B4E1 - Practice Exam
A 52-year-old man complains of bilateral knee pain for about 1 year. He is noted to have a body mass index of 40 kg/m2. Which of the following is the best therapy? A. Allopurinol B. Ibuprofen C. Methotrexate D. Intravenous ceftriaxone E. Oral glucocorticoids
B
A 56-year-old woman is prescribed oral hydrocodone 10 mg to use every 4 hours as needed after total knee replacement. She uses 6 doses per day. What is the equivalent daily dose of oral morphine? A. 30 mg oral morphine per day B. 60 mg oral morphine per day C. 90 mg oral morphine per day D. 120 mg oral morphine per day
B
A 61-year-old male patient has 5-6 painful gouty attacks every year despite being treated with febuxostat. He is highly allergic to probenecid. Which of the following would be the best course of treatment for this patient? A. NSAIDs at maximal doses B. Pegloticase C. Sulfinpyrazone D. Allopurinol
B
Which of the following interventions is not indicated in the treatment of fibromyalgia pain? A. Moderate aerobic exercise B. Gabapentin C. Steroid injections to trigger points D. Patient education
C
A 48-year-old man is diagnosed with gout. Allopurinol is useful in treating gout because of which of the following property? A. It increases the catabolism of uric acid. B. It increases the degradation of uric acid. C. It decreases the production of uric acid. D. It increases renal excretion of uric acid.
C
Which of the following muscles is NOT a part of the rotator cuff? A. Supraspinatus B. Infraspinatus C. Subscapularis D. Teres major E. Teres minor
D
In general, all of the following are risk factors for gout EXCEPT: A. Tobacco use B. Alcohol use C. Obesity D. Diuretic use E. Family history
A
Which of the following is true regarding the prognosis of PMR? A. PMR is associated with an increased risk of mortality B. Most patients with PMR will require corticosteroid therapy for life C. Up to 50% of patients who initially have a successful remission will experience a relapse while tapering prednisone D. A relapse of PMR requires high-dose corticosteroids (prednisone 50 mg daily) for successful treatment
C
Which of the following lab values has a high sensitivity and specificity for rheumatoid arthritis (RA)? A. Rheumatoid factor B. Antinuclear antibody (ANA) C. Anti-cyclic citrullinated peptides (anti-CCP) D. Erythrocyte sedimentation rate (ESR)
C
Which portion of the biceps is most commonly involved in ruptures? A. Distal tendon B. Proximal short head tendon C. Proximal long head tendon D. Midmuscle belly E. Proximal short head belly
C
You decide this patient has a rupture of the long head of the biceps tendon. How is this injury treated initially? A. Immediate surgical repair B. Delayed surgical repair C. Immobilization for 4 to 6 weeks with sling D. NSAIDs and physical therapy E. Biceps muscle transplant, preferably from a retired NFL player
D
A 45-year-old female hospital clerk presents with bilateral aching pain in the forearms and thenar eminences. The pain is made worse with driving and typing. She also has intermittent numbness over the same areas. She tried to ignore the symptoms, but today she dropped her coffee mug on her computer keyboard and became alarmed at her loss of strength. She has hypothyroidism and is obese, but she reports that her health is otherwise good. Based on the history alone, which of the following is the most likely diagnosis? A. Carpal tunnel syndrome B. Osteoarthritis C. Ulnar neuropathy D. Diabetic neuropathy E. Stroke
A
A 58-year-old male presents after sudden onset of right upper arm pain. He was working in the yard, cutting and pulling out some bushes, when he heard a "snap" and felt the pain. He has a history of rotator cuff tendinosis and osteoarthritis. You should look for all of the following on physical examination EXCEPT: A. A positive elevated arm stress test ("Roos" test) B. A palpable biceps muscle defect C. Normal grip strength D. An asymmetric bulge in the affected arm
A
A 3-year-old boy is brought into the pediatric neurologist's office because of progressive weakness of the past 3 months. The mother says the child has been clumsy lately and has had trouble walking up the hill of the playground. The delivery and developmental history are normal. On examination, the height and weight are in the 50th and 55th percentiles, respectively. The patient has weakness in his proximal muscles, legs more than arms, and needs to use his hands to push himself up to an upright position. The calves appear large. The serum creatine kinase (CK) level is elevated. In addition to skeletal muscle involvement in these patients, which of the following is most likely affected? A. Cardiac muscle B. Esophagus C. Small intestine D. Large intestine E. Urinary bladder
A
A 43-year-old female presents with body aches and stiffness, which are worse in the morning. She further describes a low-grade fever and pain in her hands, feet, and left knee. She feels that her grip strength is diminished. These symptoms started rather abruptly 2 weeks ago and have not responded to acetaminophen. She frequently camps with her family. She remembers that 1 week they could not go because her 8-year-old daughter had a fever, mild diarrhea, abdominal pain, and a skin rash ("legs, arms, and especially face were red and warm, and she seemed 'flushed' all the time"). Her daughter's symptoms resolved in a few days, she did not see a doctor, and no one else was sick. She has no other illnesses, and review of systems is otherwise negative. On PE, her vitals are normal. She is unable to close her hands completely. Although the PE is somewhat limited by pain, there appears to be swelling of all metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, as well as mild erythema over the MCP joints bilaterally. In addition, upon examination of the left knee, the bulge sign (indicating effusion) is detected. If found on physical examination, which of the following would be LEAST useful in helping you in narrowing your diagnosis? A. Bilateral metatarsophalangeal (MTP) joint swelling and tenderness B. Painless oral ulcerations, with clean edges C. Firm, slightly tender subcutaneous nodules at the olecranon bursae D. A "bull's eye" rash in the right axilla E. Icterus and tender hepatomegaly
A
A 62-year-old male who you have followed for hypertension for several years presents with complaints of worsening fatigue and aching in his back, shoulders, and neck. He notes 3 months of symptoms unresponsive to acetaminophen. Further history reveals that your patient has experienced stiffness of the neck and shoulders each morning for over 30 minutes. He occasionally has difficulty getting out of bed due to pain. Vital signs are within normal limits. There is no evidence of synovitis of the hands, wrists, or elbows. Active range of motion in the neck and shoulders is slow but full. There is tenderness to palpation of the shoulders, upper back, and neck, but no apparent muscle atrophy. Which of the following is the most appropriate next step in the diagnosis of this illness? A. Obtain an ESR and CRP B. Obtain a urinalysis C. Prescribe a diagnostic trial of corticosteroids D. Order a rheumatology panel, including ANA, uric acid, ESR, CRP, and RF E. Perform shoulder radiograph
A
Adhesive capsulitis is most commonly associated with which of the following? A. Diabetes B. Hyperthyroidism C. Spondyloarthritis D. Nondominant arm E. Male gender
A
All of the following are side effects of allopurinol EXCEPT: A. Aseptic meningitis B. Rash C. Leukopenia D. Fever E. GI disturbance
A
All of the following diseases and conditions are secondary causes of osteoarthritis EXCEPT: A. Fibromyalgia B. Hemochromatosis C. Hyperparathyroidism D. Amyloidosis E. Previous joint trauma
A
Based on history and physical examination, you diagnose a rotator cuff tendinosis. Appropriate initial management of y 65-year-old male should be: A. Acetaminophen and physical therapy B. Oral corticosteroids and physical therapy C. Subacromial injection with corticosteroid and physical therapy D. Surgical repair and physical therapy E. Figure-of-eight strap
A
In drug-related lupus, you expect to see all of the following EXCEPT: A. Negative ANA B. Rapid resolution of symptoms after discontinuing the drug C. Polyarthralgia D. Negative anti-dsDNA E. Low-grade fever
A
Plain film radiographs, from your patient you highly suspect has a scaphoid fracture, including AP and lateral of the hand and wrist as well as scaphoid views, are negative for fracture. What is the most appropriate next step for this patient? A. Short-arm thumb spica cast with follow-up in 10 to 14 days B. NSAIDs, ice, compression, and elevation followed by physical therapy C. MRI or CT to rule out an occult fracture D. Orthopedic referral E. Return to play within the week
A
The next patient in the ED is an 18-year-old high school football player. He was playing in a football game this evening when he was tackled from the side and landed directly on the lateral aspect of his right shoulder. He states that he can actively move his arm, but is limited by pain on the top of his shoulder. He has also noticed a small painful bump on top of the right shoulder and is concerned that he "broke his collarbone." Based on the mechanism of injury and patient history, the most likely injury would be? A. Acromioclavicular (AC) sprain B. Biceps tendon rupture C. Glenohumeral dislocation D. Rotator cuff tear E. Scapula fracture
A
What is the most common injury pattern for an acute traumatic injury in a child with open growth plates? A. Fracture through the open growth plate B. Ligament sprain C. Muscle strain D. Tendon strain
A
Which of the following is NOT an appropriate medication for treating fibromyalgia-type pain? A. Hydrocodone/acetaminophen B. Gabapentin or pregabalin C. Amitriptyline D. Duloxetine E. Combination duloxetine and pregabalin
A
Which of the following is not a risk factor for gout? A. Depression B. Congestive heart failure C. Diabetes D. Chronic kidney disease
A
Which of the following is the advantage of specific cyclooxygenase-2 (COX-2) inhibitors? A. Decreased GI side effects B. Decreased vasoconstrictor activity C. Increased anti-inflammatory activity D. Increased inhibition of platelet aggregation
A
Which of the following medications should be used as first-line therapy for mild neuropathic pain? A. Gabapentin B. Tramadol C. Oxycodone D. Levetiracetam
A
Which of the following muscles is the most commonly torn in the rotator cuff? A. Supraspinatus B. Infraspinatus C. Subscapularis D. Teres minor
A
You send the patient for x-rays. AP radiographs showslightwidening of the AC joint on the injured side. The examination and radiograph confirm your suspicion of an AC injury. For a patient with an AC sprain, you offer: A. Sling for comfort, ice, and NSAIDs or analgesics for pain control B. Referral for open fixation C. Figure-of-eight strap for 4 to 6 weeks D. Corticosteroid injection followed by physical therapy E. Manual reduction, then sling-and-swath immobilization for 6 to 8 weeks
A
A 12-year-old boy is diagnosed with an upper brachial plexus injury after falling from a tree. He presents with his right upper arm lying limp at his side because of loss of abduction. Which of the following muscles are primarily responsible for abduction of the arm at the shoulder? A. Deltoid and biceps brachii B. Deltoid and supraspinatus C. Deltoid and infraspinatus D. Supraspinatus and infraspinatus E. Coracobrachialis and supraspinatus
B
A 24-year-old male presents to the clinic 2 days after a collision during a softball game in which he fell on his outstretched right hand ("But I made the play!" he exclaims). He reports he could not continue playing and that his pain has not improved. He has some general edema around the right wrist, poor grip strength secondary to pain, point tenderness over the radial aspect of the wrist ("snuff box tenderness"), and decreased ROM. There is no obvious deformity, and he is neurovascularly intact. Of the following, what would be the most likely diagnosis for this patient? A. Colles fracture B. Scaphoid fracture C. Smith fracture D. Extensor carpi radialis strain E. Scapholunate sprain
B
A 32-year-old woman is 32 weeks pregnant and is a known carrier for Duchenne muscular dystrophy (DMD). She asks what the ramifications are for her unborn child. Which of the following statements is most accurate? A. About 25% of her daughters will be affected with the disease. B. About 50% of her daughters will be carriers. C. About 75% of her sons will be affected with the disease. D. All of sons will either be carriers or inherit the disease.
B
A 76-year-old patient with locally invasive bladder cancer presents with nausea and vomiting for the past 24 hours. He has been unable to take his home morphine regimen and is having severe abdominal pain. He uses immediate-release morphine 15 mg every 4 hours as needed for pain and takes a total of 60 mg of oral morphine per day. Oral morphine 60 mg is equivalent to how much intravenous morphine? A. 10 mg intravenous morphine B. 20 mg intravenous morphine C. 60 mg intravenous morphine D. 120 mg intravenous morphine
B
A mother returns now with her 2-year-old daughter who is refusing to move her right arm. Earlier today she threw a tantrum at the store when her father refused to buy her the new "princess toy" (advertising hits them young). Dad was holding on to her arm when she flopped to the floor. She immediately began crying and refusing to move her right arm. In the office, she is well but holds her right arm adducted, flexed, and pronated. (The princess toy is in the other hand. Guilt is a powerful weapon.) Despite every trick you know, you can't get her to move that arm. You inspect and palpate the entire extremity and clavicle and find no crepitus, swelling, or tenderness. What is your next diagnostic step? A. Obtain an x-ray of the elbow B. Actively supinate the forearm and flex the elbow while applying pressure over the radial head C. Actively twist the forearm at the elbow 360 degrees D. Consult orthopedics E. Perform a skeletal survey, mostly to bide time
B
Compared with RA, osteoarthritis has a greater predilection for which of the following joints? A. MCPs B. DIPs C. Knees D. Wrists
B
Lumbar spine x-rays show squaring of the vertebral bodies. Pelvic x-rays identify mild symmetric sacroiliitis. You are now confident of the diagnosis of ankylosing spondylitis. Which of the following management plans is best for this patient? A. Aspirin 650 mg by mouth four times daily (or Zorprin or other extended-release aspirin twice daily) and physical therapy referral B. Naproxen 500 mg twice daily and physical therapy referral C. Orthopedic referral for early surgical consideration D. Prednisone 40 mg daily and fitting for a back brace E. Naproxen 500 mg twice daily and fitting for a back brace
B
On forward bending test, you find slight elevation of the left paravertebral muscles mass, which you estimate to be 7 degrees. The remainder of the examination is normal. You decide to obtain radiographs that show 12 degrees of angulation (Cobb angle). This patient's scoliosis is most likely: A. Congenital B. Idiopathic C. Related to a tumor D. Secondary to infection E. Secondary to demonic possession
B
Once again, your fabled diagnostic and therapeutic abilities have earned you a well-deserved referral. Your previous patient is so pleased with the way things are going that she refers her sister-in-law to you. The sister-in-law is 46 years old and reports having been diagnosed with fibromyalgia several months ago. She reports having all-over pain, all the time, which has been worsening for the last 5 years. "Great," you think to yourself, "Thanks for the referral." She takes only acetaminophen and codeine as needed for pain (she typically needs it four times per day). She does not exercise because it hurts too much. She drinks 2 liters of Mountain Dew a day, from sun-up to sundown. Her sleep is reported as poor and nonrestorative. Which of the following statements is true regarding management of fibromyalgia? A. Fibromyalgia pain is increased during exercise, so exercise should be avoided B. Regular low-impact exercise, and nonpharmacologic measures to improve sleep are more effective than medications for improving fibromyalgia-type pain C. SNRI agents such as duloxetine and milnacipran lead to rapid and long-term remission of fibromyalgia-type pain D. Both NSAIDs and prednisone are helpful in reducing fibromyalgia pain E. Opioids act on the central nervous system, which is why they are the most effective agents for treatment of fibromyalgia pain
B
Over the next year, your patient does very well. She establishes care with a rheumatologist and is in remission when she sees you next. She is interested in becoming pregnant and wishes to seek your advice prior to trying to conceive. ("Start a college fund early," you say. "Oh, that's not what you meant?") Fortunately, she has been able to discontinue prednisone and continues to tolerate hydroxychloroquine. With regard to pregnancy and SLE, your patient is at higher risk for all of the following EXCEPT: A. Premature birth B. Infertility C. Intrauterine fetal demise D. Spontaneous abortion
B
Painful, swollen metatarsophalangeal great toe (unilateral) with redness and warmth after eating a steak and shrimp dinner in a 45-year-old man A. Gonococcal arthritis B. Gout C. Pseudogout D. Osteoarthritis
B
Since your patient is taking methotrexate, you caution her to avoid which of the following? A. Aspirin B. Sulfonamide antibiotics C. Ibuprofen D. Folate E. Penicillin antibiotics
B
The most appropriate initial management plan for a patient with 12 degrees Cobb Angle includes: A. Bracing B. Observation C. Physical therapy D. Surgery E. Any of the above are equally appropriate initial management plans
B
The sensitivity of an elevated ESR in the diagnosis of PMR and giant cell arteritis (GCA) is: A. 100% B. 85% C. 50% D. 25%
B
What is the most common cause of cervical radiculopathy? A. Spinal tumors B. Osteoarthritis C. Vertebral fracture D. Fibromyalgia
B
Which of the following imaging modalities should be used to assess for rotator cuff tears? A. Anteroposterior x-ray of the shoulder B. MRI of the shoulder without contrast C. CT scan of the shoulder with contrast D. Axillary x-ray of the shoulder
B
Which of the following medications should be used for first-line therapy for mild osteoarthritis pain? A. Gabapentin B. Acetaminophen C. Hydrocodone D. Amitriptyline
B
Which of the following methods is the most sensitive for detecting scoliosis? A. Observe the patient from the front with a loose-fitting shirt on; measure the difference in shoulder height B. Observe the patient from behind, with shirt off, while he bends forward at the waist; look for elevation of the ribs or paravertebral muscle mass on one side C. Observe the patient from the front, with shirt off, while he bends forward at the waist; look for elevation of the ribs or paravertebral muscle mass on one side D. Observe the patient from the side, with shirt off, while he bends forward at the waist; look for elevation of the ribs or paravertebral muscle mass on one side
B
Which of the following should be considered in the treatment of mild osteoarthritis? A. Oral opioids B. Weight loss and physical activity C. Intra-articular steroid injection D. Joint replacemen
B
You order radiographs of the neck, which demonstrate mild degenerative disease. A CBC is unremarkable, except for a mild thrombocytosis. The ESR is 80 mm/hr. You relate these findings to the patient and tell him that your presumptive diagnosis is PMR. Which of the following is the most appropriate initial treatment in this case? A. Naproxen 500 mg twice daily B. Prednisone 15 mg daily C. Aspirin 650 mg twice daily D. Prednisone 50 mg daily E. Referral to physical therapy
B
Your patient returns with a painful, swollen left knee, and she wants to do something about it. You also discuss the following laboratory test results: WBC 5,100 cells/mm3, Hgb 11.0 g/dL, platelets 309,000 cells/mm3; BUN 10 mg/dL, creatinine 1.0 mg/dL; ESR 77 mm/hr; ANA 1:1,280 with a nucleolar pattern; urinalysis +1 protein, otherwise negative; urine microscopic examination shows no RBCs or casts; chest x-ray shows no cardiomegaly and normal lung fields; ECG shows normal sinus rhythm. You believe that your patient has SLE. Which of the following management plans do you suggest to the patient? A. Start ibuprofen 600 mg by mouth three times daily and refer to a rheumatologist (3-6 month wait—sheesh, they are busy) B. Start prednisone 20 mg by mouth daily and hydroxychloroquine 400 mg by mouth daily, schedule for follow-up in 1 month, and refer to a rheumatologist (3-6 month wait) C. Start methotrexate 10 mg by mouth weekly, prednisone 60 mg by mouth daily, and hydroxychloroquine 400 mg by mouth daily, and schedule follow-up in 1 month D. Start prednisone 60 mg by mouth daily and refer to a rheumatologist (3-6 month wait) E. Start ibuprofen 600 mg by mouth daily and adopt a "watchful waiting" approach with follow-up in 6 months
B
A 26-year-old man presents with a fever, dysuria, and left knee pain of 3 days' duration. He reports being sexually active with a new partner as recently as 2 weeks ago. On physical examination, his temperature is 102 °F. His left knee is erythematous, warm, swollen, and tender. He denies a previous history of arthritis. Which of the following is the next best step? A. Complete blood count with differential B. X-ray of the knee C. Aspiration of synovial fluid D. Serum uric acid level
C
A 35-year-old man with hypertension presents with the sudden onset of right big toe pain. He denies trauma of the foot. On examination, he is noted to have a swollen, red, and tender base of the right great toe. Which of the following is the best treatment for the probable condition? A. Ibuprofen B. Methotrexate C. Colchicine D. Intravenous antibiotics
C
A 36-year-old woman is being seen by her physician in the office due to pain in her hands, wrists, and knees that has progressed over the past 6 months. She has tried over-the-counter ibuprofen without relief. Which of the following treatments will reduce joint inflammation and slow progression of this patient's disease? A. NSAIDs B. Joint aspiration C. Methotrexate D. Systemic corticosteroids
C
A 40-year-old man presents to primary care clinic one week after a motor vehicle collision in which he was rear-ended at a red light. He is unsure how fast the other car was going. He has diffuse cervical neck tenderness, decreased range of motion, and intermittent paresthesias of his hands bilaterally. What is the initial imaging modality that should be obtained to evaluate his neck pain? A. MRI B. CT scan C. Anteroposterior, lateral, and odontoid x-rays D. He does not need imaging
C
A 44-year-old man is suffering from recurrent gouty arthritis. His serum uric acid level is elevated, and you prescribe allopurinol. Within 1 week of the allopurinol, he develops a painful episode that "feels like gout." Which of the following is the best explanation? A. The patient is resistant to the allopurinol and should be placed on another medication. B. The patient likely has an arthritis syndrome produced by allopurinol and should have an antinuclear antibody (ANA) drawn. C. The patient likely developed acute gout as a result of mobilization of the urate from joints and tissues. D. This likely represents a drug-drug interaction, and so the allopurinol should be discontinued.
C
A 46-year-old man presents with an acute burn to his right hand. He is in severe pain and has not taken opioids in the past. He is given a dose of intravenous morphine 2 mg. How long is the duration of analgesia of intravenous morphine? A. 15 to 20 minutes B. 60 to 90 minutes C. 3 to 6 hours D. 8 to 12 hours
C
A 72-year-old woman presents with acute upper back pain and was found to have a compression fracture of T10. She is in severe pain and has not taken opioids in the past. She is given a dose of oral morphine 5 mg. How long is the duration of analgesia of oral morphine? A. 30 to 60 minutes B. 2 to 3 hours C. 4 to 7 hours D. 10 to 12 hours
C
A long-term patient with RA presents to your clinic for follow-up. She has been on treatment for several years, but she does have some chronic changes in her hands. You expect to find which of the following radiographic changes in her hands? A. Pencil-in-cup deformities B. Osteophyte formation C. Marginal erosions D. Syndesmophytes
C
All of the following are expected findings in patients with primary Raynaud phenomenon EXCEPT: A. Symmetric involvement of the hands B. Well-demarcated cyanosis C. Digital ulcerations D. Normal ESR
C
Colchicine is especially useful in treating an acute attack of gout because it achieves which of the following? A. Decreases uric acid deposition B. Is potent anti-inflammatory agent C. Impairs leukocyte migration D. Increases the solubility of uric acid
C
It is 9 years later. Your favorite gout patient is back. He's had 9 years of acute intermittent gout attacks ("Of course I took my medication, Doc, but it didn't work so I stopped taking it"). He presents complaining of pain in his knees and feet that has been present for several months. He has also developed swelling and pain in his hands. The pain is less intense than his attacks of gout, but occurs in the same areas and never completely resolves between attacks. He has no morning stiffness, no muscle complaints, and no other systemic complaints. You find diffuse edema of both hands and palpable hard nodules on the knees, fingers, toes, and in the olecranon bursa. Which of the following is the most likely cause of his current symptoms? A. RA B. Osteoarthritis C. Tophaceous gout D. PMR
C
Symmetric bilateral ulnar deviation of both hands in a 42-year-old woman A. Gout B. Osteoarthritis C. Rheumatoid arthritis D. Systemic lupus erythematosus
C
What is the first-line treatment for mild chronic shoulder pain caused by osteoarthritis? A. Injection of triamcinolone with lidocaine into the shoulder joint B. Hydrocodone C. Acetaminophen D. Oral corticosteroids
C
What is the maximal acceptable angulation and rotation for a boxer fracture, fourth or fifth metacarpal, to maintain full hand function? A. 10 degrees of dorsal angulation and 10 degrees of rotation B. 30 degrees of dorsal angulation and 5 degrees of rotation C. 40 degrees of dorsal angulation and 0 degrees of rotation D. 90 degrees of dorsal angulation and 0 degrees of rotation
C
What is the most appropriate initial treatment for carpal tunnel syndrome? A. Thumb spica splint B. Steroid injection C. NSAIDs and neutral position wrist splints D. Short-arm casts E. Bilateral figure-of-eight splints
C
What is the most common nerve root affected by cervical radiculopathy? A. C5 B. C6 C. C7 D. T1
C
Which of the following drugs used to treat lupus is associated with macular damage, corneal opacities, and ciliary muscle dysfunction? A. Azathioprine B. Prednisone C. Hydroxychloroquine D. Cyclophosphamide E. Methotrexate
C
Your patient, who was diagnosed with Primary Reynaud's, returns 10 months later with new complaints. Both hands are swollen, stiff, and painful. She complains of multiple joint aches and fatigue despite sleeping well. Her appetite is normal, and she has no GI complaints. Although she has no rash, she complains of itchy hands (surely a sign of cancer, she thinks). On examination, you note that there is diffuse, nonpitting edema on her fingers and hands. She has difficulty making a fist. She has no skin findings. Her CBC is normal. Her ANA is strongly positive with a nucleolar pattern. Which of the following is the most likely explanation of these findings and the most appropriate provisional diagnosis? A. Raynaud phenomenon B. RA C. Scleroderma D. CREST syndrome E. Osteoarthritis
C
A 17-year-old male presents to your office with a history of low-back pain worsening over the past few months. He recalls having intermittent back pain for at least a year. The pain does not radiate. He runs cross-country and track without exacerbating his back pain. He denies fevers, weight loss, weakness, incontinence, and history of trauma. He is unaware of any family history of back pain. He is otherwise healthy. What further information will help you differentiate between potential causes of his back pain? A. Relief with acetaminophen B. Morning stiffness C. Relief with rest D. A and C E. B or C
E
Which of the following medications should be used as first-line therapy for the treatment of mild osteoarthritis pain in a patient with chronic kidney disease? A. NSAIDs B. Intra-articular corticosteroid injections C. Oral opioids D. Acetaminophen
D
Your 55yo patient with HTN on a thiazide comes in complaining of severe left knee pain. The knee is erythematous and warm, with some tenderness. The patient is febrile. You successfully aspirate 5 cc of slightly cloudy yellow synovial fluid from the left knee. While the patient is waiting, the laboratory reports the following findings: 5,000 WBC/mm3, Gram stain negative for bacteria, and many needle-shaped negatively birefringent crystals. These synovial fluid findings are most consistent with which of the following diagnoses? A. Osteoarthritis B. Septic arthritis C. CPPD ("pseudogout") D. Gout
D
Your patient is worried that he broke his "collarbone." If he did sustain a nondisplaced clavicle fracture, which of the following would be appropriate treatment? A. Rest, ice, and NSAIDs for pain control B. A sling for comfort only C. A figure-of-eight splint D. A and B E. Any of the above is an equally valid treatment
D
A 24-year-old female is hospitalized with a kidney stone and pyelonephritis. She is started on appropriate intravenous antibiotics and fluid therapy. She has no allergies and has never had opioids in the past. Her weight is 48 kg. Her colicky pain is rated at 7 to 8 out of 10 in severity at admission, with significant nausea and occasional vomiting. She has not passed the stone. What is/are reasonable analgesic option(s)? A. Fentanyl transdermal 12 μg/h patch every 3 days B. Acetaminophen 1000 mg orally every 8 hours as needed C. Naloxone 0.4 mg IV every 8 hours as needed D. Hydromorphone 0.6 mg IV every 3 hours as needed
D
A 44-year-old woman has a 5-month history of malaise and stiff hands in the morning that improve as the day goes by. She notes that both hands are involved at the wrists. Initial laboratory tests show an elevated ESR and high positive anti-CCP. Which of the following treatments is most likely to lead to the best long-term disease outcome for this patient? A. Allopurinol B. Ibuprofen C. Naproxen D. Methotrexate E. Intravenous ceftriaxone
D
A 45-year-old female with a history of rheumatoid arthritis, on chronic low-dose prednisone, presents to your clinic with 2 days of right knee pain. The patient reports that her knee has been swollen and painful to touch, and she now is having difficulty bearing weight due to the pain. She has had previous knee pain, but nothing this severe. She denies any trauma, fevers, chills, knee surgery, illegal drug use, or risky sexual behavior. On examination, she is well appearing, afebrile, and has a moderate right knee effusion with limited ROM. There is no overlying erythema, but the knee feels warm to touch. Which of the following diagnostics is the most valuable to rule in or rule out the diagnosis with the highest potential morbidity? A. Plain films of the affected knee B. WBC count C. ESR D. Arthrocentesis E. MRI
D
Your patient with newly diagnosed RA returns in 4 weeks and is now about 7 weeks into her illness. She reports a moderate response to your intervention (you started methotrexate 15 mg weekly with 1 mg folic acid daily and prednisone 20 mg daily), but now she has 1 to 2 hours of morning stiffness. She continues to complain of pain in her hands and feet, with poor grip. In fact, she had to take time off from work during the last week. On examination, she has persistent swelling of MCPs 2 to 5 bilaterally and MTPs 3 and 4 bilaterally. You also note swelling in the left wrist and both knees, but tenderness is reduced and there is no erythema. You are now reconsidering your diagnosis. Did you miss something? What examination finding is so general that it would NOT help you support/reconsider your diagnosis? A. Pleural rub auscultated on lung examination B. Firm, slightly tender subcutaneous nodules at the olecranon bursae C. Faint pink rash over chest, which is not visible 15 minutes later D. Reduced passive flexion in left knee E. Left foot drop
D
A 55-year-old male presents to your office complaining of severe left knee pain of 2 days duration. Although he was also out partying over the weekend (is there a pattern here to the patients in our practice?), he went home early (say, 2 or 3 o'clock). He denies any previous history of knee pain or arthritis. He has felt feverish over the last 2 days. He recalls a similar episode of pain in his right great toe 2 years before, but the pain resolved in a few days and he did not seek medical attention. He has hypertension treated with chlorthalidone but is otherwise healthy. He drinks about a case of beer per week—unless he's been partying, in which case he doubles his effort. His family history is remarkable for osteoarthritis. Physical examination reveals an uncomfortable-appearing obese male in no acute distress. His temperature is 37.9°C, blood pressure 168/98 mm Hg, and pulse 84 bpm. The left knee is red, warm, and diffusely tender with a palpable effusion. There are no visible or palpable subcutaneous nodules on the fingers, toes, or at the elbows. Which of the following is the most appropriate next step to accurately diagnose this condition? A. Radiograph of the affected knee B. CBC C. Serum uric acid level D. Knee aspiration and synovial fluid analysis E. Diagnostic corticosteroid injection
D
A Colles fracture consists of: A. Fractures of the midshaft of the radius and ulna B. Fractures of the head of radius and ulna that is displaced dorsally and is angulated C. Fractures of the head of the radius and ulna that are displaced ventrally and is angulated D. Fracture of the distal radius at the metaphysis, dorsally displaced and often angulated
D
Citing your characteristic compassion and attention to detail, your "gout guy" (as he now calls himself) refers a friend he met at a meeting of his favorite club, Gouty Retirees in Love with Life ("GRILL"). This friend of his is a 65-year-old female who reports a history of joint swelling, pain, and redness, usually involving her knees, wrists, and hands; she has never had first MTP joint involvement. Although she has never had a joint aspiration performed, she has been treated for gout for 5 years. She faithfully takes her medication but has found allopurinol unhelpful. She is currently asymptomatic but uses ibuprofen for acute attacks. The joint examination is notable only for some knee crepitus and reduced wrist range of motion—but, again, she is currently asymptomatic. Which of the following studies is most appropriate for this patient? A. Diagnostic knee injection with corticosteroids B. CBC C. RF D. Radiographs of the knees and wrists
D
Injury to the lateral cord of the brachial plexus will also injure its continuation, the musculocutaneous nerve. Which of the following findings would you observe in a patient with this injury? A. Weakness of abduction of the arm at the shoulder B. Weakness of adduction of the arm at the shoulder C. Weakness of extension of the forearm at the elbow D. Weakness of flexion of the forearm at the elbow E. Weakness of supination of the forearm and hand
D
On further questioning, your patient 17yo who came in with low back pain, reports morning stiffness and pain that improves with stretching. Activity does not seem to aggravate his back but inactivity does. He has had no penile discharge, rash, or conjunctivitis, and denies diarrhea or other GI symptoms. On physical examination, your patient is surprised to find that he cannot reach his toes as he had been able to do just a few months ago in track practice. Range of motion in the neck, arms, and legs is normal. A focused neurologic examination is normal. There is mild, diffuse tenderness over the lumbosacral spine and with percussion over the sacroiliac joints. When supine on the examination table, a FABER maneuver (flexion, abduction, external rotation) reproduces sacral pain. The history and physical examination are most consistent with a diagnosis of: A. Reactive arthritis (formerly termed Reiter syndrome) B. Osteoarthritis of the lumbar spine C. Degenerative disc disease D. Ankylosing spondylitis E. Vertebral body tumor
D
Patients with fibromyalgia have higher rates of which of the following conditions compared to people without fibromyalgia? A. Post-traumatic stress disorder B. Irritable bowel syndrome C. Sleep disturbance D. All of the above
D
The cardiovascular risk associated with celecoxib results from A. inhibition of prostaglandin production in the gastric epithelium. B. inhibition of platelet thromboxane production. C. effects on myocardial ion channels. D. inhibition of prostaglandin in the kidney. E. enhanced prostacyclin production by vascular endothelium
D
The parents of a 3-year-old child are worried about the child's apparent clumsiness with frequent falls and a waddling gait. The child had normal development of motor skills during the first year of life and has normal language development. Which of the following is consistent with Duchenne muscular dystrophy (DMD)? A. Female gender B. Hypertrophy of the quadriceps C. 22-year-old sister with Becker muscular dystophy (MD) D. Gower sign E. Positive antinuclear antibodies in the blood
D
The proper treatment for a clavicle fracture that is minimally displaced is: A. Closed reduction and then a sling B. Open reduction and immobilization C. Open reduction and early mobilization D. A sling E. Clavicular disarticulation
D
Unilateral nontender bony enlargement of the first DIP and activity-related right hip pain in a 68-year-old woman A. Rheumatoid arthritis B. Gout C. Pseudogout D. Osteoarthritis
D
What initial treatment do you recommend for a patient with adhesive capsulitis? A. Arthroscopic debridement B. Oral corticosteroids C. NSAIDs and a sling for comfort D. Extended progressive physical therapy E. Mobilization under anesthesia
D
What is the primary mechanism of action of allopurinol in treating gout? A. It is an analgesic agent. B. It is an anti-inflammatory agent. C. It blocks inflammatory responses to urate crystals. D. It inhibits urate formation. E. It augments urate excretion.
D
Which of the following IS NOT associated with carpal tunnel syndrome? A. Hypothyroidism B. Diabetes mellitus C. Amyloidosis D. Polycythemia vera E. Rheumatoid arthritis
D
Which of the following is the next step in the management of a patient newly diagnosed with acute gout pain ? A. Prescribe allopurinol B. Prescribe acetaminophen C. Discontinue chlorthalidone D. Prescribe naproxen at a full anti-inflammatory dose
D
Which of the following medications has been shown to improve pain, fatigue, and sleep disturbance in patients with fibromyalgia? A. Fluoxetine B. Pregabalin C. Cyclobenzaprine D. Amitriptyline
D
A 22-year-old graduate student presents to the ED on a Monday night with an acutely swollen left knee. He admits to "wild partying" over the weekend but only had "a couple of beers" (that is the "college couple"... so, 6 or 7). His knee was OK then. However, when he woke up this morning, he noticed the knee was swollen and painful (so was his head, but that's another matter). By early afternoon, he had difficulty bearing weight. He denies fever, but feels tired. He reports a history of JIA (juvenile idiopathic arthritis) and has had ankle and knee swelling previously, but not to this degree. He took prednisone intermittently, as well as hydroxychloroquine and methotrexate, for his JIA until age 18. He then continued on hydroxychloroquine until 8 months ago, when he stopped it because he felt fine. He denies any other medical problems. He smokes only when drinking—which happens way too often. What other information from the history would be most helpful in establishing the diagnosis? A. Sexual history, including sexual orientation, practices, and last contact B. Personal or family history of gout or kidney stones C. History of IV drug use D. Family history of pseudogout E. A, B, and C
E
A 22-year-old man is brought into the emergency department with a knife injury to the axilla. The physician suspects injury to the lower brachial plexus. Which of the following nerves will most likely be affected? A. Axillary B. Musculocutaneous C. Vagus D. Radial E. Ulnar
E
A 65-year-old male presents with left shoulder pain and weakness, which started 2 weeks ago after he put a new roof on his house. He does not recall a specific injury. The pain is worse with reaching for and lifting objects as well as with overhead activities. Nighttime pain is present. He describes himself active and healthy, and he only takes acetaminophen when needed for shoulder pain. You suspect that he may have rotator cuff tendinopathy. If this is the case, what do you expect to find on examination? A. Tenderness to palpation of the greater tuberosity of the humerus B. Limited active ROM C. Normal passive ROM D. Shoulder shrug with attempted abduction (such as with a frozen shoulder) E. Any of the above
E
All of the following are associated with fibromyalgia EXCEPT: A. Irritable bowel syndrome B. Subjective fullness/swelling of hands and feet C. Paresthesias D. Fatigue E. Night sweats
E
Based on your history, you recognize that your patient may be at higher than normal risk for developing SLE. All of the following groups have a higher incidence of SLE than the general population EXCEPT: A. Family members of patients with SLE B. Females C. Asian Americans D. Age in the third to fifth decades E. Caucasians
E
CPPD (pseudogout) is associated with which of the following? A. Hypothyroidism B. Hyperparathyroidism C. Amyloidosis D. Hemochromatosis E. All of the above
E
Which of the following is the best initial test to confirm the diagnosis of ankylosing spondylitis? A. ANA B. Lumbar spine radiographs C. HLA-B27 D. ESR E. Sacroiliac joint radiographs
E
Which of the following is the best screening test for a child you suspect with Duchenne Muscular Dystrophy? A. Muscle biopsy B. Measurement of serum creatinine C. Electromyography (EMG) D. Blood analysis for antinuclear antibodies E. Measurement of serum creatine kinase (CK) level
E
