PMR 10 - joint & connective tissue disorders Flashcards
All of the following are common in idiopathic osteoarthritis (A) of the knee except:
a. Age > 50
b. Bony tenderness
c. Stiffness
d. Erythrocyte sedimentation rate
(ESR) > 40
D) OA is not associated with an elevated erythrocyte sedimentation rate. It is commonly characterized as “wear and tear arthritis.” The other choices are common in OA.
All of the following are common in idiopathic osteoarthritis (OA) of the knee except:
a. Palpable warmth
b. Negative rheumatoid factor (or low titer)
c. Bony enlargement
d. Bony tendemess
A) OA is not typically associated with inflammation or warmth. The other choices are common.
Rheumatoid arthritis (RA):
a. Is primarily a noninflammatory disorder of weight-bearing joints
b. Primarily affects the distal interphalangeal (DIP) joints.
C. Is more prevalent in females than in males
d. Is also known as “wear and tear” arthritis
C) RA has a 3:1 female:male predominance.
The other choices describe OA.
A reasonable first line of treatment in osteoarthritis (OA) of the knee is:
a. Intra-articular injections
b. Oral steroids
c. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs)
d. Colchicine
C) The other choices are used in inflammatory arthritis, or as treatments for refractory OA, but not as a first-line treatment.
All of the following are true in systemic lupus erythematosus (SLE) except:
a. Avascular necrosis typically occurs in small joints
b. Low-dose steroids can be used to manage SLE
С. Arthritis is not necessary to diagnose SLE
d. Antimalarial drugs can be used for symptom control
A) Avascular necrosis typically affects large joints. Although joint pain is common arthritis is not necessary to diagnose SLE and is not always present. The other choices are true.
Which of the following is true of gouty arthritis?
a. Calcium pyrophosphate dihydrate crystals are found in joint fluid
b. Female predominance
c. Allopurinol can be used during an attack
d. Tophi (deposits of uric acid crystals) may be present
D) Tophi can be seen in gout. Calcium pyrophosphate dihydrate crystals are seen in pseudogout. Gout has a male predominance.
Allopurinol is used to lower serum uric acid and prevent or decrease attacks, but is not used for an acute attack.
Which of the following is true about rheumatoid arthritis (RA)?
a. Asymmetric and non-erosive
b. Symmetric and erosive
c. Asymmetric and erosive
d. Symmetric and non-erosive
B) Rheumatoid arthritis is a systemic. autoimmune inflammatory disorder of unknown etiology that affects multiple organ systems. It affects the musculoskeletal system and specifically the synovial lining of diarthrodial joints. Diarthrodial joints contain type lI hyaline cartilage, subchondral bone, synovial membranes, joint capsule, and synovial fluid. It is a chronic, symmetric, erosive synovitis that develops in the joints and leads to joint destruction. Erosions are specific to RA.
Which of the following are characteristic of rheumatoid arthritis (RA)?
a. Morning stiffness
b. Symmetric arthritis
c. Arthritis of the hand joints
d. All of the above
D) Morning stiffness lasting more than 1 hour, arthritis of three or more joints simultaneously affected with soft-tissue swelling, arthritis of the hand joints including the wrist/ metacarpophalangeal joint/proximal interphalangeal joint, symmetric arthritis of the same joints on both sides of the body, rheumatoid nodules (subcutaneous nodules over the extensor surfaces), positive serum rheumatoid factor, and radiographic changes such as erosions/joint space narrowing are all characteristics of rheumatoid arthritis. Not all are necessary for diagnosis.
What causes a Boutonnière deformity?
a. Rupture of the extensor hood at the proximal interphalangeal joint (PIP), which causes subluxation of the lateral bands of the extensor hood
b. Flexor synovitis
c. Ligamentous laxity
d. Rupture of the flexors with subluxation causing hyperextension at the PIP
A) A Boutonnière deformity is characterized by weakness or rupture of the terminal portion of the extensor hood, which holds the lateral bands in place at the PIP joint. There is initially PIP synovitis then a downward slippage of the lateral bands, causing flexion at the PIP joint.
What tendons are affected by de
Quervain’s synovitis?
a. Extensor carpi radialis longus
ECRL) and extensor carpi radialis brevis (ECRB)
b. Abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
c. Extensor pollicis longs (EPL) and
EPB
d. Extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU)
B) The first compartment of the wrist contains the APL and EPB tendons and is affected in de Quervain’s synovitis.
Which of the following exercises is recommended for rheumatoid arthritis?
a. Isotonic
b. Concentric
C. Isokinetic
d. Isometric
D) Isometric contraction of a muscle does not cause a change in muscle length or joint angle and is ideal for rheumatoid arthritis because it allows the joint to rest.
Which of the following are characteristics of osteoarthritis (OA)?
a. Dull, aching pain better with activity
b. Joint stiffness lasting < 30 minutes and improving as the day progresses
c. Typically involves the
metacarpophalangeal (MCP) joints in the hands
d. Infrequently involves the spine
B) Osteoarthritis is characterized by joint stiffness worse in the morning, lasting less than 30 minutes and improving as the day goes on.
Which of the following is not a characteristic radiographic finding in osteoarthritis (OA)?
a. Asymmetric narrowing of the joint space
b. Erosive changes seen on x-ray
c. Subchondral bony sclerosis
d. Osteophytosis,
B) In patients with OA, characteristic changes on x-ray are as follows: asymmetric narrowing of the joint space, no erosive changes on x-ray, joint involvement that does not have to be symmetric, no osteoporosis or osteopenia, osseous cysts, subchondral bony sclerosis, osteophytosis, and loose bodies.
Common joints involved include the first carpometacarpal joint, distal interphalangeal joints, knees, and hips.
Which of the following is not a characteristic radiographic finding in rheumatoid arthritis (RA)?
a. Erosion of the ulnar styloid
b. Marginal bony erosions
c. Asymmetric joint involvement.
d. Uniform joint space narrowing
C) In patients with RA, characteristic changes on x-ray are as follows: uniform joint space narrowing, symmetric joint involvement, marginal bony erosions, juxta-articular osteopenia, ulnar deviation of phalanges, radial deviation of the radiocarpal joint (carpal and metacarpals), erosion of the ulnar styloid, atlantoaxial subluxation, and small joint involvement, including metacarpophalangeal joints, proximal interphalangeal joints, and carpal joints.
What is the most common form of childhood arthritis?
a. Osteoarthritis
b. Juvenile rheumatoid arthritis
c. Rheumatic fever
d. Ankylosing spondylitis
B) Juvenile rheumatoid arthritis is the most common form of childhood arthritis and is characterized by onset < 16 years of age, persistent arthritis of one or more joints for at least 6 weeks, exclusion of other types of childhood arthritis, type of onset of disease during the first 6 months classified as polyarthritis, oligoarthritis, or systemic arthritis with intermittent fever.
Which of the following is a characteristic of gout?
a. Negative birefringence crystals noted on microscopy of joint aspiration
b. Positive birefringence crystals noted on microscopy of joint aspiration
c. Chondrocalcinosis
d. Affects hyaline cartilage
A) Gout is inflammation caused by monosodium rate crystals. Goutis characterized by needle shaped crystals seen under microscopy after joint aspiration. If a polarizing filter is used, the crystals are yellow when they align parallel but turn blue when aligned across the direction of the polarizer (negative birefringence).
Which of the following is not associated with HLA-B27 (+) serology?
a. Reiter’s syndrome (reactive arthritis)
b. Ankylosing spondylitis
c. Psoriatic arthritis
d. Osteoarthritis
D) All of the choices above except osteoarthritis are associated with HLA-B27 (+) serology. They are called seronegative arthropathies. Other HLA-B27 (+) diseases include enteropathic arthropathy and pauciarticular juvenile rheumatoid arthritis.
Which joint/area of the body is affected first in ankylosing spondylitis (AS)?
a. Lumbar spine
b. Sacroiliac joint
c. Cervical spine
d. Thoracic spine
B) In AS, the typical order of progression is that the sacroiliac joint is affected first, followed by the lumbar spine, thoracic spine, and lastly cervical spine. This is a distal to proximal progression.
Which of the following is not true about ankylosing spondylitis (AS)?
a. Onset is usually late adolescence or eariv adulthood
b. It is three times more common in men than in women
c. It can be associated with HLA-B27
d. The sacroiliac joint is usually not involved
D) In ankylosing spondylitis, the sacroiliac joint is usually the first joint to be involved, and both sides are affected. It can be associated with HLA-B27. It is much more common in men than in women, and the onset is usually late adolescence to early adulthood.
Which of the following is not a common disease complication of ankylosing spondylitis (AS)?
a. Iritis/uveitis
b. Inflammatory bowel disease
C. Osteoporosis
d. Dementia
D) Common potential complications of ankylosing spondylitis (AS) include iritis or uveitis, inflammatory bowel disease, aortic insufficiency and aortic root dilatation, osteoporosis, and spine fracture. Dementia is not a common complication of AS.
What is the position of a swan-neck deformity of the finger typical in rheumatoid arthritis?
a. Hyperextension of the proximal interphalangeal joint (PIP) with hyperextension of the distal interphalangeal joint (DIP)
b. Hyperextension of the PIP with flexion of the DIP
c. Flexion of the PIP with flexion of the DIP
d. Flexion of the PIP with hyperextension of the DIP
B) A swan-neck deformity can be seen in the hands of rheumatoid arthritis patients and is hyperextension of the PIP with flexion of the DIP. There is also flexion at the metacarpophalangeal joint (MCP). It is caused by chronic inflammation at the PIP, which causes a stretch of the volar plate. The PIP joint then moves into hyperextension. At the DIP, there is elongation or rupture of the extensor hood at the base of the phalanx.
What is the earliest radiographic sign of rheumatoid arthritis?
a. Diffuse periarticular osteopenia
b. Ulnar deviation of the phalanges at the metacarpophalangeal joints (MCP)
c. Periarticular erosions
d. Pencil-in-cup deformity
A) Diffuse periarticular osteopenia is the earliest radiographic sign of rheumatoid arthritis. Joint space narrowing and periarticular erosions may be observed later (usually within 2 years of the disease). Other deformities such as ulnar deviation of the MCP, radial deviation of the wrist, and swan-neck deformities are later findings.
What is the “gold standard” for diagnostic imaging in rheumatoid arthritis (RA)?
a. Ultrasound
b. Magnetic resonance imaging (MRI)
c. Plain radiograph
d. Bone scan
C) Plain radio graph remains the “gold standard” for diagnostic imaging in rheumatoid arthritis.
Which of the following is not a part of rehabilitation of the hand in a patient with rheumatoid arthritis?
a. Resting the involved joints
b. Heavy exercise of the involved joints
c. Joint protection instructions
d. Splinting regimens
B) In rheumatoid arthritis, it is important to rest the involved joints. Heavy exercise of the involved joints is contraindicated as it could cause more damage. Other important rehabilitation measures include modification of activities that stress the joints, joint protection, work simplification instructions, splinting regimens, heat modalities followed by active range of motion exercise, and resistive exercise.
What is a characteristic finding in polymyositis?
a. Skin abnormalities
b. Proximal muscle weakness
c. Distal muscle weakness
d. Ligamentous laxity
B) Polymyositis is characterized by proximal muscle weakness (hips are affected first, then the shoulders), dysphagia, and elevated muscle enzymes. Dermatomyositis has dermatological abnormalities in addition to the other listed symptoms.
Which of the following is not a subtype of juvenile rheumatoid arthritis?
a. Chronic
b. Systemic
c. Pauciarticular
d. Polyarticular
A) The subtypes of rheumatoid arthritis are systemic, pauciarticular, and polyarticular.
Pauciarticular involves 1 to 4 joints, poly articular involves 25 joints, and systemic is characterized by a systemic onset. Age of onset is less than 16, and duration of disease is equal to or more than 6 weeks.
Which of the following is characteristic of pseudogout?
a. Negative birefringence
b. Positive birefringence M
c. Caused by calcium pyrophosphate crystals
d. Both B and C
D) Pseudogout is caused by calcium pyrophosphate crystals and exhibits positive birefringence when a polarizer is used. The crystals line up parallel to the polarizer and are yellow.
Which of the following is not a characteristic symptom or sign in systemic lupus erythematosus (SLE)?
a. Asymmetric joint pain.
b. Pain disproportionate to swelling
c. Fatigue and fever
d. Erosive arthritis
D) SLE is associated with a nonerosive arthritis.
What is the name for an abnormal fibrous hyperplasia and contracture of the palmar fascia that causes a flexion contracture of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints?
a. Charcot joint
b. Duputren’s contracture
c. De Quervain’s tenosynovitis
d. Trigger finger
B) Dupuvtren’s contracture is an abnormal fibrous hyperplasia and contracture of the palmar fascia that causes a flexion contracture of the MCP and PIP joints. It is more common in white men age 50 to 70. It is associated with alcoholism, pulmonary tuberculosis, epilepsy, and diabetes mellitus.
It is painless, but can cause functional problems.
Which of the following is not a typical severe side effect leading to rehabilitation hospitalization in patients with rheumatic diseases?
a. Decline in activities of daily living (ADLs)
b. Steroid myopathy
c. Vasculitis
d. Pressure ulcers
D) Typical reasons for hospitalizing rheumatic disease patients include a decline in ADLs, steroid myopathy, tetraparesis, vasculitis, severe anemia, uncontrolled inflammation, and amputation. Pressure ulcers are not common in rheumatic disease patients.
Which physical modality has demonstrated improvement in patients with rheumatic diseases by increasing activity of synovial collagenase in the joint?
a. Ultrasound
b. Superficial heat
c. Diathermy
d. Massage
B) Heating the joint to therapeutic levels increases the activity of synovial collagenase obtained from a rheumatoid joint. Superficial heat is commonly used by patients for selftreatment in those with rheumatic diseases.
Which of the following is associated most strongly with obesity in women?
a. Hip osteoarthritis
b. Rheumatoid arthritis
c. Knee osteoarthritis
d. Lupus
C) Osteoarthritis (OA) of the knee is associated with obesity in women. OA has not been shown to be the result of
osteochondritis dissecans or athletic activity.
What is the most appropriate treatment for pain relief for osteoarthritis of the base of the thumb (carpometacarpal and metacarpophalangeal joints)?
a. Massage
b. Transcutaneous electrical nerve stimulation (TENS)
c. Range of motion exercises
d. Thumb spica splint
D) A thumb spica splint immobilizes the two joints of the thumb. Although it may interfere with some activities of daily living (ADLs), it does provide consistent pain relief.
What is the most serious complication of osteoarthritis (OA) of the cervical spine?
a. Radiculopathy
b. Myelopathy
c. Osteoporosis
d. Chronic pain
B) Cervical myelopathy (spinal cord compression) is the most serious complication of OA of the cervical spine.
Although nerve roots can become impinged because of osteophytes (radiculopathy) as well, it is not as serious as spinal cord compression. Cervical myelopathy from 0A usually requires surgical intervention.
Chronic pain can be associated with OA, but is not as serious as myelopathy.
A swan neck deformity is noted in your patient. Which condition is most likely, and which area would have a hyperflexion deformity?
a. Osteoarthritis, proximal interphalangeal joint (PIP)
b. Rheumatoid arthritis, proximal interphalangeal joint (PIP)
c. Osteoarthritis, distal interphalangeal joint (DIP)
d. Rheumatoid arthritis, distal interphalangeal joint (DIP)
D) Rheumatoid arthritis is an autoimmune disease resulting in inflammation in tissue and joints. The disease affects the digits of the hand. Swan neck deformity is caused by a rupture of the lateral retinaculum of the extensor tendon at the proximal interphalangeal joint, resulting in hyperextension of the proximal
interphalangeal joint and hyperflexion of the distal interphalangeal joint. Osteoarthritis results from generalized wear and tear on the body with progressive degeneration of joints, including cartilage, bone, synovium, muscles, and ligaments. Rheumatoid arthritis is more commonly found in women, whereas osteoarthritis has more equal sex distribution.
Rheumatoid arthritis is commonly diagnosed as early as age 20, whereas osteoarthritis affects those above age 40. Answer choices A and C are incorrect because swan neck deformity is seen in rheumatoid arthritis.
Answer choice B is incorrect because hyperflexion of the PIP would result in Boutonnière deformity. This is caused by chronic synovitis of the joint, resulting in elongation and eventual rupture of the central slip tendon.
A Boutonnière deformity is noted in your patient. Which condition is most likely, and which area would have a hyperflexion deformity?
a. Osteoarthritis, proximal interphalangeal joint (PIP)
b. Rheumatoid arthritis, proximal interphalangeal joint (PIP)
C. Osteoarthritis, distal interphalangeal joint (DIP)
d. Rheumatoid arthritis, distal interphalangeal joint (DIP)
B) Rheumatoid arthritis is an autoimmune disease resulting in inflammation in tissue and joints. The disease affects the digits of the hand. Boutonnière deformity is caused when the PIP is slowly forced into flexion by chronic synovitis of the joint from rheumatoid arthritis. This causes an elongation of the central slip, ultimately leading to rupture.
Subsequent volar displacement of the lateral bands below the axis of the PIP rotation creates increased tension on the DIP extensor mechanism, leading to hyperextension and limited flexion of the DIP. Osteoarthritis results from generalized wear and tear on the body with progressive degeneration of joints, including cartilage, bone, synovium, muscles, and ligaments. Rheumatoid arthritis is more commonly found in women, whereas osteoarthritis has more equal sex distribution.
Rheumatoid arthritis is commonly diagnosed as early as age 20, whereas osteoarthritis affects those above age 40. Answer choices A and C are incorrect because Boutonnière deformity is seen in rheumatoid arthritis.
Answer choice D is incorrect because hyperflexion of the DIP would result in swan neck deformity.
How many tender points need to be present for the diagnosis of fi bromyalgia?)
a. 7
b. 9
c. 11
d. 13
C) According to the American College of Rheumatology Fibromyalgia Diagnostic
Criteria, 18 specific tender points and 9 bilateral sites are used in the diagnosis of fibromyalgia. Out of 18 tender points, 11 must be present for more than 3 months duration.
The bilateral tender point sites include the occiput, lower cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, and knee.
Pseudogout commonly involves which of the following areas?
a. Knee
b. Toe
c. Elbow
d. Fingers
A) Pseudogout commonly involves the knee and wrist as opposed to gout, which usually affects the big toe (termed podagra).
Pseudogout is inflammation caused by calcium pyrophosphate crystals. Gout is inflammation caused by monosodium rate monohydrate crystals. Both can be diagnosed with aspirated synovial fluid. Pseudogout presents with acute joint swelling and pain commonly in the knee, but can also affect the wrist, shoulders, and hip.
Gout commonly involves which of the following areas?
a. Knee
b. Toe
c. Elbow
d. Fingers
B) Gout is an inflammatory arthritis most commonly found in the metatarsophalangeal joint at the base of the big toe, also termed podagra. Gout is caused by elevated levels of uric acid in the blood, which crystallizes into monosodium rate monohydrate crystals.
These crystals are deposited into joints, most commonly the great toe. Causes include genetic predisposition, medications such as diuretics, increased alcohol consumption, and high purine diets. During an acute gouty attack, the great toe can become red, tender, and swollen. Acute gouty attacks can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and steroids. For long-term prevention, xanthine oxidase inhibitors such as allopurinol would be indicated.
Later stage of rheumatoid arthritis affects which type of joint?
a. Amphiarthrodial joint
b. Synarthrodial
C. Diarthrodial joint
d. None of the above
C) Diarthrodial joints are freely moveable joints that are held together by a joint capsule. The composition of diarthrodial joints includes type 2 hyaline cartilage, subchondral bone, synovial membrane, synovial fluid, and joint capsule. Examples include the knee and shoulder. Rheumatoid arthritis first commonly affects the small joints of the hands. In later stages, it affects larger joints such as the knee and shoulder, both of which are diarthrodial joints. An amphiarthrodial joint is a slightly movable joint such as the spinal joints. A synarthrodial joint is an immovable joint such as sutural joints.
In rheumatoid arthritis, which of the following is considered to be the most destructive element?
a. Infiltration of T lymphocytes
b. Formation of pannus
c. Activation of synoviocytes
d. None of the above
B) Rheumatoid arthritis is an inflammatory disorder that primarily affects synovial joints.
Inflammation of the capsule around the joints, known as the synovium, is the first step in this destructive disease. Overtime, synovial cells are destroyed, causing hyperplasia.
Neutrophils, macrophages, and B- and T-cell lymphocytes are activated to increase the inflammatory response. Pannus develops when the inflammation causing fibrin deposits develops into granulation tissue.
All of the following statements are true except:
a. Pseudogout is caused by a buildup of uric acid in the bloodstream
b. Pseudogout is caused by the formation of calcium pyrophosphate
c. The big toe is the most common joint involved in gout
d. Swelling, warmth, pain, and redness of the joint are common symptoms of gout
A) Hyperuricemia is found in gout, not pseudogout. Pseudogout is inflammation caused by calcium pyrophosphate crystal deposition. The exact mechanism is unknown, but aging is the only true risk factor. The onset is between ages 60 and 70. Gout is inflammation caused by monosodium rate monohydrate crystals. Both can be diagnosed with aspirated synovial fluid. Pseudogout is an acute form of the broader calcium pyrophosphate dihydrate deposition disease,
L presenting with acute joint swelling and pain commonly in the knee, but can also affect the wrist, shoulders, hip, elbows, and metacarpophalangeal (MCP) joints.
Where are Bouchard’s nodes found?
a. Distal interphal angel joint (DIP)
b. Proximal interphalangeal joint
c. Metacarpophalangeal joint
d. Intermediate phalanges
B) The DIP is the location for Heberden’s nodes. Bouchard’s nodes and Heberden’s nodes are formed when osteophytes, also known as calcific spurs, develop in the cartilage of the articular joint. Bouchard’s and Heberden’s nodes are seen in osteoarthritis.
Metacarpophalangeal (MCP) joints are joints formed between the metacarpal bones and the proximal ends of the phalanges. Arthritis in the MCP joint is commonly found in patients with rheumatoid arthritis.
Which of the following is not a criterion for rheumatoid arthritis according to the American College of Rheumatology (ACR)?
a. Involvement of three or more joints
b. Nodules present
c. Asymmetric involvement
d. Morning stiffness
C) The ACR criteria state that rheumatoid arthritis involves the same area on both sides of the body. Involvement of three or more joints, presence of nodules, and morning stiffness are all seen in rheumatoid arthritis.
Morning stiffness, arthritis of three or more joints, arthritis of the hand joints, and symmetric arthritis must be present for more than 6 weeks to qualify under the ACR guidelines. Radiographic changes and serum rheumatoid factor are included in the criteria.
Four of the above mentioned criteria must be present.
Which of the following synovial fluid laboratory values is not consistent with an inflammatory arthritis?
a. WBC > 3,000
b. 70% polymorphonuclear leukocytes
c. Decreased erythrocyte sedimentation rate (ESR)
d. Low viscosity
C) Joint fluid analysis in a patient with an inflammatory arthritis would consist of a white blood cell count greater than 3,000 cells/mm3, greater than 70% polymorphonuclear leukocytes, lower viscosity due to its inflammatory nature, and elevated ESR. ESR is a sign of inflammation and as such, ESR would be elevated in inflammatory arthritis. The differential diagnosis for inflammatory arthritis includes rheumatoid arthritis, systemic lupus ery them atosus, gouty arthritis, Reiter’s disease, pseudogout, and psoriatic arthritis.
Decreased ESR would be found in noninflammatory arthritis, most commonly in osteoarthritis. Inflammatory arthritis patients usually have an acute onset, whereas noninflammatory arthritis patients usually have a slow, progressive, and degenerative course.
Reiter’s syndrome, or reactive arthritis, is made up of a triad of symptoms. Which of the 46. following is not involved in Reiter’s syndrome?
a. Urethritis
b. Conjunctivitis
c. Arthritis
d. Pericarditis
D) Reactive arthritis is an autoimmune condition developed in response to a recent infection, particularly after a genital infection with Chlamydia trachomatis or after an episode of gastroenteritis by Campylobacter species. The triad of symptoms includes urethritis, conjunctivitis, and arthritis. The mechanism of action is unknown, but it is assumed to involve the migration of bacterial antigens into the affected triad sites which proceed to cause an inflammatory response.
This syndrome is usually self-limiting, but if symptoms are more severe, a course of steroids and immunosuppressants may be indicated. Of the answer choices, pericarditis is not a finding in Reiter’s syndrome. Patients with rheumatic fever, an inflammatory disease after a streptococcal infection affecting the heart, joint, skin, and brain, can develop pericarditis. Patients with systemic lupus erythematosus can develop antigen-antibody complexes in the pericardium, causing inflammation or pericarditis.
What type of hypersensitivity reaction is noted in systemic lupus erythematosus
(SLE)?
a. Type I
b. Type lI
c. Type IlI
d. Type IV
C) Type I hypersensitivity reaction is immediate with IgE as a mediator. Examples include asthma and anaphylaxis. Type Il is also known as cytotoxic, or antibody-dependent, with IgM or IgG as mediators.
Examples of type il hypersensitivity reaction include thrombocytopenia and
erythroblastosis fetalis. Type Ill is also known as immune complex with laG as a mediator.
Examples include rheumatoid arthritis and systemic lupus erythematosus. SLE is an autoimmune connective tissue disease. The immune system attacks the patient’s own cells and tissues, causing inflammation and damage to the tissue. Type IV is also known as delayed-type or cell-mediated, with T-cells as a mediator. Examples include multiple sclerosis and chronic transplant rejection.
The Wright-Schober test is used in which of the following conditions?
a. Ankylosing spondylitis (AS)
b. Systemic lupus erythematosus
c. Reiter’s syndrome
d. Dermatomyositis
A) The Wright-Schober test is used to measure the ability to flex the lower back in a patient with AS. AS is a chronic inflammatory L condition of the spine and sacroiliac joint that leads to osseous formation in the spine. The test is conducted with the examiner identifying the fifth lumbar vertebrae (L5), marking 5 cm below this point, and another point 10 cm above L5. The examiner instructs the patient to attempt to touch his or her toes.
Lumbar flexion should increase the distance between the two points by more than 5 cm. If the distance between the two points does not increase by 5 cm, flexion is limited and the test is considered positive.
Which of the following sports would be contraindicated in a patient with ankylosing spondylitis?
a. Archery
b. Badminton
c. Bicycling
d. Table tennis
C) Owing to the loss of joint and spinal motion in patients with ankylosing spondylitis, these patients should engage in range of motion exercises, including stretching and strengthening. Spinal extension exercises help decrease the severity of the condition. Sports that promote spinal extension are favored, including archery, badminton, and table tennis. Sports that require spinal flexion should be avoided in this group, including golf, bicycling, and bowling. Ninety percent of patients with ankylosing spondylitis are HLAB27 positive.
Which of the following radiographic features is not seen in patients with rheumatoid arthritis?
a. Narrowing of the joint space
b. Increased bone densitv
c. Marginal erosion of bone
d. Joint fusion
B) Radiographic findings of rheumatoid arthritis include osteopenia. All of the other answer choices can be seen in radiographs of patients with rheumatoid arthritis. Patients with osteoarthritis show no signs of osteopenia on radiographs.
Antihistone antibodies are present in which of the following conditions?
a. Rheumatoid arthritis
b. Sjögren’s syndrome
c. Polymyositis
d. Drug-induced lupus
D) Drug-induced lupus is a lupus-like syndrome without involvement of the central nervous system or kidneys. Certain drugs, including hydralazine, procainamide, isoniazid, chlorpromazine, methyldopa, and quinidine, have been linked to drug-induced lupus. Upon discontinuing the offending drug, symptoms usually resolve. Antihistone antibodies are present, which can help identify the problem. Rheumatoid arthritis is an autoimmune disease resulting in inflammation in tissue and joints. Sjögren’s syndrome is an autoimmune disease involving lymphocyte infiltration and destruction of lacrimal and salivary glands.
Patients with Sjögren’s syndrome usually have dry eyes and dry mouth. Polymyositis is an inflammatory myopathy that results in symmetrical proximal muscle weakness.
Massage, manipulation, and traction are all examples of which type of therapy?
a. Relaxation
b. Hydrotherapy
c. Mobilization
d. Immobilization
C) Mobilization therapy aids in pain control and range of motion of joints and muscles. It includes massage, manipulation, and traction. Manipulation involves moving the stiff joints in their normal range of motion.
Traction is the constant, steady pull of the joint or muscle. Relaxation therapy involves techniques that are taught to help release the tension formed in the muscles and ioints of the body. Hydrotherapy consists of patients relaxing the muscles and joints in warm water.
Which condition is associated with the following features: heliotrope rash, Gottron’s papules, and shawl sign?
a. Dermatomyositis
b. Inclusion body myositis
c. Osteoarthritis
d. Fibromyalgia
A) Dermatomyositis is a term used to describe polymyositis with the addition of a characteristic heliotrope rash, Gottron’s papules, and shawl sign. A heliotrope rash is a butterfly rash around the eyes, bridge of the nose, and cheeks. Gottron’s papules are papular, erythematous, scaly lesions over the metacarpophalangeal joints, proximal interphal angel joints, and distal
interphal angel joints. Shawl sign is a rash on the shoulders and upper back, elbows, and knees. Similar to polymyositis, there is symmetric proximal muscle weakness sparing the distal musculature. Creatine kinase (CK) levels are markedly elevated, indicating muscle breakdown. The rash usually precedes the muscle weakness.
All of the following are true regarding rheumatoid arthritis except:
a. 85% of cases are rheumatoid factor
b. Rheumatoid nodules are present
c. More common in males
d. Inflammation of the synovial capsule
C) Rheumatoid arthritis is more common in females than in males. Rheumatoid arthritis is an inflammatory disorder that primarily affects synovial joints. Inflammation of the capsule around the joints, known as the synovium, is the first step in this destructive disease. Nodules are present in about 50% of patients with rheumatoid arthritis and are located most commonly over the pressure points of joints.
Which specific autoantibody is associated with systemic lupus erythematosus (SLE)?
a. Anti-Smith
b. Anti-sci-70
c. Anticentromere
d. Anti-Jo-1
A) Indirect immunofluorescence pattern assists in determining the type of antibody present in the serum. Anti-dsDNA and anti-Smith antibodies are specific for SLE. Anti-sci-70 or antitopoisomerase and anticentromere antibodies are specific for scleroderma. Antisci-70 or antitopoisomerase antibody is specific for diffuse scleroderma.
Anticentromere antibody is specific for limited scleroderma. Anti-Jo-1 antibody is associated with polymyositis and/or dermatomyositis.
What type of collagen deficiency is present in osteogenesis imperfecta?
a. Type 1 collagen
b. Type 2 collagen
c. Type 3 collagen
d. Type 4 collagen
A) Osteogenesis imperfecta, or brittle bone disease, is an autosomal dominant disorder caused by a gene mutation producing type 1 collagen. Type 1 collagen is the most abundant collagen in the body, found in scar tissue during healing. The bone mass in individuals with this disorder is diminished. Patients classically have blue sclera because of the lack of type 1 collagen formation in the eye allowing the choroidal veins to be seen.
Which of the following conditions is associated with formation of abnormal fi brillin?
a. Osteogenesis imperfecta
b. Scleroderma
c. Marfan syndrome
d. Ehlers-Danlos syndrome
C) Marfan syndrome is an autosomal dominant connective tissue disorder. There is a defect in the fibrillin protein. Fibrillin is normally found in connective tissue and is necessary for formation of elastic fibers.
Patient’s with Marfan syndrome exhibit long fingers and toes (arachnodactyly), dislocation of the lens in either or both eyes (ectopia lentis), skeletal deformities such as pectus excavatum and scoliosis. The most potentially fatal effect is cardiac involvement, especially with aortic root dilatation and aortic dissection.
In Duchenne muscular dystrophy, which protein is absent?
a. Fibrillin
b. Dystrophin
c. Huntington
d. Sarcoglycan
B) Duchenne muscular dystrophy is an X-linked recessive muscle disease caused by an absence of the muscle protein dystrophin, leading to rapid muscle weakness. The first sign and symptom of Duchenne muscular dystrophy is progressive muscle weakness in the proximal muscles of the lower extremities.
This can result in a positive Gower’s sign (the child has to use hands and arms to stand up because of weakness of hip and thigh muscles). Levels of creatine kinase are very elevated. The prognosis is poor, with affected individuals having life expectancy less than 25 years of age. A less severe form of muscular dystrophy is Becker’s muscular dystrophy. Becker’s muscular dystrophy is caused by deficient dystrophin production, causing a slower progression of proximal muscle weakness. Fibrillin is deficient in patients with Marfan syndrome. Fibrillin is normally found in connective tissue and is necessary for formation of elastic fibers.
Which of the following is not a seronegative arthritis?
a. Psoriatic arthritis
b. Rheumatoid arthritis
c. Reactive arthritis
d. Ankylosing spondylitis
B) A seronegative arthritis is an arthritis in which the rheumatoid factor is negative. Of the choices, psoriatic arthritis, reactive arthritis and ankylosing spondylitis are all rheumatoid factor negative. Psoriatic arthritis is often a milder inflammatory arthritis that develops in approximately 30% of patients who already suffer with psoriasis. During flares, the arthritic symptoms may worsen.
Reactive arthritis is an autoimmune condition developed in response to a recent infection, particularly after a genital infection with Chlamydia trachomatis or after an episode of gastroenteritis by Campylobacter species.
The triad of symptoms includes urethritis, conjunctivitis, and arthritis. Ankylosing spondylitis is a chronic inflammatory condition of the spine and sacroiliac joint with osseous formation. Rheumatoid arthritis is an autoimmune disease, usually with a positive rheumatoid factor, resulting in inflammation in tissue and joints.
Which of the following is elevated in
Paget’s disease?
a. Calcium
b. Phosphate
c. Aminotransferase
d. Alkaline phosphatase
D) Paget’s disease is a disease of bone.
The bones are broken down and regenerated, causing them to weaken. Arthritic pain is common near sites of bone weakening, especially when subchondral bone is involved. Paget’s disease commonly involves the pelvis, vertebrae, skull, tibia, and femur.
Patients are usually asymptomatic; diagnosis is made by increased alkaline phosphatase levels or patchy appearance of bones on X-ray. The skull can become enlarged, and patients may complain of increased hat size over time. In addition, if the temporal bone is involved, headaches and hearing loss can occur from cranial nerve palsies.
Fibroblast growth factor receptor 3 mutation causes which of the following conditions?
a. Paget’s disease
b. Achondroplasia
c. Osteogenesis imperfecta
d. Osteoporosis
B) Achondroplasia is an autosomal
L dominant genetic disorder caused by a mutation in the fibroblast growth factor receptor 3 (FGFR3). It is the most common form of dwarfism. This mutation leads to impaired cartilage maturation in the growth plate, resulting in shortened bone, shortened stature, and a prominent forehead. The frequency is approximately 1 case in 15,000 to 40,000 births worldwide. No evidence of receptor mutation is linked with Paget’s disease of bone, a disease of bone where bone is broken down and regenerated, causing bones to weaken. Osteogenesis imperfecta, or brittle bone disease, is an autosomal dominant disorder caused by a mutation in the gene producing type 1 collagen. Osteoporosis is caused when there is an imbalance between bone formation and bone resorption, leading to weak and fragile bones.
Which contracture is caused by forearm injuries leading to lack of blood supply to the 62. region?
a. Dupuytren’s contracture
b. Capsular contracture
c. Volkmann’s contracture
d. None of the above
C) Volkmann’s contracture is contracture of the flexor muscles due to ischemia in the volar aspect of the forearm. It usually occurs after a forearm injury. Forearm fractures and supracondylar fractures leading to compartment syndrome secondary to swelling can lead to ischemia of the affected region. Extended episodes of ischemia will cause necrosis of the muscle fibers causing them to scar and shorten. Usually, the deep muscles of the forearm, flexor digitorum profundus, and flexor pollicis longs are involved. Capsular contracture is the formation of capsular collagen fibers due to an abnormal immune response to artificial materials in the body (such as breast implants or prosthetic devices). Dupuytren’s contracture is a flexion contracture caused by thickening of the connective tissue in the palmar fascia resulting in flexion of the fingers, particularly the fourth and fifth digits.
Pain on ulnar deviation of the wrist with the thumb grasped in the fist is a positive sign for which of the following conditions?
a. Carpal tunnel syndrome
b. Rheumatoid arthritis
c. Medial epicondylitis
d. De Quervain’s tenosynovitis
D) A positive Finkelstein’s test (as described in the stem above) is suggestive of de Quervain’s tenosynovitis, which is a tendonopathy of the extensor pollicis brevis and abductor pollicis longus tendons. This syndrome is commonly seen in new mothers and repetitive movements that involve repetitive ulnar or radial deviation of the wrist.
De Quervain’s tenosynovitis may also be seen in patients with rheumatoid arthritis.
Symmetric erosive destruction of multiple joints is more likely to be seen in which of the following arthropathies?
a. Osteoarthritis
b. Reactive arthritis
c. Rheumatoid arthritis (RA)
d. Gout
C) RA usually presents as morning stiffness in multiple joints. RA is caused by autoimmune destruction of unknown etiology.
Current American College of Rheumatology criteria for rheumatoid arthritis include morning stiffness lasting for at least 1 hour, involvement of three or more joints, involvement of at least one joint in the hand, symmetric involvement of joints, rheumatoid nodules, positive rheumatoid factor, and radiographic evidence of erosions or decalcification of joints. At least four of the seven criteria must be met for diagnosis.
A patient presenting with flexion contracture of the metacarpophalangeal
(MCP), hyperextension of the proximal interphalangeal (PIP) joint, and the flexion of the distal interphalangeal (DIP) joint is seen in which of the following diseases?
a. Osteoarthritis
b. Gout
c. Psoriatic arthritis
d. Rheumatoid arthritis
D) Swan neck deformity is commonly seen in patients with rheumatoid arthritis, but can also be seen in patients with Ehlers-Danlos syndrome.
A painful joint is aspirated and is found to contain calcium pyrophosphate dihydrate crystals. These joint crystals are pathognomonic of which of the following conditions?
a. Gout
b. Pseudogout
c. Psoriatic arthritis
d. Osteoarthritis
B) Pseudogout is an arthropathy caused by a collection of positively birefringent crystals of calcium pyrophosphate dihydrate crystals. Symptoms are usually noted in the knee, but can be present in other joints as well. Inflammation and limited range of motion of the involved joint are noted.
Which of the following disorders is caused by a fi brillin defect?
a. Osteogenesis imperfecta
b. Rheumatoid arthritis
c. Marfan syndrome
d. Scleroderma
C) Marfan syndrome is an autosomal dominant condition caused by FBN1 gene mutation located on chromosome 5. Excess linear growth of long bones, arachnodactyly, and joint laxity are common skeletal findings.
Cardiac conditions such as aortic root dilation and mitral valve pathology may be noted.
Ectopia lentis seen in 50% to 80% of patients with Marfan syndrome.
Which of the following is the leading cause of morbidity and mortality in patients with Marfan syndrome?
a. Arachnodactyly
b. Pneumothorax
c. Ectopia Lentis
d. Aortic disease
D) Aortic root disease causing aortic dilatation, aortic dissection, and regurgitation is the main cause of morbidity and mortality in patients with Maran syndrome.
Approximately 60% to 80% of adult patients with Marfan syndrome have aortic root dilatation, and the American Heart Association recommends an echocardiograph at the time of diagnosis.
Which of the following antibodies is tested in patients suspected of having systemic lupus erythematosus (SLE)?
a. Anticentromere
b. Antigliadin
c. P-ANCA
d. Anti-Smith
D) SLE is a chronic inflammatory disorder involving multiple organs of the body, including skin, lungs, kidneys, and joints.
Antibody testing for SLE usually includes antinuclear antibodies (ANA), antiphospholipid, anti-dsDNA, and anti-Smith antibodies. Complement levels C3 and C4 are monitored for response to therapy.
Which of the following pulmonary conditions is often seen in patients with systemic sclerosis?
a. Interstitial lung disease
b. Pneumothorax
c. Aspiration pneumonia
d. Chronic obstructive pulmonary disease (COPD)
A) Interstitial lung disease is reported in more than 75% of patients with systemic sclerosis. A 5-fold increase in lung neoplasm is also noted in patients with systemic sclerosis.
Which of the following is an acute phase protein seen in response to tissue injury?
a. Antinuclear antibody (ANA)
b. Creactive protein (CRP)
C. C-ANCA
d. Anticentromere
B) CRP is an acute phase reactant that plavs a role in host defense with both inflammatory and anti-inflammatory actions.
Serum CRP levels increase within 4 to 6 hours and normalize in 7 days.
Which of the following organisms is commonly responsible for inflammatory polyarthritis?
a. Parvovirus B-19
b. Haemophilus influenzae
c. Streptococcus pneumonia
d. Neis seria gonorrhoeae
A) A cute inflammatory polyarthritis is a self-limiting viral arthritis that presents with morning stiffness and symmetrical joint involvement of the upper extremities lasting a few weeks. Viruses commonly noted to cause polyarthritis include parvovirus B-19, Rubella, alphavirus, and hepatitis B and C viruses.
Which of the following is the most destructive element of rheumatoid arthritis?
a. Joint erosion
b. Pannus formation
c. Crystalline formation
d. Rheumatoid nodules
B) Pannus is a tissue derived from synovial membrane that causes destruction of cartilage and bone. Multinucleated cells with osteoclastic characteristics have been identified in the pannus-bone interface. This destruction can lead to instability of joints and eventual fibrosis, becoming the leading cause of morbidity in patients with rheumatoid arthritis.
Which of the following pediatric conditions leads to fragile bones resulting in multiple fractures?
a. Juvenile rheumatoid arthritis
b. Sickle cell disease
c. Osteogenesis imperfecta
d. Osteoarthritis
C) Osteogenesis imperfecta, also known as brittle bone disease, is caused by gene mutations of alpha-1 and alpha-2 chains of type 1 collagen and posttransitional modifi cation of type 1 collagen. Type 1 collagen is an important structural protein for ligament, tendon, sclera, and bone. Dysfunctional type 1 collagen results in defective quality and fragility of bone seen in patients with osteogenesis imperfecta.
Which of the following is not part of the
CREST syndrome?
a. Telangiectasia
b. Scleroderma
c. Raynaud’s phenomenon
d. Calcinosis
B) The CREST syndrome comprises calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.
In which of the following disorders would patients have a negative rheumatoid factor
(RF)?
a. Mixed connective tissue disease
b. Rheumatoid arthritis
c. Scleroderma
d. Siogren’s syndrome
C) RFs are antibodies against the Fc part of the lgG and are not commonly seen in patients with scleroderma. Although the sensitivity of rheumatoid factor in rheumatoid arthritis is close to 90%, it is nonspecific because elevated levels of RF are found in Sjögren’s syndrome, mixed connective tissue disease, systemic lupus erythematosus, and myositis.
Which of the following vitamin deficiencies can cause scurvy?
a. Vitamin A
b. Vitamin B
c. Vitamin C
d. Vitamin D
C) Vitamin C deficiency leads to impaired collagen synthesis, resulting in pathological manifestations in tissues and organs containing collagen.
Which of the following organisms has been identified as the cause of Lyme disease?
a. Borrelia burgdorferi
b. Streptococcus pyogenes
C. Neis seria meningitidis
d. Babesia microti
A) Lyme disease is a tick-borne illness caused mostly by B. burgdorferi in the United States. The early stage of Lyme disease involves formation of erythema migrans, a characteristic skin lesion that develops within 2 weeks to a month of exposure. Later stages can involve neurological and cardiac symptoms along with persistent arthritis involving large joints such as the knee.
What is the most common cause of neuropathic arthropathy?
a. Osteoarthritis
b. Septic arthritis
c. Systemic lupus
d. Diabetes
D) Most commonly seen in patients with diabetes mellitus, Charcot foot is a term given to neuropathic arthropathy causing painless soft-tissue swelling, bony fragments, and joint effusion in the ankle. Although the pathophysiology of this process is unknown, current theories suggest that diabetic neuropathy causes lack of proprioception and results in ligamentous laxity, bone destruction, and instability. Other causes of Charcot joint are syphilis and syringomyelia.
Which of the following is 80. not a feature of fibromyalgia?
a. Pain in all four quadrants
b. CREST syndrome
c. Pain in 11 to 18 tender points
d. Symptoms for at least 3 months
B) Diagnosis of fibromyalgia syndrome according to the American College of Rheumatology (ACR) classification requires widespread pain in all four quadrants of the body, pain in 11 to 18 tender points, and symptoms lasting for at least 3 months. The syndrome is most commonly seen in women 20 to 60 years old. Triggers include physical activity, inactivity, sleep disturbance, and emotional stress.
Which of the following is the most common benign tumor composed of adipocytes?
a. Focal nodular hyperplasia
b. Neuroblastoma
c. Hemangioma
d. Lipoma
D) Lipomas are lobules of adipocytes found in subcutaneous tissue, deep soft tissue, or surfaces of bone. These lesions are usually painless, unless compressing against adjacent tissue or nerves resulting in neurological or functional deficits.
Which of the following is not a type of connective tissue fiber?
a. Ependymal
b. Collagen
c. Elastic
d. Reticular
A) Collagenous fibers are the most abundant of the connective tissue fibers and are found in vessels, cartilage, gut, skin, bone, tendons, and ligaments. Elastic fibers form the extracellular matrix and can stretch up to 1.5 times their length. Reticular fibers provide a framework and are found in the liver, marrow, and lymphatic organs.
Which of the following conditions causes calcification of connective tissue?
a. Fibrodysplasia ossificans progressiva
b. Hajdu-Cheney syndrome
c. Fetal hydantoin syndrome
d. Hurler disease
A) Fibrodysplasia ossifi cans progressiva is an autosomal dominant disorder of connective tissue characterized by bone formation within connective tissue. Trauma usually precipitates the ossification of connective tissue, including minor trauma r such as intramuscular injections or bruises.
Attempts to remove the calcified bone from the connective tissue result in further ossification.
What is the most common cause of acute nontraumatic monoarthritis in young adults?
a. Septic arthritis
b. Gonococcal arthritis
C. Gout
d. Rheumatoid arthritis
B) Disseminated gonococcal infection can lead to gonococcal arthritis. This may present initially as tenosynovitis and eventually lead to destruction of the articular cartilage and fibrosis of the joint. Culture from synovial fluid is important for early diagnosis and to determine sensitivity to antibiotic therapy.
Pain relieved by activity is a feature of which of the following types of arthritis?
a. Osteoarthritis
b. Rheumatoid arthritis
c. Septic arthritis
d. Gouty arthritis
B) Morning stiffness is a feature of nearly all types of arthropathies, but rheumatoid arthritis has classically been noted to have morning stiffness lasting longer than an hour and relieved by movement.
Ankylosing spondylitis is associated with which of the following HLA allele?
a. HLA-B47
b. HLA-B27
C. HLA-DR4
d. LA-B72
B) The human leukocyte antigen is synonymous with the major histocompatibility complex and describes a group of genes on chromosome 6. Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton commonly associated with HLA-B27.
Which of the following is not a feature of
Scheuermann kyphosis?
a. Vertebral body wedging of at least 5 degrees
b. Flattening of curvature with extension
C. Involvement of at least three vertebral bodies
d. Anterior wedging
B) Scheuermann kyphosis occurs in early adolescence and is defined as anterior wedging of at least 5 degrees involving at least three vertebral bodies. Forward bending, extension, or lying supine does not resolve this rigid kyphosis that usually involves the thoracic or thoracolumbar spine.
Heberden’s nodes are a common feature in which of the following disease processes?
a. Rheumatoid arthritis
b. Septic arthritis
c. Osteoarthritis
d. Gouty arthritis
C) Heberden’s nodes are osteoarthritis enlargements in the distal interphalangeal joints and appear in more than half of patients with osteoarthritis. Repeated trauma causes these osteophyte formations to develop and may cause joint stiffness and tenderness.
What is the term given to the enlargement of the gastrocnemius-semimembranosus bursa?
a. Baker’s cyst
b. Septic arthritis
c. Gout
d. Pseudogout
A) The gastrocnemius-semimembranosus bursa is found between the tendons of the medial head of the gastrocnemius and the semimembranosus muscles. The distention of this bursa is called a Baker’s cyst. Although usually asymptomatic, the rupture of a
Baker’s cyst can cause acute pain in the back of the knee.
