Rheumatology Core Learning Session: Management of Early Rheumatoid Arthritis
10 ITEM MCQ: IRAT, GRAT
INSTRUCTIONS: Please select the best answer by encircling the letter corresponding to your selected
option.
TIME: You are allotted 10 minutes to answer these questions individually. This will be followed by a team
activity.
1.
CASE/STEM: None
LEAD-IN/QUESTION:
What are the radiologic features of Rheumatoid arthritis?
A. A. Joint space narrowing, erosions (eg. PIP, MCP and wrist joints), deformities/subluxation
B. Joint space narrowing, erosions (at DIP, PIP joints), osteophytes
C. Joint space narrowing, erosions (eg. PIP, DIP joints), pencil-in-cup deformity, osteolysis
D. Joint space narrowing, erosions with overhanging edge
ANSWER: A
OBJECTIVE:
Recognize the pattern of joint involvement and radiologic features of RA
2.
CASE/STEM: NONE
LEAD-IN/QUESTION:
Which of the disease-modifying antirheumatic drugs (DMARD) is the mainstay of RA treatment?
A. Hydroxychloroquine
B. Sulfasalazine
C. Methotrexate
D. Leflunomide
ANSWER: C
OBJECTIVE: Recognize DMARDs as the treatment of choice in RA
3.
CASE/STEM:
A 23-year-old male patient was diagnosed with rheumatoid arthritis recently. His rheumatologist
recommends starting Methotrexate at 10mg weekly.
LEAD-IN/QUESTION:
What laboratory tests are needed to monitor for side effects due to Methotrexate?
A. CBC, AST, ALT, Creatinine every 8-12 weeks, baseline Chest x-ray
B. PPD, CXR
C. CBC, AST, ALT every 8-12 weeks, G6PD level at baseline
D. Yearly eye exam
ANSWER: A
OBJECTIVE: Recognize monitoring parameters for DMARD toxicity
4.
CASE/STEM:
A 35-year-old female is scheduled to undergo surgery requiring general anesthesia. She has a history of
rheumatoid arthritis. She complains of 1 week of numbness and weakness in his upper extremities. She
has difficulty gripping things. She has been experiencing headaches with some stiffness mostly at the
neck and occipital region of the neck for a month.
LEAD-IN/QUESTION:
What is the next step in diagnosing this potentially life-threatening complication of rheumatoid arthritis?
A. Angiogram
B. Cspine x-rays with oblique views
C. Lumbar puncture
D. Cspine x-rays with lateral flexion and extension views
ANSWER: D
OBJECTIVE: Recognize C1-C2 subluxation as a lifethreatening emergency in RA; Work-up for neurologic
dysfunction in RA
5.
CASE/STEM:
A 35-year-old female with rheumatoid arthritis comes into your office complaining of right leg pain and
swelling. Patient is noted to have diffuse swelling, tenderness, pitting edema of the right foreleg and
ankle, with bruising around the ankle.
LEAD-IN/QUESTION:
What is the most likely diagnosis in this case?
A. DVT
B. Ruptured Baker’s cyst
C. Compartment synd.
D. Ruptured popliteal aneurysm
ANSWER: B
OBJECTIVE:
Recognize features of popliteal cyst rupture and its differential diagnoses
6.
CASE/STEM: None
LEAD-IN/QUESTION:
What cytokine is the treatment target for methotrexate-non-responsive patients on Adalimumab,
Etanercept and Infliximab?
A. IL-1
B. IL6
C. TNF beta
D. TNF alpha
ANSWER: D
OBJECTIVE:
Recognize the role and mechanisms of action of biologic DMARD treatments for RA
7.
CASE/STEM: None
LEAD-IN/QUESTION:
RA, when left untreated, can result in functional disability and job losses within how many years from
onset of RA?
A. 5 years
B. 10 years
C. 2 years
D. 20 years
ANSWER: C
OBJECTIVE: Recognize RA as a rapidly disabling disease
8.
CASE/STEM: None
LEAD-IN/QUESTION:
What is the major cause of mortality among patients with Rheumatoid arthritis?
A. Lung disease
B. Cardiovascular disease
C. Basilar invagination
D. Renal failure
ANSWER: B
OBJECTIVE:
Recognize cardiovascular disease as the major cause of mortality in RA
9.
CASE/STEM:
A 29-year old patient wants to get pregnant within the next two years. She is currently on Leflunomide
and Methotrexate.
LEAD-IN/QUESTION:
What measures should be done to ensure safety during pregnancy for the fetus?
A. Stop both drugs 1 year prior to conception, administer cholestyramine clearance protocol
B. Stop only Methotrexate 1 year prior to conception, continue Leflunomide
C. Stop Leflunomide 1 year prior to conception, administer cholestyramine clearance protocol
D. Stop Methotrexate 1 year prior to conception, administer cholestyramine clearance protocol
ANSWER: A
OBJECTIVE: Recognize teratogenic toxicities associated with use of DMARDs in RA; Manage DMARD
therapy in preparation for or during pregnancy
10.
CASE/STEM: None
LEAD-IN/QUESTION:
What vaccines can be safely administered to Rheumatoid arthritis patients on immunosuppressants?
A. Herpes Zoster
B. Intranasal H1N1
C. Measles
D. Pneumovax
ANSWER: D
OBJECTIVE:
recognize
Recognize vaccination as a preventive measure for preventing infections in RA;
CASE APPLICATION
CASE/STEM: A 30-year-old female arrives at the emergency room complaining of shortness of breath and
chest pain. She has a 5-year-history of rheumatoid arthritis, and is maintained on Methotrexate 15mg po
weekly, Hydroxychloroquine 400mg daily. She does not smoke, and has no family history of cardiac or
pulmonary problems.
You are co-managing this patient with a rheumatologist.
QUESTIONS:
Develop a patient-care-plan for this patient, based on the following questions:
What do you think is going on with this patient?
What is your plan of action to determine the cause of this patient’s symptoms?
*You may development a diagnostic and treatment algorithm to facilitate your treatment planning.
ANSWER:
Possibilities are:
1. Myocardial Infarction
2. Pericardial Effusion
3. Pleural effusion
4. Aortic Aneurysm
5. Pulmonary Embolism
6. Pulmonary Hypertension
7. Rheumatoid arthritis-associated ILD
8. Esophagitis, infectious
Plan of care:
Diagnostic (sample):
Obtain VS including O2 sat, EKG, CXR, evaluate severity of cardiorespiratory distress
CBC, CMP,ESR, CRP, cultures if needed
2D Echo, stress test
PFT, HRCTscan
Therapeutic plan (sample):
Oxygenation
Consider admission criteria for hospitalization, and criteria for ICU admission
MI protocol if applicable
OBJECTIVES:
1. Recognize pulmonary and cardiovascular complications in RA that can present as chest pain
2. Formulate an effective plan of care, in co-management with a rheumatologist, in dealing with
pulmonary and cardiovascular complications of RA