Rheum 2 practice

Question 1

A 40 year old woman has been experiencing bilateral morning stiffness and joint pain in her hands, feet, and neck for the past 8 weeks. On PE, you note Bouchard’s nodes at her PIP, but Heberden’s nodes are absent. What should be at the top of your differentials list?

a) Reactive arthritis
b) Rheumatoid arthritis (RA)
c) Osteoarthritis (OA)
d) SLE

Answer 1

b) Rheumatoid arthritis (RA)

Question 2

On XR of the above patient, you should expect to see what findings?
a) Joint erosions (esp. of the ulnar styloid), and severe joint space narrowing
b) New bone formation, “pencil and cup appearance”
c) None of the above
d) All of the above

Answer 2

c) None of the above

(XR is normally normal in the first 6 months; A is what you’ll see later, and B is describing psoriatic arthritis)

Question 3

What is a part of the triad of Felty Syndrome (a very rare condition)? Select three
a) RA
b) OA
c) Splenomegaly
d) Hepatomegaly
e) Leukopenia
f) Neutropenia

Answer 3

a) RA
c) Splenomegaly
f) Neutropenia

Question 4

What 2 things are present in 70-80% of pts with RA? Select two
a) Anti-Histone Antibodies
b) Anti-Smith Antibodies
c) Anti-CCP antibodies
d) Rheumatoid Factor (RF)
e) HLA-B27

Answer 4

c) Anti-CCP antibodies
d) Rheumatoid Factor (RF)

Question 5

You are about to diagnose a patient with RA, but you know you need to do arthrocentesis to rule out a potentially superimposed condition first. What is that condition?
a) SLE
b) Osteoarthritis
c) Reactive arthritis
d) Septic arthritis

Answer 5

d) Septic arthritis

Question 6

What is the most common DMARD combo for treating RA patients?
a) Methotrexate and a TNF inhibitor
b) Sulfasalazine and Hydroxychloroquine
c) Hydroxychloroquine and a TNF inhibitor

Answer 6

a) Methotrexate and a TNF inhibitor

(TNF inhibitor example = infliximab)

Question 7

What hepatotoxic and teratogenic medication needs to be taken with a folic acid supplement?
a) Hydroxychloroquine
b) Methotrexate
c) Tofacitinib (Xeljanz)
d) Adalimumab (Humira)

Answer 7

b) Methotrexate

Question 8

_____________ monotherapy is reserved for pts with very mild RA and is contraindicated in G6PD, while _______________ is reserved for refractory severe disease
a) Leflunomide; Janus kinase inhibitors
b) Hydroxychloroquine; Janus kinase inhibitors
c) Hydroxychloroquine; Sulfasalazine

Answer 8

b) Hydroxychloroquine; Janus kinase inhibitors

(Janus kinase inhibitors end in -nib)

Question 9

What is the second-line treatment for RA?
a) Methotrexate
b) Leflunomide
c) Sulfasalazine
d) IL-6 blockers

Answer 9

c) Sulfasalazine

Question 10

Which is NOT one of the 3 major subtypes of Juvenile Idiopathic Arthritis (JIA)?
a) Systemic
b) Oligoarticular
c) Polyarticular
d) Monoarticular

Answer 10

d) Monoarticular

Question 11

Which is NOT one of the major presenting features of systemic JIA?
a) Fever
b) Arthritis
c) Rash
d) Lymphadenopathy
e) Splenomegaly

Answer 11

e) Splenomegaly

Question 12

Arthritis in what 3 areas are the most typical of JIA? Select three
a) Hands
b) Wrists
c) Knees
d) Ankles
e) Feet
f) Back

Answer 12

b) Wrists
c) Knees
d) Ankles

(important; she said to know this slide well)

Question 13

Which is incorrect about JIA?
a) Pts may have a prolonged interval b/t the onset of systemic symptoms and appearance of arthritis
b) Systemic JIA often begins in the hips
c) Micrognathia and cervical auto fusions may occur due to TMJ and spine arthritis
d) Macular, slightly raised, pink salmon rashes most commonly occur post-fever

Answer 13

d) Macular, slightly raised, pink salmon rashes most commonly occur post-fever

(rashes are most common during fever)

Question 14

A 4 y/o pt is experiencing daily intermittent fevers, rashes, and uveitis and iridocyclitis. You suspect JIA. What test(s) can be done to definitively diagnose JIA?
a) ANA and RF
b) CBC to show leukocytosis and thrombocytosis
c) ANA + ESR/CRP
d) CBC + Ferratin
e) None of the above

Answer 14

e) None of the above

(there is no definitive test, but all of the above may be present)

Question 15

What is the first line Tx for mild cases of JIA?
a) NSAIDs
b) Acetaminophen
c) Low-dose steroids
d) DMARDs
e) Topical lidocaine

Answer 15

a) NSAIDs

Question 16

What is a part of the common triad of reactive arthritis? Select three
a) Conjunctivitis
b) Uveitis
c) Urethritis
d) Asymmetric arthritis
e) Balanitis
f) Fever

Answer 16

a) Conjunctivitis
c) Urethritis
d) Asymmetric arthritis

(but all those other Sx can occur)

Question 17

A pt has been diagnosed with reactive arthritis. They know they had an STI 3 weeks ago, but can’t remember which one. Which STI is the most classically associated with reactive arthritis?
a) Syphilis
b) Hep B
c) Gonorrhea
d) Chlamydia

Answer 17

d) Chlamydia

(1-4 weeks after infection)

Question 18

What is incorrect about reactive arthritis?

a) HLA-B27 positive in 80% of patients
b) On joint aspiration, fluid will have >50% neutrophils, and show an increase in WBC (1K-8K) but be culture-negative (aseptic)
c) Gonococcal septic arthritis is a common subtype
d) It can occur after a GI infection
e) Joint fluid will be yellow and may be translucent or opaque

Answer 18

c) Gonococcal septic arthritis is a common subtype

(this is a separate condition; its arthrocentesis will be likely be culture-positive and WBC much higher (>50K))

Question 19

What is the mainstay of Tx for reactive arthritis?
a) NSAIDs
b) Acetaminophen
c) Low-dose steroids
d) DMARDs
e) Anti-TNF agents

Answer 19

a) NSAIDs

Question 20

What is Polyarteritis Nodosa (PAN)?
a) An inflammatory arteritis of small vessels
b) An auto-antibody arteritis of large vessels
c) An auto-antibody arteritis that causes nodes
d) A necrotizing arteritis of medium sized vessels

Answer 20

d) A necrotizing arteritis of medium sized vessels

Question 21

What is a common cause of PAN?
a) Syphilis
b) Hep B
c) Gonorrhea
d )Chlamydia

Answer 21

b) Hep B

Question 22

Which is NOT a symptom of PAN?
a) Fever
b) Pain in the extremities
c) Post-prandial abd pain
d) Livedo reticularis
e) Pleuritis
f) HTN

Answer 22

e) Pleuritis

(the lungs are spared)

Question 23

What is correct about PAN? Select all that apply

a) Angiography is the gold standard of diagnosis
b) Tissue biopsy is the gold standard of diagnosis
c) Pts are ANCA-positive
d) Adding cyclophosphamide to Tx lowers risk of death and morbidity in those with severe disease
e) Treatment for all pts is short course of prednisone, anti-HBV therapy, and then plasmapheresis

Answer 23

b) Tissue biopsy is the gold standard of diagnosis
d) Adding cyclophosphamide to Tx lowers risk of death and morbidity in those with severe disease

(E is only correct if HBV positive)

Question 24

Which is caused by polymyalgia rheumatica (PMR)?
a) Synovitis
b) Bursitis
c) Tenosynovitis
d) All of the above

Answer 24

d) All of the above

Question 25

A 55 y/o pt has hip/pelvic and shoulder girdle pain with no other explanation. They are not experiencing weakness. What condition is this describing? a) GCA b) PMR c) PAN d) RA e) Polymyositis

Answer 25

b) PMR

Question 26

Which of the following can be treated with prednisone? Select all that apply a) PMR b) GCA c) Polymyositis d) PAN

Answer 26

a) PMR b) GCA c) Polymyositis

Question 27

A pt has proximal limb, neck, and pharynx weakness. They are not experiencing any pain, but they have a dusky red rash in malar distribution. What condition is this describing? a) GCA b) PMR c) PAN d) RA e) Polymyositis

Answer 27

e) Polymyositis

Question 28

Which are S/Sxs of dermatomyositis? Select all that apply a) Malar rash b) Shawl sign c) Gottron’s papules d) Heberden’s nodes e) Heliotrope rash

Answer 28

a) Malar rash b) Shawl sign c) Gottron’s papules e) Heliotrope rash (dermatomyositis is seen in polymyositis)

Question 29

What lab findings were mentioned to be seen with polymyositis? a) Elevated ESR/ CRP b) Anemia of chronic disease and leukocytosis c) Increased serum aldolase and creatine kinase d) All of the above

Answer 29

c) Increased serum aldolase and creatine kinase (ESR/CRP are normal)

Question 30

Which polymyositis antibody is the myositis specific antibody & is associated with “mechanic hands” and interstitial lung fibrosis? a) Anti-Jo 1 Ab b) Anti-SRP Ab c) Anti-Mi-2 Ab

Answer 30

a) Anti-Jo 1 Ab (Anti-Mi-2 Ab is specific for dermatomyositis)

Question 31

Muscle biopsy is the gold standard to diagnose what? a) Polymyalgia Rheumatica (PMR) b) Polymyositis c) Both of the above

Answer 31

b) Polymyositis

Question 32

Which is incorrect about psoriatic arthritis? a) Considered “seronegative” b) + HLA-B27 is associated with psoriatic arthritis with spinal involvement c) Serum uric acid level may be elevated d) DMARDs are effective for axial spondylarthritis

Answer 32

d) DMARDs are effective for axial spondylarthritis (they’re considered ineffective, use IL-17 and IL-23 inhibitor for moderate-severe axial disease)

Question 33

What is the DMARD of choice for RA? How often is it taken? (important)

Answer 33

Methotrexate; once a week

Question 34

What is the triad of reactive arthritis? (important)

Answer 34

Conjunctivitis Urethritis Arthritis

Question 35

Which has a 10% 5-year survival rate without treatment? a) PAN b) Polymyositis c) RA d) Reactive arthritis (important)

Answer 35

a) PAN

Question 36

Pencil-in-cup appearance is indicative of?

Answer 36

Psoriatic arthritis (important)