Rheum SAEs Flashcards
A 55-year-old postal worker with a 1-year history of increasing left knee pain and decreasing
ability to ambulate arrives at your office. Her history is significant for 30 minutes of morning
stiffness and a left medial meniscal tear that was repaired arthroscopically 5 years ago. Her exam
is significant for a body mass index of 35, left knee varus deformity, and mild quadriceps
weakness. Her radiograph demonstrates medial compartment narrowing and bony sclerosis. She
has
(a) rheumatoid arthritis.
(b) osteoarthritis.
(c) parvovirus infection.
(d) pseudogout.
Answer: (b)
Commentary: Osteoarthritis (OA) is the leading cause of impaired mobility in elderly persons.
Risk factors include obesity, malalignment, prior trauma or surgery, and occupational bending or
lifting. Radiographs of knee OA demonstrate joint space narrowing, osteophytes, bony sclerosis
and cysts.
A 25-year-old man with a history of plantar fasciitis complains of low back and buttock pain.
The pain is worse at rest and better with activity. Schober test (signifying restricted lumbar
flexion) is positive. The laboratory or radiology result that would help confirm your most likely
diagnosis is a positive
(a) antinuclear antibody (ANA).
(b) human leukocyte antigen (HLA) B27.
(c) discogram.
(d) myelogram.
Answer: (b)
Commentary: The patient may have ankylosing spondylitis (AS). Enthesitis, such as plantar
fasciitis, is common in patients with AS. HLA B27 is usually positive in this condition, which is
a seronegative spondyloarthropathy. Schober test is performed by marking a point 5 cm below
the iliac crest line and 10 cm above. On forward flexion, the line should increase by more than 5
cm. An ANA test, discogram and myelogram would not help to diagnosis AS.
A 60-year-old man has first metatarsophalangeal joint pain. Joint fluid analysis confirms your
suspected diagnosis. What lifestyle or medication changes would reduce flare-ups of his
condition?
(a) Increase seafood intake
(b) Decrease alcohol intake
(c) Increase diuretic use
(d) Decrease vitamin C use
Answer: (b)
Commentary: Alcohol increases uric acid production and can provoke an acute gout attack.
Seafood and red meat contain purines which increase serum uric acid levels and thus increase
gout flares. Gout can also be provoked by trauma and drugs such as thiazide diuretics. In
contrast, vitamin C has been found to decrease gout attacks.
A 35-year-old woman sustained an ischemic stroke and is currently undergoing workup in the
acute care hospital. Systemic lupus erythematosus (SLE) is suspected. An immunoglobulin G
(IgG) or IgM anticardiolipin antibody analysis is ordered to evaluate for which associated
condition?
(a) Antiphospholipid antibody syndrome
(b) Activated protein C resistance
(c) Antinuclear antibody
(d) Antithrombin III deficiency
Answer: (a)
Commentary: Antiphospholipid antibody is associated with systemic lupus erythematosus (SLE)
and can increase risk of thrombosis. SLE is diagnosed with an abnormal serum level of IgG or
IgM anticardiolipin antibodies, positive lupus anticoagulant, or false-positive serologic test for
syphilis. Activated protein C resistance and antithrombin III deficiency are risk factors for
thrombosis and stroke, but do not have the same association with SLE. Antinuclear antibody is
usually positive in SLE and is part of the diagnostic criteria, but is not associated with
thrombosis.
The ulnar deviation of her fingers at the metacarpal phalangeal joints is due to the rupture of the
(a) lateral retinaculum of the extensor tendon sheath.
(b) central slip of the extensor tendon.
(c) radial retinaculum.
(d) ulnar collateral ligament.
Answer: (c)
Commentary: Rupture of the radial retinaculum produces ulnar subluxation of the metacarpal
phalangeal (MCP) joints. Rupture of the lateral retinaculum of the extensor tendon sheath at the
proximal interphalangeal joints produces swan-neck deformities. Rupture of the central slip of
the extensor tendon produces boutonniere deformities. Rupture of the ulnar collateral ligament
would result in radial deviation of the fingers.
- A 70-year-old obese gentleman presents to your office for follow-up with a several month history
of increasing left hip and groin pain that occurs with walking. His history is significant for prior
alcoholism, hypothyroidism, gout, and right knee osteoarthritis. He completed a physical therapy
course that did not help much. He now has difficulty even standing or walking for a few minutes
and complains of pain with moving his leg. Radiographs taken today demonstrate sclerosis and
slight collapse of the femoral head. What is his main risk factor for developing the condition
found on his radiographs?
(a) Obesity
(b) Alcoholism
(c) Hypothyroidism
(d) Older age
Answer: (b)
Commentary: The radiographic findings are typical for avascular necrosis which can be due to
trauma, high doses and/or prolonged use of steroids, heavy alcohol use, and certain systemic
diseases (diabetes, systemic lupus erythematosus). Obesity and older age are risk factors for
developing osteoarthritis. Typical radiographic findings of osteoarthritis include joint space
narrowing, osteophytes, subchondral cysts and sclerosis; collapse of bone is not seen.
Hypothyroidism is not a risk factor for avascular necrosis.
In Lyme disease, beyond the initial erythema migrans lesion from infection with the spirochete
Borrelia burgdorfer what other findings may be seen later on?
(a) Facial nerve palsy
(b) Renal insufficiency
(c) Pleural effusion
(d) Cardiomyopathy
Answer: (a)
Commentary: Lyme disease is the result of a bite from a tick infected with Borrelia burgdorferi.
Erythema migrans lesion is typically the initial skin lesion seen. Other findings from systemic
infection include mono-/polyarticular arthritis, facial nerve palsy, aseptic meningitis,
radiculopathy, or heart block. Renal insufficiency and pleural effusion are not seen.
A 47-year-old woman develops complex regional pain syndrome (CRPS) type I following a fall
at work which resulted in a distal radius fracture. Although no established gold-standard
treatment for CRPS currently exists, which option has been studied in multiple, large-scale
randomized trials?
(a) Bisphosphonates
(b) Gabapentin
(c) Stellate/lumbar sympathetic blocks
(d) Calcitonin
Answer: (a)
Commentary: While all of the listed options have been used for the treatment of CRPS, only
bisphosphonates have been investigated in multiple, large-scale randomized trials. Clear benefits
have not been reported with gabapentin or stellate/lumbar sympathetic blocks. Available evidence
does not support the use of calcitonin.
You receive a call from your 70-year-old patient with osteoporosis. She has been taking
alendronate (Fosamax) for 3 years. The news reports and her friends are all talking about hip
fractures in patients taking biphosphonates. You state that based upon scientific evidence there is
(a) increased risk of femoral fractures.
(b) increased risk with the initiation of bisphosphonates at a younger age.
(c) no increased risk in patients with prior fractures.
(d) no increased risk of femoral fractures
Answer: (d)
Commentary: Recent secondary analysis of 3 large, randomized biphosphonate studies did not
find increased risk of subtrochanteric or femoral fractures. Proposed risk factors such as younger
age upon initiation of biphosphonate treatment has not been confirmed or studied. A risk factor
for future fractures is a history of prior fractures.
- The use of a magnetic knee wraps in patients suffering with mild to moderate knee osteoarthritis
has been shown to
(a) decrease edema.
(b) increase walking distance.
(c) increase isokinetic strength.
(d) increase range of motion.
Answer: (c)
Commentary: The application of magnetic knee wraps has been shown to increase isokinetic
strength and improve pain scales. Edema, walking distance and range of motion were not
outcome measures.
A 35-year-old gentleman with a history of Lyme disease that was treated adequately with antibiotics 1 year ago complains of continued muscle aches, joint pain, fatigue, and difficulty concentrating. His repeat Lyme serologies have been negative, as have all other laboratory tests. He has had a full medical work-up from his internist that has been unremarkable. You recommend
(a) intravenousceftriaxone for 28 days.
(b) sulfasalazine for his muscle and joint pains.
(c) intra-articular cortisone injections for joint pain.
(d) emotional support and symptom management.
Answer: D
Commentary: The patient has postLyme disease syndrome, which occurs in a minority of patients who have had Lyme disease. There is no specific treatment. Physicians should provide support and management of patient complaints. Antibiotic treatment is contraindicated. Sulfasalazine is not a treatment for Lyme disease.
A 75-year-old manwith a recent calcaneal stress fracture after starting a walking program presents to your clinic. Initially, you should
(a) order a bone mineral density test.
(b) prescribe a lower extremity strengthening program.
(c) obtain a nuclear bone scan.
(d) prescribe a swimming program
Answer: A
Commentary: The initial assessment should include checking his bone density to establish a diagnosis of osteopenia/osteoporosis and then identifying secondary risk factors (such as hypogonadism, corticosteroid use, excessive alcohol use). Once a diagnosis is established, prescribing weight-bearing and strengthening exercises are important. Obtaining a nuclear bone scan is not as helpful. Swimming is a non-weight bearing exercise.
- Which factor is a criterion for hip osteoarthritis?
(a) Periarticularosteopenia
(b) Femoral head erosions with sclerosis
(c) Acetabular osteophytes
(d) Erythrocyte sedimentation rate above20mm/hr
Answer: C
Commentary: The American College of Rheumatology states that the criteria for osteoarthritis of the hip are hip pain along with 2 of the three findings: erythrocyte sedimentation rate less than 20mm/hr, radiographic evidence of femoral/acetabular osteophytes, radiographic evidence joint-space narrowing.
- The most common clinical manifestation of Lyme disease is
(a) monoarticular or oligoarticular arthritis.
(b) facial-nerve palsy.
(c) atrioventricular block.
(d) erythema migrans.
(d)Erythema migrans (EM) is a skin lesion that is erythematous, and may be round or oval, flat or raised, and possibly have
central clearing. Of persons with untreated EM, sixty percent will have monoarticular or oligoarticular arthritis. Ten percent
will have a neurologic presentation, such as facial-nerve palsy. Approximately 5 percent will have a cardiac manifestation
such as atrioventricular block.
- Myositis is defined as
(a) muscle aching.
(b) muscle aching with weakness.
(c) muscle symptoms with creatine kinase elevation.
(d) muscle symptoms with creatine kinase and creatinine elevations.
Myopathy refers to a disease or an abnormal condition of striated muscle, whereas myalgia is defined as muscle aching or weakness without serum creatine kinase (CK) elevations. Myositis implies muscle symptoms accompanied by CK elevations. Rhabdomyolysis signifies muscle complaints with CK elevations 10 times the upper limits of normal (ULN) with creatinine elevation. Clinically important myopathy with CK elevations greater than 10 times ULN is estimated to occur in approximately 0.1% of patients who receive statin monotherapy. Clinically important myopathy and rhabdomyolysis have been reported with all statins with an overall death rate of .15 per 1 million prescriptions.
The most significant risk factor for continued structural destruction of the knee in osteoarthritis is
(a) joint malalignment.
(b) obesity.
(c) prior surgery.
(d) occupational bending and lifting.
(a) Joint malalignment is the most significant risk factor for further joint deterioration, since it creates uneven focal loading.
A 35-year-old man with history of psoriatic arthritis complains of localized low back pain of insidious onset. The pain is worse in the morning and improves as the day progresses. What is the most likely cause of his back pain?
(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis
(b) Spondylonegative spondylarthropathies, such as psoriatic arthritis, are often associated with sacroiliitis. The Gelling phenomenon, characterized by stiffness after prolonged immobility, occurs with many inflammatory arthropathies
The arthropathy in persons with systemic lupus erythematosus (SLE) generally is in the wrists, knees and small joints of the hands. It is also
(a) symmetric and non-erosive.
(b) symmetric and erosive.
(c) asymmetric and non-erosive.
(d) asymmetric and erosive.
(a) The arthritis in SLE is symmetric and non-erosive. It is also generally non-deforming and reducible due to its involvement of the para-articular tissues.
In addition to routine weight-bearing exercises and calcium supplements, vitamin D is important in persons with osteoporosis because it
(a) decreases the amount of calcium supplementation needed.
(b) enhances muscle strength and reduces the risk of falling.
(c) decreases bone turnover.
(d) improves the mechanism of action of bisphosphonates
(b) Vitamin D is essential for skeletal maintenance and has been shown to enhance muscle strength and reduce the risk of falling.
A 24-year-old college student reports low back and lower limb joint pain for the past several months. His heels are especially painful, which makes it difficult for him to walk or stand for prolonged periods of time. He recalls an episode of gastroenteritis requiring hospitalization 6 months ago. Upon further questioning, he admits to some mild dysuria. His neurologic exam is normal. Radiographs of his ankles will most likely demonstrate
(a) a normal joint.
(b) osteophytes and subchondral cysts in the tibiotalar joint.
(c) periosteal reaction and bony erosions of the calcaneus.
(d) avascular necrosis of the talus.
(c) The diagnosis is reactive arthritis / seronegative spondyloarthropathy that develops after certain genitourinary or gastrointestinal infections, most commonly in young men. Non-gonococcal urethritis and conjunctivitis is the remainder of the clinical triad. Heel pain is one of the most frequent and distinctive clinical features, along with low back pain radiating into the buttocks. Periostitis and erosions occur in the ankle joint in individuals with a several month history of heel pain. Osteophytes and subchondral cysts are typical of osteoarthritis. Avascular necrosis is not typical.
What articular abnormality is associated with systemic lupus erythematosus and its treatment?
(a) Avascular necrosis
(b) Erosions with subchondral sclerosis
(c) Erosions with overhanging edges
(d) Syndesmophytes
(a) Avascular necrosis (or ostenecrosis) is the second form of joint disease that occurs in persons with SLE; it is associated with use of corticosteroids. Erosions are not seen with systemic lupus erythematosus. Erosions with subchondral sclerosis are seen in rheumatoid arthritis and overhanging edge in gout. Syndesmophytes occur in spondyloarthropathies at the anterior and posterior longitudinal ligaments of the spine.
A patient presents to your office with knee pain from a flare of rheumatoid arthritis. She has a mild effusion and warmth at her knee. The therapist wants to use ultrasound to her knee for treatment. You advise that ultrasound
(a) accelerates healing.
(b) helps with pain control.
(c) is contraindicated.
(d) will not help with the pain.
(c) Ultrasound use is contraindicated in acute rheumatoid arthritis. Ultrasound has been shown to help with pain, but not in the context of acute inflammation.
- The initial treatment for osteoarthritis is
(a) medication to reverse articular cartilage damage.
(b) surgical correction of joint deformities.
(c) therapy to relieve joint symptoms.
(d) immobilization of the joint to prevent deformity.
(c) General treatment principles of osteoarthritis include medications and/or therapy to relieve joint symptoms, along with maintaining or improving function and minimizing drug toxicity. To date, no medications can reverse or repair damaged articular cartilage. Exercises, such as range of motion and strengthening, are part of nonpharmacologic therapy of osteoarthritis. Surgical correction is not an initial treatment strategy.
- Myositis is defined as
(a) muscle aching.
(b) muscle aching with weakness.
(c) muscle symptoms with creatine kinase elevation.
(d) muscle symptoms with creatine kinase and creatinine elevations
(c) Myopathy refers to a disease or abnormal condition of striated muscle; whereas, myalgia is defined as muscle aching or weakness without serum creatine kinase (CK) elevations. Myositis implies muscle symptoms accompanied by CK elevations. Rhabdomyolysis signifies muscle complaints with CK elevations 10 times the upper limits of normal (ULN) with creatinine elevation. Clinically important myopathy with CK elevations greater than 10 times ULN is estimated to occur in approximately 0.1% of patients who receive statin monotherapy. Clinically important myopathy and rhabdomyolysis have been reported with all statins with an overall death rate of .15 per 1 million prescriptions.
- Which injury level is the most common location for an osteoporotic vertebral compression fracture?
(a) Upper thoracic spine
(b) Middle thoracic spine
(c) Thoracolumbar junction
(d) Middle lumbar spine
(b) The most common location for vertebral compression fractures due to osteoporosis is the midthoracic spine, followed by the thoracolumbar junction. If fractures are seen at other levels, a higher degree of suspicion for a pathologic (due to cancer) fracture should be raised.
- Which of the following is the most important lifestyle modification for prevention of osteoporosis?
(a) Avoiding cigarette smoking and high intake of caffeine
(b) Decreasing the intake of alcohol
(c) Minimizing the use of nonsteroidal anti-inflammatory medications
(d) Eating a diet high in protein and phosphorus
(a) Factors that impact bone mineral density negatively are smoking and high intake of caffeine, protein, and phosphorus. An active lifestyle with regular weight-bearing exercise is advised. Eliminating fall hazards such as throw rugs throughout the home is also essential.
A 40-year-old man with psoriatic arthritis consults you regarding his hand pain. On examination, you notice that his left index finger is noticeably shorter than all of his other fingers and has extra folds of skin. The most likely diagnosis is
(a) arthritis mutilans.
(b) Auspitz’s sign.
(c) dactylitis.
(d) Jaccoud’s arthritis.
(a) Arthritis mutilans is osteolysis of the phalanges and metacarpals, which results in telescoping, or shortening, of the involved digit. It is a highly characteristic feature of psoriatic arthritis. Auspitz’s sign is pinpoint bleeding after scraping a psoriatic plaque. Dactylitis, or “sausage digits,” is a combination of tenosynovitis and arthritis of the distal or proximal interphalangeal joint. Jaccoud’s arthritis is a non-erosive deforming arthritis in systemic lupus erythematosus.
(a) Boumpas DT, Illei GG, Tassiulas IO. Psoriatic arthritis. In: Klippel JH, editor. Primer on the rheumatic diseases. 12th ed. Atlanta (GA): Arthritis Foundation; 2001. p233-8.
(b) Nicholas JJ. Rehabilitation of patients with rheumatological disorders. In: Braddom
A 66-year-old woman with rheumatoid arthritis is admitted to inpatient rehabilitation following a right total knee arthroplasty (TKA). On her initial day of therapy, she had difficulty walking with her physical therapist. Her medications included methotrexate (Trexall), etanercept (Enbrel), ezetimibe (Zetia), multi-vitamin, calcium with vitamin D, alendronate (Fosamax), acetaminophen/hydrocodone (Norco), and warfarin (Coumadin). Re-examination shows hip flexion 5/5, knee extension 4/5, knee flexion 4/4, ankle dorsiflexion 1–2/5, ankle plantar flexion 5/5. You suspect
(a) sciatic nerve stretch injury.
(b) posterior tibialis tendon rupture.
(c) inadequate pain control.
(d) peroneal nerve injury.
(d) Temporary weaknesses of peri-articular muscles typically occurs after knee arthroplasty along with loss of full flexion and extension due to pain, edema, and the procedure itself. Ankle dorsiflexion is not typically weak following TKA and therefore peroneal nerve injury due to a hematoma would be suspected, especially since the patient is on warfarin. This injury requires surgical exploration and decompression. Sciatic nerve stretch injury, posterior tibialis tendon rupture, and inadequate pain control would not present as ankle dorsiflexion weakness
- Which statement is TRUE regarding complex regional pain syndrome (CRPS)?
(a) Pain is characterized by allodynia.
(b) Local osteopenia is a common early occurrence.
(c) CRPS type 1 is also known as causalgia.
(d) Adults with CRPS have a better prognosis than children with CRPS.
(a) Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy, as well as by other names, is characterized by a preceding noxious event; allodynia is an exaggerated pain response (ie, hyperesthesia) in response to a non-noxious stimulus or to vascular changes such as those indicated by paleness and coolness or by edema. Sudeck’s atrophy is a name previously given to late stage CRPS when osteopenia is present. Osteopenia is a rare and late occurrence with CRPS. CRPS type 2 is also referred to as causalgia and is instigated from an initial nerve injury. Children with CRPS have a better prognosis than adults
- A 65-year-old woman describes a 6-year history of progressive pain and stiffness in her left knee,
right hip, and distal fingers. Plain radiographs of her left knee and right hip demonstrate
osteophytes and asymmetric joint space narrowing with subchondral bony sclerosis. The most
likely diagnosis is
(a) systemic lupus erythematosus.
(b) rheumatoid arthritis.
(c) gouty arthropathy.
(d) osteoarthritis.
(d) Arthritis in systemic lupus erythematosus is non-erosive and does not have articular cartilage
involvement. In rheumatoid arthritis, periarticular bony erosions and osteopenia are seen on
radiographs. Radiographic changes in gouty erosions are usually slightly removed from the joint
space and have atrophic and hypertrophic features (an overhanging edge and soft-tissue tophus).
Characteristic radiographic findings of osteoarthritis include bony proliferation at the joint margin,
asymmetric joint-space narrowing, and subchondral bone sclerosis.
Klippel JH, Weyand CM, Crofford LJ, Stone JH, Arthritis Foundation, editors. Primer on the rheumatic
diseases. 12th ed. Atlanta (GA): Arthritis Foundation; 2001. pp 220, 291, 318, 337.
- A 42-year-old woman presents with a 3-month history of difficulty walking up stairs and rising from
chairs. She has no headaches or scalp pain and is currently on no medications. Physical
examination reveals bilateral weakness of her proximal legs and arms. Laboratory studies reveal a
markedly elevated creatine phosphokinase (CPK) level and a normal erythrocyte sedimentation rate
(ESR). The most likely diagnosis is
(a) myasthenia gravis.
(b) polymyalgia rheumatica.
(c) polymyositis.
(d) rhabdomyolysis.
(c) The hallmark features of polymyositis, or idiopathic inflammatory myopathy, are symmetric muscle
weakness of the shoulder and pelvic girdles, occasionally accompanied by mild pain and
tenderness. Eventually, weakness of the proximal leg and arm muscles follows. The symptoms
usually appear insidiously, with no identifiable precipitating event. Laboratory examination shows
an elevation in skeletal muscle enzymes, especially creatine phosphokinase. Electromyographic
changes are consistent with inflammatory myopathy: short small, polyphasic motor units;
filbrillations; positive waves; and high frequency, repetitive discharges. The absence of headaches
and scalp pain makes polymyalgia rheumatica less likely. Rhabdomyolysis is typically more acute
in onset and is associated with trauma or use of certain medications such as the statins.
- Which surgical option would be most appropriate for a patient with rheumatoid arthritis who has
severe uncontrollable knee pain and loss of function?
(a) Synovectomy
(b) Hemiarthroplasty
(c) Total knee arthroplasty
(d) Arthrodesis
(c) Total knee arthroplasty is the surgery of choice in persons with severe pain and loss of function. A
synovectomy provides temporary pain relief and decreased swelling. Hemiarthroplasty is
contraindicated in rheumatoid arthritis due to total joint involvement. Arthrodesis would not
provide the range of motion needed for stairs, ambulation, and dressing.
