IM - RHEUMATOLOGY SET

IM - RHEUMATOLOGY SET
1. A 66-year-old man comes to the outpatient clinic because of severe pain and swelling in the
right foot for the last 12 hours. He cannot bear weight on the foot because of pain. There is
no history of injury. Physical examination shows redness, warmth, swelling, tenderness and
decreased range of motion in the left first metatarsophalangeal joint.
a. What is the most likely diagnosis?
b. What is the most appropriate next step in management?

2. What drugs are used to treat acute gout and chronic gout?

3. A 43-year-old woman presents with a 2-day history of left-sided chest pain. The pain is
sharp and is worse during deep inspiration or coughing. It is worse when lying supine and
is somewhat relieved by sitting up and leaning forward. She reports minimal shortness of
breath. She complains of malaise, intermittent fever and joint pains in her hands and knees.
Physical examination shows a rash on the patients face, arms and upper chest consistent
with photosensitivity. Breath sounds are diminished in the left posterior lung field. There is
mild tenderness of the joints in the hands. Laboratory studies show:

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An x-ray of the chest shows diffuse, hazy pulmonary infiltrates and a left-sided pleural effusion.
a. What is the most likely diagnosis?
b. What is the best initial diagnostic test for this condition?
c. What serologic tests are most specific for this condition?

Serum creatinine
Hemoglobin
Leukocyte count

1.9 mg/dL
10.6 g/dL
3,600/mm3

a. Asymmetric arthritis preceded by GI or GU infection

b. Inflammatory back pain + bamboo spine on x-ray
c. Skin plaques with silvery scaling + pitting of the nails + arthritis

5. A 72-year-old woman presents with a 2-day history of right-sided headache and vision
disturbances. She also complains of jaw pain when chewing. Her temperature is 38.1C
(100.6F). On exam, there is tenderness to palpation on the right side of the scalp.
a. What treatment should be started even before the diagnosis is established?
b. What test is the most appropriate first test to order?
c. What test is most likely to confirm the diagnosis?

6. A 46-year-old woman presents with pain and swelling in her fingers that began about 3
months ago, and has been gradually getting worse. The pain and stiffness are generally
worse when she first gets up in the morning but improve after she loosens up. She also
complains of stiffness in her knees and generalized fatigue. Physical examination reveals
slight tenderness and swelling of multiple MCP and PIP joints bilaterally and the right
wrist.
a. What is the most specific lab test to confirm the most likely diagnosis?
b. How is this diagnosis treated?

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INTERNAL MEDICINE

IM - RHEUMATOLOGY SET

4. Which seronegative spondyloarthropathy matches each of the following statements?

IM - RHEUMATOLOGY SET

7. A 32-year-old woman comes to the physician with a two-week history of bilateral arm
weakness. She has difficulty lifting her arms to fix her hair in the morning, and it is getting
progressively worse. She denies muscle soreness or pain. Physical examination shows
modest difficulty rising from a chair and climbing onto the examination table. She has 2/5
motor strength of shoulder abduction and 3/5 motor strength of hip flexion and extension.
Handgrip strength and the rest of the neurological exam are normal. She is noted to have
symmetrical, pinkish-red papules on the dorsal surfaces of the metacarpophalangeal (MCP)
joints and interphalangeal (IP) joints of both hands. Further examination of the skin reveals
hyperpigmentation of the shoulders and anterior upper chest.
a. What serum markers are likely to be present in this patient?
b. What other diagnostic studies would help establish the diagnosis?
c. How is this condition treated?

8. What medications have the highest risk of causing drug-induced lupus?

9. What disorder is most strongly associated with each of the following autoantibodies?
a.
b.
c.
d.
e.
f.

Anti-dsDNA
Anti-histone
Anti-La/SSB
Anti-Smith
Anti-topoisomerase 1
Anticentromere

10. What is the first-line pharmacotherapy for Raynaud phenomenon?

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