Rheumatology and Immunology multiple choice questions

Q 1. A 73-year-old woman with a medical history of obesity

and diabetes mellitus presents to your clinic complaining

of right knee pain that has been progressive and

is worse with walking or standing. She has taken overthe-

counter nonsteroidal anti-inflammatory drugs without

relief. She wants to know what is wrong with her knee

and what may have caused it. X-rays are performed and

reveal cartilage loss and osteophyte formation. Which of

the following represents the most potent risk factor for

the development of osteoarthritis?

A. Age

B. Gender

C. Genetic susceptibility

D. Obesity

E. Previous joint injury

Answer   A

Q 2. A 42-year-old obese male presents to your office with

complaints of paresthesias in the right hand that are

worst in the fourth and fifth fingers. Symptoms have been

present intermittently for the last 4 months. He has no

other past medical history and takes no medications. The

examination is significant for an intact neurologic examination

of the right upper extremity but mild wasting of

the intrinsic muscles on inspection of the right hand.

Laboratories show a normal white blood cell count, hemoglobin,

and sedimentation rate. Electrolytes and creatinine

and liver function tests are normal except for a

serum glucose of 148 mg/dL. What is the most likely etiology

of this patient’s symptoms?

A. Diabetes mellitus

B. Cholesterol emboli

C. Churg-Strauss disease

D. Cervical spondylosis

E. Neurogenic thoracic outlet syndrome

Answer   E

Q 3 A 54-year-old man is admitted for persistent lower abdominal

and groin pain that began 7 months previously.

Two months before his present admission, he required exploratory

laparoscopy for acute abdominal pain and presumed

cholecystitis. This revealed necrotic omental tissue

and pericholecystitis necessitating omentectomy and cholecystectomy.

However, the pain continued unchanged. He

currently describes it as periumbilical and radiating into his

groin and legs. It becomes worse with eating. The patient has

also had episodic severe testicular pain, bowel urgency, nausea,

vomiting, and diuresis. He has lost ~22.7 kg over the

preceding 6 months. His past medical history is significant

of hypertension that has recently become difficult to control.

Medications on admission include aspirin, hydrochlorothiazide,

hydromorphone, lansoprazole, metoprolol,

and quinapril. On physical examination, the patient appears

comfortable. His blood pressure is 170/100 mmHg,

his heart rate is 88 beats/min, and he is afebrile. He has

normal first and second heart sounds without murmurs,

and an S4 is present. There are no carotid, renal, abdominal,

or femoral bruits.

His lungs are clear to auscultation. Bowel sounds are normal.

Abdominal palpation demonstrates minimal diffuse

tenderness without rebound or guarding. No masses are

present, and the stool is negative for occult blood. During

the examination, the patient develops Raynaud's phenomenon

in his right hand that persists for several minutes. His

neurologic examination is intact. Admission laboratory

studies reveal an erythrocyte sedimentation rate of 72 mm/h,

a BUN of 17 mg/dL, and a creatinine of 0.8 mg/dL. The patient

has no proteinuria or hematuria. Tests for antinuclear

antibodies, anti-double-stranded-DNA antibodies, and antineutrophil

cytoplasmic antibodies are negative. Liver

function tests are abnormal with an AST of 89 IU/L and an

ALT of 112 IU/L. Hepatitis B surface antigen and e antigen

are positive. Mesenteric angiography demonstrates small

beaded aneurysms of the superior and inferior mesenteric

veins. What is the most likely diagnosis?

A. Hepatocellular carcinoma

B. Ischemic colitis

C. Microscopic polyangiitis

D. Mixed cryoglobulinemia

E. Polyarteritis nodosa

Answer   E

Q 4 A 64-year-old African-American male is evaluated in

the hospital for congestive heart failure, renal failure, and

polyneuropathy. Physical examination on admission was

notable for these findings and raised waxy papules in the

axilla and inguinal region. Admission laboratories showed

a BUN of 90 mg/dL and a creatinine of 6.3 mg/dL. Total

protein was 9.0 g/dL, with an albumin of 3.2 g/dL. Hematocrit

was 24%, and white blood cell and platelet counts

were normal. Urinalysis was remarkable for 3+ proteinuria

but no cellular casts. Further evaluation included

an echocardiogram with a thickened left ventricle and preserved

systolic function. Which of the following tests is

most likely to diagnose the underlying condition?

A. Bone marrow biopsy

B. Electromyogram (EMG) with nerve conduction

studies

C. Fat pad biopsy

D. Right heart catheterization

E. Renal ultrasound

Answer   A

Q 5  31-year-old woman presents to your clinic complaining

of painful arthritis that is worse in the mornings

when she wakes up. She was recently evaluated by an

ophthalmologist for uveitis in her right eye. A recent laboratory

report shows an erythrocyte sedimentation rate

of 48 mm/h. Which of the following will be helpful in distinguishing

relapsing polychondritis from rheumatoid

arthritis (RA)?

A. Arthritis associated with RA is nonerosive.

B. Eye inflammation is absent in relapsing polychondritis.

C. Relapsing polychondritis will not present with vasculitis.

D. Relapsing polychondritis will present with high-titer

rheumatoid factor.

E. The arthritis of relapsing polychondritis is asymmetric.

Answer   E

Q  6 A 66-year-old woman with a history of rheumatoid

arthritis and frequent pseudogout attacks in her left knee

presents with night sweats and a 2-day history of left knee

pain. On physical examination, her temperature is 38.6°C,

heart rate is 110 beats/min, blood pressure is 104/78

mmHg, and oxygen saturation is 97% on room air. Her

left knee is swollen, red, painful, and warm. With 5° of

flexion or extension, she develops extreme pain. She has

evidence of chronic joint deformity in her hands, knees,

and spine. Peripheral white blood cell (WBC) count is

16,700 cells/μL with 95% neutrophils. A diagnostic tap

of her left knee reveals 168,300 WBCs per microliter,

99% neutrophils, and diffuse needle-shaped birefringent

crystals present. Gram stain shows rare gram-positive

cocci in clusters. Management includes all of the following

except

A. blood cultures

B. glucocorticoids

C. needle aspiration of joint fluid

D. orthopedic surgery consult

E. vancomycin

Answer   B

Q 7  A 58-year-old female presents complaining of right

shoulder pain. She does not recall any prior injury but

notes that she feels that the shoulder has been getting

progressively more stiff over the last several months. She

previously had several episodes of bursitis of the right

shoulder that were treated successfully with NSAIDs and

steroid injections. The patient’s past medical history is

also significant for diabetes mellitus, for which she takes

metformin and glyburide. On physical examination, the

right shoulder is not warm or red but is tender to touch.

Passive and active range of motion is limited in flexion,

extension, and abduction. A right shoulder radiogram

shows osteopenia without evidence of joint erosion or osteophytes.

What is the most likely diagnosis?

A. Adhesive capsulitis

B. Avascular necrosis

C. Bicipital tendinitis

D. Osteoarthritis

E. Rotator cuff tea

Answer    A

Q 8 A 44-year-old woman presents for evaluation of dry

eyes and mouth. She first noticed these symptoms >5

years ago and the symptoms have worsened over time.

She describes her eyes as gritty-feeling, as if there were

sand in her eyes. Sometimes her eyes burn, and she states

that it is difficult to be outside in bright sunlight. In addition,

her mouth is quite dry. In her job, she is frequently

asked to give business presentations and finds it increasingly

difficult to complete a 30- to 60-minute presentation.

She usually has water with her at all times. Although

she reports good dental hygiene without any recent

changes, her dentist has had to place fillings twice in the

past 3 years for dental caries. Her only other past medical

history is treated tuberculosis that she contracted while in

the Peace Corp in Southeast Asia when in her twenties.

She takes no medication regularly and does not smoke.

Ocular examination reveals punctuate corneal ulcerations

on Rose Bengal stain, and the Schirmer test shows

<5 mm of wetness after 5 min. Her oral mucosa is dry

with thick mucous secretions, and the parotid glands are

enlarged bilaterally. Laboratory examination reveals positive

antibodies to Ro and La (SS-A and SS-B). In addition,

her chemistries reveal a sodium of 142 mEq/L,

potassium 2.6 mEq/L, chloride 115 mEq/L, and bicarbonate

of 15 mEq/L. What is the most likely cause of the

hypokalemia and acidemia in this patient?

A. Diarrhea

B. Distal (type I) renal tubular acidosis

C. Hypoaldosteronism

D. Purging with underlying anorexia nervosa

E. Renal compensation for chronic respiratory alkalosis

Answer  B

Q 9  A patient with end-stage renal disease on hemodialysis

presents to your office with hand pain and you diagnose

carpal tunnel syndrome. A serum thyroid-stimulating hormone

level is normal. You also note bilateral knee effusions, which the patient states have been there for many months.

Suspecting an amyloid deposition disease, you perform a fat

pad biopsy. Which protein do you expect to find on immunohistochemical

staining?

A. β2 -Microglobulin

B. Fibrinogen α-chain

C. Immunoglobulin light chain

D. Serum amyloid A

E. Transthyretin

Answer   A 

Q 10 A 41-year-old female presents to your clinic with 3

weeks of weakness, lethargy. and depressed mood. She

notes increasing difficulty with climbing steps, rising from

a chair, and combing her hair. She has no difficulty buttoning

her blouse or writing. The patient also notes some

dyspnea on exertion and orthopnea. She denies rash, joint

aches, or constitutional symptoms. She is on no medications,

and the past medical history is otherwise uninformative.

The family history is notable only for coronary

artery disease. The physical examination is notable for an

elevated jugular venous pressure, an S 3, and some bibasilar

crackles. The neurologic examination shows some marked

proximal muscle weakness in the deltoids and biceps and

the hip flexors. Distal muscle strength is normal. Sensory

examination and reflexes are normal. Laboratories are unremarkable

except for a negative antinuclear antibody

screen and a creatinine kinase of 3200 IU/L. You suspect a

diagnosis of polymyositis. All the following clinical conditions

may occur in polymyositis except

A. an increased incidence of malignancy

B. interstitial lung disease

C. dilated cardiomyopathy

D. dysphagia

E. Raynaud’s phenomenon

Answer   A