Question 1

A 46-year-old woman comes to the office for follow-up of rheumatoid arthritis.  The patient was diagnosed 2 years ago and started on treatment with prednisone and methotrexate; she had a good initial response to treatment, and the oral glucocorticoid was gradually tapered.  However, her symptoms have progressively worsened over the last several months, despite increases in the methotrexate dose.  The patient continues to have hand stiffness and pain lasting 2-3 hours every morning and increasing knee and ankle pain.  She takes frequent doses of acetaminophen and ibuprofen but her symptoms still significantly restrict her daily activities.  Medical history is otherwise unremarkable.  The patient does not use tobacco, alcohol, or illicit drugs.  Physical examination shows symmetric swelling and tenderness of the proximal small hand joints, wrists, and knees.  Blood cell count shows mild normochromic, normocytic anemia with normal leukocyte and platelet counts.  Erythrocyte sedimentation rate is 55 mm/hr.  Hand x-ray reveals periarticular osteopenia and mild joint erosions. 
After discussion of treatment options, tumor necrosis factor inhibitor therapy is planned.  Which of the following tests is most appropriate prior to beginning the treatment?

Accepted Answer

Explanation: 11ec2b69_c0c1_815d_8f63_83d0cf5446ec_MD0005_00 The primary treatment goals in rheumatoid arthritis are to control the acute synovitis and to slow or stop the chronic progression of joint destruction. A number of disease-modifying antirheumatic drugs have been shown to slow progression of the disease, but no single treatment regimen is ideal for every patient. The choice of therapy depends on individual patient factors and potential toxicity of the different drugs. Methotrexate is commonly chosen for initial therapy and can be combined with a limited course of oral glucocorticoids (eg, prednisone) for rapid symptom relief. For patients who have persistent or recurrent symptoms despite methotrexate therapy, large-molecule anticytokine agents ("biologics") are often considered. However these agents, primarily tumor necrosis factor (TNF) inhibitors (eg, infliximab, etanercept), are associated with an increased risk for opportunistic infections, especially reactivation of tuberculosis. Therefore, patients should be screened for latent tuberculosis with a tuberculin (purified protein derivative) skin test or interferon-gamma release assay prior to treatment. (Choice A) Long-term glucocorticoid therapy is associated with accelerated bone loss. Although this patient's initial treatment with systemic glucocorticoids may warrant DXA screening, this is not needed prior to initiating TNF inhibitor therapy. (Choice B) TNF inhibitors have been reported to cause worsening of heart failure and are relatively contraindicated in patients who have symptomatic heart failure at baseline. However, there is no clear evidence for increased risk of incident heart failure, and pretreatment echocardiography is not needed. (Choice D) High rheumatoid factor titers are associated with more aggressive disease and greater risk for extra-articular manifestations (eg, pulmonary disease). However, titers do not reliably correlate with disease activity and are not needed to determine choice of therapy. (Choice E) Elevated serum immunoglobulin levels can be due to monoclonal (eg, multiple myeloma) or polyclonal immune activation. Polyclonal hypergammaglobulinemia is common in rheumatoid arthritis, but serum immunoglobulins are not assayed routinely in management. Educational objective: Tumor necrosis factor inhibitors are large-molecule antirheumatic agents that are commonly used in patients with rheumatoid arthritis who fail first-line therapy. However, they are associated with increased risk for opportunistic infections, including reactivation of latent tuberculosis. Patients should be screened with a tuberculin skin test or interferon-gamma release assay prior to treatment. References: The risk of tuberculosis in patients with rheumatoid arthritis treated with tumor necrosis factor-a antagonist: a metaanalysis of both randomized controlled trials and registry/cohort studies. (http://www.ncbi.nlm.nih.gov/pubmed/26472414)

Question 2

A 16-year-old girl comes to the office due to her posture.  The patient is a competitive diver and has difficulty maintaining a handstand on the diving platform due to the tendency to "lean sideways."  She also "leans to the side" when trying to stand up straight.  The patient has no other symptoms or medical conditions.  She takes no medications and has no allergies.  Her last menstrual period was 2 weeks ago.  Height and weight are at the 50th percentile.  The patient is alert and engaging.  The neck is supple.  The lungs have good air entry in all fields.  Breast and pubic hair are Tanner stage 5.  Forward bend test reveals a right rib prominence that is not relieved by placing a block under the contralateral foot.  Achilles and patellar deep tendon reflexes are 2+.  Posteroanterior and lateral spine x-rays reveal a Cobb angle of 17 degrees, indicating mild scoliosis.  Which of the following is true about management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0c5_7905_8f63_b7795ef308bb_MD0005_00 Scoliosis, or lateral curvature of the spine, is typically idiopathic and occurs most commonly in adolescents during periods of rapid growth. A thoracic or lumbar prominence is present on the forward bend test. Limb length discrepancy is excluded if back asymmetry does not correct with block placement under the shorter leg, as in this case. Posteroanterior and lateral x-rays of the spine confirm the diagnosis. Management of adolescent idiopathic scoliosis is determined by the risk for progression, which depends on skeletal maturity (ie, growth potential remaining) and the degree of the curvature (ie, Cobb angle). Skeletal maturity is reflected by the pubertal status, which can help in estimating the remaining growth potential. By Tanner stage 5, this postmenarcheal patient has completed puberty, undergone epiphyseal fusion, and likely reached her full growth potential. Because curve progression is minimal to nonexistent once skeletal maturity is reached, treatment is generally unnecessary, and no follow-up is required for mild/moderate scoliosis (Cobb angle <40 degrees, as in this patient). Cobb angle (Choice A) Monitoring for progression with serial imaging is appropriate for mild scoliosis until skeletal maturity is reached; age alone does not determine management. Monitoring this patient's mild scoliosis is unnecessary because she is skeletally mature with a low risk of progression. (Choice B) Bracing the back helps reduce the risk of curve progression and the need for surgery in skeletally immature patients. However, it is ineffective in those with minimal growth potential, such as this patient who has completed puberty. (Choice D) Orthopedic referral for surgical evaluation is required for severe scoliosis (Cobb angle ≥40 degrees) at high risk for progression and complications, such as chronic back pain, neurologic symptoms, and pulmonary compromise. In contrast, this patient has mild scoliosis and no other symptoms. Educational objective: Mild adolescent idiopathic scoliosis in a skeletally mature patient has a low risk for progression and does not require treatment or follow-up. References: Adolescent idiopathic scoliosis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/24506121)

Question 3

A 45-year-old woman comes to the office due to progressive stiffness, pain, and swelling of the joints in the hands and wrists for the past 3 months.  The symptoms are worse when she wakes up and gradually improve after several hours.  The patient also feels fatigued but has had no skin rashes, oral lesions, or fever.  She recently began taking chlorthalidone for hypertension and takes no other medications.  She works in a daycare center.  The patient drinks alcohol occasionally and does not use tobacco or illicit drugs.  Her mother had "arthritis" in her older age, and her sister has systemic lupus erythematosus.  Temperature and other vital signs are within normal limits.  Physical examination shows warmth, swelling, and tenderness of the second and third proximal interphalangeal joints, the metacarpophalangeal joints, and the wrists of both hands.  The remainder of the examination shows no abnormalities. 
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0bf_fab9_8f63_4b31d3ef19ac_MD0005_00 This patient has chronic, symmetric polyarthritis and prolonged morning stiffness in the hands and wrists, consistent with rheumatoid arthritis (RA). RA is diagnosed primarily based on clinical findings, but serologic studies, such as rheumatoid factor (limited predictive value in the overall population) and cyclic citrullinated peptide antibodies (specificity >90%), may help clarify the diagnosis. Results are positive in most patients at some point in the disease course but may be negative in 50% of patients at the time of initial presentation. Acute-phase inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) are nonspecific but should also be ordered, as they are usually elevated in active disease and can be used to follow the disease course. This patient should also be started on a nonsteroidal anti-inflammatory drug (eg, ibuprofen, naproxen), which can acutely relieve symptoms while the diagnostic evaluation is being completed. (Choice A) Lyme disease can occasionally present with small joint arthritis. However, symptoms are typically intermittent, asymmetric, and migratory, rather than chronic, progressive, and symmetric, as in this patient. In addition, most patients experience the characteristic rash before the onset of musculoskeletal symptoms. characteristic rash (Choice B) Parvovirus B19 can cause symmetric polyarticular arthritis of the hands, wrists, and feet that resembles RA. However, palpable synovitis is less prominent in parvovirus arthritis, and most patients have at least partial improvement within 3-6 weeks. (Choice C) Gout typically presents as acute monoarticular arthritis in the first metatarsophalangeal joint or knee. Chronic polyarticular symptoms are more consistent with RA. (Choice D) Evaluation of systemic lupus erythematosus starts with an antinuclear antibody assay (high sensitivity), which, if positive, is followed by a double-stranded DNA antibody assay (high specificity). However, the arthritis in systemic lupus erythematosus is typically transient, migratory, and associated with only brief morning stiffness. Educational objective: Rheumatoid arthritis is characterized by chronic, symmetric synovitis, most commonly in the small joints of the hands and wrists. Serologic markers (eg, rheumatoid factor, cyclic citrullinated peptide antibodies) are helpful for confirmation. Nonsteroidal anti-inflammatory drugs can relieve symptoms while the evaluation is in progress. References: Diagnosis and classification of rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/24568777)

Question 4

A 55-year-old woman comes to the physician due to a 2-month history of malaise, mild fever, and difficulty climbing stairs and rising from a chair.  She has unintentionally lost 9.1 kg (20.1 lb) over this period.  The patient has hypertension and asthma.  Medications include amlodipine, as-needed albuterol, and inhaled glucocorticoids during winter.  The patient does not smoke or use illicit drugs.  She worked for 20 years supervising cotton processing in a textile factory but has been working as a secretary for the past 10 years.  Temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min.  Chest examination reveals clear lung fields and normal S1 and S2.  The patient has bilateral proximal upper and lower extremity weakness with normal reflexes.  Plantar reflexes are down-going bilaterally.  Violaceous papules and plaques are seen on the dorsum of both hands, as shown in the image below:
 Kidney and liver function are within normal limits.  Creatine kinase level is 1,200 IU/L.
Which of the following conditions is most likely associated with this patient's disease?

Accepted Answer

Explanation: Dermatomyositis may occur alone but is often seen as a paraneoplastic syndrome of malignancy, which may be detected before, after, or with the skin and muscle symptoms. This patient's malaise, weight loss, and low-grade fever should raise suspicion further. All patients with newly diagnosed dermatomyositis should undergo age-appropriate cancer screening. The most common associated cancers include adenocarcinoma of the cervix, ovaries, lung, pancreas, bladder, and stomach. Dermatomyositis secondary to cancer may resolve completely once the malignancy has been successfully treated. (Choices A and E) Bacterial and viral infections can cause malaise and low-grade fever. However, the signs of dermatomyositis with unintentional weight loss make malignancy a more likely diagnosis. (Choice B) This patient has no features of degenerative disease (eg, osteoarthritis causing hip pain) that could explain her symptoms. (Choice D) This patient's history of working in the textile industry suggests asbestos or cotton dust exposure. Asbestosis can increase the risk of lung cancer, but it does not directly cause dermatomyositis. Cotton dust can cause byssinosis (a type of obstructive lung disease), not dermatomyositis. Educational objective: Dermatomyositis is associated with an increased risk of malignancy, and all patients should undergo age-appropriate cancer screening. Symptoms of dermatomyositis may resolve if the cancer is treated successfully. References: Polymyositis and dermatomyositis-challenges in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/32743506)

Question 5

A 45-year-old woman comes to the office due to progressive stiffness, pain, and swelling of the joints in the hands and wrists for the past 3 months.  The symptoms are worse when she wakes up and gradually improve after several hours.  The patient also feels fatigued but has had no skin rashes, oral lesions, or fever.  She recently began taking chlorthalidone for hypertension and takes no other medications.  She works in a daycare center.  The patient drinks alcohol occasionally and does not use tobacco or illicit drugs.  Her mother had "arthritis" in her older age, and her sister has systemic lupus erythematosus.  Temperature and other vital signs are within normal limits.  Physical examination shows warmth, swelling, and tenderness of the second and third proximal interphalangeal joints, the metacarpophalangeal joints, and the wrists of both hands.  The remainder of the examination shows no abnormalities. A week later, the patient returns to the office and says that her symptoms have improved with the prescribed treatment.  Laboratory results are as follows:
 Hand x-rays reveal mild periarticular osteopenia and early erosions of the proximal interphalangeal and metacarpophalangeal joints.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient's clinical presentation is consistent with rheumatoid arthritis (RA), although her serologic markers (ie, rheumatoid factor [RF], cyclic citrullinated peptide [CCP] antibody) are negative. A positive assay for RF or CCP antibodies is associated with accelerated joint destruction, whereas patients who are negative for both RF and CCP antibodies (seronegative RA) often have a less aggressive course. However, this patient has a significant elevation in C-reactive protein and already has early joint destruction visible on x-ray, suggesting at least moderate severity of disease. Patients with active RA should be started on a disease-modifying antirheumatic drug (DMARD), as these agents have been shown to slow the progression of bony erosions and cartilage loss (Choice D). Commonly used DMARDs include methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, and azathioprine. Methotrexate is the initial drug of choice for most patients, but if the response is not adequate, other DMARDs may be used. (Choices A and B) Nonsteroidal anti-inflammatory drugs are useful in controlling the symptoms of RA during the initial assessment and for relief of acute flares but have not been shown to prevent long-term joint destruction. Systemic glucocorticoids are used primarily for acute symptomatic treatment, or in low doses, for patients with residual symptoms on appropriate DMARD therapy. However, glucocorticoids have significant long-term side effects and should not be used in place of DMARD therapy. (Choice E) Tumor necrosis factor inhibitors (eg, etanercept, infliximab) are large-molecule anticytokine agents ("biologics") that are very effective in chronic management of RA. However, they are expensive and have significant adverse effects, so they are used primarily in patients who fail first-line therapy. Educational objective: Patients with active rheumatoid arthritis should be started on a disease-modifying antirheumatic drug to slow the progression of bony erosions and cartilage loss. Methotrexate is the initial drug of choice for most patients. References: 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/26545940) Methotrexate for treating rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/24916606)

Question 6

A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance.  When the weather is cold, her third and fourth fingers on both hands get numb and turn blue.  She says, 'I wear gloves to keep my hands warm, but it does not always work'.  Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole.  She does not smoke or consume alcohol, and denies any recreational drug use.  She has no known drug allergies.  She works as a nurse at a local hospital and considers her job moderately stressful.  She is sexually active with her husband and uses condoms for contraception.  Physical examination findings are within normal limits.
The patient returns in one month and complains that the treatment 'does not help much.'  In addition, she has started to experience periodic joint and muscle pain.  She says that she has been adherent to the medication and has tried to avoid going out in cold weather as much as possible.  Her husband even gave up smoking because you had warned her that passive smoking may worsen her condition.  Which of the following is the best next step in the management of this patient?

Accepted Answer

Explanation: Raynaud phenomenon may be idiopathic (also called Raynaud disease) or secondary to other conditions such as connective tissue diseases, vascular lesions, medications, etc. When managing patients with Raynaud phenomenon, potential precipitating factors such as medications and environmental factors (e.g., frostbite, vibration) should first be excluded. The presence of symptoms suggestive of systemic disease (arthralgias and myalgias) and resistance to treatment (such as in this patient) warrant further evaluation; this may include ANA, RF, CBC, blood chemistry, urinalysis and measurement of complement levels. (Choice E) Patients are diagnosed with primary Raynaud phenomenon when there are no historic clues to a secondary condition, normal physical findings and no ischemic digital lesions. No specialized studies are indicated in these patients. (Choice C)In patients who have symptoms suggestive of vascular lesions (e.g., asymmetric involvement and deficient pulses), further evaluation with digital plethysmography, arterial Doppler ultrasonography or angiography should be considered. (Choices A and B) It is not reasonable to change the treatment without first excluding a systemic disease that may be responsible for the condition. Educational Objective: The presence of symptoms suggestive of systemic disease (arthralgias, myalgias, fever, and weight loss) in patients with Raynaud phenomenon warrants further evaluation; this may include ANA, RF, CBC, blood chemistry, urinalysis and measurement of complement levels.

Question 7

A 2-year-old girl is brought to the emergency department due to sudden refusal to move her right arm for the past hour.  Her mother says that this started immediately after she grabbed her daughter by the right wrist to prevent her from falling out of a chair, but there was no other trauma.  The patient is an active girl who likes to run and play at the beach and playground.  She takes no medications and her vaccinations are up to date.  The girl lives with her parents, who work at home as writers.  She does not attend day care or have other caregivers.  Temperature is 36.7 C (98 F) and pulse is 94/min.  On physical examination, the girl holds her right arm close to her body with the forearm pronated.  No swelling or focal point tenderness of her upper extremities is elicited, but she winces when supination of her right arm is attempted.  Radial pulse is 2+ bilaterally, and there is no pallor, cyanosis, or ecchymosis.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0bd_d7d4_8f63_91b1ad50fe03_MD0005_00 This child's sudden refusal to move the arm immediately after her forearm was pulled is classic for radial head subluxation. This injury, also known as nursemaid's elbow or annular ligament displacement, typically occurs in children age 6 months to 5 years. Another common mechanism of injury includes swinging a child by the arms. The sudden pulling force causes the annular ligament to slide over the radial head and become entrapped in the radiohumeral joint. annular ligament Children with this injury typically hold the arm close to their body with the forearm pronated and the elbow extended. Radiographs are not necessary to make the diagnosis when the history and examination findings are classic, as in this case. Treatment consists of reduction by hyperpronation or supination/flexion. In the hyperpronation method, the child's arm is held at the elbow, pressure is applied to the radial head, and the forearm is hyperpronated. In the supination/flexion method, the elbow is supported similarly while the patient's forearm is quickly supinated and fully flexed at the elbow in a continuous motion. Hyperpronation has a significantly higher chance of successful reduction than supination, although practitioners may use whichever method they are most comfortable performing. Following reduction, the child should be able to move the arm normally in a few minutes. hyperpronation supination/flexion (Choices B and C) Radial head subluxation can be reduced at the bedside without casting or immobilization. Reduction can be performed as an outpatient or by an emergency department provider without operative repair. (Choice D) MRI can be used to diagnose ligament and tendon disorders (sprains, partial/complete tears), cartilage lesions, occult fractures, and osteomyelitis. It is not indicated for the diagnosis of radial head subluxation. (Choice E) X-rays should be considered if there is a history of trauma or fall on an outstretched arm. X-rays should also be ordered to evaluate for fracture if there is focal tenderness or swelling. The patient's history of arm disuse after a pulling motion is unlikely to cause a fracture. Educational objective: Radial head subluxation, or nursemaid's elbow, classically presents as sudden refusal to move an arm after a pulling force is exerted on the forearm. Examination shows a child who holds the affected arm close to the body with the forearm pronated. Hyperpronation of the affected forearm is the treatment of choice. References: Investigation on 2331 cases of pulled elbow over the last 10 years. (http://www.ncbi.nlm.nih.gov/pubmed/24987508) Manipulative interventions for reducing pulled elbow in young children. (http://www.ncbi.nlm.nih.gov/pubmed/22258973)

Question 8

A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance.  When the weather is cold, her third and fourth fingers on both hands get numb and turn blue.  She says, 'I wear gloves to keep my hands warm, but it does not always work'.  Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole.  She does not smoke or consume alcohol, and denies any recreational drug use.  She has no known drug allergies.  She works as a nurse at a local hospital and considers her job moderately stressful.  She is sexually active with her husband and uses condoms for contraception.  Physical examination findings are within normal limits. 
Which of the following medications is the best initial treatment for this patient?

Accepted Answer

Explanation: This patient presents with symptoms suggestive of Raynaud phenomenon, an exaggerated vascular response to cold temperature or emotional stress. Calcium antagonists are considered the first-line pharmacological therapy for these patients, but it should be mentioned that not all calcium antagonists are equally effective. Most dihydropyridine calcium channel blockers (e.g., nifedipine and amlodipine), as well as diltiazem, are proven to work well in these patients. Many other vasodilator agents have been tried to treat this condition. (Choice C)Unlike dihydropyridine calcium channel blockers, verapamil has not been shown to be effective or at least equally effective. (Choice A)Alpha-adrenergic blockers such as prazosin are effective; however, patients eventually become refractory to these agents after prolonged usage. (Choice E)Nitroglycerin is usually used as an adjunct agent to calcium antagonist therapy in patients with severe Raynaud phenomenon. It is not recommended as the first-line agent. (Choice D)Some authors recommend adding aspirin to the treatment regimen in patients with severe ischemia and necrosis to prevent platelet aggregation; however, aspirin should be used with caution because it can actually worsen vasospasm by blocking the synthesis of vasodilatory prostaglandins. Educational Objective: Calcium antagonists, typically nifedipine or amlodipine, are considered the first-line pharmacological therapy for patients with Raynaud phenomenon. References: Calcium-channel blockers for Raynaud's phenomenon in systemic sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/11508437) Rational use of calcium-channel antagonists in Raynaud's phenomenon. (http://www.ncbi.nlm.nih.gov/pubmed/9812220)

Question 9

A 45-year-old woman comes to the office due to progressive stiffness, pain, and swelling of the joints in the hands and wrists for the past 3 months.  The symptoms are worse when she wakes up and gradually improve after several hours.  The patient also feels fatigued but has had no skin rashes, oral lesions, or fever.  She recently began taking chlorthalidone for hypertension and takes no other medications.  She works in a daycare center.  The patient drinks alcohol occasionally and does not use tobacco or illicit drugs.  Her mother had "arthritis" in her older age, and her sister has systemic lupus erythematosus.  Temperature and other vital signs are within normal limits.  Physical examination shows warmth, swelling, and tenderness of the second and third proximal interphalangeal joints, the metacarpophalangeal joints, and the wrists of both hands.  The remainder of the examination shows no abnormalities. Additional laboratory results show normal hepatic aminotransferase levels.  The patient is advised to avoid alcohol consumption.  She receives appropriate immunizations, and methotrexate therapy is begun.  Which of the following additional interventions is the most appropriate in this patient?

Accepted Answer

Explanation: Methotrexate is a folate antimetabolite that targets rapidly proliferating cells. It inhibits dihydrofolate reductase, blocking synthesis of purines and impairing replication of DNA. Major side effects include hepatotoxicity, stomatitis, and bone marrow suppression. Folic acid supplementation is recommended for patients on methotrexate therapy as it reduces the risk of adverse effects without the loss of efficacy. Most adverse effects of methotrexate are reversible if the medication is discontinued, but patients should be observed closely as withdrawal may precipitate a flare of rheumatoid arthritis symptoms. (Choice B) Drug-induced myopathy with elevated creatine phosphokinase levels is seen with some disease-modifying antirheumatic drugs (eg, hydroxychloroquine, tumor necrosis factor inhibitors) but is not a common complication of methotrexate. (Choice C) Methotrexate can occasionally cause inflammatory pneumonitis and pulmonary fibrosis. Some experts advise a chest x-ray prior to treatment, but baseline pulmonary function tests are not necessary. (Choice D) High-dose methotrexate can cause myelosuppression. However, at the low doses used in rheumatoid arthritis, methotrexate is not associated with a significant risk of opportunistic infections, and prophylactic antibiotics are not indicated. Specifically, trimethoprim-sulfamethoxazole can inhibit folate metabolism and should be avoided. (Choice E) Pyridoxine (vitamin B₆) supplementation is indicated for the prevention of neuropathy associated with isoniazid therapy. Neuropathy is not a common effect of methotrexate. ₆ Educational objective: Folic acid supplementation is recommended for patients on methotrexate therapy and reduces the risk of adverse effects without the loss of efficacy. References: Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/24737913)

Question 10

A 29-year-old woman comes to the office due to 3 months of worsening exertional dyspnea and nonproductive cough.  The patient says, "I thought the symptoms were from a cold or allergies, but they have not gone away and have gotten worse.  None of the over-the-counter congestion medicines from the pharmacy have helped."  She has also had occasional joint pain and has felt too tired to keep up with her exercise routine of running 5 miles 3 times a week.  She has had no chest pain, palpitations, syncope, or leg edema.  The patient has no chronic medical problems and does not use tobacco, alcohol, or illicit drugs.  Her brother has asthma.  Laboratory results are as follows:  Chest radiography is shown in the exhibit.  Pulmonary function testing reveals that FEV1 is 60% of the predicted value, FEV1/FVC is 80%, and diffusion capacity for carbon monoxide is 60% of predicted.  After discussion of a likely diagnosis and possible therapy, the patient asks about long-term prognosis.  Which of the following is the most appropriate response to this patient?

Accepted Answer

Explanation: 11ec2b69_c0c2_1d9f_8f63_cd8546c62384_MD0005_00 This young adult with 3 months of exertional dyspnea and cough has hypercalcemia and bilateral hilar lymphadenopathy, raising suspicion for pulmonary sarcoidosis. Sarcoidosis is a systemic inflammatory disorder characterized by the formation of noncaseating granulomas against an unknown antigen. Most cases arise in young adults and present with pulmonary (eg, cough, dyspnea, chest pain) and systemic (eg, fatigue, malaise, weight loss) symptoms. Clinical investigation often reveals: Bilateral hilar lymphadenopathy with or without diffuse interstitial infiltrates A mixed restrictive (reduced diffusion capacity for carbon monoxide) and obstructive (reduced FEV1 and FEV1/FVC) pattern on pulmonary function testing Hypercalcemia and elevated inflammatory markers (eg, erythrocyte sedimentation rate) A biopsy (eg, bronchoscopy with transbronchial biopsy) is typically required for definitive diagnosis. Asymptomatic patients often require no treatment; those with symptoms or pulmonary function impairment usually receive 12-24 months of oral glucocorticoids. Most cases (~75%) resolve over time and do not recur. (Choice A) The triggering agent that induces sarcoidosis is unclear. As such, avoiding certain factors has not proved beneficial. Other inflammatory lung conditions such as asthma and hypersensitivity pneumonitis can often be improved by avoiding triggers (eg, pet dander, dust mites). (Choice B) Most patients with sarcoidosis improve over time, but a minority have progressive lung disease (25%) or organ dysfunction (10%). These patients often require treatment with methotrexate, azathioprine, or tumor necrosis factor-alpha antagonists. (Choice D) Patients age >40 typically have a higher risk of sarcoid complications. African American patients or those who have progressive pulmonary fibrosis or certain extraocular manifestations (eg, cardiac, neurologic) also tend to have worse outcomes. (Choice E) Most symptomatic patients with pulmonary sarcoidosis require treatment with oral glucocorticoids for 12-24 months. Lifelong treatment is not typically required and is usually reserved for the minority of patients with progressive or worsening symptoms. Educational objective: Pulmonary sarcoidosis often manifests with pulmonary (eg, cough, dyspnea, chest pain) and systemic (eg, fatigue, malaise, weight loss) symptoms. Chest imaging usually reveals bilateral hilar lymphadenopathy with or without diffuse interstitial infiltrates. Asymptomatic patients rarely require treatment; those with symptoms or impaired pulmonary function usually receive 12-24 months of oral glucocorticoids. Most cases resolve over time and do not recur. References: Management of sarcoidosis in clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/27246591) Acute pulmonary exacerbations of sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/23032450)

Question 11

A 12-year-old girl is brought to the office for a preventive health maintenance examination.  The patient's mother has noticed that over the last few months, her daughter "seems to sit sideways" and does not sit up straight when asked.  The patient occasionally takes acetaminophen in the morning due to mild "aches and pains."  She fractured her left femur in a horse-riding accident at age 8.  Height and weight are at the 75th and 50th percentiles, respectively.  Physical examination shows a well-appearing, nondysmorphic girl.  Forward bend test demonstrates a right thoracic prominence that measures a 9-degree angle of trunk rotation and does not improve when a block is placed under the left foot.  Flexion of the lumbar spine is normal and the patient is able to touch her toes.  Lower extremity strength is normal.  Patellar and Achilles deep tendon reflexes are 2+.  Gait is normal.
Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0c3_f261_8f63_0343ebe5e1ab_MD0005_00 Adolescent idiopathic scoliosis is the most common type of scoliosis. During puberty, a period of rapid growth, the spine may grow asymmetrically, resulting in a lateral curvature of the spine. Patients may present with poor posture; however, scoliosis is often otherwise asymptomatic and identified incidentally on routine examination. A thoracic or lumbar prominence on forward bend test is the most sensitive examination finding for scoliosis. To estimate the severity of curvature, a scoliometer is placed sequentially along the spine, measuring the angle of trunk rotation. Spinal rotation ≥7 degrees (or ≥5 degrees in overweight children) may suggest clinically significant scoliosis. Abnormal scoliometry or obvious deformity on examination necessitates posteroanterior and lateral x-rays of the spine to confirm the diagnosis. scoliometer (Choice A) MRI of the spine is indicated when a secondary cause of scoliosis (eg, tumor, spina bifida) is suspected based on red flags such as significant pain (eg, that limits activity or wakes the patient up at night), rapidly progressive scoliosis, or neurologic deficits (eg, weakness, abnormal reflexes). None of these findings are present in this patient. (Choice B) Reassurance is appropriate if the angle of trunk rotation is <7 degrees. However, this patient's 9-degree rotation requires further evaluation. (Choice C) X-ray of the spine is required prior to initiating treatment. A back brace may be appropriate depending on the degree of scoliosis seen on x-ray; however, physical therapy is not typically beneficial. (Choice D) This patient's past femur fracture puts her at increased risk for leg-length discrepancy. Although leg-length discrepancy may also present with a thoracic prominence on forward bend test and may be evaluated by femur x-ray, the thoracic prominence should correct by placing a block under the contralateral foot, a finding not seen in this patient. Educational objective: Adolescent idiopathic scoliosis is characterized by lateral curvature of the spine in an otherwise healthy adolescent. A thoracic or lumbar prominence on forward bend test is indicative of scoliosis, and a scoliometer angle of rotation ≥7 degrees requires additional evaluation with an x-ray of the spine. References: Optimal management of idiopathic scoliosis in adolescence. (http://www.ncbi.nlm.nih.gov/pubmed/24600296)

Question 12

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:
 After confirmation of the diagnosis, the patient is started on appropriate therapy.  During a follow-up visit 6 months later, he says the muscle weakness has improved but he becomes breathless on moderate exertion.  The patient has to stop to catch his breath when walking 3 blocks to his office, which he had previously been able to do without stopping.  He has also had a mild nonproductive cough.  Temperature is 36.6 C (98 F), blood pressure is 130/80 mm Hg, pulse is 82/min, and respirations are 16/min.  The neck veins are flat.  Heart sounds are normal, but lung auscultation reveals bibasilar fine crackles.  Muscle strength is normal.  Blood cell counts and serum chemistry are within normal limits.  Chest radiograph is normal.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0bc_2a1e_8f63_117984411159_MD0005_00 Polymyositis is treated with systemic glucocorticoids, often with corticosteroid-sparing agents (eg, methotrexate, azathioprine). This patient has had a good response, with improved muscle strength and normalization of muscle enzymes and inflammatory markers. However, patients with polymyositis can also develop a number of pulmonary complications, including interstitial lung disease (ILD), infection (due to immune suppressive therapy), drug-induced pneumonitis (eg, methotrexate pneumonitis), and respiratory muscle weakness. ILD is especially common in patients with a positive anti-Jo-1 antibody, and can be identified on high-resolution CT imaging as ground-glass opacities, reticular changes, honeycombing, or patchy consolidation. Pulmonary function tests (PFTs) should be performed to distinguish ILD from respiratory muscle weakness and will show decreased forced vital capacity, total lung capacity, and diffusing capacity. Initial management of ILD in patients with polymyositis is similar to treatment of the underlying polymyositis with systemic glucocorticoids and corticosteroid-sparing agents, but ILD may progress despite improvement in myopathic features. (Choice A) Bronchoscopy with transbronchial biopsy or bronchoalveolar lavage may be needed to diagnose ILD in patients who do not have characteristic findings on CT imaging and PFTs. However, CT and PFTs are usually performed first. (Choice B) Myocarditis with conduction system disease and congestive heart failure is a potential complication of polymyositis. However, this patient does not have any suggestive findings such as jugular venous distension, wet crackles, or signs of pulmonary edema on chest x-ray. (Choice D) Serum IgE levels are nonspecific, and can be elevated in a variety of allergic and inflammatory conditions. IgE levels are commonly used in the evaluation of allergic bronchopulmonary aspergillosis, but these patients typically have underlying progressive asthma with recurrent exacerbations and infiltrates on chest x-ray. (Choice E) Ventilation/perfusion scan is useful in diagnosis of pulmonary embolism, which would usually present with acute dyspnea, tachycardia, and hypoxemia. This patient does not have typical features and has low probability for pulmonary embolism; to exclude pulmonary embolism, a D-dimer could be considered for risk stratification prior to imaging. Educational objective: Patients with polymyositis can develop pulmonary complications, including interstitial lung disease, infection, drug-induced pneumonitis, and respiratory muscle weakness. Interstitial lung disease can be identified on high-resolution CT imaging as ground-glass opacities, reticular changes, honeycombing, or patchy consolidation. Pulmonary function tests show decreased forced vital capacity, total lung capacity, and diffusing capacity.

Question 13

A 27-year-old man comes to the physician with pain in his left knee, ankle, and lower back over the last week. His back feels stiff in the morning and improves with activity. Three months ago, he was treated for chlamydia proctitis with azithromycin and ceftriaxone. He also had painless sores on his glans penis, but tests for syphilis were negative at that time. On examination, he still has multiple shallow ulcers on the glans penis. The patient reports no change in appearance of the ulcers over the 3-month period. There is no urethral discharge or inguinal lymphadenopathy. The left knee and ankle joints are swollen and nontender. No redness or warmth is noted. Laboratory results are as follows: Synovial fluid aspirated from the knee shows a white blood cell count of 4,000/mm³ with 80% neutrophils. Gram stain is negative and no pathogen is isolated on fluid culture. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0bf_1056_8f63_27d10ba46a89_MD0005_00 Recent-onset asymmetric oligoarthritis that is inflammatory (elevated white blood cell count) yet sterile (culture negative) in a patient with a recent history of chlamydia infection is suggestive of reactive arthritis (ReA). Sacroiliac joints may also be involved. Extraarticular symptoms such as urethritis, uveitis, circinate balanitis, and keratoderma blennorrhagicum may be present. ReA usually develops within 1-4 weeks of the inciting infection. Therefore, new symptoms suspicious for ReA in a patient with history of chlamydia should prompt repeat testing for infection even in the absence of obvious symptoms. The nucleic acid amplification test (NAAT) for chlamydia is usually performed on urine samples. Rectal screening is recommended for men who have sex with men or in patients with a history of chlamydia proctitis. Circinate balanitis (painless, shallow ulcers of the glans penis) is an extraarticular manifestation of ReA occurs in 20%-40% of patients. In some patients, it may be the only initial symptom. Circinate balanitis appears within weeks of the primary infection. It may persist for several months before spontaneous resolution, as seen in this patient. By contrast, the painless lesions of lymphogranuloma venereum (LGV) resolve within a few days, and those of syphilis resolve within 3-6 weeks. In addition, this patient does not have lymphadenopathy present in the secondary stages of syphilis and LGV. Therefore, dark field microscopy for syphilitic chancre is not necessary (Choice C). Similarly, NAAT of the penile ulcers, which can be performed to diagnosed LGV (caused by L1, L2, and L3 serovars of Chlamydia trachomatis), is not indicated (Choice B). Circinate balanitis may be treated with topical steroids. (Choice A) Antinuclear antibodies are a nonspecific indicator of autoimmune disease. They are not found in patients with ReA. (Choice E) Herpes simplex virus can be diagnosed with viral cultures or with polymerase chain reaction-based assays. Herpetic lesions are painful, usually vesicular, and resolve within a few weeks. Tender lymphadenopathy may also be present. Educational objective: Reactive arthritis (ReA) may develop within 1-4 weeks of chlamydia infection. Circinate balanitis is an extraarticular manifestation of ReA that is painless, resolves after several months, and is not associated with inguinal lymphadenopathy. New-onset ReA in patients with a history of chlamydia infection should prompt repeat testing for chlamydia, even in those who are otherwise asymptomatic. References: Chlamydia-induced reactive arthritis: hidden in plain sight? (http://www.ncbi.nlm.nih.gov/pubmed/22100286) Successful use of dapsone for the management of circinate balanitis. (http://www.ncbi.nlm.nih.gov/pubmed/24635073)

Question 14

A 12-year-old girl is brought to the office for a preventive health maintenance examination.  The patient's mother has noticed that over the last few months, her daughter "seems to sit sideways" and does not sit up straight when asked.  The patient occasionally takes acetaminophen in the morning due to mild "aches and pains."  She fractured her left femur in a horse-riding accident at age 8.  Height and weight are at the 75th and 50th percentiles, respectively.  Physical examination shows a well-appearing, nondysmorphic girl.  Forward bend test demonstrates a right thoracic prominence that measures a 9-degree angle of trunk rotation and does not improve when a block is placed under the left foot.  Flexion of the lumbar spine is normal and the patient is able to touch her toes.  Lower extremity strength is normal.  Patellar and Achilles deep tendon reflexes are 2+.  Gait is normal. Posteroanterior and lateral x-rays of the spine are obtained, which reveal a Cobb angle of 5 degrees.  Which of the following is the best next step in management of this patient's spinal problem?

Accepted Answer

Explanation: 11ec2b69_c0c4_6793_8f63_f1a99222ec26_MD0005_00 Although scoliometry helps to predict patients with clinically significant scoliosis, the results are user-dependent and nonspecific. Therefore, concerning scoliometer findings require further evaluation with posteroanterior and lateral x-rays. Cobb angle measures spine curvature on x-ray and is the gold standard for determining diagnosis and treatment of scoliosis. A Cobb angle <10 degrees, as seen in this patient, is considered a variant of normal. Therefore, no follow-up is needed unless new findings (eg, significant pain, neurologic symptoms) develop. Conversely, patients with a Cobb angle ≥10 degrees have scoliosis. Scoliosis management depends on the risk for curve progression, with a larger Cobb angle signifying higher risk. Although observation or the use of a back brace is typically sufficient for low/medium risk curves (Choice B), severe scoliosis (Cobb angle ≥40 degrees) requires surgical evaluation for possible spinal fusion given the high risk for progression and future complications (eg, chronic back pain, pulmonary compromise) (Choice E). However, once puberty and skeletal maturity are complete, progression is typically minimal and treatment is not required unless severe deformity is present. (Choice C) MRI of the spine can evaluate for congenital or neuromuscular causes of scoliosis if x-ray of the spine reveals concerning vertebral anomalies (eg, wedged or hemi-vertebrae, vertebral lucency), not seen in this case. (Choice D) Although idiopathic scoliosis may have a hereditary component, genetic testing is expensive and unnecessary as x-ray determines diagnosis and management. This patient does not have scoliosis based on her Cobb angle and does not need further testing. Educational objective: Abnormal scoliometry results must be confirmed on x-ray by measuring the Cobb angle. A Cobb angle <10 degrees is considered normal and requires no follow-up unless back pain or neurologic symptoms develop. References: Optimal management of idiopathic scoliosis in adolescence. (http://www.ncbi.nlm.nih.gov/pubmed/24600296)

Question 15

A 25-year-old man comes to the emergency department with pain in his right hand and wrist.  A few hours earlier, he fell forward and landed on his outstretched right hand while playing football.  He could not continue playing due to intolerable pain.  The patient has no other medical problems and does not use tobacco, alcohol, or illicit drugs.  Examination shows mild swelling in the dorsum of the right hand with preserved range of motion.  Right hand grip strength is reduced.  There is severe tenderness on palpation of the radial dorsal aspect of the wrist. Subsequent assessment confirms a nondisplaced scaphoid fracture.  The patient is managed by a short arm cast and returns to his physician for follow-up in 2 weeks.  Inadequate management of this injury is most likely to produce which of the following potential complications?

Accepted Answer

Explanation: Scaphoid fractures are most commonly complicated by nonunion and avascular necrosis. The arterial blood supply to the scaphoid enters in the distal pole and travels to the proximal pole. Scaphoid fractures (particularly at the waist and proximal end of the scaphoid) can compromise the blood supply, causing avascular necrosis and increasing the risk of nonunion in up to 10% of cases. As a result, proximal fractures of the scaphoid require longer immobilization (up to 12 weeks) for adequate healing. Other factors that cause nonunion include delay of care, an unstable fracture fragment, and delay in surgical treatment when indicated. (Choice A) Acute carpal tunnel syndrome is a possible early complication in patients with a displaced or comminuted distal radial (Colles) fracture that has been treated with multiple reductions or splinted in extreme wrist flexion. (Choice B) Complex regional pain syndrome (CRPS) can occur as a complication of a distal radial fracture and in patients with wrist fracture splinted with palmar flexion >15 degrees. Early mobilization and vitamin C have been recommended to reduce the incidence of CRPS. (Choice C) Dupuytren contracture is characterized by progressive fibrosis of the palmar fascia of unknown etiology. It is associated with diabetes mellitus, exposure to repetitive vibration to the hands, CRPS, alcohol consumption, and occasionally malignancy. (Choice D) Malunion is more commonly seen in physeal fractures of the distal forearm in children (less common in adults) due to injury of the growth plate and growth arrest; this causes growth disparity between the radius and ulna and results in possible wrist deformity. Educational objective: Scaphoid fractures that are not treated appropriately or in a timely fashion can result in avascular necrosis and increase the risk of nonunion.

Question 16

A 25-year-old man comes to the emergency department with pain in his right hand and wrist.  A few hours earlier, he fell forward and landed on his outstretched right hand while playing football.  He could not continue playing due to intolerable pain.  The patient has no other medical problems and does not use tobacco, alcohol, or illicit drugs.  Examination shows mild swelling in the dorsum of the right hand with preserved range of motion.  Right hand grip strength is reduced.  There is severe tenderness on palpation of the radial dorsal aspect of the wrist. An x-ray of the wrist reveals no evidence of dislocation or fracture.  After receiving analgesic therapy, the patient reports that the pain in his wrist is almost gone.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: Initial plain radiography of a scaphoid fracture may reveal the fracture but may appear normal if the fracture is compressed or minimally displaced. In light of the limited sensitivity of initial x-rays, patients with suspected scaphoid fracture should have additional imaging: fracture MRI (or CT scan) of the wrist Repeat radiographs in 7-14 days Radioscintigraphy bone scan in 3-5 days MRI is the most sensitive test and allows for immediate assessment of a fracture, but is subject to limited availability and high up-front costs. Alternatively, the patient may be placed in a thumb spica splint with repeat x-rays in 7-14 days, but this approach can lead to delayed diagnosis, unnecessary immobilization, and greater follow-up costs. Patients with a confirmed scaphoid fracture should be referred to an orthopedic surgeon if they are found to have associated tilt of the lunate, a fracture displaced >1 mm, nonunion during follow-up, osteonecrosis, or scapholunate dissociation (Choice D). Patients with a nondisplaced fracture who do not meet surgical indications should be placed in a short arm thumb spica cast; serial x-rays should be done in 2-week intervals to monitor healing. (Choice A) Patients with a fracture should have wrist immobilization until there is evidence of radiographic union. However, confirmation of fracture should be obtained first as prolonged immobilization of a minor soft-tissue injury may impede return to normal function. (Choices B and C) Patients in whom a fracture has been definitively ruled out may be managed with light splinting and early mobilization. However, light or full mobilization is not advised in a patient with possible scaphoid fracture. Patients with a confirmed fracture may return to work or resume noncontact sports with a thumb cast, but should have rigid wrist protection for 2 months after cast removal to prevent re-injury. Educational objective: X-rays can initially be negative for nondisplaced scaphoid fractures. Patients with suspected scaphoid fracture should be evaluated further with either an immediate MRI or CT scan, repeat x-ray in 7-14 days, or bone scan in 3-5 days. Nondisplaced fractures should be treated with a short arm thumb spica cast, but other fractures should be referred to an orthopedic surgeon for evaluation. References: Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26582616) Adult scaphoid fracture. (http://www.ncbi.nlm.nih.gov/pubmed/24673666)

Question 17

A 55-year-old woman comes to the physician due to a 2-month history of malaise, mild fever, and difficulty climbing stairs and rising from a chair.  She has unintentionally lost 9.1 kg (20.1 lb) over this period.  The patient has hypertension and asthma.  Medications include amlodipine, as-needed albuterol, and inhaled glucocorticoids during winter.  The patient does not smoke or use illicit drugs.  She worked for 20 years supervising cotton processing in a textile factory but has been working as a secretary for the past 10 years.  Temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min.  Chest examination reveals clear lung fields and normal S1 and S2.  The patient has bilateral proximal upper and lower extremity weakness with normal reflexes.  Plantar reflexes are down-going bilaterally.  Violaceous papules and plaques are seen on the dorsum of both hands, as shown in the image below:  Kidney and liver function are within normal limits.  Creatine kinase level is 1,200 IU/L.
Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c0bc_ed71_8f63_0b9f79fc3eec_MD0005_00 This patient has proximal myopathy (as evidenced by difficulty rising from a chair and climbing stairs) as well as an elevated creatine kinase level. An insidious onset of symmetric proximal myopathy associated with Gottron papules (ie, violaceous papules/plaques on the dorsal hands, as seen in this patient) or a heliotrope rash is highly characteristic of dermatomyositis. heliotrope rash The diagnosis of dermatomyositis is based primarily on clinical findings and serologic tests. Antinuclear antibody (ANA) assay is the initial test of choice and is positive in up to 80% of patients. Confirmatory tests include myositis-specific antibodies (eg, anti-Jo, anti-Mi2). Because dermatomyositis is associated with interstitial lung disease (ILD), chest x-ray is performed to screen for ILD if no pulmonary symptoms are present; in patients with respiratory symptoms and those with abnormal x-ray findings, CT scan of the chest and pulmonary function testing are recommended. (Choices A and C) Patients with nonspecific findings (eg, facial erythema, psoriasiform scalp lesions), isolated skin/muscle involvement, or negative antibody testing may need tissue (eg, muscle, skin) biopsy for diagnosis. However, biopsy is not needed for those with characteristic clinical findings and serologic confirmation. (Choice D) Glucocorticoids can cause proximal myopathy but not the characteristic skin findings of dermatomyositis. Myopathy is unusual with an oral prednisone dose <10 mg or inhaled glucocorticoids. (Choice E) In HIV myopathy, proximal muscle weakness is more prominent in the lower extremities and is accompanied by myalgias and muscle tenderness. In addition, the violaceous lesions of HIV-associated psoriasis have more scaling and more extensive involvement (nails, palms, and soles) than Gottron papules. psoriasis Educational objective: Dermatomyositis presents with symmetric proximal muscle weakness, elevated creatine kinase, and skin lesions (eg, Gottron papules, heliotrope rash). Diagnosis is based primarily on clinical features and serum antibody testing. Antinuclear antibody test is sensitive, and confirmatory tests include myositis-specific antibodies (eg, anti-Jo, anti-Mi2). Muscle and skin biopsies are needed only if the diagnosis is uncertain. References: Polymyositis and dermatomyositis-challenges in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/32743506)

Question 18

An 11-year-old girl is brought to the clinic due to concerns about her posture.  She does not fully extend her back and has difficulty with some of the positions in her ballet class.  The patient is active in multiple sports as well as dance and typically practices 2 hours a day with various activities.  She also has mid-thoracic back pain that feels like a "dull ache," and she occasionally wakes up at night to adjust her position due to discomfort.  The patient takes no medications and has no allergies.  She has not undergone menarche.  There is no family history of scoliosis.  The patient is at the 50th percentile for height and weight.  Examination shows a talkative girl with no dysmorphic features.  Cardiopulmonary examination reveals normal heart tones and good air entry in all fields.  The breasts and pubic hair are sexual maturity rating stage 3.  Forward bend test reveals moderate scoliosis with a right rib hump that does not correct by placing a block under the left leg.  Gait is normal.  Two café-au-lait spots, each measuring 2 cm, are noted on the right flank.  Which of the following features of this patient's presentation is concerning for a pathologic cause of scoliosis?

Accepted Answer

Explanation: 11ec2b69_c0c4_dcc4_8f63_a3444009ee2f_MD0005_00 Scoliosis, lateral curvature of the spine, is most commonly idiopathic in asymptomatic adolescents. Rarely, scoliosis is a complication of spinal pathology and may be life-threatening. Further evaluation is required if the following red flags for a pathologic etiology are present: Back pain Neurologic symptoms Rapidly progressing curvature (>10 degrees each year) Vertebral anomalies on x-ray This patient's back pain that causes nocturnal awakening is concerning for an underlying spinal cord tumor. A spinal cord tumor can extend and disturb surrounding nerves, causing constant pain that is described as "dull" or "gnawing." In addition, impingement of spinal cord pathways can cause dysesthesias, weakness, and neurogenic bladder/bowel. Other pathologic causes of scoliosis include infection and trauma, which are less likely in this patient due to lack of fever or history of injury. Diagnostic workup often begins with x-ray of the spine, which may show abnormalities such as vertebral lucencies, pedicle erosion, or widened canal. However, MRI of the spine is the gold standard to delineate spinal anatomy. (Choice A) The degree of curvature on x-ray determines the severity of scoliosis but does not correlate with idiopathic versus pathologic etiology. (Choice B) Although adolescent idiopathic scoliosis is believed to have a hereditary component, a negative family history, as seen in this patient, does not make pathologic scoliosis more likely. (Choice C) Certain genetic disorders involving tissue formation, such as neurofibromatosis, Marfan syndrome, and osteogenesis imperfecta, can cause syndromic scoliosis. However, neurofibromatosis is characterized by multiple large café-au-lait macules, but this patient has only 2 and they are small, which is considered normal. (Choice E) Sexual maturity rating helps to predict remaining growth potential and risk for curvature progression in patients with idiopathic scoliosis. Patients who develop scoliosis before menarche are at risk for further curvature progression. However, this patient's risk for pathologic scoliosis is unaffected by sexual maturity. Educational objective: Although scoliosis is most commonly idiopathic, patients with associated back pain (nocturnal awakening), neurologic findings, rapidly progressing curvature, or abnormal vertebrae should undergo further evaluation for underlying spinal pathology (eg, spinal tumor). References: Back pain during growth. (http://www.ncbi.nlm.nih.gov/pubmed/23299906)

Question 19

A 27-year-old man comes to the physician with pain in his left knee, ankle, and lower back over the last week. His back feels stiff in the morning and improves with activity. Three months ago, he was treated for chlamydia proctitis with azithromycin and ceftriaxone. He also had painless sores on his glans penis, but tests for syphilis were negative at that time. On examination, he still has multiple shallow ulcers on the glans penis. The patient reports no change in appearance of the ulcers over the 3-month period. There is no urethral discharge or inguinal lymphadenopathy. The left knee and ankle joints are swollen and nontender. No redness or warmth is noted. Laboratory results are as follows: Synovial fluid aspirated from the knee shows a white blood cell count of 4,000/mm³ with 80% neutrophils. Gram stain is negative and no pathogen is isolated on fluid culture. The suspected pathogen is detected in this patient. Which of the following is the most appropriate therapeutic regimen?

Accepted Answer

Explanation: This patient most likely has reactive arthritis (ReA) from the recurrent chlamydia infection. In studies, chlamydia DNA has been isolated from synovial fluid of affected patients. Because persistent chlamydia infection may lead to chronic (>6 months) ReA, an active infection (symptomatic or asymptomatic) requires treatment with antibiotics. Self-limited gastrointestinal infections do not warrant antibiotic therapy. Antibiotic use in itself does not provide rapid relief of arthritic symptoms, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen or indomethacin, are indicated (Choice A). (Choices C, D and E) Exercise is useful in preserving joint mobility when lumbosacral joints are affected. In peripheral arthritis, rest and icing of the affected joint are recommended. Persistent arthritic symptoms, despite adequate NSAID therapy, may require intraarticular glucocorticoids, systemic glucocorticoids, and disease-modifying antirheumatic drugs such as sulfasalazine or methotrexate in a step-wise manner. Educational objective: Active chlamydia infection should be treated in patients with reactive arthritis. Symptomatic treatment with nonsteroidal anti-inflammatory drugs is also indicated. References: Chlamydia and chronic arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/21864020) Treatment of reactive arthritis: a practical guide. (http://www.ncbi.nlm.nih.gov/pubmed/18034510) Seronegative arthritis in South Asia: an up-to-date review. (http://www.ncbi.nlm.nih.gov/pubmed/24515283)

Question 20

A 25-year-old man comes to the emergency department with pain in his right hand and wrist.  A few hours earlier, he fell forward and landed on his outstretched right hand while playing football.  He could not continue playing due to intolerable pain.  The patient has no other medical problems and does not use tobacco, alcohol, or illicit drugs.  Examination shows mild swelling in the dorsum of the right hand with preserved range of motion.  Right hand grip strength is reduced.  There is severe tenderness on palpation of the radial dorsal aspect of the wrist.
Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: This patient fell onto his outstretched hand and has acute pain at the wrist and tenderness at the anatomic snuffbox. These are clinical features concerning for a scaphoid fracture, which is the most common carpal bone fracture and is typically caused by forceful dorsiflexion at the wrist. The scaphoid can be forced against the dorsal part of the distal radius, creating a fulcrum for injury. Patients can have swelling, decreased grip strength, pain and tenderness at the radial aspect of the wrist in the anatomic snuffbox, and minimally decreased range of motion (unless dislocated fracture is present). anatomic snuffbox The next step in management would be to confirm the diagnosis with x-rays of the wrist in full pronation and ulnar deviation to better expose the scaphoid. Initial x-rays can be negative if the fracture is compressed or minimally displaced. (Choice A) A Colles fracture is another common fracture caused by falling onto an outstretched hand. It is a dorsally angulated or displaced distal radius fracture that is typically associated with visible angulation proximal to the wrist joint ("dinner fork deformity"). Lateral radiographs can confirm Colles fracture diagnosis. Colles fracture (Choice B) A hamate fracture can occur while falling onto an outstretched hand, usually near the hook of the hamate (hamulus) containing the ulnar artery and nerve. Pain and swelling of a hamate fracture occur in the hypothenar eminence and ulnar aspect of the wrist; however, this patient's pain is in the radial aspect. (Choice C) A radial styloid fracture (Hutchinson or chauffeur fracture) typically occurs due to a direct blow to the styloid while falling onto an outstretched hand with ulnar deviation and supination; this results in a fracture dislocation of the radial styloid and either the lunate or scaphoid. It is significantly less common than scaphoid fracture. (Choice E) A sprain of the wrist ligaments is typically associated with mild pain or stiffness with normal range of motion and resolves with conservative and supportive care. A wrist sprain typically causes pain that worsens with flexion and extension of the ligaments. Instead, this patient has severe point tenderness with palpation. Educational objective: Scaphoid fracture is the most common carpal bone fracture, and commonly occurs due to falling onto an outstretched hand with a dorsiflexed wrist. Findings include decreased grip strength, decreased range of motion in the wrist, and tenderness to palpation of the scaphoid within the anatomic snuffbox. References: Treatment of scaphoid fractures and nonunions. (http://www.ncbi.nlm.nih.gov/pubmed/18656779)

Exam 1: Advanced Clinical Medicine