WBR0409

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Musculoskeletal/Rheumatology
Prompt	[[Prompt::40 year old nurse presents to the office with one year H/O joint pains and stiffness. She says her symptoms are gradually progressing and not responding to over the counter NSAID’s. She experiences pain usually early morning that improves during the day. Since the start of this august she feels her symptoms are prolonged and her physical activities are restricted due to her symptoms. Her past medical history and family history are insignificant. She is a chronic smoker and alcoholic. Physical examination shows mild hyperemia and swelling of the proximal small hand joints, wrists and knees with restriction of movements. Examination of the other joints are normal. Initial knee X-ray shows periarticular joint erosions. RF and ESR are markedly elevated. What is most appropriate next step before starting her on her first DMARD?]]
Answer A	AnswerA::Influenza vaccination
Answer A Explanation	[[AnswerAExp::Incorrect : Influenza vaccine should be given to all RA patients who are going to be or are already treated with immunosuppressive drugs, regardless of when the drugs are initiated, unless the patient was vaccinated during the previous influenza season. Since the month is august, hepatitis vaccination is better choice to off season influenza vaccination.]]
Answer B	AnswerB::Sputum microscopy
Answer B Explanation	[[AnswerBExp::Incorrect : Tumor necrosis factor-alpha (TNF-alpha) inhibitors increase the risk of reactivation of latent TB infection. Sputum microscopy is not the option for screening latent TB.]]
Answer C	AnswerC::Hepatitis B vaccination
Answer C Explanation	[[AnswerCExp::Correct : Hepatitis B vaccine should be given before methotrexate, leflunomide, and biologic DMARDs, if risk factors for hepatitis B are present, such as a history of multiple sexual partners in past six months, household contacts with hepatitis B, intravenous drug abuse, or work in healthcare.]]
Answer D	AnswerD::Hepatitis C vaccination
Answer D Explanation	AnswerDExp::'''Incorrect''' : No prophylactic or therapeutic vaccine for hepatitis C exists.
Answer E	AnswerE::PPD
Answer E Explanation	[[AnswerEExp::Incorrect : Tumor necrosis factor-alpha (TNF-alpha) inhibitors increase the risk of reactivation of latent TB infection (LTBI). This risk is greater for the anti-TNF antibodies infliximab and adalimumab than for etanercept.]]
Right Answer	RightAnswer::C
Explanation	[[Explanation::Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder of unknown etiology that primarily involves joints symmetrically and may lead to destruction of joints due to erosion of cartilage and bone which leads to deformity. The disease usually involves metacarpophalangeal and proximal interphalangeal joints of the fingers with showing progress from the periphery to more proximal joints. In patients with mildly active RA, we initiate NSAID for rapid symptomatic relief and begin DMARD treatment with either hydroxychloroquine (HCQ) or sulfasalazine (SSZ). In patients with moderately to severely active RA, we initiate antiinflammatory therapy with either a NSAID or glucocorticoid, depending upon the degree of disease activity, and generally start DMARD therapy with methotrexate. In patients resistant to initial DMARD therapy (eg, MTX), we treat with a combination of DMARDs (eg, MTX plus either a TNF inhibitor or SSZ and HCQ). Laboratory assessment of complete blood count, serum creatinine, aminotransferases; evaluation of comorbidities; vaccinations; and screening for hepatitis C, hepatitis B, and latent tuberculosis infection should be done before starting on DMARD. This patient has moderate disease and hence methotrexate would be the initial DMARD of choice. Educational Objective: References: ]]
Approved	Approved::Yes
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