A 42-year-old female who was referred by an orthopedic surgeon presents to your office with multiple joint complaints. The orthopedist has seen her for left knee pain, intermittent swelling, occasional “clicking and locking,” present for about 10 years. After knee radiograph and exam, the orthopedist diagnosed a chronically damaged meniscus, but he wants the patient evaluated by you for her other joint complaints.

Laboratory data included with her records show an ANA 1:40 (speckled pattern) and an ESR 20 mm/hour. The patient moved to the U.S. from Guam 4 years ago. She reports poor sleep and feeling quite depressed. She feels that she has no friends, and she has had trouble adjusting to the colder weather. You notice she has a bottle of water with her and upon your specific questioning she states, “I have to sip some water throughout the day. I’ve done this for the last 15 years because my mouth gets so dry.” She denies problems with skin rash, cavities, swallowing, and eye pain. She does not use artificial tears.

1		Which of the following is the most specific for inflammatory arthritis?
			A)	Spider angiomas (telangiectasia) on the back and abdomen.
			B)	A positive “bulge sign” on left knee exam.
			C)	Presence of 16/18 fibromyalgia tender points, with nontender control points.
			D)	Incomplete left grip, due to swelling in her second and third proximal interphalangeal joints.
			E)	Presence of a holosystolic murmur at the left sternal border, without radiation.
2		On physical examination, you find a “bulge sign” on the left knee, but no other joint swelling. She has 16/18 tender points and normal range of motion and strength. Lung, heart, and abdominal exams are unremarkable. The neurological exam is grossly normal, except for poorly defined numbness and pain to touch on the left side of her face. She has poor saliva pooling under the tongue, and Schirmer test is 3.5 mm on the left and 4 mm on the right at 5 minutes. (The Schirmer test is accomplished by placing sterile filter paper under the lower eyelid for 5 minutes and measuring the length of wetting with tears. Normally tears saturate 5 mm or more.) You also notice a mildly tender, hard, nodular swelling behind the angle of the mandible on the left in the area of the parotid gland. All of the following studies and interventions are appropriate EXCEPT:
			A)	CBC, transaminases, uric acid, ESR, c-reactive protein (CRP).
			B)	Anti-SS-A (Ro), anti-SS-B (La), anti-double-stranded DNA, rheumatoid factor, serum protein electrophoresis.
			C)	Prescribe trazodone 50 mg PO QHS and recommend aerobic exercises.
			D)	Prescribe prednisone 20 mg PO QD, with calcium and vitamin D supplements.
			E)	Maxillofacial MRI.
3		She starts trazodone and exercise and feels better. The tests you order return as follows: negative SSA, SSB, and Ds-DNA; elevated rheumatoid factor (RF); and no monoclonal protein on SPEP but diffusely elevated globulins. A chest x-ray is normal. Her ESR is 35 mm/hour and CRP 0.5. A maxillofacial MRI shows an enlarged left parotid, with an ill-defined 2 cm _1.5 cm dense signal in the center, and there was no neurovascular compromise. What is the most appropriate next step in the management of this patient?
			A)	Continue your current management and adopt a “watchful waiting” approach.
			B)	Refer for biopsy of the left parotid.
			C)	Initiate prednisone 20 mg PO QD, with calcium and vitamin D.
			D)	Refer for lip biopsy.
			E)	Perform a gallium scan.
4		Results of the parotid gland biopsy report read, “lymphocytic infiltrate, no malignant cells noted.” You then order flow cytometry, and it has no markers for lymphoma. Her biopsy scar has healed nicely, and she has no pain or numbness. You believe that she probably has Sjögren’s syndrome. What would you do next?
			A)	CT chest/abdomen/pelvis.
			B)	Start prednisone 20 mg PO QD, with calcium and vitamin D.
			C)	Recommend sugarless lemon drops and artificial tears as needed and continued trazodone and exercise.
			D)	Refer for lip biopsy.