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Self-Assessment Test tn .D l[ Which of the following is the most appropriate diagnostic behavioral therapy, land and aquatic therapy, and tai chi. ut E testtoperformnext? She also has depression, treated with escitalopram. UI (D CONT. On physical examination, vital signs are normal. There vt (A) Kidneybiopsy is tenderness at multiple soft-tissue sites with soft palpa- (B) Sinus biopsy a tion. All other flndings are normal. o (C) Skin biopsy (D) Ihoracoscopic lung biopsy Which ofthe following is the most appropriate additional (D vr treatrnent?

tn .D l[ Which of the following is the most appropriate diagnostic behavioral therapy, land and aquatic therapy, and tai chi. ut E testtoperformnext? She also has depression, treated with escitalopram. UI (D CONT. On physical examination, vital signs are normal. There vt (A) Kidneybiopsy is tenderness at multiple soft-tissue sites with soft palpa- (B) Sinus biopsy a tion. All other flndings are normal. o (C) Skin biopsy (D) Ihoracoscopic lung biopsy Which ofthe following is the most appropriate additional (D vr treatrnent? Item 5 (A) Duloxetine (B) Medical cannabis A 32-year-old man is evaluated forlowbackpain of 6 months' duration. He experiences back pain at night and back pain (C) Oxycodone and stifftress in the morning for more than 30 minutes. He (D) Prednisone feels less back pain when he exercises. He had an episode of (E) Pregabalin left Achilles tendinitis 4 months ago and continues to have some pain and swelling at the Achilles insertion. On physical examination, vital signs are normal. Item 8 Peripheral joints are normal. Lumbar spine flexion is lim- A 56-year-old man is evaluated for a 2-year history of mid ited, and hip flexion, abduction, and external rotation to lower back pain and stiffness. He reports no buttock pain. cause discomfort in the buttocks bilaterally. He has tried home-based exercises, with minimal benefit. Laboratory evaluation reveals normal erythrocyte On physical examination, there is diffuse tenderness sedimentation rate and blood C-reactive protein level. to palpation of the lower thoracic spine and upper lumbar Anteroposterior pelvic radiograph shows no evidence spine, with reduced flexion and extension. There is no sa- ofsacroiliitis. croiliac joint tenderness. taboratory evaluation reveals a normal blood C-reactive Which of the following is the most appropriate diagnostic protein level. test to perform next? Radiograph of the spine is shown. Sacroiliac joint (A) Additional radiographic views of sacroiliac joints radiographs are normal. (B) CTofsacroiliacjoints (C) HLA-B27 antigen testing (D) MRI of sacroiliac joints (E) Rheumatoid factor and anti-cyclic citrullinated peptide antibodies

Item 5 (A) Duloxetine (B) Medical cannabis A 32-year-old man is evaluated forlowbackpain of 6 months' duration. He experiences back pain at night and back pain (C) Oxycodone and stifftress in the morning for more than 30 minutes. He (D) Prednisone feels less back pain when he exercises. He had an episode of (E) Pregabalin left Achilles tendinitis 4 months ago and continues to have some pain and swelling at the Achilles insertion. On physical examination, vital signs are normal. Item 8 Peripheral joints are normal. Lumbar spine flexion is lim- A 56-year-old man is evaluated for a 2-year history of mid ited, and hip flexion, abduction, and external rotation to lower back pain and stiffness. He reports no buttock pain. cause discomfort in the buttocks bilaterally. He has tried home-based exercises, with minimal benefit. Laboratory evaluation reveals normal erythrocyte On physical examination, there is diffuse tenderness sedimentation rate and blood C-reactive protein level. to palpation of the lower thoracic spine and upper lumbar Anteroposterior pelvic radiograph shows no evidence spine, with reduced flexion and extension. There is no sa- ofsacroiliitis. croiliac joint tenderness. taboratory evaluation reveals a normal blood C-reactive Which of the following is the most appropriate diagnostic protein level. test to perform next? Radiograph of the spine is shown. Sacroiliac joint (A) Additional radiographic views of sacroiliac joints radiographs are normal. (B) CTofsacroiliacjoints (C) HLA-B27 antigen testing (D) MRI of sacroiliac joints (E) Rheumatoid factor and anti-cyclic citrullinated peptide antibodies Item 6 A 2S-year-old woman is evaluated for a 3-year history of joint pain involving her hands with more than L hour of morning stiffness. She also has intermittent photosensitive facial rash, fatigue, and intermittent subjective fever. On physical examination, vital signs are normal. There is tenderness to palpation with swelling of the second and third metacarpophalangeal joints bilaterally. Complete blood count, serum creatinine level, and urinal- ysis are normal. Erythroclte sedimentation rate is 35 mm/h.

Item 6 A 2S-year-old woman is evaluated for a 3-year history of joint pain involving her hands with more than L hour of morning stiffness. She also has intermittent photosensitive facial rash, fatigue, and intermittent subjective fever. On physical examination, vital signs are normal. There is tenderness to palpation with swelling of the second and third metacarpophalangeal joints bilaterally. Complete blood count, serum creatinine level, and urinal- ysis are normal. Erythroclte sedimentation rate is 35 mm/h. Which of the following is the most appropriate diagnostic test to perform next? (A) Anti-double-stranded DNA antibodies (B) Antinuclearantibodies (C) Anti-Ro/SSA, anti-La/SSB antibodies (D) Anti-Smith antibodies (E) Anti-Uf-ribonucleoprotein antibodies Item 7 A 43-year-old woman is evaluated for flbromyalgia. She continues to be symptomatic with poor sleep qualit5r and diffuse stiffness despite her participation in cognitive 100

Self-Assessment Test t o, Which of the following is the most likely diagnosis? experienced unintentional weight loss of 3 kg (0.0 lb). the abdominal pain is poorly localized and unrelated to delcca (A) Ankylosingspondylitis o tion. Stools are loose but not greasy, mucoid, or bloody. Shc tr (B) Diffuse idiopathic skeletal hyperostosis has been taking naproxen twice daily, with good control of' tt t (C) Spinal calcium pyrophosphate deposition disease her ankylosing spondylitis. She reports no recent travel or q, t,l (D) Spondylosis deformans antibiotic therapy. She has no other medical problems and tt t:rkes no additional medictrtions. On physical eramination, vital signs are normal. o rrl Item 9 There is mild nonlocalizing abdominal tenderness. Range A 36 year-old woman is evaluated during a routine well- of motion of cervical and lumbar spine is normal. Sacroiliac joints are not tender. ness visit. She is asymptomatic and has no medical prob lems. She works as an accountant and rarely engages in physical activity. She drinks a glass of red wine with dinner Which of the following is the most likely diagnosis? five times weekly. Her diet is rich in protein and starches (A) Celiac disease and low in fruits, vegetables, and nuts. She has smoked (B) Inflammatory bowel disease one pack ofcigarettes per day for 5 years. Her mother has rheumatoid arthritis, and the patient is concerned that she (C) Irritable bowel syndrome might also develop the disease. Her only medication is a (D) Small intestinal bacterial overgrowth combined oral contraceptive. Physical examination, including vital signs, is normal. Item 12 Which of the following is most likely to reduce this patient's A 68-year-old man is evaluated for recent onset of mild risk for developing rheumatoid arthritis? pain and signiflcant swelling of his left knee. He lives in (A) Alcohol cessation eastern Pennsylvania and is an avid golfer. Several months (B) Discontinuation of combined oral contraceptive ago he had an illness characterized by an enlarging ery thematous annular skin lesion in the left popliteal fossa (C) Increased physical activity associated with fever, arthralgia, and myalgia that sponta (D) Mediterranean diet neously resolved after several days. (E) Smoking cessation On physical examination, vital signs are normal. Joint examination shows diffuse swelling of the left knee with minimal warmth but no erythema, slight reduction in full Item 10 flexion of the knee but pain-free range of motion, and a A 75-year-old man is evaluated for facial redness and hand, popliteal cyst. elbow, and knee rash that have progressed over the past Results of serologic testing are positive for Borrelio 6 months. He has no other medical problems and takes no burgdorferi. medications. On physical examination, vital signs are normal. There Which of the following is the most appropriate treatment? is an erythematous, slightly elevated, irregular rash over (A) Ceftriaxone both cheeks, forehead, and chin, sparing the nasolabial folds. Eyelids also appear pink and swollen. There is faint (B) Doxycycline erythema over the dorsal hands. An indurated rash with (C) Hydroxychloroquine faint scale is present over the extensor surfaces of the (D) Methotrexate elbows and knees. Muscle strength and the remainder of the examination are normal. Complete blood count, comprehensive metabolic panel, and serum aldolase and creatine kinase levels are normal. Item 13 An 85 year old woman is evaluated ftir a 10 day history ol' tr right knee pain and swelling. which is impairing her ability I to walk and climb stairs. She has a history of similar symp Which of the following is the most likely diagnosis? toms over the past 2 years. [iach episode has lasted about (A) Acute cutaneous lupus erythematosus ll wecks and resolves with rest and ice. (B) Amyopathic dermatomyositis On physical examination. vital signs are normal. She (C) Psoriasis has moderate swelling of the right knee, with warmth and tenderness, and decreased range of motion related to pain. (D) Rosacea No skin lesions or tophi arc noted. l-aboratory studies: Erythrocyte seditnentation rate tr Item 11 A 36 year old rvoman is evaluated lbr abdominal pain Cornplete blood count Comprehensive metabolic panel 65 mmrh Normal Normal and diarrhea. She has a 3 year history of ankylosirtg spon Urate Normal dylitis. For the past 6 months. she l-ras had fbur or five bowel movements daily and over the past month she has Radiograph ofthe right knee is shown (top ofnext page).

t o, Which of the following is the most likely diagnosis? experienced unintentional weight loss of 3 kg (0.0 lb). the abdominal pain is poorly localized and unrelated to delcca (A) Ankylosingspondylitis o tion. Stools are loose but not greasy, mucoid, or bloody. Shc tr (B) Diffuse idiopathic skeletal hyperostosis has been taking naproxen twice daily, with good control of' tt t (C) Spinal calcium pyrophosphate deposition disease her ankylosing spondylitis. She reports no recent travel or q, t,l (D) Spondylosis deformans antibiotic therapy. She has no other medical problems and tt t:rkes no additional medictrtions. On physical eramination, vital signs are normal. o rrl Item 9 There is mild nonlocalizing abdominal tenderness. Range A 36 year-old woman is evaluated during a routine well- of motion of cervical and lumbar spine is normal. Sacroiliac joints are not tender. ness visit. She is asymptomatic and has no medical prob lems. She works as an accountant and rarely engages in physical activity. She drinks a glass of red wine with dinner Which of the following is the most likely diagnosis? five times weekly. Her diet is rich in protein and starches (A) Celiac disease and low in fruits, vegetables, and nuts. She has smoked (B) Inflammatory bowel disease one pack ofcigarettes per day for 5 years. Her mother has rheumatoid arthritis, and the patient is concerned that she (C) Irritable bowel syndrome might also develop the disease. Her only medication is a (D) Small intestinal bacterial overgrowth combined oral contraceptive. Physical examination, including vital signs, is normal. Item 12 Which of the following is most likely to reduce this patient's A 68-year-old man is evaluated for recent onset of mild risk for developing rheumatoid arthritis? pain and signiflcant swelling of his left knee. He lives in (A) Alcohol cessation eastern Pennsylvania and is an avid golfer. Several months (B) Discontinuation of combined oral contraceptive ago he had an illness characterized by an enlarging ery thematous annular skin lesion in the left popliteal fossa (C) Increased physical activity associated with fever, arthralgia, and myalgia that sponta (D) Mediterranean diet neously resolved after several days. (E) Smoking cessation On physical examination, vital signs are normal. Joint examination shows diffuse swelling of the left knee with minimal warmth but no erythema, slight reduction in full Item 10 flexion of the knee but pain-free range of motion, and a A 75-year-old man is evaluated for facial redness and hand, popliteal cyst. elbow, and knee rash that have progressed over the past Results of serologic testing are positive for Borrelio 6 months. He has no other medical problems and takes no burgdorferi. medications. On physical examination, vital signs are normal. There Which of the following is the most appropriate treatment? is an erythematous, slightly elevated, irregular rash over (A) Ceftriaxone both cheeks, forehead, and chin, sparing the nasolabial folds. Eyelids also appear pink and swollen. There is faint (B) Doxycycline erythema over the dorsal hands. An indurated rash with (C) Hydroxychloroquine faint scale is present over the extensor surfaces of the (D) Methotrexate elbows and knees. Muscle strength and the remainder of the examination are normal. Complete blood count, comprehensive metabolic panel, and serum aldolase and creatine kinase levels are normal. Item 13 An 85 year old woman is evaluated ftir a 10 day history ol' tr right knee pain and swelling. which is impairing her ability I to walk and climb stairs. She has a history of similar symp Which of the following is the most likely diagnosis? toms over the past 2 years. [iach episode has lasted about (A) Acute cutaneous lupus erythematosus ll wecks and resolves with rest and ice. (B) Amyopathic dermatomyositis On physical examination. vital signs are normal. She (C) Psoriasis has moderate swelling of the right knee, with warmth and tenderness, and decreased range of motion related to pain. (D) Rosacea No skin lesions or tophi arc noted. l-aboratory studies: Erythrocyte seditnentation rate tr Item 11 A 36 year old rvoman is evaluated lbr abdominal pain Cornplete blood count Comprehensive metabolic panel 65 mmrh Normal Normal and diarrhea. She has a 3 year history of ankylosirtg spon Urate Normal dylitis. For the past 6 months. she l-ras had fbur or five bowel movements daily and over the past month she has Radiograph ofthe right knee is shown (top ofnext page). 101

Self-Assessment Test vt (D ? On physical examination, temperature is 37.0 "C vt (98.6 "F), blood pressure is 2.,101120 mm Hg. pulse rate is lrt 90i min, respiration rate is ltllmin. and oxygen saturation (D ut is 96'1, with the patient breathing ambient air. The skin art J over the hands. forearms, trunk, lower legs, and feet is .D tight and appears thickened. The fingers on both hands show cyanosis. No nuchal rigidity is noted. and flndings on .D UI neurologic examination are normal. laboratory studies: []ematocrit .).) t, Leukoclle count Normal Platelet count 90,0001pL (90 x 1O'q L) Creatinine 2.4 mg1dl. (212.2 pmol, L) Urinalysis 2+ protein; no blood or casts Peripheral blood smear reveals diminished platelet numbers and schistocytes.

vt (D ? On physical examination, temperature is 37.0 "C vt (98.6 "F), blood pressure is 2.,101120 mm Hg. pulse rate is lrt 90i min, respiration rate is ltllmin. and oxygen saturation (D ut is 96'1, with the patient breathing ambient air. The skin art J over the hands. forearms, trunk, lower legs, and feet is .D tight and appears thickened. The fingers on both hands show cyanosis. No nuchal rigidity is noted. and flndings on .D UI neurologic examination are normal. laboratory studies: []ematocrit .).) t, Leukoclle count Normal Platelet count 90,0001pL (90 x 1O'q L) Creatinine 2.4 mg1dl. (212.2 pmol, L) Urinalysis 2+ protein; no blood or casts Peripheral blood smear reveals diminished platelet numbers and schistocytes. Which of the following is the most appropriate intravenous treatment? (A) Captopril (B) Cyclophosphamide (C) Methylprednisolone (l)) Metoproloi Wtictr of the following is the most likely diagnosis? f,l cour. (A) Acute calcium pyrophosphate crystal arthritis (tl) Gout flare Item 16 A 78-year-old man is evaluated at a follon'-up visit. Two tr (C) Inlectiousarthritis r.r,eeks ago, he presented n,ith severe nelv onset head (D) Rheumatoid arthritis aches, claudicative ja$, pain, and proximal myalgia of all four limbs. He r.t,as diagnosed with biopsy-confirmed giant cell arteritis. and prednisone. 60 mg d, was initiated. Item 14 Since initiation of prednisone. his presenting symptoms have improved but he has also developed mood su,ings, A 35 year old woman is evaluated in follow-up for a recent insomnia. significant hypergtycemia. elevated blood pres diagnosis of ankylosing spondylitis. Despite the use of sure, and dependent edema. His other medical problems three different NSAIDs and physical therapy, she continues are type 2 diabetes mellitus. hypertension, dyslipidemia, to have night pain and morning stiffness/pain lasting more and atherosclerotic coronary artery disease. Other current than t hour. medications are aspirin. metfbrmin. metoprolol. atorvas On physical examination, vital signs are normal. There tatin, losartan. and hydrochlorothiazide. is pain at the sacroiliac joints with hip flexion, abduction, On physical examination, blood pressure is 172,'94 mm I Ig and external rotation. Lumbar spine range of motion is and pulse rate is 90/min. Other than pitting pedal edema. the mildly limited. Peripheral joints are normal. cardiopulmonary examination is normal. Initial anteroposterior radiograph of pelvis showed Point-of-care blood glucose level is 310 mgrdl bilateral sacroiliitis. (t2.2 mmol;L). Changes in the patient's current medical regimen. Which of the following is the most appropriate next including prednisone taper, are made to control glucose. treatment? blood pressure. and edema. (A) Etanercept (B) Methotrexate Which of the following is the most appropriate additional treatment? (C) Prednisone (D) Sulfasalazine (A) Cyclophosphamide (B) Infliximab (C) Methotrexate tr AItem 15 36 year-old r,r,oman is evaluated in the emergency (D) 'focilizumab

Which of the following is the most appropriate intravenous treatment? (A) Captopril (B) Cyclophosphamide (C) Methylprednisolone (l)) Metoproloi Wtictr of the following is the most likely diagnosis? f,l cour. (A) Acute calcium pyrophosphate crystal arthritis (tl) Gout flare Item 16 A 78-year-old man is evaluated at a follon'-up visit. Two tr (C) Inlectiousarthritis r.r,eeks ago, he presented n,ith severe nelv onset head (D) Rheumatoid arthritis aches, claudicative ja$, pain, and proximal myalgia of all four limbs. He r.t,as diagnosed with biopsy-confirmed giant cell arteritis. and prednisone. 60 mg d, was initiated. Item 14 Since initiation of prednisone. his presenting symptoms have improved but he has also developed mood su,ings, A 35 year old woman is evaluated in follow-up for a recent insomnia. significant hypergtycemia. elevated blood pres diagnosis of ankylosing spondylitis. Despite the use of sure, and dependent edema. His other medical problems three different NSAIDs and physical therapy, she continues are type 2 diabetes mellitus. hypertension, dyslipidemia, to have night pain and morning stiffness/pain lasting more and atherosclerotic coronary artery disease. Other current than t hour. medications are aspirin. metfbrmin. metoprolol. atorvas On physical examination, vital signs are normal. There tatin, losartan. and hydrochlorothiazide. is pain at the sacroiliac joints with hip flexion, abduction, On physical examination, blood pressure is 172,'94 mm I Ig and external rotation. Lumbar spine range of motion is and pulse rate is 90/min. Other than pitting pedal edema. the mildly limited. Peripheral joints are normal. cardiopulmonary examination is normal. Initial anteroposterior radiograph of pelvis showed Point-of-care blood glucose level is 310 mgrdl bilateral sacroiliitis. (t2.2 mmol;L). Changes in the patient's current medical regimen. Which of the following is the most appropriate next including prednisone taper, are made to control glucose. treatment? blood pressure. and edema. (A) Etanercept (B) Methotrexate Which of the following is the most appropriate additional treatment? (C) Prednisone (D) Sulfasalazine (A) Cyclophosphamide (B) Infliximab (C) Methotrexate tr AItem 15 36 year-old r,r,oman is evaluated in the emergency (D) 'focilizumab department after experiencing a tonic-clonic seizure. For I week she has had severe headaches. Eight months ago, Item 17 Raynaud phenomenon of the hands and feet developed. A 62 year old man is evaluated for worsening exertional Current medication is sustained release nifedipine. dyspnea and nonproductive cough over the past year. He

department after experiencing a tonic-clonic seizure. For I week she has had severe headaches. Eight months ago, Item 17 Raynaud phenomenon of the hands and feet developed. A 62 year old man is evaluated for worsening exertional Current medication is sustained release nifedipine. dyspnea and nonproductive cough over the past year. He 102

Self-Assessment Test Ut has a 6 year history of seropositive rheumatoid arthri- Item 20 €, F tis. Current medications are tofacitinib, methotrexate, and A 66 year-old man is evaluated fbr a 10-year history of folic acid. pain affecting the flngers and bases of the thumbs, hips, o On physical examination, vital signs are normal. Car- UI and knees. Morning stiffness lasts less than l5 minutes, and t diac examination reveals normal jugular venous pressure c, pain is worse with activity. UI and S, without extra sounds. There are reduced breath vl Physical examination reveals bony hypertrophy of sounds throughout the lung flelds, with bibasilar inspi the distal and proximal interphalangeal joints of the hands ratory crackles. Lung percussion is resonant throughout. o and squaring of the thumb bases bilaterally. Both knees are ta Joint examination shows advanced changes of rheumatoid tender to palpation medially and laterally. Bony enlarge, arthritis involving the hands and wrists. The remainder of ment of medial knees and crepitus on range of motion the examination is unremarkable. are noted. There is no soft tissue swelling, warmth, or effusion. Which of the following is the most likely cause of this patient's exertional dyspnea? Which of the following is the most appropriate test? (A) Heart failure (A) Antinuclear antibodies (B) Interstitial lung disease (B) Rheumatoid factor (C) Pulmonaryarterial hypertension (C) Serologic testing for Borrelia burgdorferi (D) Rheumatoid arthritis pleural eflusion (D) Synovial fluid analysis (E) No additional laboratory studies

Ut has a 6 year history of seropositive rheumatoid arthri- Item 20 €, F tis. Current medications are tofacitinib, methotrexate, and A 66 year-old man is evaluated fbr a 10-year history of folic acid. pain affecting the flngers and bases of the thumbs, hips, o On physical examination, vital signs are normal. Car- UI and knees. Morning stiffness lasts less than l5 minutes, and t diac examination reveals normal jugular venous pressure c, pain is worse with activity. UI and S, without extra sounds. There are reduced breath vl Physical examination reveals bony hypertrophy of sounds throughout the lung flelds, with bibasilar inspi the distal and proximal interphalangeal joints of the hands ratory crackles. Lung percussion is resonant throughout. o and squaring of the thumb bases bilaterally. Both knees are ta Joint examination shows advanced changes of rheumatoid tender to palpation medially and laterally. Bony enlarge, arthritis involving the hands and wrists. The remainder of ment of medial knees and crepitus on range of motion the examination is unremarkable. are noted. There is no soft tissue swelling, warmth, or effusion. Which of the following is the most likely cause of this patient's exertional dyspnea? Which of the following is the most appropriate test? (A) Heart failure (A) Antinuclear antibodies (B) Interstitial lung disease (B) Rheumatoid factor (C) Pulmonaryarterial hypertension (C) Serologic testing for Borrelia burgdorferi (D) Rheumatoid arthritis pleural eflusion (D) Synovial fluid analysis (E) No additional laboratory studies tr Item 18 A 50 year old man is evaluated for severe pain and swell Item 21 EI ing in the left knee of 2 days' duration. He has a long A 56 year old woman is evaluated at a folkrw-up visit. history of psoriasis and polyarticular psoriatic arthritis. She has polyarticular tophaceous gout affecting her hancls, He reports no fever, chills. or pain in other joints. Current Ieet, and knees bilaterally. She is receiving a tapering dose medications are methotrexate, lolic acid, and topical clo- of prednisone following an acute gout flare. She had previ betasol propionate. ously received allopurinol but discontinued it atter devel : On physical examination, vital signs are normal. There oping a rash. She has hypertensicln and chronic kidney : are psoriatic plaques on the elbows. sacrum, and anterior disease. Current medications are losartan and prednisone. shins. The lelt knee is swollen and warm; the patient holds s mgid. it at 45 degrees olflexion, and he is unwilling to further flex Laboratory studies show a serum creatinine level ol I or extend. There is no othcr joint swelling. 1.8 mgi dL (159.1pmol/L), a serum urate level of 10.1 mg/dl Arthrocentesis of the left knee reveals a synovial fluid (0.60 mmolrL), and an estimated glomerular filtration rate lcukocl,te count of 40,0001pL (a0 x 10eiL) with 90'7, neu- of 31 ml-imin 11.73 m). trophils. Gram stain is negative, and synovial fluid analysis for crystals and bacterial culture are pending. Which of the following is the most appropriate additional treatment? Which of the following is the most likely diagnosis? (A) Allopurinol (A) Gouty arthritis (B) Colchicine I (B) lnf'ectir-rusarthritis (C) Febuxostat (C) Osteoarthritis (D) Pegloticase (D) Psoriatic arthritis (E) Probcnecid

tr Item 18 A 50 year old man is evaluated for severe pain and swell Item 21 EI ing in the left knee of 2 days' duration. He has a long A 56 year old woman is evaluated at a folkrw-up visit. history of psoriasis and polyarticular psoriatic arthritis. She has polyarticular tophaceous gout affecting her hancls, He reports no fever, chills. or pain in other joints. Current Ieet, and knees bilaterally. She is receiving a tapering dose medications are methotrexate, lolic acid, and topical clo- of prednisone following an acute gout flare. She had previ betasol propionate. ously received allopurinol but discontinued it atter devel : On physical examination, vital signs are normal. There oping a rash. She has hypertensicln and chronic kidney : are psoriatic plaques on the elbows. sacrum, and anterior disease. Current medications are losartan and prednisone. shins. The lelt knee is swollen and warm; the patient holds s mgid. it at 45 degrees olflexion, and he is unwilling to further flex Laboratory studies show a serum creatinine level ol I or extend. There is no othcr joint swelling. 1.8 mgi dL (159.1pmol/L), a serum urate level of 10.1 mg/dl Arthrocentesis of the left knee reveals a synovial fluid (0.60 mmolrL), and an estimated glomerular filtration rate lcukocl,te count of 40,0001pL (a0 x 10eiL) with 90'7, neu- of 31 ml-imin 11.73 m). trophils. Gram stain is negative, and synovial fluid analysis for crystals and bacterial culture are pending. Which of the following is the most appropriate additional treatment? Which of the following is the most likely diagnosis? (A) Allopurinol (A) Gouty arthritis (B) Colchicine I (B) lnf'ectir-rusarthritis (C) Febuxostat (C) Osteoarthritis (D) Pegloticase (D) Psoriatic arthritis (E) Probcnecid tr L

tr Item 18 A 50 year old man is evaluated for severe pain and swell Item 21 EI ing in the left knee of 2 days' duration. He has a long A 56 year old woman is evaluated at a folkrw-up visit. history of psoriasis and polyarticular psoriatic arthritis. She has polyarticular tophaceous gout affecting her hancls, He reports no fever, chills. or pain in other joints. Current Ieet, and knees bilaterally. She is receiving a tapering dose medications are methotrexate, lolic acid, and topical clo- of prednisone following an acute gout flare. She had previ betasol propionate. ously received allopurinol but discontinued it atter devel : On physical examination, vital signs are normal. There oping a rash. She has hypertensicln and chronic kidney : are psoriatic plaques on the elbows. sacrum, and anterior disease. Current medications are losartan and prednisone. shins. The lelt knee is swollen and warm; the patient holds s mgid. it at 45 degrees olflexion, and he is unwilling to further flex Laboratory studies show a serum creatinine level ol I or extend. There is no othcr joint swelling. 1.8 mgi dL (159.1pmol/L), a serum urate level of 10.1 mg/dl Arthrocentesis of the left knee reveals a synovial fluid (0.60 mmolrL), and an estimated glomerular filtration rate lcukocl,te count of 40,0001pL (a0 x 10eiL) with 90'7, neu- of 31 ml-imin 11.73 m). trophils. Gram stain is negative, and synovial fluid analysis for crystals and bacterial culture are pending. Which of the following is the most appropriate additional treatment? Which of the following is the most likely diagnosis? (A) Allopurinol (A) Gouty arthritis (B) Colchicine I (B) lnf'ectir-rusarthritis (C) Febuxostat (C) Osteoarthritis (D) Pegloticase (D) Psoriatic arthritis (E) Probcnecid tr L ! Item 19 Item 22 A 3O-year-old woman is seen in follow up. She was diag- A 35 year old woman is evaluated in the emergency nosed with systemic lupus erythematosus 12 years ago. department lbr sudden vision loss in the lefl eye. Two years 1 She was treated for lupus nephritis, which is now quies ago, she had developed intermittent fever. myalgia, and I cent. Clinical and laboratory flndings have been stable for ! chronic tatigue. She reports recent postprandial abdominal 5 years, with no disease flares. Medications are hydroxy pain and eflbrt related left arm pain. chloroquine and azathioprine. On physical examination, bltnd pressure is 160/100 mm Ilg in the lefl arm and 130i 80 mm I Ig in the right arm. Pulse Which of the following health risk assessments should be rate is 88/min. Radial pulse in the left arm is abscnt; left-sided performed now? subclavian bruit is present. : Laboratory studies reveal an erythrocyte sedimenta (A) Breast cancer tion rate o1 76 mm/h and a blood hemoglobin level o1' I (B) Cardiovasculardisease e.2 gtdL (e2 s,tL). i (C) Iron overload Magnetic resonance angiogram of the chest and (D) Pulmonary disease abdomen shows focal luminal narrorving in several areas. : 103

Self-Assessment Test t,l ID t,l UI tr CONT, including the ascending aorta. lelt subclavian artery. supe rior mesenteric artery. and right renal artery. Item 25 A 26 year-old woman is evaluated for a 3-month history of increasing left hip pain that is worse with prolonged stand- o 6 UI Whieh of the following is the most likely diagnosis? ing. Systemic lupus erythematosus was diagnosed 5 years = (D (A) Cryoglobulinemic vasculitis ago, characterized by small joint arthralgia, malar rash, cytopenias, and Raynaud phenomenon. At diagnosis she (B) Giant cell arteritis { .D (C) Polyarteritisnodosa required high-dose prednisone, hydroxychloroquine, and an azathioprine therapy. Prednisone dosage was tapered over (D) Takayasu arteritis 6 months. Periodic flares have been treated with increased dosages ofprednisone. Current medications are hydroxy chloroquine, azathioprine, and low-dose prednisone. Item 23 On physical examination, internal rotation and A 62 year-old man is evaluated in the hospital for an arthro- full flexion of the left hip are limited and elicit pain. The centesis conflrmed diagnosis of acute polyarticular gout remainder of the examination is normal. involving the right knee, left ankle, and forefoot. Joint fluid Complete blood count, erythrocyte sedimentation Gram stain and culture were negative. He was hospitalized rate, and serum complement levels are normal. Anti 4 days ago with heart failure complicated by pulmonary double-stranded DNA antibody titer is low and has been embolism. He has a history of recurrent acute gout. The flrst unchanged for 6 months. night ofhis hospital stay, he developed polyarticular gout Radiograph of the left hip is normal. that has not responded to appropriate prednisone doses. He also has hypertension, hyperlipidemia, type 2 diabetes mel- Which ofthe following is the most appropriate litus, and stage G3a chronic kidney disease; he underwent management? kidney transplantation 10 years ago. Current medications (A) Change azathioprine to mycophenolate mofetil include low molecular-weight heparin, metoprolol, Iosar tan, furosemide, insulin glargine, and tacrolimus. (B) Increase prednisone dosage The right knee, left ankle, and forefoot are swollen, (C) MRI of left hip tender. and warm. (D) Physical therapy

t,l UI tr CONT, including the ascending aorta. lelt subclavian artery. supe rior mesenteric artery. and right renal artery. Item 25 A 26 year-old woman is evaluated for a 3-month history of increasing left hip pain that is worse with prolonged stand- o 6 UI Whieh of the following is the most likely diagnosis? ing. Systemic lupus erythematosus was diagnosed 5 years = (D (A) Cryoglobulinemic vasculitis ago, characterized by small joint arthralgia, malar rash, cytopenias, and Raynaud phenomenon. At diagnosis she (B) Giant cell arteritis { .D (C) Polyarteritisnodosa required high-dose prednisone, hydroxychloroquine, and an azathioprine therapy. Prednisone dosage was tapered over (D) Takayasu arteritis 6 months. Periodic flares have been treated with increased dosages ofprednisone. Current medications are hydroxy chloroquine, azathioprine, and low-dose prednisone. Item 23 On physical examination, internal rotation and A 62 year-old man is evaluated in the hospital for an arthro- full flexion of the left hip are limited and elicit pain. The centesis conflrmed diagnosis of acute polyarticular gout remainder of the examination is normal. involving the right knee, left ankle, and forefoot. Joint fluid Complete blood count, erythrocyte sedimentation Gram stain and culture were negative. He was hospitalized rate, and serum complement levels are normal. Anti 4 days ago with heart failure complicated by pulmonary double-stranded DNA antibody titer is low and has been embolism. He has a history of recurrent acute gout. The flrst unchanged for 6 months. night ofhis hospital stay, he developed polyarticular gout Radiograph of the left hip is normal. that has not responded to appropriate prednisone doses. He also has hypertension, hyperlipidemia, type 2 diabetes mel- Which ofthe following is the most appropriate litus, and stage G3a chronic kidney disease; he underwent management? kidney transplantation 10 years ago. Current medications (A) Change azathioprine to mycophenolate mofetil include low molecular-weight heparin, metoprolol, Iosar tan, furosemide, insulin glargine, and tacrolimus. (B) Increase prednisone dosage The right knee, left ankle, and forefoot are swollen, (C) MRI of left hip tender. and warm. (D) Physical therapy Which of the following is the most appropriate treatment? Item 26 (A) Anakinra A 48 year old woman is evaluated for sicca. She has a2 year (B) Colchicine history of Sjdgren slmdrome. Chewing sugarless gum and tak ing frequent small sips ofwater are increasingly less helpful for (C) Intra-articulartriamcinolone oral dry,rress. Current medications are artificial tears and oph (D) Naproxen thalmic cyclosporine. She has no other conceming symptoms. On physical examination, vital signs are normal. Other than dry oral mucosa, the examination is normal. Item 24 A 66 year-old woman is evaluated for a 10 year history Which of the following is the most appropriate treatment? I

Which of the following is the most appropriate treatment? Item 26 (A) Anakinra A 48 year old woman is evaluated for sicca. She has a2 year (B) Colchicine history of Sjdgren slmdrome. Chewing sugarless gum and tak ing frequent small sips ofwater are increasingly less helpful for (C) Intra-articulartriamcinolone oral dry,rress. Current medications are artificial tears and oph (D) Naproxen thalmic cyclosporine. She has no other conceming symptoms. On physical examination, vital signs are normal. Other than dry oral mucosa, the examination is normal. Item 24 A 66 year-old woman is evaluated for a 10 year history Which of the following is the most appropriate treatment? I of pain in the hands and knees. She has tried occupa- tional therapy, with minimal beneflt; she is enrolled in a (A) Cevimeline ! weight loss program. She has hypertension and chronic (B) Hydroxychloroquine kidney disease. Current medications are lisinopril and (C) Low-doseprednisone amlodipine. (D) Rituximab On physical examination, Heberden and Bouchard :

weight loss program. She has hypertension and chronic (B) Hydroxychloroquine kidney disease. Current medications are lisinopril and (C) Low-doseprednisone amlodipine. (D) Rituximab On physical examination, Heberden and Bouchard : nodes are present and there is carpometacarpal joint ten- derness. The medial joint line of each knee is tender to palpation. There is bony enlargement of the medial knees, with crepitus on range of motion. ltem 27 A 58-year-old \\"oman is evaluated fbr brief episodes of pain, swelling. and rcdness in thc right wrist for ,1 days. tr Laboratory evaluation shows a serum creatinine level of 2.2 mgldL (194.5 pmouL) and an estimated glomerular During the past 2 years, she has had similar episodes in her flltration rate of 45 ml/min/l.73 m2. lcf't wrist and left third metacarpophalangeal joint, which resolved without treatment. On physical ex:rmination, vital signs are normal. Joint \ Which of the following is the most appropriate examination reveals swelling. warmth, and redness olthe treatment? Ieft wrist and redness and bony enlargement of'the left (A) Hydrocodone third metacarpophalangeal joint. Othcr joints are normal. (B) Meloxicam Laboratory studies show norntal complete blood count. (C) Topical capsaicin conrprehensive metabolic panel, and serum calcium, mag nesium, and thyroid stimulating hormone levels. (D) Topical diclofenac Radiographs of wrist and melacarpophalangeal joir.rts (E) Topical lidocaine are sholvn (top ofnext page). :

nodes are present and there is carpometacarpal joint ten- derness. The medial joint line of each knee is tender to palpation. There is bony enlargement of the medial knees, with crepitus on range of motion. ltem 27 A 58-year-old \\"oman is evaluated fbr brief episodes of pain, swelling. and rcdness in thc right wrist for ,1 days. tr Laboratory evaluation shows a serum creatinine level of 2.2 mgldL (194.5 pmouL) and an estimated glomerular During the past 2 years, she has had similar episodes in her flltration rate of 45 ml/min/l.73 m2. lcf't wrist and left third metacarpophalangeal joint, which resolved without treatment. On physical ex:rmination, vital signs are normal. Joint \ Which of the following is the most appropriate examination reveals swelling. warmth, and redness olthe treatment? Ieft wrist and redness and bony enlargement of'the left (A) Hydrocodone third metacarpophalangeal joint. Othcr joints are normal. (B) Meloxicam Laboratory studies show norntal complete blood count. (C) Topical capsaicin conrprehensive metabolic panel, and serum calcium, mag nesium, and thyroid stimulating hormone levels. (D) Topical diclofenac Radiographs of wrist and melacarpophalangeal joir.rts (E) Topical lidocaine are sholvn (top ofnext page). : 1(J4

Self-Assessment Test vt 6' h E o = t! UI c, UI l,t €, tt

vt 6' h E o = t! UI c, UI l,t €, tt Fl 51 novial ftuid from tl.re left nrist shonrs a leukocyte to control rheumatoid arthritis. She has no sicca symp l*l c,runt tl1 30.000 pl. (30 x 10'),'1.) u,ith 90')1, neutrophilsl torns. Current medications are preclnisone. methotrexatc. coNT pollrizing microscopy shou,s nunrerous positively bire ftrlic acid. and adalimumab. fiingent rhomboid crystals within ncutrophils. Synovial On physical examination, vital signs are normal.'lhere Ilnid Cram stain and cullure are ncgative. are rheumatoid nodules over the olecranon processes. Thc spleen tip is palpable. Joint examination reveals ulnar Which of the following is the most appropriate laboratory deviation, subluxation at the mct:rcarpophalangeal joints, study to perform next? rcduced range of motion at the wrists, and bilateral swell ing of the \,\,rists and Ieft ankle. (A) Antinuclelr anlihodies Laboratory studies: (B) llrythrocytesedimentation rate Absolute neutrophil count 1l00rpL (1.1 x 10'r,L) (C) Itheumatoid factor l-cr-rkocyte count :l800i pL (3.8 x 10'q,'l-) (l)) Serum ferritin Absolute lymphocyte count Normal Platelet count Normal Item 28 Urir-ralysis Normal

Fl 51 novial ftuid from tl.re left nrist shonrs a leukocyte to control rheumatoid arthritis. She has no sicca symp l*l c,runt tl1 30.000 pl. (30 x 10'),'1.) u,ith 90')1, neutrophilsl torns. Current medications are preclnisone. methotrexatc. coNT pollrizing microscopy shou,s nunrerous positively bire ftrlic acid. and adalimumab. fiingent rhomboid crystals within ncutrophils. Synovial On physical examination, vital signs are normal.'lhere Ilnid Cram stain and cullure are ncgative. are rheumatoid nodules over the olecranon processes. Thc spleen tip is palpable. Joint examination reveals ulnar Which of the following is the most appropriate laboratory deviation, subluxation at the mct:rcarpophalangeal joints, study to perform next? rcduced range of motion at the wrists, and bilateral swell ing of the \,\,rists and Ieft ankle. (A) Antinuclelr anlihodies Laboratory studies: (B) llrythrocytesedimentation rate Absolute neutrophil count 1l00rpL (1.1 x 10'r,L) (C) Itheumatoid factor l-cr-rkocyte count :l800i pL (3.8 x 10'q,'l-) (l)) Serum ferritin Absolute lymphocyte count Normal Platelet count Normal Item 28 Urir-ralysis Normal A 52 year-old woman is evaluated at a follow-up visit. Der Which of the following is the most likely diagnosis? matomyositis was diagnosed 4 weeks ago; she was positive (A) AA amyloidosis fbr anti Mi 2 antibodies. Prednisone has improved helio- trope and photosensitive rashes and proximal muscle weak (B) Fclty syndrome ness. She is currently asymptomatic. Current medication is (C) Sjdgren syndrome prednisone, 60 mg/d. She is participating in physical therapy. (l)) Systemic lupus erytl.renrlitosus On physical examination, vital signs are normal. There is no rash. Muscle strength is normal. Serum creatine kinase level is 200 U/L, decreased from Item 30 520 U/L I month ago. A 27-year-old woman is evaluated for a 4-year history of Results of screening colonoscopy, mammography, progressive achy and stiff low back pain that wakes her and cervical cancer screening are all normal. up at night and a 2-year history of intermittent, severe, sharp bilateral buttock pain. She has stiffness for 90 min Which of the following is the most appropriate treatment? utes each morning. Exercise and ibuprofen help relieve pain. She has a history of unilateral uveitis. She has no (A) Add hydroxychloroquine children. (B) Add methotrexate On physical examination, vital signs are normal. (C) Add rituximab Range of motion of the lumbar spine is decreased in all (D) Continue current therapy directions. The eye examination, occiput-to-wall distance, chest expansion, and peripheral joints are normal. Laboratory studies reveal an elevated blood C-reactive

A 52 year-old woman is evaluated at a follow-up visit. Der Which of the following is the most likely diagnosis? matomyositis was diagnosed 4 weeks ago; she was positive (A) AA amyloidosis fbr anti Mi 2 antibodies. Prednisone has improved helio- trope and photosensitive rashes and proximal muscle weak (B) Fclty syndrome ness. She is currently asymptomatic. Current medication is (C) Sjdgren syndrome prednisone, 60 mg/d. She is participating in physical therapy. (l)) Systemic lupus erytl.renrlitosus On physical examination, vital signs are normal. There is no rash. Muscle strength is normal. Serum creatine kinase level is 200 U/L, decreased from Item 30 520 U/L I month ago. A 27-year-old woman is evaluated for a 4-year history of Results of screening colonoscopy, mammography, progressive achy and stiff low back pain that wakes her and cervical cancer screening are all normal. up at night and a 2-year history of intermittent, severe, sharp bilateral buttock pain. She has stiffness for 90 min Which of the following is the most appropriate treatment? utes each morning. Exercise and ibuprofen help relieve pain. She has a history of unilateral uveitis. She has no (A) Add hydroxychloroquine children. (B) Add methotrexate On physical examination, vital signs are normal. (C) Add rituximab Range of motion of the lumbar spine is decreased in all (D) Continue current therapy directions. The eye examination, occiput-to-wall distance, chest expansion, and peripheral joints are normal. Laboratory studies reveal an elevated blood C-reactive tr Item 29 A :)9 year-old woman is evaluated for newly discovered protein level and negative HLA- 827 antigen result. Radiographs of the pelvis and lumbar spine are normal. ncutrcpenia. She has a 10 year history of severe, diflicult

tr Item 29 A :)9 year-old woman is evaluated for newly discovered protein level and negative HLA- 827 antigen result. Radiographs of the pelvis and lumbar spine are normal. ncutrcpenia. She has a 10 year history of severe, diflicult 105

Self-Assessment Test l/r .D Which of the following is the most appropriate diagnostic On physical examination, vital signs are norrnal. Exam- D Ut test to perform next? ination ofthe hands reveals bilateral polyarticular joint swell- u) ing and tenderness involving the metacarpophalangeal joints. lD u! (A) Bone scanning vt (B) CT of pelvis Which of the following is the most likely cause of this (D (C) MRI of pelvis patient's joint pain? (D) Rheumatoid factor and anti-cyclic citrullinated peptide .D (A) Ankylosingspondylitis u) antibodies (B) Erosive osteoarthritis (C) Reactive arthritis Item 31 (D) Rheumatoidarthritis A22 year old woman is evaluated for a l-month history of progressive rash on the face, chest, and arms following sun exposure. She also has experienced wrist arthralgia and malaise for the past 2 weeks. On physical examination, blood pressure is l42l Item 33 A 73 year-old woman is hospitalized for progressive dys- tr pnea. Six months ago, she developed chronic sinusitis and 82 mm Hg, pulse rate is 88/min, and respiration rate is nose bleeds. Four months ago, a persistent dry chronic 16/min. The facial rash is shown. cough developed, followed by myalgia and distal paresthe- sia. She has lost 13.6 kg (30 lb). On physical examination, temperature is 38.2 'C (100.8 "F), blood pressure is 148/96 mm Hg, pulse rate is 104/min, respiration rate is 24lmin, and oxygen saturation is 94% with the patient breathing ambient air. Dry crack- les are heard at the lung bases. There is loss of sensation to light touch in the left foot. Numerous small palpable red-purple lesions are present on the lower legs. laboratory studies: Ery.throcyte 120 mm/h 't I sedimentation rate I

l/r .D Which of the following is the most appropriate diagnostic On physical examination, vital signs are norrnal. Exam- D Ut test to perform next? ination ofthe hands reveals bilateral polyarticular joint swell- u) ing and tenderness involving the metacarpophalangeal joints. lD u! (A) Bone scanning vt (B) CT of pelvis Which of the following is the most likely cause of this (D (C) MRI of pelvis patient's joint pain? (D) Rheumatoid factor and anti-cyclic citrullinated peptide .D (A) Ankylosingspondylitis u) antibodies (B) Erosive osteoarthritis (C) Reactive arthritis Item 31 (D) Rheumatoidarthritis A22 year old woman is evaluated for a l-month history of progressive rash on the face, chest, and arms following sun exposure. She also has experienced wrist arthralgia and malaise for the past 2 weeks. On physical examination, blood pressure is l42l Item 33 A 73 year-old woman is hospitalized for progressive dys- tr pnea. Six months ago, she developed chronic sinusitis and 82 mm Hg, pulse rate is 88/min, and respiration rate is nose bleeds. Four months ago, a persistent dry chronic 16/min. The facial rash is shown. cough developed, followed by myalgia and distal paresthe- sia. She has lost 13.6 kg (30 lb). On physical examination, temperature is 38.2 'C (100.8 "F), blood pressure is 148/96 mm Hg, pulse rate is 104/min, respiration rate is 24lmin, and oxygen saturation is 94% with the patient breathing ambient air. Dry crack- les are heard at the lung bases. There is loss of sensation to light touch in the left foot. Numerous small palpable red-purple lesions are present on the lower legs. laboratory studies: Ery.throcyte 120 mm/h 't I sedimentation rate I Creatinine 1.7 mgldL (150.3 pmol/L) ANCA Positive Antiproteinase-3 70 antibody index (normal 1 I antibodies <1 antibody index) Urinalysis 3+ blood; 2+ protein; 20-30 dysmorphic erythrocltes / hpfi 5-10 leukocytes/hpf Chest radiograph shows peripheral pulmonary paren Similar-appearing patchy skin lesions are seen over chymal opacities. Chest CT scan shows multiple opacities the upper chest in a V-neck distribution and the dorsal and nodules throughout both lungs. forearms. Active and passive wrist extension elicits dis- Kidney biopsy results are pending. comfort. The remainder of the examination is normal. High-dose glucocorticoids are started.

Creatinine 1.7 mgldL (150.3 pmol/L) ANCA Positive Antiproteinase-3 70 antibody index (normal 1 I antibodies <1 antibody index) Urinalysis 3+ blood; 2+ protein; 20-30 dysmorphic erythrocltes / hpfi 5-10 leukocytes/hpf Chest radiograph shows peripheral pulmonary paren Similar-appearing patchy skin lesions are seen over chymal opacities. Chest CT scan shows multiple opacities the upper chest in a V-neck distribution and the dorsal and nodules throughout both lungs. forearms. Active and passive wrist extension elicits dis- Kidney biopsy results are pending. comfort. The remainder of the examination is normal. High-dose glucocorticoids are started. Which of the following is the most likely diagnosis? Which of the following will most likely be the appropriate additional treatment? (A) Acute cutaneous lupus erythematosus (A) Azathioprine (B) Lupus pernio (C) Rosacea (B) Methotrexate (C) Mycophenolatemofetil (D) Subacute cutaneous lupus erythematosus (D) Rituximab

Which of the following is the most likely diagnosis? Which of the following will most likely be the appropriate additional treatment? (A) Acute cutaneous lupus erythematosus (A) Azathioprine (B) Lupus pernio (C) Rosacea (B) Methotrexate (C) Mycophenolatemofetil (D) Subacute cutaneous lupus erythematosus (D) Rituximab Item 32 A 33 year-old woman is evaluated for a 1-month history of Item 34 pain in the hands. She also has stiffness in the hands upon A S0-year-old woman is evaluated for a 2-year history arising in the morning that lasts 90 minutes. She otherwise of pain affecting the knee joints. The pain is associated has been well. She reports no tingling or numbness in the with walking or standing and occurs 1 to 2 days per week. flngers; changes in the color of the digits; or rash, oral She has tried acetaminophen with minimal beneflt; she ulcers, or alopecia. Her vaccinations are up to date. She is enrolled in a weight loss program. She prefers a home- works in her home as a computer software engineer, is not based self-management treatment option. sexually active, has no contact with children, and has not On physical examination, vital signs are normal. BMI traveled. is 33. there is mild tenderness to palpation of knee medial 106

Self-Assessment Test UI joint lines bilaterally. Knee joints are not warm or swol- coronary artery disease, COPD, and a history of diverticuli Fo, len and have normal range of motion. No other joints are tis. Current medications are aspirin, lisinopril, metoprolol, involved. a tiotropium inhaler, methotrexate, and sulfasalazine. €, On physical examination, blood pressure is 136/84 mm E UI vt Which of the following is the most appropriate Hg. BMI is 29. Multiple metacarpophalangeal joints are (u U! treatment? tender to palpation, and there is active synovitis. UI Result of an interferon-gamma release assay is (A) High-impact aerobic exercise negative. (l, (B) Tai chi Hand radiographs show joint space narrowing and t (C) Transcutaneouselectrical nerve stimulation three new erosions. (D) Vegan diet Which of the following is the most appropriate treatment?

UI joint lines bilaterally. Knee joints are not warm or swol- coronary artery disease, COPD, and a history of diverticuli Fo, len and have normal range of motion. No other joints are tis. Current medications are aspirin, lisinopril, metoprolol, involved. a tiotropium inhaler, methotrexate, and sulfasalazine. €, On physical examination, blood pressure is 136/84 mm E UI vt Which of the following is the most appropriate Hg. BMI is 29. Multiple metacarpophalangeal joints are (u U! treatment? tender to palpation, and there is active synovitis. UI Result of an interferon-gamma release assay is (A) High-impact aerobic exercise negative. (l, (B) Tai chi Hand radiographs show joint space narrowing and t (C) Transcutaneouselectrical nerve stimulation three new erosions. (D) Vegan diet Which of the following is the most appropriate treatment? tr Item 35 An 85-year-old woman is evaluated lbr worsening chronic (A) Abatacept (B) Adalimumab right shoulder pain of 1 year's duration. 'lhe pain is more severe with use. She has no history of trauma to the (C) Anakinra shoulder. (D) Tocilizumab On physical examination, vital signs are normal. The (E) Tofacitinib right shoulder is swollen and tender, with no warmth or redness. There is pain-related decreased range of motion of the shoujder in all directions. Other joints are normal. Item 37 Ervthrocfie sedimentation rate and blood C reactive A 42 year old woman is evaluated for 3 months of pain protein level are normal. and swelling in her hands and multiple other joints, as Radiograph of right shoulder is shown. well as morning stiflness lasting more than t hour. She has increasing difficulty with daily activities, such as walking and making the bed. She has no other symptoms or medi- cal problems and takes no medication. On physical examination, vital signs are normal. She has swelling and tenderness of the second and third proxi- mal interphalangeal joints bilaterally, right second and left third metacarpophalangeal joints, left wrist, and bilateral ankles. laboratory studies: C reactive protein 6.4mgldL(64mglL) Rheumatoid factor Positive Antinuclearantibodies 1:80(>1:160positive) Anti-cyclic citrullinated Positive peptide antibodies

tr Item 35 An 85-year-old woman is evaluated lbr worsening chronic (A) Abatacept (B) Adalimumab right shoulder pain of 1 year's duration. 'lhe pain is more severe with use. She has no history of trauma to the (C) Anakinra shoulder. (D) Tocilizumab On physical examination, vital signs are normal. The (E) Tofacitinib right shoulder is swollen and tender, with no warmth or redness. There is pain-related decreased range of motion of the shoujder in all directions. Other joints are normal. Item 37 Ervthrocfie sedimentation rate and blood C reactive A 42 year old woman is evaluated for 3 months of pain protein level are normal. and swelling in her hands and multiple other joints, as Radiograph of right shoulder is shown. well as morning stiflness lasting more than t hour. She has increasing difficulty with daily activities, such as walking and making the bed. She has no other symptoms or medi- cal problems and takes no medication. On physical examination, vital signs are normal. She has swelling and tenderness of the second and third proxi- mal interphalangeal joints bilaterally, right second and left third metacarpophalangeal joints, left wrist, and bilateral ankles. laboratory studies: C reactive protein 6.4mgldL(64mglL) Rheumatoid factor Positive Antinuclearantibodies 1:80(>1:160positive) Anti-cyclic citrullinated Positive peptide antibodies Which of the following is the most likely diagnosis? (A) Chikungunya virus infection Synovial fluid from the right shoulder is blood-tinged; (B) Parvovirus 819 infection analysis of fluid reveals a lcukocyte count of 500rpl (0.5 x 10'i L), negative Gram stain and culture results. and (C) Rheumatoidarthritis no crystals. (D) Systemic lupus erythematosus

Which of the following is the most likely diagnosis? (A) Chikungunya virus infection Synovial fluid from the right shoulder is blood-tinged; (B) Parvovirus 819 infection analysis of fluid reveals a lcukocyte count of 500rpl (0.5 x 10'i L), negative Gram stain and culture results. and (C) Rheumatoidarthritis no crystals. (D) Systemic lupus erythematosus Which of the following is the most likely diagnosis? Item 38 (A) Adhesivecapsulitis A 65 year-old man is evaluated for a 4-month history of (B) Basic calcium phosphate associated arthritis a rash over the face and hands and a 3 month history of (C) Calcium pyrophosphate deposition disease progressive proximal muscle weakness. He also reports (D) Rheumatoidarthritis a 6.8-kg (15-lb) unintentional weight loss. He has had no fevers, respiratory symptoms, or sensory changes. On physical examination, vital signs are normal. There Item 36 is weakness in the proximal muscles of the arms and legs. A 58 year-old man is evaluated at a follow-up visit. He has A thickened, red rash is seen on the cheeks, forehead, and had rheumatoid arthritis for 5 years. Increasing morning upper chest. Photograph ofhand is shown (top ofnext page); stiffness, fatigue, increasing joint pain, and swelling of similar flndings are seen on both elbows. There is no muscle small hand joints have developed in the past 6 months. His tenderness, joint swelling, or edema. The remainder of the disease activity score shows moderate activity. He also has examination is normal. 107

Self-Assessment Test vr TD Which of the following is the most likely diagnosis? D UI (A) Adult-onset Still disease ra .D ta (B) Familial Mediterranean fever art (C) Infectiousendocarditis (D (D) Systemic lupus erythematosus { .D t (,l Item 40 A 47-year-old woman is evaluated for a 3-year history of pain in all of her muscles and joints. She is a commercial truck driver. Her sleep is poor, and she awakens unre- freshed. She completes a flbromyalgia diagnostic ques- tionnaire and meets the criteria for flbromyalgia. She has anxiety and depression, with a history of opioid use disor- der. She takes no medications. On physical examination, vital signs are normal. Physical examination flndings are limited to widespread muscle tenderness with normal strength. Laboratory evaluation reveals an erythrocyte sedi- mentation rate of 19 mm/h, a blood C reactive protein level of 0.3 mg/dl (3 mg/L), and a thyroid-stimulating hormone level of 1.6 pU/mL (1.6 mU/L). Low-impact aerobic exercise is recommended. Laboratory evaluation reveals a hemoglobin level of Which of the following is the most appropriate additional 12.5 g/dl (125 g/L) and serum creatine kinase Ievel of4500 U/L. treatment?

vr TD Which of the following is the most likely diagnosis? D UI (A) Adult-onset Still disease ra .D ta (B) Familial Mediterranean fever art (C) Infectiousendocarditis (D (D) Systemic lupus erythematosus { .D t (,l Item 40 A 47-year-old woman is evaluated for a 3-year history of pain in all of her muscles and joints. She is a commercial truck driver. Her sleep is poor, and she awakens unre- freshed. She completes a flbromyalgia diagnostic ques- tionnaire and meets the criteria for flbromyalgia. She has anxiety and depression, with a history of opioid use disor- der. She takes no medications. On physical examination, vital signs are normal. Physical examination flndings are limited to widespread muscle tenderness with normal strength. Laboratory evaluation reveals an erythrocyte sedi- mentation rate of 19 mm/h, a blood C reactive protein level of 0.3 mg/dl (3 mg/L), and a thyroid-stimulating hormone level of 1.6 pU/mL (1.6 mU/L). Low-impact aerobic exercise is recommended. Laboratory evaluation reveals a hemoglobin level of Which of the following is the most appropriate additional 12.5 g/dl (125 g/L) and serum creatine kinase Ievel of4500 U/L. treatment? Which of the following is the most appropriate test to (A) Amitriptyline perform next? (B) Diclofenac (A) Antinuclear antibody testing (C) Duloxetine (B) Colonoscopy (D) Pregabalin (C) Muscle biopsy (E) Tramadol (D) Pulmonary function testing Item 41 Item 39 A 46 year-old woman is evaluated at a follow-up visit to A 24-year-old man is evaluated for fever of 6 weeks' dura- discuss results of bone mineral density testing. She has tion. He also has joint pain, myalgia, and occasional sore a l0-year history of myasthenia gravis and is receiving throat. The fever begins in the early evening and resolves long-term glucocorticoid therapy. Current medications by morning. His most recent temperature in the eve- are azathioprine, prednisone, calcium/vitamin D, and ning was 39.5 'C (103.1 'F). The fever is accompanied by a pyridostigmine. salmon-pink macular rash on the trunk and arms, which Dual energy x ray absorptiometry shows T-scores of resolves with the fever. He has no history of travel. Current 2.1 at the lumbar spine and 1.9 at the femoral neck, with medication is acetaminophen. corrected Fracture Risk Assessment Tool scores of 3.5u1, at On physical examination, temperature is 37.5 'C the hip and17% overall. (99.6'F). The remaining vital signs are normal. There is bilateral cervical lymphadenopathy. A friction rub is heard Which of the following is the most appropriate bilaterally at the lung bases. Abdomen is tender without treatment? guarding. The knees have eflusions. Cardiac examination is normai. (A) Alendronate [.aboratory studies: (B) Calcitonin Erythrocyte sedimentation rate 125 mm/h (C) Romosozumab Leukocyte count 22,OOOl1tL (22xtoe lL) (D) Teriparatide Hemoglobin 11.5 g/dl (11s g/L) Ferritin 5200 ng/ml (5200 pg/L) Blood cultures are pending. Item 42 A chest CT scan shows small pleural effusions bilater- A 32 year-old woman is evaluated for pain in the right elbow ally with moderate pleural thickening. An abdominal CT of a few months' duration. She has no history of injury. The scan shows a small amount of ascitic fluid with evidence of pain worsened after she began a new exercise program that peritoneal thickening. includes weights, and it is exacerbated with use. The pain

Which of the following is the most appropriate test to (A) Amitriptyline perform next? (B) Diclofenac (A) Antinuclear antibody testing (C) Duloxetine (B) Colonoscopy (D) Pregabalin (C) Muscle biopsy (E) Tramadol (D) Pulmonary function testing Item 41 Item 39 A 46 year-old woman is evaluated at a follow-up visit to A 24-year-old man is evaluated for fever of 6 weeks' dura- discuss results of bone mineral density testing. She has tion. He also has joint pain, myalgia, and occasional sore a l0-year history of myasthenia gravis and is receiving throat. The fever begins in the early evening and resolves long-term glucocorticoid therapy. Current medications by morning. His most recent temperature in the eve- are azathioprine, prednisone, calcium/vitamin D, and ning was 39.5 'C (103.1 'F). The fever is accompanied by a pyridostigmine. salmon-pink macular rash on the trunk and arms, which Dual energy x ray absorptiometry shows T-scores of resolves with the fever. He has no history of travel. Current 2.1 at the lumbar spine and 1.9 at the femoral neck, with medication is acetaminophen. corrected Fracture Risk Assessment Tool scores of 3.5u1, at On physical examination, temperature is 37.5 'C the hip and17% overall. (99.6'F). The remaining vital signs are normal. There is bilateral cervical lymphadenopathy. A friction rub is heard Which of the following is the most appropriate bilaterally at the lung bases. Abdomen is tender without treatment? guarding. The knees have eflusions. Cardiac examination is normai. (A) Alendronate [.aboratory studies: (B) Calcitonin Erythrocyte sedimentation rate 125 mm/h (C) Romosozumab Leukocyte count 22,OOOl1tL (22xtoe lL) (D) Teriparatide Hemoglobin 11.5 g/dl (11s g/L) Ferritin 5200 ng/ml (5200 pg/L) Blood cultures are pending. Item 42 A chest CT scan shows small pleural effusions bilater- A 32 year-old woman is evaluated for pain in the right elbow ally with moderate pleural thickening. An abdominal CT of a few months' duration. She has no history of injury. The scan shows a small amount of ascitic fluid with evidence of pain worsened after she began a new exercise program that peritoneal thickening. includes weights, and it is exacerbated with use. The pain 108

Self-Assessment Test Ul makes it hard to lift things. She also has increased fatigue. On physical examination, vital signs are normal. Sym att Acetaminophen partially alleviates the pain. metric proximal and distal weakness in both arms is noted. There is local tenderness over the right lateral epicon Hip flexor strength is diminished, and he has a waddling c, dyle, and active wrist extension against resistance elicits gait. Otherwise, Iower extremity strength is normal. Upper ra pain. She has full range of motion of the shoulder, elbow, t! extremity examination is notable for atrophy of the fore o vt and wrist. There is no warmth, redness, or swelling. All arm muscles and a weak grip. No muscle tenderness, joint tt other joints are normal. swelling, edema, or rash is observed. Serum creatine kinase level is 310 U/L. Erythrocyte +q, Which of the following is the most likely cause of the sedimentation rate, serum aminotransferase levels, and (a patient's symptoms? thyroid-stimulating hormone level are normal. (A) Degenerat ive joint disease Which of the following is the most likely diagnosis? (B) Disorder ofcenlral pain processing (C) Inflammatoryarthritis (A) Inclusion body myositis (D) Mechanical soft-tissue injury (B) Polymyositis (C) Statin myopathy (D) Systemic lupus erythematosus Item 43 A Sl-year old woman is evaluated for an immigration physical examination. She has a 2 year history of rheuma toid arthritis. Immigration requirements include multiple Item 46 A 28 year old man is seen in lbllow up for management of tr vaccinations, and she has no recollection or record ofher a multisystem febrile illness. Up until 6 neeks ago he was immunizations. Current medications are oral methotrex in good health. He takes no medications. ate, tofacitinib, and folic acid. On physical examination, temperature is ll8.2 'C (10o.8 'F), and blood pressure is 1SBi 84 nlm Hg. Bilateral Which of the following vaccines is contraindicated in this 2+ ankle edema and bilateral tenderness and swelling of patient? the metacarpophalangeal joints and wrists are observed. 'lhe remainder of the examination is normal. (A) Hepatitis B virus Laborato4r studies: t (B) Measles, mumps, and rubella Henroglobin B.e gi dL (Be g/L) (C) Quadrivalentinfluenza Leukocyte count 3U00/pt- (3.8 x 10erL) (D) Tetanus toxoid, reduced diphtheria toxoid, and acel- Platelet count 90.000iirl (90 x 10ei L) lular pertussis Cl) complement l.ow (E) 13-Valent pneumococcal conjugate 04 cornplement Low (lreatinine 1.6 mgrdl. (t41.4 pn-rolrL) Anti double-stranded Positivc Item 44 DNA antibodies Antinuclear antibodies I :1 280 (speckted pattern) ; A 40 year old woman is evaluated fbr a 6 month history Urinalysis 2+ blor-rd; 3+ protein; dysmorphic of bilateral hand and wrist pain and swelling. She has erythrocytes; no casts morning stiflness lasting for t hour. Her hands and wrists Urine protein -creatinine :150 mg/g i are swollen. ratio Soft tissue swelling and warmth and tenderness of the second through fourth metacarpophalangeal joints and Kidney biopsy results are pending. t Prednisone is initiated. wrists bilaterally are noted. Range of motion of these joints i is normal but painful. A diagnosis of rheumatoid arthritis is being considered. Which of the following is the most appropriate additional ; treatment? Which of the following will be most helptul in establishing (A) Azathioprine It the diagnosis? (B) Ilydroxychloroquine (A) Anti-cyclic citrullinated peptide (CCP) antibodies (C) I Iydroxychloroquine and mycophenolate mofetil (B) Anti-CCP antibodies and rheumatoid factor (D) No additional therapy 5 (C) C3 and C4 complements (D) Rheumatoid factor i Item 47 A S7-year-oldwomanisevaluated forfatigue, generalDed ach Item 45 iness, and oral dryness without ocular dryness. Her review of A 73 year old man is evaluated lor a 3-year history of systems is unremarkable. She has hypothyroidism, migraine progressive weakness. He has a 7-year history of hyper- headaches, major depressive disorder, and chronic allergic lipidemia and hypertension treated with atorvastatin and rhinitis. Current medications are levothyroxine, amitripty Iisinopril. line, citalopram, intranasal glucocorticoids, and cetirizine.

Ul makes it hard to lift things. She also has increased fatigue. On physical examination, vital signs are normal. Sym att Acetaminophen partially alleviates the pain. metric proximal and distal weakness in both arms is noted. There is local tenderness over the right lateral epicon Hip flexor strength is diminished, and he has a waddling c, dyle, and active wrist extension against resistance elicits gait. Otherwise, Iower extremity strength is normal. Upper ra pain. She has full range of motion of the shoulder, elbow, t! extremity examination is notable for atrophy of the fore o vt and wrist. There is no warmth, redness, or swelling. All arm muscles and a weak grip. No muscle tenderness, joint tt other joints are normal. swelling, edema, or rash is observed. Serum creatine kinase level is 310 U/L. Erythrocyte +q, Which of the following is the most likely cause of the sedimentation rate, serum aminotransferase levels, and (a patient's symptoms? thyroid-stimulating hormone level are normal. (A) Degenerat ive joint disease Which of the following is the most likely diagnosis? (B) Disorder ofcenlral pain processing (C) Inflammatoryarthritis (A) Inclusion body myositis (D) Mechanical soft-tissue injury (B) Polymyositis (C) Statin myopathy (D) Systemic lupus erythematosus Item 43 A Sl-year old woman is evaluated for an immigration physical examination. She has a 2 year history of rheuma toid arthritis. Immigration requirements include multiple Item 46 A 28 year old man is seen in lbllow up for management of tr vaccinations, and she has no recollection or record ofher a multisystem febrile illness. Up until 6 neeks ago he was immunizations. Current medications are oral methotrex in good health. He takes no medications. ate, tofacitinib, and folic acid. On physical examination, temperature is ll8.2 'C (10o.8 'F), and blood pressure is 1SBi 84 nlm Hg. Bilateral Which of the following vaccines is contraindicated in this 2+ ankle edema and bilateral tenderness and swelling of patient? the metacarpophalangeal joints and wrists are observed. 'lhe remainder of the examination is normal. (A) Hepatitis B virus Laborato4r studies: t (B) Measles, mumps, and rubella Henroglobin B.e gi dL (Be g/L) (C) Quadrivalentinfluenza Leukocyte count 3U00/pt- (3.8 x 10erL) (D) Tetanus toxoid, reduced diphtheria toxoid, and acel- Platelet count 90.000iirl (90 x 10ei L) lular pertussis Cl) complement l.ow (E) 13-Valent pneumococcal conjugate 04 cornplement Low (lreatinine 1.6 mgrdl. (t41.4 pn-rolrL) Anti double-stranded Positivc Item 44 DNA antibodies Antinuclear antibodies I :1 280 (speckted pattern) ; A 40 year old woman is evaluated fbr a 6 month history Urinalysis 2+ blor-rd; 3+ protein; dysmorphic of bilateral hand and wrist pain and swelling. She has erythrocytes; no casts morning stiflness lasting for t hour. Her hands and wrists Urine protein -creatinine :150 mg/g i are swollen. ratio Soft tissue swelling and warmth and tenderness of the second through fourth metacarpophalangeal joints and Kidney biopsy results are pending. t Prednisone is initiated. wrists bilaterally are noted. Range of motion of these joints i is normal but painful. A diagnosis of rheumatoid arthritis is being considered. Which of the following is the most appropriate additional ; treatment? Which of the following will be most helptul in establishing (A) Azathioprine It the diagnosis? (B) Ilydroxychloroquine (A) Anti-cyclic citrullinated peptide (CCP) antibodies (C) I Iydroxychloroquine and mycophenolate mofetil (B) Anti-CCP antibodies and rheumatoid factor (D) No additional therapy 5 (C) C3 and C4 complements (D) Rheumatoid factor i Item 47 A S7-year-oldwomanisevaluated forfatigue, generalDed ach Item 45 iness, and oral dryness without ocular dryness. Her review of A 73 year old man is evaluated lor a 3-year history of systems is unremarkable. She has hypothyroidism, migraine progressive weakness. He has a 7-year history of hyper- headaches, major depressive disorder, and chronic allergic lipidemia and hypertension treated with atorvastatin and rhinitis. Current medications are levothyroxine, amitripty Iisinopril. line, citalopram, intranasal glucocorticoids, and cetirizine. 109

Self-Assessment Test ln (D On physical examination, vital signs are normal. Oral Which of the following is the most likely diagnosis? D vt dryness is noted. There is no ocular inflammation or dry- (A) Eosinophilic granulomatosis with polyangiitis UI ness or salivary gland enlargement. The remainder of the t,D gr (B) Hypersensitivityvasculitis tt examination is normal. (C) Polyarteritisnodosa .D Laboratory studies: Ery.throcyte sedimentation rate 18 mm/h (D) Rheumatoidvasculitis { .D Thyroid-stimulating hormone 1.6 pU/mL (1.6 mU/L) Ut Rheumatoid factor Negative Antinuclear antibody 1:80 Item 49 Anti-La/SSB antibody Negative A ss-year old man is evaluated for urate-iowering ther- Anti Ro/SSA antibody Negative apy. He has experienced three gout flares over the past year. He also has hypertension and chronic stable angina. Which of the following is the most likely cause of this Current medications are low dose aspirin, metoprolol, patient's oral dryness? atorvastatin, and lisinopril. He is of Han Chinese descent. (A) Hypothyroidism Laboratory evaluation reveals a serum urate level of 9.8 mg/dL (0.s8 mmol/L). (B) Medication adverse effects (C) Sjogren syndrome Which ofthe following is the most appropriate management? (D) Systemic lupus eqthematosus (A) Allopurinol (B) Discontinuation of aspirin Item 48 (C) Febuxostat A 63-year-old woman is evaluated for fatigue and a leg rash (D) HLA B.57:01 allele testing that began 4 days ago. She has no other symptoms. She has recently diagnosed hypertension, and hydrochlorothiazide (E) HLA B-58:01 allele testing was initiated 2 weeks ago. On physical examination, vital signs are normal. The rash is shown. The larger lesions are palpable. The remain Item 50 der of the examination is normal. A72 year old man is evaluated for a 15-year history of pain and stiffness in the knees. He can walk only 50 yards before needing to stop because ofthe knee pain. He has tried exer- cises and physical therapy without relief. Intra articular glucocorticoids provide minimal relief. He has no other medical problems. Current medications are maximum dosages of celecoxib, duloxetine, and acetaminophen. On physical examination, the medial joint line of each knee is tender to palpation. He has crepitus r,l'ith movement.

ln (D On physical examination, vital signs are normal. Oral Which of the following is the most likely diagnosis? D vt dryness is noted. There is no ocular inflammation or dry- (A) Eosinophilic granulomatosis with polyangiitis UI ness or salivary gland enlargement. The remainder of the t,D gr (B) Hypersensitivityvasculitis tt examination is normal. (C) Polyarteritisnodosa .D Laboratory studies: Ery.throcyte sedimentation rate 18 mm/h (D) Rheumatoidvasculitis { .D Thyroid-stimulating hormone 1.6 pU/mL (1.6 mU/L) Ut Rheumatoid factor Negative Antinuclear antibody 1:80 Item 49 Anti-La/SSB antibody Negative A ss-year old man is evaluated for urate-iowering ther- Anti Ro/SSA antibody Negative apy. He has experienced three gout flares over the past year. He also has hypertension and chronic stable angina. Which of the following is the most likely cause of this Current medications are low dose aspirin, metoprolol, patient's oral dryness? atorvastatin, and lisinopril. He is of Han Chinese descent. (A) Hypothyroidism Laboratory evaluation reveals a serum urate level of 9.8 mg/dL (0.s8 mmol/L). (B) Medication adverse effects (C) Sjogren syndrome Which ofthe following is the most appropriate management? (D) Systemic lupus eqthematosus (A) Allopurinol (B) Discontinuation of aspirin Item 48 (C) Febuxostat A 63-year-old woman is evaluated for fatigue and a leg rash (D) HLA B.57:01 allele testing that began 4 days ago. She has no other symptoms. She has recently diagnosed hypertension, and hydrochlorothiazide (E) HLA B-58:01 allele testing was initiated 2 weeks ago. On physical examination, vital signs are normal. The rash is shown. The larger lesions are palpable. The remain Item 50 der of the examination is normal. A72 year old man is evaluated for a 15-year history of pain and stiffness in the knees. He can walk only 50 yards before needing to stop because ofthe knee pain. He has tried exer- cises and physical therapy without relief. Intra articular glucocorticoids provide minimal relief. He has no other medical problems. Current medications are maximum dosages of celecoxib, duloxetine, and acetaminophen. On physical examination, the medial joint line of each knee is tender to palpation. He has crepitus r,l'ith movement. Which of the following is the most appropriate treatment? (A) Arthroscopic knee surgery (B) Chondroitin sulfate and glucosamine (C) Intra-articular hyaluronic acid injection (D) Intra articular platelet rich plasma injection (E) Total knee replacement

Which of the following is the most appropriate treatment? (A) Arthroscopic knee surgery (B) Chondroitin sulfate and glucosamine (C) Intra-articular hyaluronic acid injection (D) Intra articular platelet rich plasma injection (E) Total knee replacement Item 51 A 53 year old man is evaluated in the emergencl'depart tr ment for abdominal pain. Four rt'eeks ago. fatigue and malaise developed. followed 1 u,eek later by a rash. Trvo r,r,eeks ago. he began tripping or,er his left fbot. Three da1,s ago. he developed abdominal pain after a meai; abdominal pain is nolt constant. On physical examination. temperature is 38.0 "C (100.,1 "F). and blood pressure is 154 96 mm Hg: other vital signs are normal. The abdomen is soft and nontender. N{us cle strength at dorsiflexion of the left ankle is 315. Erythem Laboratory evaluation reveals normal complete blood atous nodules are present on the lower legs. The remainder count, comprehensive metabolic panel, and urinalysis results. of the examination is normal. 110

Self-Assessment Test vt o tr ffia.;fl;**o' g coNT reactiveprotein 8.7 gidL(87 s,tLj Item 54 A 56 year old woman is evaluated for a 2 year history of F €, 13.8 mg/dl (138 mg/L) osteoarthritis involving the flngers, bases of the thumbs, Creatinine 7.7 mgldL (rSO.: pmol/L) UI hips, and knees. She has tried physical and aquatic therapy (,} Urinalysis Normal (u with minimal beneflt, and she is enrolled in a weight loss vt Hepatitis C virus serology Negative program. She has no other medical problems and takes no t! HIV testing Negative medications. (u Chest radiograph is normal. On physical examination, vital signs are normal. vt BMI is 29. Heberden and Bouchard nodes and squaring Which of the following is most likely to establish the of the bilateral flrst carpometacarpal joints are present. diagrrosis? The flrst carpometacarpal joints and medial joint line of both knees are tender to palpation. There is pain in the (A) ANCA panel anterior left groin on internal rotation of the hip. There (B) Hepatitis A virus serology is bony enlargement of the knees, with crepitus on range (C) Kidney biopsy of motion. (D) Magnetic resonance angiography of abdomen Which of the following is the most appropriate treatment?

vt o tr ffia.;fl;**o' g coNT reactiveprotein 8.7 gidL(87 s,tLj Item 54 A 56 year old woman is evaluated for a 2 year history of F €, 13.8 mg/dl (138 mg/L) osteoarthritis involving the flngers, bases of the thumbs, Creatinine 7.7 mgldL (rSO.: pmol/L) UI hips, and knees. She has tried physical and aquatic therapy (,} Urinalysis Normal (u with minimal beneflt, and she is enrolled in a weight loss vt Hepatitis C virus serology Negative program. She has no other medical problems and takes no t! HIV testing Negative medications. (u Chest radiograph is normal. On physical examination, vital signs are normal. vt BMI is 29. Heberden and Bouchard nodes and squaring Which of the following is most likely to establish the of the bilateral flrst carpometacarpal joints are present. diagrrosis? The flrst carpometacarpal joints and medial joint line of both knees are tender to palpation. There is pain in the (A) ANCA panel anterior left groin on internal rotation of the hip. There (B) Hepatitis A virus serology is bony enlargement of the knees, with crepitus on range (C) Kidney biopsy of motion. (D) Magnetic resonance angiography of abdomen Which of the following is the most appropriate treatment? tr Item 52 A 45-year old man is evaluated 2 weeks after an ernergency (A) Acetaminophen (B) Duloxetine department visit for gouty olecranon bursitis. Naproxen was initiated at 500 mg twice daily; after clinical improvement, (C) Gabapentin the dosage was tapered. He has a 5 year history of acute gout (D) Piroxicam that occurs three times a year. He also has a history of kidney (E) Tramadol stones. Current medication is naproxen, 250 mg twice daily. There is left olecranon bursal thickening without redness, warmth, orfluid. Tophi are presentbilaterallyinthe flrst meta- Item 55 tarsophalangeal joints without swelling, redness, or warmth. A 65-year-old man is evaluated for "pain everyr,vhere." Kidney f'unction is normal. Serum urate level is Two months ago, he developed neck and upper back pain, 10.5 rng/dl (0.02 rnmolll). fatigue, and malaise. Over the next few weeks, stiffness and achiness developed in the shoulders and upper arms. He has Which of the following is the most appropriate additional no headaches, visual changes, or jaw discomfort. He takes treatment? no medications. (A) Allopurinol On physical examination, vital signs are normal. There is no scalp tenderness. Temporal artery pulses are normal. (B) Colchieine There are no swollen or tender joints. Discomfort limits (C) Febuxostat range of shoulder motion bilaterally and causes difficulty (D) Probenecid with standing from a seated position. Extremity strength and reflexes are normal. Laboratory evaluation shows a normal complete Item 53 blood count, normal serum thyroid stimulating hormone A 35-year-old man is evaluated for a 3-day history of level, and blood C-reactive protein level of 6.8 mg/dl abrupt polyarticular joint pain in both hands. His S-year- (os mg/L). old daughter recently had a low grade fever and malaise with 1 day offrequent loose stools; 2 days later she had an Which of the following is the most appropriate erythematous rash over her cheeks. management? On physical examination, vital signs are normal. Joint (A) Measurement of rheumatoid factor, antinuclear anti examination shows tenderness of the right second, third, bodies, and ANCA and fourth proximal interphalangeal joints; tenderness ofthe right second and third metacarpophalangeal joints; (B) Prednisone, 15 mg/d tenderness of the left second and third proximal interpha (C) Prednisone, 60 mg/d langeal joints; and tenderness ofthe left second and third (D) Pregabalin metacarpophalangeal joints. Results of serologic tests are pending. Item 56 Which of the following is the most appropriate treatment? A 63-year old man is evaluated for an S-week history (A) Diclofenac of a spreading rash on the feet and legs, fatigue, and arthralgia. (B) Etanercept On physical examination, vital signs are normal. The (C) Hydroxychloroquine rash is shown (top of next page). Some lesions are palpable. (D) Methotrexate He cannot extend his left wrist. Findings on pulmonary,

tr Item 52 A 45-year old man is evaluated 2 weeks after an ernergency (A) Acetaminophen (B) Duloxetine department visit for gouty olecranon bursitis. Naproxen was initiated at 500 mg twice daily; after clinical improvement, (C) Gabapentin the dosage was tapered. He has a 5 year history of acute gout (D) Piroxicam that occurs three times a year. He also has a history of kidney (E) Tramadol stones. Current medication is naproxen, 250 mg twice daily. There is left olecranon bursal thickening without redness, warmth, orfluid. Tophi are presentbilaterallyinthe flrst meta- Item 55 tarsophalangeal joints without swelling, redness, or warmth. A 65-year-old man is evaluated for "pain everyr,vhere." Kidney f'unction is normal. Serum urate level is Two months ago, he developed neck and upper back pain, 10.5 rng/dl (0.02 rnmolll). fatigue, and malaise. Over the next few weeks, stiffness and achiness developed in the shoulders and upper arms. He has Which of the following is the most appropriate additional no headaches, visual changes, or jaw discomfort. He takes treatment? no medications. (A) Allopurinol On physical examination, vital signs are normal. There is no scalp tenderness. Temporal artery pulses are normal. (B) Colchieine There are no swollen or tender joints. Discomfort limits (C) Febuxostat range of shoulder motion bilaterally and causes difficulty (D) Probenecid with standing from a seated position. Extremity strength and reflexes are normal. Laboratory evaluation shows a normal complete Item 53 blood count, normal serum thyroid stimulating hormone A 35-year-old man is evaluated for a 3-day history of level, and blood C-reactive protein level of 6.8 mg/dl abrupt polyarticular joint pain in both hands. His S-year- (os mg/L). old daughter recently had a low grade fever and malaise with 1 day offrequent loose stools; 2 days later she had an Which of the following is the most appropriate erythematous rash over her cheeks. management? On physical examination, vital signs are normal. Joint (A) Measurement of rheumatoid factor, antinuclear anti examination shows tenderness of the right second, third, bodies, and ANCA and fourth proximal interphalangeal joints; tenderness ofthe right second and third metacarpophalangeal joints; (B) Prednisone, 15 mg/d tenderness of the left second and third proximal interpha (C) Prednisone, 60 mg/d langeal joints; and tenderness ofthe left second and third (D) Pregabalin metacarpophalangeal joints. Results of serologic tests are pending. Item 56 Which of the following is the most appropriate treatment? A 63-year old man is evaluated for an S-week history (A) Diclofenac of a spreading rash on the feet and legs, fatigue, and arthralgia. (B) Etanercept On physical examination, vital signs are normal. The (C) Hydroxychloroquine rash is shown (top of next page). Some lesions are palpable. (D) Methotrexate He cannot extend his left wrist. Findings on pulmonary, 111

Self-Assessment Test vr (D cardiac, and gastrointestinal examinations are unremark- Item 58 vt able. There are no swollen or tender joints. A 62-year-old woman is evaluated for joint pain. She has a l/} (D UI 10-year history ofpsoriasis and a 3-year history ofarthritis. t Her psoriasis has been controlled with adalimumab, but (D joint symptoms persist. She has stiffness in the affected joints for less than 30 minutes every morning, and pain .D increases with activity. There is no dactylitis. Current t^ medication is adalimumab. On physical examination, there are small psoriatic plaques on the left elbow and right knee. She has bony enlargement, without swelling, of most distal and prox imal interphalangeal joints of the hands. the left knee has a small effusion. The remainder of the examination is normal. Radiographs of the hands show joint-space narrow- ing and osteophytes at the distal and proximal interpha- Iangeal joints of both hands. Radiographs of the knees show medial joint-space narrowing and subchondral sclerosis of the left medial compartment. laboratory studies: Erythrocyte sedimentation rate 110 mm/h Which of the following is the most likely cause of this Alanine aminotransferase 93UIL patient's joint pain? Aspartate aminotransferase 89 U/L (A) Chronic gout C3 complement 113 mg/dl (rrao mg/L) (B) Osteoarthritis C4 complement Not detected Creatinine 2.r mgl dL (18s.6 pmol/L) (C) Psoriaticarthritis Rheumatoid factor 118 U/mL (118 kU/L) (D) Rheumatoidarthritis Anti-cyclic citrullinated Not detected peptide antibodies Urinalysis 2+ blood; 2+ protein; Item 59 dysmorphic A 40 year-old woman is evaluated for a 9-month history erythrocytes; no casts of Raynaud phenomenon. She reports no dilficulty swal- lowing, dyspnea on exertion, or hand stiffness. She has Which of the following is the most likely diagnosis? recently developed gastroesophageal reflux disease. (A) Cryoglobulinemicvasculitis On physical examination, vital signs are normal. The (B) Hlpersensitivityvasculitis skin between the distal and proximal interphalangeal joints ofthe flngers is difficult to tent. Ihree telangiectasias (C) Polyarteritisnodosa on the right hand and four on the left are noted. She also (D) Rheumatoidvasculitis has two small telangiectasias on the face and one on the inside bottom lip. No digital pitting is seen. Laboratory evaluation reveals a positive antinuclear Item 57 antibody titer (1:SZO) and positive anticentromere antibody A 36-year-old woman is evaluated for preconception titer (1:160). counseling. She has a 3 year history of rheumatoid arthri- tis well controlled with leflunomide, hydroxychloroquine, Which of the following is the most likely diagnosis? and certolizumab. Her most recent disease activity score showed remission. In the past, attempts to discontinue her (A) Diffuse cutaneous systemic sclerosis medications have been unsuccessful because ofrecurrent (B) Eosinophilicfasciitis active disease. (C) Limited cutaneous systemic sclerosis On physical examination, vital signs are normal. BMI (D) Mixed connective tissue disease is 24. Range of motion is normal, and joints are not warm or swollen. Item 6O Which of the following is the most appropriate A 60-year-oldwoman is evaluated for achiness and fatigue. preconception management? She reports dry mouth, irritated eyes, and discoloration of (A) Discontinue all drugs flngers after exposure to cold temperature that rapidly (B) Discontinuecertolizumab responds to rewarming. (C) Discontinuehydroxychloroquine On physical examination, vital signs are normal. Parotid glands are enlarged, and salivary pooling is (D) Discontinueleflunomide decreased. There is no lymphadenopathy. All appendicular (E) No changes are needed joints have preserved range of motion without discomfort.

vr (D cardiac, and gastrointestinal examinations are unremark- Item 58 vt able. There are no swollen or tender joints. A 62-year-old woman is evaluated for joint pain. She has a l/} (D UI 10-year history ofpsoriasis and a 3-year history ofarthritis. t Her psoriasis has been controlled with adalimumab, but (D joint symptoms persist. She has stiffness in the affected joints for less than 30 minutes every morning, and pain .D increases with activity. There is no dactylitis. Current t^ medication is adalimumab. On physical examination, there are small psoriatic plaques on the left elbow and right knee. She has bony enlargement, without swelling, of most distal and prox imal interphalangeal joints of the hands. the left knee has a small effusion. The remainder of the examination is normal. Radiographs of the hands show joint-space narrow- ing and osteophytes at the distal and proximal interpha- Iangeal joints of both hands. Radiographs of the knees show medial joint-space narrowing and subchondral sclerosis of the left medial compartment. laboratory studies: Erythrocyte sedimentation rate 110 mm/h Which of the following is the most likely cause of this Alanine aminotransferase 93UIL patient's joint pain? Aspartate aminotransferase 89 U/L (A) Chronic gout C3 complement 113 mg/dl (rrao mg/L) (B) Osteoarthritis C4 complement Not detected Creatinine 2.r mgl dL (18s.6 pmol/L) (C) Psoriaticarthritis Rheumatoid factor 118 U/mL (118 kU/L) (D) Rheumatoidarthritis Anti-cyclic citrullinated Not detected peptide antibodies Urinalysis 2+ blood; 2+ protein; Item 59 dysmorphic A 40 year-old woman is evaluated for a 9-month history erythrocytes; no casts of Raynaud phenomenon. She reports no dilficulty swal- lowing, dyspnea on exertion, or hand stiffness. She has Which of the following is the most likely diagnosis? recently developed gastroesophageal reflux disease. (A) Cryoglobulinemicvasculitis On physical examination, vital signs are normal. The (B) Hlpersensitivityvasculitis skin between the distal and proximal interphalangeal joints ofthe flngers is difficult to tent. Ihree telangiectasias (C) Polyarteritisnodosa on the right hand and four on the left are noted. She also (D) Rheumatoidvasculitis has two small telangiectasias on the face and one on the inside bottom lip. No digital pitting is seen. Laboratory evaluation reveals a positive antinuclear Item 57 antibody titer (1:SZO) and positive anticentromere antibody A 36-year-old woman is evaluated for preconception titer (1:160). counseling. She has a 3 year history of rheumatoid arthri- tis well controlled with leflunomide, hydroxychloroquine, Which of the following is the most likely diagnosis? and certolizumab. Her most recent disease activity score showed remission. In the past, attempts to discontinue her (A) Diffuse cutaneous systemic sclerosis medications have been unsuccessful because ofrecurrent (B) Eosinophilicfasciitis active disease. (C) Limited cutaneous systemic sclerosis On physical examination, vital signs are normal. BMI (D) Mixed connective tissue disease is 24. Range of motion is normal, and joints are not warm or swollen. Item 6O Which of the following is the most appropriate A 60-year-oldwoman is evaluated for achiness and fatigue. preconception management? She reports dry mouth, irritated eyes, and discoloration of (A) Discontinue all drugs flngers after exposure to cold temperature that rapidly (B) Discontinuecertolizumab responds to rewarming. (C) Discontinuehydroxychloroquine On physical examination, vital signs are normal. Parotid glands are enlarged, and salivary pooling is (D) Discontinueleflunomide decreased. There is no lymphadenopathy. All appendicular (E) No changes are needed joints have preserved range of motion without discomfort. 112

Self-Assessment Test ta Laboratory evaluation reveals erythrocyte sedimen On physical examination, respiration rate is 18/min c, F tation rate of 77 mmlh, a blood C-reactive protein level of and oxygen saturation is 97% with the patient breathing 0.23 mg/dl (2.3 mglL), and a rheumatoid factor level of ambient air. On a 6 minute walk test, oxygen saturation €, 202UtmL(202kUtL). drops to 90%. Crackles are heard at both lung bases. Heart tt vt sounds are normal. Skin changes consistent with diffuse (l, ra Which of the following is the most appropriate diagnostic cutaneous systemic sclerosis are present. t, test to perform next? A high-resolution CT scan shows ground glass changes in the lower lung flelds. (l, (A) ANCA Pulmonary function tests show an FVC of 82% of tt (B) Anti-cycliccitrullinatedpeptide antibodies predicted and a Dr-co of 65% of predicted. (C) Anti Ro/SSA antibodies (D) Cryoglobulins Which of the following is the most appropriate treatment? (A) Hydroxychloroquine Item 61 (B) Methotrexate A 70 year-old woman is evaluated for a S-year history of (C) Mycophenolatemofetil tophaceous gout in both hands. Previous treatment with allo- (D) Nintedanib purinol resulted in rash. Over the past year, maximum-dose febuxostat has decreased serum urate levels to 9.5 mg/dl (O.SO mmol/L). She also has hlpertension and stage G3b chronic kidney disease. Current medications are febuxostat Item 63 An 18 year old woman is evaluated for f'ever, chills. and tr and losartan- malaise that developed 5 days after her last menstrual Radiograph of the right hand obtained before initia period. The following day, she developed arthralgia that tion of febuxostat therapy is shown. first involved the left wrist and then the right knee: the left flfth toe became exquisitely painful and diffusely swollen, with limited range of motion. She is sexually active with one male partner. Her only medication is a combined oral contraceptive. \ On physical examination, temperature is 38.1 'C (i00.6 'F). Her feet and left hand are shown. i

ta Laboratory evaluation reveals erythrocyte sedimen On physical examination, respiration rate is 18/min c, F tation rate of 77 mmlh, a blood C-reactive protein level of and oxygen saturation is 97% with the patient breathing 0.23 mg/dl (2.3 mglL), and a rheumatoid factor level of ambient air. On a 6 minute walk test, oxygen saturation €, 202UtmL(202kUtL). drops to 90%. Crackles are heard at both lung bases. Heart tt vt sounds are normal. Skin changes consistent with diffuse (l, ra Which of the following is the most appropriate diagnostic cutaneous systemic sclerosis are present. t, test to perform next? A high-resolution CT scan shows ground glass changes in the lower lung flelds. (l, (A) ANCA Pulmonary function tests show an FVC of 82% of tt (B) Anti-cycliccitrullinatedpeptide antibodies predicted and a Dr-co of 65% of predicted. (C) Anti Ro/SSA antibodies (D) Cryoglobulins Which of the following is the most appropriate treatment? (A) Hydroxychloroquine Item 61 (B) Methotrexate A 70 year-old woman is evaluated for a S-year history of (C) Mycophenolatemofetil tophaceous gout in both hands. Previous treatment with allo- (D) Nintedanib purinol resulted in rash. Over the past year, maximum-dose febuxostat has decreased serum urate levels to 9.5 mg/dl (O.SO mmol/L). She also has hlpertension and stage G3b chronic kidney disease. Current medications are febuxostat Item 63 An 18 year old woman is evaluated for f'ever, chills. and tr and losartan- malaise that developed 5 days after her last menstrual Radiograph of the right hand obtained before initia period. The following day, she developed arthralgia that tion of febuxostat therapy is shown. first involved the left wrist and then the right knee: the left flfth toe became exquisitely painful and diffusely swollen, with limited range of motion. She is sexually active with one male partner. Her only medication is a combined oral contraceptive. \ On physical examination, temperature is 38.1 'C (i00.6 'F). Her feet and left hand are shown. i I

ta Laboratory evaluation reveals erythrocyte sedimen On physical examination, respiration rate is 18/min c, F tation rate of 77 mmlh, a blood C-reactive protein level of and oxygen saturation is 97% with the patient breathing 0.23 mg/dl (2.3 mglL), and a rheumatoid factor level of ambient air. On a 6 minute walk test, oxygen saturation €, 202UtmL(202kUtL). drops to 90%. Crackles are heard at both lung bases. Heart tt vt sounds are normal. Skin changes consistent with diffuse (l, ra Which of the following is the most appropriate diagnostic cutaneous systemic sclerosis are present. t, test to perform next? A high-resolution CT scan shows ground glass changes in the lower lung flelds. (l, (A) ANCA Pulmonary function tests show an FVC of 82% of tt (B) Anti-cycliccitrullinatedpeptide antibodies predicted and a Dr-co of 65% of predicted. (C) Anti Ro/SSA antibodies (D) Cryoglobulins Which of the following is the most appropriate treatment? (A) Hydroxychloroquine Item 61 (B) Methotrexate A 70 year-old woman is evaluated for a S-year history of (C) Mycophenolatemofetil tophaceous gout in both hands. Previous treatment with allo- (D) Nintedanib purinol resulted in rash. Over the past year, maximum-dose febuxostat has decreased serum urate levels to 9.5 mg/dl (O.SO mmol/L). She also has hlpertension and stage G3b chronic kidney disease. Current medications are febuxostat Item 63 An 18 year old woman is evaluated for f'ever, chills. and tr and losartan- malaise that developed 5 days after her last menstrual Radiograph of the right hand obtained before initia period. The following day, she developed arthralgia that tion of febuxostat therapy is shown. first involved the left wrist and then the right knee: the left flfth toe became exquisitely painful and diffusely swollen, with limited range of motion. She is sexually active with one male partner. Her only medication is a combined oral contraceptive. \ On physical examination, temperature is 38.1 'C (i00.6 'F). Her feet and left hand are shown. i I t

ta Laboratory evaluation reveals erythrocyte sedimen On physical examination, respiration rate is 18/min c, F tation rate of 77 mmlh, a blood C-reactive protein level of and oxygen saturation is 97% with the patient breathing 0.23 mg/dl (2.3 mglL), and a rheumatoid factor level of ambient air. On a 6 minute walk test, oxygen saturation €, 202UtmL(202kUtL). drops to 90%. Crackles are heard at both lung bases. Heart tt vt sounds are normal. Skin changes consistent with diffuse (l, ra Which of the following is the most appropriate diagnostic cutaneous systemic sclerosis are present. t, test to perform next? A high-resolution CT scan shows ground glass changes in the lower lung flelds. (l, (A) ANCA Pulmonary function tests show an FVC of 82% of tt (B) Anti-cycliccitrullinatedpeptide antibodies predicted and a Dr-co of 65% of predicted. (C) Anti Ro/SSA antibodies (D) Cryoglobulins Which of the following is the most appropriate treatment? (A) Hydroxychloroquine Item 61 (B) Methotrexate A 70 year-old woman is evaluated for a S-year history of (C) Mycophenolatemofetil tophaceous gout in both hands. Previous treatment with allo- (D) Nintedanib purinol resulted in rash. Over the past year, maximum-dose febuxostat has decreased serum urate levels to 9.5 mg/dl (O.SO mmol/L). She also has hlpertension and stage G3b chronic kidney disease. Current medications are febuxostat Item 63 An 18 year old woman is evaluated for f'ever, chills. and tr and losartan- malaise that developed 5 days after her last menstrual Radiograph of the right hand obtained before initia period. The following day, she developed arthralgia that tion of febuxostat therapy is shown. first involved the left wrist and then the right knee: the left flfth toe became exquisitely painful and diffusely swollen, with limited range of motion. She is sexually active with one male partner. Her only medication is a combined oral contraceptive. \ On physical examination, temperature is 38.1 'C (i00.6 'F). Her feet and left hand are shown. i I t Which of the following is the most appropriate treatment? Which of the following is the most likely diagnosis? (A) Addhydroxychloroquine (A) Disseminated gonococcalinfection (B) Addprobenecid (B) I{epatitis B virus infection (C) Stop febuxostat and start pegloticase (C) HtV associated ar-thritis I

Which of the following is the most appropriate treatment? Which of the following is the most likely diagnosis? (A) Addhydroxychloroquine (A) Disseminated gonococcalinfection (B) Addprobenecid (B) I{epatitis B virus infection (C) Stop febuxostat and start pegloticase (C) HtV associated ar-thritis I (D) No treatment changes (D) l.yme arthritis (E) Systemic lupus erythematosus Item 62 A 52 year old man is evaluated for treatment of intersti Item 64 tial lung disease. Over the last 6 months, he develgped a A 50 year-old woman is evaluated for a 6-month history of nonproductive cough and dyspnea on exertion. He has progressive difficulty getting out of a chair and raising her a 3 year history of diffuse cutaneous systemic sclerosis arms above her head. She has a l0-year history ofRaynaud and gastroesophageal reflux disease. Current medication phenomenon and gastroesophageal reflux. Current medi- is pantoprazole. cations are omeprazole and acetaminophen. 113

Self-Assessment Test vr (D On physical examination, vital signs are normal. Fin- the proximal interphalangeal joints, metacarpophalangeal la gers are pufflz bilaterally, without digital ulcers or skin joints, wrists, elbows, ankles, and metatarsophalangeal joints. UI thickening. Neurologic examination shows bilateral prox (D UI imal muscle weakness; distal muscle strength in upper and UI Infection with which of the following is the most likely lower extremities is normal bilaterally. The remainder of diagnosis? .D the examination is normal. (A) Chikungunya virus Iaboratory studies: (D tt (B) Hepatitis B virus Complete blood count Normal C3 complement Normal (C) Hepatitis C virus C4 complement Normal (D) HIV Creatine kinase 2000 u/L Antinuclear antibodies Strongly positive Anti-U1-ribonucleoprotein antibodies Positive Item 67 Anti-Ro/SSA antibodies Negative A 26-year-old man is evaluated for a 1 week history of Anti-La/SSB antibodies Negative pain and swelling in the left ankle, along with pain in Anti-smooth muscle antibodies Negative the toes and tenderness in the left heel. Three weeks ago, Anti-double-stranded DNA antibodies Negative he returned from a vacation in Central America. Before Urinalysis Normal returning home, he experienced 4 days of diarrhea that spontaneously resolved. Current medication is acetamin- Which of the following is the most likely diagnosis? ophen as needed. (A) Mixed connective tissue disease On physical examination, vital signs are normal. The (B) Rheumatoidarthritis left ankle is swollen, with reduced range of motion. Several (C) Systemic lupus erythematosus toes are swollen, as shown, and the Achilles insertion on the left is swollen and tender. (D) Undifferentiated connective tissue disease

vr (D On physical examination, vital signs are normal. Fin- the proximal interphalangeal joints, metacarpophalangeal la gers are pufflz bilaterally, without digital ulcers or skin joints, wrists, elbows, ankles, and metatarsophalangeal joints. UI thickening. Neurologic examination shows bilateral prox (D UI imal muscle weakness; distal muscle strength in upper and UI Infection with which of the following is the most likely lower extremities is normal bilaterally. The remainder of diagnosis? .D the examination is normal. (A) Chikungunya virus Iaboratory studies: (D tt (B) Hepatitis B virus Complete blood count Normal C3 complement Normal (C) Hepatitis C virus C4 complement Normal (D) HIV Creatine kinase 2000 u/L Antinuclear antibodies Strongly positive Anti-U1-ribonucleoprotein antibodies Positive Item 67 Anti-Ro/SSA antibodies Negative A 26-year-old man is evaluated for a 1 week history of Anti-La/SSB antibodies Negative pain and swelling in the left ankle, along with pain in Anti-smooth muscle antibodies Negative the toes and tenderness in the left heel. Three weeks ago, Anti-double-stranded DNA antibodies Negative he returned from a vacation in Central America. Before Urinalysis Normal returning home, he experienced 4 days of diarrhea that spontaneously resolved. Current medication is acetamin- Which of the following is the most likely diagnosis? ophen as needed. (A) Mixed connective tissue disease On physical examination, vital signs are normal. The (B) Rheumatoidarthritis left ankle is swollen, with reduced range of motion. Several (C) Systemic lupus erythematosus toes are swollen, as shown, and the Achilles insertion on the left is swollen and tender. (D) Undifferentiated connective tissue disease Item 55 An 82-year-old man is seen in follow-up for inclusion body myositis. A prednisone taper over the past 4 months was completed without clinical improvement. On physical examination, vital signs are normal. There is weakness in the shoulders, forearms, hand grip, hip gir- dle, and knee extensors that is unchanged from previous examinations. Serum creatine kinase level is 370 U/L, minimally decreased from 4 months ago. Laboratory evaluation reveals a blood C-reactive pro- tein level of 3.5 mg/dl (ss mg/L). Which of the following is the most appropriate treatment? (A) Addcyclophosphamide Which of the following is the most appropriate (B) Add intravenous immune globulin management? (C) Add methotrexate (A) Azithromycin (D) Initiate physical therapy (B) HLA-B27 testing (E) Restart prednisone (C) Piroxicam (D) Stool cultures for enteric pathogens

Item 55 An 82-year-old man is seen in follow-up for inclusion body myositis. A prednisone taper over the past 4 months was completed without clinical improvement. On physical examination, vital signs are normal. There is weakness in the shoulders, forearms, hand grip, hip gir- dle, and knee extensors that is unchanged from previous examinations. Serum creatine kinase level is 370 U/L, minimally decreased from 4 months ago. Laboratory evaluation reveals a blood C-reactive pro- tein level of 3.5 mg/dl (ss mg/L). Which of the following is the most appropriate treatment? (A) Addcyclophosphamide Which of the following is the most appropriate (B) Add intravenous immune globulin management? (C) Add methotrexate (A) Azithromycin (D) Initiate physical therapy (B) HLA-B27 testing (E) Restart prednisone (C) Piroxicam (D) Stool cultures for enteric pathogens tr Item 56 A 45 year-old man is hospitalized for incapacitating poly Item 58 tr arthralgia and fever. One week before hospitalization, pain A 72-year-old woman is evaluated for a 3-month history in multiple joints of the hands, wrists, elbows, ankles, and of abdominal and back pain and 4-month history of an feet developed over a 24-hour period. Five days before increasingly rounded face. hospitalization. fever, malaise, and intensification of the On physical examination, vital signs are normal. BMI joint pain developed. Two days before hospitalization, a is 29. Bilateral lacrimal and parotid glands are enlarged. rash appeared on the extremities and trunk and spread to Laboratory evaluation shows a hemoglobin A,. value the face. He lives in southern Florida and has not recently of 5.4"1,, an alkaline phosphatase level of 255 UlL, and an traveled outside the United States. estimated glomerular filtration rate of 59 mliminll.T3 m2 On physical examination, temlxrature is 39.1'C (102.4.F) (same as l year ago). and pulse rate is 116/min. He has bilateral conjunctivi An abdominal CT scan shows periaortitis with a retro tis and a maculopapular rash on the face, extremities, and peritoneal mass that extends bilaterally and encircles both trunk. Joint examination shows swelling and tendemess of ureters without hydronephrosis.

tr Item 56 A 45 year-old man is hospitalized for incapacitating poly Item 58 tr arthralgia and fever. One week before hospitalization, pain A 72-year-old woman is evaluated for a 3-month history in multiple joints of the hands, wrists, elbows, ankles, and of abdominal and back pain and 4-month history of an feet developed over a 24-hour period. Five days before increasingly rounded face. hospitalization. fever, malaise, and intensification of the On physical examination, vital signs are normal. BMI joint pain developed. Two days before hospitalization, a is 29. Bilateral lacrimal and parotid glands are enlarged. rash appeared on the extremities and trunk and spread to Laboratory evaluation shows a hemoglobin A,. value the face. He lives in southern Florida and has not recently of 5.4"1,, an alkaline phosphatase level of 255 UlL, and an traveled outside the United States. estimated glomerular filtration rate of 59 mliminll.T3 m2 On physical examination, temlxrature is 39.1'C (102.4.F) (same as l year ago). and pulse rate is 116/min. He has bilateral conjunctivi An abdominal CT scan shows periaortitis with a retro tis and a maculopapular rash on the face, extremities, and peritoneal mass that extends bilaterally and encircles both trunk. Joint examination shows swelling and tendemess of ureters without hydronephrosis. 114

Self-Assessment Test tt c, m Needle biopsy of the mass reveals dense fibrous tissue llJ in a storifbrm pattern, interspersed with an inflammatory cONT irrg11."1., including increased numbers of IgG4 positive Item 71 A 38-year old woman is evaluated fbr pain in multiple tr (u fingers. She fractured her left second digit 1 year ago after plasmablasts. Serum IgG,l levels are not elevated. |a a minor trauma. For the past 2 years, she has occasionally |n (l, experienced f'ever and night sweats. a In addition to prednisone, which of the following is the most On physical examination, vital signs are normal. Parotid vt appropriate treatment? and lacrimal glands are eniarged. Multiple coin-sized pink. (u (A) Cevimeline red, and violaceous papular skin lesions are present on the t (B) Methotrexate arms and anterior chest. The right second and flfth digits are swollen and tender. Hepatomegaly is present. (C) Rituximab l-aboratory studies: (D) Surgicaldebridement Complete blood count Normal Erythrocl.tesedimentationrate 62mmlh Alkaline phosphatase 166U lL Item 69 Alanine aminotransferase 58 UIL A 50 year-old woman is evaluated for exertional dyspnea Aspartate aminotransferase 64UlL of 6 months'duration. Limited cutaneous systemic sclerosis FIIV test Negative was diagnosed 6 years ago. She reports no other cardiopul- Purified protein derivative skin test Negative monary symptoms. Other medical problems include sclero dactyly, Raynaud phenomenon, and gastroesophageal reflux Chest radiograph shows hilar lymphadenopathy. disease. Current medications are nifedipine and omeprazole. Abdominal ultrasound reveals liver enlargement with On physical examination, oxygen saturation is 97% multiple infiltrating nodules. A hand radiograph is shown. with the patient breathing ambient air. Other vital signs are normal. Sclerodactyly of the flngers is noted. Telangi- ectasias are present on the hands and face. Lungs are clear to auscultation. Heart examination is normal. Twelve months ago, a baseline high resolution chest CT scan was normal. FVC is 96% of predicted, and Dr-co is 58% of predicted. Twelve months ago, these values were 97"/. and 75ok of predicted, respectively.

tt c, m Needle biopsy of the mass reveals dense fibrous tissue llJ in a storifbrm pattern, interspersed with an inflammatory cONT irrg11."1., including increased numbers of IgG4 positive Item 71 A 38-year old woman is evaluated fbr pain in multiple tr (u fingers. She fractured her left second digit 1 year ago after plasmablasts. Serum IgG,l levels are not elevated. |a a minor trauma. For the past 2 years, she has occasionally |n (l, experienced f'ever and night sweats. a In addition to prednisone, which of the following is the most On physical examination, vital signs are normal. Parotid vt appropriate treatment? and lacrimal glands are eniarged. Multiple coin-sized pink. (u (A) Cevimeline red, and violaceous papular skin lesions are present on the t (B) Methotrexate arms and anterior chest. The right second and flfth digits are swollen and tender. Hepatomegaly is present. (C) Rituximab l-aboratory studies: (D) Surgicaldebridement Complete blood count Normal Erythrocl.tesedimentationrate 62mmlh Alkaline phosphatase 166U lL Item 69 Alanine aminotransferase 58 UIL A 50 year-old woman is evaluated for exertional dyspnea Aspartate aminotransferase 64UlL of 6 months'duration. Limited cutaneous systemic sclerosis FIIV test Negative was diagnosed 6 years ago. She reports no other cardiopul- Purified protein derivative skin test Negative monary symptoms. Other medical problems include sclero dactyly, Raynaud phenomenon, and gastroesophageal reflux Chest radiograph shows hilar lymphadenopathy. disease. Current medications are nifedipine and omeprazole. Abdominal ultrasound reveals liver enlargement with On physical examination, oxygen saturation is 97% multiple infiltrating nodules. A hand radiograph is shown. with the patient breathing ambient air. Other vital signs are normal. Sclerodactyly of the flngers is noted. Telangi- ectasias are present on the hands and face. Lungs are clear to auscultation. Heart examination is normal. Twelve months ago, a baseline high resolution chest CT scan was normal. FVC is 96% of predicted, and Dr-co is 58% of predicted. Twelve months ago, these values were 97"/. and 75ok of predicted, respectively. Which of the following is the most appropriate diagnostic test to perform next? (A) Cardiac magnetic resonance imaging (B) Repeat high resolution chest CT (C) nignt heart catheterization (D) Transthoracic echocardiography

tt c, m Needle biopsy of the mass reveals dense fibrous tissue llJ in a storifbrm pattern, interspersed with an inflammatory cONT irrg11."1., including increased numbers of IgG4 positive Item 71 A 38-year old woman is evaluated fbr pain in multiple tr (u fingers. She fractured her left second digit 1 year ago after plasmablasts. Serum IgG,l levels are not elevated. |a a minor trauma. For the past 2 years, she has occasionally |n (l, experienced f'ever and night sweats. a In addition to prednisone, which of the following is the most On physical examination, vital signs are normal. Parotid vt appropriate treatment? and lacrimal glands are eniarged. Multiple coin-sized pink. (u (A) Cevimeline red, and violaceous papular skin lesions are present on the t (B) Methotrexate arms and anterior chest. The right second and flfth digits are swollen and tender. Hepatomegaly is present. (C) Rituximab l-aboratory studies: (D) Surgicaldebridement Complete blood count Normal Erythrocl.tesedimentationrate 62mmlh Alkaline phosphatase 166U lL Item 69 Alanine aminotransferase 58 UIL A 50 year-old woman is evaluated for exertional dyspnea Aspartate aminotransferase 64UlL of 6 months'duration. Limited cutaneous systemic sclerosis FIIV test Negative was diagnosed 6 years ago. She reports no other cardiopul- Purified protein derivative skin test Negative monary symptoms. Other medical problems include sclero dactyly, Raynaud phenomenon, and gastroesophageal reflux Chest radiograph shows hilar lymphadenopathy. disease. Current medications are nifedipine and omeprazole. Abdominal ultrasound reveals liver enlargement with On physical examination, oxygen saturation is 97% multiple infiltrating nodules. A hand radiograph is shown. with the patient breathing ambient air. Other vital signs are normal. Sclerodactyly of the flngers is noted. Telangi- ectasias are present on the hands and face. Lungs are clear to auscultation. Heart examination is normal. Twelve months ago, a baseline high resolution chest CT scan was normal. FVC is 96% of predicted, and Dr-co is 58% of predicted. Twelve months ago, these values were 97"/. and 75ok of predicted, respectively. Which of the following is the most appropriate diagnostic test to perform next? (A) Cardiac magnetic resonance imaging (B) Repeat high resolution chest CT (C) nignt heart catheterization (D) Transthoracic echocardiography Item 70 A 40 year old woman is evaluated for several months of joint pain and stiffness in the hands and feet. Over the past 7 weeks, she has developed swelling in several of her flnger joints and in her right wrist. On physical examination, vital signs are normal. Joint examination shows bilateral swelling and tenderness of the second metacarpophalangeal joints, third proximal inter phalangeal joints, and right wrist, along with tenderness of the metatarsals.

Item 70 A 40 year old woman is evaluated for several months of joint pain and stiffness in the hands and feet. Over the past 7 weeks, she has developed swelling in several of her flnger joints and in her right wrist. On physical examination, vital signs are normal. Joint examination shows bilateral swelling and tenderness of the second metacarpophalangeal joints, third proximal inter phalangeal joints, and right wrist, along with tenderness of the metatarsals. Which of the following will be the most helpful diagnostic tests? (A) C-reactive protein and erythrocyte sedimentation rate (B) Lyme disease enzyme linked immunosorbent assay and Western blot serologies (C) Rheumatoid factor and anti-cyclic citrullinated pep- tide antibodies (D) Rubella and parvovirus serologies 115

Self-Assessment Test tt (D D l^ UI tr CONT. Which of the following is the most appropriate diagnostic test to perform next? Item 74 A 70 1'ear-old man is evaluated for a 3 n'eek history of tr .D U! (A) Bone biopsy gradually increasing pain ar-rd swelling in the left knee. vt (B) Bronchoscopicbiopsy I{e has osteoarthritis. Six months ago he underu'ent total \ = o joint arthroplastl, of the left knee. Current medication is (C) Lip biopsy acetaminophen. (D) Skin biopsy On phl,sical examination, vital signs are normal. .D tt Examination of the left knee shows slight n'armth. a small Item 72 effusion u'ithout erythema, and a well healed midline scar. A 60-year-old man is evaluated for a l-year history of Examination olthe right knee is normal. lower extremity edema. He has a 30-year history of poorly Laboratory evaluation reveals an er1'throc1,'te sedi controlled ankylosing spondylitis. He also has intermit- mentation rate of 40 mm/h, leukocl,te count of 8000 pl. tent uveitis. His only medication is naproxen; he has been (8.0 x 10'r,'L). and blood C-reactive protein level of 1.2 mg reluctant to initiate biologic agents. dL (12 mg'l-). On physical examination, blood pressure is 158/90 mm Hg. Other vital signs are normal. He has kyphosis with immo Infection with which of the following organisms is most bility of the cervical, thoracic, and lumbar spine. There is likely? decreased range of motion of the shoulders and hips with (A) Neisserio gonorrhoeae 30-degree flexion contractures at both hips. There is 2+ bilateral swelling of the lower extremities. (B) Pseudomonas oeruginosa (C) Stophylococcus epidermidis laboratory studies: Albumin 2.5 gldL(2s glL) (D) StreptococcLts pAogenes C-reactive protein 6.3 mg/dl (0S mg/L) Creatinine 1.8 mg/dl (fSg.f pmol/L) Urinalysis 3+ protein; no erythrocytes, Item 75 leukocytes, casts, or eosinophils A 19 year old woman is evaluated for recent onset of a Protein-creatinine ratio 5200 mg/g malar rash and arthralgia, which Iimits her daily activities. On physical examination, vital signs are normal. She Which of the following is the most likely diagnosis? has an edematous, erythematous malar rash and small joint (A) Analgesicnephropathy tenderness and swelling in several proximal interphalan (B) IgAnephropathy geal joints, metacarpophalangeal joints, wrists, and ankles. (C) Interstitialnephritis The remainder of the physical examination is normal.

D l^ UI tr CONT. Which of the following is the most appropriate diagnostic test to perform next? Item 74 A 70 1'ear-old man is evaluated for a 3 n'eek history of tr .D U! (A) Bone biopsy gradually increasing pain ar-rd swelling in the left knee. vt (B) Bronchoscopicbiopsy I{e has osteoarthritis. Six months ago he underu'ent total \ = o joint arthroplastl, of the left knee. Current medication is (C) Lip biopsy acetaminophen. (D) Skin biopsy On phl,sical examination, vital signs are normal. .D tt Examination of the left knee shows slight n'armth. a small Item 72 effusion u'ithout erythema, and a well healed midline scar. A 60-year-old man is evaluated for a l-year history of Examination olthe right knee is normal. lower extremity edema. He has a 30-year history of poorly Laboratory evaluation reveals an er1'throc1,'te sedi controlled ankylosing spondylitis. He also has intermit- mentation rate of 40 mm/h, leukocl,te count of 8000 pl. tent uveitis. His only medication is naproxen; he has been (8.0 x 10'r,'L). and blood C-reactive protein level of 1.2 mg reluctant to initiate biologic agents. dL (12 mg'l-). On physical examination, blood pressure is 158/90 mm Hg. Other vital signs are normal. He has kyphosis with immo Infection with which of the following organisms is most bility of the cervical, thoracic, and lumbar spine. There is likely? decreased range of motion of the shoulders and hips with (A) Neisserio gonorrhoeae 30-degree flexion contractures at both hips. There is 2+ bilateral swelling of the lower extremities. (B) Pseudomonas oeruginosa (C) Stophylococcus epidermidis laboratory studies: Albumin 2.5 gldL(2s glL) (D) StreptococcLts pAogenes C-reactive protein 6.3 mg/dl (0S mg/L) Creatinine 1.8 mg/dl (fSg.f pmol/L) Urinalysis 3+ protein; no erythrocytes, Item 75 leukocytes, casts, or eosinophils A 19 year old woman is evaluated for recent onset of a Protein-creatinine ratio 5200 mg/g malar rash and arthralgia, which Iimits her daily activities. On physical examination, vital signs are normal. She Which of the following is the most likely diagnosis? has an edematous, erythematous malar rash and small joint (A) Analgesicnephropathy tenderness and swelling in several proximal interphalan (B) IgAnephropathy geal joints, metacarpophalangeal joints, wrists, and ankles. (C) Interstitialnephritis The remainder of the physical examination is normal. (D) Renal amyloidosis laboratory studies: Erythrocyte sedimentation rate 35 mm/h Platelet count 92,OOOl1tL(92xr}elL) Item 73 Comprehensive metabolic panel Normal A 36-year-old woman is evaluated for a recent diagnosis C3 complement Normal of rheumatoid arthritis. Over the past 2 months she has C4 complement Normal had increasingly severe pain and swelling in the hands and Anti-double stranded DNA Positive wrists and pain in the feet. Her only medication is a com antibodies bined oral contraceptive. Antinuclear antibodies 1:1280 homogenous On physical examination, vital signs are normal. Joint Urinalysis Normal examination reveals swelling and tenderness of the left second, third, and flfth proximal interphalangeal joints; Chest radiograph is normal. right second and third proximal interphalangeal joints; Sun protection, including use of a broad spectrum bilateral second, third, and fourth metacarpophalangeal sunscreen, is recommended. joints; right wrist; left ankle; and left second and third metatarsophalangeal joints. Which of the following is the most appropriate additional Radiographs of hands and feet demonstrate juxta treatment? articular osteopenia without erosions. (A) Prednisone Laboratory evaluation reveals a hemoglobin level of 10.8 g/dl (108 g/L), leukocyte count of s4O0/pL (5.4 x (B) Prednisoneandhydroxychloroquine l0eil) with normal diflerential, and platelet count of (C) Prednisone, hydroxychloroquine, and cyclophospha- 435,000/gL (435 x l0'/L). mide (D) Topical hydrocortisone cream Which of the following is the most appropriate treatment? (A) Diclofenac (B) Methotrexate (C) Mycophenolatemofetil Item 76 A 50 year-old man is evaluated for pain, swelling, ten- tr derness, and redness ofthe right great toe that began last (D) Rituximab lright. He has hacl several similar episodes over the past

(D) Renal amyloidosis laboratory studies: Erythrocyte sedimentation rate 35 mm/h Platelet count 92,OOOl1tL(92xr}elL) Item 73 Comprehensive metabolic panel Normal A 36-year-old woman is evaluated for a recent diagnosis C3 complement Normal of rheumatoid arthritis. Over the past 2 months she has C4 complement Normal had increasingly severe pain and swelling in the hands and Anti-double stranded DNA Positive wrists and pain in the feet. Her only medication is a com antibodies bined oral contraceptive. Antinuclear antibodies 1:1280 homogenous On physical examination, vital signs are normal. Joint Urinalysis Normal examination reveals swelling and tenderness of the left second, third, and flfth proximal interphalangeal joints; Chest radiograph is normal. right second and third proximal interphalangeal joints; Sun protection, including use of a broad spectrum bilateral second, third, and fourth metacarpophalangeal sunscreen, is recommended. joints; right wrist; left ankle; and left second and third metatarsophalangeal joints. Which of the following is the most appropriate additional Radiographs of hands and feet demonstrate juxta treatment? articular osteopenia without erosions. (A) Prednisone Laboratory evaluation reveals a hemoglobin level of 10.8 g/dl (108 g/L), leukocyte count of s4O0/pL (5.4 x (B) Prednisoneandhydroxychloroquine l0eil) with normal diflerential, and platelet count of (C) Prednisone, hydroxychloroquine, and cyclophospha- 435,000/gL (435 x l0'/L). mide (D) Topical hydrocortisone cream Which of the following is the most appropriate treatment? (A) Diclofenac (B) Methotrexate (C) Mycophenolatemofetil Item 76 A 50 year-old man is evaluated for pain, swelling, ten- tr derness, and redness ofthe right great toe that began last (D) Rituximab lright. He has hacl several similar episodes over the past 116

5elf-Assessment Test tt pl 2 years. He has type 2 diabetes mellitus and a recent diag- Which of the following is the most appropriate diagnostic G'

5elf-Assessment Test tt pl 2 years. He has type 2 diabetes mellitus and a recent diag- Which of the following is the most appropriate diagnostic G' l*l nosis of deep venous thrombosis. Current medications are test to perform next? (l, coNT apixaban, metfbrmin, and rosuvastatin. (A) Brain MRI E On physical examination, the right first metatarso tt vt phalangeal joint is tender. red. warm, and swollen. (B) ChestCT (l, ta Laboratory evaluation reveals a serum urate level of (C) Echocardiography ta 9.0 mg/dl (0.53 mmol/L). (D) Kidney biopsy Radiograph of the right foot is shown. = tto Item 78 A 31-year old man is evaluated following a recent diagno- sis of ankylosing spondylitis. He has low back and pelvic pain that interrupts his sleep. Acetaminophen has not helped. On physical examination, vital signs are normal. The FABER (Flexion, ABduction, and External Rotation) test of the hip elicits pain at both sacroiliac joints. Lumbar spine range of motion is slightly limited. There is good range of motion of the cervical spine and peripheral joints, includ- ing the hips. No peripheral joint swelling or tenderness is noted. Radiographs of the lumbar spine show bilateral sacroiliitis. The patient is referred to physical therapy.

l*l nosis of deep venous thrombosis. Current medications are test to perform next? (l, coNT apixaban, metfbrmin, and rosuvastatin. (A) Brain MRI E On physical examination, the right first metatarso tt vt phalangeal joint is tender. red. warm, and swollen. (B) ChestCT (l, ta Laboratory evaluation reveals a serum urate level of (C) Echocardiography ta 9.0 mg/dl (0.53 mmol/L). (D) Kidney biopsy Radiograph of the right foot is shown. = tto Item 78 A 31-year old man is evaluated following a recent diagno- sis of ankylosing spondylitis. He has low back and pelvic pain that interrupts his sleep. Acetaminophen has not helped. On physical examination, vital signs are normal. The FABER (Flexion, ABduction, and External Rotation) test of the hip elicits pain at both sacroiliac joints. Lumbar spine range of motion is slightly limited. There is good range of motion of the cervical spine and peripheral joints, includ- ing the hips. No peripheral joint swelling or tenderness is noted. Radiographs of the lumbar spine show bilateral sacroiliitis. The patient is referred to physical therapy. Which of the following is the most appropriate additional treatment? (A) Etanercept (B) Methotrexate (C) Naproxen Which of the following is the most appropriate initial (D) Sulfasalazine treatment? (A) Allopurinol Item 79 (B) Colchicine A Sl-year-old woman is evaluated at a follow-up visit. (C) Indomethacin Sj0gren syndrome was diagnosed 3 years ago. For the past (D) Prednisone 4 weeks she has experienced arthralgia, unintentional weight loss, fever, and drenching night sweats. She has hypothyroidism. Current medications are levothyroxine,

Which of the following is the most appropriate additional treatment? (A) Etanercept (B) Methotrexate (C) Naproxen Which of the following is the most appropriate initial (D) Sulfasalazine treatment? (A) Allopurinol Item 79 (B) Colchicine A Sl-year-old woman is evaluated at a follow-up visit. (C) Indomethacin Sj0gren syndrome was diagnosed 3 years ago. For the past (D) Prednisone 4 weeks she has experienced arthralgia, unintentional weight loss, fever, and drenching night sweats. She has hypothyroidism. Current medications are levothyroxine, tr Item 77 A24 year old woman is hospitalized fbr rapidly progressive artiflcial tears, and ophthalmic cyclosporine suspension. On physical examination, vital signs are normal. Parotid glands are enlarged, and the oropharynx is dry. lower extremity edema and rising serum creatinine level. She Lungs are clear to auscultation. There are no skin lesions or is diagnosed with new-onset systemic lupus ery,.thematosus. On physical examination, blood pressure is 162/94 mm evidence of joint synovitis. Hg, and pulse rate is 98/min. An erythematous malar rash Laboratory studies: is present. The metacarpophalangeal joints are swollen Erythrocyte sedimentation rate 73mm/h bilaterally. Lower extremity edema and facial puffiness Hemoglobin ro.2gldL (102 g/L) are present.'lhe cardiopulmonary examination is normal. C3 complement 102 mg/dl (1020 mg/L) C4 complement 8 mg/dl (80 mg/L) Laboratory studies: Thyroid-stimulating hormone 3.0 pU/mL (3.0 mU/L) C3 complement Low Rheumatoid factor 442UlmL(442kUlL) C4 complement Low Anti-cyclic citrullinated peptide Negative Creatinine 1.3 mg/dl (114.9 pmol/L) antibodies Anti double stranded DNA Positive Anti-La/SSB antibodies Negative antibodies Anti Ro/SSA antibodies >8 U/L (normal, <1 U/L) Antinuclear antibodies 1:1280 (speckled pattern) Urinalysis O 1+ protein; no Urinalysis 3+ protein; 2+ blotidl 35 erythrocytes, Ieukocytes, erythrocytes/hpf: no or casts leukocytes; no casts Spot urine protein creatinine 600 mg/g Immunoflxation studies show a monoclonal IgM ratio gammopathy (r type).

tr Item 77 A24 year old woman is hospitalized fbr rapidly progressive artiflcial tears, and ophthalmic cyclosporine suspension. On physical examination, vital signs are normal. Parotid glands are enlarged, and the oropharynx is dry. lower extremity edema and rising serum creatinine level. She Lungs are clear to auscultation. There are no skin lesions or is diagnosed with new-onset systemic lupus ery,.thematosus. On physical examination, blood pressure is 162/94 mm evidence of joint synovitis. Hg, and pulse rate is 98/min. An erythematous malar rash Laboratory studies: is present. The metacarpophalangeal joints are swollen Erythrocyte sedimentation rate 73mm/h bilaterally. Lower extremity edema and facial puffiness Hemoglobin ro.2gldL (102 g/L) are present.'lhe cardiopulmonary examination is normal. C3 complement 102 mg/dl (1020 mg/L) C4 complement 8 mg/dl (80 mg/L) Laboratory studies: Thyroid-stimulating hormone 3.0 pU/mL (3.0 mU/L) C3 complement Low Rheumatoid factor 442UlmL(442kUlL) C4 complement Low Anti-cyclic citrullinated peptide Negative Creatinine 1.3 mg/dl (114.9 pmol/L) antibodies Anti double stranded DNA Positive Anti-La/SSB antibodies Negative antibodies Anti Ro/SSA antibodies >8 U/L (normal, <1 U/L) Antinuclear antibodies 1:1280 (speckled pattern) Urinalysis O 1+ protein; no Urinalysis 3+ protein; 2+ blotidl 35 erythrocytes, Ieukocytes, erythrocytes/hpf: no or casts leukocytes; no casts Spot urine protein creatinine 600 mg/g Immunoflxation studies show a monoclonal IgM ratio gammopathy (r type). 117

Self-Assessment Test ur .D + D Which of the following conditions is most likely (C) Polymyalgia rheumatica U! responsible for her recent symptoms? (D) Rheumatoid arthritis Ut .D UI (A) AL amyloidosis (E) Systemic lupus erythematosus (a J (B) Hypothyroidism .D (C) Lymphoma Item 82 (D) Rheumatoidarthritis .D A72 year-old man is evaluated for chronic right knee pain t^ with morning stiffness lasting 15 minutes. He is experi encing increased difficulty walking because of knee pain. tr Item 8O An 18 year old woman is evaluated lbr a I week history He has no other medical problems other than overweight. His only medication is acetaminophen, which provides of'f'ever and dilfuse myalgia, and pain and slvelling in the minimal pain relief. hands and knees that have progressed over the last month. On physical examination, BMI is 34. There is bony She also has acnc. Current medicatiorrs are minocl,cline. hypertrophy of the knee without effusion or signs of topical tretinoin, and an oral contraceptive. inflammation. He has moderate pain with lull knee flexion On physical examination, temperature is 38.3 'C but no restriction of motion. The remainder of the exam (100.9 "F)i other vital signs are normal. She has synovitis ination is noncontributory. in her hands and wrists and inflammatory acne on the Iace Topical diclofenac is prescribed. and upper back. laboratory studies: Which of the following is the most appropriate additional Complete blood count Normal treatment? Erythrocyte sedimentation rate 36mm h Normal (A) Exercise and weight loss Creatinine Anti cyclic citrullinated peptide Negative (B) Massage therapy antibodies (C) Mobilization/manipulation and passive range of Antinuclear antibodies 1 :320 (speckled pattem) motion ANCA Positive (p ANCA (D) Transcutaneous electrical nerve stimulation pattern) Rheumatoid factor Negative Urinalysis Nornral Item 83 Test results ft-rr antihistone and othcr specific autoanti A 42 year-old woman is evaluated for increasingly severe bodies are negative. and serum complement levels are normal pain and swelling in both hands for the last 6 months. She has morning stiffness that lasts t hour. Current medication Which of the following is the most likely diagnosis? is ibuprofen. On physical examination, vital signs are normal. Joint (A) Drug induced lupus erythematosus examination reveals bilateral swelling and tenderness of (B) Granulonratosis'^'ith polyangiitis the second and third metacarpophalangeal joints and third (C) Rheumatoidarthritis proximal interphalangeal joint. (D) Systemic lupus erythematosus laboratory studies: Hemoglobin 10.8 gi dL (108 g/L) Rheumatoid factor Positive Item 81 Anti-cyclic citrullinated Positive A 37 year-old woman is evaluated for a l-year history of peptide antibodies widespread joint and muscle pain, fatigue, poor sleep, Antinuclear antibodies Negative and difflculty focusing. She also has irritable bowel syn Which of the following is the most appropriate test to drome and migraine headaches. Current medications are perform next? sumatriptan and topiramate. On physical examination, vital signs are normal. No (A) ANCA rash is present on the face or extremities. Joint examina (B) Anti double stranded DNA antibodies tion shows normal range of motion and no joint swelling. (C) MRI of hands Most soft tissue is tender to light palpation. Muscle strength is normal. (D) Plainradiographyofhands Laboratory evaluation shows a normal complete blood count, serum thyroid stimulating hormone level, and urinalysis as well as an erythrocyte sedimentation rate of Item 84 20 mm/h. A 3O-year old woman is evaluated for a 2 month history of skin changes, primarily on her chest and arms. She Which ofthe following is the most likely diagnosis? has no other symptoms. Her only medication is an oral contraceptive. (A) Fibromyalgia On physical examination, vital signs are normal. The (B) Generalized osteoarthritis rash on her chest is shown (top ofnext page).

ur .D + D Which of the following conditions is most likely (C) Polymyalgia rheumatica U! responsible for her recent symptoms? (D) Rheumatoid arthritis Ut .D UI (A) AL amyloidosis (E) Systemic lupus erythematosus (a J (B) Hypothyroidism .D (C) Lymphoma Item 82 (D) Rheumatoidarthritis .D A72 year-old man is evaluated for chronic right knee pain t^ with morning stiffness lasting 15 minutes. He is experi encing increased difficulty walking because of knee pain. tr Item 8O An 18 year old woman is evaluated lbr a I week history He has no other medical problems other than overweight. His only medication is acetaminophen, which provides of'f'ever and dilfuse myalgia, and pain and slvelling in the minimal pain relief. hands and knees that have progressed over the last month. On physical examination, BMI is 34. There is bony She also has acnc. Current medicatiorrs are minocl,cline. hypertrophy of the knee without effusion or signs of topical tretinoin, and an oral contraceptive. inflammation. He has moderate pain with lull knee flexion On physical examination, temperature is 38.3 'C but no restriction of motion. The remainder of the exam (100.9 "F)i other vital signs are normal. She has synovitis ination is noncontributory. in her hands and wrists and inflammatory acne on the Iace Topical diclofenac is prescribed. and upper back. laboratory studies: Which of the following is the most appropriate additional Complete blood count Normal treatment? Erythrocyte sedimentation rate 36mm h Normal (A) Exercise and weight loss Creatinine Anti cyclic citrullinated peptide Negative (B) Massage therapy antibodies (C) Mobilization/manipulation and passive range of Antinuclear antibodies 1 :320 (speckled pattem) motion ANCA Positive (p ANCA (D) Transcutaneous electrical nerve stimulation pattern) Rheumatoid factor Negative Urinalysis Nornral Item 83 Test results ft-rr antihistone and othcr specific autoanti A 42 year-old woman is evaluated for increasingly severe bodies are negative. and serum complement levels are normal pain and swelling in both hands for the last 6 months. She has morning stiffness that lasts t hour. Current medication Which of the following is the most likely diagnosis? is ibuprofen. On physical examination, vital signs are normal. Joint (A) Drug induced lupus erythematosus examination reveals bilateral swelling and tenderness of (B) Granulonratosis'^'ith polyangiitis the second and third metacarpophalangeal joints and third (C) Rheumatoidarthritis proximal interphalangeal joint. (D) Systemic lupus erythematosus laboratory studies: Hemoglobin 10.8 gi dL (108 g/L) Rheumatoid factor Positive Item 81 Anti-cyclic citrullinated Positive A 37 year-old woman is evaluated for a l-year history of peptide antibodies widespread joint and muscle pain, fatigue, poor sleep, Antinuclear antibodies Negative and difflculty focusing. She also has irritable bowel syn Which of the following is the most appropriate test to drome and migraine headaches. Current medications are perform next? sumatriptan and topiramate. On physical examination, vital signs are normal. No (A) ANCA rash is present on the face or extremities. Joint examina (B) Anti double stranded DNA antibodies tion shows normal range of motion and no joint swelling. (C) MRI of hands Most soft tissue is tender to light palpation. Muscle strength is normal. (D) Plainradiographyofhands Laboratory evaluation shows a normal complete blood count, serum thyroid stimulating hormone level, and urinalysis as well as an erythrocyte sedimentation rate of Item 84 20 mm/h. A 3O-year old woman is evaluated for a 2 month history of skin changes, primarily on her chest and arms. She Which ofthe following is the most likely diagnosis? has no other symptoms. Her only medication is an oral contraceptive. (A) Fibromyalgia On physical examination, vital signs are normal. The (B) Generalized osteoarthritis rash on her chest is shown (top ofnext page). 118

) Self-Assessment Test t I v! I 6' swollen and warm, with erythema, tenderness to palpation, and limited range of motion due to pain. Other joints are I

) Self-Assessment Test t I v! I 6' swollen and warm, with erythema, tenderness to palpation, and limited range of motion due to pain. Other joints are I t (u normal. t r/l r,l I Which of the following is the most appropriate diagnostic (l, t test to perform next? vt t t (A) Aspiration of the left knee o (B) Erythrocyte sedimentation rate arl t (C) Radiographyoftheleft knee t (D) Serum urate level t t t Item 87 A S5-year old woman is evaluated for a 5,day history of tr There is no evident scarring or lesions in the scalp increasing pain, swelling,, and warmth in the left knee. She has a 30-year history of rheumatoid arthritis. Current t or ears, hair loss, or joint swelling. The remainder of the medications are etanercept, prednisone, methotrexate, examination is normal. t Laboratory evaluation reveals an antinuclear antibody folic acid, and meloxicam. titer of 1:640 with speckled pattern; result for anti-Ro/SSA On physical examination, temperature is 37.5 "C t antibody is positive. (99.s "F); nther vital signs are normal. Joint examina- tion of the hands reveals nonpainful deformities and L restricted movement characteristic of advanced but Which of the following is the most likely diagnosis? quiescent rheumatoid arthritis. The left knee exhibits t (A) Acute cutaneous lupus erythematosus warmth and a moderate effusion without erythema; flex- t (B) Cutaneousleukocytoclasticvasculitis ion is restricted because of pain. The right knee shows I (C) Discoid lupus erythematosus bony hypertrophy. L Laboratory evaluation shows an erythroqrte sedimen, (D) Subacute cutaneous lupus ery,thematosus I tation rate of 7O mmlh and leukocyte count of 13,500/pL L (13.5 x lOelL).

t (u normal. t r/l r,l I Which of the following is the most appropriate diagnostic (l, t test to perform next? vt t t (A) Aspiration of the left knee o (B) Erythrocyte sedimentation rate arl t (C) Radiographyoftheleft knee t (D) Serum urate level t t t Item 87 A S5-year old woman is evaluated for a 5,day history of tr There is no evident scarring or lesions in the scalp increasing pain, swelling,, and warmth in the left knee. She has a 30-year history of rheumatoid arthritis. Current t or ears, hair loss, or joint swelling. The remainder of the medications are etanercept, prednisone, methotrexate, examination is normal. t Laboratory evaluation reveals an antinuclear antibody folic acid, and meloxicam. titer of 1:640 with speckled pattern; result for anti-Ro/SSA On physical examination, temperature is 37.5 "C t antibody is positive. (99.s "F); nther vital signs are normal. Joint examina- tion of the hands reveals nonpainful deformities and L restricted movement characteristic of advanced but Which of the following is the most likely diagnosis? quiescent rheumatoid arthritis. The left knee exhibits t (A) Acute cutaneous lupus erythematosus warmth and a moderate effusion without erythema; flex- t (B) Cutaneousleukocytoclasticvasculitis ion is restricted because of pain. The right knee shows I (C) Discoid lupus erythematosus bony hypertrophy. L Laboratory evaluation shows an erythroqrte sedimen, (D) Subacute cutaneous lupus ery,thematosus I tation rate of 7O mmlh and leukocyte count of 13,500/pL L (13.5 x lOelL). t I I tr Item 85 A 78-year-old woman is evaluated for constant bilateral Which of the following is the most appropriate diagnostic test to perform next? headache of I week's duration. Two months ago, she was diagnosed with polymyalgia rheumatica. Symptoms were (A) C'reactive protein ; : relieved with prednisone, 15 mgld. Headache appeared (B) Serum procalcitonin i shortly after the dosage was tapered to 5 mg/d. She also (C) Synovial biopsy has experienced new-onset intermittent muscular jaw dis, (D) Synovial fluid analysis ; comfort with chewing. On physical examination, vital signs are normal. The scalp and temporal arteries are not tender to palpation. No bruit is heard over the great vessels; temporal artery pulses Item 88 are intact. A 3O-year-old woman is seen for preconception coun- Laboratory evaluation shows a blood C reactive pro- seling. Three years ago, she was diagnosed with systemic tein level of 12.8 mg/dl (128 mg/L). lupus erythematosus and nephritis. She responded rapidly to induction therapy with combination immunosuppres- Which of the following is the most likely diagrrosis? sants and has been maintained on mycophenolate mofetil and hydroxychloroquine for the past 2 years. An intrauter (A) Giant cell arteritis ine device is used for contraception. (B) Granulomatosiswith polyangiitis Laboratory evaluation is consistent with quiescent (C) Microscopicpolyangiitis disease, and there is no evidence of kidney dysfunc- (D) Polyarteritisnodosa tion.

t I I tr Item 85 A 78-year-old woman is evaluated for constant bilateral Which of the following is the most appropriate diagnostic test to perform next? headache of I week's duration. Two months ago, she was diagnosed with polymyalgia rheumatica. Symptoms were (A) C'reactive protein ; : relieved with prednisone, 15 mgld. Headache appeared (B) Serum procalcitonin i shortly after the dosage was tapered to 5 mg/d. She also (C) Synovial biopsy has experienced new-onset intermittent muscular jaw dis, (D) Synovial fluid analysis ; comfort with chewing. On physical examination, vital signs are normal. The scalp and temporal arteries are not tender to palpation. No bruit is heard over the great vessels; temporal artery pulses Item 88 are intact. A 3O-year-old woman is seen for preconception coun- Laboratory evaluation shows a blood C reactive pro- seling. Three years ago, she was diagnosed with systemic tein level of 12.8 mg/dl (128 mg/L). lupus erythematosus and nephritis. She responded rapidly to induction therapy with combination immunosuppres- Which of the following is the most likely diagrrosis? sants and has been maintained on mycophenolate mofetil and hydroxychloroquine for the past 2 years. An intrauter (A) Giant cell arteritis ine device is used for contraception. (B) Granulomatosiswith polyangiitis Laboratory evaluation is consistent with quiescent (C) Microscopicpolyangiitis disease, and there is no evidence of kidney dysfunc- (D) Polyarteritisnodosa tion. Which of the following is the most appropriate preconception management?

t I I tr Item 85 A 78-year-old woman is evaluated for constant bilateral Which of the following is the most appropriate diagnostic test to perform next? headache of I week's duration. Two months ago, she was diagnosed with polymyalgia rheumatica. Symptoms were (A) C'reactive protein ; : relieved with prednisone, 15 mgld. Headache appeared (B) Serum procalcitonin i shortly after the dosage was tapered to 5 mg/d. She also (C) Synovial biopsy has experienced new-onset intermittent muscular jaw dis, (D) Synovial fluid analysis ; comfort with chewing. On physical examination, vital signs are normal. The scalp and temporal arteries are not tender to palpation. No bruit is heard over the great vessels; temporal artery pulses Item 88 are intact. A 3O-year-old woman is seen for preconception coun- Laboratory evaluation shows a blood C reactive pro- seling. Three years ago, she was diagnosed with systemic tein level of 12.8 mg/dl (128 mg/L). lupus erythematosus and nephritis. She responded rapidly to induction therapy with combination immunosuppres- Which of the following is the most likely diagrrosis? sants and has been maintained on mycophenolate mofetil and hydroxychloroquine for the past 2 years. An intrauter (A) Giant cell arteritis ine device is used for contraception. (B) Granulomatosiswith polyangiitis Laboratory evaluation is consistent with quiescent (C) Microscopicpolyangiitis disease, and there is no evidence of kidney dysfunc- (D) Polyarteritisnodosa tion. Which of the following is the most appropriate preconception management? tr Item 86 A 72-year-old man is evaluated for severe left knee pain (A) Advise against pregnancy (B) Continue current medications with swelling that has worsened over the past 5 days. Pain is exacerbated with weight bearing. He has no history of (C) Discontinue hydroxychloroquine and mycophenolate trauma. Current medication is acetaminophen. mofetil; add prednisone On physical examination, temperature is 38.2 "C (D) Discontinue mycophenolate mofetil; add azathio- (100.8 "F). Other vital signs are normal. The left knee is prine

tr Item 86 A 72-year-old man is evaluated for severe left knee pain (A) Advise against pregnancy (B) Continue current medications with swelling that has worsened over the past 5 days. Pain is exacerbated with weight bearing. He has no history of (C) Discontinue hydroxychloroquine and mycophenolate trauma. Current medication is acetaminophen. mofetil; add prednisone On physical examination, temperature is 38.2 "C (D) Discontinue mycophenolate mofetil; add azathio- (100.8 "F). Other vital signs are normal. The left knee is prine 119

Self-Assessment Test t/t o t^ t^ tr Item 89 A 60-year old man is evaluated in follow up after an l-aboratory studies: I Iematocrit Leukocyte count 30"1, 4000/prl (4.0 x 10e,il). \^,ith lymphopenia .D t, episode of podagra. which u,as treated with colchicine. UI This r.r,as his first gout flare. f{e also has hypertension and Platelet count T2,OOO StL (72 x 10'q L) hyperlipidemia. Current medications are hydrochlorothi C reactive protein s.s mg/dl (55 mgrL) .D Creatinine 1.4 mg/dL (12:l.B pmollL) azide and atorvastatin. Urinalysis 1+ protein, 1+ blood; 2 3 ery'throclles: (D On physical examination. blood pressure and other u) findings are normal. no leukocytes; no casts Laboratory evaluation reveals a semm urate level of' Which of the following is the most likely cause of this 9.0 mgldl. (o.se mmoliL). patient's pericarditis?

hyperlipidemia. Current medications are hydrochlorothi C reactive protein s.s mg/dl (55 mgrL) .D Creatinine 1.4 mg/dL (12:l.B pmollL) azide and atorvastatin. Urinalysis 1+ protein, 1+ blood; 2 3 ery'throclles: (D On physical examination. blood pressure and other u) findings are normal. no leukocytes; no casts Laboratory evaluation reveals a semm urate level of' Which of the following is the most likely cause of this 9.0 mgldl. (o.se mmoliL). patient's pericarditis? Which of the following is the most appropriate (A) Adult onset Still disease treatment? (B) Coxsackievirus infectior-t (A) Start allopurinol (C) Idiopathicpericarditis (B) Start vitamin C (D) Systemic lupus erythenlatosus (C) Stop atorvastatin and start fenofibrate (D) Stop hydrochlorothiazide and start losartan Item 92 A 4S-year-old woman is evaluated for progressive short ness of breath for 6 months, hearing impairment, and knee Item 90 pain. She has no additional medical problems and takes no A 57-year-old woman is evaluated for a 2.5 year history medications. I of pain and swelling in the hands and wrists. She also has On physical examination, vital signs are normal; oxygen joint stiffness for over an hour after awakening. saturation is 98% with the patient breathing ambient air. She On physical examination, vital signs are normal. She has swelling and redness of the helices of the ear, with sparing has swelling and tenderness of the following: second, third, of the lobule; diminished hearing bilaterally; bilateral con- and fourth proximal interphalangeal joints of the right junctivitis; and redness, tendemess, and flattening of the nasal hand and third and fourth proximal interphalangeal joints bridge. Lung examination reveals inspiratory stridor loudest of the left hand; the left second and right third metacarpo- over the trachea. Knees show joint-line tendemess bilaterally. phalangeal joints; and both wrists. The remainder of the physical examination is normal. Laboratory evaluation reveals a blood C*reactive pro Laboratory tests, chest radiography, and CT of the tein level of 4.8 mg/dl (+s mg/L) and positive results on upper airways and chest are ordered. tests for serum rheumatoid factor and anti cyclic citrulli- nated peptide antibodies. Which of the following is the most likely diagnosis? Radiographs of the hands show periarticular osteo- penia and joint-space narrowing of the proximal inter- (A) Cryoglobulinemia phalangeal joints, periarticular osteopenia and marginal (B) Granulomatosiswithpolyangiitis erosions at the second proximal interphalangeal and meta- (C) Relapsingpolychondritis carpophalangeal joints of both hands, and radiocarpal (D) Rheumatoidarthritis joint-space narrowing.

Which of the following is the most appropriate (A) Adult onset Still disease treatment? (B) Coxsackievirus infectior-t (A) Start allopurinol (C) Idiopathicpericarditis (B) Start vitamin C (D) Systemic lupus erythenlatosus (C) Stop atorvastatin and start fenofibrate (D) Stop hydrochlorothiazide and start losartan Item 92 A 4S-year-old woman is evaluated for progressive short ness of breath for 6 months, hearing impairment, and knee Item 90 pain. She has no additional medical problems and takes no A 57-year-old woman is evaluated for a 2.5 year history medications. I of pain and swelling in the hands and wrists. She also has On physical examination, vital signs are normal; oxygen joint stiffness for over an hour after awakening. saturation is 98% with the patient breathing ambient air. She On physical examination, vital signs are normal. She has swelling and redness of the helices of the ear, with sparing has swelling and tenderness of the following: second, third, of the lobule; diminished hearing bilaterally; bilateral con- and fourth proximal interphalangeal joints of the right junctivitis; and redness, tendemess, and flattening of the nasal hand and third and fourth proximal interphalangeal joints bridge. Lung examination reveals inspiratory stridor loudest of the left hand; the left second and right third metacarpo- over the trachea. Knees show joint-line tendemess bilaterally. phalangeal joints; and both wrists. The remainder of the physical examination is normal. Laboratory evaluation reveals a blood C*reactive pro Laboratory tests, chest radiography, and CT of the tein level of 4.8 mg/dl (+s mg/L) and positive results on upper airways and chest are ordered. tests for serum rheumatoid factor and anti cyclic citrulli- nated peptide antibodies. Which of the following is the most likely diagnosis? Radiographs of the hands show periarticular osteo- penia and joint-space narrowing of the proximal inter- (A) Cryoglobulinemia phalangeal joints, periarticular osteopenia and marginal (B) Granulomatosiswithpolyangiitis erosions at the second proximal interphalangeal and meta- (C) Relapsingpolychondritis carpophalangeal joints of both hands, and radiocarpal (D) Rheumatoidarthritis joint-space narrowing. Which of the following imaging studies should be done Item 93 next? A 58-year-old woman is evaluated for a 4-month history (A) Bone scanning of diarrhea and weight loss. Diffuse cutaneous systemic sclerosis was diagnosed 10 years ago. She reports explosive (B) MRI of hands diarrhea soon after eating a meal. She has lost 5 kg (11 lb) (C) Ultrasonographyofhands since the symptoms began. She also has Raynaud phe (D) No further imaging nomenon and gastroesophageal reflux disease controlled with pantoprazole once a day. Current medications are sustained release nifedipine and pantoprazole.

Which of the following imaging studies should be done Item 93 next? A 58-year-old woman is evaluated for a 4-month history (A) Bone scanning of diarrhea and weight loss. Diffuse cutaneous systemic sclerosis was diagnosed 10 years ago. She reports explosive (B) MRI of hands diarrhea soon after eating a meal. She has lost 5 kg (11 lb) (C) Ultrasonographyofhands since the symptoms began. She also has Raynaud phe (D) No further imaging nomenon and gastroesophageal reflux disease controlled with pantoprazole once a day. Current medications are sustained release nifedipine and pantoprazole. tr Item 91 A 40 year-old man is hospitalized for acute pericarditis. He On physical examination, vital signs are normal. Skin changes consistent with diffuse cutaneous systemic scle rosis are present. Findings on the abdominal examination also reports pain in the wrists, ankles, and knees for I week are normal. but no other symptoms. He has otherwise been well and takes no medications. On physical examination, temperature is 38.0 'C Which of the following is the most appropriate treatment? (10o.+ "F): the ren.rainder of'the vital signs are normal. (A) Cholestyramine A pericardial friction rub is present. The wrists, knees. (B) Ciprofloxacin and ankles are tender. There are small bilateral wrist and knee effusions. The remainder of the examination is (C) Increase in pantoprazole dosage unrcmarkable. (D) Loperamide

tr Item 91 A 40 year-old man is hospitalized for acute pericarditis. He On physical examination, vital signs are normal. Skin changes consistent with diffuse cutaneous systemic scle rosis are present. Findings on the abdominal examination also reports pain in the wrists, ankles, and knees for I week are normal. but no other symptoms. He has otherwise been well and takes no medications. On physical examination, temperature is 38.0 'C Which of the following is the most appropriate treatment? (10o.+ "F): the ren.rainder of'the vital signs are normal. (A) Cholestyramine A pericardial friction rub is present. The wrists, knees. (B) Ciprofloxacin and ankles are tender. There are small bilateral wrist and knee effusions. The remainder of the examination is (C) Increase in pantoprazole dosage unrcmarkable. (D) Loperamide 120

Self-Assessment Test ut q, Item 94 Which of the following is the most appropriaG A 29-year-old man is evaluated after an episode of anterior management? (u uveitis. He has 2 year history of low back stiffness at night (A) Cyclophosphamide E and in the morning that improves with activity. Current (B) Immediate delivery ut t medication is meloxicam as needed. (l, (C) Magnesium sulfate vt On physical examination, he cannot touch his toes, UI

ut q, Item 94 Which of the following is the most appropriaG A 29-year-old man is evaluated after an episode of anterior management? (u uveitis. He has 2 year history of low back stiffness at night (A) Cyclophosphamide E and in the morning that improves with activity. Current (B) Immediate delivery ut t medication is meloxicam as needed. (l, (C) Magnesium sulfate vt On physical examination, he cannot touch his toes, UI and there is flattening of the normal lumbar lordosis. Inter- (D) Prednisone nal rotation and flexion elicit pain in the right hip; range (u r/t of motion of the right hip is diminished. Flexion, external rotation, and abduction ofthe hips cause pain in the right Item 96 hip and low back. The remainder of the examination is unremarkable. A 46-year old man is evaluated for a S-year history of pain in the lower spine, knees, and hands. The hand pain is associated with occasional swelling. Morning Which of the following is the most appropriate diagnostic stiffness lasts less than 30 minutes. Type 2 diabetes test to perform next? mellitus was diagnosed 2 years ago. His only medication (A) Anteroposteriorradiographyofpelvis is metformin. (B) Antinuclear antibody assay On physical examination, there is bilateral enlargement (C) HLA-B27 testing of the second, third, and fourth metacarpophalangeal joints as well as all proximal and distal interphalangeal joints. The (D) Sacroiliac joint MRI medial joint line of each knee is tender to palpation. Iaboratory studies: Alanine aminotransferase tr Item 95 A 2S-year-old woman is hospitalized at 26 weeks of preg- 48UlL Aspartate aminotransferase 52U lL Calcium Normal nancy for lower extremity swelling, proteinuria, and elevated C-reactive protein Normal blood pressure. Systemic lupus erythematosus was diagnosed Ferritin Elevated last year. Her disease has been well controlled, with stable Transferrin saturation Elevated laboratory values and no recent clinical evidence of disease activity. Her only medication is hydroxychloroquine. Radiograph of both hands is shown. On physical examination, blood pressure is 152/ 90 mm Hg, and pulse rate is 80/min. Facial swelling, bilat- eral lower extremity edema, swelling of both hands, and tenderness over the metacarpophalangeal joints are pres- ent. She has a gravid abdomen with normal fetal heart tones. Iaboratory studies: 8 Weeks Ago Current Platelet count Normal 85,000/pL (85 x t}e tL) Alanine Normal Normal aminotransferase Aspartate Normal Normal aminotransferase Serum urate 4.5. mg/dl (0.30 mmoliL) Anti-double 50 250 stranded DNA antibodies C3 complement 85 mg/dl 60 mg/dl (8so mg/L) (600 mg/L) C4 complement 16 mg/dl 4mgldL (aO mg/L) Which of the following is the most appropriate diagnostic (160 mg/L) test to perform next? Urinalysis Normal 3+ protein; no (A) HFEgenetesting erythrocytes; no (B) Insulin-like growth factor 1 leuko€ytes; no casts (C) Parathyroidhormone Protein-creatinine 50mglg 32Omglg ratio (D) Rheumatoid factor

and there is flattening of the normal lumbar lordosis. Inter- (D) Prednisone nal rotation and flexion elicit pain in the right hip; range (u r/t of motion of the right hip is diminished. Flexion, external rotation, and abduction ofthe hips cause pain in the right Item 96 hip and low back. The remainder of the examination is unremarkable. A 46-year old man is evaluated for a S-year history of pain in the lower spine, knees, and hands. The hand pain is associated with occasional swelling. Morning Which of the following is the most appropriate diagnostic stiffness lasts less than 30 minutes. Type 2 diabetes test to perform next? mellitus was diagnosed 2 years ago. His only medication (A) Anteroposteriorradiographyofpelvis is metformin. (B) Antinuclear antibody assay On physical examination, there is bilateral enlargement (C) HLA-B27 testing of the second, third, and fourth metacarpophalangeal joints as well as all proximal and distal interphalangeal joints. The (D) Sacroiliac joint MRI medial joint line of each knee is tender to palpation. Iaboratory studies: Alanine aminotransferase tr Item 95 A 2S-year-old woman is hospitalized at 26 weeks of preg- 48UlL Aspartate aminotransferase 52U lL Calcium Normal nancy for lower extremity swelling, proteinuria, and elevated C-reactive protein Normal blood pressure. Systemic lupus erythematosus was diagnosed Ferritin Elevated last year. Her disease has been well controlled, with stable Transferrin saturation Elevated laboratory values and no recent clinical evidence of disease activity. Her only medication is hydroxychloroquine. Radiograph of both hands is shown. On physical examination, blood pressure is 152/ 90 mm Hg, and pulse rate is 80/min. Facial swelling, bilat- eral lower extremity edema, swelling of both hands, and tenderness over the metacarpophalangeal joints are pres- ent. She has a gravid abdomen with normal fetal heart tones. Iaboratory studies: 8 Weeks Ago Current Platelet count Normal 85,000/pL (85 x t}e tL) Alanine Normal Normal aminotransferase Aspartate Normal Normal aminotransferase Serum urate 4.5. mg/dl (0.30 mmoliL) Anti-double 50 250 stranded DNA antibodies C3 complement 85 mg/dl 60 mg/dl (8so mg/L) (600 mg/L) C4 complement 16 mg/dl 4mgldL (aO mg/L) Which of the following is the most appropriate diagnostic (160 mg/L) test to perform next? Urinalysis Normal 3+ protein; no (A) HFEgenetesting erythrocytes; no (B) Insulin-like growth factor 1 leuko€ytes; no casts (C) Parathyroidhormone Protein-creatinine 50mglg 32Omglg ratio (D) Rheumatoid factor 121

I 'l I 't I 'l I \ i t I 'I ! I 'l I I I I I I! t 1 I 1 'l t t I iI I l I ! I tt j I I 'l I I l I I 1 I .t I I I 'l I I ! I I 1 , 1 I II ! i l{ 1