Question 1

A 52-year-old man comes to the office due to difficulty using his left hand.  Over the last year, he has had progressive stiffness at the palm and third and fourth digits, which has led to difficulty doing yard work and typing at his computer.  The patient has tried splints and warm compresses without relief.  He has no history of trauma to the hand and no other musculoskeletal issues.  On examination, the patient has decreased extension at the left third and fourth metacarpophalangeal joints.  Findings of the left hand examination are shown below:  Which of the following is most closely associated with this patient's condition?

Accepted Answer

Explanation: 11ec2b69_c0ac_99a5_8f63_7376f9deba07_MD0005_00 This patient's findings are consistent with Dupuytren contracture (DC) at the base of the third and possibly fourth digits. DC is characterized by progressive fibrosis of the palmar fascia. Although the etiology is unknown, risk factors include age >50, male sex, family history, and Northern European ancestry. DC occurs more commonly in patients with a history of smoking and alcohol use. In addition, some studies have shown that up to 40% of patients with DC have diabetes mellitus. DC begins with thickening along the flexor tendons near the distal palmar crease. As the condition progresses, patients may develop discomfort, nodules, and fibrous cords, leading to contractures with decreased extension. The diagnosis is made clinically and does not require imaging. Mild cases can usually be managed with modification of hand tools (eg, padded gloves, cushion tape). Persistent or progressive disease may require needle disruption of cords (aponeurotomy) or intralesional glucocorticoid injections. Surgery is occasionally required for advanced disease or contractures. (Choice A) Acromegaly is characterized by the coarsening of facial features and enlargement of the hands and feet. Patients often notice an increase in ring or glove size and thickening of the skin, but palmar contractures are not typical. Other complications include arthritis, peripheral neuropathy, and carpal tunnel syndrome. Acromegaly (Choice B) Common skeletal manifestations of ankylosing spondylitis include back pain, sacroiliitis, dactylitis (swelling of fingers and toes), and enthesitis (tenderness at tendon insertion sites). DC is not commonly associated with ankylosing spondylitis. (Choice D) Hypertrophic osteoarthropathy is characterized by digital clubbing and bony swelling of the toes and fingers. Causes include pulmonary diseases (eg, cystic fibrosis), malignancy (eg, lung adenocarcinoma), and cyanotic heart disease. Periostitis may cause pain in the digits, but the palmar fascia and tendons are not affected. clubbing (Choice E) Extradermal manifestations of psoriasis include nail pitting, dactylitis, and psoriatic arthritis, but the risk of DC is not significantly increased. Educational objective: Dupuytren contracture is characterized by progressive fibrosis of the palmar fascia. It presents with thickening and nodule formation along the flexor tendons near the distal palmar crease, leading to contractures with decreased extension. Risk factors include age >50, male sex, family history, Northern European ancestry, and diabetes mellitus. References: Hand disorders associated with diabetes: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26280955)

Question 2

A 35-year-old man comes to the office due to joint pain.  The patient is a charter pilot and operates flights from Wisconsin to the Caribbean islands, where he frequently stays for several weeks.  During his most recent trip 3 months ago, he had fever and malaise for several days accompanied by severe pain in his fingers, wrists, and ankles.  Since then, he has had persistent joint pain that has slightly improved over time.  The patient has no fever, night sweats, rash, or abdominal symptoms.  He is also an avid hiker.  Temperature is 37 C (98.6 F), blood pressure is 130/72 mm Hg, and pulse is 80/min.  No scleral icterus, mucosal lesions, or lymphadenopathy is present.  The lungs are clear on auscultation, and there are no heart murmurs.  The abdomen is soft and nontender with no hepatosplenomegaly.  Tenderness and mild swelling are noted in the bilateral wrists, metacarpophalangeal joints, and ankles.  No rash is present.  Blood cell counts and serum chemistry study results are within normal limits.  Which of the following is the most likely cause of this patient's symptoms?

Accepted Answer

Explanation: 11ec2b69_c0aa_76c2_8f63_d373063aff50_MD0005_00 This patient went to the Caribbean islands and developed a transient febrile illness accompanied by severe, persistent joint pain indicating chikungunya, an alphavirus infection transmitted by Aedes mosquitoes. Outbreaks are common in tropical and subtropical areas (eg, Africa, Asia, Europe, Caribbean region, the Americas) during the rainy seasons, and travelers may return to their home countries with sequelae of infection. Initial manifestations usually include high fever [>39 C (102 F)], diffuse maculopapular rash, and severe polyarthralgia. The joint pains are typically bilateral and symmetric and begin in the distal extremities (eg, hands, wrists, ankles) but may move proximally; the pain is often severe and frequently limits daily activities. Laboratory assessment usually reveals transient lymphopenia and thrombocytopenia. The diagnosis is made by polymerase chain reaction or serology testing. Although most initial manifestations (eg, fever, rash) resolve spontaneously within a few days, up to 70% of patients develop persistent arthralgia or arthritis lasting months or years. Those with long-standing joint symptoms often require treatment with disease-modifying antirheumatic drugs (eg, methotrexate) for adequate pain relief. (Choice B) Ehrlichiosis is a tick-borne bacterial illness that usually causes acute fever and nonspecific symptoms (eg, malaise, headache). Although arthralgia is common, the presence of severe, persistent polyarticular joint pain indicates a different diagnosis. (Choice C) Lyme disease is a tick-borne bacterial illness that usually causes erythema migrans (a spreading, annular rash) and systemic symptoms in early infection. Monoarthritis of a large joint (eg, knee) may occur in late infection; however, severe polyarticular joint pain in the distal small joints is not consistent with Lyme disease. (Choice D) Malaria is a mosquito-borne protozoal illness that causes fever and flu-like symptoms (eg, shaking chills, headache, myalgia, malaise). Laboratory abnormalities such as anemia and hyperbilirubinemia are common due to red blood cell lysis. Severe, persistent polyarthritis would be atypical. (Choice E) Typhoid fever is a bacterial illness caused by Salmonella infection. Manifestations progress slowly and begin with a week of fever (often with temperature-pulse dissociation) followed by abdominal pain and cutaneous "rose spots." By week 3, hepatosplenomegaly, intestinal bleeding, and intestinal perforation often occur. Educational objective: Chikungunya is a mosquito-borne virus that causes high fever and severe polyarthralgia. The arthralgia is typically bilateral and symmetric and affects distal joints (eg, hands, wrists, ankles). Most symptoms resolve spontaneously, but up to 70% of infected patients develop chronic arthralgia or arthritis. References: Emerging vector-borne diseases. (http://www.ncbi.nlm.nih.gov/pubmed/27929218) Dengue, Zika and chikungunya: emerging arboviruses in the new world. (http://www.ncbi.nlm.nih.gov/pubmed/27833670)

Question 3

A 36-year-old man comes to the emergency department due to acute pain in his left foot. He was previously feeling well but suddenly woke from sleep with severe pain at the base of his great toe. The patient has type 1 diabetes mellitus complicated by peripheral sensory neuropathy and proliferative retinopathy. He also has end-stage renal disease due to diabetic nephropathy, for which he underwent cadaveric renal transplant 18 months ago. The patient's diabetes is controlled by an insulin pump. His other medications include lisinopril, amlodipine, cyclosporine, mycophenolate, and prednisone (5 mg/day). Temperature is 37.3 C (99.1 F), blood pressure is 126/84 mm Hg, and pulse is 88/min. Physical examination shows an erythematous, swollen, warm, and tender left first metatarsophalangeal joint. Range of motion testing is limited by severe pain. There is a moderate hammertoe deformity at the third toe but no abnormal calluses. Posterior tibial and dorsalis pedis pulses are easily palpable. Bedside capillary glucose is 184 mg/dL. Examination of joint aspirate confirms the presence of crystals. Leukocyte count in the synovial fluid is 30,000/mm³. Gram stain is negative for organisms. Which of the following is the most appropriate drug for management of acute monoarthritis in this patient?

Accepted Answer

Explanation: The management of acute gout is challenging in patients with renal failure or in those who have undergone renal transplant as nonsteroidal anti-inflammatory drugs (eg, indomethacin), which are the usual first-line treatment, are relatively contraindicated (Choice C). Low-dose colchicine (eg, renal dose adjustment) is usually effective; however, concurrent use of cyclosporine can cause delayed clearance of colchicine, leading to increased toxicity (eg, myoneuropathy). Additional options for the management of acute gout include systemic and intra-articular glucocorticoids. Because many patients receive glucocorticoids as part of their anti-rejection regimen, a temporary increase in the dose is a convenient way to terminate an acute gout flare and is especially useful for polyarticular gout. However, systemic glucocorticoids are associated with significant adverse effects, and intra-articular glucocorticoids (eg, triamcinolone) are better tolerated for those with monoarticular symptoms and would be most appropriate for this patient. (Choices A, B, and E) Urate-lowering therapy with either a xanthine oxidase inhibitor (eg, allopurinol, febuxostat) or a uricosuric agent (eg, probenecid) can be considered for patients with gouty arthritis following renal transplant. However, these agents should not be initiated until the acute attack has been fully treated; they can be continued in those who were taking them prior to the flare. If a patient is taking azathioprine (sometimes used following organ transplant), care should be taken when prescribing xanthine oxidase inhibitors because these agents can impair the metabolism of azathioprine. Educational objective: Treatment options for acute gout in patients with a history of renal transplant include low-dose colchicine and systemic and intra-articular glucocorticoids. Cyclosporine can cause delayed clearance of colchicine, leading to increased toxicity. References: Colchicine-induced myoneuropathy in a cyclosporine-treated renal transplant recipient. (http://www.ncbi.nlm.nih.gov/pubmed/26877917)

Question 4

A 36-year-old man comes to the emergency department due to acute pain in his left foot.  He was previously feeling well but suddenly woke from sleep with severe pain at the base of his great toe.  The patient has type 1 diabetes mellitus complicated by peripheral sensory neuropathy and proliferative retinopathy.  He also has end-stage renal disease due to diabetic nephropathy, for which he underwent cadaveric renal transplant 18 months ago.  The patient's diabetes is controlled by an insulin pump.  His other medications include lisinopril, amlodipine, cyclosporine, mycophenolate, and prednisone (5 mg/day).  Temperature is 37.3 C (99.1 F), blood pressure is 126/84 mm Hg, and pulse is 88/min.  Physical examination shows an erythematous, swollen, warm, and tender left first metatarsophalangeal joint.  Range of motion testing is limited by severe pain.  There is a moderate hammertoe deformity at the third toe but no abnormal calluses.  Posterior tibial and dorsalis pedis pulses are easily palpable.  Bedside capillary glucose is 184 mg/dL. 
Aspiration of the affected joint is likely to reveal which of the following in this patient?

Accepted Answer

Explanation: 11ec2b69_c0b0_1c1b_8f63_dfbd009bf217_MD0005_00 This patient has acute monoarticular arthritis involving the first metatarsophalangeal (MTP) joint, consistent with acute gout. Gout attacks typically develop abruptly, often starting overnight or in the early morning, with maximal intensity within 12-24 hours. The first MTP joint is most commonly affected. The risk of gout is increased in patients with chronic kidney disease, although this risk can be decreased by dialysis in patients with end-stage renal disease. In addition, the risk is increased following renal (and other solid organ) transplant in patients taking cyclosporine, which decreases uric acid excretion. The diagnosis can be confirmed on synovial fluid analysis, which shows an inflammatory effusion (2,000-100,000/mm³, neutrophilic predominance) and negatively birefringent, needle-shaped monosodium urate crystals. Serum uric acid levels can be suppressed in a gout attack and should not be used for diagnosis during the acute phase of the disease. (Choice A) Tuberculous and nontuberculous mycobacterial arthritis can be seen in patients on immunosuppressive therapy. However, symptoms typically have an insidious onset. Swelling may be present but erythema and warmth are unusual. (Choices B and C) Disseminated Neisseria gonorrhoeae infection usually presents with migratory polyarthritis, tenosynovitis, and rash, although acute septic monoarthritis can also be seen. Staphylococcus species also cause septic arthritis, and the risk is increased in patients on immunosuppressive therapy. However, septic arthritis usually affects the large joints (eg, knees) rather than the small joints of the hands and feet. It evolves over a few days rather than appearing abruptly, as in this patient. (Choice E) Positively birefringent, rhomboid crystals are seen in calcium pyrophosphate dihydrate deposition disease, also known as pseudogout. This condition presents as acute monoarticular arthritis, but the knee joints are more frequently involved than the MTP joints. Educational objective: The risk of gout is increased following renal transplant in patients taking cyclosporine, which decreases uric acid excretion. The diagnosis is confirmed on synovial fluid analysis, which shows an inflammatory effusion and negatively birefringent, needle-shaped urate crystals.

Question 5

A 43-year-old man comes to the office for follow up regarding back pain. He had acute onset of pain in the low back radiating to the buttocks 3 weeks ago after lifting heavy bags of fertilizer at his farm. The patient was treated with naproxen; with treatment, his pain has decreased from an 8/10 to 3/10 in severity, and he no longer has radiation of the pain. Medical history is notable only for 2 prior episodes of back pain in the last year. Vital signs are normal. BMI is 33 kg/m². Physical examination shows no spinal tenderness, normal lower extremity strength and reflexes, and a negative straight-leg raising test bilaterally. The patient asks what is needed to prevent future episodes of back pain. Which of the following is the most appropriate response to this patient's question?

Accepted Answer

Explanation: This patient has acute, uncomplicated low back pain (LBP), which is improving with appropriate initial measures (eg, nonsteroidal anti-inflammatory drugs). In addition to reduced pain severity, he has experienced centralization of pain (ie, a reduction in the extent of referred pain), which carries a favorable prognosis. However, in his extended history, he has had recurrent episodes of LBP, which is associated with an increased risk for additional recurrences. In patients with LBP, physical activity is important for promoting resolution of the initial symptoms, as well as for lowering the risk of recurrence. During acute episodes of pain, patients should be counseled to maintain normal moderate activity. As pain improves, they should be advised to initiate (or resume) a regular exercise program to lower the risk of future episodes. Evidence supports a variety of exercise modalities, including stretching, core-strengthening exercises, and aerobic exercises (eg, walking). Although obesity is associated with an increased risk of LBP, it is not clear that weight loss apart from regular exercise lowers the risk of recurrence. (Choice A) Patients with acute LBP should be advised to continue normal moderate activity, which is associated with reduced duration of pain. However, normal activity alone without additional exercise is associated with a 1-year risk of recurrent pain of approximately 50%. This risk can be significantly reduced with a dedicated exercise program. (Choice B) Spinal manipulation is effective for short-term relief of acute LBP. However, it is not effective for preventing recurrent episodes. (Choice D) MRI is indicated for the evaluation of lumbosacral radiculopathy associated with significant or progressive neurologic deficits, LBP associated with features of cauda equina syndrome (eg, saddle anesthesia), or suspected epidural abscess (eg, fever, intravenous drug use). Otherwise, MRI does not improve outcomes or alter standard treatment advice. (Choice E) Lumbar support braces (back belts) are not associated with a decreased risk of recurrent LBP. In fact, some studies have noted an increased risk, possibly due to restricted mobility or muscular deconditioning. Educational objective: During an acute episode of low back pain, patients should be counseled to maintain normal moderate activity. As pain improves, they should be advised to initiate (or resume) a regular exercise program, which can decrease the risk of recurrent pain; modalities can include stretching, core-strengthening exercises, and aerobic exercises. References: Prevention of low back pain: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26752509)

Question 6

A 57-year-old woman comes to the office due to discomfort in her right hand. She reports that periodically her fingers "feel numb, with some tingling, sort of like they fell asleep." When the patient shakes her hands, normal sensation is partially restored. The symptoms are more often present at night but are occasionally experienced during the daytime as well. She has not had abnormalities of sensation on the dorsal surfaces of her hands, and she reports no shoulder or neck pain. There is no history of injury to the upper extremities. Medical history is notable for irritable bowel syndrome, mitral valve prolapse, degenerative knee arthritis, and hypertension controlled with lisinopril. She also takes an over-the-counter fiber supplement. The patient works as a bookkeeper. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 32 kg/m². Neurologic examination shows no sensory loss, muscle weakness, or muscle atrophy in the right upper extremity. The patient comes for follow-up 6 weeks after the initial visit. She has had no noticeable benefit from initial treatment measures and reports that she has had to reduce her work hours due to increasingly severe symptoms. Which of the following tests should be offered to this patient?

Accepted Answer

Explanation: Compression of the median nerve in carpal tunnel syndrome (CTS) results in loss of myelination. Axonal loss may also occur if the compression is severe. Nerve conduction studies (NCS) can confirm the diagnosis and assess the severity of CTS by demonstrating slowed conduction along the nerve at the level of the carpal tunnel. Reduced amplitudes indicate axonal loss. Electromyography (EMG) is frequently combined with NCS and may show denervation of muscles innervated by the median nerve with relative sparing of those that are not. NCS and EMG are indicated for patients with chronic or refractory CTS who are being considered for surgery. They are not usually needed in the initial diagnosis (which is typically based on clinical features) but can be considered if the diagnosis is uncertain. (Choice A) CTS occurs more frequently in certain connective tissue diseases (eg, rheumatoid arthritis), but serologic testing is not necessary unless there are other findings (eg, pain, swelling in the metacarpophalangeal joints). (Choice B) Neck MRI is useful to evaluate a cervical radiculopathy. Clinical features that warrant neck MRI include symptoms that are worse with neck movement, symptoms involving the dorsal hand, radicular pain in the neck and upper arm, and proximal arm weakness or diminished reflexes. (Choice C) Wrist MRI can demonstrate changes in the median nerve and carpal tunnel to support a diagnosis of CTS, but this is typically reserved for excluding a local mass lesion in atypical cases. (Choice E) X-rays of the hand do not show the median nerve, flexor tendons, or carpal ligament. X-rays are used in acute traumatic CTS to exclude a fracture. Educational objective: Nerve conduction studies can confirm the diagnosis and assess the severity of carpal tunnel syndrome. They are used in preparation for surgery or when the diagnosis is uncertain.

Question 7

A 13-month-old girl is brought to the office by her maternal grandmother for a well-child visit.  The grandmother is the girl's primary caregiver while the parents work full-time.  The girl is happy and active, but the grandmother is concerned that she is not yet walking.  When she takes the child to the playground, the girl crawls and cruises along the playground equipment.  The child wears sunscreen and a wide-brim hat outdoors.  Every day, the child is fed expressed breast milk in a cup and eats a variety of foods, including meat, fruit, and dark-green vegetables.  She also eats yogurt but refuses to drink cow's milk.  The child takes an oral vitamin D supplement daily and no daily medications.  Medical history is significant for a cesarean delivery at 39 weeks gestation for breech presentation.  Weight and length are at the 65th and 30th percentiles, respectively.  Physical examination shows equal leg lengths.  Bilateral hip, knee, and ankle joints have full range of motion.  When the patient stands with her feet together, a symmetric, mild tibiofemoral outward bend results in a gap between the knees.  The child is able to stand for only a few seconds before she falls to the ground and resumes crawling.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0ae_9578_8f63_c9593cf1d3c1_MD0005_00 This child's symmetric bow-legs with normal growth pattern are most likely due to physiologic genu varum, a deformity in which the knees curve away from midline. Due to the normal progression of lower extremity alignment, genu varum is considered physiologic from birth to age 2 years. It is not associated with delayed walking (average age to walk: 12-15 months), and cruising and standing alone briefly at this age are normal. Patients with physiologic genu varum have the following: Bilateral symmetric bowing of the femurs and tibias Normal stature No leg length discrepancy No lateral thrust (eg, knee joint protrudes laterally when walking) Femoral condyle distance <6 cm on examination Physiologic genu varum is a clinical diagnosis; imaging and laboratory studies are unnecessary unless pathologic bowing (eg, Blount disease, rickets, skeletal dysplasia) is suspected. Bilateral leg x-rays are indicated if bowing is progressive, unilateral, persistent after age 3 years, or associated with short stature (eg, possible metabolic disease) (Choice B). Management of physiologic genu varum is reassurance and observation, as spontaneous correction is expected. (Choice A) Exclusive breastfeeding and low sun exposure are risk factors for vitamin D deficiency (eg, rickets). Although rickets causes symmetric bowing, it is unlikely in a patient who is taking vitamin D supplementation and has a normal height. (Choice D) Orthotics are ineffective and not recommended, as the condition typically resolves without intervention. (Choice E) Referral for possible surgical intervention is indicated if there is pathologic genu varum (eg, severe bowing, leg length discrepancy) despite medical therapy. Educational objective: Physiologic genu varum presents in infants age 0-2 years with bilateral, symmetric bow-legs, normal stature, and no lateral thrust. Diagnosis is clinical, and management is reassurance and observation. References: Lower extremity rotational and angular issues in children. (http://www.ncbi.nlm.nih.gov/pubmed/25439018) Management of bow legs in children: a primary care protocol. (http://www.ncbi.nlm.nih.gov/pubmed/28459895)

Question 8

A 53-year-old woman comes to the office with a 6-month history of pain and tightness in the neck, posterior shoulders, and buttocks.  The pain is aggravated by exertion, stress, and lack of sleep.  She also has fatigue and insomnia.  The patient has had intermittent constipation but no other bowel or bladder problems or daytime somnolence.  Vital signs are normal.  Examination shows widespread symmetric tenderness to firm palpation over muscles and bony prominences.  Spinal motion is normal.  Strength is 5/5 and deep tendon reflexes are 2+ in all extremities.  There are no sensory deficits, rashes, or areas of joint swelling or tenderness.  Recent laboratory testing shows a normal complete blood count and erythrocyte sedimentation rate.  Based on these findings, what is the most appropriate next step in evaluation of this patient?

Accepted Answer

Explanation: 11ec2b69_c0ad_5cf6_8f63_619094e62595_MD0005_00 This patient's presentation is consistent with fibromyalgia (FM). FM presents most commonly in young to middle-age women with widespread pain, fatigue, and cognitive/mood disturbances. Patients typically have a fairly normal physical examination except for point tenderness in areas such as the mid-trapezius, lateral epicondyle, costochondral junction, and greater trochanter. Revised 2010 American College of Rheumatology criteria suggest using the widespread pain index and symptom severity scale , rather than trigger point counts, for diagnosis, as the index and scale better emphasize cognitive problems, fatigue, and severity of somatic symptoms. widespread pain index and symptom severity scale FM is a clinical diagnosis and has no specific diagnostic laboratory findings. However, limited laboratory testing is recommended to rule out common conditions that mimic FM, such as anemia (complete blood count) and inflammatory arthropathy (erythrocyte sedimentation rate or C-reactive protein). In addition, hypothyroidism is prevalent in this patient population, and hypothyroid myopathy frequently presents with findings similar to those of FM; a serum assay for TSH is warranted for most patients. Some experts also advise ruling out myositis with creatine kinase, although this is not always needed. In contrast, serologic testing (eg, antinuclear antibody, rheumatoid factor) has low specificity and is not recommended in the absence of additional objective findings (Choice A). (Choice B) Iron deficiency, even in the absence of anemia, increases the risk of restless legs syndrome. This condition can cause impaired sleep, but most patients also have an uncomfortable sensation of needing to move when falling asleep. FM is more likely to cause multiple tender points on examination. (Choice C) This patient has normal muscle strength. In the absence of more specific features or elevated creatine kinase, muscle biopsy is unnecessary. (Choice D) Patients with FM often have sleep problems, and measures to improve sleep hygiene may decrease symptoms. This patient's sleep problems are mild and likely explained by FM, and she has no daytime somnolence or erythrocytosis to suggest sleep apnea or narcolepsy. Educational objective: Fibromyalgia is diagnosed clinically based on widespread musculoskeletal pain, fatigue, disordered sleep, and impaired cognition. Extensive laboratory testing is unnecessary, but a limited evaluation (eg, complete blood count, erythrocyte sedimentation rate, TSH) for common conditions with similar symptoms can be considered. References: Common questions about the diagnosis and management of fibromyalgia. (http://www.ncbi.nlm.nih.gov/pubmed/25884747)

Question 9

A 46-year-old woman comes to the office to follow up on back pain. The patient was involved in a motor vehicle collision 2 weeks ago and was transported to the emergency department due to back pain. Imaging revealed a bulging disc at L4-L5, with no nerve root impingement, and she was released with a prescription for naproxen. Since then, the patient has had only partial relief of pain; it is rated as 7 on a scale of 0-10 in severity and radiates to her right hip and thigh. Medical history is notable for hypothyroidism and irritable bowel syndrome. Vital signs are normal. BMI is 27 kg/m². Examination shows tenderness in the right paraspinal region at the L4 level. Lower extremity motor strength and reflexes are normal, and straight-leg raising test is negative. The patient states, "My back is going to ruin my life. My mother lost her job due to back pain, and now I just know I'm going to lose my job, too." Which of the following is most predictive of poor long-term functional status in this patient?

Accepted Answer

Explanation: 11ec2b69_c0a7_697d_8f63_5103b2f1ecf1_MD0005_00 This patient has acute low back pain and paraspinal tenderness, findings consistent with lumbosacral strain. Acute low back pain spontaneously resolves in most patients. Initial management emphasizes measures to provide temporary pain relief, such as nonsteroidal anti-inflammatory drugs, heat, massage, and spinal manipulation. Only a small number of patients (ie, <20%) with acute low back pain go on to develop chronic pain. However, certain factors (yellow flags), including the following, are associated with poor prognosis and an increased risk of long-term disability: Maladaptive pain coping behaviors Psychosocial comorbidities High level of functional impairment Maladaptive pain coping behaviors include, as in this patient, catastrophizing (ie, assuming the worst possible outcome) and poor expectation of recovery. In most cases, patients with low back pain are simply advised to maintain normal activity, with gradual introduction of a regular exercise program as pain improves. However, patients at high risk for extended disability should be considered for additional interventions, including education, occupational ergonomic assessment, and supervised physical therapy. (Choice A) Minor, nonspecific abnormalities on imaging (eg, bulging discs) are common, both in patients with low back pain and in asymptomatic patients. In the absence of more specific clinical features (eg, radiculopathy with progressive neurologic deficits), these features have little to no impact on prognosis. (Choice B) Localized tenderness in the paraspinal tissues is common in acute lumbosacral strain and is not associated with poor prognosis. In contrast, midline point tenderness suggests an alternate etiology (eg, vertebral compression fracture, vertebral osteomyelitis), which could adversely impact prognosis. (Choice D) Pain referred to the buttocks, hips, and thighs is common in patients with benign lumbosacral strain. It does not indicate radiculopathy or suggest an unusually poor prognosis. (Choice E) The use of opioid analgesics in acute low back pain is associated with an increased risk of prolonged pain and disability. Nonsteroidal anti-inflammatory drugs are not associated with a worse prognosis. Educational objective: Only a small number of patients with acute low back pain develop chronic pain and long-term disability. High-risk features (yellow flags) for prolonged disability include maladaptive coping behaviors, psychosocial comorbidities, and a high level of functional impairment. Maladaptive coping behaviors include catastrophizing (ie, assuming the worst possible outcome) and poor expectation of recovery. References: Yellow flags as predictors of rehabilitation outcome in chronic low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/30024205)

Question 10

A 3-year-old girl is brought to the office by her mother for evaluation of her legs.  The mother says, "I have noticed that her knees turn in more than before, and I am concerned that my daughter will be teased for 'walking funny.'  Her grandmother insists that she needs special shoes to fix her knock-knees."  The patient's father wore "corrective shoes" as a child and "now walks normally."  The patient is otherwise healthy and has had no fever, joint pain, or swelling.  She is a picky eater and her diet consists mostly of bread, pasta, cheese, and 1 cup of cow's milk a day.  The patient is active and "sometimes a bit clumsy" but has never had a fracture or serious injury.  She started walking at age 14 months and now can climb up and down stairs while alternating feet.  She takes no daily medications or vitamin supplements.  Vital signs are normal.  Weight and height are at the 60th and 75th percentile, respectively.  Physical examination reveals a well-appearing girl with a steady gait, legs swinging outward as she walks.  No medial thrust is observed with ambulation.  Legs are equal in length.  With the legs extended and knees touching, a small gap is present between the ankles.  There is mild valgus angulation at the knee.  Which of the following is the most appropriate advice regarding this patient's condition?

Accepted Answer

Explanation: 11ec2b69_c0ad_f937_8f63_d17c3b3d0633_MD0005_00 This patient has physiologic genu valgum, a condition in which the knees angulate toward midline, giving the appearance of "knock-knees." Genu valgum, part of the normal progression of lower extremity alignment, occurs in children age 2-5. Patients with physiologic genu valgum do not have significant pain or difficulty ambulating. They are of normal height. On examination, bilateral leg curvature is symmetric with no leg-length discrepancy and no medial thrust (ie, knee protrudes medially while walking); with walking, legs can appear to swing outward. With knees extended and pointed forward and distal femurs touching, <8 cm between the medial malleoli is considered physiologic genu valgum. Pes planus (ie, flatfoot) also commonly accompanies genu valgum.Diagnosis is clinical; however, radiographs are indicated if there is a history of metabolic disease, lower-extremity fracture, infection, tumor, or joint swelling/warmth. Imaging is also indicated if genu valgum is severe (ie, medial malleoli distance >8 cm), progressive (ie, worsens after age 4-5), persistent (ie, present after age 7), unilateral, causing medial thrust, or associated with short stature (Choice E). These findings are concerning for pathologic causes of genu valgum, which can be secondary to trauma, metabolic conditions, skeletal dysplasia, or neoplasms. Treatment of physiologic genu valgum is reassurance and observation, as spontaneous correction is expected by age 7. (Choice A) Orthotic braces are ineffective and not recommended, as the condition typically resolves without intervention. (Choice B) Physical therapy is not required, as it will not alter the progression of physiologic genu valgum. Although patients with developmental delay benefit from physical therapy, this patient is meeting developmental milestones (eg, ambulating by 14 months, climbing stairs while alternating feet). (Choice D) Vitamin D supplementation is the treatment for rickets (vitamin D deficiency), which can result in pathologic genu varum or genu valgum. Rickets is unlikely in patients with adequate vitamin D intake, normal height and development, and no medial thrust. Educational objective: Genu valgum ("knock-knees") is a symmetric angulation of the knees toward the midline that occurs in children age 2-5. Patients are asymptomatic and have normal stature. Treatment is reassurance, and spontaneous correction is expected. References: Genu valgum and flat feet in children with healthy and excessive body weight. (http://www.ncbi.nlm.nih.gov/pubmed/26914720)

Question 11

A 32-year-old male was admitted to the orthopedic department after being involved in a motor vehicle accident.  His initial injuries included a transverse fracture of the right femur, tibia, fibula, and a comminuted fracture of the left femur shaft.  The secondary survey revealed no other fracture or injuries.  Thirty-six hours after admission, the patient complains of shortness of breath.  His blood pressure is 112/76 mmHg, heart rate is 95/min, respirations are 34/min, and temperature is 37.9 C (100.1 F).  His oxygen saturation on 3L per nasal cannula is 88%.  Physical examination reveals a petechial rash on his head, neck, anterior thorax, and axilla.  He appears confused.  The portable chest x-ray reveals a right lower lobe patchy consolidation.  Emergency V/Q scan shows a mottled pattern of sub-segmental perfusion defects with normal ventilation.  Which of the following would have prevented this complication in this patient?

Accepted Answer

Explanation: Fat embolism is a clinical diagnosis. It typically manifests 24-72 hours after severe trauma, and is usually characterized by a triad of respiratory insufficiency, neurological impairment, and a petechial rash. Other common findings include fever, tachycardia, and altered mental status. The classic petechial rash is most commonly found on the trunk; this is typically a late manifestation, and is described in fewer than 50% of cases. Petechiae result from the occlusion of dermal capillaries by fat globules, thereby leading to extravasation of erythrocytes. No abnormalities of platelet function have been documented. Early immobilization and operative fixation of fractures reduces the chances of fat embolism. Supportive care is the mainstay of therapy for clinically apparent fat embolism. (Choice B)There is no evidence that prophylactic heparin reduces the risk of fat embolism. The use of corticosteroid prophylaxis is controversial, largely because it is difficult to definitively prove its efficacy in a condition with a low incidence, unclear risk factors, low mortality, and a good outcome with conservative management. Educational objective: Always consider the risk of fat embolism in patients with multiple complicated fractures. Fat embolism is a clinical diagnosis that is usually characterized by a triad of respiratory insufficiency, neurological impairment, and a petechial rash. Early immobilization and operative fixation of fractures reduce the chances of fat embolism. References: Emergency management of fat embolism syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19561953) Fat embolism. (http://www.ncbi.nlm.nih.gov/pubmed/16603016)

Question 12

A 17-year-old girl comes to the office for evaluation of pain in her right hip and groin. She first noticed the pain approximately 3 months ago during a scuba class. The patient initially felt an intermittent ache in the right hip and groin that she attributed to carrying heavy scuba gear. She recently started competitive rowing, and the pain has become more intense and constant. She sometimes experiences a "clicking" sensation in the right hip. The patient has had no swelling or stiffness of the knees, feet, hands, or elbows. However, she now has difficulty exercising due to the pain; ibuprofen and ice provide no relief. The patient was adopted at age 18 months from a developing country and has no known medical problems. She lives with her parents and a cat. BMI is 20 kg/m². The patient is afebrile and vital signs are normal. The left side of the pelvis drops when she bears weight on the right leg. She stands on her right toes with her left foot flat on the ground. During supine examination, the right hip has decreased abduction. Which of the following is the most likely cause of this patient's condition?

Accepted Answer

Explanation: Developmental dysplasia of the hip (DDH) is characterized by abnormal acetabular development resulting in a shallow hip socket and inadequate support of the femoral head. When DDH is identified and treated in infancy, the prognosis is excellent as >95% of patients have reduction of a dislocated hip. However, DDH may be missed in the newborn period if classic symptoms and signs (eg, hip clunk, asymmetric leg creases) are absent or undiagnosed. asymmetric leg creases Children with DDH may initially be asymptomatic until they are weight-bearing. However, due to posterior positioning of the femoral head, adolescents and young adults may have a leg-length discrepancy and gait abnormalities such as toe-walking on the affected side or a Trendelenburg gait. In addition, abnormal traction on the dysplastic hip joint accelerates wear on the cartilage, resulting in premature joint degeneration and osteoarthritis in adolescents and young adults. Young patients may develop activity-related pain in the front hip and groin, as seen in this patient. Trendelenburg gait (Choice B) Juvenile idiopathic arthritis is an autoinflammatory disease characterized by fever, joint pain, and rash. This diagnosis is unlikely in this patient who has isolated hip pain and a Trendelenburg gait. (Choice C) Osteoid osteoma is a benign tumor most commonly occurring in the proximal femur in adolescents. The typical presentation is significant pain at night rather than with activity. (Choice D) Focal pain is expected with chronic osteomyelitis, but the absence of fever, erythema, and swelling makes infection less likely. (Choice E) Legg-Calvé-Perthes disease is characterized by avascular necrosis of the femoral head. Idiopathic interruption of blood supply can result in limp and/or hip pain, typically in children age 5-7. This patient's age and leg-length discrepancy are not typical of this disease. Legg-Calvé-Perthes disease Educational objective: Abnormal acetabular development is characterized by a shallow hip socket with inadequate support of the femoral head. The misaligned and dysplastic hip undergoes accelerated cartilage wearing, resulting in chronic, activity-related hip pain and osteoarthritis in adolescents and young adults. References: Diagnosing and managing hip problems in childhood. (http://www.ncbi.nlm.nih.gov/pubmed/23905285) Developmental dysplasia of the hip. (http://www.ncbi.nlm.nih.gov/pubmed/21808709) Hip dysplasia in the young adult caused by residual childhood and adolescent-onset dysplasia. (http://www.ncbi.nlm.nih.gov/pubmed/27613709)

Question 13

A 55-year-old man comes to the office with 3 weeks of persistent low back pain.  The pain increases in severity at night and when he lifts heavy objects.  Over-the-counter naproxen initially improved the patient's pain slightly.  There is no history of trauma.  He has had no fever, weight loss, muscle weakness, urinary retention, bowel incontinence, or night sweats.  The patient has no other medical problems and takes no other medications.  He is a construction worker, has a 40-pack-year smoking history, and drinks 1 or 2 beers on weekends.  Vital signs are within normal limits.  Physical examination shows moderate paravertebral muscular tenderness.  The range of motion of the spine is normal, and there is no scoliosis or excessive kyphosis.  Neurologic examination is normal.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0a6_cd3c_8f63_8f6b38f6c144_MD0005_00 Most cases of low back pain are due to benign, self-limited musculoskeletal conditions, and diagnostic testing to identify specific causes generally does not improve outcomes. However, some patients have red flag features that increase the risk of infectious, malignant, or inflammatory conditions and warrant more aggressive evaluation: Constitutional symptoms (eg, fever, weight loss) Age >50 Intravenous drug use, immune suppression, or recent bacterial infection Nocturnal pain History of malignancy Although this patient's examination findings suggest benign musculoskeletal pain, his age, nocturnal pain, and smoking history raise concern for malignancy. He therefore warrants further evaluation with plain film spinal x-rays, which can often identify lytic bone lesions. Erythrocyte sedimentation rate (ESR) is also indicated; although this test is nonspecific, ESR can be elevated in infection, malignancy, and inflammatory conditions. If x-ray or ESR is abnormal, advanced imaging with MRI is indicated (Choice C). MRI is also indicated for patients with suspected infection (eg, vertebral osteomyelitis), lumbosacral radiculopathy (sciatica) lasting >1 month, known malignancy, significant neurologic deficits, or features of cauda equina syndrome (eg, saddle anesthesia, acute urine retention, motor deficits). (Choice A) Most patients with back pain should maintain moderate activity. Physical therapy is not usually necessary, although it may be useful for patients with poor functional status who are at risk for prolonged or recurrent pain. However, this patient has indications for diagnostic testing, which should be performed first. (Choice B) HLA-B27 is associated with spondyloarthropathies, especially ankylosing spondylitis (AS). Although AS characteristically causes pain that is worse at night and with prolonged rest, it usually presents at age <40 and is often associated with limited spinal mobility, hip and shoulder pain, peripheral arthritis, and enthesitis, which are not present in this patient. (Choice E) Radionuclide bone scan can identify osteomyelitis or spinal metastases but has lower sensitivity than MRI. It is typically recommended for patients who are unable to undergo MRI or CT imaging. Educational objective: Most cases of low back pain are due to benign musculoskeletal conditions. However, red flag features that warrant diagnostic evaluation include constitutional symptoms (eg, fever, weight loss), age >50, intravenous drug use, immune suppression, recent bacterial infection, nocturnal pain, and history of malignancy. Spinal x-ray can identify lytic bone lesions. Erythrocyte sedimentation rate is often elevated in infection, malignancy, and inflammatory conditions. References: Treatment: current treatment recommendations for acute and chronic undifferentiated low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/22958557) An evidence-based approach to the evaluation and treatment of low back pain in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/24044786)

Question 14

A 57-year-old woman comes to the office due to discomfort in her right hand. She reports that periodically her fingers "feel numb, with some tingling, sort of like they fell asleep." When the patient shakes her hands, normal sensation is partially restored. The symptoms are more often present at night but are occasionally experienced during the daytime as well. She has not had abnormalities of sensation on the dorsal surfaces of her hands, and she reports no shoulder or neck pain. There is no history of injury to the upper extremities. Medical history is notable for irritable bowel syndrome, mitral valve prolapse, degenerative knee arthritis, and hypertension controlled with lisinopril. She also takes an over-the-counter fiber supplement. The patient works as a bookkeeper. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 32 kg/m². Neurologic examination shows no sensory loss, muscle weakness, or muscle atrophy in the right upper extremity. Provocative testing reproduces the patient's symptoms. Which of the following is the most appropriate next step in management of this patient's condition?

Accepted Answer

Explanation: Initial treatment of carpal tunnel syndrome (CTS) includes splints to hold the wrist in a neutral position. Splinting prevents excessive flexion or extension that could narrow the tunnel and worsen median nerve compression. Nighttime splinting is usually adequate, although patients may opt for full-time use. Splinting is most effective in patients with mild symptoms for <10 months. Surgery is more effective than splinting but is usually unnecessary; it is often reserved for patients with moderate to severe symptoms for at least 6 months that do not resolve with conservative measures or are associated with significant neurologic deficits (Choice D). (Choice A) Corticosteroid injection into the carpal tunnel usually provides only short-term relief and is associated with a risk of complications (eg, tendon rupture). For most patients, treatment should start with splinting, with corticosteroid injections later for those who fail initial treatment. (Choice C) Nonsteroidal anti-inflammatory drugs in CTS have shown no benefit compared with placebo and are generally not recommended. (Choice E) Median nerve compression may result in tethering and decreased mobility of the nerve. Physical therapy referral for tendon and nerve-gliding exercises theoretically may improve this complication, but studies are inconclusive. Educational objective: Initial treatment of carpal tunnel syndrome utilizes nighttime splinting to hold the wrist in a neutral position. Corticoid injections can provide short-term relief. Surgical decompression is effective but usually reserved for patients with more severe or chronic symptoms that fail conservative measures.

Question 15

A 55-year-old man comes to the office due to severe pain and swelling in his right big toe. He has hypertension, osteoarthritis, glucose intolerance controlled with diet, and recent peptic ulcer disease. The patient is not on medication for hypertension. On physical examination, his first metatarsophalangeal joint has diffuse swelling, and the skin surrounding the joint is erythematous. The joint is exquisitely tender to palpation and has severe restrictions in movement. Aspiration of the joint fluid reveals an inflammatory effusion with multiple negatively birefringent, needle-shaped crystals within polymorphonuclear cells. The patient is treated with colchicine and shows good response to therapy. Two weeks later, he comes for follow-up. Blood pressure is 152/93 mm Hg and pulse is 78/min. BMI is 36 kg/m². Serum uric acid is 8.2 mg/dL, potassium is 4.1 mEq/L, serum creatinine is 1.2 mg/dL, and liver function tests are within normal limits. Which of the following is the best additional therapy for this patient?

Accepted Answer

Explanation: This patient has typical symptoms of acute gout. This condition is usually treated with an oral nonsteroidal anti-inflammatory drug (NSAID; eg, indomethacin), but colchicine is an appropriate alternate treatment for those with contraindications to NSAIDs, such as peptic ulcer disease. A dedicated urate-lowering drug (eg, allopurinol) would also be recommended for patients who experience recurrent attacks or have gouty tophi. Serum uric acid levels can be normal in gout attacks and should not be used to guide acute management. gouty tophi This patient also has uncontrolled hypertension, which must be managed cautiously in patients with gout. Most diuretics (eg, hydrochlorothiazide, furosemide) decrease the fractional excretion of urate and should be avoided when possible (Choices B and C). By contrast, the angiotensin receptor blocker losartan has a mild uricosuric effect and is effective as first-line treatment for hypertension in patients with gout. ACE inhibitors and angiotensin receptor blockers are also preferred for treating hypertension in patients with chronic kidney disease (regardless of baseline creatinine level) as they improve proteinuria and slow kidney disease progression; renal function should be monitored closely as these medications can cause hyperkalemia and an acute drop in glomerular filtration rate. (Choice A) Clonidine is effective for treating hypertension in patients with gout. However, it is poorly tolerated (eg, dry mouth, constipation, sedation) and is not recommended as first-line therapy. (Choice E) Low-dose aspirin has been recommended to prevent cardiovascular events in high-risk patients with diabetes. However, it is not clearly beneficial in low-risk patients or those with nondiabetic glucose intolerance. In addition, aspirin decreases renal urate excretion and is not recommended in patients with gout. Educational objective: The angiotensin receptor blocker losartan has a modest uricosuric effect and is a good choice for treating hypertension in patients with gout. Thiazides, loop diuretics, and low-dose aspirin should be avoided in patients with hyperuricemia when possible. References: The effect of angiotensin II receptor blockers on hyperuricemia. (http://www.ncbi.nlm.nih.gov/pubmed/26568810)

Question 16

A 48-year-old man comes to the emergency department due to a 3-day history of worsening low back pain.  He had no significant trauma to account for the pain, which started after he drove 12 hours in a day while returning from vacation.  The patient says, "As long as I stay in bed or in a recliner, it's okay, but if I twist, bend over, or stand up too fast the pain is excruciating."  He has tried using a heating pad with no relief.  Medical history is unremarkable, and he takes no medications.  Vital signs are normal.  Examination shows reduced lumbar lordosis and tenderness in the right midlumbar paraspinal area.  Motor strength, reflexes, and sensation in the lower extremities are normal.  With the patient supine and the knee extended, lifting the right leg over 60 degrees elicits achy pain in the posterior thigh.  Which of the following is the most appropriate next step in management?

Accepted Answer

Explanation: This patient has acute, uncomplicated low back pain. He has no apparent neurologic deficits, and his examination shows nonspecific features (paraspinal tenderness, reduced lumbar lordosis) that are common in benign lumbosacral strain. In addition, the presence of hamstring pain (eg, achy pain in the posterior thigh) on the straight-leg raising (SLR) test represents a negative finding, suggestive of a nonradicular etiology of pain; positive findings on the SLR include the presence of shooting or burning pain radiating to the calf and foot. Most young (ie, age <50) patients with acute low back pain can be managed empirically based on clinical features; diagnostic testing (ie, laboratory studies, imaging) is not associated with improved outcomes and is not routinely recommended. Patients should be advised to maintain normal, moderate activity; bed rest is associated with prolonged recovery times and is not recommended (Choice C). Other nonpharmacologic interventions that may be considered include heat, massage, and spinal manipulation. If medication is needed for pain relief, nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen) are first-line analgesics and are adequate for most patients. Acetaminophen is less effective but can be considered for patients with contraindications to NSAIDs. If pain persists, nonbenzodiazepine muscle relaxants (eg, cyclobenzaprine, tizanidine) can be added. However, opioids are not more effective than NSAIDs and are not recommended. (Choice A) Inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) are used in the evaluation of inflammatory back pain (ie, chronic, progressive pain and stiffness that are worse at night and with prolonged rest) and in patients with increased risk of infection (eg, intravenous drug use) or malignancy. (Choice B) MRI of the lumbar spine is indicated for patients with significant neurologic compromise (eg, cauda equina syndrome, severe/progressive radiculopathy) or suspected epidural abscess (eg, fever, history of intravenous drug use). (Choice E) X-ray of the lumbar spine is useful in patients with suspected vertebral metastasis (eg, history of cancer, nocturnal pain, unexplained weight loss). It is also used to confirm an osteoporotic vertebral compression fracture (eg, postmenopausal woman, midline tenderness). Educational objective: For patients with acute, uncomplicated low back pain, diagnostic testing (eg, laboratory studies, imaging) is not routinely required. Patients should be advised to maintain regular, moderate activity. When needed, nonsteroidal anti-inflammatory drugs are the first-line medication. References: Non-specific low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/27745712)

Question 17

A 61-year-old man comes to the emergency department because of severe pain in his right knee over the last 12 hours. He also has had malaise and low-grade fever. He has not had any trauma. He has peptic ulcer disease, type 2 diabetes mellitus, hypertension, and chronic renal insufficiency. He was hospitalized one year ago for upper gastrointestinal bleeding that required a blood transfusion. He has smoked one pack of cigarettes daily for 40 years. He describes himself as a "heavy drinker." Temperature is 37.9 C (100.1 F), blood pressure is 152/87 mm Hg, and pulse is 96/min. BMI is 32 kg/m². Examination shows a swollen, warm, and tender right knee. Laboratory results are as follows: Aspiration of the knee joint is performed. Compensated, polarized, light microscopic analysis of the aspirate shows intracellular needle-shaped, negatively birefringent crystals. Gram staining of the synovial fluid shows no bacteria. Which of the following is the most appropriate next step in management?

Accepted Answer

Explanation: This patient's presentation is most consistent with an acute gout attack. Gout commonly presents as a mono-articular arthritis in the lower extremity (most commonly in the first metatarsophalangeal joint but also in the knee). High alcohol intake can precipitate a gout attack. This patient's uric acid level is mildly elevated, although this could be an incidental finding and cannot confirm the diagnosis by itself. This patient's borderline fever and elevated leukocyte count can be seen with gout, although septic arthritis should always be a concern and arthrocentesis may be needed to differentiate between the 2 conditions. The presence of negatively birefringent, needle-shaped crystals on the joint aspirate confirms the diagnosis of gout. Non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin are the first line treatment for patients with acute gout. However, this patient's chronic renal failure and history of a gastrointestinal bleed are contraindications to NSAID use (Choice D). Colchicineshould also be avoided in renal failure (eg, creatinine 3.9 mg/dL in this patient) (Choice B). Because of the above contraindications, intra-articular corticosteroids are the best option for this patient, especially because there is only one joint involved. Excluding septic arthritis is particularly important if the use of intra-articular corticosteroids is being considered. (Choice A) Allopurinol is a medication that decreases uric acid production. It is used to prevent gout flares but is not typically initiated during acute gout flares. (Choice C) Oral prednisone would be the treatment of choice if this patient had multiple involved joints. Because the patient has a mono-articular arthritis, corticosteroids can easily be injected into the affected joint. Systemic (eg, oral) corticosteroids should be avoided if possible given the patient's history of gastrointestinal bleed and type 2 diabetes mellitus. Educational objective: Nonsteroidal anti-inflammatory drugs and colchicine are the first line treatments for acute gout flares but are contraindicated in patients with renal failure. Instead, corticosteroids should be used in these patients and can be injected locally in patients with a mono-articular arthritis or given orally in patients with multiple joint involvement. References: Current therapy of acute microcrystalline arthritis and the role of corticosteroids. (http://www.ncbi.nlm.nih.gov/pubmed/19078115) Management of acute and chronic gouty arthritis: present state-of-the-art. (http://www.ncbi.nlm.nih.gov/pubmed/15481999)

Question 18

A 10-month-old boy is brought to the clinic due to abnormal feet and gait.  The patient was recently adopted from overseas, and the adoptive parents state that he just began pulling himself up to stand a few weeks ago.  However, he appears clumsy when trying to take steps.  Height and weight are at the 25th percentile.  Head circumference is at the 50th percentile.  Vital signs are normal.  The patient is alert while sitting in the parent's lap.  The head appears normal, and the anterior fontanelle is open and flat.  Examination of the chest is unremarkable, and the abdomen is soft and nontender.  The back appears normal.  Examination of the feet shows bilateral plantar flexion with adduction and inversion.  The feet resist range-of-motion assessment.  The knees and hips have normal range of motion.  After pulling himself up to stand, the patient puts weight on the lateral sides of both feet.  As he attempts to take a step, he falls.  The parents ask about the prognosis of his condition.  Which of the following is the most appropriate response?

Accepted Answer

Explanation: 11ec2b69_c0ab_6123_8f63_41e47c4645db_MD0005_00 This patient with plantar flexed, adducted, and inverted feet has bilateral congenital clubfoot (talipes equinovarus), a developmental deformity of the talus bone. talus bone In congenital clubfoot, the tissues surrounding the talus are underdeveloped and the muscles are shortened and contracted, resulting in an internally rotated foot. In contrast to positional clubfoot (due to in utero crowding), in which the foot is flexible and can be easily manipulated to midline, congenital clubfoot is fixed and resists range-of-motion testing, as seen in this patient. The ipsilateral calf may also be less muscular and, in unilateral cases, shortened leg length is apparent on the affected side. If untreated, the child will attempt to bear weight on the lateral aspect of the inverted foot, as seen in this patient, and the ability to stand and walk will be affected, particularly with bilateral deformities. Initial treatment of congenital clubfoot is nonsurgical and involves stretching and serial casting. Although treatment is ideally started in the first few weeks of life when the anatomy is most supple, serial casting remains effective at correcting the majority of clubfoot in older infants and toddlers. After treatment is complete, bracing is usually required for a few years to prevent recurrence. If the response to casting is inadequate or if clubfoot recurs, surgical intervention may be considered (Choice D). (Choice A) Although certain progressive neuromuscular disorders such as congenital myotonic dystrophy are associated with an increased incidence of clubfoot, other findings such as muscle weakness and hypotonia would be present. This infant's ability to sit and pull to stand suggests normal tone, and clubfoot is a nonprogressive, congenital deformity. (Choice B) Rickets due to vitamin D deficiency causes pathologic genu varum (bowlegs) and is treated with vitamin replacement. Rickets is not associated with clubfoot. (Choice E) Physiologic genu varum is a normal lower-extremity angulation of the knees that is often most noticeable when children begin ambulating; it self-resolves by age 2. This patient has a fixed, plantar flexed foot consistent with clubfoot, and it will persist without intervention. Physiologic genu varum Educational objective: Congenital clubfoot is a deformity of the talus bone, resulting in a fixed, plantar flexed, adducted, and inverted foot. Nonsurgical treatment with serial casting is effective in most infants. References: Ponseti method in management of clubfoot under 2 years of age: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/28632733) Expanded age indication for Ponseti method for correction of congenital idiopathic talipes equinovarus: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/29268899)

Question 19

A 26-year-old Italian-American man comes to your office for the evaluation of low back pain.  He has had this pain for the last eight months, and it is progressively getting worse.  The pain is worse in the morning and gets better as the day progresses.  He denies any history of trauma in the past.  He works as a chef at a local restaurant.  His father and uncles also have "back problems."  His physical examination reveals a limited range of motion of his lumbosacral spine and markedly reduced chest expansion.  The rest of his physical and musculoskeletal examination is unremarkable. Which of the following is the most appropriate statement regarding the prognosis of this condition?

Accepted Answer

Explanation: There are no studies that have demonstrated an increased overall mortality or reduced life expectancy in patients with ankylosing spondylitis. Most patients do well and have no functional or employment disabilities. (Choice C) Smoking cessation should be strongly advised, as this is associated with a very bad prognosis. (Choice E) Prolonged standing at work or exposure to cold conditions are risk factors for disability. Educational objective: Most patients with ankylosing spondylitis do well and have no functional or employment disabilities. There is no increased overall mortality or reduced life expectancy.

Question 20

A 57-year-old woman comes to the office due to discomfort in her right hand. She reports that periodically her fingers "feel numb, with some tingling, sort of like they fell asleep." When the patient shakes her hands, normal sensation is partially restored. The symptoms are more often present at night but are occasionally experienced during the daytime as well. She has not had abnormalities of sensation on the dorsal surfaces of her hands, and she reports no shoulder or neck pain. There is no history of injury to the upper extremities. Medical history is notable for irritable bowel syndrome, mitral valve prolapse, degenerative knee arthritis, and hypertension controlled with lisinopril. She also takes an over-the-counter fiber supplement. The patient works as a bookkeeper. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 32 kg/m². Neurologic examination shows no sensory loss, muscle weakness, or muscle atrophy in the right upper extremity. Which of the following is most likely in this patient?

Accepted Answer

Explanation: 11ec2b69_c0a9_172f_8f63_3b0063cbdde3_MD0005_00 This patient has subjective numbness and paresthesias in the hands with dorsal sparing consistent with carpal tunnel syndrome (CTS). CTS is caused by compression of the median nerve as it passes under the transverse carpal ligament in the wrist. Symptoms of CTS are frequently worse at night and may be relieved by shaking the hands ("flick sign") or running them under warm water. transverse carpal ligament CTS is primarily a clinical diagnosis, and several physical examination maneuvers can be used for confirmation. The Phalen test consists of hyperflexion of the wrist, either by pressure from the examiner with the patient's elbow extended or by having the patient press the dorsal surface of the hands together. Hyperflexion at the wrist exacerbates compression of the median nerve in the carpal tunnel, and a positive test reproduces characteristic symptoms within one minute. Other useful maneuvers that can reproduce or worsen the patient's symptoms include: Tinel sign (tapping over the nerve in the carpal tunnel) Hand elevation test (holding the hand over the head) (Choice D) Reverse Phalen test (hyperextension of the wrist) Sensory deficits and atrophy of the thenar muscles may be seen in advanced cases, but these signs are less sensitive. (Choice A) The painful arc test refers to the onset of shoulder pain when the arm is abducted between 60 and 120 degrees. This finding is characteristic of rotator cuff impingement, which typically presents with shoulder rather than hand pain. (Choice C) A lower cervical radiculopathy (eg, C6 or C7) can cause pain and paresthesias that are worse with neck movement, but otherwise may resemble CTS. However, a cervical radiculopathy can also involve the dorsum of the hand and may be associated with diminished upper-extremity reflexes or proximal arm weakness. Also, a cervical radiculopathy often causes pain in the neck and upper arm, whereas CTS rarely causes referred pain proximal to the distal forearm. (Choice E) DeQuervain tenosynovitis is due to overuse of the extensor pollicis brevis and abductor pollicis longus tendons, and presents with sharp pain at the base of the thumb. Pain is reproduced by ulnar deviation at the wrist, especially when the thumb is held in opposition across the palm (Finkelstein test). Educational objective: Carpal tunnel syndrome presents as pain or paresthesias in the median nerve distribution. Reproduction of symptoms by hyperflexion of the wrists (Phalen test), tapping over the median nerve (Tinel sign), and hand elevation above the head can help to confirm the diagnosis.

Exam 1: Advanced Clinical Medicine