Internal Medicine Exam Rheumatology and Orthopedics 2 — Questions and Answers
Question 1: A 45-year-old woman presents with a butterfly-shaped facial rash, joint pain, and a positive anti-dsDNA antibody. Which complement levels would most likely be found during active disease flare?
- Elevated C3 and C4
- Decreased C3 and C4 (Correct answer)
- Normal C3 with elevated C4
- Elevated C3 with decreased C4
Correct answer: Decreased C3 and C4
In active SLE, complement is consumed by immune complex deposition, leading to decreased C3 and C4 levels.
Question 2: A 60-year-old man with gout has a serum uric acid of 9.8 mg/dL and has experienced 3 flares in the past year. Which medication is first-line for long-term urate-lowering therapy?
- Colchicine
- Indomethacin
- Allopurinol (Correct answer)
- Probenecid
Correct answer: Allopurinol
Allopurinol is the first-line urate-lowering therapy for gout, targeting a serum uric acid level below 6 mg/dL.
Question 3: A 35-year-old man with ankylosing spondylitis has failed NSAIDs. Which biologic class is most appropriate as next-line therapy?
- IL-6 inhibitors
- TNF-alpha inhibitors (Correct answer)
- IL-12/23 inhibitors
- CTLA-4 Ig fusion proteins
Correct answer: TNF-alpha inhibitors
TNF-alpha inhibitors (e.g., adalimumab, etanercept) are the recommended biologic class for ankylosing spondylitis refractory to NSAIDs.
Question 4: A 70-year-old woman presents with proximal muscle weakness, difficulty rising from a chair, and heliotrope rash. Which laboratory finding best confirms the diagnosis?
- Elevated ESR
- Elevated CK and positive anti-Jo-1 (Correct answer)
- Positive ANA
- Positive rheumatoid factor
Correct answer: Elevated CK and positive anti-Jo-1
Dermatomyositis presents with elevated creatine kinase and myositis-specific antibodies such as anti-Jo-1.
Question 5: A patient with rheumatoid arthritis on methotrexate develops a dry cough and progressive dyspnea. Chest CT shows interstitial infiltrates. What is the most likely diagnosis?
- Rheumatoid pleural effusion
- Methotrexate-induced pneumonitis (Correct answer)
- Pulmonary embolism
- Bacterial pneumonia
Correct answer: Methotrexate-induced pneumonitis
Methotrexate-induced pneumonitis is a serious hypersensitivity reaction presenting with cough, dyspnea, and interstitial infiltrates.
Question 6: A 50-year-old woman with osteoporosis and a T-score of -2.8 has been on oral bisphosphonate therapy for 5 years. Which rare adverse effect should be discussed at this point?
- Hypercalcemia
- Atypical femur fracture (Correct answer)
- Osteosarcoma
- Avascular necrosis of the hip
Correct answer: Atypical femur fracture
Atypical subtrochanteric femur fractures are a recognized rare complication of prolonged bisphosphonate therapy, typically after 5+ years.
Question 7: A 28-year-old man presents with urethritis, conjunctivitis, and asymmetric oligoarthritis after a recent Chlamydia infection. What is the classic triad associated with this condition?
- Arthritis, uveitis, aortic regurgitation
- Urethritis, conjunctivitis, arthritis (Correct answer)
- Rash, arthritis, fever
- Dactylitis, enthesitis, sacroiliitis
Correct answer: Urethritis, conjunctivitis, arthritis
Reactive arthritis (formerly Reiter's syndrome) classically presents with the triad of urethritis, conjunctivitis, and arthritis following genitourinary or GI infection.
Internal Medicine Exam Rheumatology and Orthopedics 2
A 45-year-old woman presents with a butterfly-shaped facial rash, joint pain, and a positive anti-dsDNA antibody.
Which complement levels would most likely be found during active disease flare?