RHEUMA

Question 1

Which of the following characteristics points to an articular problem versus a non-articular problem?

a. Pain is deep and diffuse
b. Prominent on active rather than passive motion
c. Reproducible in certain movements only
d. Association of PE findings remote from the affected joint

Answer 1

The correct answer is: Pain is deep and diffuse

Question 2

Which of the following characteristics will indicate an inflammatory musculoskeletal condition?

a. Gel phenomenon
b. Synovial swelling is absent
c. Stiffness/pain improves with activity
d. Shorter duration of stiffness (<60 minutes)

Answer 2

The correct answer is: Stiffness/pain improves with activity

Question 3

A 30/F presented with a 2-day history of left knee swelling, redness and pain with undocumented fever. Positive bulge sign was noted. She underwent synovial fluid aspiration which showed findings compatible with an inflammatory pathology. Which of the following results is LEAST LIKELY to be seen?

a. Clear color of synovial fluid
b. Reduced viscosity
c. Absence of stringing effect
d. WBC of 10,000/uL

Answer 3

The correct answer is: Clear color of synovial fluid

Question 4

A 70/F presented in the OPD with chronic bilateral knee pain, progressive over the past 5 years. She has difficulty getting up and walking in the morning but notes improvement within 10 minutes. Her mother also suffered from bilateral knee pains during her old age. The patient competed as a professional marathoner during her younger years. On physical examination, there was crepitus in the bilateral knees. Which of the following characteristics contributed the most to this patient’s condition?

a. Age
b. Obesity
c. Genetic predisposition
d. Overuse

Answer 4

The correct answer is: Age

Question 5

A 55/M jeepney driver presents with bilateral hand pain which he especially experiences after driving the whole day. He also reports brief morning stiffness on both his hands. Bony enlargements on DIP and PIP joints were also noted. What is the likely diagnosis?

a. Carpal tunnel syndrome
b. Gouty arthritis
c. Osteoarthritis
d. Rheumatoid arthritis

Answer 5

The correct answer is: Osteoarthritis

Question 6

A 50/M consulted your clinic due to joint pain. He started to experience the pain on his right big toe and ankle a day after binge drinking with his friends. On physical exam, both joints appear swollen, erythematous and is warm to touch. If a synovial fluid sample is taken, which of the following will most likely be found?

a. WBC < 2000/uL
b. Gram positive cocci
c. Monosodium urate crystals
d. Viscous straw colored fluid

Answer 6

The correct answer is: Monosodium urate crystals

Question 7

Which of the following is a characteristic finding on x-ray of gouty arthritis?

a. Narrowed joint spaces and with stippling in the area of joint space
b. Presence of osteophytes and cortical sclerosis
c. Juxtaarticular osteopenia and bony marrow lesions (BML)
d. Well-defined erosions and overhanging cortical edges

Answer 7

The correct answer is: Well-defined erosions and overhanging cortical edges

Question 8

Which of the following patients with symptomatic gout would require hypouricemic therapy?

a. A 55/M with documented radio-opaque kidney stone
b. A 48/M 2 weeks after resolution of his first acute gouty attack
c. A 38/M with serum uric acid level of 14 mg/dL
d. A 50/M with concomitant osteoarthritis

Answer 8

The correct answer is: A 38/M with serum uric acid level of 14 mg/dL

Question 9

Which of the following descriptions match the so-called “piano-key movement” in rheumatoid arthritis?

a. Flexion of the PIP with hyperextension of the DIP
b. Subluxation of the first MCP joint with hyperextension of the first interphalangeal joint
c. Subluxation of the distal ulna
d. Hypertextension of the PIP joint with flexion of the DIP

Answer 9

The correct answer is: Subluxation of the distal ulna

Question 10

What is the most common cardiac manifestation of rheumatoid arthritis?

a. Pericarditis
b. Cardiomyopathy
c. Valvular abnormalities
d. Coronary artery disease

Answer 10

The correct answer is: Pericarditis

Question 11

Which antibody is associated with neonatal lupus with congenital heart block?

a. Anti-SSA
b. Anti-histone
c. Anti-RNP

Answer 11

The correct answer is: Anti-SSA

Question 12

Which of the following patients would be diagnosed to have SLE based on the SLICC criteria?

a. 20/F with kidney biopsy consistent with lupus nephritis
b. 25/F with nonscarring alopecia, oral ulcers, positive ANA and low serum CH50
c. 26/F with normocytic, normochromic anemia, platelet 80,000, WBC 3000 and RBCs urinalysis
d. 24/F with panniculitis, cognitive dysfunction, ascites and positive ANA

Answer 12

The correct answer is: 20/F with kidney biopsy consistent with lupus nephritis

Question 13

A 56/F consults to you for chronic joint pains. Which site of involvement would warrant a high suspicion for osteoarthritis?

a. Ankle
b. Base of thumb
c. Elbow
d. Wrist

Answer 13

• Osteoarthritis is the most common cause of chronic knee pain in age 45+
• Joints commonly affected by osteoarthritis
o Cervical vertebrae, lower lumbar vertebrae, first carpometacarpal, distal and proximal interphalangeal, hip, knee, first metatarsophalangeal
• Joints usually spared from osteoarthritis: wrist, elbow, ankle

The correct answer is: Base of thumb

Question 14

Which of the following can be found in all joints with osteoarthritis?

a. Loss of hyaline cartilage
b. Meniscal degeneration
c. Appearance of osteophytes
d. Synovial inflammation

Answer 14

• Pathology of OA (joint failure)
* initial step is joint injury in the setting of failure of protective mechanisms
• Hyaline articular cartilage loss (pathologic sine qua non); focal, initially non-uniform
• Thickening and sclerosis of the subchondral bony plate
• Outgrowth of osteophytes at the joint margin
• Stretching of the articular capsule
• Variable degrees of synovitis
• Weakness of muscles bridging the joint
• Meniscal degeneration (knee OA)

The correct answer is: Loss of hyaline cartilage

Question 15

A 63F recently diagnosed with osteoarthritis of the hip asks you if her children are at higher risk to develop the same condition. Considering her profile, which is the most appropriate response?

a. Her pattern of joint involvement makes heritability more likely
b. Her pattern of joint involvement makes heritability less likely
c. Her age at disease onset makes heritability more likely
d. Her age at disease onset makes heritability less likely

Answer 15

•	Heritability of OA
o	Hip and hand (50%)
o	Knee (up to 30%)
o	Generalized OA (rarely inherited)
•	Growth differentiation factor 5 (GDF5) polymorphism is an associated mutation

The correct answer is: Her pattern of joint involvement makes heritability more likely

Question 16

Obese individuals are at higher risk for osteoarthritis in which joint/s?

a. Hip
b. Knee
c. Hip and knee
d. Hip, knee and hand

Answer 16

Obesity and OA
• Risk factor for knee, hip, and hand OA
• Obese persons have more severe OA symptoms
• Not just a consequence of inactivity due to OA
• Stronger risk factor among women
• In women, risk is correlated to weight in a linear fashion
• Weight loss reduces risk for symptomatic OA
• Adipokines may also play a role (note risk for hand OA)
Risk factors that increase joint vulnerability
• Congenital dysplasia, Legg-Perthes disease, slipped capital femoral epiphysis
• Femoroacetabular impingement
• Major joint injuries
• Avascular necrosis
• Ligament and fibrocartilagenous tears (meniscus/labrum)
• Joint malalignment
• Quadriceps weakness
• Increased bone density
Repetitive joint use and exercise
• Exercise is not associated with OA risk in most people
• Joint injury – involved joints are at greater risk with certain types of exercise
• Recreational runners – modestly increased risk for hip OA (but not knee OA)
• Professional runners – high risk for hip and knee OA
• Workers performing repetitive tasks for many years – high risk for involved joints
The correct answer is: Hip, knee and hand

Question 17

What happens to the amount of proteoglycan and water in the cartilage of a joint with osteoarthritis?
a. Decrease in proteoglycan, decrease in water content
b. Decrease in proteoglycan, increase in water content
c. No change in proteoglycan, decrease in water content
d. No change in proteoglycan, increase in water content
Feedback

Answer 17

Pathology
• Cartilage surface fibrillation → non-uniform erosions → extension to bone
• Injury → chondrocyte mitosis and clustering → catabolic > synthetic activity → negative charges of proteoglycans are exposed → cartilage swelling → vulnerability to injury
• Activation of osteoclasts and osteoblasts in subchondral bone
• Osteophyte formation at the joint margin – radiologic hallmark of OA
• Synovial inflammation and proliferation accelerate matrix destruction
• Capsular edema and fibrosis
• •Basic calcium phosphate and calcium pyrophosphate dihydrate crystals in end-stage OA → synovitis

The correct answer is: Decrease in proteoglycan, increase in water content

Question 18

A 60F was referred to you for management of diabetes mellitus. On examination, you note foot deformities including loss of the arch of the midfoot and bony prominences. What was the primary predisposing factor that led to this condition?

a. Acute trauma
b. Atherosclerosis
c. Neuropathy
d. Obesity

Answer 18

• Neuropathic joint disease (Charcot joint) is a progressive destructive arthritis associated with loss of pain sensation, proprioception, or both.
• Diabetes mellitus is the most frequent cause of neuropathic joint disease.
• Radiographs and physical exam demonstrate loss of the arch due to bony fragmentation and dislocation in the midfoot.

The correct answer is: Neuropathy

Question 19

A 65F is in your clinic for a wellness check-up. Which intervention is most effective in the prevention of symptomatic knee osteoarthritis?

a. Calcium + Vitamin D supplementation
b. Glucosamine supplementation
c. Quadriceps exercise
d. Smoking cessation

Answer 19

• Weakness in the quadriceps muscles bridging the knee increases the risk of the development of osteoarthritis in the knee.

The correct answer is: Quadriceps exercise

Question 20

A 56F consults you for chronic joint pains in her hands as well as difficulty in certain activities such as cooking and doing laundry. You inspect her hands and see nodes on distal interphalangeal joints and the proximal interphalangeal joints.

What is the most likely diagnosis?

a. Gouty arthritis
b. Osteoarthritis
c. Psoriatic arthritis
d. Rheumatoid arthritis

Answer 20

• Hand OA affects the distal interphalangeal joints (Heberden’s nodes) and the proximal interphalangeal joints (Bouchard’s nodes). Another common site of bony enlargement in the hands is the thumb base.
HPIM 20e Ch364 P2628
Sources of pain in osteoarthritis
• Cartilage loss is NOT accompanied by pain, unless if with neurovascular invasion in advanced OA
• Innervated structures:
o Synovium, ligaments, joint capsule, muscles, subchondral bone
• Severity of X-ray changes does not correlate well with pain severity
Likely sources of pain
• Synovitis
• Joint effusion
• Bone marrow edema (from loading-related bone injury)
• Periarticular sources including bursae (ie. anserine bursitis, iliotibial band syndrome)
• Peripheral and central sensitization

The correct answer is: Osteoarthritis

Question 21

In a 55M with knee osteoarthritis, which pattern of symptoms is most consistent with his condition?

a. No morning stiffness; pain is associated with fatigue
b. No morning stiffness; swelling is noted above the joint
c. Morning stiffness for 30 minutes, pain subsides with prolonged activity
d. Morning stiffness for 30 minutes, pain worsens with prolonged activity

Answer 21

Clinical features
• Pain is initially episodic, activity-related, triggered by overactive use of involved joint
• Can become continuous pain at progression
• Morning stiffness <30mins

The correct answer is: Morning stiffness for 30 minutes, pain worsens with prolonged activity

Question 22

A 57M consults you for 1 month history of left knee pain especially when going up and down the stairs. On physical examination, you note swelling and erythema on the inferomedial aspect of the left knee. What is the most likely diagnosis?

a. Anserine bursitis
b. Iliotibial band syndrome
c. Medial meniscus tear
d. Osteoarthritis

Answer 22

• Bursitis occurs commonly around knees and hips. A physical examination should focus on whether tenderness is over the joint line (at the junction of the two bones around which the joint is articulating) or outside of it. Anserine bursitis, medial and distal to the knee, is an extremely common cause of chronic knee pain that may respond to a glucocorticoid injection.

The correct answer is: Anserine bursitis

Question 23

A 62F consults you for on-and-off right hip pain especially after jogging. Physical examination revealed a loss of internal rotation on passive movement. What is the most likely diagnosis?

a. Ankylosing spondylitis
b. Avascular necrosis
c. Osteoarthritis
d. Trochanteric bursitis

Answer 23

• For hip pain, OA can be detected by loss of internal rotation on passive movement, and pain isolated to an area lateral to the hip joint usually reflects the presence of trochanteric bursitis.
• Ankylosing spondylitis: (+) Schober test, (+) sacroiliitis

The correct answer is: Osteoarthritis

Question 24

A 60/M presents with on and off knee pain especially after jogging, as well as morning stiffness lasting 30 minutes. Physical exam shows no swelling or crepitus. What is the next appropriate step?

a. Order a knee X-ray, AP and lateral view
b. Order serum uric acid
c. Start Naproxen 500mg BID as needed for pain
d. Start Paracetamol 500mg every 6 hours

Answer 24

• X-rays are indicated to evaluate the possibility of OA only when joint pain and physical findings are not typical of OA or if pain persists after inauguration of treatment effective for OA

The correct answer is: Start Paracetamol 500mg every 6 hours

Question 25

A 70F reports chronic hip pain. X-ray of the hip did not reveal any osteophytes. What other imaging finding would support a diagnosis of osteoarthritis?

a. Joint space widening
b. Periarticular osteopenia
c. Osteolytic lesions
d. Subchondral sclerosis

Answer 25

• Note the narrowed joint space on medial side of the joint only (white arrow), the sclerosis of the bone in the medial compartment providing evidence of cortical thickening (black arrow), and the osteophytes in the medial femur (white wedge).

The correct answer is: Subchondral sclerosis
Question 14

Question 26

A 50F consults you for episodic knee pain especially after walking long distances. She also reports difficulty in getting up from the bed in the morning. There is no joint swelling or crepitus. An x-ray done recently shows a radiographically unremarkable knee. What is the appropriate next step?

a. Request for a knee ultrasound
b. Request for a knee MRI
c. Prescribe an oral analgesic
d. Refer to Psychiatry

Answer 26

• In OA, radiographic findings correlate poorly with the presence and severity of pain. Further, in both knees and hips, radiographs may be normal in early disease as they are insensitive to cartilage loss and other early findings.

The correct answer is: Prescribe an oral analgesic

Question 27

A 65M with knee osteoarthritis follows-up with you in the clinic. You note warmth over the joint and a moderate amount of effusion, which upon aspiration was clear, straw-colored and stringy. What should be the expected result for synovial fluid white count?

a. <100 /uL
b. <1,000 /uL
c. >1,000 /uL
d. >10,000 /uL

Answer 27

Workup for osteoarthritis
• No routine blood test indicated, unless inflammatory arthritis is suspected
• Synovial fluid WBC <1000/uL
Indications for radiographs
• Symptoms or PE findings are atypical for OA
• Pain persists after initial treatment
• Imaging correlates poorly with presence/severity of symptoms
• May be normal in early knee and hip OA
MRI
• Not part of diagnostic workup for OA
• Meniscal tears, cartilage and bone lesions are common in knee OA
• These findings are also common in older persons who are asymptomatic
• MRI findings almost never warrant a change in therapy

The correct answer is: <1,000 /uL

Question 28

A 63M with osteoarthritis reports hip pain whenever he plays tennis. What is the most appropriate advice for this patient?

a. Work through the pain as it will subside eventually
b. Take a dose of analgesic prior to his tennis games
c. Do weighted squats to strengthen his leg muscles
d. Shift to another sport that does not trigger pain

Answer 28

Treatment
• Reassurance and non-pharmacologic tx for mild and intermittent symptoms
• Add pharmacotherapy for ongoing, disabling pain
o Adjunct for symptomatic relief only
o Does not alter disease process
• The simplest treatment for many patients is to avoid activities that precipitate pain.

The correct answer is: Shift to another sport that does not trigger pain

Question 29

An obese patient with osteoarthritis has lost 1kg over the past two weeks. As a result, the expected reduction in the load on each of his/her knee joints during walking is approximately:

a. 0.5 kg
b. 1 kg
c. 2 kg
d. 4 kg

Answer 29

• Three to six times body weight is transmitted across the knee during single-leg stance. Any increase in weight may be multiplied by this factor to reveal the excess force across the knee in overweight persons during walking.

The correct answer is: 4 kg

Question 30

What is the proper way of using a cane for a patient with hip osteoarthritis?

a. Use the hand contralateral to the affected hip, and the elbow bent by around 15 degrees
b. Use the hand contralateral to the affected hip, and the elbow bent by around 90 degrees
c. Use the hand ipsilateral to the affected hip, and the elbow bent by around 15 degrees
d. Use the hand ipsilateral to the affected hip, and the elbow bent by around 90 degrees

Answer 30

Ways to decrease focal load on joint
• Avoid painful activities
• Improve strength and conditioning of bridging muscles
• Redistribute load using a brace or splint
• Unload the joint during weight bearing by using a crane in the opposite hand
• Weight loss – each pound lost has a 3 to 6-fold multiplier effect in unloading knees and hips

The correct answer is: Use the hand contralateral to the affected hip, and the elbow bent by around 15 degrees

Question 31

Which exercise regimens are effective in decreasing pain from knee osteoarthritis?

a. Aerobic and range of motion exercise
b. Aerobic exercise and resistance training
c. Isometric and range of motion exercise
d. Isometric exercise and resistance training

Answer 31

Causes of weakness of bridging muscles
• Age-related decline in muscle strength
• Limited mobility leading to disuse muscle atrophy
• Altered gait to lessen loading across a painful joint
• Arthrogenous inhibition – joint swelling results in an afferent feedback inihibition of bridging muscles
Exercise
• Benefits: Improves physical function, lessens pain, especially in combination with weight loss
o No strong evidence of benefit for hand OA
• Approach: Train muscles used in daily activities
o Avoid activities that trigger joint pain
• Regimens: Aerobic and/or resistance training regimens are effective
• Range of motion and isometric exercises are unlikely to be effective

The correct answer is: Aerobic exercise and resistance training

Question 32

Which is the most appropriate exercise regimen for an obese patient with symptomatic hip osteoarthritis?

a. Side planks
b. Treadmill exercises
c. Water aerobics
d. Yoga

Answer 32

• Low-impact exercises (water aerobics, water resistance training) are better tolerated
• Impact loading exercised (running, treadmill) are less tolerable
• Tai chi may be effective for knee OA

The correct answer is: Water aerobics

Question 33

A 58F with hand osteoarthritis complains of pain over the first carpometacarpal joint on her left hand. In addition to analgesics, which is the most appropriate intervention to improve her symptoms?

a. Handgrip exercises
b. Splinting
c. Weight loss
d. Prednisone for 5 days

Answer 33

• In hand joints affected by OA, splinting, by limiting motion, often minimizes pain for patients with involvement especially in the base of the thumb. There is no strong evidence that patients with hand OA benefit from therapeutic exercise.

The correct answer is: Splinting

Question 34

A 48M complains of chronic left knee pain. Physical examination reveals varus knee deformity, however the patient is not keen on undergoing surgery. What is an appropriate option for the patient?

a. Lateral unloader knee brace
b. Lateral unloader neoprene sleeve
c. Medial unloader knee brace
d. Medial unloader neoprene sleeve

Answer 34

Correction of malalignment can lessen pain in OA
• Varus-valgus malalignment - surgical correction or fitted knee brace (must not slip)
• Patellar malalignment - patellar brace or tape
Other non-pharmacologic approaches to lessen pain (adjuncts)
• Neoprene sleeves – questionable effect on malalignment
• Acupuncture

The correct answer is: Medial unloader knee brace

Question 35

A 65M with hip osteoarthritis reports inadequate pain relief from paracetamol. His current medications include clopidogrel, carvedilol and simvastatin. What is the most appropriate choice of analgesic for the patient?

a. Prednisone
b. Diclofenac
c. Ibuprofen
d. Naproxen

Answer 35

• The only conventional NSAID that appears safe from a cardiovascular perspective is naproxen, but it does have GI toxicity.

The correct answer is: Naproxen

Question 36

Your patient with hand osteoarthritis experiences worsening of pain over the past week that is not adequately relieved by oral NSAID. You note swelling and tenderness in the area of the 1st carpometacarpal joint. What is the most appropriate intervention?

a. Topical capsaicin
b. Topical NSAID
c. Intraarticular hyaluronic acid
d. Intraarticular steroid

Answer 36

• Topical NSAIDs are slightly less efficacious than oral agents, but have far fewer GI and systemic side effects.
• Glucocorticoid injections are useful to get patients over acute flares of pain, but their effects usually last less than 3 months.
• Hyaluronic acid injections can be given but there is controversy as to whether they have efficacy versus placebo

The correct answer is: Intraarticular steroid

Question 37

A 62F with knee osteoarthritis consults you for worsening knee pain over the past week. You note moderate swelling in the affected joint. You recommend intraarticular steroid injection, however she recalls being given the same medication 6 months prior, and asks if repeat administration may be done. What is the appropriate response?

a. Yes, it may be given
b. Yes, but only after synovial fluid analysis rules out septic arthritis
c. No, it is unlikely to result in any additional benefit
d. No, it can accelerate the progression of osteoarthritis

Answer 37

• Glucocorticoid injections - response is variable, with some patients having little relief of pain, whereas others experience pain relief lasting several months. Their effects usually last less than 3 months. Repeated injections may cause minor amounts of cartilage loss with probably unimportant clinical consequences.

The correct answer is: Yes, it may be given

Question 38

A 68M with hip osteoarthritis reports moderate episodic pain despite taking paracetamol. Pertinent medical history include an eGFR of 45 mL/min and several episodes of falls. What is the most appropriate pharmacologic agent for the patient?

a. Topical NSAID
b. Chondroitin sulfate
c. Prednisone
d. Oxycodone

Answer 38

• Topical NSAIDs are slightly less efficacious than oral agents, but have far fewer GI and systemic side effects.
• Guidelines recommend against the use of glucosamine or chondroitin for OA. Large trials have failed to show that these compounds relieve pain in persons with disease.
• Opiates - Common side effects include dizziness, sedation, nausea or vomiting, dry mouth, constipation, urinary retention, and pruritus.
Pharmacotherapy
• Paracetamol: Initial analgesic of choice for knee, hip and hand OA, but adequate only in a minority
• NSAIDs: 30% greater pain reduction vs high dose paracetamol
o Start as topical or prn only
o GI toxicity when taken together with aspirin
o Increased rates of CV events, except for naproxen
• Caution in stage III, contraindicated in stage IV, V CKD
• Topical NSAIDs
o Slightly less effective, but fewer side effects vs oral NSAIDs
• May cause skin irritation
Pharmacotherapy
• Glucocorticoids: Variable efficacy
o Useful for acute flares, effect lasts <3 months
o Repeated doses may lead to minor cartilage loss
• Hyaluronic acid: Symptomatic treatment of knee and hip OA; Questionable efficacy
• Opioids: Modest efficacy
• Duloxetine: Modest efficacy
• Glucosamine: Ineffective
• Chondroitin: Ineffective
o Intraarticular injections have greater placebo effect than pills

The correct answer is: Topical NSAID

Question 39

Your patient with knee osteoarthritis remains to have difficulty performing ADLs despite optimal non-surgical therapy. What procedure should be recommended for this patient?

a. Arthroscopic debridement & lavage
b. Partial meniscectomy
c. Meniscal transplantation
d. Total knee replacement

Answer 39

• Arthroscopic debri¬dement and lavage – no better than sham surgery for relief of pain or disability
• Partial meniscectomy in persons with OA and a symptomatic meniscal tear does not relieve knee pain or improve
• function or even lead to resolution of catching or locking of the knee
• Chondrocyte transplantation has not been found to be efficacious in OA, perhaps because OA includes pathol¬ogy of joint mechanics, which is not corrected by chondrocyte transplants.

The correct answer is: Total knee replacement

Question 40

A 68M consults you for chronic knee pain. He shows you a recent knee MRI which reveals cartilage degeneration and a meniscal tear. What should be recommended to the patient?

a. Optimal non-surgical therapy
b. Optimal non-surgical therapy plus arthroscopic debridement
c. Optimal non-surgical therapy plus partial meniscectomy
d. Optimal non-surgical therapy plus total knee replacement

Answer 40

• Although MRI may reveal the extent of pathology in an osteoarthritic joint, it is not indicated as part of the diagnostic workup. Findings such as meniscal tears and cartilage and bone lesions occur not only in most patients with OA in the knee, but also in most older persons without joint pain. MRI findings almost never warrant a change in therapy.
Surgery for OA
• For unacceptably poor QOL despite optimal medical therapy
• Knee OA
o Arthroscopic debridement & lavage: No advantage over sham surgery
o Partial meniscectomy: Not effective for OA with symptomatic meniscal tear
o High tibial osteotomy: Years of pain relief is possible
o Unicompartmental replacement with alignment: Years of pain relief is possible
o Total knee replacement
Total hip/knee replacement
• ~1% failure rate, higher in obese patients, lower in high-volume centers
• Ideally performed while patient still has good performance status and muscle strength
Cartilage regeneration
• Do not address non-cartilage abnormalities
• Chondrocyte transplantation: Not effective for OA
• Abrasion arthroplasty (chondroplasty): Not well-studied for OA

The correct answer is: Optimal non-surgical therapy

Question 41

A 36F seeks consult for rashes, which were noted to be round lesions on the face with slightly raised and hyperpigmented edges and depigmented centers. Biopsy of the central portion of one of the lesions reveals loss of dermal appendages. She also mentions she has been having on and off pain and swelling in her knees and hands since two months prior. What should be included in the diagnostic workup of this patient?

a. ANA, anti-dsDNA
b. ANA, CBC with platelet, urinalysis
c. ASO, 12L ECG, 2d echo
d. RF, anti-CCP, ESR, CRP

Answer 41

• Discoid lupus erythematosus (DLE) is the most common chronic dermatitis in lupus; lesions are roughly circular with slightly raised, scaly hyperpigmented erythematous rims and depigmented, atrophic centers in which all dermal appendages are permanently destroyed.

The correct answer is: ANA, CBC with platelet, urinalysis

Question 42

A 28F presents with progressive bipedal edema for the past month. Workup reveals proteinuria of 5g in 24 hours, serum albumin of 2.0 g/dL as well as total serum cholesterol of 420 mg/dL. There are no cellular casts on urinalysis. Renal ultrasound shows normal-sized kidneys with intact corticomedullary junction. Pertinent physical exam findings include decreased vocal fremiti on bilateral lung bases and grade III bipedal edema. What is the appropriate next step in the evaluation of this patient?

a. ANA and kidney biopsy
b. ANA, anti-dsDNA and kidney biopsy
c. ANA, do kidney biopsy if ANA is positive
d. Kidney biopsy, do ANA if biopsy shows lupus nephritis

Answer 42

• Symptom complex of patient in the case can be adequately explained by nephrotic syndrome.

The correct answer is: Kidney biopsy, do ANA if biopsy shows lupus nephritis

Question 43

. A 32F diagnosed with antiphospholipid syndrome was referred to you after also testing positive for ANA ELISA and anti-RNP. She reports having occasional joint pains but is otherwise asymptomatic. CBC and urinalysis are normal. What is the most appropriate management for the patient?

a. Advise to monitor for symptoms
b. Repeat ANA ELISA after 3 months
c. Request for ANA IF
d. Start mycophenolate mofetil maintenance

Answer 43

• The presence in an individual of multiple autoantibodies without clinical symptoms should not be con¬sidered diagnostic for SLE, although such persons are at increased risk.

The correct answer is: Advise to monitor for symptoms

Question 44

A 35F is referred to you for evaluation of a decreased platelet count of 75,000/uL. On examination, you notice a patch of alopecia with scar tissue on her scalp. While her hemoglobin and leukocyte count are currently within normal range, you note in her medical records that she had a positive direct Coomb’s test five years ago that was done for evaluation of hemolytic anemia. How many criteria for SLE has the patient satisfied?

a. 1 clinical, 1 immunologic
b. 2 clinical, 1 immunologic
c. 2 clinical, 0 immunologic
d. 3 clinical, 0 immunologic

Answer 44

• Clinical criteria: thrombocytopenia and history of Coomb’s (+) hemolytic anemia
• Alopecia from SLE is non-scarring
• Any combi¬nation of four or more criteria, with at least one in the clinical and one in the immunologic category, well documented at any time during an individual’s history, makes it likely that the patient has SLE.

The correct answer is: 2 clinical, 0 immunologic

Question 45

Aside from antiphospholipid antibodies, which test should be performed in a patient with SLE who is planning to conceive?

a. Anti-erythrocyte
b. Anti-RNP
c. Anti-Sm
d. Anti-SSA

Answer 45

• Anti-Ro (SSA) Not specific for SLE; associated with sicca syndrome, predisposes to subacute cutaneous lupus, and to neonatal lupus with congenital heart block; associated with decreased risk for nephritis

The correct answer is: Anti-SSA

Question 46

A patient with SLE complains of increasing difficulty in climbing stairs and getting up from a chair. She reportedly does not have any myalgia or muscle tenderness, and is otherwise asymptomatic. Her medications include mycophenolate mofetil 1000mg BID and prednisone 20mg BID. CK-MM is normal. What is the appropriate next step in management?

a. Request for EMG/NCV
b. Refer for a muscle biopsy
c. Decrease prednisone dose
d. Decrease mycophenolate mofetil dose

Answer 46

• In SLE, myositis with clinical muscle weakness, elevated creatine kinase levels, positive magnetic resonance imaging (MRI) scan, and muscle necrosis and inflammation on biopsy can occur, although most patients have myalgias without frank myositis.
• Gluco¬corticoid therapies (commonly) and antimalarial therapies (rarely) can cause muscle weakness; these adverse effects must be distinguished from active inflammatory disease.

The correct answer is: Decrease prednisone dose

Question 47

Among patients with SLE, disease flare may be heralded by a rise in the levels of which of the following?

a. ANA
b. Anti-dsDNA
c. Anti-Sm
d. C3

Answer 47

• Titers of anti-dsDNA vary over time. In some patients, increases in quantities of anti-dsDNA herald a flare, particularly of nephritis or vasculitis, especially when associ¬ated with declining levels of C3 or C4 complement. Antibodies to Sm are also specific for SLE and assist in diagnosis; anti-Sm antibodies do not usually correlate with disease activity or clinical manifesta¬tions.

The correct answer is: Anti-dsDNA

Question 48

A 42F develops malaise, joint pains and a photosensitive rash one month after she started taking hydrochlorothiazide. A drug-induced etiology for her condition is supported by a positive result in which test/s?

a. Anti-histone only
b. ANA and Anti-histone
c. Anti-La only
d. ANA, and Anti-La

Answer 48

• Drug-induced lupus: This is a syndrome of positive ANA associated with symptoms such as fever, malaise, arthritis or intense arthralgias/myalgias, serositis, and/ or rash. It is predominant in whites, has less female pre¬dilection than SLE, rarely involves kidneys or brain, is rarely associated with anti-dsDNA, is commonly associated with antibodies to histones, and usually resolves over several weeks after discontinuation of the offending medication.

The correct answer is: ANA and Anti-histone

Question 49

What is the most common manifestation of CNS lupus?

a. Headache
b. Impaired memory and reasoning
c. Mood changes
d. Sensory neuropathy

Answer 49

• The most common manifestation of diffuse CNS lupus is cognitive dysfunction, including difficulties with memory and rea¬soning.

The correct answer is: Impaired memory and reasoning

Question 50

Which test should be included in the long-term follow-up of all patients with SLE?

a. C3
b. ESR, CRP
c. Lipid profile
d. Bone densitometry

Answer 50

• Strategies to prevent osteoporosis should be initiated in most patients likely to require long-term glucocorticoid therapy and/or with other predis¬posing factors.
• Control of hypertension and appropriate prevention strategies for atherosclerosis, including monitoring and treatment of dyslipidemias, management of hyperglycemia, and management of obesity, are recom-mended. There is increasing evidence that statin therapies can reduce deaths from cardiac events in SLE patients.
The correct answer is: Lipid profile

Question 51

Which of the following confer an increased risk for developing systemic sclerosis?

a. Bleomycin
b. Family history
c. Smoking
d. Silicone implants

Answer 51

• Some evidence suggests potential roles for parvovirus B19, EBV, CMV, and Rhodotorula glutinis and other microorganisms. Drugs implicated in SSc-like illnesses include bleomycin, pentazocine, and cocaine, and appetite suppressants linked with PAH. Radiation therapy for cancer has been linked with de novo onset of SSc as well as with exacerbation of pre-existing SSc. In contrast to rheu¬matoid arthritis, cigarette smoking does not increase the risk of SSc. An additional risk factor is having an affected first-degree family member, which increases disease risk 13-fold.

The correct answer is: Family history

Question 52

A 52F with recently diagnosed breast cancer presents with progressive skin tightening and joint contractures in her hands. Antibodies against which antigen are most likely to be detected in the patient?

a. Centromere
b. RNA polymerase III
c. Scl-70
d. U1-RNP

Answer 52

• Autoantibodies against RNA polymerase III can be found in the diffuse cutaneous SSc subset, and characteristically present with rapidly progressive skin, tendon friction rubs, joint contractures, GAVE, renal crisis, contemporaneous cancers; digital ulcers rare.

The correct answer is: RNA polymerase III

Question 53

A patient with systemic sclerosis presents with palpable subcutaneous lumps on her palms and elbows, with some areas having visible whitish deposits. What is the pathophysiology behind the development of these lesions?

a. Chronic inflammation
b. Hyperparathyroidism
c. Hyperuricemia
d. Paraneoplastic deposition

Answer 53

• Calcinosis cutis: Dystrophic calcifications in the skin, subcutaneous, and soft tissues (calcinosis cutis) in the presence of normal serum calcium and phos-phate levels occur in up to 40% of patients, most commonly in those with long-standing anti-centromere antibody-positive lcSSc. These deposits occur when calcium precipitates in tissue damaged by inflammation, hypoxia, or local trauma. Common locations include the finger pads, palms, extensor surfaces of the forearms, and the olecranon and prepatellar bursae

The correct answer is: Chronic inflammation

Question 54

A 32F consults you after presenting with cyanosis of her hands after carrying a bag of ice. It reportedly lasted 15 minutes and was followed by hyperemia of the involved area. Review of systems was unremarkable and examination of her hands reveal no ulcers or deformities. What is the most appropriate next step in management?

a. Reassure the patient
b. Perform nail microscopy
c. Request for ANA
d. Start metoprolol

Answer 54

• Primary Raynaud’s disease is a benign condition that must be differentiated from early or limited SSc. Nailfold microscopy is particularly helpful in this situation, because in contrast to SSc, nail¬fold capillaries are normal.

The correct answer is: Perform nail microscopy

Question 55

Aside from the scalp, where else in the body are the “salt-and-pepper” appearance of the skin most prominent in systemic sclerosis?

a. Face
b. Neck
c. Chest
d. Abdomen

Answer 55

• Because pigment loss spares the perifollicular areas, the skin may have a “salt-and-pepper” appearance, most prominently on the scalp, upper back, and chest.

The correct answer is: Chest

Question 56

. A 42F consults for joint pains involving her hands. You note that aside from flexion contractures, her skin appears taut and with a loss of transverse creases. She says she has also been having mild heartburn and occasional indigestion over the past 2 months. Which tests should be included in the evaluation of this patient?

a. Anti-centromere, Anti-topoisomerase I
b. Pulmonary function test, 2D echocardiogram
c. Chest radiograph, esophageal manometry

Answer 56

• The diagnosis of SSc is made primarily on clinical grounds and is generally straightforward in patients with established disease.
• Patients with PAH are often asymptomatic in early stages. In light of the poor prognosis of untreated PAH and better therapeutic response in patients with early diagnosis, all SSc patients should be screened for PAH at initial evaluation, followed by annual evaluation. Doppler echocardiography provides a noninvasive screening method for estimating the pulmonary arterial pressure.
• Pulmonary involvement can remain asymptomatic until it is advanced. Pulmonary function testing (PFT) is relatively sensitive for detecting early pulmonary involvement. Chest radiography is relatively insensitive for the detection of early ILD

The correct answer is: Pulmonary function test, 2D echocardiogram

Question 57

A patient with systemic sclerosis consults you for a complaint of alternating diarrhea and constipation. What is the most appropriate treatment?

a. Bulk-forming agents
b. Antimotility agents
c. Prokinetics
d. Antibiotics

Answer 57

• Weight loss and malnutrition due to impaired intestinal motility, mal¬absorption, and chronic diarrhea secondary to bacterial overgrowth are common.

The correct answer is: Prokinetics

Question 58

A 45M with systemic sclerosis follows up with you in the clinic. You note increased progression of skin involvement since his previous consult three months ago, as well as palpable tendon friction rubs that were not present previously. What should be monitored closely for this patient?

a. Blood pressure
b. ESR
c. NT-proBNP
d. DLCO

Answer 58

• Risk factors for scleroderma renal crisis include African-American race, male sex, and diffuse or progressive skin involvement.
• Palpable tendon friction rubs, pericardial effusion, new unexplained anemia, and thrombocytopenia may be harbingers of impending scleroderma renal crisis. High-risk patients with early SSc should monitor their blood pressure daily.

The correct answer is: Blood pressure

Question 59

A 40F reports having progressive muscle weakness especially when climbing stairs. Physical exam shows erythematous papules on her elbows and on the back of her fingers. Which finding on muscle biopsy is consistent with the most likely diagnosis?

a. Endomysial inflammation
b. Perifascicular atrophy
c. Necrotic muscle fibers
d. Ragged red fibers

Answer 59

Dermatomyositis
• Macular erythema plaques (Gottron sign) and erythematous papules (Gottron papules) on extensor surface of fingers.
• The characteristic histopathological abnormality on muscle biopsy is perifa-sicular atrophy; however, this is present in perhaps only 50% of patients. The inflammatory cell infiltrate is predominantly perivas¬cular and in the perimysium.
• Necrotic muscle fibers – necrotizing myopathy
• Ragged red fibers – inclusion body myositis

The correct answer is: Perifascicular atrophy

Question 60

In patients clinically suspected to have dermatomyotisis but with equivocal findings on muscle biopsy, what test can be performed to confirm the diagnosis?

a. Myxovirus resistance protein
b. Fibrillin-1
c. Bactericidal/permeability increasing protein
d. Alkaline phosphatase

Answer 60

• Immunohistochemical staining for myxovirus resistance protein A (MxA) is diagnostically more sensitive and highly specific (than perifascicular atrophy)

The correct answer is: Myxovirus resistance protein

Question 61

A 45F presents at the ER for progressive muscle weakness. On examination, the patient has symmetric weakness of both upper and lower extremities, more pronounced on the proximal muscle groups. You also note erythematous discoloration of the eyelids, as well as periorbital and grade II bipedal edema. Creatinine and urinalysis were normal. Which test should be included in the evaluation of this patient?

a. 2D echocardiography
b. Chest CT scan
c. Liver ultrasound
d. TSH

Answer 61

• Common associated conditions: myocarditis, ILD, malignancy, vasculitis, other CTDs

The correct answer is: 2D echocardiography

Question 62

A 60M presents with proximal muscle weakness, shawl sign and positive anti-TIF1 antibodies. Which of the following tests is most useful in the evaluation of this patient?

a. ANA
b. Colonoscopy
c. EMG/NCV
d. Skeletal MRI

Answer 62

• There is a higher risk for malignancy in adult onset cases, ~15% within the first 2–3 years. Anti-TIF1 (or p155) antibodies and anti-NXP2 antibodies are associated with an increased risk of cancer. EMG findings are non-specific and can be seen in other myopathies.

The correct answer is: Colonoscopy

Question 63

In which subset of patients will gout be an unlikely to occur?

a. Middle aged male
b. Middle aged women
c. Post menopausal women
d. Middle aged women with renal disease

Answer 63

• Gout is a metabolic disease that most often affects middle-aged to elderly men and postmenopausal women. Women represent only 5–20% of all patients with gout. Most women with gouty arthritis are postmenopausal and elderly, have osteoarthritis and arterial hypertension that causes mild renal insufficiency, and usually are receiving diuretics. Pre-menopausal gout is rare.

The correct answer is: Middle aged women

Question 64

Which statement is correct in terms of epidemiology of Calcium pyrophosphate deposition disease (CPPD)?

a. CPPD commonly occurs in the middle aged population
b. CPPD commonly occurs in patients with pre-existing joint damage
c. Majority of CPPD patients have metabolic abnormalities such as hyperparathyroidism or hemochromatosis
d. CPPD commonly occurs in chronic renal failure

Answer 64

• The deposition of CPP crystals in articular tissues is most common in the elderly. > 80% of patients are >60 years old and 70% have pre-existing joint damage from other conditions. A minority of patients with CPPD arthropathy have metabolic abnormalities (such as hyperparathyroidism, hemochromatosis, hypophosphatasia, and hypomagnesemia) or hereditary CPP disease. The presence of CPPD arthritis in individuals aged <50 years should lead to consideration of these metabolic disorders and inherited forms of disease.

The correct answer is: CPPD commonly occurs in patients with pre-existing joint damage

Question 65

Which is an expected early presentation of gouty arthritis?

a. Acute monoarthritis
b. Acute polyarthritis
c. Tophaceous deposits
d. non-symmetrical synovitis

Answer 65

• Acute arthritis is the most common early clinical manifestation of gout. Usually, only one joint is affected initially, but polyarticular acute gout can occur in subsequent episodes. After many acute mono- or oligoarticular attacks, a proportion of gouty patients may present with a chronic nonsymmetric synovitis.

The correct answer is: Acute monoarthritis

Question 66

Which joint is most commonly involved in gout?

a. Ankles
b. Knees
c. Metatarsophalangeal
d. Tarsal

Answer 66

• Metatarsophalangeal joint of the first toe often is involved, but tarsal joints, ankles, and knees also are affected commonly. Especially in elderly patients or in advanced disease, finger joints may be involved. Inflamed Heberden’s or Bouchard’s nodes may be a first manifestation of gouty arthritis

The correct answer is: Metatarsophalangeal

Question 67

. Which statement is correct with first episodes of gouty attack?

a. Frequently begins in upon waking up
b. Joint stiffness is prominent clinical feature
c. Attacks are usually long lasting until treated with anti-inflammatory
d. Frequently precipitated by an inciting event

Answer 67

• The first episode of acute gouty arthritis frequently begins at night with dramatic joint pain and swelling. Joints rapidly become warm, red, and tender, with a clinical appearance that often mimics that of cellulitis. Early attacks tend to subside spontaneously within 3–10 days, and most patients have intervals of varying length with no residual symptoms until the next episode. Several events may precipitate acute gouty arthritis: dietary excess, trauma, surgery, excessive ethanol ingestion, hypouricemic therapy, and serious medical illnesses such as myocardial infarction and stroke.

The correct answer is: Frequently precipitated by an inciting event

Question 68

Which joint is most commonly affected in CPPD arthropathy?

a. Ankles
b. Knees
c. Metatarsophalangeal
d. Tarsal

Answer 68

• The knee is the joint most frequently affected in CPPD arthropathy. Other sites include the wrist, shoulder, ankle, elbow, and hands. The temporomandibular joint may be involved

The correct answer is: Knees

Question 69

Which is not an expected site of involvement in Calcium Apatite Deposition Disease?

a. knees
b. Shoulders
c. Hips
d. Ankle

Answer 69

• The most common sites of apatite deposition include bursae and tendons in and/or around the knees, shoulders, hips, and fingers.

The correct answer is: Ankle

Question 70

Which of the following is not known to precipitate acute gouty arthritis?

a. Excessive ethanol ingestion
b. Hypouricemic therapy
c. Menstruation
d. Trauma

Answer 70

• Several events may precipitate acute gouty arthritis: dietary excess, trauma, surgery, excessive ethanol ingestion, hypouricemic therapy, and serious medical illnesses such as myocardial infarction and stroke.

The correct answer is: Menstruation

Question 71

Which statement correctly explains the increased pyrophosphates in joints of Calcium pyrophosphate deposition disease (CPPD)?

a. Increased pyrophosphatase activity
b. Decreased ATP pyrophophohydrolase activity
c. Decreased 5-nucleotidase activity
d. Mutations in ANKH gene

Answer 71

• In patients with CPPD arthritis, there is increased production of inorganic pyrophosphate and decreased levels of pyrophosphatases in cartilage extracts. Mutations in the ANKH gene, as described in both familial and sporadic cases, can increase elaboration and extracellular transport of pyrophosphate. The increase in pyrophosphate production appears to be related to enhanced activity of ATP pyrophosphohydrolase and 5′-nucleotidase, which catalyze the reaction of ATP to adenosine and pyrophosphate. This pyrophosphate could combine with calcium to form CPP crystals in matrix vesicles or on collagen fibers. There are decreased levels of cartilage glycosaminoglycans that normally inhibit and regulate crystal nucleation. High activities of transglutaminase enzymes also may contribute to the deposition of CPP crystals.

The correct answer is: Mutations in ANKH gene

Question 72

A 30 year old obese doctor develops severe acute pain of the metatarsophalangeal joint of the first toe after a drinking binge with his batchmates. You suspect gout. Which is an expected synovial fluid finding to confirm your diagnosis?
a. Needle shaped with negative birefringent crystals
b. Synovial fluid WBC <2000/uL
c. Clear effusions
d. mononuclear cell infiltration
Feedback

Answer 72

• If the clinical appearance strongly suggests gout, the presumptive diagnosis ideally should be confirmed by needle aspiration of the acutely involved joint. Need shaped MSU crystals are typically seen. These are brightly birefringent with negative elongation on polarized light. Synovial fluid leukocyte counts are elevated from 200 to 60,000 / uL. Effusions appear cloudy due to increased numbers of leukocytes. Large amounts of crystals occasionally produce a thick pasty or chalky joint fluid

The correct answer is: Needle shaped with negative birefringent crystals

Question 73

A 70 year old male presented in your clinic with a 3 day history of right knee pain and swelling. You performed arthrocentesis which showed monosodium urate crystals which are needle- and rod-shaped negative birefringent crystals. What is the diagnosis?

a. Gout
b. Calcium pyrophosphate Disease
c. Calcium Apatite Disease
d. Calcium oxalate Disase

Answer 73

• The image above shows monosodium urate crystals which are needle- and rod-shaped negative birefringent crystals. This is diagnostic for gout.

The correct answer is: Gout

Question 74

A 70 year old male presented in your clinic with a 3 day history of right knee pain and swelling. You performed arthrocentesis which showed rectangular, rod-shaped, and rhomboid crystals that are weakly positively or nonbirefringent crystals. What is the diagnosis?

a. Gout
b. Calcium pyrophosphate Disease
c. Calcium Apatite Disease
d. Calcium oxalate Disase

Answer 74

• The image above shows rectangular, rod-shaped, and rhomboid crystals that are weakly positively or nonbirefringent crystals. This is diagnostic for CPPD.

The correct answer is: Calcium pyrophosphate Disease

Question 75

A patient with long-standing polyarticular pain develops pain, swelling, and warmth in the knee. On synovial fluid aspiration, the fluid is turbid and yellow. WBC is 60,000/uL with polymorphonuclear cell predominance. On polarized microscopy, there are long needle-shaped, negatively birefringent crystal noted. What diagnosis can be EXCLUDED in this patient?

a. Gout
b. Calcium pyrophosphate disease
c. Septic arthritis
d. Osteoarthritis

Answer 75

• During acute gouty attacks, needle-shaped MSU brightly birefringent crystals are typically seen. Synovial fluid leukocyte counts are elevated from 2000 to 60,000/μL. Effusions appear cloudy due to the increased numbers of leukocyte. Bacterial infection can coexist with urate crystals in synovial fluid; if there is any suspicion of septic arthritis, joint fluid must be cultured. CPP crystals may coexist with MSU and apatite in some cases and would also present with elevated leukocyte counts in the synovial fluid. Osteoarthritis usually has non inflammatory synovial fluid.

The correct answer is: Osteoarthritis

Question 76

Which microscopy finding correctly matches their corresponding crystal associated arthropathy?

a. Small nonbirefringent globules: Gout
b. Needle-shaped negative birefringent crystals: Calcium pyrophosphate disease
c. Rhomboid-shaped weakly positively crystals: Calcium Apatite Disease
d. Bipyramidal shaped strongly birefringent crystals: Calcium Oxalate deposition Disease

Answer 76

• Needle- and rod-shaped negative birefringent crystals are consistent with gout.
• Rod-shaped, and rhomboid crystals that are weakly positively or nonbirefringent crystals are consistent with CPPD.
• Small nonbirefringent globules that stain purplish with Wright’s stain and bright red with alizarin red S are consistent with Calcium appatite deposition disease.
• Calcium oxalate deposition disease crystals have variable shape and variable birefringence to polarized light. The most easily recognized forms are bipyramidal, have strong birefringence and stain with alizarin red S.
The correct answer is: Bipyramidal shaped strongly birefringent crystals: Calcium Oxalate deposition Disease

Question 77

Which radiologic finding correctly matches their corresponding crystal associated arthropathy?

a. Double contour sign on ultrasound: CaOx deposition disease
b. Linear radio dense deposits within articular hyaline carriage: CPPD
c. Periarticular calcifications: Gout
d. Soft tissue masses: Osteoarthritis

Answer 77

• Radiographic findings of gout include cystic changes, well-defined erosions with sclerotic margins (often with overhanging bony edges), and soft tissue masses are characteristic radiographic features of advanced chronic tophaceous gout. Ultrasound may aid earlier diagnosis by showing a double contour sign overlying the articular cartilage.
• CPPD shows radiographs or ultrasound findings of punctate and/or linear radiodense deposits within fibrocartilaginous joint menisci or articular hyaline cartilage (chondrocalcinosis). This can also be seen in Calcium oxalate deposition disease in some patients with chronic renal disease.
• Intra- and/or periarticular calcifications with or without erosive, destructive, or hypertrophic changes may be seen on radiographs of Calcium appatite deposition disease

The correct answer is: Linear radio dense deposits within articular hyaline carriage: CPPD

Question 78

A 50-year old male presented in your clinic for 3-day history right knee pain and swelling. He is a chronic kidney disease secondary to diabetic nephropathy patient undergoing hemodialysis 3x/week for 3 years. on Physical examination, he was afebrile with localized warmth and tenderness of the right knee. The rest of the joints were normal. X-ray of the knee showed joint effusion with punctate radio dense deposits in the joint menisci. You perform arthrocentesis of the knee and showed WBC <2000 /uL with bipyramidal variable bifringent crystals. What is your diagnosis?

a. Gout
b. Calcium Pyrophosphate Disease
c. Calcium Apatite Disease
d. Calcium oxalate Disase

Answer 78

• CaOx deposits are now known to be one of the causes of arthritis in chronic renal failure. Deposits have been documented in fingers, wrists, elbows, knees, ankles, and feet. Clinical features of acute CaOx arthritis may not be distinguishable from those due to urate, CPP, or apatite Radiographs may reveal chondrocalcinosis or soft tissue calcifications. CaOx-induced synovial effusions are usually noninflammatory, with <2000 leukocytes/μL, or mildly inflammatory. Neutrophils or mononuclear cells can predominate. CaOx crystals have a variable shape and variable birefringence to polarized light. The most easily recognized forms are bipyramidal, have strong birefringence and stain with alizarin red S.

The correct answer is: Calcium oxalate Disase

Question 79

The patient above had inquired about vitamin supplementation due to fear of COVID infection. Which supplement should be avoided in his case?

a. Vitamin B
b. Vitamin C
c. FeSO tablet
d. Zinc

Answer 79

• Ascorbic acid is metabolized to oxalate, which is inadequately cleared in uremia and by dialysis. Such supplements and foods high in oxalate content usually are avoided in dialysis programs because of the risk of enhancing hyperoxalosis and its sequelae

The correct answer is: Vitamin C

Question 80

50 year-old male presented for an evaluation of rapid onset of pain and swelling in his right toe. He had beer drinking binge with his friends the night before. Past medical history is significant for hypertension and is being treated with Hydrochlorothiazide. Which of the following is not part of the mainstay management for acute gouty arthritis?
a. Celecoxib 400 mg/cap BID
b. Colchicine 0.6 mg/tab TID
c. Febuxostat 40 mg/tab OD
d. Prednisone 30–50 mg/day  
Feedback

Answer 80

• The mainstay of treatment during an acute attack is the administration of anti-inflammatory drugs such as NSAIDs, colchicine, or glucocorticoids.
• Colchicine is given as 0.6-mg tablet given every 8 h with subsequent tapering or 1.2 mg followed by 0.6 mg in 1 h with subsequent day dosing depending on response.
• NSAIDs are as follows: indomethacin, 25–50 mg tid; naproxen, 500 mg bid; ibuprofen, 800 mg tid; diclofenac, 50 mg tid; and celecoxib 800 mg followed by 400 mg 12 later, then 400 mg bid.
• Glucocorticoids given as an intramuscular injection or orally, for example, prednisone, 30–50 mg/d as the initial dose and gradually tapered with the resolution of the attack, can be effective in polyarticular gout. For a single joint or a few involved joints, intraarticular triamcinolone acetonide, 20–40 mg, or methylprednisolone, 25–50 mg, have been effective and well tolerated. Urate-lowering drugs are generally not initiated during acute attacks.

The correct answer is: Febuxostat 40 mg/tab OD

Question 81

Which biologic agent is part of the armamentarium for the management of gout?

a. Anakinra
b. Abatacept
c. Infliximab
d. Tocilizumab

Answer 81

• Based on recent evidence on the essential role of the inflammasome and interleukin 1β (IL-1β) in acute gout, daily anakinra has been used when other treatments have failed or were contraindicated.

The correct answer is: Anakinra

Question 82

Which statement regarding the management of gout is correct?

a. The mainstay of treatment during an acute attack is the administration of anti inflammatory and hypouricemic drugs
b. Initiation of hypouricemic therapy is indicated after the initial acute attack
c. Ultimate control of gout requires correction of hyperuricemia to <5.0-6.0mg/dL
d. Febuxostat is the best drug to lower serum rate in overproducers, rate stone formers and patients with renal disease

Answer 82

• The mainstay of treatment during an acute attack is the administration of anti-inflammatory drugs. Hypouricemic drugs are generally not initiated during acute attacks but it is usually given to prevent recurrent gouty attacks and eliminate tophaceous deposits. Therefore the ultimate control of gout requires correction of hyperuricemia to <5-6mg/dL. Xanthine oxidase inhibitor allopurinol is by far the most commonly used hypouricemic agent and is the best drug to lower serum urate in overproducers, urate stone formers, and patients with renal disease.

The correct answer is: Ultimate control of gout requires correction of hyperuricemia to <5.0-6.0mg/dL

Question 83

A 30 year old obese doctor develops severe acute pain of the metatarsophalangeal joint of the first toe after a drinking binge with his batchmates. He decides to self-medicate but develops pain in his other joints. What medication did this doctor most likely take?

a. Allopurinol
b. Anakinra
c. Colchicine
d. Prednisone

Answer 83

• Several events may precipitate acute gouty arthritis and hypouricemic therapy is one of them. Urate-lowering drugs are generally not initiated during acute attacks, but after the patient is stable and low-dose colchicine has been initiated to decrease the risk of the flares that often, without anti-inflammatory treatment, occur with urate lowering.

The correct answer is: Allopurinol

Question 84

Which of the following is a clear-cut indication to start hypouricemic agent?

a. 50 year old male with radio-opaque kidney stones
b. 50 year old male with first attack of podagra
c. 50 year old male with uric acid level of 7 mg/dL
d. 50 year old male with tophi in his R hand

Answer 84

• The decision to initiate hypouricemic therapy usually is made taking into consideration the number of acute attacks (urate lowering may be cost-effective after two attacks), serum uric acid levels (progression is more rapid in patients with serum uric acid >535 μmol/L [>9.0 mg/dL]), the patient’s willingness to commit to lifelong therapy, or the presence of uric acid stones. Urate-lowering therapy should be initiated in any patient who already has tophi or chronic gouty arthritis.
The correct answer is: 50 year old male with tophi in his R hand

Question 85

A 60 year old male presented for an evaluation of rapid onset of pain and swelling in his right toe. The patient reported that multiple episodes before with the same symptoms lasting four to five days. He is a known case of ESRD secondary to DMN and is on regular HD. What is the best agent to give to this patient to avoid flares of gouty attack?

a. Colchicine
b. Febuxostat
c. Lesinurad
d. Probenacid

Answer 85

• Attempts to normalize serum uric acid to <300–360 μmol/L (5.0–6.0 mg/dL) and low dose anti-inflammatory agents are used to prevent recurrent gouty attacks. Probenacid and Lesinurad are uricosuric agents but are contraindicated in ERSD. Colchicine should not be used in dialysis patients and is given in lower doses to the patients with renal disease. Febuxostat is a hypouricemic agent and no dose adjustment is reported in end stage renal failure.

The correct answer is: Febuxostat

Question 86

Caution in the colchicine dosage should be practiced when combined with which drug?

a. Amlodepine
b. Clarithromycin
c. Ciprofloxacin
d. Thiazide diuretics

Answer 86

• Colchicine should be given in lower doses to the patients with P glycoprotein or CYP3A4 inhibitors such as clarithromycin that can increase toxicity of colchicine.

The correct answer is: Clarithromycin

Question 87

When is colchicine therapy as prophylaxis for patients who have gouty arthritis after an attack, stopped?

a. 1 month without gouty attacks
b. 3 months without gouty attacks
c. Until the patient develops diarrhea
d. Until the patient has no tophi

Answer 87

• Colchicine as anti-inflammatory prophylaxis in doses of 0.6 mg one to two times daily should be given along with the hypouricemic therapy until the patient is normouricemic and without gouty attacks for 6 months or as long as tophi are present. It must be discontinued temporarily at the first sign of loose stools, and symptomatic treatment must be given for the diarrhea.

The correct answer is: Until the patient has no tophi

Question 88

Which statement is true regarding the epidemiology of rheumatoid arthritis?

a. Rheumatoid arthritis affects >1% of the adult population worldwide.
b. Incidence of rheumatoid arthritis has been increasing in recent decades
c. Africa and Asia shows lower prevalence rates for rheumatoid arthritis
d. Rheumatoid arthritis affects males and females equally

Answer 88

• RA affects ~0.5–1% of the adult population worldwide. Overall incidence of RA has been decreasing in recent decades, whereas the prevalence has remained the same because individuals with RA are living longer. The incidence and prevalence of RA varies based on geographic location, both globally and among certain ethnic groups within a country. Africa and Asia show lower prevalence rates for RA in the range of 0.2–0.4% making this statement true. Like many other autoimmune diseases, RA occurs more commonly in females than in males, with a 2–3:1 ratio

The correct answer is: Africa and Asia shows lower prevalence rates for rheumatoid arthritis

Question 89

Which statement is true regarding the clinical features of Rheumatoid Arthritis?

a. Incidence increases from 55 years old and above
b. Presenting symptoms commonly involve large joints such as knees and shoulders.
c. Most commonly reported joint involvement are distal interphalyngeal and metatarsophalangeal joints.
d. Extraarticular manifestation are significant and may occur prior to the onset of arthritis.

Answer 89

• Incidence of RA increases between 25 and 55 years of age, after which it plateaus until the age of 75 and then decreases. Patients often complain of early morning joint stiffness lasting more than 1 h that eases with physical activity.
• Presenting symptoms typically involve the small joints of the hands and feet, usually in a symmetric distribution. Once the disease process of RA is established, the wrists, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints stand out as the most frequently involved joints. Distal interphalangeal joint are usually an manifestation as compared to the ankle and mid tarsal region but is not one of the most common involved joints. Extraarticular manifestations may develop during the clinical course of RA in up to 40% of patients, even prior to the onset of arthritis
The correct answer is: Extraarticular manifestation are significant and may occur prior to the onset of arthritis.

Question 90

Which of the following joints will rheumatoid arthritis LEAST likely involve?

a. Elbows
b. knees
c. Cervical spine
d. Lumbar spine

Answer 90

• The wrists, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints stand out as the most frequently involved joints in rheumatoid arthritis. Elbows are commonly involved, and can have rheumatoid nodules. In the feet, metatarsophalangeal (MTP) involvement are frequent and is an early feature of disease while chronic inflammation of the ankle and midtarsal regions usually comes late. Large joints such as knees and shoulders are also often affected in established disease. Cervical spine involvement was more prevalent before and can cause compressive myelopathy and neurologic dysfunction. Thoracolumbar spine are rarely affected.

The correct answer is: Lumbar spine

Question 91

B.C. is a 55 year old old female who was brought by her daughter to your clinic for a 5 year history of progressive joint stiffness and swelling, It initially starting in the hands and feet and more prominent upon waking up and would resolve with movement. It had gradually involved the knees, elbows and shoulders with the duration of the pain lasting longer and longer. She also had difficulty standing or ambulating due to foot and ankle pain. On PE, you noted this deformity in her hand. What deformity is this?

a. Swan neck deformity
b. Boutonnière deformity
c. Z line deformity
d. Pencil in cup deformity

Answer 91

CHRONIC SEQUELAE: Progressive destruction of the joints and soft tissues may lead to chronic, irreversible deformities.

• Ulnar deviation: subluxation of the MCP joints, with subluxation, or partial dislocation, of the proximal phalanx to the volar side of the hand
• Swan-neck deformity: Hyperextension of the PIP joint with flexion of the DIP joint
• Boutonnière deformity: flexion of the PIP joint with hyperextension of the DIP joint
• Z line deformity: subluxation of the first MCP joint with hyperextension of the first interphalangeal (IP) joint
• Piano key movement: Inflammation about the ulnar styloid and tenosynovitis of the extensor carpi ulnaris may cause subluxation of the distal ulna
• Pencil in cup deformity is found in psoriatic arthritis; usually involving the DIP joint

The correct answer is: Boutonnière deformity

Question 92

B.C. is a 55 year old old female who was brought by her daughter to your clinic for a 5 year history of progressive joint stiffness and swelling, It initially starting in the hands and feet and more prominent upon waking up and would resolve with movement. It had gradually involved the knees, elbows and shoulders with the duration of the pain lasting longer and longer. She also had difficulty standing or ambulating due to foot and ankle pain. On review of system, you noted that she has been also been having chronic dry cough x 3 months and progressive shortness of breath. She has no chest pain or orthopnea. You include a chest X-ray in your diagnostic tests and expect to see what finding?

a. Normal findings
b. Pleural thickening
c. Bilateral interstitial infiltrates
d. Pulmonary nodules

Answer 92

All are potential pulmonary manifestations in RA. Pleuritis is the most common and presents with pleuritic chest pain and dyspnea. Pulmonary nodules maybe solitary or multiple. ILD are found in up to 12% of RA patients and is heralded by symptoms of dry cough and progressive shortness of breath. Diagnosis is readily made by high resolution chest CT scan, which shows infiltrative opacification in the periphery of both lung. Pulmonary nodules associated with rheumatoid arthritis may be solitary or multiple. They often occur in conjunction with cutaneous nodules. Bronchiectasis and respiratory bronchiolitis may also be due to rheumatoid arthritis.

The correct answer is: Bilateral interstitial infiltrates

Question 93

B.C. returned to your clinic the next day with results of the laboratories you requested. Refer to the table below. What condition should be highly considered in this case?

Hgb 11 HCt 30 Plt 200 WBC 2 Neutrophil 30% lymphocyte 69%
ESR and CRP were 2X ULN; Rheumatoid factor and anti-CCP were positive
X-ray showed erosive bone lesions in her hands and feet
Whole abdominal ultrasound showed splenomegaly
a. Banti’s Syndrome
b. Caplan’s Syndrome
c. Felty’s Syndrome
d. Kasabach Merritt’s Syndrome

Answer 93

• Felty syndrome, typically occurring in late-stage poorly controlled disease, is characterized by the triad of neutropenia, splenomegaly, and rheumatoid nodules.
• Banti’s syndrome is splenomegaly that causes portal hypertension.
• Caplan’s syndrome is a rare subset of pulmonary nodulosis characterized by the development of nodules and pneumoconiosis following silica exposure.
• Kasabach Merritt’s Syndrome is a large hemangioma that causes thrombocytopenia from sequestration.

The correct answer is: Felty’s Syndrome

Question 94

Which of the type malignancies should be monitored in B.C.’s case?

a. Colon cancer
b. Lung cancer
c. Lymphoma
d. Melanoma

Answer 94

• Large cohort studies have shown a two- to fourfold increased risk of lymphoma in RA patients compared with the general population. The most common histopathologic type of lymphoma is a diffuse large B-cell lymphoma. The risk of developing lymphoma increases if the patient has high levels of disease activity or Felty syndrome.

The correct answer is: Lymphoma

Question 95

Which statement is correct regarding extraarticular manifestation of rheumatoid arthritis?

a. Subcutaneous nodules are the most common extraarticular manifestation of rheumatoid arthritis
b. Subcutaneous Nodules are fluctuant, warm to touch and tender.
c. Subcutaneous nodules are usually in the muscle tissue near the inflamed joints
d. Subcutaneous nodules can become malignant therefore monitoring is advised

Answer 95

• Subcutaneous nodules have been reported to occur in 30–40% of patients and more commonly in those with the highest levels of disease activity. the nodules are generally firm; nontender; and adherent to periosteum, tendons, or bursae; developing in areas of the skeleton subject to repeated trauma or irritation such as the forearm, sacral prominences, and Achilles tendon. They may also occur in the lungs, pleura, pericardium, and peritoneum. Nodules are typically benign, although they can be associated with infection, ulceration, and gangrene.

The correct answer is: Subcutaneous nodules are the most common extraarticular manifestation of rheumatoid arthritis

Question 96

What is the most common cause of death in patients in rheumatoid arthritis?

a. Ischemic heart disease
b. Septic shock
c. Pathologic fractures
d. Pulmonary embolism

Answer 96

• The most common cause of death in patients with RA is cardiovascular disease. CAD, carotid atherosclerosis and CHF is more common in RA than in general population. The presence of elevated serum inflammatory markers appears to confer an increased risk of cardiovascular disease in this population. Osteoporosis, hip fractures and hypoandrogenism are also more common in RA.

The correct answer is: Ischemic heart disease

Question 97

Which of the following statement is true regarding the pathophysiology of rheumatoid arthritis?

a. The preclinical stage of rheumatoid arthritis is characterized by a break-down in self-tolerance of immune cells
b. B cell derived inflammation is the central causative driver of chronic inflammation in Rheumatoid arthritis
c. Activated synovial CD4+ T cells mainly differentiates into T cell helper type 2 cells
d. Synovial cells and osteoclasts are predominant source of pro inflammatory cytokines inside the joints

Answer 97

• The pathogenic mechanisms of synovial inflammation are likely to result from a complex interplay of genetic, environmental, and immunologic factors that produces dysregulation of the immune system and a breakdown in self-tolerance. Smoking, silicone dust, mineral oil, periodontal pathogens are some of the environmental factors described.
• Synovial CD4+ T cells differentiate into TH1 and TH17 cells, each with their distinctive cytokine profile. CD4+ TH cells in turn activate B cells, some of which are destined to differentiate into autoantibody-producing plasma cells. Immune complexes, possibly comprised of rheumatoid factors (RFs) and anti–cyclic citrullinated peptides (CCP) antibodies, may form inside the joint, activating the complement pathway and amplifying inflammation.
• T effector cells stimulate synovial macrophages and fibroblasts to secrete proinflammatory mediators, among which is tumor necrosis factor α (TNF-α). TNF-α upregulates adhesion molecules on endothelial cells, promoting leukocyte influx into the joint and stimulates production of other inflammatory mediator. TNF-α also has a role in regulating other mediators in bone destruction and bone formation.

The correct answer is: The preclinical stage of rheumatoid arthritis is characterized by a break-down in self-tolerance of immune cells

Question 98

Which microbe has been linked as a possible infectious etiology of rheumatoid arthritis?

a. Bacteriodes gingivitis
b. Streptococcus spp.
c. Porphyromonas gingivitis
d. Proprionibacterium spp.

Answer 98

• Periodontal disease, and the oral microbiome, specifically Porphyromonas gingivalis has been linked to Rheumatoid arthritis. It has been hypothesized that the immune response to P. gingivalis may trigger the development of RA and that induction of anti-CCP antibodies results from citrullination of arginine residues in human tissues by the enzyme peptidyl arginine deiminase (PAD). Interestingly, P. gingivalis is the only oral bacterial species known to harbor this enzyme. Some studies have shown a relationship between circulating antibodies to P. gingivalis and RA, as well as these antibodies and first-degree relatives at risk for this disease.

The correct answer is: Porphyromonas gingivitis

Question 99

Which of the following pathologic findings is consistent with rheumatoid arthritis?

a. Synovial lining hyperplasia
b. Cartilage surface fibrillation and irregularity
c. Increased thickness of subchondral bone plate
d. Osteophyte formation

Answer 99

• The pathologic hallmarks of RA are synovial inflammation and proliferation, focal bone erosions, and thinning of articular cartilage. Chronic inflammation leads to synovial lining hyperplasia and the formation of pannus, a thickened cellular membrane containing fibroblast like synoviocytes and granulation-reactive fibrovascular tissue that invades the underlying cartilage and bone. the rest of the pathologic findings are consistent with osteoarthritis.

The correct answer is: Synovial lining hyperplasia

Question 100

. Which of the following is included in the 2010 ACR-EULAR Classification criteria for rheumatoid arthritis?

a. Morning stiffness
b. Rheumatoid nodules
c. Acute phase reactant
d. Radiographic changes

Answer 100

• Morning stiffness, rheumatoid nodules and radiographic changes were part of the 1987 diagnostic criteria of rheumatoid arthritis. In 2010, a collaborative effort between the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) revised the 1987 ACR classification criteria for RA to improve early diagnosis. In comparison to the 1987 ACR classification, the new criteria include as an item a positive test for serum anti-CCP antibodies and do not consider whether the patient has rheumatoid nodules or radiographic joint damage because these findings occur rarely in early RA.

The correct answer is: Acute phase reactant

Question 101

Based on the 2010 ACR-EULAR Classification criteria for rheumatoid arthritis, what score will give a definite diagnosis of rheumatoid arthritis?

a. >6
b. ≥6
c. >8
d. ≥8

Answer 101

The correct answer is: ≥6

Question 102

Which statement is true with laboratory features of rheumatoid arthritis?
a. Rheumatoid factor has the most value for predicting worse outcome in rheumatoid arthritis
b. Anti-CCP is more sensitive than anti-rheumatoid factor in diagnosing rheumatoid arthritis
c. A negative anti-rheumatoid factor rules out rheumatoid arthritis
d. Testing for both rheumatoid factor and anti-CCP has added value
Feedback

Answer 102

• Serum RF and anti-CCP antibodies is important in differentiating RA from other polyarticular diseases. RF (IgM subtype) is found in 75-80% of RA patients; therefore, a negative result does not exclude the presence of this disease. It is also found in other diseases (Sjogren, SLE, type II mixed cryoglobulinemia, subacute bacterial endocarditis and hepatitis B and C) as well as in 1-5% of normal population. anti-CCP is as sensitive as rheumatoid factor, but more specific. Therefore positive anti-CCP in early inflammatory arthritis distinguishes RA from other arthritis.
• Both RF and anti-CCP has prognostic significance, with anti-CCP showing the most value for predicting worse outcomes. Lastly, there is some incremental value in testing for the presence of both RF and anti-CCP, as some patients with RA are positive for RF but negative for anti-CCP and vice versa.

The correct answer is: Testing for both rheumatoid factor and anti-CCP has added value

Question 103

Which of the following laboratory finding is not consistent with the diagnosis of rheumatoid arthritis?

a. Synovial fluid WBC < 2000 /uL
b. Negative serum rheumatoid factor
c. Absence of radiographic joint erosions
d. Absence of subcutaneous nodules

Answer 103

• Typically, the cellular composition of synovial fluid from patients with RA reflects an acute inflammatory state. Synovial fluid white blood cell (WBC) counts can vary widely, but generally range between 5000 and 50,000 WBC/μL compared to <2000 WBC/μL for a non-inflammatory condition such as osteoarthritis. Rheumatoid factors is found in 75-80% of patients. Serum anti-CCP antibodies has about the same sensitivity. Therefore, negative results does not exclude the presence of RA. The presence of radiographic joint erosions or subcutaneous nodules may not be present early in the disease and its absence does not exclude RA.

The correct answer is: Synovial fluid WBC < 2000 /uL

Question 104

What is the classic initial radiographic finding in rheumatoid arthritis?

a. Soft tissue swelling
b. Subchondral erosion
c. Symmetric joint space loss
d. Periarticular osteopenia

Answer 104

• Joint imaging is for diagnosing RA and for tracking progression of joint damage.
• Plain X-ray is the most common imaging modality used, but is limited to visualization of bony structures and inferences on the state father articular cartilages based on the amount of joint space narrowing. Classically in RA, the initial radiographic finding is periarticular osteopenia. Other findings on plain radiographs include soft tissue swelling, symmetric joint space loss, and subchondral erosions, most frequently in the wrists and hands (MCPs and PIPs) and the feet (MTPs).
• MRI and ultrasound techniques offer the added value of detecting changes in the soft tissues such as synovitis, tenosynovitis, and effusions, as well as providing greater sensitivity for identifying bony abnormalities.

The correct answer is: Periarticular osteopenia

Question 105

Which statement is true regarding imaging findings of rheumatoid arthritis?

a. MRI and ultrasound has no added value over X-ray in detecting joint abnormalities in rheumatoid arthritis
b. Soft tissue abnormalities on MRI occurs later than osseous changes in rheumatoid arthritis
c. Ultrasound can detect more bone erosions than plain radiography
d. Ultrasound offers the greatest sensitivity for detecting synovitis and joint effusion

Answer 105

• MRI and ultrasound offer added value over x-ray in detecting changes in the soft tissues such as synovitis, tenosynovitis, and effusions, as well as providing greater sensitivity for identifying bony abnormalities. MRI offers the greatest sensitivity for detecting synovitis and joint effusions, as well as early bone and bone marrow changes. These soft tissue abnormalities often occur before osseous changes are noted on x-ray. Presence of bone marrow edema has been recognized to be an early sign of inflammatory joint disease and can predict the subsequent development of erosions on plain radiographs as well as MRI scans.
• Ultrasound can detect more erosions than plain radiography. It can also reliably detect synovitis, including increased joint vascularity indicative of inflammation. It is technician dependent; however, it does offer the advantages of portability, lack of radiation, and low expense relative to MRI, factors that make it attractive as a clinical tool.

The correct answer is: Ultrasound can detect more bone erosions than plain radiography
Question 94

Question 106

Which is the clinical course seen in the vast majority of rheumatoid arthritis patients?

a. Spontaneous remission
b. Persistent and progressive disease
c. intermittent and recurrent explosive attacks
d. Aggressive severe erosive joint disease?

Answer 106

• 10% of patients will undergo a spontaneous remission within 6 months (particularly seronegative patients). The vast majority will exhibit a pattern of persistent and progressive disease activity that waxes and wanes in intensity over time. A minority of patients will show intermittent and recurrent explosive attacks of inflammatory arthritis interspersed with periods of disease quiescence. Finally, an aggressive form of RA may occur in an unfortunate few with inexorable progression of severe erosive joint disease, although this highly destructive course is less common in the modern treatment era.

The correct answer is: Persistent and progressive disease

Question 107

A.G. is a 48 year old married female who came into your clinic for a seven month history of stiffness in both hands in the morning that lasted longer and longer. Stiffness now lasts more than 1 hour every morning and included hands, wrist and ankles. She also had difficulty standing for long periods at work or at home due to foot and ankle pain. She began taking advil 3x/day and found it helped her get through her day with less pain. On PE she had 21 tender joints with no rashes or nodules, CBC Creatinine and liver function tests were normal, ESR and CRP were 1.5x ULN, anti-CCP was positive. CXR was normal and radiograph of the hand indicated 1 erosion of the second metacarpal joint. Which of the following medications would you consider to starting for this patient?

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

Answer 107

• Methotrexate is the DMARD of first choice for initial treatment of moderate to severe RA.

The correct answer is: Methotrexate

Question 108

A.G. followed up in 3 months with worsening pain and stiffness in her joints. She claims that she was compliant to medications, and takes NSAIDs on top without relief. She is now unable to do household chores and needs assistance on daily activities. ESR and CRP is 2.5xULN and Xray shows new erosions in multiple metacarpal joints. CXR showed What would you advise the patient?

a. Continue current DMARD
b. Switch to another DMARD
c. Continue current DMARD and add on glucocorticoids
d. Continue current DMARD and add on anti-TNF therapy

Answer 108

• Failure to achieve adequate improvement with DMARD monotherapy calls for a change in DMARD therapy, usually a transition to an effective combination regimen. Effective combinations include methotrexate, sulfasalazine, and hydroxychloroquine (oral triple therapy); methotrexate and leflunomide; and methotrexate plus a biological.

The correct answer is: Continue current DMARD and add on anti-TNF therapy

Question 109

Which of the following conventional DMARD was shown to be ineffective in preventing radiographic progressive disease?

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

Answer 109

• Conventional DMARDs include hydroxychloroquine sulfasalazine, methotrexate, and leflunomide and all have ability to slow or prevent structural progression of RA except for hydroxychloroquine has not been shown to delay radiographic progression of disease and thus is not considered to be a true DMARD.

The correct answer is: Hydroxychloroquine

Question 110

A 40 year old female being recently diagnosed with rheumatoid arthritis consulted your clinic for difficulty eating secondary to mouth ulcers. Her joint pains have improved and she is not complaining of any fever, malaise, cough, colds or rashes. Examination of her mouth revealed small aphthous ulcers at the buccal side mouth and gums. Which medication is the likely culprit?

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

Answer 110

The correct answer is: Methotrexate

Question 111

Which of the following is an anti-TNF inhibitor?

a. Anakinra
b. Etanercept
c. Abatacept
d. Tocilizumab

Answer 111

• Anakinra is a recombinant IL-1 receptor antagonist.
• Abtacept inhibits the co-stimulation of T cells by blocking CD28-CD80/86 interactions.
• Tocilizumab is a humanized monoclonal antibody directed against IL-6 receptor.

The correct answer is: Etanercept

Question 112

To decrease the risk of reactivation, antiviral is indicated for hepatitis B patients or those with previous exposure if will receive this medication?

a. Rituximab
b. Hydroxychloroquine
c. Methotrexate
d. Sulfasalazine

Answer 112

• Reactivation of viral hepatitis has been observed in association with some of the DMARDs, such as rituximab. Antiviral prophylaxis is indicated to prevent hepatitis flares and complications.

The correct answer is: Rituximab

Question 113

Which of the following clinical scenario will prompt you to consider osteoarthritis as a diagnosis?

a. 65-year old male farmer with pain on walking due to swollen and painful ankle of 6 months duration
b. A 35-year old malewith low b ack pain especially in the mornings and progressive difficulty of walking since 3 months prior to consult
c. A 45-year old male with pain in the right hip on walking, Cushingoid habitus following years of taking steroids for arthritis attacks
d. A 50-year old female office worker, obese with knee pain on standing and prolonged walking.

Answer 113

The correct answer is: A 50-year old female office worker, obese with knee pain on standing and prolonged walking.

Question 114

In the treatment of osteoarthritis, which clinical scenario will you consider using coxibs?

a. 55-year old female, warm right knee, with varus deformity non-hypertensive, nondiabetic, complaining of dyspepsia with paracetamol
b. 57-year old male with swollen right knee, borderline diabetic and hypertensive, smoker
c. 60-year old female with pain in the knees, no swelling on examination. With history of H. pylori infection
d. 45-year old male, executive, obese, smoker and borderline hypertensive, non-diabetic, swollen right knee

Answer 114

The correct answer is: 55-year old female, warm right knee, with varus deformity non-hypertensive, nondiabetic, complaining of dyspepsia with paracetamol

Question 115

Which co-morbid condition warrants clinical evaluation and treatment in the setting of a 45-year old executive who comes with recurrent attacks of monoarthritis?

a. Heart
b. Thyroid
c. Lungs
d. Prostate

Answer 115

The correct answer is: Heart

Question 116

Which drug is considered most appropriate first line treatment for relief of pain and inflammation in the setting of acute monoarthritis in a peripheral joint in a 45 year-old, obese, hypertensive male?

a. Etoricoxib
b. Prednisone
c. Colchicine
d. Diclofenac

Answer 116

The correct answer is: Colchicine

Question 117

Which of the following presenting manifestations is common in gouty arthritis?

a. arthritis of the ankle and heel after a bout of sexually transmitted disease
b. chronic knee pain, aggravated by long walks
c. acute low back pain, more severe in the morning on waking up
d. acute monoarthritis involving a peripheral joint or bursa

Answer 117

The correct answer is: acute monoarthritis involving a peripheral joint or bursa

Question 118

6. A patient is diagnosed with rheumatoid arthritis. Which of the following findings is considered characteristic of RA?
   a. Swan neck and buttoniere deformity
   b. Cervical spine pain and stiffness
   c. Wrist and MCP arthritis
   d. Lumbar spine arthritis

Answer 118

The correct answer is: Wrist and MCP arthritis

Question 119

What are the most common sites of Pott’s disease?

a. Cervical and lumbar spine
b. Thoracic and lumbar spine
c. Atlanto-axial cervical spine
d. Coccyx and sacrum

Answer 119

The correct answer is: Thoracic and lumbar spine

Question 120

32 -ear old female OFW came home from Saudi Arabia after 3 months of low back pain, swelling of the 4th right finger and toes of the left foot which made rising in the mornings difficult. On examination, there were several 1 cm scaly lesions on the back and her dandruff had crossed the hairline in the forehead. What is the diagnosis?

a. Rheumatoid arthritis with seborrheic dermatitis
b. Systemic lupus erythematosus
c. Psoriatic arthritis
d. Dermatomyositis

Answer 120

The correct answer is: Psoriatic arthritis

Question 121

Which tests has been shown to be present years before the arthritis manifestations in rheumatoid arthritis?

a. Anti Ro antibody
b. Rheumatoid factor
c. Anti-sm antibody
d. Anti-CCP antibody

Answer 121

The correct answer is: Anti-CCP antibody

Question 122

Which of the following factors will make you consider avoiding use of diclofenac in an osteoarthritis patient?

a. Presence of pulmonary TB
b. Prior diagnosis of hepatitis B
c. Age
d. Presence of BPH

Answer 122

The correct answer is: Age

Question 123

Which of the following diseases tests positive for ANA?

a. Dermatomyositis
b. Takayasu’s arteritis
c. Microscopic polyangiitis
d. Acute Rheumatic fever

Answer 123

The correct answer is: Dermatomyositis

Question 124

Which of the following joints are also affected most commonly with osteoarthritis, aside from the knees, hips and fingers?

a. shoulders
b. ankles
c. wrists
d. lumbar spine

Answer 124

The correct answer is: lumbar spine