Exam 1 Practice Questions

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1.

A 63-year-old female presents to her primary care physician with a 3-day history of
significant pain and swelling in her right knee. She denies any acute trauma. She drinks
3-4 glasses of wine with dinner every night, smokes a half a pack of cigarettes a day, and
uses marijuana occasionally. Her past medical history is significant for hypertension
and diabetes but she takes no medications for these problems. Her temperature is
99.5F and her blood pressure is 146/93. Physical examination reveals a warm and
edematous right knee with decreased range of motion. The rest of the musculoskeletal
exam was negative. A radiograph of her right knee is shown in Figure A. What is the
most likely synovial fluid analysis?

1. negative birefringence; needle-like

crystals
2. weakly positive birefringence;
rhomboid crystals
3. positive Gram stain; >50,000 WBCs
4. crystals composed of calcium oxalate
5. clear; < 200 WBCs; negative culture
2.

A 61-year-old male presents with acute onset left knee pain. He states that the joint is
warm, swollen, and red. The patient has not experienced this type of pain previously,
and he denies any trauma. His medical history is significant only for diabetes; he does
not have a history of knee pain. Physical exam demonstrates an erythematous left knee
that is tender to palpation. Vital signs are T 37.1 C, BP 136/68 mmHg, HR 76 bpm, O2Sat
99% on RA. Analysis of aspirated joint fluid reveals weakly positively birefringent
rhomboid-shaped crystals. Which of the following radiographic findings might be seen
in this patient's knee?

3.

A 64-year-old male presents to his primary care physician with a chief complaint of left
knee pain. He describes acute-onset knee pain last evening that was accompanied by
redness of the skin around the joint. He denies any precipitating injury or recent
activity that could have caused this pain. He describes a similar episode that occurred
in his right knee 2 months ago; he did not seek medical treatment, and the pain
mitigated after 5 days. Physical examination is significant for the following: left knee is
warm-to-touch, erythematous, and extremely tender to palpation; range of motion in
flexion and extension is limited by pain; crepitus noted with passive movement of the
knee joint. The patient is noted to be afebrile with all vital signs within normal limits.
Aspiration of the left knee joint is ordered and reveals the findings shown in Figure A.
Which of the following conditions is linked to this patient's presenting diagnosis?

1. Segond fracture
2. Osteophytes
3. Joint space narrowing
4. Lipohemarthrosis
5. Chondrocalcinosis

1. Hypoparathyroidism
2. Diabetes mellitus type I
3. Diabetes mellitus type II
4. Hemochromatosis
5. Wilson's disease

4.

A 32-year-old female presents with complaints of joint stiffness over the last two
months. She reports the pain is worse in the morning than at night. On physical exam,
her wrists and MCP joints are red and erythematous and is her right knee. Whats the
most likely Dx?

A. Rheumatoid arthritis
B. Osteoarthritis
C. SLE
D. Myalgias

5.

A middle-aged man presents to the emergency department complaining of stiff, painful

joints and dry, cracking finger nails. The nurse notes scaly lesions on his elbows. He
reports that he has had these lesions for most of his adult life.Whats the most likely Dx?

A. Rheumatoid arthritis
B. Osteoarthritis
C. Reactive Arthritis
D. Psoriatic Arthritis

6.

A 45-year-old male with no significant medical history comes to your office

complaining of pain and stiffness in his hands upon awakening in the morning. He
says the pain and stiffness tends to go away an hour or so after waking up. On physical
exam, you note scaly rashes on his elbows bilaterally. You obtain radiographs, shown
in Figure A. What is the most likely diagnosis?

1. Gouty arthritis
2. Osteoarthritis
3. Rheumatoid arthritis
4. Psoriatic arthritis
5. Systemic lupus erythematosus
7.

A 32-year-old business man returns from a trip abroad. He presents to his primary care
physician a few days later complaining of pain on urination. His physician notes that
he has a slight limp and severe uveitis What's most likely the Dx?

A. Rheumatoid arthritis
B. Osteoarthritis
C. Reactive Arthritis
D. Psoriatic Arthritis

8.

A 29-year-old male presents to his primary care physician with complaints of pain
with urination, eye dryness, and left ankle and knee pain that has developed over the
last several weeks. He reports an illness 3 weeks ago that involved frequent diarrhea as
well as nausea and vomiting. This episode resolved without treatment within 2 days.
Physical exam shows moderate conjunctivitis the knee and ankle joints show mild
crepitus but no overlying redness or warmth. Which of the following is the best next
step in the management of this patient?

1. Prescribe azithromycin and

doxycycline
2. Initiate ibuprofen (NSAIDs)
3. Aspiration of the left knee and ankle
joints
4. Initiate PO prednisone
5. Obtain MRI of the left knee and ankle

9.

A 32-year-old male presents to his physician with a complaint of pain with urination
that has developed and persisted over the past 8 days. Upon awakening the past 3
mornings, he also noted a clear discharge from the urethra. Review of symptoms is
positive for left knee and ankle pain, as well as eye redness and itching, which both
began yesterday morning. Physical examination confirms the presence of bilateral
conjunctivitis and urethritis. Which of the following genetic markers is associated
with the development of this patient's presenting condition

1. Variation in the NOD2 gene

2. IRF5 positive
3. Complete C1q deficiency
4. HLA-B27 positive
5. HLA-DR4 positive

10.

A 21-year-old male presents with diffuse pain. Specifically, he complains of back, left
knee, and left heel pain of a week duration. His only significant medical history is that
he was treated for penile discharge three weeks ago at his student health clinic. His
temperature is 98.0 degrees F, blood pressure is 115/80 mmHg, pulse is 82/min and
regular, and respirations are 12/min. On exam you notice mouth ulcers. Synovial fluid
analysis shows many polymorphonuclear leukocytes, a negative gram stain, and a
white blood cell count of 10,000/mm3. What is the appropriate treatment for this
patient?

1. Nonsteroidal anti-inflammatory
drugs
2. Methotrexate
3. Antibiotics
4. Colchicine
5. Allopurinol

11.

A 21-year-old man complains of severe morning back pain over the past three months.
His pain improves as the day progreses and improves with excercise. Physical exam
shows diminished anterior flexion of the lumbar spine, muscle spasms in the lower
back, and forward-stooping when the patient walks. Radiography of the lumbar spine
shows bilateral sclerotic changes in the sacroiliac area. The patient is HLA-B27
positive. What is the most likely Dx?

A. Rheumatoid arthritis
B. Osteoarthritis
C. Ankylosing Spondylitis
D. Gouty arthritis

12.

An obese 42-year-old man presents with acute onset of left toe pain, which appears
swollen and red. He reports the pain awakens him at night and severe pain results
from light touch. He has a history of obesity, hypertension,alcohol abuse, and
currently takes hydrochlorothiazide. On exam he has a temperature of 38 degrees
with a swollen erythematous left great toe. What is the most likely Dx?

1. Gout
2. Pseudogout
3. Fractured toe
4. Arthritis

13.

A 60-year-old man presents with pain and swelling in his great toe of three days
duration. He has never had these symptoms before. On physical exam he is afebrile,
and has erythema over the great toe. A clinical image is shown in Figure A. Which of
the following laboratory or imaging results would confirm the diagnosis of acute gout
in this patient?

14.

A 47-year-old male presents with pain and swelling in his great toe for three days
duration. He has never had similar symptoms. He his afebrile, but has erthema and
warmth over his great toe. A clinical image is shown in Figure A and a radiograph is
shown in Figure B. Serum laboratory levels show a elevated uric acid level. The joint is
aspirated, and crystal analysis is shown in Figure C. What is the most appropriate first
line of treatment

1. Elevated serum uric acid level

2. Radiographs showing joint space
narrowing of the 1st metarsalphalangeal
joint and soft tissue radio-densities
3. Magnetic-resonance imaging showing
increased joint fluid and T2 signal
intensity in the metatarsal head
4. Arthrocentesis showing
intracellular crystals that are thin,
needle-shaped, and strongly
positively birefringent
5. Arthrocentesis showing intracellular
crystals that are rhomboid-shaped and
weakly positively birefringent

1. Allopurinol
2. Colchicine
3. Indomethacin (NSAIDs)
4. Cephalosporin
5. Surgical irrigation and debridement
15.

A 67-year-old male active smoker with a history of gout, congestive heart failure
(ejection fraction 35%), and moderate COPD is hospitalized for a CHF exacerbation. On
the third day of his hospitalization, the patient has much improved from a respiratory
stand-point but has developed a warm, painful right knee. Of note, the patient's home
allopurinol was held during his hospitalization. Which of the following joint fluid
analysis results would be most consistent with a diagnosis of recurrent gout

1. Color: yellow; Clarity: clear; WBC: 700

(15% PNM); Bacteria: none
2. Color: straw Clarity: cloudy; WBC: 1000
(25% PNM); Bacteria: none
3. Color: straw; Clarity: clear; WBC: 2000
(30% PNM); Bacteria: none
4. Color: yellow; Clarity: cloudy; WBC:
20000 (70% PNM); Bacteria: none
5. Color: grey or bloody; Clarity: turbid;
WBC: 90000 (90% PNM); Bacteria: many

16.

Following a weekend of binge drinking, an obese 45-year-old male presents with pain
of acute onset in his right big toe. He notes that the pain started yesterday and has
worsened significantly over the past 24 hours. This is the first time the patient has ever
had such pain, however he notes that he is currently being treated for gastric ulcers.
On exam, the first metatarsophalangeal joint is noticeably red and swollen. It is warm
to the touch and light touch elicits severe pain. A joint aspiration reveals the presence
of needle-shaped crystals. What is the most appropriate initial therapy for this
patient?

1. Naproxen -->Avoid NSAIDs w/ ulcers

2. Colchicine
3. Vancomycin
4. Allopurinol
5. Oral prednisone

17.

A 58-year-old male presents to the emergency department with rapid onset of severe
pain and swelling in his right great toe overnight. He reports experiencing a similar
episode several years ago but cannot recall the diagnosis or the medication he was
given for treatment. His medical history is significant for hyperlipidemia, poorly
controlled diabetes, and stage 3 chronic kidney disease. The patient's last
documented GFR estimate 2 weeks ago was 32 mL/min/1.73m^2. The interphalangeal
joint of the right great toe is aspirated, with the synovial fluid aspirate shown under
polarized light microscopy in Figure A. Which of the following is the best management
option for this patient?
1. Initiate long-term colchicine therapy
2. Intrarticular glucocorticoid
injection
3. Oral prednisone
4. Aspirin
5. Indomethacin

18.

A 55-year-old male presents to the emergency department with severe right knee pain.
He states he woke last night with sharp, 10/10 non-radiating pain in his right knee. He
denies recent trauma and states he had been previously healthy. He denies tobacco
use and reports drinking a six-pack of beer on the weekends. Vital signs are T 38 C, HR
95 bpm, BP 140/90 mmHg, RR 18 bpm, SpO2 100%. Physical exam reveals an
erythematous, edematous right knee that is exquisitely tender to palpation. Synovial
fluid aspiration is performed and sent for analysis, which reveals 20,000
leukocytes/mm3, no organisms visualized, and is examined under polarized light
(Figure A). Which of the following is the most likely diagnosis?

1. Lyme arthritis
2. Septic arthritis
3. Pseudogout
4. Gout
5. Rheumatoid arthritis

19.

A 62-year-old woman presents to her primary care doctor for evaluation of left knee
pain. The pain has been present in both knees for approximately 5 years and has been
steadily getting worse. Over the last 2 weeks she has been taking ibuprofen almost
every day, requiring increasing frequency of doses for adequate pain control. A
radiograph of the left knee is shown in Figure A. Which of the following is the most
appropriate treatment for her knee pain?

1. Addition of acetaminophen to current

pain regimen
2. Glucosamine and chondroitin sulfate
supplementation
3. Bed rest
4. Stop ibuprofen and initiate
treatment with acetaminophen
5. Antibiotics

20.

A 72-year-old female with a past medical history of morbid obesity presents to clinic
with joint pain. She has severe pain in both of her knees for which she has been taking
non-steroidal anti-inflammatory drugs daily. You examine her hands (Figure A).
Radiographs of the knees show the following in Figure B. All of the following are
diagnostic criteria for this patient's joint disease EXCEPT:

1. Age >40
2. Bony tenderness
3. Bony crepitus
4. Early morning stiffness of greater
than 30 minutes
5. Bony enlargement
21.

A 66-year-old gentleman presents to his primary care physician complaining that his
joints ache. Specifically, he states that his right knee has been bothering him the most
recently, but notes that there is minimal to no morning stiffness. On physical
examination there is considerable tenderness to palpation over the right knee. What
other piece of information would be most helpful to make a diagnosis of
osteoarthritis?

1. Subcutaneous nodules
2. Sexually active adult
3. Cool joint
4. Rash over the extensor surfaces
5. IV drug use

22.

A 28-year-old man develops swelling, pain, and tenderness in his left ankle and right knee. He had severe
diarrhea after a picnic 1 month prior to the onset of his arthritis. In between his episodes of diarrhea and
arthritis, he had also developed "pink eye," which was mild and lasted only 3 days. He was treated for
"gonorrhea" 2 weeks ago but continues to have some clear penile discharge. He wonders if he needs more
antibiotics because "the gonorrhea has never lasted this long before."

E) Reactive
arthritis

Which of the following is the most likely diagnosis?

A) Pseudogout
B) Gout
C) Resistant gonococcal arthritis
D) Ankylosing spondylitis
E) Reactive arthritis
23.

A 60-year-old man presents with complaints of a swollen left big toe for 3 days. This has never happened before.
He has a negative past medical history. Examination shows a large swollen left big toe. This is likely to be acute
gouty arthritis.

D)
Allopurinol

Of the following agents, which would NOT be useful in the treatment of acute gouty arthritis?
A) Oral steroid
B) Intraarticular steroids
C) Indomethacin
D) Allopurinol
E) Oral colchicine
24.

Radiographs of a patient's hands show narrowed joint spaces of the DIP and PIP joints without erosions or
chondrocalcinosis.

B)
Osteoarthritis

Which of the following is the most likely diagnosis?

A) Psoriatic arthritis
B) Osteoarthritis
C) Chronic polyarticular gout
D) Hemochromatosis
E) Rheumatoid arthritis
25.

Osteophyte formation at DIP

D) Heberden
node

What is the name given to the physical features identified by the arrows?
A) Rheumatoid nodule
B) Bouchard node
C) Tophi
D) Heberden node
E) Ganglion cyst
26.

An 80-year-old woman with rheumatoid arthritis for 30 years presents for follow-up. She has had an extensive
history and has developed many complications from her disease.
Which of the following is NOT a characteristic deformity associated with rheumatoid arthritis?
A) Ulnar deviation
B) Heberden node
C) Boutonniere deformity
D) Hammer toe
E) Swan-neck deformity

B) Heberden
node

27.

A 55-year-old man presents for routine physical examination. He gives a 10-year history of intermittent episodes of
severe pain and swelling of the joints, occurring about every 3 to 5 months and lasting for about 1 week. He says
these episodes "are just like my pappy has." Between the attacks, he has virtually no joint pain. His last attack was
about 2 months ago, and he is without symptoms when he sees you today.

B) Gout

PAST MEDICAL HISTORY: Essentially negative

FAMILY HISTORY: His father is 70 years old with similar joint complaints
SOCIAL HISTORY: Lives alone with his 2 cats
Doesn't smoke
Drinks a 6-pack of beer daily
PHYSICAL EXAMINATION: Extremities: Hallux valgus (bunion) deformity of both 1st metatarsophalangeal joints
Firm, enlargement of the right 2nd and 4th proximal interphalangeal joints and the left 1st and 5th proximal
interphalangeal joints
Several hard nodules are palpated in the left olecranon bursa, which is swollen but not tender, not warm, and not
erythematous
An x-ray of the right foot shows soft tissue density around the 1st metatarsophalangeal joint and an oval bone
erosion with an overhanging edge in the 1st metatarsal bone at the metatarsophalangeal joint.
Which of the following is the most likely cause of his complaints?
A) Pseudogout
B) Gout
C) Osteoarthritis
D) Rheumatoid arthritis
E) Tendinosis universalis
28.

A 40-year-old woman presents for a follow-up appointment. Last month you evaluated her for complaints of
persistent joint pains. At that time she had symmetrical swelling of her wrists, MCPs, and PIPs. You placed her on a
nonsteroidal antiinflammatory agent that provided some relief, but she still has similar complaints. Her physical
examination today is no different from last month's. An x-ray of the hands shows erosive synovitis in the MCP and
PIP joints of both hands.

B)
Sacroiliitis

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

A) Mononeuritis multiplex
B) Sacroiliitis
C) Erosive synovitis changes of her hands on x-ray
D) Swelling of the wrist, MCPs, or PIPs for 6 weeks
E) Morning stiffness for longer than 45 minutes for 6 weeks
29.

A 50-year-old man presents with acute swelling of his first metatarsophalangeal joint. He admits to excessive
alcohol intake and is on hydrochlorothiazide for hypertension. He is obese.
You tap the joint and discover urate crystals in the joint fluid.
Uric acid levels are normal.
What is the most likely diagnosis?
A) Without knowing the birefringence, unable to assess if this is pseudogout or gout.
B) Because of his age, alcohol intake, and normal uric acid levels, pseudogout is more likely.
C) Gout has definitively been diagnosed.
D) Because of his age, alcohol intake, and normal uric acid levels, hemochromatosis is more likely.
E) Septic arthritis is most likely.

C) Gout
has
definitively
been
diagnosed.

30.

A 50-year-old woman with complaints of joint pain for several months presents for evaluation. She reports
that she has had morning stiffness for the last 3 months that lasts over an hour and gradually improves
throughout the day. She has had swelling of her wrists and PIP joints for about 2 months and some swelling
in her knees for about 6 weeks.

D) Rheumatoid
arthritis

Physical examination shows marked swelling of her wrists and PIP joints that is symmetrical. You note
some nodules on the dorsum of her hands as well. Plain film x-rays of her hands show erosive synovitis.
Which of the following is her most likely diagnosis?
A) Psoriatic arthritis
B) Pseudoxanthoma elasticum
C) Ankylosing spondylitis
D) Rheumatoid arthritis
E) Osteoarthritis
31.

Sausage digits with the additional finding of pitted nail beds are associated with which of the following
inflammatory arthritis?
A) Psoriatic arthritis
B) Rheumatoid arthritis
C) Reactive spondyloarthropathy
D) Ankylosing spondylitis
E) Sjgren arthritis

A) Psoriatic
arthritis

32.

A 28-year-old man complains of a 3-month history of morning lower back pain, lasting 2 hours. He also
noticed a swollen left second toe for 2 months, has had pain in the bottom of both heels when he walks, and
has a scaly skin rash along his scalp hairline.

D) Methotrexate

What is the most appropriate initial therapy?

A) Etanercept
B) Celecoxib
C) Glucosamine
D) Methotrexate
E) Prednisone
33.

A 44-year-old Caucasian male presents to the emergency department with a swollen left knee for 4 days. He
has experienced 2 episodes of podagra within a year. He denies any other medical problems, but admits to
drinking beer on weekends. He does not take any medications.
Physical exam: Temp: 99.6 F, BP 140/86, P 90 reg, RR 12
Skin: Mild erythema and warmth over dorsum of left knee
Lungs: CTA
Cor: N1 S1, S2; no murmurs, rubs, or gallops
Abd: Soft, with normal bowel sounds
MS: No tophi or nodules noted; large left knee effusion is present
Knee arthrocentesis removed 20 cc of yellow, turbid fluid. Aspiration confirmed negatively birefringent
monosodium urate crystals.
Which of the following strategies will be most effective in preventing further episodes of joint attacks?
A) Start allopurinol and titrate to serum uric acid < 6.0 mg/dL.
B) Dietary and lifestyle changes.
C) Start ibuprofen 800 mg PO every 6 hours.
D) Alkalinize the urine.
E) Start IV colchicine as prophylaxis for 6 months.

A) Start
allopurinol and
titrate to serum
uric acid < 6.0
mg/dL.

34.

A 19-year-old male presents with low back pain and stiffness. These symptoms have been of gradual onset over
the past 6 months. In general, he finds that a shower in the morning tends to make him feel less stiff, and once
he starts walking around, the stiffness seems to disappear. There is no family history of consequence. His other
peripheral joints have not been a problem, but more recently he has begun to notice some pain in the left groin
area. There is no history of urethritis or of conjunctivitis. He has had no rashes. Otherwise, he has been in
excellent health.

C) An antiTNF agent

The patient is well-appearing. His peripheral joints are benign. Schober test reveals 3 cm of movement.
Cutaneous exam reveals no vasculitis, but some pitting is noticed on several nails and onycholysis of several
others. Investigations reveal a sedimentation rate of 97, normal CBC and CMP, negative ANA and RF. X-ray of the
lumbar spine reveals bilateral asymmetric SI joint sclerosis and narrowing. X-ray of the hips is normal.
Which is the drug of choice?
A) Hydroxychloroquine sulfate
B) Prednisone 60 mg qd
C) An anti-TNF agent
D) Azulfidine
E) Methotrexate
35.

A 60-year-old man presents with complaints of left knee pain. He says that he has had chronic bilateral hip,
knee, and shoulder pain for many months. These joints are usually "stiff" in the morning but improve after 20
minutes. His left knee became swollen 3 days ago, and this is new. He cannot bear weight on this leg without
severe pain in his knee. His physical examination shows a swollen, red, warm left knee. He has a palpable
effusion of the affected knee. The neurological, vascular, and sensory functions of the knee area are intact.
You aspirate the knee and it shows 1,800 WBC/L with 95% lymphocytes. No crystals or other abnormalities are
noted.
What is the probable etiology of his left knee findings?
A) Rheumatoid arthritis
B) Osteoarthritis
C) Septic arthritis
D) Gout
E) Pseudogout

B)
Osteoarthritis

36.

A 32-year-old nurse presents to your office with a complaint of intermittent episodes of pain, stiffness, and
swelling in both hands and wrists for approximately 1 year. The episodes last for several weeks and then
resolve. More recently, she noticed similar symptoms in her knees and ankles. Joint pain and stiffness are
making it harder for her to get out of bed in the morning and are interfering with her ability to perform her
duties at work. The joint stiffness usually lasts for several hours before improving. She also reports malaise and
easy fatigability for the past few months, but she denies having fever, chills, skin rashes, and weight loss.
Physical examination reveals a well-developed woman, with blood pressure 120/70 mm Hg, heart rate 82 bpm,
and respiratory rate 14 breaths per minute. Her skin does not reveal any rashes. Head, neck, cardiovascular,
chest, and abdominal examinations are normal. There is no hepatosplenomegaly. The joint examination
reveals the presence of bilateral swelling, redness, and tenderness of most proximal interphalangeal (PIP)
joints, metacarpophalangeal (MCP) joints, the wrists, and the knees.
Laboratory studies show a mild anemia with hemoglobin 11.2 g/dL, hematocrit 32.5%, mean corpuscular
volume (MCV) 85.7 fL, white blood cell (WBC) count 7.9/mm3 with a normal differential, and platelet count 300
000/mm3. The urinalysis is clear with no protein and no red blood cells (RBCs). The erythrocyte sedimentation
rate (ESR) is 75 mm/h, and the kidney and liver function tests are normal.

Dx: Ankylosis
Spondylitis
(feels better
with exercise)
Physical Exam:
-SI joint
tenderness
-<5cm Lumbar
Flexion
-Reduced
chest
expansion
-Sausage digits
Imaging
-Back: Bamboo
Spine
-Pelvis
-Labs: HLAB27 +
-Synovial
Analysis:
Inflammatory
Tx:
-NSAIDS
-DMARDS
-Physical
Therapy

37.

A 72-year-old man presents to his primary care physician for his annual exam. He has a very stoic personality
and says that he is generally very healthy and has "the normal aches and pains of old age." On further probing,
you learn that he does have pretty significant back and hip pain that worsens throughout the day. On physical
exam you note bony enlargement of the distal interphalangeal joints bilaterally. Which of the following is the
likely cause of his symptoms?

1. Gout
2. Pseudogout
3. Rheumatoid
arthritis
4.
Osteoarthritis
5. Osteopaenia

38.

A 38-year-old female visits your office complaining of several years of joint swelling and stiffness that is worse
in the morning and improves throughout the day. Physical examination reveals bilateral deformities at her
proximal interphalangeal and metacarpophalangeal joints. The presence of which of the following in this
patient's serum would most help 'rule in' a diagnosis of rheumatoid arthritis

1. Rheumatoid
factor
2. Anti-nuclear
antibody
3. Anticitrullinated
protein
antibody
4. Anticentromere
antibody
5. Anti-smooth
muscle
antibody

39.

A 60-year-old man has had intermittent pain in his right great toe for the past 2 years.
Joint aspiration and crystal analysis shows thin, tapered, needle shaped intracellular
crystals that are strongly negatively birefringent. What is the most likely cause of this
condition?

40.

A 75-year-old woman presents with worsening "nodules" on her body. She describes
several years of intermittent, severe joint pain, which she ascribed to arthritis with
"old age." Her hand is shown in Figure A. Which of the following interventions is best
for long-term treatment of this condition

1. Monosodium urate crystal

deposition
2. Calcium pyrophosphate deposition
3. Uric acid crystal deposition
4. Tuberculosis
5. Rheumatoid arthritis

1. Probenecid
2. Colchicine
3. Allopurinol
4. Non-steroidal anti-inflammatory
agents
5. Thiazides
41.

A 29-year-old woman with a 3-year history of systemic lupus erythematosus (SLE)

presents to her rheumatologist for routine follow up. Her course has been
complicated by lupus nephritis (baseline creatinine 1.1 mg/dL) and she has been on
stable doses of methotrexate and hydroxychloroquine for the last 2 months following
a flare. Which of the following lab values can be used to best monitor this patient's
disease?

1. Anti-nuclear antibody
2. Anti-dsDNA antibody
3. Anti-Smith antibody
4. Anti-RNP antibody
5. CH50 level

42.

A 24-year-old African-American woman presents to her primary care physician

complaining of weakness and malaise. She complains that she has unintentionally
lost 10 pounds of weight in 2 weeks. Upon further questioning, it is found that she
gets a painful rash on her face when she goes outside in the sun. Her hemoglobin level
was found to be 8.1 g/dl. What is most likely to be found on laboratory testing?

1. Positive anti-ds-DNA antibodies

2. Positive anti-La antibodies
3. Positive anti-centromere antibodies
4. Positive anti-cardiolipin antibodies
5. Positive anti-ganglioside antibodies

43.

Dx of SLE is supported by a positive initial antibody screen however this test is not
specific. What is most specific in the dx of SLE?

a) gliadin antibody
b) anti-dsDNA
c) ANA
d) anticentromere antibody
e) anti ribosomal P antibody

44.

40-year-old Caucasian female presents to your office with fever, fatigue, cold fingers,
and the rash shown in Figure A. The presence of which of the following antibodies has
the highest specificity for diagnosis of this patient's condition?

1. Anti-acetylcholine receptor
2. Anti-Ro
3. Anti-La
4. Anti-ssDNA
5. Anti-dsDNA

45.

27-year-old woman presents to her primary care physician for evaluation of malaise, joint
pains, and rash. Over the last 1-2 months, she has felt generally unwell with fatigue and
low-grade fever. More recently, she has started to experience joint pains in her hands and
noticed a rash over her face after sun exposure. She is otherwise healthy and takes no
medications. Examination reveals an erythematous rash with a small amount of
underlying edema (Figure A). Which of the following is the most common cardiac
manifestation of this patient's underlying condition?

1. Pericarditis
2. Myocarditis
3. Conduction arrhythmias
4. Valvular disease
5. Coronary artery disease
46.

Skin thickening that begins as swelling of the fingers and hands associated with
telangiectasis, dysphagia and hypomotiligy of the GI that is most likely seen with which of
the following?

a) sarcoidosis
b) scleroderma
c)dermatomyositis
d) eosinophilic fasciitis
e) eosinophilia-myalgia syndrome

47.

Which of the following is strongly associated with systemic sclerosis?

a) polymyositis
b) reactive arthritis
c) dermatomyositis
d) Sjogren disease
e) raynaud phenomenon

48.

A 39-year-old woman presents to clinic with multiple complaints. She has trouble
swallowing both solids and liquids. She also reports that when she goes out in the cold,
her fingers get extremely pale. Vital signs are stable. Physical exam reveals calcinosis of the
digits and sclerodactyly as well as telangiectasia over the digits and at the nail bed. One
would expect which of the following diagnostic tests to be positive?

1. Antihistone antibodies
2. Anticentromere antibodies
3. Antidesmoglein antibodies
4. Antimitochondrial antibodies
5. Anti-glomerular basement
antibodies
Pt has CREST syndrome

49.

A 35-year-old woman comes to your office with a variety of complaints. As part of her
evaluation, she undergoes laboratory testing which reveals the presence of anticentromere antibodies. All of the following symptoms and signs would be expected to be
present EXCEPT:

1. Pallor, cyanosis, and erythema of

the hands
2. Calcium deposits on digits
3. Blanching vascular abnormalities
4. Hypercoagulable state
5. Heartburn and regurgitation
-Anti-centromere antibodies are
specific for limited systemic
scleroderma (CREST)

50.

A 66-year-old female presents to the emergency department with a chief complaint of a

throbbing, right-sided headache for the past 5 days. She states that the pain is worse when
eating. Earlier today she also had a transient 5 second period of blindness of her right eye.
The patient describes a multiple year history of pain and weakness of her bilateral
shoulders and hips. Physical examination is significant for extreme tenderness to
palpation of the right scalp. The patient's right temple is shown in Figure A. Serology
reveals an elevated WBC count and an ESR of 111 mm/h. Which of the following is the best
next step in management of this patient?

Tx: Prednisone 40-60mg

51.

A 62-year-old female presents to her primary care physician complaining of a new, right-sided, throbbing
headache that has lasted for roughly one week. She reports that the pain is worsened by eating.

Giant Cell
Arteritis

What's most likely the dx?

52.

67 yo man presents with pain and stiffness in shoulder and hips lasting several weeks with no hx of trauma. He
also complains of headache, throat pain, jaw claudication. It is imperative to dx this patient properly to
prevent which of the following?

a) anemia
b) cerebral
aneurysms
c) mononeuritis
multiplex
d)ischemic
optic
neuropathy
e) restpiratory
infection

53.

A 60-year-old woman presents to her physician's office complaining of severe aching and stiffness in her neck,
shoulders, and hips for last two months. She reports the pain to be much worse in the morning and shortly
after awakening, and is often accompanied by fatigue and low-grade fevers. On exam, range-of-motion of the
neck, shoulders, and hips is normal; however, the muscles are tender to palpation. Muscle strenth and
sensation are normal. Serum creatinine kinase is 40 U/L, and ESR is 80. What is the most likely dx?

Polymyalgia
Rheumatica

54.

Which of the following clinical findings is most characteristic of polymyalgia rheumatica?

a)
subcutaneous
inflammatory
lesions
b) pain and
stiffness of
proximal
muscle groups
c) insidious
onset of
symmetric
joints
d) widespread
musculoskeletal
pain and
tender points
e) symmetric
weakness
initially in the
legs that
progresses
caudally

55.

65-year-old woman comes to clinic complaining of pain with chewing solid foods. She reports that she has
been feeling unwell lately, with pains in her shoulders and hips, and she has lost five pounds in the past few
months. Her vital signs are T 39C, RR 18 breaths/min, HR 95 bpm, BP 120/65 mmHg. When you ask her to stand
from her chair to get on the exam table she moves stiffly but displays preserved proximal muscle strength.
Another potential symptom or sign of this disease could be:

1. Violaceous
rash across the
eyelids
2. Blindness
3. Easily
sunburned on
face and hands
4. Hemoptysis
5. Thickened,
tight skin on
the fingers

56.

A 43-year-old man with Hepatitis C complains of severe chest pain that worsens when he leans back. On
exam, the physician notes superficial, erythematous vascular marking on the lower limbs. What is the
most likely dx?

Polyarteritis
nodosa

57.

60-year-old male with a history of hypertension and hepatitis B presents to his primary care physician
complaining of several months of fever, weakness, myalgias, and arthralgias. Home medications include
lisinopril. No evidence of involvement of microscopic vessels, pulmonary vessels, or glomerulonephritis is
found. Which of the following is the most likely diagnosis?

Polyarteritis
nodosa

58.

A 29-year-old African American female presents to your office with extreme fatigue and bilateral joint pain.
Serologies demonstrate the presence of rheumatoid factor along with anti-Smith and anti-dsDNA
antibodies. A VDRL syphilis test is positive. You order a coagulation profile, which reveals normal bleeding
time, normal PT, and prolonged PTT as well as normal platelet count. Further evaluation is most likely to
reveal which of the following?

1. Palmar rash
2. HLA-B27
positivity
3. Factor VIII
deficiency
4. History of
multiple
spontaneous
abortions
5. Immune
thrombocytopenia
Patient has AntiPhospholipid
Syndrome

59.

A 40-year-old female presents to her primary care physician with complaints of worsening muscle aches
and diffuse weakness over the past several months. She states that she now has difficulty climbing stairs
and extending her neck. Ultimately, she became more concerned when she began having trouble
swallowing and experienced shortness of breath. Physical examination confirms symmetric proximal
muscle weakness and is also significant for bilateral atrophy of the shoulder and hip girdle musculature.
An EMG is conducted and shows fibrillations. A muscle biopsy is ordered; however, results are pending.
Which of the following is the first-line treatment for this patient's condition?

1. Naproxen
2. Intravenous
immunoglobulin
3. Prednisone
4.
Cyclophosphamide
5. Neostigmine

60.

A 49-year-old woman presents to general medicine clinic with weakness. Her symptoms started a few
months ago and have become progressively more severe. She reports difficulty getting up from a chair.
Vital signs are stable. Physical exam is remarkable for weakness in the biceps, triceps, deltoids, and
quadriceps. Weakness is symmetric, and the patient reports mild tenderness of these muscle groups on
exam. Further workup shows an elevated creatine phosphokinase and a positive ANA. What test is used to
confirm the diagnosis?

1.
Electromyography
2. LDH
3. Anti-Mi-2
antibodies
4. Anti-synthetase
(anti-Jo-1)
antibodies
5. Muscle biopsy

61.

A 40-year-old male presents to your office complaining that he is too weak to climb stairs or brush his hair.
He denies any headaches or change in vision. A muscle biopsy reveals CD8+ lymphocyte infiltration in the
endomysium. Which of the following is the most likely diagnosis?

1. Systemic lupus
erythematosus
2. Scleroderma
3. Polymyalgia
rheumatica
4. Polymyositis
5. Dermatomyositis

62.

A 42-year-old female complains of aching in her shoulders and pelvis and difficulty climbing stairs. She has
a butterfly rash over her nose and cheeks, as well as painful, erythematous skin on the chest wall. She also
has erythema and edema over her eyelids and knuckles. An EMG reveals low amplitude polyphasic
potentials, and laboratory testing shows an elevated creatinine phosphokinase. What is the most likely
Dx?

Dermatomyositis

63.

A 42-year-old man presents to clinic complaining of increasing difficulty climbing stairs and standing up
from sitting in his chair. On exam you perceive that his strength to be 5/5 distally, but only 3/5 in proximal
muscle groups bilaterally. There is a distinctive rash on his upper eyelids and around his eyes. Examination
of the fingers is most likely to reveal which of the following?

1. Dactylitis
2. Enlargement of
the PIP
3. Ulnar deviation
of the fingers
4. Nail pitting with
oil spots
5. Violaceous
papules over the
MCP, PIP, and
DIP (Gottron's
Papules)