1. ABIM

2. 39 yo female evaluated for malar rash, arthralgias, and serositis. CBC and P2 are normal. ANA, anti-dsDNA, and anti-Smith antibodies are positive. HIV is negative. CXR is normal. PPD testing reveals 8mm of induration. Before initiating prednisone, which of the following is the most appropriate next step in this patient’s management? A)Rifampin and pyrazinamide for 2 months B) Pyrazinamide for 4 months C) INH for 9 months D) No anti-TB therapy

3. - Any immunosuppression medication increases the risk for TB activation. - Anyone on prednisone >15mg/d with induration >5mm should be treated - INH is recommended 1 st line treatment of latent TB infection.

4. A 50 yo asymptomatic female is evaluated as a new patient. She was diagnosed with polyarteritis nodosa 11 years ago, and was treated with prednisone and daily oral cyclophosphamide for 2 years. She has remained in remission for 8 years, and currently takes no medication. In addition to age and gender appropriate screening, which of the following is most appropriate in this patient? A) Pelvic ultrasound B) CXR C) Upper endoscopy D) UA E) No additional studies

5. Acrolein, a metabolite of cyclophosphamide, is toxic to urothelium with increased risk for cystitis and transitional cell bladder cancer. Acrolein, a metabolite of cyclophosphamide, is toxic to urothelium with increased risk for cystitis and transitional cell bladder cancer. Yearly screening with UA is recommended for lifetime Yearly screening with UA is recommended for lifetime Routine cystoscopy is recommended if any changes noted on cystoscopy Routine cystoscopy is recommended if any changes noted on cystoscopy Urine cytology may be helpful, but not sensitive. Urine cytology may be helpful, but not sensitive.

6. A 70 yo woman is evaluated for a 4-week history of aching bilateral pain and AM stiffness around the proximal muscles of the arms, shoulders, hip, and thighs. She does not have rash, neck pain, visual symptoms, cough, HA, jaw stiffness, or claudication. Although her muscles are sore and she feels fatigues, she does not have muscle weakness. On exam, strength and ROM is normal. No tenderness to palpation of the hip or shoulders. Otherwise unremarkable exam. ESR is 55 mm/hr.

7. Which if the following is the most appropriate management at this time? A) S teroid injection into both glenohumeral joints B) A mitriptyline with exercise program C) P rednisone D) I buprofen E) A cetaminophen

8. - Symptoms consistent with PMR -AM pain or stiffness in proximal joints/muscles -ESR > 40 mm/hr -No evidence for other disease process - Prednisone 10 – 20 mg/d 1 st line therapy

9. A 40 yo female is evaluated for a 4-month history of swelling, pain, and stiffness in her wrists, MCP, and PIP joints with similar symptoms in her feet. She has been fatigued but is able to work. Neither NSAIDS or tylenol have alleviated her symptoms. On exam, vitals are normal and she is afebrile. She appears health in NAD. She walks slowly. She does not have a rash or adenapathy. She has swelling and tenderness to palpation in affected joints. The remainder of exam is unremarkable.

10. Measurement of which of the following may help predict this patient’s clinical course? A) Anti-cyclic citrullinated peptide antibodies B) ESR C) CRP D) Hemoglobin

11. Anti-CCP can help prognosticate which patients will have self-limiting disease, and who is likely to progress. Positive predictors for aggressive disease: - RF, CCP positive, female, erosions, functional limitations - Both RF+ and CCP+ very suggestive of aggressive disease

12. A 75 yo female is evaluated for fever, fatigue, malaise, a severe headache in both temples, and discomfort in her jaw when chewing food. Last week, she also had an isolated episode of transient diplopia. On exam, temp is 100.1. Except for scalp tenderness, PE is normal. ESR is 30. Temporal artery biopsy will be performed in 4 days.

13. Which of the following is the most appropriate management until biopsy is performed? A) Heparin B) Prednisone C) Vicodin D) MTX plus prednisone E) No therapy until biopsy results

14. Giant Cell Arteritis – aka temporal arteritis Treat anytime you are suspicious – biopsy results will not be affected with < 2 weeks of steroids

15. A 70 yo male with active GCA begins treatment with prednisone. His only manifestation is headache, and he has no evidence of GI or renal disease. ESR is 80. DEXA is normal. In addition to calcium and vit D, what is the most appropriate next step? A) C alcitonin B) A bisphosphonate C) T eripartide D) N o additional therapy

16. Per ACR: Any patient on prednisone >5mg/day for >3 months should have calcium, vit d, and bisphosphonate Also encourage exercise, tob cessasion, decrease ETOH use Teriparatide – synthetic PTH – only for severe osteoporosis. Contraindicated if hx bone malignancy, XRT, Paget’s disease, hypercalcemia.

17. A 30 yo male is evaluated for 3 month history of epistaxis and 1 month history of night sweats and cough. He has lost 10 lbs. No travel outside of Montana, and no drug use. On exam, temp is 98.4, pulse 70, RR 14, BP 120/84. He has a large nasal septal perforation. Lungs are clear. UA shows 3+ protein, red cells, red cell casts. CT chest reveals bilateral cavitary nodules.

18. Which if the following is the most likely diagnosis? A) S arcoidosis B) A nti-GBM disease (Goodpasture’s) C) T B D) W egener’s granulomatosis

19. A 48 yo male is evaluated during an annual physical. He has HTN and gout for several years. Last gout attack was mild, > 6 months ago, and resolved after several doses of naproxen. Current meds are enalapril, colchicine 0.6mg/d, and allopurinol 300mg/d. Exam reveals several nontender, movable olecranon nodules and a slightly tender left 1 st MTP joint with overlying nodules. Urate is 7.2.

20. Which of the following is the most appropriate next step in this patient’s management? A) Stop colchicine B) Stop colchicine, increase allopurinol to 400 mg/d C) Increase allopurinol to 400 mg/d D) Obtain a 24-hour urine urate excretion

21. Pt has elevated urate and tophi, so treatment is indicated even in absence of symptoms. Goal urate is 6.0 (any level above 6.8 will continue to deposit urate in tissues) Continue NSAIDs while adjusting allopurinol as decreasing urate level can precipitate an attack. D/C daily NSAID when on stable therapy.

22. A 69 yo male is evaluated for severe left hip pain for 3 days. He has a hx of degenerative joint disease involving the hip that is treated with tylenol. He has been unable to walk. No fever or chills. One week ago, he had extensive dental surgery. Xrays 2 days ago demonstrate mild join-space narrowing. On exam, temp is 100.6. Cardiac exam is normal without murmurs. No rash. Any ROM of hip causes severe pain.

23. In addition to blood cultures, which of the following is most likely to establish a diagnosis? A) I maging-guided hip joint aspiration B) B one scan C) E mpiric antibiotics D) M RI of the hip

24. Must exclude septic arthritis: - Gram stain (positive in 50%) - Cell count – average WBC count is 50,000-150,000 cells/mm3 (neutrophil predominance) - Culture - 50% of nongonococcal will have positive blood cultures