Rheumatology Quiz

A 52-year-old woman presents with a 6-month history of symmetrical pain and swelling affecting the MCP and PIP joints of both hands, associated with morning stiffness lasting over 60 minutes. Examination reveals tenderness of the MCP and PIP joints bilaterally, with no joint deformity. Blood tests show raised ESR and CRP. Rheumatoid factor and anti-CCP antibodies are positive. X-rays of the hands show no erosions. What is the most appropriate initial disease-modifying management?

• Start methotrexate with folic acid supplementation

• Start NSAIDs alone and await radiographic progression

• Start hydroxychloroquine only as symptoms are mild

• Start biologics immediately due to positive anti-CCP antibodies

A 68-year-old woman comes to her primary care doctor for evaluation of left knee pain. The symptoms began about half-a-year ago. She works as a supermarket cashier and reports that the pain is worse in the evening. Past medical history is notable for hypertension and atherosclerosis. Temperature is 37.2°C (99.0°F), blood pressure is 137/85 mmHg, and body mass index is 30 kg/m2. Physical examination is notable for crepitus and reduced range of motion in the left knee. No erythema or warmth is noted at the affected joint. Cardiac, pulmonary, and abdominal examinations are noncontributory. Which of the following is the next best step in the management of this patient?

• Referral for knee arthroplasty

• Initiation of ibuprofen therapy

• Perform intra-articular glucocorticoid injection

• Administration of methotrexate

A 48-year-old woman presented with a 2-month history of increasingly painful swelling behind her right knee, associated with intermittent low-grade fevers and fatigue. Over the past year, she has had occasional pain in her hands and wrists bilaterally. Examination shows a 3-cm nontender mass in the right popliteal fossa that becomes prominent when the knee is extended. There is mild swelling and redness of her right knee joint. Which of the following is the most likely diagnosis?

• Osteoarthritis

• Gout

• Rheumatoid arthritis

• SLE

Most specific antibody for rheumatoid arthritis is

• ANA

• Rheumatoid factor

• Anti CCP

• Anti dsDNA

A 42-year-old woman comes to the physician because of stiffness and pain in multiple joints. The patient says that the fingers on both of her hands have become increasingly stiff and difficult to move over the past 8 months. During this time, she has also noticed that her nails break easily and look spotty. One year ago, she had a urinary tract infection that was treated with antibiotics. Her only medication is occasional ibuprofen for chronic back pain. She is sexually active with 2 male partners and uses condoms inconsistently. Her vitals are within normal limits. There are multiple, well-demarcated red plaques with silvery-white scales over the shins and back. Serum studies show a negative rheumatoid factor and ANA. Which of the following is the most likely diagnosis?

• Psoriatic arthritis

• Rheumatoid arthritis

• Reactive arthritis

• Systemic lupus erythematosus

A 42-year-old Malay woman presents to your clinic with a 9-month history of gradually tightening skin over her fingers and forearms. She reports episodes of fingertips turning white then blue on exposure to cold, accompanied by numbness and tingling. Over the past 3 months, she has developed increasing difficulty swallowing solid food and a persistent heartburn, particularly at night. On examination, there is thickened, shiny skin over the hands with decreased range of motion in the fingers, and capillary change at the nail folds. Cardiovascular and respiratory examination is unremarkable. Investigation reveals: ANA positive with a centromere pattern, Renal function is normal. Esophageal manometry: low amplitude peristalsis in the lower two-thirds of the esophagus. High-resolution CT (HRCT) of the chest: early reticular changes at the lung bases. Which of the following is the most appropriate next step in management for this patient’s condition?

• Start high-dose oral corticosteroids and cyclophosphamide

• Begin calcium channel blocker and proton pump inhibitor therapy

• Initiate broad-spectrum antibiotics

• Observe and review in 6 months without intervention

A 62-year-old woman presents after sustaining a wrist fracture following a fall from standing height. She reached menopause at age 51. She has a history of rheumatoid arthritis for 12 years and has been taking oral prednisolone 10–15 mg daily for the past 5 years. She does not smoke or drink alcohol. On examination, she has a rounded face, supraclavicular fullness, proximal muscle weakness, and thinning of the skin with easy bruising.

Investigations show: Serum calcium: normal; serum phosphate: normal, alkaline phosphatase: normal, 25-hydroxyvitamin D: low, DEXA scan: T-score −2.9 (≥-1.0).

Which of the following is the most likely cause of this patient’s osteoporosis?

• Postmenopausal estrogen deficiency

• Vitamin D deficiency due to poor sun exposure

• Long-term glucocorticoid therapy

• Primary hyperparathyroidism

A 62-year-old man with stage 3 CKD presents with an acute gout attack for the 2nd time in 12 months. His serum uric acid is 590 umol/L. Which of the following is the most appropriate management strategy in this patient?

• Start allopurinol at 300mg.

• Delay allopurinol until the next gout flare

• Avoid allopurinol because chronic kidney disease is a contraindication

• Start allopurinol at 100mg after one month under the cover of colchicine.

A 42-year-old woman presents with progressive tightening of the skin over her fingers and face for the past 1 year. She also complains of cold-induced color changes in her fingers, dysphagia, and exertional dyspnea. On examination, she has sclerodactyly, digital pitting scars, and telangiectasia. Chest auscultation reveals fine bibasal crackles. Which of the following laboratory investigations is most specific for confirming the underlying diagnosis?

• Anti–double-stranded DNA antibodies

• Anti-centromere antibodies

• Rheumatoid factor

• Anti–cyclic citrullinated peptide antibodies

A 65-year-old man presents to his GP with a 3-day history of severe pain, swelling, and redness affecting his right wrist. The symptoms developed rapidly overnight after a dinner with friends where he consumed several glasses of wine. He has a past medical history of hypertension and type 2 diabetes. On examination, his right wrist is warm, erythematous, and exquisitely tender to touch with limited range of movement. His temperature is 37.8°C. Which radiological feature would be most consistent with the likely diagnosis?

• Periarticular osteopenia

• Joint space narrowing

• Juxta-articular erosions with overhanging edges

• Uniform joint space widening

• Subchondral cysts