SHELF / USMLE Step 2 Practice Questions > Internal Medicine > Rheumatology
Q1) A 36-year-old man is evaluated for worsening left knee pain and swelling of 2 days' duration. He does not have dysuria or any systemic symptoms. He has not seen a physician since his last routine physical examination, which was normal and occurred 2 years ago. His father has gout and coronary artery disease. On physical examination, he is afebrile. He walks with a limp because of his pain. The left knee is warm, tender, and distended. The remainder of the examination is unremarkable.
Hemoglobin - 13.3 g/dL
Leukocyte count - 8600/µL normal differential)
Platelet count - 320,000/µL
Urinalysis - Normal
Aspiration of the knee joint yields 20 mL of fluid (leukocyte count, 30,000/µL; 94% neutrophils). No crystals are seen on polarized light microscopy of the fluid, and Gram stain is negative. Results of mucosal, blood, and synovial fluid cultures are pending. Which of the following is the most appropriate next step in this patient's management?
a) IV antibiotics; repeat aspiration of the knee jointQ2) A 45-year-old woman is evaluated for a facial rash of 6 months' duration that involves the cheeks and nose. She is unsure whether sun exposure worsens the rash. She does not have rash elsewhere, fatigue, ulcers, or joint pain. She has a history of autoimmune hypothyroidism with positive antimicrosomal antibodies and is antinuclear antibody positive. Physical examination reveals an erythematous rash with discrete papules and pustules limited to the cheeks, nasolabial folds, and nose. The remainder of the examination is unremarkable. Current laboratory studies, including complete blood count, serum chemistry studies, and thyroid-stimulating hormone, are normal. Which of the following is the most likely diagnosis?
c) NSAIDS and oral antibiotics
d) Knee radiograph; erythrocyte sedimentation rate
b) systemic lupus erythematosus
d) seborrheic dermatitis
Q3) A 60 year-old woman with rheumatoid arthritis is hospitalized for a 3-day history of fever, rigors, and cough productive of rusty sputum. Outpatient medications include alendronate, hydroxychloroquine, etanercept, a multivitamin, and calcium supplementation. On physical examination, T = 38.1 °C (100.6 °F), HR = 90/min, RR = 20/min, and bp = 130/72 mmHg. Pulmonary examination reveals crackles in the right lung base. Cardiovascular and abdominal examinations are unremarkable, and musculoskeletal examination reveals no joint swelling or tenderness. Laboratory studies, sputum Gram stain, and blood and sputum culture are performed. Chest radiograph reveals right lower-lobe pneumonia, and intravenous antibiotic therapy is initiated. Which of the following is the most appropriate adjunctive step in this patient's management?
a) discontinue alendronate
b) discontinue etanercept
c) discontinue hydroxychloroquine
d) administer stress-dose hydrocortisone therapy
A1) a - IV antibiotics; repeat aspiration of the knee joint - Drainage and IV antibiotics are standard treatment for a “closed-space” joint infection.
A2) c - roseacea - An inflammatory dermatitis characterized by erythema, telangiectasias, papules, pustules, and sebaceous hyperplasia that affects the central face, including the nasolabial folds.
A3) b - discontinue etanercept - Anti–tumor necrosis factor-α therapy is contraindicated in patients with infection.