient’s left knee pain. a. What is the possible mechanism of this pathology? b. What is the recommended treatment plan for this patient? Answer a. This patient presents with inflammation of the iliotibial band. The iliotibial band is a thick connective tissue that runs along the outer thigh from the ilium to the fibula. When this band becomes tightened or inflamed, pain most commonly occurs where the band passes over the lateral femoral condyle of the knee, leading to a burning or aching pain in this area that can radiate toward the outer thigh. This overuse injury is most often seen in runners and can be caused by improperly fitted shoes, running on uneven surfaces, and excessive running. It is also more common in individuals with a varus alignment of the knee (bowlegged). b. Treatment of iliotibial band syndrome involves rest, nonsteroidal anti-inflammatory drugs, physical therapy, and addressing risk factors such as poorly fitted shoes or uneven running