Question 1

A 65-year-old woman comes to the office to discuss the results of bone density testing. She is worried because her 85-year-old mother recently died while recovering from a hip fracture. The patient does not use tobacco or alcohol and gets regular exercise. Her last menstrual period was 13 years ago, and she is not taking any form of hormone replacement therapy. Vital signs and physical examination are within normal limits. BMI is 19 kg/m². DXA scan reveals a T-score of −1.8 at the lumbar spine and −1.7 at the hip, consistent with osteopenia. In addition to appropriate calcium and vitamin D supplementation, which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c1d3_b453_8f63_9d9a3ac8d202_MD0005_00 On DXA testing, the T-score indicates how a patient's bone density compares to an average young adult at peak bone density. A T-score ≥−1.0 is considered normal, between −1.0 and −2.5 is osteopenia, and ≤−2.5 is osteoporosis. This postmenopausal woman has osteopenia and other significant risk factors for fracture, including low BMI and family history of parental hip fracture. All patients with low bone density (osteopenia or osteoporosis) should get regular weight-bearing exercise, avoid smoking and excessive alcohol intake, and maintain adequate intake of calcium and vitamin D (using supplements as needed). Patients with osteoporosis (by DXA criteria or confirmed osteoporotic fracture) also warrant antiresorptive therapy; bisphosphonates (eg, alendronate) are first-line treatment for most patients. In addition, patients with osteopenia who are at increased risk of fracture may benefit from bisphosphonate therapy. The 10-year fracture risk can be calculated using the Fracture Risk Assessment Tool (FRAX), which takes into account bone density, age, and other clinical factors. Most experts consider bisphosphonates warranted for those with a risk of hip fracture ≥3.0% or combined major osteoporotic fracture ≥20%. (FRAX) (Choice B) Menopausal hormone therapy is indicated for significant vasomotor symptoms (eg, hot flashes) in women with no contraindications (eg, breast cancer, venous thromboembolism). Although estrogen has benefits for maintaining bone density, bisphosphonates are preferred for initial treatment of osteoporosis or osteopenia with high fracture risk. (Choice C) Bone turnover markers (eg, bone-specific alkaline phosphatase, propeptide of type I procollagen) correlate with the rate of bone loss and risk of fracture. However, their clinical use in osteoporosis is complicated by biologic variability and lack of standardization. Fracture risk is better estimated using the FRAX calculator. (Choice D) Bisphosphonates have little benefit for patients with osteopenia at low fracture risk and carry certain risks (eg, jaw osteonecrosis, pill esophagitis). Therefore, fracture risk should be assessed before determining the need for treatment. (Choice E) Frequent (eg, at 6-month intervals) bone density testing is recommended for patients with unusually rapid bone loss (eg, systemic glucocorticoid therapy). When follow-up testing is needed for patients with postmenopausal bone loss, a 2-year interval is generally appropriate. Educational objective: Patients with osteoporosis (T-score ≤−2.5 or osteoporotic fracture) warrant antiresorptive therapy; bisphosphonates (eg, alendronate) are first-line treatment for most patients. For patients with osteopenia (T-score between −1.0 and −2.5), the 10-year fracture risk can be calculated using the Fracture Risk Assessment Tool (FRAX) to determine if antiresorptive therapy is indicated. References: A systematic review of intervention thresholds based on FRAX: a report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. (http://www.ncbi.nlm.nih.gov/pubmed/27465509)

Question 2

A 39-month-old boy is brought to the office due to fever.  He has had fever spikes the past 5 days that have not improved with oral acetaminophen.  He has been very cranky and his appetite has decreased.  The patient has had a slightly stuffy nose but no cough, emesis, or diarrhea.  He has also developed a bad diaper rash that has not improved with topical barrier ointments.  The patient does not attend day care, and there are no sick contacts at home.  Medical history is significant for an episode of otitis media last year and occasional upper respiratory infections, but he has had no chronic medical illnesses.  Immunizations are up to date, and the patient takes no medications.  Temperature is 40 C (104 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 18/min.  On physical examination, the child is awake and alert but very cranky.  The head is normocephalic and atraumatic.  The conjunctivae are injected without discharge bilaterally, and the pupils are equal and reactive to light and accommodation.  There is scant nasal congestion.  The lips, tongue, and oral mucosa are erythematous, but there is no pharyngeal erythema or exudate.  Neck is supple without lymphadenopathy.  S1 and S2 are normal without murmurs; lungs are clear to auscultation bilaterally.  Abdomen is soft, nontender, and nondistended, without organomegaly.  There is nontender erythema and peeling of the skin in the perineum and inguinal folds and several erythematous, blanching macules on the trunk; there are no other skin lesions. 
Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: 11ec2b69_c1ce_842d_8f63_399046edfdd9_MD0005_00 This boy age <5 has had fever for 5 days as well as the following symptoms: Rash (inguinal folds, perineum, trunk) Nonexudative conjunctivitis Mucositis (erythematous lips, tongue ["strawberry tongue"], oral mucosa) He therefore meets 3 of the 5 diagnostic criteria of Kawasaki disease (KD), a febrile vasculitis of unknown etiology. An additional criterion (cervical lymphadenopathy or extremity erythema/edema) is required for diagnosis. However, KD symptoms often do not manifest simultaneously; therefore, when <3 diagnostic criteria are met in a child with >5 days of fever, C-reactive protein or erythrocyte sedimentation rate (inflammatory markers that are elevated in KD) should be ordered, with daily follow-up scheduled to assess for new symptoms. KD can present a diagnostic challenge because viral illnesses can cause fever >5 days and similar features (eg, rash, conjunctivitis, oropharyngeal erythema). However, failure to treat KD in a timely manner significantly increases the risk of serious sequelae (eg, coronary artery aneurysms), with substantial risk after the 10th day of illness. Therefore, unless a definite alternate diagnosis has been established, waiting 3-4 days without performing laboratory studies or reexamination is inappropriate (Choice E). (Choice B) Scarlet fever, treated with oral amoxicillin, is caused by a streptococcal infection and presents with a "sandpaper" rash (small papules), "strawberry tongue," and circumoral pallor. However, it typically accompanies streptococcal pharyngitis (eg, pharyngeal erythema/exudate) and would not cause conjunctivitis. "sandpaper" rash (Choice C) Oral antibiotics would be necessary for rashes caused by cellulitis or toxic shock syndrome. Bacterial cellulitis does not typically cause a nontender, peeling perineal rash with papules on the trunk. Toxic shock syndrome can cause desquamation but is usually seen with tampon use and associated with hypotension. (Choice D) Fungal diaper dermatitis (beefy red skin with satellite lesions) is common in children; however, the presence of fever, conjunctivitis, and oral erythema is not suggestive of this diagnosis. In addition, even if fungal dermatitis is suspected, topical antifungal treatment (not simply topical barrier ointments) should be attempted first. Educational objective: Kawasaki disease is a febrile vasculitis of childhood, diagnosed based on fever >5 days with >4 of the following: conjunctivitis, mucous membrane changes, rash, lymphadenopathy, and extremity edema/erythema. Because symptoms required for diagnosis do not always present simultaneously, patients who have been febrile for >5 days but who fill <3 diagnostic criteria should have supporting laboratory studies (C-reactive protein or erythrocyte sedimentation rate) ordered and should be reexamined the following day. References: Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. (http://www.ncbi.nlm.nih.gov/pubmed/15574639) Kawasaki disease. (http://www.ncbi.nlm.nih.gov/pubmed/18765469)

Question 3

A 24-year-old female soccer player comes to the office with right anterior knee pain.  The pain has been present for 3-4 months with gradual onset and a persistent course.  It is worsened by climbing and descending stairs and prolonged sitting.  A trial of over-the-counter ibuprofen was not helpful.  The patient reports several previous minor lower-extremity injuries from playing soccer but no significant trauma.  Her past medical history is otherwise negative.  There is crepitation and pain on extension of the knee with anterior patellar compression.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_c1d4_77a4_8f63_21713dd9a6ba_MD0005_00 Patellofemoral pain syndrome (PFPS) is the most common cause of knee pain in young adults. It is much more common in women than men, likely due to the greater angle between the main axis of the quadriceps group and the generally vertical axis of the patellofemoral groove. Patients with PFPS have poorly localized pain at the anterior knee that is worsened by activities that involve quadriceps contraction such as squatting or ascending and descending stairs. The course is usually subacute to chronic. The diagnosis of PFPS is primarily clinical and may be challenging as objective findings are often minimal. The patellofemoral compression test (pain elicited by extending the knee while compressing the patella) and reproduction of pain with squatting are highly suggestive. Imaging tests such as x-ray and magnetic resonance imaging of the knee are usually normal and are generally needed only if the diagnosis is in doubt or the patient fails to improve as expected. Patellofemoral pain syndrome (PFPS) Management of PFPS is primarily biomechanical - exercises to stretch and strengthen the thigh muscles -and avoiding activities that aggravate the pain. Nonsteroidal anti-inflammatory drugs are often prescribed but frequently are not helpful. Persistence is required on the part of the patient as resolution of symptoms may take weeks to months. (Choice A) Anserine bursitis is a common cause of medial knee pain. Patients have localized pain and tenderness at the medial aspect of the knee joint distal to the joint line. Symptoms are usually acute/episodic rather than chronic and are not usually felt at the anterior knee. Anserine bursitis (Choice B) Osgood-Schlatter syndrome causes pain at the insertion of the patellar tendon at the anterior tibial tubercle. It occurs almost exclusively in adolescent and preadolescent patients, frequently following a rapid growth spurt. Patients will have localized tenderness at the tibial tubercle. Osgood-Schlatter syndrome (Choice C) Patellar tendonitis ("jumper's knee") is most common in patients who participate in jumping sports (eg, volleyball, basketball). Pain is episodic and localized to the inferior patella and patellar tendon. Tenderness at the inferior margin of the patella is a typical finding. Patellar tendonitis ("jumper's knee") (Choice E) Prepatellar bursitis ("housemaid's knee") is a common cause of anterior knee pain in patients who work extensively on their knees. Unlike PFPS, the pain of prepatellar bursitis is typically acute and highly localized with visible swelling anterior to the patella. Prepatellar bursitis is frequently complicated by secondary infection (septic bursitis) due to Staphylococcus aureus. Prepatellar bursitis ("housemaid's knee") Educational objective: Patellofemoral pain syndrome is the most common cause of knee pain in young adults, especially women. Pain is subacute to chronic and poorly localized. Diagnosis is clinical and may be challenging. Patients may have reproduction of pain by extension of the knee with anterior pressure on the patella (patellofemoral compression test). Treatment is primarily biomechanical with stretching and strengthening exercises of the thigh muscles. References: Patellofemoral pain syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20610028)

Question 4

A 13-year-old boy is brought to the office by his mother who is concerned that he has "a round back."  She says, "He will not sit up straight," and she is afraid that he will have permanent deformity.  The boy has no back pain, lower extremity weakness, or difficulty with bowel and bladder control.  He is physically active and plays soccer on the local team.  He has had no significant trauma.  The patient has no chronic health issues and takes no medications.  Vital signs are normal.  Physical examination shows an awake and alert adolescent with no dysmorphic features.  Pubic hair and genitalia are sexual maturity rating score 3.  He has a postural round back that is corrected by voluntary hyperextension.  Forward bending indicates no lateral deformity and no angulation.  Abdominal reflexes are symmetric.  Achilles and patellar deep tendon reflexes are 2/4 with normal strength noted in both lower extremities.  Gait is normal.  Lateral x-rays of the spine reveal a convex alignment of the thoracic spine at 35 degrees (normal: <20 degrees).  Which of the following is the most accurate statement regarding this patient's condition?

Accepted Answer

Explanation: 11ec2b69_c1d2_a2e1_8f63_d1d446e0d25a_MD0005_00 Kyphosis is the forward curvature, or convexity, of the thoracic/thoracolumbar spine. Although the spine is mildly kyphotic by nature to absorb the impact from movement, excessive curvature creates a hump deformity of the upper back. A hump that is easily correctible by voluntary back extension or by lying supine is termed postural (flexible) kyphosis; in contrast, structural kyphosis does not self-correct. This patient has postural kyphosis due to slouching. This is the most common type of kyphosis and is seen frequently in adolescents. Patients are typically asymptomatic with no neurologic abnormalities (2/4 reflexes are normal). On lateral radiographs, the angle of spinal convexity is generally normal to slightly increased (20-40 degrees), as seen in this patient. The deformity is not permanent, and no treatment is required as proper posture is corrective. In contrast, structural kyphosis is a pathologic abnormality of the spinal column that often presents with progressive back pain and deformity. Although some cases are due to congenital or acquired vertebral anomalies (eg, wedging), it is imperative to exclude potentially dangerous secondary causes (eg, spinal infection, fracture, tumor, degeneration). After managing any secondary source, treatment of structural kyphosis generally involves special exercises to strengthen and straighten the back; using a back brace or having surgical correction is considered only for chronic pain or significant spinal convexity (>60 degrees) (Choices B and C). (Choice D) Idiopathic scoliosis is also common in adolescents; however, lateral angulation of a spine with scoliosis causes an asymmetric prominence on forward bending, which is not seen in this patient. Although scoliosis is at high risk of progression during pubertal growth spurts, postural kyphosis is reversible with slouching cessation. (Choice E) Spondylolisthesis, anterior slippage of a vertebral body, usually involves the lower lumbar vertebrae and classically causes pain with lumbar extension. Patients may develop a kyphotic posture to avoid hyperextension, but radiography would demonstrate vertebral subluxation. Educational objective: Postural kyphosis, or slouching, is a common finding in adolescents; it is easily correctable by voluntary back extension and requires no treatment. In contrast, structural kyphosis is due to underlying spinal pathology and does not self-correct. References: Round and angular kyphosis in paediatric patients. (http://www.ncbi.nlm.nih.gov/pubmed/23287399)

Question 5

A 24-year-old man comes to the urgent care clinic due to severe right knee pain.  He was playing football with friends earlier that afternoon when he was tackled from the right side.  He felt a pop and had difficulty walking and pivoting, but he is able to ambulate slowly.  On physical examination, the patient has pain when externally rotating the right tibia with the right knee bent at a 90-degree angle.  Pain and moderate laxity are demonstrated with valgus stress testing of the knee.  There is no significant effusion.  Plain film of the knee is normal.  What is the most likely diagnosis?

Accepted Answer

Explanation: 11ec2b69_c1d2_06a0_8f63_4d845a0c81f9_MD0005_00 Medial collateral ligament (MCL) tear is a common knee injury that is typically caused by a valgus (abductor) stress to the partially flexed knee. It typically occurs following a blow to the lateral knee with the foot fixed but may also be seen following a severe twisting injury (eg, skiing). MCL tears may occur in isolation or can be associated with injury to the medial meniscus. MCL tears are characterized by tenderness at the medial knee and laxity when the foot is forced into abduction with the knee stationary (valgus stress test). Acute effusion/hemarthrosis is uncommon unless there is concurrent injury to the anterior cruciate ligament. Due to local swelling and muscle spasm, examination findings may be unclear if the patient is examined more than 30 minutes after the injury; in such cases, repeat examination at a later date may reveal the full extent of the injury. X-ray is not needed unless there is concern for additional bony injury, and MRI is generally reserved for patients being considered for surgical intervention. Patients with uncomplicated MCL tears can be managed nonoperatively with rest, ice, compression, and elevation (RICE measures) and analgesics, with progressive return to activity as tolerated. (Choice A) Anterior cruciate ligament tears occur during rapid pivots, deceleration, or direction changes, or from a blow to the knee with a significant twisting force. Rapid-onset hemarthrosis is common. Examination shows laxity with the anterior drawer or Lachman maneuver. (Choice B) Lateral collateral ligament injury is associated with tenderness and pain along the lateral joint line and is most frequently caused by an injury involving dramatic varus (adductor) stress. (Choice D) Posterior cruciate ligament injury is often caused by hyperextension or by a blow to the anterior aspect of the proximal tibia with the knee flexed. It is usually associated with little pain or alteration in range of motion, but the posterior drawer test is positive. (Choice E) Prepatellar bursitis is most frequently caused by trauma from a fall or secondary to prolonged friction and pressure from repetitive kneeling ("housemaid's knee"). Educational objective: Medial collateral ligament injuries commonly occur when a force is applied to the knee from the lateral to medial direction during skiing or contact sports. Examination shows valgus laxity. Most patients are managed nonoperatively. References: Treatment of medial collateral ligament injuries. (http://www.ncbi.nlm.nih.gov/pubmed/19264708)

Question 6

A healthy 27-year-old Caucasian man is brought to the emergency department after being involved in a motor vehicle accident.  He complains of right knee pain and swelling.  He was sitting in the front seat without a seat belt.  His knees hit the front dashboard.  His vital signs are stable.  On examination, there is mild swelling and stiffness.  Which of the following was most likely injured in this patient's knee joint?

Accepted Answer

Explanation: This patient has a classic 'dashboard' injury, wherein a posteriorly directed force is placed on the anterior aspect of the proximal tibia, with the knee in a flexed position. This results in disruption of the posterior cruciate ligament (PCL). A similar injury can be seen in an athlete who falls on a flexed knee with the foot in plantar flexion. Unlike patients with ACL injury, these patients do not complain of a typical 'popping' sound, and may not have an unstable knee. (Choice A) ACL injuries are common in athletic activities. An isolated injury may occur after hyperextension of the knee. Up to 33% to 90% of patients with an ACL tear experience a 'popping' sensation. The rapid onset of a knee effusion and an unstable knee are common. Lachman's test is a very sensitive physical test for acute anterior cruciate ligament tear. It is done with the patient's knee flexed at 20 degrees; one hand pulls the proximal tibia, while the other hand stabilizes the femur. (Choices C) Meniscal injuries principally occur after a twisting injury to the knee with one foot fixed to the ground (e.g. with sudden turning while running). The medial meniscus is more commonly injured, as compared to the lateral meniscus. A bucket handle tear is the most common type of medial meniscus tear. Patients generally complain of pain and swelling of the knee, and a popping sensation at the time of injury. In medial meniscus injuries, tenderness is generally felt along the medial side of the knee. Effusion with meniscus injuries takes about 24 hours to form, and is often not significantly bloody, unlike ACL or osteochondral injuries. Locking of the knee joint on extension is generally seen. McMurray's sign is snapping felt with tibial torsion and the knee flexed at 90 degrees. (Choices D and E) Medial and lateral collateral ligaments are injured when the line of force strikes from the side of the joint. An abduction injury with a torsional component causes a medial collateral ligament tear in most of the instances. On examination, the knee joint is swollen due to the effusion, with tenderness over the medial aspect of the knee. As the medial collateral ligament resists valgus angulations at the knee, injury to this ligament leads to increased angulation of the affected knee on valgus stress. A valgus stress test is generally performed with the knee flexed at 20-30 degrees. Educational Objective: The classic dashboard injury results from a posteriorly directed force on the anterior aspect of the proximal tibia with the knee in a flexed position. This results in disruption of the posterior cruciate ligament (PCL).

Question 7

A 39-year-old African-American woman comes to see you in the office with complaints of left shoulder pain for the past two months. She describes the pain as a dull constant ache which gets worse whenever she reaches over her head with her left arm. She denies any recent or remote history of trauma or falls. There is no weakness or loss in the range of motion of the shoulder joint. You do a thorough musculoskeletal examination of both her shoulder joints, and conclude that she is suffering from rotator cuff tendonitis. Which of the following pain patterns will most likely support your clinical diagnosis of rotator cuff tendonitis?

Accepted Answer

Explanation: Shoulder pain is a common musculoskeletal problem encountered in primary care practice. A careful history and physical examination can determine the cause of shoulder pain in the majority of patients. Most of the patients presenting with shoulder pain have an intrinsic shoulder disorder. Lateral shoulder or deltoid pain aggravated by reaching or lifting the arms up is the classic pattern of pain seen in patients with rotator cuff tendonitis or tear, impingement syndrome, and frozen shoulder. Rotator cuff tendonitis and tear are the two most common causes of chronic shoulder pain in middle-aged and older patients. A rotator cuff tear is likely if the pain is accompanied by weakness or loss of strength during external rotation or abduction of the shoulder. Frozen shoulder refers to a stiffened glenohumeral joint, and is most commonly caused by rotator cuff tendonitis. It is suspected when the lateral pain pattern is accompanied by stiffness and a decreased range of motion in abduction and external rotation. (Choice A) Anterior shoulder pain is seen in patients with acromioclavicular or glenohumeral joint osteoarthritis and biceps tendonitis. This pain pattern is seen less frequently than lateral deltoid pain. (Choice B) Posterior shoulder pain is the least common pain pattern, and is usually a referred pain from the cervical spine. The common causes are nerve impingement due to disc herniation, and spinal stenosis at the cervical spine level. (Choice D) Axillary pain is not a classic pain pattern for any of the common shoulder disorders. It may be caused by an external trauma or extensive rotator cuff disease. (Choice E) Poorly localized pain is usually due to referred pain from the neck, bony structures, or nerve compression. Educational Objective: Rotator cuff tendonitis usually manifests as lateral shoulder pain aggravated by movements requiring abduction and external rotation of the shoulder. abduction and external rotation

Question 8

A 39-month-old boy is brought to the office due to fever.  He has had fever spikes the past 5 days that have not improved with oral acetaminophen.  He has been very cranky and his appetite has decreased.  The patient has had a slightly stuffy nose but no cough, emesis, or diarrhea.  He has also developed a bad diaper rash that has not improved with topical barrier ointments.  The patient does not attend day care, and there are no sick contacts at home.  Medical history is significant for an episode of otitis media last year and occasional upper respiratory infections, but he has had no chronic medical illnesses.  Immunizations are up to date, and the patient takes no medications.  Temperature is 40 C (104 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 18/min.  On physical examination, the child is awake and alert but very cranky.  The head is normocephalic and atraumatic.  The conjunctivae are injected without discharge bilaterally, and the pupils are equal and reactive to light and accommodation.  There is scant nasal congestion.  The lips, tongue, and oral mucosa are erythematous, but there is no pharyngeal erythema or exudate.  Neck is supple without lymphadenopathy.  S1 and S2 are normal without murmurs; lungs are clear to auscultation bilaterally.  Abdomen is soft, nontender, and nondistended, without organomegaly.  There is nontender erythema and peeling of the skin in the perineum and inguinal folds and several erythematous, blanching macules on the trunk; there are no other skin lesions. The appropriate study is performed and demonstrates no abnormalities.  After treatment is initiated, the patient improves and remains afebrile for 48 hours.  He is awake, alert, and active without crankiness.  Physical examination demonstrates superficial desquamation of his rash and no other abnormality.  Preparations are made for discharge with appropriate follow-up.  The patient's mother has concerns about his long-term prognosis.  Which of the following is the most appropriate response to her question?

Accepted Answer

Explanation: The patient has been treated with intravenous immunoglobulin (IVIg), which is composed of pooled antibodies. These antibodies interfere with the body's normal immune response to live vaccines. Because of this, patients should defer live vaccines for 11 months after receiving IVIg. The vaccines typically administered at age 4 include live vaccinations (second dose of measles-mumps-rubella and varicella), so they should be postponed in this 39-month-old patient until the appropriate amount of time has elapsed. (Choice A) The likelihood of relapse and recurrence after an episode of Kawasaki disease is low (<2.5% recurrence during the first 3 years after treatment). (Choice B) Kawasaki disease is a self-limited condition, so treatment is only necessary in the acute phase of illness. Once a patient has responded to initial treatment with IVIg, no further immunosuppression or immune modulation is necessary. (Choices C and D) If the patient had coronary artery dilation, coronary artery aneurysms, or myocardial dysfunction on his baseline echocardiogram, he would be at increased risk for future cardiac events and his participation in contact sports and strenuous activities would need to be restricted. However, his cardiac function is normal, and no restriction is necessary at this time. Educational objective: Intravenous immunoglobulin is composed of pooled antibodies and can alter a person's normal immune response to live vaccines. Because of this, live vaccines should not be administered for 11 months after treatment of Kawasaki disease. References: Epidemiological features of Kawasaki disease in Korea, 2006-2008. (http://www.ncbi.nlm.nih.gov/pubmed/20534021)

Question 9

A 35-year-old man comes to the physician with pain in his right knee and ankle for the last 2 weeks.  He also has bilateral eye pain, irritation, and blurry vision.  On further questioning, he reports burning urination.  Last month, the patient developed diarrhea after eating at a local restaurant.  The episode resolved spontaneously.  On examination, there is bilateral conjunctival injection.  He has tenderness in the lumbosacral area.  There is swelling and tenderness of the right knee joint and at the calcaneal tuberosity.  Urinalysis is normal. 
Which of the following is the most likely finding in this patient?

Accepted Answer

Explanation: 11ec2b69_c1d5_b027_8f63_83cdd115f385_MD0005_00 The spondyloarthropathies are a group of disorders characterized by sacroiliitis, peripheral asymmetric oligoarthritis, dactylitis, and enthesitis. Reactive arthritis (ReA) is a spondyloarthropathy that presents with peripheral asymmetric oligoarthritis, often associated with: Uveitis Urethritis Achilles enthesitis (pain at ligament/tendon insertion site) Dactylitis Keratoderma blennorrhagica Circinate balanitis ReA usually occurs after a genitourinary (eg, Chlamydia trachomatis) or gastrointestinal (eg, Salmonella, Shigella, Yersinia, Campylobacter) infection. No pathogen is usually isolated on synovial fluid cultures (Choice B), although signs of inflammation (elevated white blood cell count) are present on fluid analysis, and some studies have reported detection of Chlamydia DNA from synovial fluid by polymerase chain reaction. (Choice A) Antinuclear antibodies are nonspecific, and are positive in several autoimmune disorders, including lupus erythematosus and scleroderma. However, they are not a common finding in ReA. (Choice D) Only 30%-50% of patients with ReA are HLA-B27 positive. Testing for the HLA-B27 allele may assist with the diagnosis of ReA in indeterminate cases, but the marker is neither sensitive nor specific. (Choice E) No bony joint abnormalities are seen on x-ray imaging of affected peripheral joints in acute ReA. Calcaneal spurs may be seen in patients with enthesitis; in rare cases, sacroiliitis may be present with axial joint involvement. Educational objective: Reactive arthritis presents with asymmetric oligoarthritis, usually with a history of genitourinary or gastrointestinal infection. Enthesitis and dactylitis may also be seen. Extra-articular symptoms such as uveitis, urethritis, keratoderma blennorrhagica, and circinate balanitis occur in a minority of patients. Synovial fluid has a high white blood cell count but is culture negative. References: Diagnosis and classification of reactive arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/24418301)

Question 10

A 53-year-old man comes to the office due to progressive pain and stiffness in his hands for the past several months. The patient's symptoms are worse in the morning, and he has difficulty shaving or holding a coffee cup. The stiffness lasts for about 15 minutes and the pain gradually improves through the course of the day, but he often has to take acetaminophen for complete relief. For the past 3 weeks, he has experienced pain in the left knee, especially after prolonged rest. The patient has also had progressive fatigue over the past year. Medical history is notable for type 2 diabetes mellitus, which was diagnosed 6 months ago and is treated with metformin. He works as a sales representative and does not use tobacco, alcohol, or illicit drugs. Family history is remarkable for diabetes mellitus in his father. Temperature is 37.1 C (98.8 F), blood pressure is 126/78 mm Hg, and pulse is 82/min. Physical examination shows normal jugular venous pressure, clear lung fields, and normal heart sounds. The abdomen is nondistended, soft, and nontender. The liver is palpable 1 cm below the right costal margin. There is moderate swelling, warmth, and mild tenderness and decreased range of motion of the second and third metacarpophalangeal joints in both hands. A small effusion and tenderness of the left knee is present without any redness. Radiography of the hand reveals narrowing of the joint space, particularly of the second and third metacarpophalangeal joints, along with subchondral sclerosis, curved osteophytes, subchondral cysts, and osteopenia. An arthrocentesis of the knee is performed, and the synovial fluid analysis shows a leukocyte count of 20,000 cells/mm³ with 80% neutrophils. Gram stain shows no organisms, and polarization microscopy reveals positively birefringent rhomboid-shaped crystals. Which of the following is the most likely cause of this patient's joint pain?

Accepted Answer

Explanation: 11ec2b69_c1cd_4bac_8f63_db9c6a953380_MD0005_00 This patient has a polyarticular arthropathy associated with hepatomegaly and a personal and family history of diabetes. This constellation of findings is most consistent with hereditary hemochromatosis (HH), an autosomal recessive disorder characterized by iron deposition in a variety of tissues. Clinical manifestations usually start to appear in the fourth to sixth decade, with women presenting later due to menstrual iron loss. The arthropathy of HH shows significant variability. The second and third metacarpophalangeal joints are commonly affected, although it also frequently affects the knees, ankles, and shoulders. X-rays show subchondral cysts, sclerosis, osteopenia, and hook-like osteophytes. Joint aspiration can identify calcium pyrophosphate dihydrate (CPPD) crystals in approximately 50% of patients; these crystals have a rhomboid shape and positive birefringence under polarized light. CPPD deposition in HH can cause a chronic arthropathy or an acute inflammatory arthritis resembling gout (pseudogout). Treatment of HH involves serial phlebotomy to reduce iron stores, although joint symptoms usually do not improve with phlebotomy. (Choice A) Gout typically causes an episodic, acute inflammatory arthritis affecting the 1st metatarsophalangeal joint or knee. It is somewhat more common in patients with diabetes, but microscopy shows needle-shaped, negatively birefringent crystals. (Choice C) Osteoarthritis most commonly causes a slowly progressive arthropathy affecting the weight-bearing joints of the lower extremities and interphalangeal joints of the hands. Synovial fluid is typically bland, with <2000 cells/mm³, <50% neutrophils, and no crystals. (Choice D) Reactive arthritis presents with acute asymmetric arthritis and typically follows a gastrointestinal or genitourinary infection. The chronic nature of this patient's pain and crystals in the synovial fluid make reactive arthritis unlikely. (Choice E) Rheumatoid arthritis can cause a variety of joint manifestations, although the proximal interphalangeal, metacarpophalangeal, and wrist joints are most commonly affected. However, morning stiffness is usually more prolonged than in this patient, and, although rheumatoid arthritis causes an inflammatory synovial effusion, crystals are not present. Educational objective: The arthropathy of hereditary hemochromatosis commonly affects the second and third metacarpophalangeal joints, knees, ankles, and shoulders. Joint aspiration can identify calcium pyrophosphate dihydrate crystals in approximately 50% of patients. Treatment of hereditary hemochromatosis with phlebotomy does not usually improve the arthropathy. References: Hereditary hemochromatosis. (http://www.ncbi.nlm.nih.gov/pubmed/23418762)

Question 11

A 69-year-old man comes to the physician with bilateral shoulder and thigh pain for 2-3 months.  The pain is associated with prolonged morning stiffness.  He also complains of new-onset intermittent right-sided headaches and jaw pain.  His only other medical problem is hypertension.  The patient's medications include acetaminophen, lisinopril, and chlorthalidone.  Examination shows no significant neck, shoulder, or thigh tenderness.  He has normal passive range of motion at the shoulders but bilateral stiffness with active abduction.  Joints show no obvious synovitis.  Neurologic examination, including muscular strength, is normal.  Which of the following is the most appropriate screening test for this patient?

Accepted Answer

Explanation: 11ec2b69_c1cc_885b_8f63_bd42765541ac_MD0005_00 This patient with age >50 and subacute onset of diffuse muscle pain and stiffness has characteristic features of polymyalgia rheumatica (PMR). In PMR, the physical examination is frequently unremarkable, with little or no significant muscle or joint tenderness. Patients may have mild stiffness with active range of motion (ROM), but passive ROM is usually normal. Signs of inflammation in the joints are minimal to absent. This patient's headaches and jaw pain raise the possibility of associated giant cell arteritis (GCA), also known as temporal arteritis, which frequently accompanies PMR. Untreated GCA can lead to ischemic optic neuritis and vision loss and requires urgent evaluation. The diagnoses of PMR and GCA are primarily clinical, but erythrocyte sedimentation rate (ESR) should be obtained for confirmation and is highly sensitive. In patients age >50 with a new, localized headache or tenderness of the temporal artery, ESR >50 mm/h is 91% specific for GCA. If GCA is suspected, patients should be considered for an expedited temporal artery biopsy and should receive high-dose glucocorticoids (eg, prednisone 40-60 mg or more daily) while the evaluation is in progress. temporal artery biopsy (Choices A and B) Aldolase and creatine kinase are markers of myocyte injury and are used to rule out myopathies such as polymyositis. Polymyositis may occasionally mimic PMR, but it is generally characterized by muscle weakness with little or no associated pain. (Choice D) This patient has large muscle (shoulders and thighs) pain with subjective muscular stiffness, typical for PMR. By contrast, rheumatoid arthritis is characterized by pain and stiffness in the joints themselves, especially the small joints of the hands. Rheumatoid arthritis also usually has signs of synovitis at the time of presentation. (Choice E) Although hypothyroid myopathy can present with generalized muscle pain, it typically has significant associated weakness. Hypothyroid myopathy usually develops in the context of florid hypothyroidism with fatigue, weight gain, and cold intolerance. Educational objective: Polymyalgia rheumatica (PMR) affects patients age >50 and is characterized by pain in the large muscles of the shoulders and pelvic girdle. Headache, jaw pain, visual loss, or temporal tenderness suggests the presence of giant cell arteritis, which often accompanies PMR. The diagnosis of PMR is primarily clinical, and erythrocyte sedimentation rate should be obtained for confirmation. Patients with possible giant cell arteritis should receive high-dose glucocorticoids and be considered for temporal artery biopsy. References: The diagnosis and treatment of giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/23795218) Diagnosis and management of giant cell arteritis and polymyalgia rheumatica: challenges, controversies and practical tips. (http://www.ncbi.nlm.nih.gov/pubmed/23355687)

Question 12

A 53-year-old man comes to the office due to progressive pain and stiffness in his hands for the past several months. The patient's symptoms are worse in the morning, and he has difficulty shaving or holding a coffee cup. The stiffness lasts for about 15 minutes and the pain gradually improves through the course of the day, but he often has to take acetaminophen for complete relief. For the past 3 weeks, he has experienced pain in the left knee, especially after prolonged rest. The patient has also had progressive fatigue over the past year. Medical history is notable for type 2 diabetes mellitus, which was diagnosed 6 months ago and is treated with metformin. He works as a sales representative and does not use tobacco, alcohol, or illicit drugs. Family history is remarkable for diabetes mellitus in his father. Temperature is 37.1 C (98.8 F), blood pressure is 126/78 mm Hg, and pulse is 82/min. Physical examination shows normal jugular venous pressure, clear lung fields, and normal heart sounds. The abdomen is nondistended, soft, and nontender. The liver is palpable 1 cm below the right costal margin. There is moderate swelling, warmth, and mild tenderness and decreased range of motion of the second and third metacarpophalangeal joints in both hands. A small effusion and tenderness of the left knee is present without any redness. Radiography of the hand reveals narrowing of the joint space, particularly of the second and third metacarpophalangeal joints, along with subchondral sclerosis, curved osteophytes, subchondral cysts, and osteopenia. An arthrocentesis of the knee is performed, and the synovial fluid analysis shows a leukocyte count of 20,000 cells/mm³ with 80% neutrophils. Gram stain shows no organisms, and polarization microscopy reveals positively birefringent rhomboid-shaped crystals. Additional studies are performed and the diagnosis is established. If this patient's current condition remains untreated, he is at greatest risk for which of the following?

Accepted Answer

Explanation: The initial evaluation of hereditary hemochromatosis (HH) includes serum iron studies, which show increased levels of iron, ferritin, and transferrin saturation. The diagnosis can be confirmed with genetic testing for hemochromatosis-associated mutations (eg, HFE). Long-term management of HH involves serial phlebotomy to deplete excess iron stores. Due to the associated chronic liver disease, patients with HH have an approximately 20-fold increased risk for hepatocellular cancer, accounting for 30%-45% of deaths in patients with HH. Treatment of HH with phlebotomy can lead to improved hepatocellular function, with reduced progression to cirrhosis and an associated reduction in the risk of hepatocellular carcinoma. Phlebotomy also typically alleviates fatigue, reduces skin pigmentation, lowers the risk of heart failure, and may improve glycemic control. (Choice A) Myeloproliferative disorders (eg, polycythemia vera, idiopathic myelofibrosis) can cause hepatosplenomegaly due to hepatic congestion and extramedullary hematopoiesis. They can also cause gouty arthropathy due to increased red cell turnover. However, these disorders are not associated with calcium pyrophosphate dihydrate deposition. (Choice B) Compression radiculopathy is a potential complication of spinal stenosis, which typically presents in patients age >60 and is characterized by lower extremity pain, numbness, and weakness. (Choice D) Interstitial lung disease is a potential extraarticular manifestation of rheumatoid arthritis but is not seen in HH. (Choice E) Uric acid nephrolithiasis can occur in patients with gout, which typically causes an episodic, acute inflammatory arthritis affecting the 1st metatarsophalangeal joint or knee. HH is not associated with nephrolithiasis. Educational objective: Due to the associated chronic liver disease, patients with hereditary hemochromatosis have an increased risk for hepatocellular cancer. Treatment with phlebotomy can lead to improved hepatocellular function, with reduced progression to cirrhosis and an associated reduction in the risk of hepatocellular carcinoma.

Question 13

A 22-year-old soccer player comes to the emergency department with knee pain.  During her practice earlier that day she tried to run around another player on the right when she felt a popping sensation in her right knee followed by pain and rapid swelling.  The patient has no other injury or blow to the knee.  She has had no significant prior knee injuries.  Her past medical history is unremarkable.  On physical examination, the right knee is significantly swollen and tender.  Ambulation appears awkward and she hesitates to bear weight on the right leg.  Aspiration of the knee yields grossly bloody joint fluid.  Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: 11ec2b69_c1d1_6a5f_8f63_490a5015983a_MD0005_00 Injuries to the anterior cruciate ligament (ACL) are common in young athletes, especially women who participate in noncontact sports requiring rapid direction changes or pivots on the lower extremity (eg, soccer, basketball, tennis). ACL tears can also occur in high-contact sports or injuries involving a blow to the knee or significant twisting force. Patients with partial- or full-thickness tears of the ACL complain of a "popping" sensation in the knee at the time of injury, followed by development of rapid-onset hemarthrosis and a feeling of joint instability with weight bearing. anterior cruciate ligament (ACL) Patients with an ACL tear will show laxity at the knee with the tibia able to be pulled forward relative to the femur. Two such maneuvers - the Lachman test and the anterior drawer test - are highly sensitive and specific for ACL injuries. The diagnosis is usually confirmed on magnetic resonance imaging. (Choice B) Medial collateral ligament (MCL) tears commonly occur following injuries in which the knee is struck from the lateral side with the foot planted. MCL injuries will usually show tenderness at the medial knee along the joint line, and there may be laxity when the lower leg is gently forced into abduction with the knee stationary (valgus stress test). However, MCL injuries are not typically associated with significant hemarthrosis unless there is a concurrent ACL injury. Medial collateral ligament (MCL) (Choice C) Patients with a meniscal tear may report a subacute or chronic locking or catching sensation in the knee but often do not appreciate the extent of the injury when it occurs. Effusions, when they occur, typically develop slowly and hemarthrosis is rare. (Choice D) Patellofemoral pain syndrome is associated with chronic overuse rather than acute trauma. Patients report pain over the anterior knee, which can be reproduced by extending the knee while compressing the patella (patellofemoral compression test). Although there may be some degree of swelling at the anterior knee, true knee effusions and hemarthrosis are not seen. Patellofemoral pain syndrome (Choice E) Rupture of a popliteal cyst (Baker cyst) may cause posterior knee pain. This is a common condition in older patients (associated with osteoarthritis of the knee) but is uncommon in young adults. Patients may have pain and swelling at the posterior knee and calf resembling deep venous thrombosis. Knee effusions and hemarthrosis are not seen. Educational objective: Patients with anterior cruciate ligament injuries complain of a "popping" sensation in the knee at the time of injury, followed by development of rapid-onset hemarthrosis and a feeling of joint instability with weight bearing. Examination findings include laxity of anterior motion of the tibia relative to the femur; the diagnosis is confirmed with magnetic resonance imaging. References: Anterior cruciate ligament rupture: differences between males and females. (http://www.ncbi.nlm.nih.gov/pubmed/23281470) Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. (http://www.ncbi.nlm.nih.gov/pubmed/22695402)

Question 14

A 25-year-old male is brought to the emergency room after a fight in a bar.  He was attacked with a knife, and in an attempt to save himself, he grabbed the knife in his right hand.  On examination, a deep lacerated wound is found on the palmar surface of the right hand, extending from the index finger at the metacarpophalangeal (MCP) joint through the proximal phalanges of the middle and ring fingers to the middle phalanx of the little finger.  He is unable to flex the distal phalanges of these fingers.  Which of the following structures is most likely to be injured in his hand?

Accepted Answer

Explanation: Digital arteries, nerves, and veins run on the sides, while the flexor tendons run on the anterior surface of the phalanges. Attempting to grab a knife with a hand is likely to injure the tendons than arteries, veins, or nerves due to their relative, vulnerable, anatomic location. Educational Objective: In digital injuries, tendons are more likely to be injured than arteries, veins, or nerves due to their relative, vulnerable, anatomic location.

Question 15

A 39-month-old boy is brought to the office due to fever.  He has had fever spikes the past 5 days that have not improved with oral acetaminophen.  He has been very cranky and his appetite has decreased.  The patient has had a slightly stuffy nose but no cough, emesis, or diarrhea.  He has also developed a bad diaper rash that has not improved with topical barrier ointments.  The patient does not attend day care, and there are no sick contacts at home.  Medical history is significant for an episode of otitis media last year and occasional upper respiratory infections, but he has had no chronic medical illnesses.  Immunizations are up to date, and the patient takes no medications.  Temperature is 40 C (104 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 18/min.  On physical examination, the child is awake and alert but very cranky.  The head is normocephalic and atraumatic.  The conjunctivae are injected without discharge bilaterally, and the pupils are equal and reactive to light and accommodation.  There is scant nasal congestion.  The lips, tongue, and oral mucosa are erythematous, but there is no pharyngeal erythema or exudate.  Neck is supple without lymphadenopathy.  S1 and S2 are normal without murmurs; lungs are clear to auscultation bilaterally.  Abdomen is soft, nontender, and nondistended, without organomegaly.  There is nontender erythema and peeling of the skin in the perineum and inguinal folds and several erythematous, blanching macules on the trunk; there are no other skin lesions. The patient is sent home but returns to the office a day later due to worsening symptoms.  His fever has persisted and he remains extremely cranky.  His mother states that his rash has worsened and he now looks "swollen."  Temperature is 39.4 C (103 F), blood pressure is 102/74 mm Hg, pulse is 118/min, and respirations are 18/min.  On physical examination, he remains awake and alert but irritable.  The lips now appear cracked.  The neck is supple without lymphadenopathy.  S1 and S2 are normal without murmurs, lungs are clear to auscultation bilaterally, and there is no abdominal tenderness or organomegaly.  There is a diffuse erythematous, blanching, maculopapular rash on the patient's trunk, abdomen, and extremities, with increased peeling in the perianal and inguinal areas.  Edema is present in the hands and feet.  Peripheral pulses are present and symmetrical bilaterally; capillary refill is normal.  What is the most important next step in the management of this patient?

Accepted Answer

Explanation: 11ec2b69_c1cf_6e8e_8f63_574da27f973b_MD0005_00 Besides fever, the patient now fulfills 4 diagnostic criteria for Kawasaki disease (KD): rash, conjunctivitis, mucositis, and extremity edema/erythema. Therefore, a definitive diagnosis can be made. (The fifth diagnostic criterion, lymphadenopathy, is the least frequently observed.) The first step in treatment is administration of intravenous immunoglobulin (IVIg). It is administered in conjunction with aspirin, which reduces systemic inflammation. Although its exact mechanism of action in KD is unknown, the use of IVIg greatly improves morbidity and mortality and significantly decreases the risk of cardiac sequelae. (Choice A) Intravenous acyclovir is used for herpes encephalitis, which can cause fever, irritability, and cutaneous lesions. However, this condition often presents with focal neurologic symptoms (eg, seizures), is primarily associated with a vesicular (rather than a desquamative maculopapular) rash, and does not cause conjunctivitis and extremity edema. Although a viral etiology for KD has been suggested, none has been determined, and antivirals do not provide any benefit. (Choices C and E) Corticosteroids can treat both severe juvenile idiopathic arthritis, which can cause spiking fevers and rash but would cause arthritis, and systemic lupus erythematosus, which can cause neurologic symptoms but would be associated with other findings (eg, malar rash, oral ulcers). Neither is associated with conjunctivitis or edema. In children with KD, corticosteroids and plasmapheresis are sometimes used to reduce systemic inflammation in those who fail to respond to IVIg, but these treatments have limited clinical benefit. (Choice D) Broad-spectrum antibiotics are appropriate in the setting of serious bacterial infections or sepsis. Despite having fevers for several days, this patient has normal blood pressure and heart rate, no lethargy, and no delayed capillary refill, making bacterial infection unlikely. Educational objective: First-line treatment for Kawasaki disease includes intravenous immunoglobulin (which reduces the risk of cardiac sequelae by an unknown mechanism of action) and aspirin. References: Evaluation of Kawasaki disease risk-scoring systems for intravenous immunoglobulin resistance. (http://www.ncbi.nlm.nih.gov/pubmed/21168857)

Question 16

A 35-year-old man comes to the physician with pain in his right knee and ankle for the last 2 weeks.  He also has bilateral eye pain, irritation, and blurry vision.  On further questioning, he reports burning urination.  Last month, the patient developed diarrhea after eating at a local restaurant.  The episode resolved spontaneously.  On examination, there is bilateral conjunctival injection.  He has tenderness in the lumbosacral area.  There is swelling and tenderness of the right knee joint and at the calcaneal tuberosity.  Urinalysis is normal. Which of the following patients is most likely to develop reactive arthritis?

Accepted Answer

Explanation: The risk of reactive arthritis (ReA) after Chlamydia infection is about 4%-8% in the general population. However, the risk is approximately 20% in patients who are HLA-B27 positive. The cause of this increased risk is not entirely clear. Defective antigen presentation through class I HLA molecules may play a role. Conversely, only 30%-50% of patients with ReA are HLA-B27 positive, suggesting a complex etiology. (Choice B) HLA-B27 positivity alone is a predisposing factor to the development of ReA. Infection with a pathogen likely to trigger such an inflammatory response is necessary for development of the disease. (Choices C and D) Patients with Chlamydia or Salmonella infection in the absence of HLA-B27 have a lower incidence of ReA than patients who are genetically predisposed. Education objective: The incidence of reactive arthritis after infection with Chlamydia or a predisposing gram-negative rod is higher in individuals who are HLA-B27 positive. References: Novel HLA-B27-restricted epitopes from Chlamydia trachomatis generated upon endogenous processing of bacterial proteins suggest a role of molecular mimicry in reactive arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/23867464) Endogenous processing and presentation of T-cell epitopes from Chlamydia trachomatis with relevance in HLA-B27-associated reactive arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/19443418)

Question 17

A 60-year-old man comes to the physician for preoperative evaluation prior to right total knee replacement.  He continues to smoke half a pack of cigarettes daily and has a 25-pack-year history.  He reports mild shortness of breath when walking 4 blocks and up 2 flights of stairs and thinks that his dyspnea may have progressed slowly over the past 2 years.  He uses a cane and admits to walking slowly due to knee pain.  The patient has never been hospitalized but he gets bronchitis every winter that usually responds well to rescue albuterol.  He was diagnosed with asthma and mild emphysema 4 years ago and takes tiotropium and fluticasone/salmeterol daily.  His other medical problems include hypertension, degenerative joint disease, and anemia.  The patient takes hydrochlorothiazide and as-needed tramadol for pain.  His temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is 80/min, and respirations are 16/min and unlabored.  Oxygen saturation is 95% on room air.  General physical examination (including lung examination) is unremarkable. Laboratory study results are as follows:
 Which of the following additional studies should be performed to make an appropriate risk assessment prior to the planned surgery?

Accepted Answer

Explanation: 11ec2b69_c1d5_3af6_8f63_297b97edc0c7_MD0005_00 Postoperative pulmonary complications are common and contribute to patient morbidity, mortality, and hospital length of stay. There are multiple patient and procedural risk factors for complications (Table). In general, the risk of pulmonary complications is inversely related to the distance of the surgical site from the diaphragm. Studies have shown that smoking cessation at least 4 weeks prior to surgery decreases risk of postoperative pulmonary complications. Postoperative pulmonary complications (Choices A and C) The 6-minute walk test and cardiopulmonary exercise testing are useful risk assessment tools in patients undergoing lung resection surgery or various forms of cardiac surgery. There are no data to support their routine use in preoperative evaluations for general/orthopedic surgery. (Choice B) Preoperative arterial blood gas analyses are not routinely helpful as studies have failed to show hypercapnia or hypoxemia as independent risk factors for postoperative pulmonary complications. (Choice E) Preoperative pulmonary function tests (PFTs) are recommended: Prior to lung resection to estimate postoperative lung volumes To optimize preoperative chronic obstructive pulmonary disease (COPD) control if baseline clinical status cannot be determined To evaluate the cause of dyspnea or exercise intolerance (eg, cardiac disease vs deconditioning) This patient is able to complete at least 4 metabolic equivalents (climbing a flight of stairs, demonstrating good functional status). His lung examination and oxygen saturation are within normal limits. As a result, he does not need preoperative PFTs. Educational objective: Smoking cessation at least 4 weeks prior to surgery decreases risk of postoperative pulmonary complications. Routine preoperative pulmonary function tests or arterial blood gas analyses do not help predict or change postoperative complications. References: Postoperative pulmonary complications: an update on risk assessment and reduction. (http://www.ncbi.nlm.nih.gov/pubmed/19880838) Development and validation of a risk calculator predicting postoperative respiratory failure. (http://www.ncbi.nlm.nih.gov/pubmed/21757571) Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22187226)

Question 18

A 65-year-old woman comes to the office due to osteoporosis that was recently diagnosed on a screening DXA.  She feels well, eats a balanced diet, and gets regular exercise.  Medical history is unremarkable, but the patient has a family history of osteoporosis in her mother and sister.  Vital signs and physical examination are normal.  Complete blood count and serum chemistry panel are normal.  DXA reveals a T-score of −2.7 at the lumbar spine.  The patient says, "I am interested in taking alendronate to prevent fractures.  My sister takes it, and it kept her osteoporosis from getting worse."  Which of the following tests should be performed prior to initiating this medication?

Accepted Answer

Explanation: 11ec2b69_c1d3_3f22_8f63_7d88c93e7272_MD0005_00 This patient has postmenopausal osteoporosis, confirmed with a DXA T-score of ≤−2.5. Most secondary causes of osteoporosis can be identified based on history, physical examination, and initial basic laboratory studies (eg, complete blood count, serum chemistry panel). Initial management should include weight-bearing exercise, avoidance of smoking and excessive alcohol, and adequate intake of calcium (≥1,200 mg/day) and vitamin D (≥800 IU/day), using supplements as necessary. In addition, osteoporosis diagnosed using DXA or a confirmed osteoporotic fracture warrants pharmacologic antiresorptive therapy; bisphosphonates (eg, alendronate, risedronate) are preferred for most patients. However, bisphosphates can cause hypocalcemia due to decreased bone resorption; this effect is more prominent with intravenous formulations but can occasionally occur with oral bisphosphonates. Therefore, a normal serum calcium level should be confirmed prior to treatment. In addition, vitamin D deficiency can increase the risk of hypocalcemia, and so total body stores should be assessed with a serum 25-hydroxyvitamin D level. (Choice B) Oral bisphosphonates carry a risk of medication-induced esophagitis. The risk can be minimized by taking the medication with a full glass of water and remaining upright for 30 minutes. Esophagography or endoscopy is warranted if symptoms develop but is not needed prior to treatment. (Choice C) Bisphosphonates are associated with a risk of osteonecrosis of the jaw, especially with high-dose intravenous agents. However, mandibular and maxillary imaging is needed only if symptoms develop. (Choice D) Cushing syndrome can cause secondary osteoporosis. However, the morning cortisol is often normal in patients with Cushing syndrome; nocturnal salivary cortisol, 24-hour urine cortisol, and an overnight dexamethasone suppression test are better screening tests. Although adrenal disorders should be considered in patients with premenopausal osteoporosis, testing is not routinely needed for postmenopausal women. (Choice E) Primary hyperparathyroidism is associated with accelerated bone loss. However, most patients have baseline hypercalcemia; testing with a parathyroid hormone level is not needed if serum calcium is normal. Educational objective: Bisphosphates can cause hypocalcemia due to decreased bone resorption. A normal serum calcium level should be confirmed prior to initiation of therapy. In addition, vitamin D deficiency can increase the risk of hypocalcemia; total body vitamin D stores should be assessed with a serum 25-hydroxyvitamin D level. References: 25 hydroxyvitamin D serum levels influence adequate response to bisphosphonate treatment in postmenopausal osteoporosis. (http://www.ncbi.nlm.nih.gov/pubmed/22487299)

Question 19

A 19-year-old man is brought to the emergency department after a major motor vehicle accident.  He was an unrestrained driver and confesses to consuming a moderate amount of alcohol several hours earlier.  He did not lose consciousness.  The patient's blood pressure is 150/95 mm Hg and heart rate is 110/min.  His respirations are shallow and rapid.  He is able to move his extremities and obey commands.  His pupils are equal and reactive to light.  Inspection shows anterior chest bruises and peripheral cyanosis.  Neck veins are flat and the trachea is midline.  Breath sounds are heard symmetrically over both lung fields.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_c1d6_2558_8f63_518f0ce2a72c_MD0005_00 This patient has tachypnea and tachycardia, with shallow breathing, anterior chest bruises, and signs of inadequate ventilation (cyanosis); together these suggest possible occult flail chest. Flail chest is usually the result of double rib fractures in more than one site, with paradoxical motion of the free segment of the chest wall during inspiration. It is often accompanied by muscular spasm and pain as well as pulmonary contusions, which lead to hypoxemia and increased work of breathing. The paradoxical or segmental chest wall movement will typically make the diagnosis of flail chest obvious. However, in many cases, gross findings may be absent due to muscle splinting, shallow breathing, or mechanical ventilation. Uncomplicated cases of flail chest may be managed nonoperatively with supplemental oxygen, noninvasive positive-pressure ventilation, and medications for pain control. However, mechanical ventilation and surgical stabilization may be necessary in more severe cases. (Choice A) Cardiac contusion, especially if massive, may lead to hemodynamic instability; however, disordered breathing (rapid, shallow breathing) with stable vital signs would not be typical. (Choice B) Cardiac tamponade is characterized by hypotension and neck vein distension. (Choices D and E) Pneumothorax and massive hemothorax are typically associated with hypotension, tracheal deviation, and a unilateral decrease in breath sounds. Educational objective: Flail chest is the result of double rib fractures in more than one site, resulting in paradoxical movement of the flail segment during inspiration. The diagnosis may be obvious on examination, but many cases are occult. Management includes supplemental oxygen, pain control (invasive or noninvasive), positive-pressure ventilation, and surgical stabilization. References: The management of flail chest. (http://www.ncbi.nlm.nih.gov/pubmed/17650694)

Question 20

A 39-month-old boy is brought to the office due to fever.  He has had fever spikes the past 5 days that have not improved with oral acetaminophen.  He has been very cranky and his appetite has decreased.  The patient has had a slightly stuffy nose but no cough, emesis, or diarrhea.  He has also developed a bad diaper rash that has not improved with topical barrier ointments.  The patient does not attend day care, and there are no sick contacts at home.  Medical history is significant for an episode of otitis media last year and occasional upper respiratory infections, but he has had no chronic medical illnesses.  Immunizations are up to date, and the patient takes no medications.  Temperature is 40 C (104 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 18/min.  On physical examination, the child is awake and alert but very cranky.  The head is normocephalic and atraumatic.  The conjunctivae are injected without discharge bilaterally, and the pupils are equal and reactive to light and accommodation.  There is scant nasal congestion.  The lips, tongue, and oral mucosa are erythematous, but there is no pharyngeal erythema or exudate.  Neck is supple without lymphadenopathy.  S1 and S2 are normal without murmurs; lungs are clear to auscultation bilaterally.  Abdomen is soft, nontender, and nondistended, without organomegaly.  There is nontender erythema and peeling of the skin in the perineum and inguinal folds and several erythematous, blanching macules on the trunk; there are no other skin lesions. The correct diagnosis is made and the appropriate treatment is initiated.  What additional assessment is required in the management of this patient?

Accepted Answer

Explanation: All children diagnosed with Kawasaki disease (KD) should have an echocardiogram performed at baseline. Although coronary artery aneurysms usually develop after the 10th day of fever and are often not evident during acute illness, some degree of coronary artery dilation and myocardial dysfunction may be present at diagnosis. Aneurysms may later develop even in patients who receive appropriate treatment, so follow-up studies are indicated at 2 and 6 weeks after treatment, even if the initial study is normal. Due to the high risk of sequelae in patients with KD, it would be inappropriate to omit echocardiography even in the absence of any cardiac complaints (eg, chest pain, difficulty breathing) (Choice D). (Choice A) An antinuclear antibody assay is helpful in screening for systemic lupus erythematosus, which is not associated with conjunctivitis, edema, or mucositis. Although KD is an inflammatory vasculitic condition, the antinuclear antibody is not usually positive and is not helpful in diagnosis. (Choice C) KD is sometimes confused with meningitis, as both can present with high fever and crankiness/irritability, and cerebrospinal fluid pleocytosis may be seen in both cases. However, meningitis is not associated with edema, conjunctivitis, or mucositis; and if a patient meets KD diagnostic criteria, lumbar puncture is an unnecessary and invasive procedure. (Choice E) The patient's erythematous, generalized, maculopapular rash with accentuation in the perineal and inguinal regions is typical of rashes seen in KD. Therefore, unless it fails to resolve after the patient has recovered, skin biopsy is not indicated. Educational objective: Children with Kawasaki disease are at risk for the development of coronary artery aneurysms even after appropriate treatment. They should have an echocardiogram performed at the time of diagnosis, and at 2 and 6 weeks after completion of treatment. References: Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. (http://www.ncbi.nlm.nih.gov/pubmed/15574639) Kawasaki disease. (http://www.ncbi.nlm.nih.gov/pubmed/18765469)

Exam 2: Foundations of Independent Practice