Internal Medicine Exam Rheumatology and Orthopedics 3 — Questions and Answers
Question 1: A 65-year-old woman on long-term prednisone for polymyalgia rheumatica develops vertebral compression fractures. Which medication should have been initiated at the start of corticosteroid therapy?
- Calcium and vitamin D only
- Calcium, vitamin D, and bisphosphonate (Correct answer)
- Teriparatide
- Denosumab
Correct answer: Calcium, vitamin D, and bisphosphonate
Current guidelines recommend calcium, vitamin D, and bisphosphonate prophylaxis for patients on chronic corticosteroid therapy to prevent glucocorticoid-induced osteoporosis.
Question 2: A 55-year-old woman presents with bilateral hand pain, Heberden's nodes at the DIP joints, and Bouchard's nodes at the PIP joints. X-ray shows joint space narrowing without erosions. What is the most likely diagnosis?
- Rheumatoid arthritis
- Psoriatic arthritis
- Osteoarthritis (Correct answer)
- Gout
Correct answer: Osteoarthritis
Osteoarthritis characteristically involves DIP joints with Heberden's nodes and PIP joints with Bouchard's nodes, with joint space narrowing but no erosions.
Question 3: A 40-year-old man with psoriasis develops asymmetric oligoarthritis with 'pencil-in-cup' deformity on X-ray. Which joint pattern is characteristic of this condition?
- Symmetric small joint involvement
- DIP joint arthritis with nail changes (Correct answer)
- Sacroiliitis only
- Large joint monoarthritis
Correct answer: DIP joint arthritis with nail changes
Psoriatic arthritis characteristically involves DIP joints with associated nail changes (pitting, onycholysis) and can show pencil-in-cup deformities on X-ray.
Question 4: A patient with Sjögren's syndrome develops peripheral neuropathy and purpura. Serum protein electrophoresis shows a monoclonal spike. Which complication should be suspected?
- Secondary amyloidosis
- Cryoglobulinemic vasculitis (Correct answer)
- Antiphospholipid syndrome
- Interstitial nephritis
Correct answer: Cryoglobulinemic vasculitis
Sjögren's syndrome is associated with type II cryoglobulinemia, which can present with purpura, peripheral neuropathy, and a monoclonal protein.
Question 5: A 72-year-old man presents with new severe headache, jaw claudication, and a tender, nodular temporal artery. ESR is 110 mm/hr. What is the most immediate concern requiring treatment?
- Stroke from carotid artery disease
- Permanent vision loss from ischemic optic neuropathy (Correct answer)
- Aortic aneurysm rupture
- Temporal artery aneurysm
Correct answer: Permanent vision loss from ischemic optic neuropathy
Giant cell arteritis can cause sudden, permanent vision loss due to anterior ischemic optic neuropathy, requiring immediate high-dose corticosteroid therapy.
Question 6: A 30-year-old woman with SLE develops worsening renal function, proteinuria of 3.5 g/day, and active urinary sediment. Renal biopsy shows diffuse proliferative glomerulonephritis. Which WHO/ISN class is this?
- Class II
- Class III
- Class IV (Correct answer)
- Class V
Correct answer: Class IV
ISN/RPS Class IV (diffuse proliferative) lupus nephritis is the most severe form, involving >50% of glomeruli and requiring aggressive immunosuppression.
Question 7: A 45-year-old woman presents with Raynaud's phenomenon, dysphagia, skin thickening of the fingers (sclerodactyly), and telangiectasias. Anti-centromere antibody is positive. What is the most likely diagnosis?
- Diffuse systemic sclerosis
- Limited cutaneous systemic sclerosis (CREST) (Correct answer)
- Mixed connective tissue disease
- Dermatomyositis
Correct answer: Limited cutaneous systemic sclerosis (CREST)
Anti-centromere antibody is strongly associated with limited cutaneous systemic sclerosis (CREST syndrome), which has a better prognosis than diffuse scleroderma.
Internal Medicine Exam Rheumatology and Orthopedics 3
A 65-year-old woman on long-term prednisone for polymyalgia rheumatica develops vertebral compression fractures.
Which medication should have been initiated at the start of corticosteroid therapy?