Internal Medicine Exam Common Rheumatologic Disorders 3 — Questions and Answers
Question 1: A 52-year-old woman presents with proximal muscle weakness, heliotrope rash, and Gottron's papules. CK is 4,500 U/L. Which malignancy screening is most important within the first year of diagnosis?
- Brain MRI
- Ovarian cancer screening with CA-125 and transvaginal ultrasound (Correct answer)
- Colonoscopy only
- Chest X-ray only
Correct answer: Ovarian cancer screening with CA-125 and transvaginal ultrasound
Dermatomyositis has the strongest cancer association, and ovarian cancer is one of the most commonly linked malignancies requiring active screening.
Question 2: A patient with diffuse systemic sclerosis develops dyspnea and a dry cough. PFTs show a restrictive pattern with reduced DLCO. CT chest shows bilateral basilar ground-glass opacities and honeycombing. What is the first-line treatment?
- Cyclophosphamide or mycophenolate mofetil (Correct answer)
- High-dose prednisone alone
- Rituximab
- Azathioprine
Correct answer: Cyclophosphamide or mycophenolate mofetil
Interstitial lung disease in systemic sclerosis is treated with cyclophosphamide or mycophenolate mofetil as first-line immunosuppressive agents.
Question 3: A 40-year-old woman with antiphospholipid syndrome has a second DVT despite therapeutic warfarin (INR 2.5). What is the recommended next step?
- Switch to rivaroxaban
- Increase warfarin target INR to 3.0-4.0 (Correct answer)
- Add aspirin 81mg to current warfarin dose
- Switch to fondaparinux
Correct answer: Increase warfarin target INR to 3.0-4.0
Patients with APS who have recurrent thrombosis despite standard anticoagulation should have the warfarin target INR raised to 3.0-4.0.
Question 4: A 65-year-old man presents with symmetric proximal muscle pain and stiffness, elevated ESR of 95 mm/hr, and normal CK. He responds dramatically to prednisone 15mg/day within 48 hours. What is the most concerning complication to monitor for?
- Renal failure
- Giant cell arteritis with visual loss (Correct answer)
- Peripheral neuropathy
- Cardiomyopathy
Correct answer: Giant cell arteritis with visual loss
Polymyalgia rheumatica is associated with giant cell (temporal) arteritis in 10-15% of cases, and vision loss from anterior ischemic optic neuropathy is a devastating complication.
Question 5: A 28-year-old man presents with urethritis, asymmetric oligoarthritis, conjunctivitis, and oral ulcers 3 weeks after a chlamydial infection. What is the classic triad of reactive arthritis?
- Arthritis, uveitis, and oral ulcers
- Urethritis, arthritis, and conjunctivitis (Correct answer)
- Arthritis, psoriasis, and iritis
- Diarrhea, arthritis, and sacroiliitis
Correct answer: Urethritis, arthritis, and conjunctivitis
Reactive arthritis (formerly Reiter's syndrome) classically presents with the triad of urethritis, arthritis, and conjunctivitis following a triggering infection.
Question 6: A patient with SLE is started on hydroxychloroquine. Which baseline test is mandatory before initiating therapy?
- Liver biopsy
- Ophthalmologic examination (Correct answer)
- Audiometry
- Pulmonary function tests
Correct answer: Ophthalmologic examination
Hydroxychloroquine can cause irreversible retinal toxicity, so a baseline ophthalmologic exam with retinal imaging is required before starting therapy.
Question 7: A 70-year-old woman presents with acute wrist arthritis, chondrocalcinosis on X-ray, and positively birefringent rhomboid crystals in synovial fluid under polarized light. Which metabolic condition is most strongly associated with CPPD disease?
- Hyperuricemia
- Hyperparathyroidism (Correct answer)
- Hypothyroidism only
- Hemochromatosis only
Correct answer: Hyperparathyroidism
Hyperparathyroidism causes hypercalcemia and hypophosphatemia, which predispose to calcium pyrophosphate crystal deposition (CPPD) disease.
Internal Medicine Exam Common Rheumatologic Disorders 3
A 52-year-old woman presents with proximal muscle weakness, heliotrope rash, and Gottron's papules.
CK is 4,500 U/L.
Which malignancy screening is most important within the first year of diagnosis?