Rheumatology (autoimmune diseases, arthritis) Practice Questions

Question 1

A 47-year-old woman comes to the physician because of body aches for the past 9 months. She also has stiffness of the shoulders and knees that is worse in the morning and tingling in the upper extremities. Examination shows marked tenderness over the posterior neck, bilateral mid trapezius, and medial aspect of the left knee. A complete blood count and erythrocyte sedimentation rate are within the reference ranges. Which of the following is the most likely diagnosis?

Accepted Answer

Fibromyalgia

Answer

Systemic lupus erythematosus

Answer

Rheumatoid arthritis

Answer

Polymyositis

Answer

Major depressive disorder

Question 2

A 71-year-old man presents to the clinic with complaints of right wrist pain for 2 days. On examination, redness and swelling were noted on the dorsal aspect of his right wrist. He had  pain with extreme range of motion of the wrist. His history includes 2 hip replacements, 2 previous episodes of gout in both first metatarsophalangeal joints, and hypertension. Two days later, the swelling had increased in the dorsal aspect of his right wrist and hand. Wrist flexion was limited to 80% with severe pain. The pain was present on palpation of the scaphoid bone. Due to the suspicion of fracture, the patient was referred to his general practitioner for radiographs. These findings were consistent with gouty arthritis. What is the most likely cytokine involved in this process?

Accepted Answer

IL-1

Answer

INFγ

Answer

IL-4

Answer

IL-10

Answer

IL-5

Question 3

A 32-year-old man presents to the clinic with a dull low back pain radiating to the buttocks. He first noted it about 2 years ago and it has progressed since then. He notes that it is worse in the morning and improves later in the day after physical activity. The patient also reports morning stiffness lasting up to 30 minutes and blurred vision, which started about 7 months ago. The patient's vital signs include: blood pressure 130/80 mm Hg, heart rate 88/min, respiratory rate 16/min, and temperature 36.8°C (98.2°F). Physical examination reveals tenderness over the sacroiliac joints and limitation of the lumbar spine movements in the sagittal plane. The patient's X-ray is shown in the picture below. Which of the following HLA variants is associated with this patient's condition?

Accepted Answer

HLA-B27

Answer

HLA-DQ2

Answer

HLA-DR3

Answer

HLA-B47

Answer

HLA-DR4

Question 4

A previously healthy 13-year-old girl is brought to the physician for evaluation of a 2-month history of fatigue. She reports recurrent episodes of pain in her right wrist and left knee. During this period, she has had a 4-kg (8.8-lb) weight loss. Her mother has rheumatoid arthritis. Her temperature is 38°C (100.4°F). Examination shows diffuse lymphadenopathy. Oral examination shows several painless oral ulcers. The right wrist and the left knee are swollen and tender. Laboratory studies show a hemoglobin concentration of 9.8 g/dL, a leukocyte count of 2,000/mm3, and a platelet count of 75,000/mm3. Urinalysis shows excessive protein. This patient's condition is associated with which of the following laboratory findings?

Accepted Answer

Anti-dsDNA antibodies

Answer

Anti-citrullinated peptide antibodies

Answer

Leukocytoclastic vasculitis with IgA and C3 immune complex deposition

Answer

Positive HLA-B27 test

Answer

Excessive lymphoblasts

Question 5

A 39-year-old woman comes to the physician because of progressive pain and swelling of her wrists and hands for the past 2 months. Her hands are stiff in the morning; the stiffness decreases as she starts her chores. She also reports early-morning neck pain at rest for the past 3 weeks. She has no history of serious illness and takes no medications. Her sister has systemic lupus erythematosus. Vital signs are within normal limits. Examination shows bilateral swelling and tenderness of the wrists, second, third, and fourth metacarpophalangeal joints; range of motion is limited by pain. There is no vertebral tenderness. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Laboratory studies show:
Hemoglobin 12.8 g/dL
Leukocyte count 9,800/mm3
Erythrocyte sedimentation rate 44 mm/h
Serum
Glucose 77 mg/dL
Creatinine 1.1 mg/dL
Total bilirubin 0.7 mg/dL
Alkaline phosphatase 33 U/L
AST 14 U/L
ALT 13 U/L
Rheumatoid factor positive
Which of the following is the most appropriate next step in management?

Accepted Answer

Measurement of anti-CCP antibodies

Answer

Adalimumab

Answer

CT scan of the chest

Answer

X-ray of the cervical spine

Answer

Measurement of anti-Smith antibodies

Question 6

A 45-year-old woman presents to the clinic with a variety of complaints on different areas of her body, including telangiectasias on both the upper and lower extremities, bluish discoloration of the fingertips when exposed to cold, and burning midsternal chest pain. She is a tobacco smoker and works as a school teacher. After evaluation, an anti-centromere antibody test is ordered, and returns with an elevated titer. Which of the following symptoms are least likely to be seen in this patient's condition?

Accepted Answer

Erythematous periorbital rash

Answer

Gastroesophageal reflux

Answer

Spasm of blood vessels in response to cold or stress

Answer

Thickening and tightening of the skin on the fingers

Answer

Dysphagia

Question 7

An 11-year-old boy presents with fever and joint pain for the last 3 days. His mother says that he had a sore throat 3 weeks ago but did not seek medical care at that time. The family immigrated from the Middle East 3 years ago. The patient has no past medical history. The current illness started with a fever and a swollen right knee that was very painful. The following day, his knee improved but his left elbow became swollen and painful. While in the waiting room, his left knee is also becoming swollen and painful. Vital signs include: temperature 38.7°C (101.6°F), and blood pressure 110/80 mm Hg. On physical examination, the affected joints are swollen and very tender to touch, and there are circular areas of redness on his back and left forearm (as shown in the image). Which of the following is needed to establish a diagnosis of acute rheumatic fever in this patient?

Accepted Answer

Positive anti-streptococcal serology

Answer

Elevated erythrocyte sedimentation rate (ESR)

Answer

Elevated leukocyte count

Answer

No other criterion is needed to establish the diagnosis of acute rheumatic fever

Answer

Prolonged PR interval

Question 8

A 51-year-old woman comes to the physician because of fatigue and progressive pain and stiffness in her hands for 3 months. She used to play tennis but stopped 1 month ago because of difficulties holding the racket and her skin becoming “very sensitive to sunlight.” Her last menstrual period was 1 year ago. She has diabetes mellitus controlled with insulin. She does not smoke or drink alcohol. Vital signs are within normal limits. The patient appears tanned. The second and third metacarpophalangeal joints of both hands are tender to palpation and range of motion is limited. Which of the following is the most appropriate next step in diagnosis?

Accepted Answer

Iron studies

Answer

Synovial fluid analysis

Answer

Testing for parvovirus B19 antibodies

Answer

Testing for rheumatoid factors

Answer

Testing for anti-nuclear antibodies

Question 9

A 34-year-old man with a 2-year history of rheumatoid arthritis is being evaluated on a follow-up visit. He is currently on methotrexate and celecoxib for pain management and has shown a good response until now. However, on this visit, he mentions that the morning stiffness has been getting progressively worse. On physical examination, both his wrists are erythematous and swollen, nodules on his elbows are also noted. Rheumatoid factor is 30 (normal reference values: < 15 IU/mL), ESR is 50 mm/h, anti-citrullinated protein antibodies is 55 (normal reference values: < 20). What is the next best step in the management of this patient?

Accepted Answer

Methotrexate and Infliximab

Answer

Sulfasalazine

Answer

Adalimumab monotherapy

Answer

Methotrexate and Corticosteroids

Answer

Infliximab monotherapy

Question 10

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

Accepted Answer

"Can you tell me more about the symptoms you have been experiencing?"

Answer

"Does the diarrhea typically precede the constipation, or vice-versa?"

Answer

"Is the diarrhea foul-smelling?"

Answer

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

Answer

"Are the symptoms worse in the morning or at night?"

Rheumatology (autoimmune diseases, arthritis)

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Rheumatoid arthritis

Seronegative spondyloarthropathies

Systemic lupus erythematosus

Systemic sclerosis (scleroderma)

Inflammatory myopathies

Sjögren's syndrome

Vasculitides classification

Large vessel vasculitis

Medium vessel vasculitis

Small vessel vasculitis

Crystal arthropathies (gout, pseudogout)

Osteoarthritis

DMARDs and biologic therapies

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About Rheumatology (autoimmune diseases, arthritis) for USMLE

Lessons in Rheumatology (autoimmune diseases, arthritis)

Master Rheumatology (autoimmune diseases, arthritis)