1. A 72-year-old man presents with an acutely painful right knee.

On examination, he had a temperature of 37C with a

hot, swollen right knee.

Of relevance amongst his investigations, was his white cell count which was 12.6 and a knee X-ray revealed reduced joint
space and calcification of the articular cartilage. Culture of aspirated fluid showed no growth.

What is the most likely diagnosis?

a. Gout
b. Psoriatic monoarthropathy
c. Pseudogout
d. Rheumatoid arthiritis
e. Septic arthritis
2. A 65-year-old man is evaluated for a 1-month history of progressive malaise, myalgia, a 3.6-kg weight loss and
numbness and weakness of the right foot; left testicular pain for 1 week; and a painful rash on his legs for 2 days. He was
diagnosed 2 months ago with hypertension, for which he takes hydrochlorothiazide.

On physical examination, temperature is 37.2 C, and blood pressure is 165/90 mmHg. The left testicle is tender. Small
necrotic ulcers are noted on the legs. Numbness of the right lateral ankle and calfs noted, as well as weakness of right foot
plantar flexion.

Laboratory studies reaveal erythrocyte sedimentation rate 100 mm/h, hemoglobin 10 g/dL, leukocyte count 13,000,
platelet count 430,000, creatinine 1.7 mg/dL, ANCA negative and urinalysis normal. Renal angiogram shows
microaneurysms of the renal arteries. A deep skin biopsy shows panmural inflammation with necrosis of a mediumsized
arteries

Which of the following is the most likely diagnosis?

a. Giant cell arteritis

b. lgA vasculitis
c. Microscopic polyangiitis
d. Polyarteritis nodusa
e. Immune-complex mediated vasculitis
3. A 79-year-old man is evaluated for a 2-month history of progressive malaise and weakness, aching bilateral shoulders
and hips, and stiffness for 2 hours in the morning and after immobility. He recently noted aching in his jaw when chewing.
He also reports new left-sided headaches. Last week he had an episode of diplopia lasting 1 minute. He has hypertension,
for which he takes hydrochlorothiazide.

On physical examination, vital signs are normal. Tenderness and slight swelling over the left temple are present. Painful
and limited range of motion of both hips and shoulders is noted. The remainder of the examination is unremarkable.

Laboratory studies show an erythrocyte sedimentation rate of 85 mm/h.

Which of the following is the most appropriate initial management?

a. CT of the head
b. Low-dose aspirin
c. Methotrexate
d. Prednisone
e. Temporal artery biopsy
4. A 72 year old man is evaluated in the emergency department after falling when his leg gave way as he tried to arise
from bed. He has left hip pain with the inability to stand and pain at rest. He was recently diagnosed with lymphoma, for
which he is receiving chemotherapy. History is significant for a left hip replacement 7 years ago for osteoarthritis. His
chemotherapy regimen consists of rituximab plus cyclophosphamide, vincristine, doxorubicin and dexamethasone.

On physical examination, temperature is 38.2 °C (100.8 °F): other vital signs are normal. The right upper chest is implanted
with a venous access port. Warmth and tenderness around the left hip are noted. Pain in the groin is noted. There is
limitation of motion in all directions on both active and passive range of motion of the left hip. There are no other joint
abnormalities.

Laboratory studies show an erythrocyte sedimentation rate of 73 mm/h, a leukocyte count of 13,400 and a serum urate
level of 8.2 mg/dL. Left hip radiographs show peri-prosthetic lucency.

Which of the following is the most likely diagnosis?

a. Gout flare
b. Hemarthrosis
c. Hip dislocation
d. Prosthetic joint infection
e. Pseudogout attack
5. A 32-year-old woman is evaluated for a 15-year history of low back pain. The pain is worse with rest, improves with
movement, and can awaken her during the night. Family history is notable for three paternal uncles with back problems.
She takes naproxen twice daily with some relief.

On physical examination, vital signs are normal. Joint examination does not reveal any warmth, erythema or swelling.
Tenderness over the sacroiliac joints bilaterally and reduction in the range of motion of the lumbar spine are noted.

Laboratory studies are notable for an erythrocyte sedimentation rate of 27 mm/h. A plain anteroposterior radiograph of
the pelvis shows fusion of the sacroiliac joints.

Which of the following is the most appropriate diagnostic test to perform next?

a. ANCA
b. Anti-cyclic citrullinated peptide antibodies
c. Antinuclear antibodies
d. HLA-B27 antigen
e. No additional testing
6. A 25-year-old man is evaluated for the gradual onset of bilateral low back pain without radiation to the lower
extremities daily, with increasing severity over the past year. The pain now awakens him during the night 2 to 3 times per
week, with morning stiffness lasting more than an hour. He has improvement with exercise and no improvement at rest.
He takes ibuprofen with some improvement.

On physical examination, vital signs are normal. Limited lateral bending bilaterally and a reduction in forward flexion at the
lumbar spine are noted. The remainder of the examination is normal.

An antero-posterior plain radiograph of the pelvis and sacroiliac joints is unremarkable.

Which of the following is the most appropriate diagnostic test to perform next?

(A) Bone scan

(B) CT of the lumbar spine
(C) MRI of the sacroiliac joints
(D) Radiography of the hip joints
(E) All of the above
7. A 31-year-old man is evaluated In the emergency department for fever and red painful eyes. He reports a 1-month
history of intermittent painful oral and genital ulcers, knee pain, and fever and 1 week of bilateral eye redness, pain
and photophobia.

On physical examination, temperature is 38.3 and pulse rate is 100/min. Slit lamp examination reveals white cells in the
anterior chambers of both eyes. There are aphthous ulcers on the tongue and one aphthous ulcer on the scrotum.
Swelling and warmth are noted in both knees. The heart, lung, abdominal, and neurologic examinations are normal.

Which of the following is the most likely diagnosis?

(A) Behcet syndrome

(B) Crohn disease
(C) Sarcoidosis
(D) Systemic lupus erythematosus
(E) Spondyloarthritis