MSN 622 WEEK 5 - RHEUMATOID
A 72-year-old man presents to the clinic for pre-operative evaluation. The patient says
he is feeling well, remembers many years ago, was diagnosed with some joint
condition, and was advised to take medications for which he would have to do blood
tests regularly. He was not interested in doing regular blood tests and seeing a clinician
regularly; hence he never took treatment for the disease. On examination, he has
bilateral ulnar deviation and subluxation of the metacarpophalangeal (MCP) joints. Hand
X-ray shows erosions of MCP and proximal interphalangeal (PIP) joints. Rheumatoid
factor (RF) and anti-CCP antibodies are positive. Which of the following is the next best
step in managing this patient? - Answers :Cervical spine radiographs
A 47-year-old woman presents to the clinic with swelling in both knees, morning
stiffness lasting more than an hour, and pain with walking. Further history reveals
bilateral hand and wrist pain. These symptoms have been present for about three
months and have gradually progressed. The patient has tried over-the-counter
acetaminophen without relief from the symptoms. For the past couple of months, she
has felt tired and had a low-grade fever. She denies rashes, oral ulcers, chest pain, and
difficulty breathing. On examinations, she has synovitis of both knees,
metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints bilaterally. X-
rays of the hands do not show joint damage. Lab results for rheumatoid factor (RF),
anti-CCP, and ANA are negative. What is the most likely diagnosis? - Answers
:Rheumatoid arthritis
A 54-year-old man with a history of rheumatoid arthritis presents to the clinic for a
regular follow-up appointment. He has remained stable on methotrexate 15 mg every
week, folic acid 1 mg daily, and etanercept 50 mg every week. His examination is
unremarkable, with no joint tenderness or swelling. Routine labs are within normal
limits. The patient does mention some pain along his spine. Involvement of which of the
following spinal segments is associated with the worst morbidity in this patient? -
Answers :Cervical spine
A 54-year-old female presented for evaluation at the outpatient clinic. She was
diagnosed with rheumatoid arthritis two years ago. She has been closely followed up
and found to have low-level disease activity. Currently, she is managed with NSAIDs
and has never received disease-modifying antirheumatic drugs (DMARDs). In patients
with established disease, the American College of Rheumatology recommends what
type of treatment? - Answers :Start monotherapy with a DMARD
A 65-year-old female patient complains of joint stiffness and swelling in both hands. The
stiffness worsens upon waking up in the morning and gradually improves after two to
three hours. She further reports having had more trouble opening her pill bottles in the
past few weeks. Which one of the following is going to be the most specific for reaching
a diagnosis in this patient? - Answers :Anti-citrullinated protein antibodies (ACPA)
, 32-year-old woman presents to the healthcare provider with six months of fatigue. She
also reports joint pains, chest pain, and a 3 kg weight loss ever since the fatigue started.
She denies recent travel, fever, or new sexual partners. She has no past medical history
and takes no medications. She is sexually active with her husband of five years. Her
mother has rheumatoid arthritis. Vitals include a blood pressure of 123/80 mmHg, a
heart rate of 81/min, a respiratory rate of 18/min, and oxygen saturation of 99% on room
air. On examination, she has a rash over her nose and an ulcer on her hard palate. The
chest examination reveals decreased air entry in her right lung base. Her abdomen is
soft, and there is no hepatosplenomegaly. Neurological examination is within normal
limits. Which of the following antibody titers most likely correlates with the disease
activity in this patient? - Answers :Anti-double-stranded DNA antibodies
A 24-year-old woman presents with diffuse aching and stiffness, worsened by cold
weather and stress. Her history is significant for Lyme disease 2 years ago treated with
doxycycline 100 mg twice a day for 4 weeks. Her joints show no tenderness or
synovitis, but she is tender over points bilaterally at the occiput, trapezius, lateral
epicondyle, gluteals, and knee. What is the most probable diagnosis? - Answers
:Fibromyalgia
30-year-old woman presents with widespread musculoskeletal pain, which is bilateral
and involves both upper and lower parts of the body for the past 4 months. She has
normal laboratory findings, and imaging studies are unremarkable. Which of the
following is a first-line medication used to treat this condition? - Answers :Duloxetine
40-year-old patient presented with fatigue and difficulty concentrating at work for almost
a year. She also complains of pain all over her body but mainly in the shoulder and
neck. She has had multiple ED visits but all the labs came back within normal limits.
What is the best initial therapy for this patient? - Answers :Aerobic exercise
A 40-year-old female patient presents with fatigue and insomnia for six months. She
also complains of feeling pain all over. Her inflammatory markers came back within
normal limits. There are many tender points in different parts of her body. What age
group and gender are most commonly affected by this condition? - Answers :20 to 55-
year-old females
A 66-year-old woman presents with extreme fatigue and muscle pain that has troubled
her for the past 9 months. On examination, she has many tender points on her upper
body. Laboratory tests were normal. Which of the combination of the following
medications is helpful in a patient not responding to initial therapy? - Answers :SNRI
and anticonvulsants
A 32-year-old female presented with bilateral shoulder, hip, and back pain. She was
also complaining of fatigue and mental fog for six months. TSH, ESR, CRP, ANA, and
DS DNA were within normal limits. Her mother has a history of polymyalgia rheumatica.
A 72-year-old man presents to the clinic for pre-operative evaluation. The patient says
he is feeling well, remembers many years ago, was diagnosed with some joint
condition, and was advised to take medications for which he would have to do blood
tests regularly. He was not interested in doing regular blood tests and seeing a clinician
regularly; hence he never took treatment for the disease. On examination, he has
bilateral ulnar deviation and subluxation of the metacarpophalangeal (MCP) joints. Hand
X-ray shows erosions of MCP and proximal interphalangeal (PIP) joints. Rheumatoid
factor (RF) and anti-CCP antibodies are positive. Which of the following is the next best
step in managing this patient? - Answers :Cervical spine radiographs
A 47-year-old woman presents to the clinic with swelling in both knees, morning
stiffness lasting more than an hour, and pain with walking. Further history reveals
bilateral hand and wrist pain. These symptoms have been present for about three
months and have gradually progressed. The patient has tried over-the-counter
acetaminophen without relief from the symptoms. For the past couple of months, she
has felt tired and had a low-grade fever. She denies rashes, oral ulcers, chest pain, and
difficulty breathing. On examinations, she has synovitis of both knees,
metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints bilaterally. X-
rays of the hands do not show joint damage. Lab results for rheumatoid factor (RF),
anti-CCP, and ANA are negative. What is the most likely diagnosis? - Answers
:Rheumatoid arthritis
A 54-year-old man with a history of rheumatoid arthritis presents to the clinic for a
regular follow-up appointment. He has remained stable on methotrexate 15 mg every
week, folic acid 1 mg daily, and etanercept 50 mg every week. His examination is
unremarkable, with no joint tenderness or swelling. Routine labs are within normal
limits. The patient does mention some pain along his spine. Involvement of which of the
following spinal segments is associated with the worst morbidity in this patient? -
Answers :Cervical spine
A 54-year-old female presented for evaluation at the outpatient clinic. She was
diagnosed with rheumatoid arthritis two years ago. She has been closely followed up
and found to have low-level disease activity. Currently, she is managed with NSAIDs
and has never received disease-modifying antirheumatic drugs (DMARDs). In patients
with established disease, the American College of Rheumatology recommends what
type of treatment? - Answers :Start monotherapy with a DMARD
A 65-year-old female patient complains of joint stiffness and swelling in both hands. The
stiffness worsens upon waking up in the morning and gradually improves after two to
three hours. She further reports having had more trouble opening her pill bottles in the
past few weeks. Which one of the following is going to be the most specific for reaching
a diagnosis in this patient? - Answers :Anti-citrullinated protein antibodies (ACPA)
, 32-year-old woman presents to the healthcare provider with six months of fatigue. She
also reports joint pains, chest pain, and a 3 kg weight loss ever since the fatigue started.
She denies recent travel, fever, or new sexual partners. She has no past medical history
and takes no medications. She is sexually active with her husband of five years. Her
mother has rheumatoid arthritis. Vitals include a blood pressure of 123/80 mmHg, a
heart rate of 81/min, a respiratory rate of 18/min, and oxygen saturation of 99% on room
air. On examination, she has a rash over her nose and an ulcer on her hard palate. The
chest examination reveals decreased air entry in her right lung base. Her abdomen is
soft, and there is no hepatosplenomegaly. Neurological examination is within normal
limits. Which of the following antibody titers most likely correlates with the disease
activity in this patient? - Answers :Anti-double-stranded DNA antibodies
A 24-year-old woman presents with diffuse aching and stiffness, worsened by cold
weather and stress. Her history is significant for Lyme disease 2 years ago treated with
doxycycline 100 mg twice a day for 4 weeks. Her joints show no tenderness or
synovitis, but she is tender over points bilaterally at the occiput, trapezius, lateral
epicondyle, gluteals, and knee. What is the most probable diagnosis? - Answers
:Fibromyalgia
30-year-old woman presents with widespread musculoskeletal pain, which is bilateral
and involves both upper and lower parts of the body for the past 4 months. She has
normal laboratory findings, and imaging studies are unremarkable. Which of the
following is a first-line medication used to treat this condition? - Answers :Duloxetine
40-year-old patient presented with fatigue and difficulty concentrating at work for almost
a year. She also complains of pain all over her body but mainly in the shoulder and
neck. She has had multiple ED visits but all the labs came back within normal limits.
What is the best initial therapy for this patient? - Answers :Aerobic exercise
A 40-year-old female patient presents with fatigue and insomnia for six months. She
also complains of feeling pain all over. Her inflammatory markers came back within
normal limits. There are many tender points in different parts of her body. What age
group and gender are most commonly affected by this condition? - Answers :20 to 55-
year-old females
A 66-year-old woman presents with extreme fatigue and muscle pain that has troubled
her for the past 9 months. On examination, she has many tender points on her upper
body. Laboratory tests were normal. Which of the combination of the following
medications is helpful in a patient not responding to initial therapy? - Answers :SNRI
and anticonvulsants
A 32-year-old female presented with bilateral shoulder, hip, and back pain. She was
also complaining of fatigue and mental fog for six months. TSH, ESR, CRP, ANA, and
DS DNA were within normal limits. Her mother has a history of polymyalgia rheumatica.
