Question 1

A 36-year-old woman comes to the office due to joint pain during sexual intercourse. Over the past year, she has had difficulty during intercourse due to limited range of motion of the right hip and pain radiating from the hip to the low back. The patient has tried a number of medications, including acetaminophen and naproxen, without relief. In addition to bilateral osteoarthritis of the hips and knees, medical history is notable for morbid obesity, obstructive sleep apnea, and mixed hyperlipidemia. For the past 6 months, the patient has been in a supervised weight-loss program consisting of a modified diet and orlistat and has lost 3 kg (6.6 lb). BMI is 41 kg/m². Physical examination shows limited abduction of the right leg due to pain. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0b2_660f_8f63_fd4d9f8365f5_MD0005_00 This patient has refractory hip pain due to osteoarthritis in the setting of morbid obesity. Conservative measures, including exercise, acetaminophen, and nonsteroidal anti-inflammatory drugs, are usually attempted first but may not provide adequate long-term relief. In such patients, surgical intervention (eg, joint replacement) may be needed. However, morbid obesity is a relative (although not absolute) contraindication to joint replacement and is associated with an increased risk of perioperative complications. Although aggressive weight loss may improve pain control and reduce surgical risk (eg, joint replacement), this patient has had appropriate management with dietary modification and weight-loss medication without significant weight loss. Bariatric surgery should therefore be considered, and is appropriate for patients with BMI >40 kg/m² (as in this patient) or those with BMI >35 kg/m² accompanied by an obesity-related comorbidity (eg, uncontrolled diabetes mellitus). Additional trials of other weight-loss medications (eg, bupropion/naltrexone) can also be considered and may be attempted concurrently with bariatric surgery referral. (Choices A and C) Hip resurfacing arthroplasty consists of trimming the femoral head and capping it with a metal covering, as well as replacing damaged bone with a metal shell. It is most successful in young, active men. However, it is less effective long term than joint replacement. If more aggressive weight-loss measures are not effective in relieving this patient's pain, orthopedic interventions can be considered. (Choice D) Soft pads placed under the back may provide some short-term relief for this patient, but obesity is the underlying cause of her symptoms. Weight loss would provide better long-term relief. (Choice E) This patient should be counseled to continue a low-calorie diet, but so far this has failed. Physical therapy may provide some functional improvement but would not alter her underlying disease course. Tricyclic antidepressants (eg, amitriptyline) can sometimes help in long-term pain management but are associated with weight gain. Educational objective: Morbid obesity is associated with an increased risk of complications in joint replacement surgery. Aggressive weight loss in obese patients with osteoarthritis can provide improved pain control. Weight-loss surgery should be considered for patients with BMI >40 kg/m² or with obesity-related comorbidity and BMI >35 kg/m². References: The benefits of bariatric surgery in obese patients with hip and knee osteoarthritis: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/21883871)

Question 2

A 52-year-old Caucasian woman presents to the office for the evaluation of a constant left groin pain.  The pain started spontaneously about a week ago and is gradually progressive.  It is worse with walking and weight bearing.  She has a past medical history of systemic lupus erythematosus, chronic renal insufficiency, and hypertension.  She has been maintained on 20 mg/day of prednisone for eight months.  Attempts to decrease the dose of prednisone in the past have caused a flare of lupus activity.  She does not smoke or drink alcohol.  On physical examination, she walks with a limp.  There is marked discomfort and limitation of the range of motion on the left side. The radiologic imaging reveals that the patient has stage 4 osteonecrosis of the femoral head.  She has considerable pain on weight bearing, and this is affecting her daily activities.  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: The goal of therapy of osteonecrosis is to preserve the native joint for as long as possible. The main modalities of treatment include conservative therapy, core decompression, osteotomy, and joint replacement. Total hip replacement is the therapy of choice for stage 4 disease of the femoral head (flattening of the femoral head with joint space narrowing). (Choice A) Conservative therapy with bed rest, partial weight bearing, and analgesics is usually ineffective in halting the progress of the disease. It is not recommended for advanced disease. (Choice B) Core decompression offers a chance to preserve the native joint in the early stage 1 or 2 disease (positive radiographs without femoral head collapse). It can provide significant pain relief compared to the conservative treatment. (Choice D) Discontinuing prednisone does not halt the progress of the disease. It may lead to more complications in the form of lupus flare and adrenal insufficiency. (Choice E) Aggressive physical therapy will lead to more patient discomfort and further progression of the disease. Partial weight bearing with or without crutches can be attempted, but this does not halt disease progression. Educational objective: Total hip replacement is the treatment of choice for advanced osteonecrosis of the femoral head. Conservative therapy is usually ineffective in halting the progression of the disease.

Question 3

A 70-year-old man comes to the physician for pain and stiffness of his neck, shoulders, and hips for the last 3 months.  His stiffness is worse in the morning and lasts 1-2 hours.  He also complains of general malaise and a recent weight loss of 3.17 kg (7 lb).  The patient has no headache, scalp tenderness, visual symptoms, or jaw claudication.  Examination shows no overt synovitis at the joints, with normal passive range of motion.  The arteries of the scalp, neck, and extremities are normal on palpation without any tenderness.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0ba_f199_8f63_af1bb97c4b97_MD0005_00 This patient has characteristic features of polymyalgia rheumatica (PMR): Age >50 Subacute-to-chronic (>1 month) pain in the shoulder and hip girdles Morning stiffness lasting >1 hour Constitutional symptoms Elevated erythrocyte sedimentation rate (>40 mm/h) No other apparent explanation for symptoms The physical examination in PMR is frequently unremarkable, with patients indicating no focal tenderness or pain with active or passive range of motion. Signs of inflammation in the joints are absent. When asked to identify the location of their pain, patients typically indicate the soft tissues, not the joints. Low-dose glucocorticoids are the treatment of choice for PMR (eg, prednisone 10-20 mg daily). Rapid and thorough relief of symptoms is expected, and failure to improve rapidly on prednisone should call the diagnosis into question. PMR is frequently associated with giant cell arteritis (GCA), also known as temporal arteritis. Symptoms of GCA include headache, jaw claudication, vision loss, and tenderness over the temporal artery. If GCA is suspected, patients should be considered for an expedited temporal artery biopsy (Choice B) and receive significantly higher doses of glucocorticoids (eg, prednisone 40-60 mg or higher daily) (Choice C). (Choice A) Antinuclear antibody and rheumatoid factor are screening tests for systemic lupus erythematosus and rheumatoid arthritis, respectively, and are frequently positive in a number of other inflammatory and autoimmune conditions. These tests have poor specificity in the absence of characteristic symptoms (eg, malar rash, metacarpophalangeal synovitis) and would be unlikely to change management in this patient. (Choice E) Nonsteroidal anti-inflammatory drugs are occasionally useful in PMR, for mild breakthrough discomfort or minor relapse of symptoms while tapering glucocorticoids. However, they are much less effective than glucocorticoids for initial management and are not recommended. Educational objective: Polymyalgia rheumatica (PMR) affects patients age >50 and is characterized by elevated erythrocyte sedimentation rate and pain and stiffness in the neck, shoulders, and pelvic girdle. The treatment of choice for uncomplicated PMR is low-dose prednisone, which results in rapid relief of symptoms. References: Recognition and management of polymyalgia rheumatica and giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/24364483)

Question 4

A 16-year-old girl comes to the office due to joint pain lasting several days.  The patient says, "My hands and knees feel stiff when I wake up, and those joints are painful throughout the day."  The symptoms are improving, but she still has significant discomfort with daily activities.  The patient has never before had such symptoms.  A mildly pruritic rash on her face, arms, and legs developed around the same time as the joint symptoms.  Last week, the patient had an upper respiratory infection with fever and myalgias that resolved quickly without intervention.  She has seasonal allergies for which she uses a glucocorticoid intranasal spray as needed.  She does not use tobacco, alcohol, or illicit drugs.  The patient is not in a relationship and has never been sexually active.  Temperature is 37.2 C (99 F).  She appears well and is sitting comfortably on the examination table.  Cardiopulmonary examination is normal.  Examination of the hands shows mild symmetric swelling of the proximal interphalangeal and metacarpophalangeal joints; there is no warmth or erythema.  Bilateral knees have a full range of motion, mild tenderness to palpation, and no swelling.  Strength and sensation are symmetric and intact throughout, and distal pulses are strong bilaterally.  There is a faint, erythematous, reticular rash on both arms and legs. 
Which of the following is the most likely diagnosis for this patient?

Accepted Answer

Explanation: Parvovirus B19 is a common viral infection that typically presents with nonspecific flu-like symptoms (eg, fever, myalgias), followed by variable symptoms, depending on the age of the patient. Young children classically develop a "slapped cheek" malar rash (erythema infectiosum) and, rarely, arthralgias. Adolescents and adults, particularly female patients, may develop acute-onset symmetric joint pain, swelling, and stiffness in the proximal interphalangeal and metacarpophalangeal joints a week after the flu-like symptoms. As seen in this patient, a faint, erythematous, reticular rash may be present. However, most adolescents and adults do not have a rash. Diagnosis is often clinical but can be confirmed by serum serology (parvovirus B19 IgM antibodies); sampling of synovial fluid is rarely required. "slapped cheek" (Choice A) Acute rheumatic fever, which presents 2-4 weeks after group A Streptococcus pharyngitis, causes migratory polyarthritis involving the larger joints (eg, knee, elbow). Skin findings include erythema marginatum and subcutaneous nodules. erythema marginatum (Choice B) Lyme arthritis, following a tick exposure in a Lyme-endemic area, is often monoarticular (eg, knee) and associated with erythema migrans. erythema migrans (Choice C) Rheumatoid arthritis is a chronic inflammatory arthritis that commonly presents with morning stiffness in the bilateral metacarpophalangeal and proximal interphalangeal joints. The onset is insidious, and symptoms must be present for >6 weeks to establish the diagnosis. (Choice D) Systemic lupus erythematosus can present with constitutional symptoms (eg, fever, fatigue) and polyarticular arthritis. However, its onset is generally gradual, with extensive systemic involvement and skin findings such as photosensitivity and malar rash or discoid lesions, none of which is seen in this patient. systemic involvement malar rash discoid lesions Educational objective: Parvovirus B19 infection can cause viral arthritis, sometimes with a rash, following a nonspecific flu-like illness. Acute-onset pain, swelling, and stiffness of the symmetric small joints of the hands are typical. References: Viral arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/27037381)

Question 5

A 14-year-old girl is brought to the emergency department by her parents for the evaluation of left knee pain that started 2 hours ago.  The girl landed on her left foot after jumping to spike the ball at a volleyball game and immediately felt an excruciating pain in her left knee.  Her father says, "Her knee is very swollen, and I had to carry her here because she isn't able to put any weight on her left leg."  The patient had no prior injury to the leg.  Medical history is significant for systemic lupus erythematosus, which has been well controlled on daily hydroxychloroquine for the past year.  The patient received a course of high-dose glucocorticoids last year, when she was initially diagnosed, but none since.  She is also taking calcium and vitamin D supplements.  Vital signs are normal.  The patient is crying and in moderate distress due to pain.  On physical examination, there is diffuse swelling and tenderness in the anterior left knee.  Passive extension and flexion of the left knee does not elicit pain or a palpable click along the joint line; however, the patient is unable to extend the left knee against resistance or raise the leg off the examination table without assistance.  With the knee flexed at 30 degrees, there is minimal anterior movement of the tibia in relation to the femur.  Valgus stress to the left knee does not reveal an increased laxity.  The patient has 2+ pedal pulses bilaterally and sensation is intact. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient has a complete rupture of the patellar tendon due to her inability to extend the knee or maintain passive extension. Surgical repair is the treatment of choice and should be performed as soon as possible to optimize recovery of knee function and decrease the likelihood of long-term disability. Delayed treatment can lead to limited range of motion of the knee, quadriceps muscle atrophy, and contracture formation. (Choices A and C) Supportive care (eg, rest, elevation, pain control) is appropriate initial management of a complete patellar tendon tear prior to operative management. However, such patients should not bear weight on the affected extremity or return to baseline activity prior to surgery. Incomplete tears (eg, partial ability to extend the knee) can often be treated conservatively with physical therapy and a gradual return to baseline activity. (Choice B) Intraarticular corticosteroid injections may be indicated in the treatment of joint pain in juvenile idiopathic arthritis. Such injections may predispose a patient to a patellar tendon rupture and have no role in management once a tear has occurred. (Choice D) Lower extremity casting or immobilization is indicated for fractures or after reduction of a dislocation. Surgical repair is required for a complete patellar tendon rupture. Educational objective: Early surgical repair of a ruptured patellar tendon optimizes recovery of normal knee motion to prevent long-term disability. References: Reconstruction techniques and clinical results of patellar tendon ruptures: evidence today. (http://www.ncbi.nlm.nih.gov/pubmed/25819155)

Question 6

A 41-year-old woman comes to the physician because of pain and persistent morning stiffness in both hands.  She has had these symptoms for the past six months.  She has used ibuprofen and tapering steroids; however, as soon as she stops using the steroids, the stiffness and pain recur.  She does not use tobacco, alcohol, or drugs.  Examination reveals synovitis in both metacarpophalangeal and proximal interphalangeal joints, bilaterally.  Further workup revealed systemic lupus erythematosus.  She is started on chronic steroid therapy with prednisone 7.5 mg/day along with hydroxychloroquine.  Which of the following is the most appropriate next step in managing this patient?

Accepted Answer

Explanation: Glucocorticoids decrease the intestinal absorption of calcium and increase the calcium excretion in the urine. They also accelerate bone resorption. Treatment should include the administration of supplemental calcium and vitamin D because this therapy has been shown to decrease the rate of bone loss. (Choice A)Patients who are going to be treated with corticosteroids for more than three months (or six months if low doses, i.e., <10 mg/day), should be evaluated with baseline densitometry, and the test should be repeated every year as long as the therapy continues. (Choice B) Bone turnover markers (N-telopeptide) currently have limited utility in the diagnosis of osteoporosis or the selection of candidates for therapy. (Choice D) Calcitonin is used if the bisphosphonates are contraindicated or not tolerated. (Choice E)Bisphosphonates (alendronate) can be added to calcium and vitamin D if the risk of osteoporosis is very high, especially in postmenopausal women. Caution should be exercised when prescribing these to premenopausal women given the possible teratogenic risk. Educational objective: Chronic glucocorticoid therapy increases the risk of osteoporosis. For this reason, it is important to provide the lowest dose of steroids for the shortest duration, and to add vitamin D as well as calcium supplementation to the patient's therapy. Based on the duration of therapy, bone densitometry is indicated for every year. References: The safety of bisphosphonate use in pre-menopausal women on corticosteroids. (http://www.ncbi.nlm.nih.gov/pubmed/19534636) Bone turnover markers: understanding their value in clinical trials and clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/19190842)

Question 7

A 14-year-old girl is brought to the emergency department by her parents for the evaluation of left knee pain that started 2 hours ago.  The girl landed on her left foot after jumping to spike the ball at a volleyball game and immediately felt an excruciating pain in her left knee.  Her father says, "Her knee is very swollen, and I had to carry her here because she isn't able to put any weight on her left leg."  The patient had no prior injury to the leg.  Medical history is significant for systemic lupus erythematosus, which has been well controlled on daily hydroxychloroquine for the past year.  The patient received a course of high-dose glucocorticoids last year, when she was initially diagnosed, but none since.  She is also taking calcium and vitamin D supplements.  Vital signs are normal.  The patient is crying and in moderate distress due to pain.  On physical examination, there is diffuse swelling and tenderness in the anterior left knee.  Passive extension and flexion of the left knee does not elicit pain or a palpable click along the joint line; however, the patient is unable to extend the left knee against resistance or raise the leg off the examination table without assistance.  With the knee flexed at 30 degrees, there is minimal anterior movement of the tibia in relation to the femur.  Valgus stress to the left knee does not reveal an increased laxity.  The patient has 2+ pedal pulses bilaterally and sensation is intact. 
Which of the following is the most likely explanation for the findings in this patient?

Accepted Answer

Explanation: 11ec2b69_c0b9_6af6_8f63_1fe1cb654f36_MD0005_00 This patient has a tear of the patellar tendon, the distal extension of the quadriceps insertion. Patients at risk of tendon weakness (eg, those using fluoroquinolones) are more likely to rupture the patellar tendon. The most common mechanism is a sudden, strong quadriceps contraction with the foot firmly planted and the knee in partial flexion (eg, pivot, landing). Immediate symptoms often include a "popping" sensation, pain, swelling, and difficulty bearing weight. Physical examination reveals swelling and tenderness in the anterior knee, often with superior displacement of the patella. With a complete tendon rupture, patients cannot actively extend the knee and cannot raise the leg against gravity. (Choice A) The Lachman test attempts to displace the proximal tibia anteriorly while the knee is in flexion. This test is positive when the tibia can be pulled forward, indicating an anterior cruciate ligament (ACL) tear. Although an ACL injury and a patellar tear can both result from similar mechanisms (eg, pivot, landing), an ACL tear is unlikely in this patient with a negative Lachman test. anterior cruciate ligament (ACL) tear (Choice B) Medial collateral ligament (MCL) tears are caused by a direct impact to the lateral knee, causing valgus stress to the joint. This patient does not have either laxity of the knee joint when valgus stress is applied or tenderness along the medial joint line, making an MCL tear unlikely. Medial collateral ligament (MCL) tears (Choice C) Patellar stress fractures are rare and present with chronic pain that worsens with activity. Glucocorticoid therapy can increase the risk of stress fractures, which typically involve the vertebrae, not the knees, and occur within 6 months of therapy. This patient received glucocorticoids a year ago and has acute pain. (Choice E) Tibial tuberosity apophysitis, or Osgood-Schlatter disease, is an overuse injury in pubertal children and causes chronic anterior knee pain. Physical examination may show tenderness or prominence of the tibial tubercle, but range of motion and joint stability are preserved. Osgood-Schlatter disease Educational objective: After a strong contraction of the quadriceps (eg, pivot, landing), patellar tendon rupture should be suspected in a patient with severe pain, anterior knee swelling, and an inability to actively extend the knee or maintain passive extension of the knee. References: Extensor mechanism ruptures. (http://www.ncbi.nlm.nih.gov/pubmed/19751001)

Question 8

A 76-year-old woman comes to the office due to malaise accompanied by diffuse, achy pain.  The pain began 6 weeks ago and is most pronounced around her shoulder and pelvic girdle muscles.  The patient has no headache, visual symptoms, fever, rash, muscle weakness, or urinary symptoms.  She has a history of hypertension, hypercholesterolemia, and osteoporosis.  The patient's medications include enalapril, simvastatin, alendronate, and hydrochlorothiazide.  Family history is unremarkable.  She does not use tobacco or alcohol.  Physical examination shows mild tenderness in the muscles of the pelvic girdle.  The rest of the physical examination is unrevealing.  Routine laboratory studies, including serum creatine kinase levels, are normal.  What is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0ba_5557_8f63_af3fa66f1095_MD0005_00 This patient-age >50 with subacute onset of muscle pain most prominent in the shoulders and pelvic girdle and a normal creatine kinase (CK) level-has characteristic features of polymyalgia rheumatica (PMR). Although the term "polymyalgia" implies a myopathic process, PMR is an inflammatory disorder of the proximal joints, bursae, and tendons. The muscle itself is unaffected, and therefore strength and CK levels remain normal. Pain in the soft tissue is referred from nearby joint structures, and tenderness (if present) is typically mild. Active range of motion may be limited due to pain or stiffness, but passive range of motion is usually normal. Although there are no specific tests for PMR, acute-phase inflammatory markers (eg, erythrocyte sedimentation rate [ESR], C-reactive protein) are very sensitive and, when elevated in a patient with classic symptoms, are considered adequate indications to initiate treatment. Low-dose glucocorticoids (eg, prednisone 20 mg daily) are the treatment of choice. Rapid relief of symptoms is expected; therefore, failure to improve rapidly with glucocorticoid therapy should call the diagnosis into question. (Choice A) Statin myopathy is characterized by an elevated CK level and normal ESR, in contrast to the elevated ESR and normal CPK in PMR. Statins may occasionally cause a mild myopathy with normal CPK; therefore, if the ESR is normal, discontinuation of the statin may be considered. (Choice C) Inflammatory myopathies (eg, polymyositis) usually present with significant weakness and have characteristic abnormalities on muscle biopsy. However, CK is frequently elevated in these conditions. Muscle biopsy is not useful in the diagnosis of PMR. (Choice D) Nonsteroidal anti-inflammatory drugs may be used for benign muscle pain but are much less effective than glucocorticoids in PMR and are not recommended for initial management. (Choice E) PMR is frequently associated with giant cell arteritis (GCA), which causes headache, jaw claudication, vision loss, and tenderness over the temporal artery. To prevent vision loss, high-dose glucocorticoids (eg, prednisone ≥60 mg daily) should be started immediately in patients in whom there is a concern for GCA. However, in patients with symptoms of uncomplicated PMR, treatment should be deferred until after obtaining inflammatory markers because glucocorticoids can rapidly normalize these laboratory abnormalities, which can muddy the diagnosis. Educational objective: Polymyalgia rheumatica affects patients age >50 and is characterized by pain and stiffness in the neck, shoulders, and pelvic girdle and elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein). Low-dose glucocorticoids are the treatment of choice. References: Polymyalgia rheumatica and giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/17111894) Recognition and management of polymyalgia rheumatica and giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/24364483)

Question 9

A 48-year-old man comes to the office due to progressive weakness for the past 2 months.  The patient has experienced difficulty climbing stairs, especially when carrying heavy items such as groceries, and his symptoms have become progressively worse.  He also reports occasional fevers, but no significant pain in the muscles or joints.  The patient has had no diplopia, dyspnea, dysphagia, abdominal pain, or heat or cold intolerance.  He has a history of hypertension and hyperlipidemia, for which he has taken losartan and atorvastatin, respectively, for the last 4 years.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.1 C (98.8 F), blood pressure is 132/84 mm Hg, pulse is 72/min, and respirations are 14/min.  He has no scleral icterus.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  Muscle strength is 3/5 in the deltoids and hip flexors but is otherwise normal.  Deep tendon reflexes are normal and symmetric, and sensations to pain and light touch are intact.  There is mild muscle tenderness and some of the small joints of both hands are tender to palpation without any swelling or erythema.  He has no skin rash.  Laboratory results are as follows:
 
Which of the following is the most likely cause of this patient's current symptoms?

Accepted Answer

Explanation: This patient has typical features of polymyositis, including progressive, painless proximal muscle weakness with elevated muscle enzymes (eg, creatine kinase, transaminases) and inflammatory markers (eg, C-reactive protein). Polymyositis is an inflammatory myopathy triggered by unknown, possibly viral, antigens. Peak incidence occurs at age 40-50. Proximal muscle weakness typically manifests as difficulty climbing stairs, getting into or out of a low chair or car, or working with the arms overhead (eg, combing hair). Joint pain (as in this patient) or swelling may be present. Polymyositis can also involve the upper esophageal musculature, leading to dysphagia with regurgitation and aspiration. Dermatomyositis is a similar disorder, but with characteristic skin manifestations. skin manifestations Most patients have detectable autoantibodies (eg, antinuclear antibody, anti-Jo-1). Definitive diagnosis is established on muscle biopsy. Polymyositis and dermatomyositis may occur as paraneoplastic syndromes, so patients should undergo careful examination and age-appropriate screening tests. (Choice A) Statin myopathy typically presents with mild muscular pain, although patients may occasionally experience severe myopathy with elevated creatine kinase levels. However, statin myopathy is not classically associated with joint pain and usually occurs in the first few months of therapy; it is unlikely in this patient on chronic therapy. (Choice B) Hypothyroid myopathy is a common cause of muscle weakness and can be associated with creatine kinase elevation. However, it is typically also associated with myalgias, delayed reflexes, and other symptoms of hypothyroidism. This patient has an elevated TSH consistent with subclinical hypothyroidism, but his thyroxine level is normal. (Choice D) Myasthenia gravis typically causes fatigability (ie, normal initial muscle strength that fades with repeated use) rather than weakness, although proximal muscle symptoms may resemble polymyositis. However, most patients have facial/oculobulbar symptoms, and muscle enzyme levels are normal. (Choice E) Polymyalgia rheumatica is very rare in younger patients (age <50), and typically causes stiffness and pain rather than painless weakness. Educational objective: Polymyositis is characterized by painless proximal muscle weakness with elevated muscle enzymes and inflammatory markers. Peak incidence occurs at age 40-50. Muscle weakness may manifest as difficulty climbing stairs, getting into or out of a chair or car, or working with the arms overhead. Dermatomyositis is a similar disorder but with characteristic skin manifestations. References: The diagnosis and classification of polymyositis. (http://www.ncbi.nlm.nih.gov/pubmed/24461380)

Question 10

A 73-year-old man comes to the office due to pain and restriction of movement in his left hip joint for the last 6 months.  He has been taking over-the-counter acetaminophen 2-3 times a day, although this does not give any significant relief from this pain.  His medical history is significant for type 2 diabetes mellitus and hypertension.  He is currently on metformin, hydrochlorothiazide, and atenolol.  His father has hypertension and gout.  He has a 30-pack-year history of smoking, but he quit smoking 10 years ago.  He has a history of alcohol abuse during his early 20s.  Currently, he drinks a glass of wine over the weekends.  Physical examination reveals restricted movement in his left hip joint, with pain on passive flexion.  The rest of the physical examination is unremarkable.  X-ray of his left hip joint and pelvis reveals thickening of outer cortex of his left proximal femur with mild bowing.  Sclerotic lesions are also present on the left ischial bone.  Technetium bone scan shows an increased uptake in the frontal bone, left scapula, left ischium, and whole of his left proximal femur.  A basic metabolic profile, including calcium and creatinine levels, is unremarkable.  What is the most appropriate treatment for this patient?

Accepted Answer

Explanation: This patient most likely has Paget disease of bone (osteoclast abnormalities leading to increased bone turnover and abnormal remodeling), as evidenced by his symptoms (eg, bony pain), x-ray features (eg, thickened cortex, sclerotic lesions), and bone scan findings (eg, increased uptake due to increase bone remodeling). Laboratory studies include normal calcium and, often, elevated alkaline phosphatase levels. The involvement of his left proximal femur, which is a weight-bearing bone, warrants treatment with an oral bisphosphonate such as alendronate. Treatment of Paget disease is indicated when patients have symptomatic disease, including intolerable pain, involvement of weight-bearing bones, or neurological involvement; other indications for treatment, which develop more rarely, include hypercalcemia (usually due to immobilization as a result of widespread bony lesions, not due to Paget disease itself), hypercalciuria, and congestive heart failure. Several bisphosphonates (eg, zoledronic acid, alendronate, risedronate) are approved for the treatment of Paget disease due to their antiresorptive properties. For patients who cannot tolerate bisphosphonates, calcitonin (a less potent antiresorptive agent) can be considered. (Choice B)Calcitriol (1,25-dihydroxyvitamin D), an active metabolite of vitamin D, is indicated for treatment of renal osteodystrophy and hypoparathyroidism. This patient has normal renal function and normal calcium levels. Calcitriol will not be helpful in this patient. (Choice C)Radiotherapy could be used for metastatic bone lesions. This patient's x-ray features are not consistent with metastatic bone disease, which is usually characterized by punched out lesions that are sometimes accompanied by surrounding sclerosis. Metastatic prostate cancer can cause sclerotic lesions, but the increased uptake in the frontal bone and the lack of an enlarged prostate (normal physical examination) make prostate cancer less likely. (Choice D)Ibuprofen can be used to control pain in patients with Paget disease; however, it will not lead to long-lasting remission. Ibuprofen can be used in this patient until the effect of alendronate begins. One should be cautious in using nonsteroidal anti-inflammatory drugs in elderly patients because of the danger of increased toxicity, particularly renal failure. (Choice E)Prednisone is not indicated in treatment of Paget disease. Educational objective: Indications for treatment of Paget disease include bone pain, involvement of weightbearing bones, and neurological compromise. Bisphosphonates are the preferred therapy for the treatment of Paget disease.

Question 11

A 50-year-old obese man comes to the emergency department with toe pain.  He awoke this morning with sudden severe pain in his left great toe.  He has never had this type of pain before and has had no trauma to the toe.  The patient has a history of hypertension treated with hydrochlorothiazide.  He also has osteoarthritis in his right knee that was treated with an intraarticular steroid injection 6 months ago.  He smokes a pack of cigarettes and drinks 1 or 2 glasses of wine daily.  His temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 12/min.  The patient's left great toe is inflamed, with swelling and erythema at the metatarsophalangeal joint.  There is pain with minimal range of motion.  There are no skin rashes.  The remainder of the examination is within normal limits. 
Which of the following is the best next step in confirming the diagnosis?

Accepted Answer

Explanation: 11ec2b69_c0b0_df6d_8f63_0910db27c0ec_MD0005_00 This patient's presentation suggests acute monoarticular gout, which is due to intraarticular deposition of monosodium urate (MSU) crystals. Risk factors for gout include volume depletion, certain medications (eg, diuretics), high-protein or high-fat diet, increased alcohol consumption, and recent surgery or trauma. Patients usually develop acute onset of severe joint pain with erythema, swelling, and limited range of motion. Although most cases (>80%) occur in the 1st toe or knee, gout can also occur in other joints (eg, ankle, wrist, finger, shoulder, olecranon bursa). Patients with chronic hyperuricemia may also develop tophi, nodular deposits of MSU crystals in soft tissues with associated inflammatory changes. tophi Even if it is highly suspected clinically, gout should be confirmed with arthrocentesis. The synovial fluid usually contains MSU crystals that are needle-shaped and negatively birefringent under polarizing light. In contrast, pseudogout has positively birefringent rhomboid-shaped crystals. Joint fluid analysis and culture can also rule out septic arthritis, which can coexist with acute gout. MSU crystals pseudogout In patients unable to have arthrocentesis, gout can be conditionally diagnosed with the classic clinical findings (eg, acute onset, 1st toe involvement, significantly elevated uric acid level, tophi). However, clinical features alone are not as sensitive or specific as synovial fluid analysis. Many patients can have a normal or even low uric acid during an acute gouty attack (Choice D). (Choice B) Erythrocyte sedimentation rate can be elevated in gout or other inflammatory conditions (eg, septic arthritis, osteomyelitis) but is not sensitive or specific for diagnosis. (Choices C and E) Radiologic imaging is typically done to exclude other etiologies of joint pain (eg, fracture, osteomyelitis). However, it is not as effective as synovial fluid analysis for diagnosing acute gouty arthritis and is not necessary in patients with typical clinical features. In chronic gout, imaging can detect subcortical cysts suggestive of tophi or erosions in patients with recurrent attacks. Educational objective: Arthrocentesis confirms acute gout by showing monosodium urate crystals that are negatively birefringent and needle-shaped under polarizing light. Serum uric acid does not accurately diagnose acute gout as many patients can have normal or even low uric acid during an acute gouty attack. References: Diagnosis and treatment of gout in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/22272526) EULAR evidence based recommendations for gout. part I: diagnosis. report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). (http://www.ncbi.nlm.nih.gov/pubmed/16707533) A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20625017)

Question 12

A 66-year-old man comes to a community clinic after undergoing a computed tomography scan of the head at a local emergency department.  He fell while stepping out of the bathtub and struck his head but did not lose consciousness.  The patient sustained a small head laceration that was closed with sutures, but no other injuries were identified in the emergency department.  He reports a longstanding history of normal-pressure hydrocephalus with frequent falls, but he has not followed up with his neurologist for several years.  The patient is now asymptomatic with no headaches, focal weakness, or dizziness.  His head computed tomography scan with bone windows is shown in the image below.  After the appropriate steps, the patient returns for follow-up one year later.  He now complains of hearing loss in the left ear.  What is the appropriate response to his complaint?

Accepted Answer

Explanation: This patient's hearing loss is likely secondary to Paget disease of bone (PDB). Hearing loss is a common complication of PDB, affecting as many as 37% of patients in one survey. There are likely multiple pathologic mechanisms, including compression of the auditory nerve by bony overgrowth or involvement of the cochlea and/or cochlear capsule itself. Treatment of PDB with calcitonin or bisphosphonate therapy may slow the progression of hearing loss but does not appear to reverse the loss that has already occurred (Choice E). Other interventions that have been studied include external hearing aids and cochlear implants. (Choice B) Multiple mechanisms of post-traumatic hearing loss, especially following temporal bone injury, have been described. However, most cases result in immediate rather than delayed hearing loss. Rare cases of delayed post-traumatic hearing loss have been reported, but in such cases magnetic resonance imaging is a more informative test than computed tomography. (Choice C) Hearing loss is not a typical symptom of normal-pressure hydrocephalus. Placement of a ventriculoperitoneal shunt would not likely improve this patient's hearing loss. In fact, hearing loss is a recognized complication of ventriculoperitoneal shunt placement. (Choice D) Age-related hearing loss (presbycusis) is a common problem that is typically bilateral and often managed with external hearing aids. Educational objective: Hearing loss is a common complication in patients with Paget disease of bone and likely has several different pathologic mechanisms. Treatment with calcitonin or bisphosphonates can slow the progression of hearing loss but is unlikely to reverse hearing loss that has already occurred. References: The mechanism of hearing loss in Paget's disease of bone. (http://www.ncbi.nlm.nih.gov/pubmed/15064610)

Question 13

A 50-year-old obese man comes to the emergency department with toe pain.  He awoke this morning with sudden severe pain in his left great toe.  He has never had this type of pain before and has had no trauma to the toe.  The patient has a history of hypertension treated with hydrochlorothiazide.  He also has osteoarthritis in his right knee that was treated with an intraarticular steroid injection 6 months ago.  He smokes a pack of cigarettes and drinks 1 or 2 glasses of wine daily.  His temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 12/min.  The patient's left great toe is inflamed, with swelling and erythema at the metatarsophalangeal joint.  There is pain with minimal range of motion.  There are no skin rashes.  The remainder of the examination is within normal limits. The diagnosis of acute gout is made.  Which of the following is the preferred treatment for the patient at this time?

Accepted Answer

Explanation: 11ec2b69_c0b1_7bae_8f63_ef84380b8bb0_MD0005_00 Treatment of acute gout is based on the patient's comorbidities, effectiveness of previous treatments, and patient preferences. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy and are effective in >90% of patients with acute gout. Nonselective agents with a short half-life (eg, indomethacin, ibuprofen) are usually preferred as they are inexpensive and effective in most patients. COX-2 inhibitors are also used as alternate therapy in some patients. Patients should continue the drug until 1-2 days after symptom resolution (a total of 5-7 days in most cases). Oral colchicine, an alternate therapy in patients with contraindications to NSAIDs, is used in acute or chronic kidney disease, heart failure, or peptic ulcer disease, or in those currently taking anticoagulation (Choice C). Colchicine is most effective if given within 24 hours of symptom onset. The drug is given as an initial 1.2-mg dose followed by 0.6 mg an hour later. Colchicine can then be continued at 0.6 mg once or twice daily until 2-3 days after symptoms resolve. However, the drug should be given at a reduced dose in the elderly. Colchicine is usually avoided in severe liver or renal disease and in patients taking another cytochrome P450 inhibitor. (Choice A) Hypouricemic therapy with allopurinol is avoided initially as it can worsen the acute gouty attack. Allopurinol is usually given after symptom resolution to prevent future acute gouty attacks in patients with recurrent episodes. (Choice B) Aspirin is generally not used for acute gout due to its effect on renal handling of uric acid. Low-dose aspirin (1-2 g/day) causes uric acid retention; high-dose aspirin (>3 g/day) leads to uricosuria. (Choice E) Intraarticular steroids can be used in acute gout for patients with one or two inflamed joints and contraindications to NSAIDs or colchicine. In addition, steroids are usually given after definitively diagnosing gout by arthrocentesis. Oral or intramuscular steroids are reserved for patients who cannot take NSAIDs, colchicine, or intraarticular steroids. Educational objective: Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy and are effective in >90% of patients with acute gout. Oral colchicine is an alternate therapy in patients with contraindications to NSAIDs. Intraarticular steroids can be used in acute gout for patients with one or two inflamed joints and contraindications to NSAIDs or colchicine. References: Diagnosis and treatment of gout in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/22272526)

Question 14

An 84-year-old woman is brought to the emergency department for hip pain after a fall from her bed.  Her medical problems include hypertension, type 2 diabetes mellitus, coronary artery disease, and mild cognitive impairment.  She is ambulatory and lives on her own, requiring only a home health aide to drive her around.  The patient's temperature is 36.1 C (97 F), blood pressure is 160/85 mm Hg, pulse is 102/min, and respirations are 18/min.  Physical examination shows an obese and alert elderly woman.  She has an ecchymotic area on the lateral aspect of the left thigh.  Her left leg is rotated outward and looks shorter than the right leg.  X-ray of the hip reveals a left-sided intertrochanteric hip fracture.  The patient's family members call for a meeting with the treating team to discuss whether surgical repair should be performed.  Which of the following is the most appropriate statement about the patient's condition?

Accepted Answer

Explanation: Hip fractures due to falls are common in the elderly and are classified as either intracapsular (femoral head and neck) or extracapsular (intertrochanteric or subtrochanteric). Femoral neck fractures typically present with pain without significant ecchymoses and have a higher risk of avascular necrosis. Extracapsular fractures are at higher risk for displacement and usually have visible ecchymosis, as in this patient. Both types of fractures should be evaluated by an orthopedic surgeon as most require surgical correction with either arthroplasty or open reduction with internal fixation. In elderly patients who are stable and ambulatory prior to the fracture, surgery within 48 hours is associated with lower mortality and a lower risk of pressure ulcers and pneumonia (Choice E). (Choice A) Studies have shown no benefit of traction in reducing pain or improving the quality of hip fracture reduction. Routine use of traction in hip fracture is not advised. (Choice B) Nonoperative management is reserved for patients who are nonambulatory, are demented, have end-stage terminal illness, have an old nondisplaced or impacted fracture, or are unstable with major comorbidities. Advanced age alone is not a contraindication to surgery. (Choice C) Surgery may be delayed briefly (up to 72 hours) to stabilize acute, life-threatening medical conditions, but longer delays are associated with an increased risk of complications. Preoperative cardiac stress testing prior to non-cardiovascular surgery is generally advised only if it would otherwise be indicated in the absence of surgery. medical conditions Educational objective: Hip fractures in the elderly are common and should be managed with early surgery (<48 hours) in patients who are ambulatory and stable. Nonoperative management is reserved for those who are nonambulatory, have advanced dementia, or are medically unstable. References: Management of hip fracture: the family physician's role. (http://www.ncbi.nlm.nih.gov/pubmed/16836036) Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20837683)

Question 15

A 52-year-old Caucasian woman presents to the office for the evaluation of a constant left groin pain.  The pain started spontaneously about a week ago and is gradually progressive.  It is worse with walking and weight bearing.  She has a past medical history of systemic lupus erythematosus, chronic renal insufficiency, and hypertension.  She has been maintained on 20 mg/day of prednisone for eight months.  Attempts to decrease the dose of prednisone in the past have caused a flare of lupus activity.  She does not smoke or drink alcohol.  On physical examination, she walks with a limp.  There is marked discomfort and limitation of the range of motion on the left side.
Which of the following is the most sensitive imaging modality to diagnose the patient's condition?

Accepted Answer

Explanation: The patient's clinical presentation is consistent with osteonecrosis of the femoral head, also known as avascular necrosis or osteochondritis dissecans. Osteonecrosis usually occurs in the anterolateral femoral head, although it can also affect the humeral head, femoral condyles, vertebrae, proximal tibia, and small bones of the hand and foot. The disorders that are associated with the development of osteonecrosis include systemic lupus erythematosus (SLE), sickle cell disease, antiphospholipid antibody syndrome, chronic renal insufficiency and hemodialysis, trauma, Gaucher's disease, HIV infection, following renal transplantation, and Caisson's disease. Although a variety of disorders and disease processes can cause osteonecrosis, corticosteroid use and excessive alcohol intake are responsible for approximately 90% of the cases. Those who are at greatest risk are the SLE patients on chronic high-dose corticosteroid therapy (more than 15 to 20 mg/day). An early diagnosis of osteonecrosis is important to prevent bone collapse and the need for joint replacement. Physical findings are usually nonspecific, making it necessary to obtain sensitive imaging. MRI scanning is far more sensitive than plain films or bone scanning. Focal lesions are well demarcated, and changes can be seen early in the course of the disease when other studies are negative. (Choices A and B) Plain films have a poor sensitivity for detecting early disease. These can remain normal even months after the onset of symptoms of osteonecrosis, thereby causing a delay in the diagnosis and treatment. (Choice C) Technetium 99-m scanning is useful in patients with suspected disease with unilateral symptoms or no risk factors. MRI is still far more sensitive in diagnosing early disease. (Choice D) Pelvic ultrasound has no role in the diagnosis of osteonecrosis of the femoral head. Educational objective: MRI scanning is the most sensitive imaging modality for diagnosing osteonecrosis of the femoral head. Early diagnosis and treatment is important to prevent joint destruction.

Question 16

A 53-year-old woman comes to the physician for her annual health care visit.  Her last menstrual period was >1 year ago.  She initially had hot flashes which have gradually subsided.  Her past medical history is unremarkable.  The patient takes no medications, vitamins, or herbal supplements.  She does not smoke or drink alcohol.  Her father has premature coronary artery disease.  There is no history of cancer or osteoporosis in her family.  She jogs and does weight-training exercises for up to 1 hour daily.  Her mammogram and pelvic exam were normal last year.  The patient's vital signs are normal and her physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0b4_13c0_8f63_5d212c78c872_MD0005_00 Menopause is an important risk factor for osteoporosis; most women lose considerable bone mass rapidly as estrogen declines after this period. The first step in prevention or treatment of osteoporosis is good nutrition and exercise. Adequate calcium and vitamin D intake is essential as calcium is the primary mineral in bone, and vitamin D facilitates intestinal calcium absorption. The recommended dietary allowance (RDA) for calcium is 1200 mg per day and is not to exceed 2000 mg per day. The RDA for vitamin D is 600-800 international units (IU) and is not to exceed 4000 IU per day. Dietary sources of calcium include milk, yogurt, and dark green leafy vegetables. Sources of vitamin D include milk and sunlight. Regular weight-bearing and anti-gravity exercises (eg, walking, hiking, jogging) also help maintain bone density. Supplements may be used to meet the RDA if the patient is unable to meet dietary and sunlight goals. However, dietary sources are preferred due to potential adverse effects of supplements. Side effects of excessive calcium and/or vitamin D intake include hypercalcemia, hypercalciuria, and nephrolithiasis (kidney stones). (Choice A) Hormone replacement therapy is used for menopausal symptoms (eg, hot flashes, vaginal dryness). It was previously used to prevent diseases such as osteoporosis and coronary artery disease but the current consensus is that the risks (eg, breast cancer, coronary artery disease, stroke, venous thromboembolism) outweigh the potential benefits. (Choices B and D) Bone density screening should begin at age 65 in women without risk factors. Postmenopausal women age <65 may be screened if they have risk factors such as body weight <58 kg (127 lb), chronic steroid use, smoking, malabsorptive disorders (eg, pancreatic insufficiency in cystic fibrosis), and parental history of hip fracture or personal history of low-impact fracture. Bone antiresorptive agents (eg, bisphosphonates, raloxifene) are approved for osteoporosis prevention in high-risk women. However, this patient is not at high risk and does not require further workup or prophylaxis. (Choice E) Routine vitamin D measurement is not recommended. Patients with osteoporosis or multiple risk factors (eg, chronic steroid use) should be evaluated for vitamin D deficiency. Educational objective: Adequate calcium and vitamin D intake is important for osteoporosis prevention. Dietary intake should be encouraged as vitamin supplements have increased risk of adverse effects. References: ACOG Practice Bulletin, No. 129 Osteoporosis (http://www.ncbi.nlm.nih.gov/pubmed/22914492) Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. (http://www.ncbi.nlm.nih.gov/pubmed/24729336) Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/23440163)

Question 17

A 16-year-old girl comes to the office due to joint pain lasting several days.  The patient says, "My hands and knees feel stiff when I wake up, and those joints are painful throughout the day."  The symptoms are improving, but she still has significant discomfort with daily activities.  The patient has never before had such symptoms.  A mildly pruritic rash on her face, arms, and legs developed around the same time as the joint symptoms.  Last week, the patient had an upper respiratory infection with fever and myalgias that resolved quickly without intervention.  She has seasonal allergies for which she uses a glucocorticoid intranasal spray as needed.  She does not use tobacco, alcohol, or illicit drugs.  The patient is not in a relationship and has never been sexually active.  Temperature is 37.2 C (99 F).  She appears well and is sitting comfortably on the examination table.  Cardiopulmonary examination is normal.  Examination of the hands shows mild symmetric swelling of the proximal interphalangeal and metacarpophalangeal joints; there is no warmth or erythema.  Bilateral knees have a full range of motion, mild tenderness to palpation, and no swelling.  Strength and sensation are symmetric and intact throughout, and distal pulses are strong bilaterally.  There is a faint, erythematous, reticular rash on both arms and legs. Medication is prescribed and the patient returns a month later for follow-up.  The patient says that her symptoms have resolved and she feels "quite good."  However, she is concerned about the prognosis of her disease and the possibility of recurrent joint problems.  Physical examination reveals complete resolution of the joint swelling.  Which of the following is the best response to this patient's concern?

Accepted Answer

Explanation: 11ec2b69_c0b9_1cd5_8f63_89d054c20c27_MD0005_00 The treatment of viral arthritis is supportive with nonsteroidal anti-inflammatory drugs for symptomatic relief. The prognosis is favorable; symptoms are self-limited and typically resolve within a few weeks. Parvovirus 19-associated arthritis is nonerosive and causes no long-term sequelae. (Choices A and B) Although antibiotics are prophylactic against recurrence in acute rheumatic fever and are used to treat Lyme arthritis, they are not indicated for viral arthritis. (Choice C) Episodic arthritis flare-ups requiring treatment with anti-inflammatory medications are characteristic of systemic lupus erythematosus. Recurring arthropathy is uncommon in parvoviral arthritis. (Choice E) In contrast to viral arthritis, rheumatoid arthritis can cause significant joint deformities without appropriate long-term treatment. Educational objective: Viral arthritis is typically treated with nonsteroidal anti-inflammatory drugs for symptomatic relief. Parvovirus B19-associated arthritis usually resolves within a few weeks with no long-term sequelae. References: Parvovirus infection in early arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/26886687)

Question 18

A 65-year-old white woman comes to the physician for acute mid-thoracic back pain.  Seven days ago, she slipped and fell in her driveway and has had the back pain ever since.  The pain is described as deep-seated, boring in quality, and non-radiating, and has not improved with over-the-counter pain medications.  Her past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with fluticasone, salmeterol, and ipratropium inhalers, and hypertension treated with lisinopril and hydrochlorothiazide.  She has had occasional brief courses of oral glucocorticoids for COPD exacerbations.  The patient has a 30-pack-year smoking history and quit approximately 5 years ago.  She experienced menopause when she was 48 years old.  Her mammogram and Pap smear were negative 6 months ago.  Her mother and 2 sisters have osteoporosis.  Examination shows tenderness over the mid-thoracic vertebrae.  The rest of the examination is unremarkable.  The complete blood count, basic metabolic panel, calcium, and phosphorus are within normal limits.  Plain radiographs of the thoracic spine reveal a compression fracture in the 10th and 11th vertebrae. 
In addition to pain control, what is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0b5_2531_8f63_11844672e7e9_MD0005_00 This patient has back pain due to multiple vertebral compression fractures following a fall from a standing height. She has multiple risk factors for bone loss including white ethnicity, family history of osteoporosis, smoking, prior glucocorticoid use, and postmenopausal status. Fractures following a ground-level fall suggest abnormal bone fragility, likely due to postmenopausal osteoporosis. Confirmation with measurement of central (ie, spine and hip) bone density is recommended, preferably with dual-energy x-ray absorptiometry (DEXA). Bone mineral density (BMD) is an excellent predictor of fracture risk in postmenopausal women; the fracture risk increases as the BMD decreases. Under World Health Organization (WHO) criteria, postmenopausal osteoporosis can be diagnosed with DEXA based on T-score (number of standard deviations above [+] or below [-] the mean for a healthy 30-year-old of the same gender and ethnicity). By convention, a T-score -1 and above is considered normal; a T-score between -1 and -2.5 is considered osteopenia; and a T-score of -2.5 or lower is considered osteoporosis. The WHO classification may also be used for men age >50; however, it should not be used in patients age <50 because the relation between T-score and fracture risk is not as well documented in this population. (Choice B) This patient has normal calcium and phosphorus levels and has no clinical features to suggest hyperparathyroidism. Measurement of parathyroid hormone level is not required in the routine assessment of postmenopausal osteoporosis. (Choice C) Devices to measure peripheral bone density, such as heel ultrasounds, can predict fracture risk; however, monitoring the patient's response to treatment using a peripheral device has not been studied and validated. Furthermore, the diagnostic criteria established by the WHO are only applicable for central DEXA measurements. (Choice D) Quantitative CT measures volumetric bone density of the hip and spine. It is used primarily in research settings, but is not recommended in clinical practice due to lack of validation to predict fracture risk, greater expense, and higher radiation exposure compared to DEXA. (Choice E) Although a bone scan may differentiate old from new vertebral fractures (increased uptake is seen in new compression fractures), it does not eliminate the need for DEXA and is unlikely to change management in this patient. Bone scan is a very sensitive but nonspecific test used for investigating a wide variety of skeletal disorders, including osteomyelitis, bone metastasis, Paget's disease, and arthritis. Educational objective: Patients with a fracture following minor trauma such as a ground-level fall should be tested for osteoporosis using dual-energy x-ray absorptiometry. References: Bone mineral density testing after fragility fracture: informative test results likely. (http://www.ncbi.nlm.nih.gov/pubmed/24336562)

Question 19

A 65-year-old white woman comes to the physician for acute mid-thoracic back pain.  Seven days ago, she slipped and fell in her driveway and has had the back pain ever since.  The pain is described as deep-seated, boring in quality, and non-radiating, and has not improved with over-the-counter pain medications.  Her past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with fluticasone, salmeterol, and ipratropium inhalers, and hypertension treated with lisinopril and hydrochlorothiazide.  She has had occasional brief courses of oral glucocorticoids for COPD exacerbations.  The patient has a 30-pack-year smoking history and quit approximately 5 years ago.  She experienced menopause when she was 48 years old.  Her mammogram and Pap smear were negative 6 months ago.  Her mother and 2 sisters have osteoporosis.  Examination shows tenderness over the mid-thoracic vertebrae.  The rest of the examination is unremarkable.  The complete blood count, basic metabolic panel, calcium, and phosphorus are within normal limits.  Plain radiographs of the thoracic spine reveal a compression fracture in the 10th and 11th vertebrae. Her 25-hydroxyvitamin D level is 25 ng/mL (normal 30-50 ng/mL), and TSH level is 2.1 µU/mL.  Bone density at the spine and hip shows a T-score of -2.4 at the lumbar spine and -2.0 at the hip.  In addition to optimization of calcium and vitamin D intake, which of the following is the most appropriate intervention for this patient?

Accepted Answer

Explanation: The American Association of Clinical Endocrinologists recommends pharmacological therapy for postmenopausal women with T-score <-2.5 or those with a history of low-trauma hip or vertebral fractures regardless of T-score. Another indication for treatment is presence of osteopenia with an elevated 10-year fracture risk based on the Fracture Risk Assessment Tool (FRAX), which predicts fracture risk based on clinical factors for fracture as well as bone mineral density (BMD) at the femoral neck: pharmacologic treatment is recommended when the 10-year calculated probability by FRAX is >20% for major osteoporotic fractures or >3% for a hip fracture. Fracture Risk Assessment Tool (FRAX) Because this patient has a history of low-trauma vertebral fracture, she is a candidate for pharmacologic therapy for osteoporosis regardless of her T-score; serial BMD and T-score measurements are useful in assessing response to therapy. Bisphosphonates are generally the first-line therapy for postmenopausal osteoporosis. Alendronate is a bisphosphonate that improves BMD and lowers fracture risk by decreasing bone resorption. In addition, women with post-menopausal osteoporosis should take supplemental calcium and vitamin D to ensure adequate daily intake (total intake: 1200 mg/day of elemental calcium and 800 IU/day of vitamin D). (Choice B) Similar to bisphosphonates, calcitonin also inhibits bone resorption. However, calcitonin is a weak anti-resorptive agent with very modest efficacy against fracture reduction and is not used as a first-line agent for osteoporosis. (Choice C) Hormone replacement therapy is not recommended as first-line treatment for postmenopausal osteoporosis following the report of the Women's Health Initiative in 2002. The report showed that older women who received a combination of conjugated equine estrogen and medroxyprogesterone had a significantly higher risk of myocardial infarction, stroke, deep-vein thrombosis, pulmonary embolism, and breast cancer. (Choice D) Pharmacologic treatment is necessary due to fragility of vertebral fractures. Supplementation of calcium and vitamin D alone would be suboptimal. (Choice E) Parathyroid hormone fragment (PTH 1-34, teriparatide) is effective in improving bone density and reducing the risk of fractures. However, due to high cost, it is used only as a second-line agent in patients with very high risk of fractures, particularly those in whom bisphosphonate therapy has failed. Educational objective: Pharmacologic therapy for osteoporosis is indicated for patients with a T-score <-2.5 and for those with fragility fractures regardless of bone mineral density. Bisphosphonates are first-line treatment in most cases.

Question 20

A 66-year-old man comes to a community clinic after undergoing a computed tomography scan of the head at a local emergency department.  He fell while stepping out of the bathtub and struck his head but did not lose consciousness.  The patient sustained a small head laceration that was closed with sutures, but no other injuries were identified in the emergency department.  He reports a longstanding history of normal-pressure hydrocephalus with frequent falls, but he has not followed up with his neurologist for several years.  The patient is now asymptomatic with no headaches, focal weakness, or dizziness.  His head computed tomography scan with bone windows is shown in the image below.  
What is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0b7_9633_8f63_11c83b071742_MD0005_00 This patient likely has Paget disease of bone (PDB), a common condition in older adults that is due to increased bone turnover. His head computed tomography (CT) scan shows a thickened calvarium with an inhomogeneous bone density or "cotton wool" appearance that is typical of this condition. Most patients with PDB are asymptomatic, and diagnosis is made incidentally on radiographic findings or abnormal laboratory studies. The next step in management of this patient is to obtain calcium and alkaline phosphatase levels; patients with PDB have an elevated alkaline phosphatase and a normal calcium level. If necessary, the elevated alkaline phosphatase of PDB may be differentiated from hepatobiliary disease by measuring the bone-specific fraction. Patients with PDB should also have a radionuclide bone scan to identify other involved sites. Bisphosphonates are the mainstay of treatment for PDB as they reduce bone turnover. Most patients, including those with bone pain or involvement of high-risk locations (such as this patient with skull involvement), should be considered for treatment. (Choice A) Bone densitometry is useful in patients at risk for osteoporosis, such as women age >65, patients on long-term corticosteroid therapy, and those with a fracture suggesting bone fragility. In PDB, bone density can be low, normal, or elevated, and results do not generally change management. (Choice B) Calcium and vitamin D supplementation are appropriate if osteoporosis is suspected, but this patient's CT scan is more suggestive of PDB. (Choice C) Echocardiography and carotid ultrasonography are often used to evaluate risk for recurrent stroke in patients presenting with stroke or transient ischemic attack. This patient has no symptoms of cerebral ischemia and would not likely benefit from these tests. (Choice E) Serum protein electrophoresis is a useful screening test for patients with suspected monoclonal gammopathy, such as in multiple myeloma. Multiple myeloma usually involves bone with scattered lytic lesions or occasionally diffuse osteopenia. The thickened, sclerotic bone in this patient with PDB would not be seen in myeloma. Educational objective: Paget disease of bone is often diagnosed incidentally on a radiograph showing thickened bone with inhomogeneous density. An elevated alkaline phosphatase with normal calcium and no concurrent hepatobiliary disease may also suggest Paget disease. A radionuclide bone scan can identify additional areas of involvement; bisphosphonate medications are the usual treatment. References: Imaging Paget's disease of bone - from head to toe. (http://www.ncbi.nlm.nih.gov/pubmed/21524738)

Exam 1: Advanced Clinical Medicine