PANCE Musculoskeletal 5 — Questions and Answers
Question 1: A 35-year-old female presents with diffuse musculoskeletal pain for 6 months, fatigue, non-restorative sleep, and 14 tender points. Labs including ANA and ESR are normal. What is the diagnosis?
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Fibromyalgia (Correct answer)
- Polymyalgia rheumatica
Correct answer: Fibromyalgia
Fibromyalgia is characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and multiple tender points with normal laboratory findings.
Question 2: A 60-year-old woman presents with proximal muscle weakness affecting her hips and shoulders, difficulty rising from a chair, and elevated CK and aldolase. ANA and anti-Jo-1 are positive. What is the diagnosis?
- Polymyalgia rheumatica
- Fibromyalgia
- Polymyositis (Correct answer)
- Myasthenia gravis
Correct answer: Polymyositis
Polymyositis presents with proximal muscle weakness, elevated muscle enzymes (CK, aldolase), and positive anti-Jo-1 antibodies in an inflammatory myopathy.
Question 3: A 65-year-old woman presents with bilateral shoulder and hip girdle aching, morning stiffness over 1 hour, and ESR of 85 mm/hr. Muscle strength is normal. What is the first-line treatment?
- Methotrexate
- NSAIDs alone
- Low-dose prednisone (Correct answer)
- Physical therapy alone
Correct answer: Low-dose prednisone
Polymyalgia rheumatica responds dramatically to low-dose prednisone (15-20 mg/day), which is both diagnostic and therapeutic; strength is preserved unlike in myositis.
Question 4: A 50-year-old male with psoriasis presents with sausage digits, asymmetric joint pain, and nail pitting. RF is negative. Which pattern of joint involvement is described?
- Symmetric polyarthritis
- Dactylitis (Correct answer)
- Axial-only disease
- Monoarticular arthritis
Correct answer: Dactylitis
Dactylitis (sausage digits) is a hallmark of psoriatic arthritis, caused by inflammation of the entire digit including flexor tendons and joint synovium.
Question 5: A 45-year-old male with ankylosing spondylitis has back pain unresponsive to two NSAIDs after 3 months. What is the next appropriate treatment?
- Add methotrexate
- Switch to a TNF inhibitor (Correct answer)
- Add hydroxychloroquine
- Increase NSAID dose indefinitely
Correct answer: Switch to a TNF inhibitor
TNF inhibitors (e.g., adalimumab, etanercept) are the next step in ankylosing spondylitis after failure of NSAIDs, as conventional DMARDs are not effective for axial disease.
Question 6: A 55-year-old woman on long-term corticosteroids develops a vertebral compression fracture. Which medication should be co-prescribed to prevent glucocorticoid-induced osteoporosis?
- Calcium and vitamin D alone
- Raloxifene
- Bisphosphonate plus calcium and vitamin D (Correct answer)
- Teriparatide alone
Correct answer: Bisphosphonate plus calcium and vitamin D
Glucocorticoid-induced osteoporosis is prevented and treated with bisphosphonate therapy plus calcium and vitamin D supplementation for patients on chronic steroids.
Question 7: A 30-year-old male presents with unilateral heel pain at the plantar surface, worse with the first steps in the morning, improving after walking. Tenderness at the calcaneal insertion. What is the diagnosis?
- Achilles tendinopathy
- Retrocalcaneal bursitis
- Plantar fasciitis (Correct answer)
- Stress fracture of calcaneus
Correct answer: Plantar fasciitis
Plantar fasciitis presents with plantar heel pain worst with first morning steps (post-static dyskinesia), caused by microtears at the calcaneal insertion of the plantar fascia.
PANCE Musculoskeletal 5
A 35-year-old female presents with diffuse musculoskeletal pain for 6 months, fatigue, non-restorative sleep, and 14 tender points.
Labs including ANA and ESR are normal.
What is the diagnosis?