Internal Medicine Exam Rheumatology and Orthopedics 4 — Questions and Answers
Question 1: A 25-year-old woman presents with recurrent miscarriages, livedo reticularis, and a prolonged aPTT that does not correct with mixing study. Which antibody panel should be ordered?
- Anti-dsDNA and anti-Smith
- Anticardiolipin and anti-beta-2 glycoprotein I (Correct answer)
- Anti-Ro/SSA and anti-La/SSB
- Anti-SCL-70 and anti-centromere
Correct answer: Anticardiolipin and anti-beta-2 glycoprotein I
Antiphospholipid syndrome presents with thrombosis and/or recurrent pregnancy loss with positive anticardiolipin or anti-beta-2 glycoprotein I antibodies and lupus anticoagulant.
Question 2: A 68-year-old man develops acute monoarthritis of the knee with septic joint appearance. Arthrocentesis reveals positively birefringent, rhomboid-shaped crystals. What is the diagnosis?
- Gout
- Pseudogout (CPPD) (Correct answer)
- Septic arthritis
- Calcium oxalate arthropathy
Correct answer: Pseudogout (CPPD)
Pseudogout (calcium pyrophosphate deposition disease) is characterized by positively birefringent, rhomboid-shaped crystals, in contrast to the negatively birefringent needle-shaped crystals of gout.
Question 3: A patient with RA on hydroxychloroquine for 5 years needs monitoring for which specific adverse effect?
- Hepatotoxicity
- Retinal toxicity (Correct answer)
- Pulmonary fibrosis
- Nephrotoxicity
Correct answer: Retinal toxicity
Hydroxychloroquine can cause irreversible retinal toxicity (bull's eye maculopathy), requiring annual ophthalmologic screening after 5 years of use.
Question 4: A 55-year-old woman with RA develops a painful, hot knee joint while on methotrexate. What must be excluded before attributing the flare to RA?
- Crystal arthropathy
- Septic arthritis (Correct answer)
- Avascular necrosis
- Hemarthrosis
Correct answer: Septic arthritis
Septic arthritis must be urgently excluded in any immunosuppressed patient with an acute hot joint, as it is a surgical emergency requiring prompt joint aspiration and culture.
Question 5: A 35-year-old woman presents with bilateral knee pain and swelling, erythema nodosum on her shins, and bilateral hilar adenopathy on chest X-ray. Which rheumatologic diagnosis fits this picture?
- Reactive arthritis
- Löfgren's syndrome (acute sarcoidosis) (Correct answer)
- Rheumatic fever
- Behçet's disease
Correct answer: Löfgren's syndrome (acute sarcoidosis)
Löfgren's syndrome is an acute form of sarcoidosis presenting with the triad of erythema nodosum, bilateral hilar adenopathy, and periarthritis, typically carrying a good prognosis.
Question 6: A 70-year-old woman with known osteoporosis sustains a vertebral compression fracture. She is unable to tolerate bisphosphonates. Which agent builds new bone rather than preventing its resorption?
- Denosumab
- Raloxifene
- Teriparatide (Correct answer)
- Calcitonin
Correct answer: Teriparatide
Teriparatide (PTH 1-34) is an anabolic agent that stimulates osteoblast activity to build new bone, unlike antiresorptive agents which prevent bone breakdown.
Question 7: A 50-year-old man with diffuse systemic sclerosis develops acute hypertensive crisis with creatinine rising from 1.0 to 3.5 mg/dL over days. What is the treatment of choice?
- Calcium channel blockers
- ACE inhibitors (Correct answer)
- Angiotensin receptor blockers
- Hydralazine
Correct answer: ACE inhibitors
Scleroderma renal crisis is treated with ACE inhibitors (preferably captopril), which have dramatically improved outcomes even in the setting of acute kidney injury.
Internal Medicine Exam Rheumatology and Orthopedics 4
A 25-year-old woman presents with recurrent miscarriages, livedo reticularis, and a prolonged aPTT that does not correct with mixing study.
Which antibody panel should be ordered?