Self-Assessment Test
Self-Assessment Test
Which of the following is the most likely diagnosis? (A) Amyopathic dermatomyositis (B) Polymorphous light eruption (C) Rosacea (D) Systemic lupus erythematosus
Item 5 A 62-year-old woman is evaluated for a 2-year history of progressively frequent and severe pain in the right knee. She has osteoarthritis with good control of her other joint symptoms with her current therapy that includes medication and a daily exercise regimen. She notes about 20 minutes of morning stiffness in the right knee with significant pain with use after rest; her activities are increasingly limited due to these symptoms. History is otherwise unremarkable. Medications are acetaminophen and celecoxib. On physical examination, blood pressure is 135/82 mm Hg. BMI is 32. There are Heberden nodes of the second and fifth distal interphalangeal joints bilaterally and Bouchard nodes of the second and third proximal interphalangeal joints bilaterally. Bony hypertrophy of the knees is present. There is a positive bulge sign for effusion of the right knee with slight warmth but no erythema. Standing radiographs of the knees show right (greater than left) medial joint-space narrowing, bilateral osteophytes, and bilateral peaking of the tibial spines. Aspiration of the right knee is performed; synovial fluid analysis shows a leukocyte count of 250/µL (0.25 × 109/L) and no evidence of crystals. Which of the following is the most appropriate next step in management? (A) (B) (C) (D)
Administer intra-articular glucocorticoids Administer intra-articular hyaluronic acid Refer for arthroscopic lavage Substitute indomethacin for celecoxib
Item 6 A 72-year-old man is evaluated in the emergency department for acute onset of pain and swelling of the left knee. He was diagnosed with community-acquired pneumonia 4 days ago, and a 7-day course of clarithromycin was started at that time. He reports marked improvement of his respiratory symptoms. History is also significant for gout, with attacks occurring approximately once a year; hypertension; diet-controlled diabetes mellitus; and chronic kidney disease. Other medications are nifedipine and hydrochlorothiazide. On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 117/86 mm Hg, pulse rate is 76/min, and respiration rate is 14/min. BMI is 32. Mildly decreased breath sounds in the right lung midfield are noted. The left knee is swollen, red, warm, tender, and fluctuant with limited range of motion. Laboratory studies are significant for a leukocyte count of 7200/µL (7.2 × 109/L) and a serum creatinine level of 1.7 mg/dL (150.3 µmol/L).
A radiograph of the left knee is normal. Aspiration of the left knee is performed; synovial fluid analysis reveals a leukocyte count of 20,000/µL (20 × 109/L), extracellular and intracellular urate crystals, and a negative Gram stain. Which of the following is the most appropriate treatment? (A) Acetaminophen (B) Colchicine (C) Indomethacin (D) Intra-articular glucocorticoids
Item 7 A 65-year-old man is evaluated for severe abdominal pain, joint pain, and a rash. He states that he had an upper respiratory infection about 10 days ago. Three days ago he noted a rash on his lower extremities. One day later, he experienced pain in his knees and ankles, along with abdominal pain that worsened over the past two days. He reports no visual symptoms, numbness, weakness, or other symptoms. On physical examination, the patient appears uncomfortable. The chest and cardiac examinations are unremarkable. Decreased bowel sounds and diffuse abdominal tenderness without rebound are noted. The knees and ankles are tender and mildly swollen. Palpable purpuric lesions are present on the lower extremities, including the soles of the feet. The remainder of the physical examination reveals no abnormalities. Laboratory studies show a normal complete blood count, an erythrocyte sedimentation rate of 88 mm/h, a serum creatinine level of 1.7 mg/dL (150.3 µmol/L), and a urinalysis showing 3+ protein, 20-30 erythrocytes/hpf, 20-30 leukocytes/hpf, and mixed granular and cellular casts. A stool test is positive for occult blood. An abdominal ultrasound reveals thickening and edema of the ileum. A biopsy of an affected skin lesion demonstrates the presence of small-vessel, leukocytoclastic vasculitis accompanied by deposition of IgA. Which of the following is the most appropriate therapy at this time? (A) Cyclophosphamide (B) Dapsone (C) Ibuprofen (D) Prednisone
Item 8 A 28-year-old woman is evaluated for a 6-month history of joint pain and swelling. She was diagnosed with rheumatoid arthritis 5 years ago; current medications are etanercept, sulfasalazine, and etodolac. She was initially treated with methotrexate, which was stopped due to gastrointestinal intolerance, and she refuses to retry it. On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 126/74 mm Hg, pulse rate is 68/min, and respiration rate is 14/min. BMI is 24. Two proximal interphalangeal (PIP) joints of the left
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