1.

A 39-year-old woman presents to the outpatient clinic with pain and stiffness in her hands
and wrists for the past 6 weeks. She is diagnosed with rheumatoid arthritis, although there
is no evidence of erosion on x-ray. Which of the following is the management of choice
at this time?
A. NSAID alone
B. NSAID and corticosteroids
C. Corticosteroids alone
D. Corticosteroids and methotrexate
Answer: A

2. A 24-year-old woman is recently diagnosed with systemic lupus erythematosus. Which of

the following would be appropriate counseling at the time of diagnosis?
A. The disease does not have a cure
B. The patient should use sunscreen whenever outdoors to avoid flareups
C. The patient has a higher than normal chance of spontaneous abortion if she becomes pregnant
D. Prognosis is based on the severity and evolution of the disease
E. All of the above
Answer: E

3. Which of the following is a major risk for osteoarthritis?

A. Onset at early age
B. Male gender
C. Long-term steroid use
D. Low BMI
E. Trauma
Answer: E

4. A 67-year-old woman with history of RA for many years presents with right shoulder
pain and swelling for 2 days. She has low-grade fever. Examination reveals decreased
passive and active range of motion of the right shoulder joint, as well as erythema. She
asks you if this is related to an RA flare and if she should start steroids to decrease the
pain.
The first step would be to do an arthrocentesis.

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 5. A 55-year-old man comes to the outpatient clinic complaining of right toe pain for the
past 8 hours. He is diagnosed with acute gouty arthritis. Which of the following is the
recommended drug for this patient?
A. Allopurinol
B. Indomethacin
C. Corticosteroids
D. Methotrexate
Answer: B

6. A 59-year-old woman with RA, under reasonable control with methotrexate, develops a
hot, swollen, red knee. Joint aspiration removes 10 cc of an opaque yellow-colored fluid
with a white count of 100,000/μL, predominantly neutrophils. The joint fluid protein is
high and glucose is much lower than in the blood. Which of the following is the most
likely diagnosis?

(A) uric acid deposition

(B) CPPD deposition

(C) septic arthritis

(D) reactivation of RA

(E) calcium hydroxyapatite deposition

7. A 59-year-old woman with RA, under reasonable control with methotrexate, develops a
hot, swollen, red knee. Joint aspiration removes 10 cc of an opaque yellow-colored fluid
with a white count of 100,000/μL, predominantly neutrophils. The joint fluid protein is
high and glucose is much lower than in the blood. Which of the following is the most
likely diagnosis?

(A) uric acid deposition

(B) CPPD deposition

(C) septic arthritis

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(D) reactivation of RA

(E) calcium hydroxyapatite deposition

8. the most likely organism to cause septic arthritis in the case above is

a. Streptococcus pneumoniae

b. Neisseria gonorrhea

c. Escherichia coli

d. Staphylococcus aureus

9. . A 70-year-old, non–sexually active male complains of fever and pain in his left knee.
Several days previously, the patient skinned his knee while working in his garage. The
knee is red, warm, and swollen. An arthocentesis is performed, which shows 200,000
leukocytes/μL and a glucose of 20 mg/dL. No crystals are noted. The most important next
step is

a. Gram stain and culture of joint fluid

b. Urethral culture

c. Uric acid level

d. Antinuclear antibody

10. A 64-year-old man comes to you for the evaluation of knee pain. He tells you that he has
had right knee pain for many years but recently it has gotten worse. He denies
constitutional symptoms and other joint pain except for his left second and third DIPs. He
has not noticed stiffness in the morning. On examination you hear crepitations as you
move his right knee, but otherwise there is no evidence of swelling, warmth, or erythema
of the knee. Laboratory testing is unremarkable.

1-What are some of the characteristic changes that affect the articular cartilage in patients with
OA?

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2-What are four characteristic radiographic findings encountered in patients with OA?

3-Discuss the nonpharmacologic management of OA?

4-Discuss the pharmacologic options for the treatment of OA?

 OA results in cartilage loss with secondary thickening of the subchondral bone and
formation of osteophytes.
 Radiographic findings typically encountered in patients with OA include loss of joint
space, cysts in subchondral bone, subchondral sclerosis or eburnation, and osteophytes
(bony spurs) at the joint margins.
 Nonpharmacologic modalities helpful in the management of OA consist of patient
education, heat or cold application, weight reduction, physical therapy that focuses on
muscle-strengthening exercises.
 Acetaminophen, an analgesic, should be the first-line therapy for OA. If this is
unsuccessful, NSAIDs can be used. Narcotic analgesics should be considered in patients
with refractory pain. Topical application of capsaicin cream or intraarticular injection of
hyaluronate or corticosteroids may be beneficial in some patients
11. A 43-year-old woman has been bothered by a chronic, dry cough for the past 5 years.
She has had increasing difficulty with blurred vision for the past year. On physical
examination, she has a perforated nasal septum, bilateral mild corneal scarring, and oral
cavity fissuring of the tongue and corners of her mouth. Laboratory studies show
antibodies to SS-A and SS-B. The serum creatinine is 2.5 mg/dL, and the urea nitrogen is
25 mg/dL. A renal biopsy specimen examined microscopically shows tubulointerstitial
nephritis. Which of the following is the most serious condition likely to complicate the
course of her disease?

A) Chronic renal failure

(B) Endocarditis

(C)  Non-Hodgkin lymphoma

(D) Photosensitivity

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 (E) Sclerodactyly

(F)  Subcutaneous nodules

(G) Urethritis

12. For the past 6 weeks, a 52-year-old woman has had bilateral diffuse pain in her thighs
and shoulders. She has difficulty rising from a chair and climbing steps. She has a rash
with a violaceous color around the orbits and on the skin of her knuckles. On physical
examination, she is afebrile. Muscle strength is 4/5 in all extremities. Laboratory studies
show serum creatine kinase of 753 U/L, and the ANA test result is positive with a titer of
1 : 160. Which of the following tests is most specific for the diagnosis of this patient's
underlying condition?

(A) Anti–double-stranded DNA antibodies

(B) Rheumatoid factor

(C) Anti–U1-ribonucleoprotein antibodies

(D) Antihistone antibodies

(E) Anti-Jo-1 antibodies

13. A 60-year-old man presents with complaints of a swollen left big toe for 3 days. This has
never happened before. He has a negative past medical history. Examination shows a
large swollen left big toe. This is likely to be acute gouty arthritis. Of the following
agents, which would not be useful in the treatment of acute gouty arthritis?

A. Oral colchicine

B. Indomethacin

C. Allopurinol

D. Oral steroid

E. Intraarticular steroids

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 14. A 50-year-old man presents with swelling in his left knee for 3 days. The knee is painful
and he cannot ambulate well. He denies history of trauma to the knee. An aspirate of the
knee is done and shows crystals with weakly positive birefringence on compensated
polarized light microscopy. Based on the findings, which of the following is the most
likely etiology?

A. Rheumatoid arthritis

B. Gout

C. Infection with a crystal-producing organism

D. Osteoarthritis

E. Pseudogout

15. A 70-year-old woman presents to accident and emergency with sudden onset pain and
swelling in the right knee. Her past medical history includes hypertension and
hypercholesterolaemia. She is currently taking aspirin, ramipril and simvastatin. On
examination, she is apyrexial and the right knee is swollen. There is reduced range of
movement in the knee due to swelling and pain. X-ray of the right knee shows
chondrocalcinosis. What is the most likely diagnosis?

A. Gout

B. Pseudo-gout

C. Septic arthritis

D. Reactive arthritis

E. Osteoarthritis

16. A 9-year-old girl with no past medical history presents with the acute onset of fever,
arthralgias, abdominal pain, hematochezia, and hematuria. Physical examination reveals
purpura on the patient’s lower extremities bilaterally. Which of the following is the most
likely diagnosis?

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 a. Cryoglobulinemia

b. Kawasaki’s disease

c. Wegener’s granulomatosis

d. Goodpasture’s disease

e. Henoch-Schönlein purpura

17. A 54-year-old woman presents to her family physician because of a left temporal headache and
diminished vision in the left eye. Upon physical examination, the patient is febrile with
tenderness over the left temple. A CT scan of the head does not reveal any abnormalities. Which
of the following is the best next step in management of this patient?

A. Obtain an erythrocyte sedimentation rate (ESR)

B. Make the diagnosis of a migraine headache and treat appropriately

C. Perform a biopsy of the temporal artery

D. Start the patient on a course of steroids

18. . A 52-year-old man has been seen several times in the past several months by his family
physician for recurrent episodes of sinusitis. However, over the past few weeks, he has developed
increasing shortness of breath with exertion,and in the past 24 hours,has had blood in his urine as
well as experiencing nausea and vomiting. Physical examination reveals a blood pressure of
165/95 mm Hg (he was previously always normotensive), and a urine dipstick of proteinuria
(2+).Which of the following is the most likely diagnosis?

A. Goodpasture syndrome

B. Wegener granulomatosis

C. Membranous glomerulonephropathy

D. Undiagnosed diabetes mellitus

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