Final study questions

Question 1

True or False: Rheumatic conditions generally affect men more often than women.

Answer 1

false

Question 2

Which of the following types of molecules commonly trigger pattern-recognition receptors in the innate immune system?

a. Pathogen-associated molecular patterns (PAMPs)
b. Damage-associated molecular patterns (DAMPs)
c. Both A and B
d. None of the above

Answer 2

c. Both A and B

Question 3

Antigen presenting cells commonly present antigens to T-cells through which of the following:

a. Pattern recognition receptors (PRRs)
b. Major histocompatibility complexes (MHCs)
c. T-cell receptors (TCRs)
d. Toll-like receptors (TLRs)

Answer 3

b. Major histocompatibility complexes (MHCs)

Question 4

Which of the following is NOT commonly considered to be an immunogenic determinant?

a. Dosage, route, and timing of antigen
b. Molecular size of antigen
c. Reduction in Treg activity
d. Genetic constitution of the host

Answer 4

c. Reduction in Treg activity

Question 5

Which of the following are considered to be environmental triggers for autoimmunity:

a. Hormone production
b. Infections
c. Vaccinations
d. A and B only
e. All of the above

Answer 5

d. A and B only

Question 6

Which of the following medications does NOT need regular routine monitoring of liver enzymes while a patient is on it?

a. Hydroxychloroquine
b. Azathioprine
c. Methotrexate
d. Leflunomide

Answer 6

a. Hydroxychloroquine

Question 7

Which of the following DMARDs is absolutely contraindicated in a pregnant woman?

a. Methotrexate
b. Sulfasalazine
c. Hydroxychloroquine
d. A and B

Answer 7

a. Methotrexate

Question 8

Which of the following is NOT true of using NSAIDs for rheumatic conditions?

a. They act as an analgesic and anti-inflammatory
b. They can be used to stop the progression of tissue injury
c. They can increase the risk of MI, stroke and death if used chronically
d. None of the above

Answer 8

b. They can be used to stop the progression of tissue injury

Question 9

Which of the following therapies would be the BEST option for correcting intestinal dysbiosis in a rheumatic patient?

a. Vitamin B12
b. Berberine
c. Bromelain
d. Curcumin

Answer 9

b. Berberine

Question 10

Which of the following options is MOST correct regarding diagnostic imaging for septic arthritis in a peripheral joint?

a. Plain films are very sensitive for early septic arthritis in a peripheral joint
b. Diagnostic ultrasound is reliable in detecting joint effusion in early cases
c. Tuberculous arthritis progresses faster than staph septic arthritis
d. CT is the first line investigative method for suspected septic arthritis in a peripheral joint

Answer 10

b. Diagnostic ultrasound is reliable in detecting joint effusion in early cases

Question 11

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the left knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

Which of the following is NOT a risk factor for this patient for gout?

a. His BMI
b. His history of type II diabetes
c. His recent steroid injection
d. None of the above

Answer 11

c. His recent steroid injection

Question 12

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the left knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

What clinical step would be indicated at this time?

a. Prescribe NSAIDs and tell him to elevate knee and apply ice.
b. Obtain an MRI to r/o ligament tear
c. Oral steroids to help prevent joint damage
d. Refer for immediate joint aspiration

Answer 12

d. Refer for immediate joint aspiration

Question 13

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the left knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

True or False: Normal serum uric acid levels will rule out a diagnosis of gout at this time

Answer 13

False

Question 14

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the left knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

Given a positive synovial fluid culture, which of the following treatments would be MOST appropriate for him at this time?

a. IV antibiotics
b. Joint aspiration and drainage
c. Topical NSAIDs
d. A and B

Answer 14

d. A and B

Question 15

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the left knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

Which dietary modification would be the MOST beneficial for this patient for long term care and prevention?

a. Eliminate alcohol consumption
b. Reduce protein consumption
c. Eliminate food allergens
d. All of the above

Answer 15

a. Eliminate alcohol consumption

Question 16

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st – 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following does NOT increase the risk for her developing CPPD?

a. Previous joint injury
b. Gender (female)
c. Presence of osteoarthritis
d. None of the above

Answer 16

b. Gender (female)

Question 17

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st – 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following signs and symptoms does NOT indicate osteoarthritis in this patient?

a. Crepitus
b. Morning stiffness
c. Pain worse with activity
d. None of the above

Answer 17

d. None of the above

Question 18

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st – 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following supplements would be MOST beneficial for this patient?

a. Zinc
b. Vitamin A
c. Glucosamine Sulfate
d. L-Glutamine

Answer 18

c. Glucosamine Sulfate

Question 19

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st – 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following types of exercise would NOT be beneficial for this patient?

a. Range of motion exercises
b. Low load exercises
c. Strengthening exercises
d. All the above would be beneficial to this patient

Answer 19

d. All the above would be beneficial to this patient

Question 20

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st – 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

All of the following are classic plain film findings in DJD EXCEPT for which of the following:

a. Erosions
b. Joint space narrowing
c. Subchondral sclerosis
d. Osteophytes

Answer 20

a. Erosions

Question 21

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 – L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9F, RR: 16, BP: 118/62.

Which of the following details for this patient would NOT support reactive arthritis as a DDx?

a. Low back pain progressively worse in the last 6 mos
b. Acute swelling in the right knee
c. History of recent unprotected sex
d. All are supportive of reactive arthritis

Answer 21

a. Low back pain progressively worse in the last 6 months

Question 22

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 – L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9F, RR: 16, BP: 118/62.

Which of the following is NOT required for a diagnosis of ankylosing spondylitis in this patient?

a. Low back pain > 3 months that improves with exercise
b. Decreased chest expansion for age and sex
c. Positive HLA-B27
d. Presence of grade 2 or 3 unilateral or bilateral sacroiliitis on xray

Answer 22

c. Positive HLA-B27

Question 23

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 – L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9F, RR: 16, BP: 118/62.

Given a positive Chlamydia trachomatis test, which of the following conditions do you need to monitor for in the future?

a. Osteopenia
b. Heberden’s nodes
c. Glomerulonephritis
d. None of the above – the swelling should self-resolve within 6 months

Answer 23

d. None of the above – the swelling should self-resolve within 6 months

Question 24

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 – L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9F, RR: 16, BP: 118/62.

Which of the following imaging features is MOST indicative of spondyloarthritis?

a. Fibrosis
b. Synovitis
c. Enthesitis
d. Spondylosis

Answer 24

c. Enthesitis

Question 25

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 – L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9F, RR: 16, BP: 118/62.

Which of the following treatment plans would NOT be appropriate for this patient at this time?

a. Antibiotics
b. NSAIDs for pain management
c. Probiotics
d. All of the above are appropriate

Answer 25

d. All of the above are appropriate

Question 26

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in the both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which las led to moderate depression. Physical exam shows extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows and medial knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18

Which of the following would rule out a diagnosis of Lyme in this patient?

a. No known history of tick bite
b. Swelling in the hands and wrists
c. Negative ELISA test
d. Chronic widespread pain lasting many years

Answer 26

c. Negative ELISA test

Question 27

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in the both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which las led to moderate depression. Physical exam shows extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows and medial knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18

True or False: Positive antibody testing will confirm a diagnosis of fibromyalgia.

Answer 27

False

Question 28

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in the both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which las led to moderate depression. Physical exam shows extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows and medial knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18

Given positive Lyme serology, which of the following stages would she most likely be in?

a. Early localized Lyme disease
b. Early disseminated Lyme disease
c. Late Lyme disease
d. Intermittent Lyme disease

Answer 28

c. Late Lyme disease

Question 29

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in the both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which las led to moderate depression. Physical exam shows extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows and medial knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18

Which of the following would be the best exercise regimen for this patient?

a. Low-impact cardiovascular exercises >3x a week
b. Low load bearing exercises 1-2x a week
c. High load bearing exercises 6x a week
d. High intensity resistance training 3x a week

Answer 29

a. Low-impact cardiovascular exercises >3x a week

Question 30

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in the both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which las led to moderate depression. Physical exam shows extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows and medial knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18

Which of the following medications is MOST indicated for treating late stage Lyme disease?

a. Doxycycline
b. Duloxetine
c. Amitriptyline
d. Pregabalin

Answer 30

a. Doxycycline

Question 31

For questions 1 – 7: A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which characteristics of this patient’s case would NOT contribute to a diagnosis of rheumatoid arthritis?

a. Number of joints involved
b. Presence of joint swelling
c. Elevated ESR
d. Her symptom duration

Answer 31

b. Presence of joint swelling

Question 32

For questions 1 – 7: A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which of the following LEAST contributes to poor prognosis in psoriatic arthritis in this patient?

a. Increased number of actively inflamed joints
b. Loss of joint function
c. Elevated ESR
d. Low positive RF

Answer 32

d. Low positive RF

Question 33

For questions 1 – 7: A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

True or False: The positive rheumatoid factor definitively rules out a diagnosis of psoriatic arthritis.

Answer 33

False:

Question 34

For questions 1 – 7: A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which pair of imaging methods is best for very EARLY detection of rheumatoid arthritis?

a. Endoscopy and fluoroscopy
b. Plain films and CT
c. Ultrasound and MRI
d. Elastography and nuclear imaging

Answer 34

c. Ultrasound and MRI

Question 35

For questions 1 – 7: A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

You notice bony erosions in the 2nd and 3rd left MCPs on an imaging report you do. Which of the following medications would be appropriate to start her on at this time?

a. Naproxen
b. Leflunomide
c. Methotrexate
d. B and C would be appropriate simultaneously

Answer 35

Question written incorrectly – answer should be A and C would be appropriate simultaneously – this question was thrown out for this quiz.

Question 36

For questions 1 – 7: A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which of the following hormone imbalances is MOST likely associated with rheumatoid arthritis?

a. Elevated DHEA
b. Elevated estrogen
c. Reduced prolactin
d. Elevated cortisol

Answer 36

b. Elevated estrogen

Question 37

For questions 1 – 7: A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which of the following treatments would be LEAST effective for rheumatoid arthritis?

a. Paleo-type diet
b. Probiotics
c. Bromelain
d. Uncaria tomentosa (Cat’s claw)

Answer 37

a. Paleo-type diet

Question 38

A 34 yo male presents in your office with acute pain and stiffness in the lower back. He has also had significant abdominal pain and diarrhea that has lasted for the past 4 days. He has been having these episodes of diarrhea now for a year with painful urgency lasting for a few days and then days with normal stools. Sometimes he notices blood in his stool. He notices that his back pain only occurs when he has these GI bouts. Physical exam shows tenderness to palpation of L4, L5 and the SI joint. You also find out he has a family history of autoimmune diseases.

If this patient were diagnosed with enteropathic arthritis, which type would he classify as?

a. Type 1 arthropathy
b. Type 2 arthropathy
c. Type 3 arthropathy
d. None of the above

Answer 38

a. Type 1 arthropathy

Question 39

A 34 yo male presents in your office with acute pain and stiffness in the lower back. He has also had significant abdominal pain and diarrhea that has lasted for the past 4 days. He has been having these episodes of diarrhea now for a year with painful urgency lasting for a few days and then days with normal stools. Sometimes he notices blood in his stool. He notices that his back pain only occurs when he has these GI bouts. Physical exam shows tenderness to palpation of L4, L5 and the SI joint. You also find out he has a family history of autoimmune diseases.

Which of the following could be used to differentiate rheumatoid arthritis and enteropathic arthritis?

a. ESR
b. Joint aspiration
c. Radiographic imaging
d. Number of joints involved

Answer 39

c. Radiographic imaging

Question 40

A 34 yo male presents in your office with acute pain and stiffness in the lower back. He has also had significant abdominal pain and diarrhea that has lasted for the past 4 days. He has been having these episodes of diarrhea now for a year with painful urgency lasting for a few days and then days with normal stools. Sometimes he notices blood in his stool. He notices that his back pain only occurs when he has these GI bouts. Physical exam shows tenderness to palpation of L4, L5 and the SI joint. You also find out he has a family history of autoimmune diseases.

What should be your main treatment goal in a patient with enteropathic arthritis?

a. Nutritional supplementation
b. Treat the intestinal inflammation
c. Balance hormones
d. Assess for toxicity

Answer 40

b. Treat the intestinal inflammation

Question 41

a 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her symptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

Which of the following clinical presentations of this patient is less likely to be present in Sjogren’s?

a. Enlarged submandibular glands
b. Vision loss
c. Dry eyes
d. Dry cough

Answer 41

b. Vision loss

Question 42

a 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her symptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

Which of the following lab results in this patient is not commonly seen in lupus?

a. Elevated anti-dsDNA antibodies
b. Decreased C3/C4
c. Elevated anti-SSA antibodies
d. All of the above are COMMONLY SEEN in lupus

Answer 42

d. All of the above are COMMONLY SEEN in lupus

Question 43

a 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her symptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

Regarding SLE (Lupus), scleroderma, and Sjogren’s, which of the following options is correct?

a. Imaging is imperative in the early stages to establish and accurate diagnosis
b. These conditions tend to affect the spine more than the peripheral joints
c. Scleroderma commonly causes esophageal dilatation and dysmotility
d. The arthritis that can occur with Sjogren’s is not inflammatory, but rather a secondary degenerative arthrosis.

Answer 43

c. Scleroderma commonly causes esophageal dilatation and dysmotility

Question 44

a 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her symptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

True or False: Hydroxychloroquine would be an appropriate treatment for this patient at this time.

Answer 44

True

Question 45

a 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her symptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

Hormonal imbalance can occur in patients with lupus. Estrogen is usually _______________, cortisol is usually _______________, and prolactin is usually _______________.

a. Increased, decreased, increased
b. Decreased, decreased, decreased
c. Decreased, decreased, increased
d. Increased, decreased, decreased

Answer 45

a. Increased, decreased, increased

Question 46

a 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her symptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

Which of the following treatment recommendations would be LEAST beneficial for her at this time?

a. PABA
b. Artificial tears to moisturize eyes
c. Green tea extract
d. Use sunscreen

Answer 46

a. PABA- for Scleroderma

Question 47

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

Which of the following antibodies would be LEAST likely associated with scleroderma if positive?

a. Anti-SCL-70 antibodies
b. Anti-centromere antibodies
c. Anti-RNA polymerase III antibodies
d. Anti-CCP antibodies

Answer 47

d. Anti-CCP antibodies

Question 48

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

Which of the following forms of scleroderma is CREST syndrome most associated with?

a. Limited cutaneous scleroderma
b. Diffuse cutaneous scleroderma
c. Linear scleroderma
d. Environmentally induced scleroderma

Answer 48

a. Limited cutaneous scleroderma

Question 49

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

Which of the following viral infections is MOST commonly associated with this condition:

a. HSV-1
b. HBV
c. HIV
d. CMV

Answer 49

d. CMV

Question 50

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

Which of the following would provide the LEAST support for this patient:

a. Centella Asiatica
b. High fiber diet
c. Vitamin E
d. CoQ10

Answer 50

b. High fiber diet

Question 51

True or False: The majority of patients with arthritis are overweight or obese.

Answer 51

True

Question 52

2. Major histocompatibility complexes (MHC) are also known as which of the following:

a. Pattern recofnitions receptors (PRRs)
b. Human leukocyte antigens (HLAs)
c. T-cell receptors (TCRs)
d. Toll-like receptors (TLRs)

Answer 52

b. Human leukocyte antigens (HLAs)

Question 53

Which of the following statements is true regarding C cells? (adaptive immunity)

a. B cells are stimulated by NK cells
b. B cells stimulate T-helper cells to produce antibodies
c. B cells directly activate the complement cascade
d. B cells stimulate T-helper cells through MHC peptides

Answer 53

d. B cells stimulate T-helper cells through MHC peptides

Question 54

Which of the following are commonly considered to be immunogenic determinants?

a. Molecular size
b. Genetic constitution of the hots (HLA genes)
c. Antigen epitopes
d. A and B only
e. All of the above

Answer 54

e. All of the above

Question 55

Which of the following is NOT a common environmental trigger for autoimmunity:

a. Microbial flora
b. Vaccinations
c. Toxic exposure
d. UV radiation

Answer 55

b. Vaccinations

Question 56

Which of the following DMARDs is safest in pregnancy?

a. Hydroxychloroquine
b. Methotrexate
c. Sulfasalazine
d. A and C

Answer 56

d. A and C

Question 57

How often should you monitor a CBC initially when a patient is placed on a DMARD?

a. Every 1-3 months
b. Only once at baseline
c. Every 6 months
d. Once initially and then yearly

Answer 57

a. Every 1-3 months

Question 58

Which of the following is NOT true of glucocorticoids for rheumatic conditions?

a. Glucocorticoids should not be discontinued after remission
b. Glucocorticoids can impair wound healing
c. Glucocorticoids can modify disease progression in acute flares
d. Glucocorticoids have to be tapered when they are discontinued

Answer 58

a. Glucocorticoids should not be discontinued after remission

Question 59

Which of the following supplements would be MOST effective for reducing the side effects of the Methotrexate:

a. Vitamin B12
b. Folic Acid
c. Vitamin b6
d. Vitamin C

Answer 59

b. Folic Acid

Question 60

Which of the following options is MOST correct regarding diagnostic imaging for septic arthritis in a peripheral joint?

a. Plain films are very sensitive for early septic arthritis in a peripheral joint
b. Diagnostic ultrasound is reliable in detecting joint effusion in early cases
c. Tuberculous arthritis progresses faster than staph arthritis
d. CT is the first line investigative method for suspected septic arthritis in a peripheral joint

Answer 60

b. Diagnostic ultrasound is reliable in detecting joint effusion in early cases

Question 61

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the right knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

1. Which of the following is NOT a risk factor for this patient for septic arthritis?
   a. His history of type II diabetes
   b. His BMI
   c. His recent steroid injection
   d. None of the above

Answer 61

b. His BMI

Question 62

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the right knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

What clinical step would be indicated at this time?

a. Prescribe NSAIDs and tell him to elevate knee and apply ice
b. Obtain an MRI to r/o ligament tear
c. Oral steroids to help prevent joint damage
d. Refer for immediate joint aspiration

Answer 62

d. Refer for immediate joint aspiration

Question 63

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the right knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

True or False: A negative blood culture will rule out a diagnosis of septic arthritis at this time.

Answer 63

False

Question 64

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the right knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

Given a negative synovial fluid culture and positive uric acid crystals, which of the following treatments would be LEAST appropriate for him at this time?

a. Rest and elevate the knee
b. High dose vitamin C
c. Colchicine
d. B and C

Answer 64

d. B and C

Question 65

A 67 yo male presents in your office with an acutely swollen left knee. The swelling began yesterday morning and has gotten progressively worse over the last day. He has a history of gout is a type II diabetic and had just received a steroid injection in that same knee 2 days ago and thinks it might be a drug reaction. Physical exam shows that the right knee is extremely swollen, range of motion is severely limited, and the joint is very red and very warm to touch. BP: 142/86, HR: 75, RR: 16, BMI: 30, Temp: 98.9 F.

Which dietary modification would be LEAST beneficial for this paritnet for long term care and prevention?

a. Eliminate alcohol consumption
b. Reduce fructose consumption
c. Eliminate food allergens
d. B and C

Answer 65

c. Eliminate food allergens

Question 66

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st - 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following is NOT a risk factor for this patient for osteoarthritis?

a. Her age
b. Her gender (female)
c. Her BMI
d. None of the above

Answer 66

c. Her BMI

Question 67

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st - 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following findings on a joint aspiration would support a diagnosis of CPPD?

a. Calcium pyrophosphate crystals
b. Positive synovial fluid culture
c. Low leukocyte levels
d. None of the above

Answer 67

a. Calcium pyrophosphate crystals

Question 68

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st - 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following would be appropriate for this patient for long term treatment and management?

a. Daily high load exercises
b. Topical capsaicin for pain
c. Daily low dose aspirin
d. A and B

Answer 68

b. Topical capsaicin for pain

Question 69

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st - 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

Which of the following herbs would NOT be indicated in this patient?

a. Symphytum officionalis
b. Boswellia serrata
c. Harpagophytum procumbens
d. Salix alba

Answer 69

a. Symphytum officionalis

Question 70

A 75 yo female presents in your office with pain and stiffness in her right hand and knee. The pain and stiffness has been getting progressively worse for the past 10 years. The stiffness is worse in the morning but gets better during the day. It can also get aggravated when she does her daily chores. She has had 2 surgeries on the right knee for ACL repairs in the past. Physical exam shows some bony enlargement of the PIP joints on the 1st - 3rd digits, tenderness to palpation and crepitus during AROM. In the past couple of months, she has also been experiencing pain and swelling in the same knee that starts suddenly in the morning and then goes away within a few days. She has been using ibuprofen to help control the pain on those days. BP: 146/78, HR: 68, RR: 14, BMI: 24, Temp: 97.8 F

All of the following are classic plain film findings in DJD EXCEPT for which of the following:

a. Erosions
b. Joint space narrowing
c. Subchondral sclerosis
d. Osteophytes

Answer 70

a. Erosions

Question 71

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 - L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9 F, RR: 16, BP: 116/62.

Which of the following lab tests would help support a diagnosis of reactive arthritis?

a. GC/CT urine test
b. HLA-B27
c. Complete metabolic panel
d. A and B would both be appropriate

Answer 71

d. A and B would both be appropriate

Question 72

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 - L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9 F, RR: 16, BP: 116/62.

Given the presence of grade 2 b/l sacroiliitis on an xray in this patient, which of the following conditions do you need to monitor for in the future?

a. Osteopenia
b. Heberden’s nodes
c. Glomerulonephritis
d. None of the above - the low back pain should self-resolve with in 6 months.

Answer 72

a. Osteopenia

Question 73

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 - L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9 F, RR: 16, BP: 116/62.

Which of the following imaging features is MOST indicative of spondyloarthritis?

a. Fibrosis
b. Synovitis
c. Enthesitis
d. Spondylosis

Answer 73

c. Enthesitis

Question 74

A 23 yo male presents in your office with low back pain that has gotten progressively worse in the last 6 months. The pain is located in the L3 - L5 region, is worse at night and improves with movement during the day. There is no pain from palpation to the area and no swelling apparent. He also complains of right knee pain that has been worse in the last week. Exam of the right knee shows significant swelling, and reduced PROM. He denies any recent trauma or injury but does admit to having unprotected sex on several occasions in the last 4 weeks. BMI: 22, Temp: 98.9 F, RR: 16, BP: 116/62.

Which of the following treatment plans would be appropriate for this patient at this time?

a. NSAIDs for pain management
b. Postural training
c. Anti-inflammatory diet
d. All of the above are appropriate

Answer 74

d. All of the above are appropriate

Question 75

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which has led to moderate depression. Physical exam show extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows, and medical knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18.

Which of the following would support a diagnosis of fibromyalgia in this patient?

a. The duration since the onset of her symptoms
b. The number of tender points you palpate on physical exam
c. Her joint swelling
d. The possibility of a Lyme infection

Answer 75

a. The duration since the onset of her symptoms

Question 76

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which has led to moderate depression. Physical exam show extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows, and medical knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18.

True or False: Serologic testing for Lyme would be appropriate at this time.

Answer 76

True

Question 77

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which has led to moderate depression. Physical exam show extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows, and medical knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18.

Which of the following is NOT a possible etiology of fibromyalgia in general?

a. Heavy metal toxicity
b. Viral infections
c. PTSD
d. All are possible triggers of fibromyalgia

Answer 77

d. All are possible triggers of fibromyalgia

Question 78

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which has led to moderate depression. Physical exam show extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows, and medical knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18.

Given negative Lyme serology, which of the following treatments would be LEAST beneficial for this patient:

a. 5-HTP
b. Magnesium malate
c. Harpagophytum procumbens
d. Sleep hygiene education

Answer 78

c. Harpagophytum procumbens

Question 79

A 34 yo female presents to your office with chronic widespread pain that has been going on for many years and has gotten progressively worse. She is constantly fatigued, worse in the middle of the day, and her anxiety can get very high at this time. Her pain is mostly in the upper and lower limbs. She also has significant joint swelling in both hands, wrists and knees. Swelling comes and goes, but can severely impair her ability to exercise. She has had to quit her job due to her condition which has led to moderate depression. Physical exam show extreme tenderness to palpation in the areas of the trapezius, occiput, lateral elbows, and medical knees. Mild swelling in both the right and left knees, with tenderness to palpation. AROM and PROM are all normal as are neurologic tests. She currently lives in Maryland though denies any history of tick bites or recent skin lesions. BP: 136/82, Temp: 99.2 F, BMI: 26, RR: 18.

Which of the following medications would be LEAST beneficial for the patient at this time given a negative Lyme serology?

a. Pregabalin
b. Doxycycline
c. Amitriptyline
d. Duloxetine

Answer 79

b. Doxycycline

Question 80

A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which characteristics of this patient’s case would NOT contribute to a diagnosis of psoriatic arthritis?

a. Nail lesions
b. Positive rheumatoid factor
c. Dactylitis
d. Family history of skin psoriasis

Answer 80

b. Positive rheumatoid factor

Question 81

A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which of the following MOST contributes to poor prognosis in psoriatic arthritis in this patient?

a. Hyperkeratosis in the nail beds
b. Dactylitis in the 3rd digit on the right
c. Family history of psoriasis
d. Elevated ESR

Answer 81

d. Elevated ESR

Question 82

A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

True or False: The positive rheumatoid factor on its own definitively rules in a diagnosis of RA.

Answer 82

False

Question 83

A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which pair of imaging methods is best for very EARLY detection of rheumatoid arthritis?

a. Endoscopy and fluoroscopy
b. Plain films and CT
c. Ultrasound and MRI
d. Elastography and nuclear imaging

Answer 83

c. Ultrasound and MRI

Question 84

A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

After a 2 week trial of NSAIDs, she has had minimal improvement in symptoms. Which of the following medications should be used next?

a. Naproxen
b. Sulfasalazine
c. Methotrexate
d. B or C would be appropriate

Answer 84

d. B or C would be appropriate

Question 85

A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which of the dietary and/or lifestyle modifications would be the LEAST beneficial for this patient:

a. Elimination of food allergens
b. Avoidance of smoking
c. Reduction in inflammatory foods
d. Paleo-type diet

Answer 85

d. Paleo-type diet

Question 86

A 57 yo woman walks into your office with pain and stiffness in both hands that has gotten progressively worse in the last 4 months. There has also been significant swelling that has limited range of motion. She has a family history of psoriasis and rheumatoid arthritis. Physical exam shows significant swelling in the 3rd and 4th DIPs on the right hand, 2nd and 3rd MCPs on the left hand, limited passive and active range of motion and mild pain with palpation of both hands. Dactylitis is present on the 3rd digit of the right hand. The nails on both hands are also ridged, slightly yellow in color and mildly deformed. Hyperkeratosis is present in the 1st and 2nd nail beds on both hands. Lab work done shows an elevated ESR and low positive rheumatoid factor. Temp: 98.9F, BP: 128/82, HR: 84, BMI: 26, RR: 12.

Which of the following does NOT increase the risk of developing rheumatoid arthritis in general?

a. Family history of autoimmune disease
b. Female gender
c. Previous joint damage
d. Cigarette smoking

Answer 86

c. Previous joint damage

Question 87

A 34 yo male presents in your office with acute pain and stiffness in the lower back. He has also had significant abdominal pain and diarrhea that has lasted for the past 4 days. He has been having these episodes of diarrhea now for a year with painful urgency lasting for a few days and then days with normal stools. Sometimes he notices blood in his stool. He notices that his back pain only occurs when he has these GI bouts. Physical exam shows tenderness to palpation of L4, L5 and the SI joint. You also find out he has a family history of autoimmune diseases.

What condition would be the MOST likely condition contributing to his symptoms:

a. Crohn’s disease
b. Irritable bowel syndrome
c. Systemic lupus erythematosus
d. Food poisoning

Answer 87

a. Crohn’s disease

Question 88

A 34 yo male presents in your office with acute pain and stiffness in the lower back. He has also had significant abdominal pain and diarrhea that has lasted for the past 4 days. He has been having these episodes of diarrhea now for a year with painful urgency lasting for a few days and then days with normal stools. Sometimes he notices blood in his stool. He notices that his back pain only occurs when he has these GI bouts. Physical exam shows tenderness to palpation of L4, L5 and the SI joint. You also find out he has a family history of autoimmune diseases.

Which of the following will MOST likely represent joint changes in this patient if his GI symptoms are mostly controlled?

a. Formation of osteophytes in the joint space
b. Severe erosive changes in the joint within a few months
c. Joint swelling that is non-erosive and self-limiting
d. Joint space narrowing and bony erosions

Answer 88

c. Joint swelling that is non-erosive and self-limiting

Question 89

A 34 yo male presents in your office with acute pain and stiffness in the lower back. He has also had significant abdominal pain and diarrhea that has lasted for the past 4 days. He has been having these episodes of diarrhea now for a year with painful urgency lasting for a few days and then days with normal stools. Sometimes he notices blood in his stool. He notices that his back pain only occurs when he has these GI bouts. Physical exam shows tenderness to palpation of L4, L5 and the SI joint. You also find out he has a family history of autoimmune diseases.

Which of the following medications used for treatment of enteropathic arthritis should be used cautiously, as it may exacerbate his symptoms?

a. Sulfasalazine
b. Naproxen
c. Methotrexate
d. Infliximab

Answer 89

b. Naproxen

Question 90

A 34 yo male presents in your office with acute pain and stiffness in the lower back. He has also had significant abdominal pain and diarrhea that has lasted for the past 4 days. He has been having these episodes of diarrhea now for a year with painful urgency lasting for a few days and then days with normal stools. Sometimes he notices blood in his stool. He notices that his back pain only occurs when he has these GI bouts. Physical exam shows tenderness to palpation of L4, L5 and the SI joint. You also find out he has a family history of autoimmune diseases.

Which of the following medications used for treatment of enteropathic arthritis should be used cautiously, as it may exacerbate his symptoms?

a. Sulfasalazine
b. Naproxen
c. Methotrexate
d. Infliximab

Answer 90

b. Naproxen

Question 91

A 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her ymptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

Which of the following clinical sx’s for this patient is less likely to be present in lupus?

a. Pain and swelling in the hands
b. Skin rash worse in the sun
c. Dry eyes
d. Vision loss

Answer 91

d. Vision loss

Question 92

A 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her ymptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

Which of the following would be MOST appropriate to run on this patient at the time:

a. Urinalysis
b. Joint aspiration
c. Anti-citrullinated peptide antibodies (ACPAs)
d. Chest X-ray

Answer 92

a. Urinalysis

Question 93

A 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her ymptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

a. Imaging is imperative in the early stages to establish an accurate diagnosis.
b. These conditions tend to affect the spine more than the peripheral joints
c. Scleroderma commonly causes esophageal dilatation and dysmotility
d. The arthritis that can occur with Sjogren’s is not inflammatory, but rather a secondary degenerative arthrosis.

Answer 93

c. Scleroderma commonly causes esophageal dilatation and dysmotility

Question 94

A 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her ymptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

4. True or False: Echinacea would be a beneficial supportive treatment for this patient.

Answer 94

False

Question 95

A 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her ymptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

5. Hormone imbalance can occur in patients with Sjogren’s. Testosterone is usually _______, DHEA is usually _______, and cortisol is usually ________.
   a. Increased, decreased, increased
   b. Decreased, decreased, decreased
   c. Decreased, decreased, increased
   d. Increased, decreased, decreased

Answer 95

b. Decreased, decreased, decreased

Question 96

A 45 yo woman presents in your office with fatigue, diffuse muscle pain and swelling and pain in both hands. She also has a history of stomach ulcers and is currently on a PPI. Her ymptoms seem to get worse during the summer, and she will occasionally develop a rash on her face after being in the sun that will go away with time. She also complains of dry eyes and mouth and her vision has been declining in the past couple of years. Physical exam shows some mild edema diffusely dispersed throughout the hands B/L, mildly enlarged submandibular glands and a dry cough in office, but otherwise physical exam is within normal limits. Laboratory testing shows an elevated ANA with Anti-dsDNA, Anti-SSB and Anti-SSA antibodies present. C3 and C4 are also decreased.

6. Which of the following treatment recommendations would be LEAST beneficial for her at this time?
   a. Chew sugarless gum regularly
   b. Probiotics
   c. Vitamin E
   d. Harpagophytum procumbens

Answer 96

c. Vitamin E

Question 97

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

Which of the following antibodies would MOST expect to see elevated in this patient:

a. Anti-Citrullinated Peptide Peptide Antibodies (ACPA or Anti-CCP)
b. Anti-dsDNA antibodies
c. Anti-centromere antibodies
d. Anti-SM antibodies

Answer 97

c. Anti-centromere antibodies

Question 98

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

8. Which of the forms of Scleroderma is at greatest risk for developing renal, lung, and cardiac disease?
   a. Limited Cutaneous Scleroderma
   b. Diffuse cutaneous Scleroderma
   c. Linear scleroderma
   d. Environmentally induced Scleroderma

Answer 98

b. Diffuse cutaneous Scleroderma

Question 99

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

9. Which of the following viral infection is LEAST commonly associated with his condition:
   a. Parvovirus
   b. HBV
   c. CMV
   d. A and B

Answer 99

b. HBV

Question 100

A 38 yo woman presents in your office with swelling in both hands. She has been having some numbness and color changes in a few of her fingers that has been off and on over the last 3 years. She is also an avid runner and reports numbness in the toes and loss of color in her feet after more than 30 minutes of running. She has also been having bouts of constipation in the last 6 months. Physical exam shows mild edema diffusely dispersed in both hands, along with cyanotic changes distal to the PIP joint of the 4th digit on her right hand and on the 1st digit of the left hand and both hands are extremely cold to touch. You also notice significant vasculitic changes in the nails of both of those digits. All other physical exam is normal.

10. Which of the following would provide the BEST support for this patient:
    a. Vitamin A
    b. Harpogophytum procunbens
    c. Vitamin E
    d. Boswellia serrata

Answer 100

c. Vitamin E