Q 1 A 64-year-old man with congestive heart failure presents to the emergency room complaining of acute onset of severe pain in his right foot. The pain began during the night and awoke him from a deep sleep. He reports the pain to be so severe that he could not wear a shoe or sock to the hospital. His current medications are furosemide, 40 mg twice daily, carvedilol, 6.25 mg twice daily, candesartan, 8 mg once daily, and aspirin, 325 mg once daily. On examination, he is febrile to 38.5°C. The first toe of the right foot is erythematous and exquisitely tender to touch. There is significant swelling and effusion of the first metatarsophalangeal joint on the right. No other joints are affected. Which of the following findings would be expected on arthrocentesis?
A. Glucose level of <25 mg/dL
B. Positive Gram stain
C. Presence of strongly negatively birefringent needleshaped crystals under polarized light microscopy
D. Presence of weakly positively birefringent rhomboidal crystals under polarized light microscopy
E. White blood cell (WBC) count >100,000/ μL
Answer C
Q 2 A 32-year-old African-American woman presents to her primary care doctor complaining of fatigue, joint stiffness and pain, mouth ulcers, and hair loss. She first noticed fatigue about 6 months ago, and at that time, a complete blood count and thyroid function tests were normal. Since then, she feels like her symptoms are getting progressively worse. She now states that she sleeps ≥10 h but continues to feel fatigued. She has also developed joint stiffness and pain in her hands, wrists, and knees that is present for about 1 h upon awakening. For the past 1 month, she has had an area of hair loss on her scalp associated with a raised scaly rash. During this time, she intermittently developed painful mouth ulcerations that would spontaneously resolve. She also reports a severe “sunburn” on her face, upper neck, and back that occurred after <1 h of sun exposure and which was unusual for her. Her past medical history is positive for two spontaneous vaginal deliveries that were uncomplicated. She has not had any prior miscarriages. She is taking oral contraceptive pills and has no allergies. On physical examination, the vital signs are:
temperature 36.6°C,
blood pressure 136/82 mmHg,
heart rate 88 beats/min, respiratory rate 12 breaths/min,
Sa O2 98% on room air.
She has a circular raised area on her right parietal area that is 3 cm in diameter. This area has an atrophic center with hair loss and is erythematous with a hyperpigmented rim. Her conjunctiva are pink and no scleral icterus is present. The oropharynx shows a single 2-mm aphthous ulceration on the buccal mucosa. Both wrists show some slight tenderness with palpation and pain with range of motion. The patient is incapable of closing her hands tightly. In addition, there is warmth and a possible effusion in the right knee and tenderness with range of motion in the left knee. Cardiovascular, pulmonary, abdominal, and neurologic examinations are normal.
Laboratory studies show the following:
White blood cell count 2300/ μL
Hemoglobin 8.9 g/dL
Hematocrit 26.7%
Mean corpuscular volume 88 fL
Mean corpuscular hemoglobin count 32 g/dL
Platelet 98,000/mL
The differential is 80% polymorphonuclear cells, 12% lymphocytes, 7% monocytes, 1% eosinophils, and 1% basophils.
An antinuclear antibody (ANA) is positive at a titer of 1:640. Antibodies to double-stranded DNA are negative, and anti-Smith antibodies are positive at a titer of 1:160. The rheumatoid factor level is 37 IU/L.
What is the most likely diagnosis?
A. Behçet’s disease
B. Discoid lupus erythematosus
C. Rheumatoid arthritis
D. Sarcoidosis
E. Systemic lupus erythematosus
Answer E
Q 3 In this patient, which test should be performed next?
A. Chest radiograph
B. Echocardiogram
C. Electrocardiogram
D. Skin biopsy
E. Urinalysis
Answer E
Q 4 A 35-year-old female comes to the local health clinic because for the last 6 months she has had recurrent urticarial lesions, which occasionally leave a residual discoloration. She also has had arthralgias. The sedimentation rate now is 85 mm/h. The procedure most likely to yield the correct diagnosis in this case would be
A. a battery of wheal-and-flare allergy skin tests
B. measurement of total serum IgE concentration
C. measurement of C1 esterase inhibitor activity
D. skin biopsy
E. patch testing
Answer D
Q 5 A 45-year-old obese man presents to the clinic several weeks after starting a jogging regimen. He describes right-sided heel pain that has worsened over this time. The pain is worse in the morning and when the patient is barefoot. On examination, pain can be elicited with palpation of the inferior medial right heel. Which of the following is required to make a definitive diagnosis of plantar fasciitis?
A. Compatible history and provocative testing
B. History and physical examination alone
C. History, physical examination, and nuclear medicine bone scan
D. History, physical examination, and heel ultrasound showing thickening of the fascia
E. History, physical examination, and plain radiograph demonstrating heel spur
Answer B
Q 6 Which of the following findings on joint aspiration is most likely to be associated with calcium pyrophosphate deposition disease (pseudogout)?
A. Fluid, clear and viscous; white blood cell count, 400/μL; crystals, rhomboidal and weakly positively birefringent
B. Fluid, cloudy and watery; white blood cell count, 8000/μL; no crystals
C. Fluid, dark brown and viscous; white blood cell count, 1200/μL; crystals, needle-like and strongly negatively birefringent
D. Fluid, cloudy and watery; white blood cell count, 12,000/μL; crystals, needle-like and strongly negatively birefringent
E. Fluid, cloudy and watery; white blood cell count, 4800/μL; crystals, rhomboidal and weakly positively birefringent
Answer E
Q 7 A 45-year-old woman presents to the emergency room for evaluation of fatigue, fever, and acute onset of joint pain and swelling of the right knee, left ankle, and right second toe. She reports that she was ill with a diarrheal illness about 2 weeks ago. She did not seek evaluation as the symptoms resolved spontaneously over 48 h. She did lose about 2.3 kg, which she has been unable to regain. Three days ago, she developed a feeling of malaise with fevers and pain in her right second toe. Additional oints have become inflamed over the ensuing 72 h. She denies any prior similar episodes. She is not currently sexually active and estimates her last sexual activity to be 8 months prior to presentation. She has a history of seasonal rhinitis, but is taking no medications currently. On examination, she is febrile at 38.4°C. Her left eye has evidence of conjunctival injection. There is a superficial ulcer on the inside of her lower lip that is not painful. The right knee is warm to touch with an effusion. Passive movement results in pain. The left ankle is similarly warm and painful. The right second great toe has the appearance of a “sausage digit.” There is also pain with palpation at the tendinous insertion of both Achilles tendons. There are no genital ulcers or discharge. No rash is present. Arthrocentesis is performed and is consistent with inflammatory arthritis without crystals or organisms seen on Gram stain. Cervical probes for Neisseria gonorrhoeae and Chlamydia trachomatis are negative. Reactive arthritis following Campylobacter infection is suspected with positive serum antibodies to C. jejuni. Which of the following statements is true regarding this diagnosis?
A. Chronic joint symptoms affect 15% of individuals, and recurrences of the acute syndrome may occur.
B. Presence of HLA-B27 antigen predicts individuals who are likely to have a better prognosis.
C. Reactive arthritis is self-limited and should be expected to resolve spontaneously over the next 2 weeks.
D. The causative organism has no effect on long-term outcomes following an initial episode of reactive arthritis.
Answer. A
Q 8 A 54-year-old female with rheumatoid arthritis is treated with infliximab for refractory disease. All the following are potential side effects of this treatment except
A. demyelinating disorders
B. disseminated tuberculosis
C. exacerbation of congestive heart failure
D. pancytopenia
E. pulmonary fibros
Answer E
Q 9 A 26-year-old man presents with severe bilateral pain in his hands, ankles, knees, and elbows. He is recovering from a sore throat and has had recent fevers to 38.9°C. Social history is notable for recent unprotected receptive oral intercourse with a man ~1 week ago. Physical examination reveals a well-developed man in moderate discomfort. He is afebrile. His pharynx is erythematous with pustular exudates on his tonsils. He has tender anterior cervical lymphadenopathy. His cardiac examination is notable for a normal S 1 and S2 and a soft ejection murmur. His lungs are clear. Abdomen is benign with no organomegaly. He has no rash, and genital examination is normal. His bilateral proximal interphalangeal joints, metacarpophalangeal joints, wrists, ankles, and metatarsophalangeal joints are red, warm, and boggy with tenderness noted with both passive and active movement. A complete metabolic panel and complete blood count are all within normal limits. His erythrocyte sedimentation rate is 85 mm/h and C-reactive protein is 11 mg/dL. What is the most likely diagnosis?
A. Acute HIV infection
B. Acute rheumatic fever
C. Lyme disease
D. Neisseria gonorrhoeae infection
E. Poststreptococcal reactive arthritis
Answer E
Q 10 A 27-year-old female with SLE is in remission; current treatment consists of azathioprine 75 mg/d and prednisone 5 mg/d. Last year she had a life-threatening exacerbation of her disease. She now strongly desires to become pregnant. Which of the following is the least appropriate action to take?
A. Advise her that the risk of spontaneous abortion is high.
B. Warn her that exacerbations can occur in the first trimester and in the postpartum period.
C. Tell her it is unlikely that a newborn will have lupus.
D. Advise her that fetal loss rates are higher if anticardiolipin antibodies are detected in her serum.
E. Stop the prednisone just before she attempts to become pregnant.
Answer E
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