1. A 20 year old black woman presents to your outpatient clinic with one month of increasing morning stiffness, bilateral hand swelling, and a growth on her elbow. She has pain in all hand joints, and it gradually improves during the day with activity. The growth on her elbow is a soft, nontender nodule without erythema. The blood pressure is 140/90mm Hg, pulse 80, respiratory rate 12 and she is afebrile. The exam is unremarkable except for mild bilateral nontender cervical lymphadenoapthy. Routine blood tests, serological studies, and urinalysis are obtained. A immediate microscopic examination of the urinalysis shows moderate red cells and a few red cell casts and many granular casts. The most likely diagnosis is [1]:

   A. Rheumatoid Arthritis
   B. Systemic Vasculitis
   C. HIV Infection with Nephropathy
   D. Systemic Lupus Erythematosus
   E. Psoriatic Arthritis

2. Before routine laboratory tests and serolgies return, what is the most appropriate medication for this patient's arthritis [2]:

   A. Glucocorticoids
   B. Nonsteroidal anti-inlammatory drugs (NSAIDs)
   C. Hydroxychloroquine (Plaquenil®)
   D. Azathioprine
   E. Methotrexate

3. The differential diagnosis of true arthritis with renal disease includes [3]:

   A. Minimal Change Nephritis
   B. Hepatitis B Virus Infection
   C. Rheumatic Fever
   D. Staphylococcal Infection
   E. Rickettsial Disease

4. A 58 year old man presents to your outpatient clinic with one month of increasing morning pain and stiffness in the shoulders, neck and thighs. The pain gets better as the day goes on. There is no swelling, erythema, or muscle weakness. Ibuprofen, up to 600mg, or acetaminophen do not improve the symptoms. He has a history of exertional angina which is relieved by rest and sublingual nitroglycerin. He smokes 5 cigarettes each day, and drinks one to two glasses of wine with supper. He takes only aspirin and the nitroglycerin as needed. There are no headaches, jaw claudication, scalp tenderness, weight loss, fevers, or chills. The most likely diagnosis is [4]:

   A. Giant Cell (Temporal) Arteritis
   B. Polyarteritis Nodosum
   C. Polymyalgia Rheumatica
   D. Polymyositis
   E. Ankylosing Spondylitis

5. The most appropriate treatment for this patient is [5]:

   A. Ibuprofen 600mg orally four times per day
   B. Naproxen 500mg orally three times per day
   C. Prednisone 60mg orally once daily
   D. Acetaminophen 1000mg orally four times per day
   E. Prednisone 10-15mg orally once daily

6. A 23 year old man presents to your outpatient clinic with six months of lower back pain, worse in the morning. It gradually improves as the day goes on. Exercise makes his back feel better. He has noted mild morning stiffness in both shoulders and in his left knee. There was one episode of swelling in the left knee, but it resolved with two ibuprofen tablets. The patient has an uncle with lower back pain who walks hunched over. He has one brother with psoriasis but no joint complaints. Which of the following is NOT likely in the differential diagnosis [6] ?

   A. Ankylosing Spondylitis
   B. Rheumatoid Arthritis
   C. Psoriatic Arthritis
   D. Arthritis associated with Inflammatory Bowel Disease
   E. Reiter's Syndrome or Post-Infectious Arthritis

7. The back pain is most likely to respond to [7]:

   A. High dose non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy
   B. High dose glucocorticoids and bedrest
   C. Low dose glucocorticoids and bedrest
   D. Penicillin, 500mg orally four times per day for 4 weeks
   E. Acetaminophen as needed with very light activity

8. A 38 year old man with a past medical history notable for hepatitis B virus infection 3 months ago presents to the emergency room with lethargy, confusion, and pain in his testis. He is slow to answer questions, but reports mild weight loss and nodular mildly tender skin lesions on his lower extremities which went away with calamine lotion 2 weeks ago. The pain in his testis began 4 days ago and has been increasing. Four aspirin every six hours did not help the pain. He has felt tired for several months but attributed that to overwork. On exam, he is slow to respond. The blood pressure is 150/95 in both arms, pulse 85, respirations 20, and temperature 97.6° orally. The fundi are normal, sclera are anicteric, there is mild bilateral anterior cervical lymphadenopathy, lungs are clear, cardiac exam is normal, extremities are normal with fading 1cm purple macules on the left shin, testis notable for erythema on the left with moderate pain (no change on testicular elevation). A mildly decreased ankle reflex with some dysesthesias in the right foot (normal Babinski) was also noted. The most appropriate serological test at this point is [8]:

   A. Anti-glomerular basement membrane (Anti-GBM) Antibodies
   B. Anti-smooth muscle antibodies
   C. Anti-neutrophil cytoplasmic antibodies (ANCA)
   D. Anti-DNA Antibodies
   E. Rheumatoid Factor

9. The most appropriate treatment of this condition is [9]:

   A. High dose intravenous glucocorticoids
   B. High dose intravenous glucocorticoids with oral or intravenous cyclophosphamide therapy
   C. Methotrexate combination with glucocorticoids
   D. Intravenous Gammaglobulin with glucocorticoids
   E. Intravenous Gammaglobulin and Warfarin

10. A 65 year old man presents with his first episode of a swollen, tender left knee without fever, rigors, or weight loss. There is no history of arthritis. Physical examination confirms the presence of a large left knee effusion. A radiograph of the knee shows calcification of the periarticular cartilage. The most likely diagnosis is [10]:

    A. Gout
    B. Ankylosing Spondylitis
    C. Psoriatic Arthritis
    D. Rheumatoid Arthritis
    E. Pseudogout (CPPD)

Answers

1. D
2. A (NSAIDs are contraindicated with possible azotemia or hematuria)
3. B
4. C
5. E
6. B
7. A
8. C
9. B
10. E