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6 A 65-year-old man presents w ith right shoulder pain and w eakness after falling on his outstretched hand. The
7 pain is w orse w hen he tries to position his arm above the shoulder level or w hen he pulls or pushes. He also
8 complains of pain w hen he lies on the affected shoulder. He has a 40-pack-year history of cigarette
9 smoking. His father died of multiple m yeloma . His vital signs are w ithin normal limits. Examination show s
10 limitation of mid arc abduction and external rotation that does not improve after lidocaine injection. There is no
11 sw elling, redness or w armth of the joint. Radial pulse is normal. Muscle tone and bulk is w ithin normal
12 limits. W hich of the follow ing w ould be most helpful in confirming the patient's diagnosis?
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15 A. X-ray shoulder [23%]
16 B. Chest X-ray [2%]
17 C. Bone marrow biopsy [1 %]
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19 .; D. MRI of the shoulder [69%]
20 E . MRI of the cervical spine [2%]
21 F. Aspiration of the joint [1 %]
22
23 G. Bone scan [1 %]
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25 Explanation: User ld:
26
?.7 This patient is most likely suffering from a rotator cuff tear. This condition presents w ith shoulder pain and
18 w eakness. The pain is aggravated by pushing, pulling, lifting the arm above the head, and lying on the
19 affected shoulder. Rotator cuff tears may occur as the end result of chronic rotator cuff tendonitis or as a
20 result of trauma . The classic presentation of trauma-induced rotator cuff tear involves a fall on an
21 outstretched hand. Limitation of mid arc abduction and external rotation are common findings on exam . The
22 fact that this patient's limitation of movement remains after lidocaine injection provides strong support for a
23 diagnosis of rotator cuff tear. W hile rotator cuff tendinitis may present w ith similar pain and limitation of
24 movement, the symptoms of rotator cuff tendinitis resolve w ith lidocaine injection. An MRI of the shoulder is
25 the test of choice for diagnosing a rotator cuff tear.
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?.7 (Choice A) An x-ray of the shoulder is an inexpensive w ay of diagnosing fractures, dislocations, and calcific
18 tendonitis. How ever, MRI is superior at evaluating soft tissue structures of the shoulder.
19
20 (Choice B) With this patient's extensive smoking history, a lung cancer involving the brachial plexus could
cause shoulder pain . How ever, brachial plexus damage is not corroborated by this patient's exam.
18
19 (Choice C) Though this patient has a family history of multiple m yeloma, his clinical picture is not consistent
20 w ith this diagnosis. Multiple m yeloma typically presents w ith pain in the spine, ribs, or back. It may be
21 accompanied by hypercalcemia and anemia . Bone marrow biopsy is a poor choice to evaluate this patient's
22 shoulder complaints.
23
24 (Choice E) MRI of the spine w ould help to identify the cause of cervical radiculopathy. This condition may
25 result from disc herniation (osteophytes) and presents w ith arm w eakness, paresthesias, and neck pain .
26
27 (Choice F) Aspiration of synovial fluid is useful for identifying septic and crystal-induced arthritis. The
28 absence of sw elling, w armth and fever make these diagnoses unlikely.
29
(Choice G) Bone scans are used to diagnose osteomyelitis, fractures, and metastatic disease. This patient's
30
history and physical is not consistent w ith one of these diagnoses.
31
32 Educational objective:
33 Rotator cuff tears result from chronic rotator cuff tendonitis and shoulder trauma . Shoulder pain and
34 w eakness w hen lifting the arm above the head is suggestive of rotator cuff pathology. A lidocaine injection
35 ameliorates the pain and w eakness of rotator cuff tendonitis, w hile it does not improve symptoms of a rotator
36 cuff tear. MRI is excellent at visualizing soft tissue structures and is the study of choice for diagnosing rotator
37 cuff tears.
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6 A 52-year-old man comes to the physician with a long history of joint pain . The patient has pain and stiffness
7 of the small joints of his hands. The symptoms are w orse in the morning and can last several hours. He also
8 has digit sw elling. The patient's hands are shown in the image below:
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Displayed v;ith penuission fum Spring Healtbcare Ltd. Copyrigb12005 by Current Medicine
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Which of the following is the most likely diagnosis?
21
22
23 A. Crystalline arthritis [3%1
24 B. Dermatomyositis [8%1
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C. Enteropathic arthritis [1 %1
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?.7 D. Neuropathic arthropathy [0% 1
18 E. Osteoarthritis [4%1
19
.; F. Psoriatic arthritis [73% 1
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21 G. Rheumatoid arthritis [1 0%1
22 H. Sarcoidosis [1 %1
23
24
25 Explanation: User ld:
26
?.7
18 Clinical features of psoriatic arthritis
19
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21 DIP joints
22 Asymmetric oligoarthritis
23 Arthritis Symmetric polyarthritis, similar to rheumatoid arthritis
24 Arthritis mutilans (deforming and destructive arthritis)
25 Spondyloarthritides (sacroiliitis and spondylitis)
26
?.7
18 Enthesitis (inflammation at tendon insertion site to bone)
19 Soft t issue
Dactylitis ("sausage digits") of toe or finger
20 & nail
involvement Nail pitting & onycholysis
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22
Swelling of the hands or feet with pitting edema
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24 Arthritis precedes skin disease in 15% of patients
25 Skin lesions Skin lesions are present but not yet diagnosed in 15%
26
of patients
?.7
18 @UWo~d
19
20 The clinical history and image provided are most consistent with psoriatic arthritis. Psoriatic arthritis occurs
21 in 5%-30% of patients who have psoriasis. Psoriatic arthritis can present with many different patterns, but the
22 classic presentation involves the distal interphalangeal (DIP) joints. Morning stiffness is present, as it is
23 in all inflammatory arthritides. Deformity of involved joints, dactylitis ("sausage digit," a diffusely sw ollen
24 finger), and nail involvement are common . This patient show s all of the classic signs: All of the fingers
25 (particularly the left index finger) are sw ollen, consistent with dactylitis; many of the nails show pitting and
26 onycholysis (separation of nail bed); and the DIP joints are prominently involved. Furthermore, w ell-
?.7 demarcated red plaques with silvery scaling- the classic lesions of psoriasis- are seen on the dorsum of
18 each hand. Current treatment options for psoriatic arthritis include nonsteroidal anti-inflammatory agents,
19 methotrexate, and anti-tumor necrosis factor agents.
20
21 (Choice A) Nail changes do not accompany crystalline arthritis (gout and pseudogout). Cutaneous deposits
22 of monosodium urate occur in chronic gout. These lesions, known as tophi, most commonly occur over
23 joints and the helix of the ear, and they may ulcerate.
I
24
25 (Choice B) Dermatomyositis can present with Gottron's papules (violaceous plaques, slightly scaly)
26 overlying the metacarpophalangeal (MCP) joints, which at times can look similar to psoriasis. How ever,
?.7 dermatomyositis is not associated with dactylitis or nail changes (onycholysis or nail pitting).
18
19 (Choice C) Enteropathic arthritis occurs in 10%-20% of patients with Crohn disease and ulcerative colitis. It
20 most often affects the low er extremities and sacroiliac joints and tends to w ax and w ane with the symptoms
21 of bow el disease. These patients have prominent gastrointestinal symptoms and other extraintestinal
22 manifestations of inflammatory bow el disease.
18 (Choice D) Neuropathic arthropathy (Charcot joint) most commonly affects the low er limbs. Most cases
19 occur with diabetes, but syphilis and alcoholism are other causes. Peripheral neuropathy is believed to result
20 in decreased proprioception, which leads to frequent trauma and eventual destruction of the joint.
21
22 (Choice E) Osteoarthritis often affects the DIP joints. How ever, the pain of osteoarthritis is worse with
23 activity and improves with rest (the opposite of this patient's symptoms). Osteoarthritis is noninflammatory,
24 and dactylitis should not occur.
25
26 (Choice G) Rheumatoid arthritis also presents with morning stiffness. The MCP and proximal
27 interphalangeal joints are prominently involved, whereas the DIP joints classically are not. Dactylitis and nail
28 involvement are also not expected in rheumatoid arthritis.
29
(Choice H) Polyarthritis affecting the ankles and knees sometimes occurs in sarcoidosis. Sarcoidosis
30
causes protean cutaneous manifestations, the most common of which is erythema nodosum. These
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patients also often have cough, chest pain, and dyspnea .
32
33 Educational objective:
34 Psoriatic arthritis occurs in 5%-30% of patients with psoriasis. The classic presentation involves the distal
35 interphalangeal joints. Morning stiffness, deformity, dactylitis \'sausage digit"), and nail involvement are
36 common . Current treatment options for psoriatic arthritis include nonsteroidal anti-inflammatory agents,
37 methotrexate, and anti-tumor necrosis factor agents.
38
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6 A 51-year-old man complains of difficulty w alking and mild right-sided foot pain for the past several w eeks.
7 The patient's medical history is significant for type 1 diabetes mellitus, hypertension, and
8 hypercholesterolemia. Physical examination show s a significantly deformed right foot and a mildly deformed
9 left foot. X-rays of the right toot suggest effusions in several of the tarsometatarsal joints, large osteophytes,
10 and several extra-articular bone fragments. Which of the following is the most likely cause of this patient's
11 complaints?
12
13
14 A. Avascular necrosis [7%]
15 B. Bacterial infection [3%]
16 C. Bone demineralization [18%]
17
18 D. Hyperuricemia [12%]
19 ~ E. Nerve damage [45%]
20 F. Rheumatoid arthritis [1 6%]
21
22
23 Explanation: User ld:
24
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26 Charcot joint (neurogenic arthropathy)
?.7
18 Vitamin 812 deficiency
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Diabetes
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21 Associated Peripheral nerve damage
22 conditions Spinal cord injury
23 Syringomyelia
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25 Tabes dorsalis (tertiary syphilis)
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?,7 Deformed joints
18
Lacking/decreased sensation (proprioception, pain,
19
20 temperature) with loss of neurologic input
21 Clinical Arthritis or arthropathy
22 manifestations
Mild pain
23
24 Fractures (may be unsuspected by patient)
25 Degenerative joint disease & loose bodies on joint imaging
26
?.7
18 Treat underlying condition
19
Mechanical devices (assist in weight bearing, decrease
20 Management
further trauma)
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22 X-rays (if trauma is present)
23
24 @USMLEWorld, LLC
25
This patient has neurogenic arthropathy (Charcot joint) due to diabetes. Pathogenesis involves decreased
26
?,7 proprioception, pain, and temperature perception, which can occur due to diabetes, peripheral nerve
18 damage, syringomyelia, spinal cord injury, vitamin B 12 deficiency, or tabes dorsalis. As normal neurologic
input is lost, patients unknowingly traumatize their w eight-bearing joints. This causes secondary
19
degenerative joint disease, joint deformation, and functional limitation. X-rays will reveal loss of cartilage,
20
osteophyte development, and loose bodies. In diabetes, vasculopathy also contributes to disease
21
pathogenesis. Associated pain is typically mild. Management of a Charcot joint involves treating the
22
23 underlying disease and providing mechanical devices (eg, special shoes) to assist in w eight bearing and
decrease further trauma.
24
25
(Choice A) Avascular necrosis refers to bone destruction due to poor vascular supply. It is a complication of
26
?.7 corticosteroid use, trauma, systemic lupus erythematosus, sickle cell disease, and a number of other
processes. It generally affects the proximal and distal femur with pain as the main symptom.
18
19 (Choice B) Bacterial infection is an important cause of acute monoarticular arthritis (septic joint). ~ is
20 exquisitely painful and rapidly destructive. Fever may be present. An x-ray will reveal joint destruction but not
21 osteophytes or loose bodies. A septic joint is diagnosed by joint fluid aspiration.
18
19 (Choice C) Bone demineralization is the hallmark of osteoporosis. This disease predisposes patients to
20 pathologic fractures, particularly of the hip and vertebrae. How ever, it does not cause joint destruction.
21
22 (Choice D) Gout results from uric acid deposition within joints. It is exquisitely painful and generally affects
23 the great toes, ankles, wrists, and elbows. X-rays of joints affected by chronic gout reveal punched-out
24 erosions with an overhanging rim of cortical bone known as a "rat bite" lesion.
25
26 (Choice F) Rheumatoid arthritis is a common cause of polyarticular inflammatory arthritis. It typically affects
27 the hands, w rists, feet, and ankles, generally in a symmetric fashion . X-rays of patients with long-standing,
28 poorly controlled disease will reveal periarticular osteoporosis, joint erosions, and joint space narrowing.
29
Educational objective:
30
Neurogenic arthropathy (Charcot joint) is a complication of neuropathy and repeated joint trauma. It affects
31
w eight-bearing joints and manifests with functional limitation, deformity, and degenerative joint disease and
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loose bodies on joint imaging.
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34
35 References:
36 1. Charcot neuroarthropathy: An often overlooked complication of diabetes.
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6 A 24-year-old w oman comes to the physician due to w eakness, facial rash, low -grade fever, and joint pain.
7 She has pain and sw elling of the hand joints and pain in the knees. Her mother has rheumatoid arthritis. The
8 patient's blood pressure is 145/90 mm Hg and her heart rate is 90/min. Her hematocrit is 40% and
9 erythrocyte sedimentation rate is 63 mm/h. Urinalysis is 2+ for protein . Which of the following is the best
10 statement about this patient's joint symptoms?
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A Bone resorption of the distal phalanges may result [5%]
13
14 B. Cartilage degradation and muscle atrophy cause deformity [11 %]
15 C. Excessive bony growth is characteristic [5%]
16
~ D. Permanent deformity is uncommon [58%]
17
18 v E. Subluxation and tendon damage cause permanent deformity [21 %]
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20
Explanation: User ld:
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23 Manifestations of systemic lupus erythematosus
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26 Constitutional: Fever, fatigue & weight loss
?.7 Symmetric, migratory arthritis
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19 Skin: Butterfly rash & photosensitivity
Clinical
20 sym ptoms Serositis: Pleurisy, pericarditis & peritonitis
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22 Thromboembolic events (due to vasculitis &
23 antiphospholipid antibodies)
24 Neurologic: Cognitive dysfunction & seizures
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26
?,7 Hemolytic anemia, thrombocytopenia & leukopenia
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Hypocomplementemia (C3 & C4)
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20 Laboratory Antibodies:
21 fin dings o Anti-ANA (sensitive)
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23 o Anti-dsDNA & anti-SM (specific)
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Renal involvement: Proteinuria & elevated creatinine
25
26 @UWortd
?.7
18
This patient has features suggestive of systemic lupus erythematosus (SLE), including fever, facial rash,
19
arthralgias, anemia, elevated inflammatory markers, and evidence of nephropathy. Young w omen and
20
individuals with a family history of autoimmune disease are at greatest risk for SLE. Arthritis affects 90% of
21
patients with SLE and most commonly occurs in the hands or knees. It is a migratory arthritis with pain that
22
is often disproportionate to objective physical findings. SLE arthritis has a low er incidence of erosion, synovial
23
abnormality, and permanent joint deformity than rheumatoid arthritis and is considered a non-deforming
24
arthritis.
25
26 Management of joint symptoms in patients with SLE is usually straightforward and often dependent on the
?,7 severity of systemic manifestations. Most patients will respond to conservative treatment with nonsteroidal
18 anti-inflammatory drugs. Low -dose glucocorticoids or antimalarials (eg, hydroxychloroquine) can be added for
19 more severe joint symptoms. This patient will likely require systemic therapy due to evidence of lupus
20 nephritis.
?j
18 (Choice A) Distal phalangeal resorption is characteristic of the arthritis mutilans variant of psoriatic arthritis,
19 leading to radiologic "pencil-in-cup" deformities. Bone resorption does not occur in SLE.
20
21 (Choice B) Cartilage degradation is the underlying pathologic mechanism of osteoarthritis (OA). Patients
22 with OA may develop muscle atrophy from limitations of joint movement.
23
24 (Choice C) Osteophytes are bony growths often seen around the joints of patients with OA. This patient's
25 age, family history, and systemic illness are more suggestive of SLE.
26
27 (Choice E) Subluxation of the cervical vertebrae and tendon damage in the hands may occur in rheumatoid
28 arthritis.
29
Educational objective:
30
Systemic lupus erythematosus (SLE} is an autoimmune disease that is most commonly diagnosed in young
31
w omen. More than 90% of patients with SLE have joint involvement, most often affecting the hands. Joint
32
pain may be severe but SLE induced arthritis is usually non-deforming.
33
34
35 References:
36 1. How to treat refractory arthritis in lupus?
37
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6 A 70-year-old woman comes to the physician due to joint pains in both hands. The patient has no other
7 symptoms. Her other medical problems include obesity and gastroesophageal reflux disease. She does not
8 use tobacco, alcohol, or illicit drugs. Family history is not significant. Her medications include omeprazole
9 and acetaminophen. Her vital signs are w ithin normal limits. X-ray of the joints is show n below .
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?.7
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25 W hich of the follow ing is the most likely diagnosis?
26
?,7 A. Gouty arthritis (1 %1
18 B. Hemochromatosis [0%1
19
20 ., C. Osteoarthritis [78%1
21 D. Reactive arthritis [2%1
22 E. Rheumatoid arthritis [18%1
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24 F. Systemic lupus erythematosus [0%1
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26 Explanation: User ld:
?.7
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This patient's hand x-ray is classic for degenerative joint disease or osteoarthritis; the bones are also
18 osteoporotic. Compared to a normal hand x-ray, there is diffuse degenerative joint space narrow ing, w hich
19 involves all the distal interphalangeal (DIP) joints and, to a lesser extent, the proximal interphalangeal (PIP)
20 and metacarpophalangeal (MCP) joints. Subchondral sclerosis and some osteophytes are also seen .
21
22 (Choice A) Most patients (80%) w ith gout present initially w ith monoarthritis but only 20% have polyarticular
23 involvement.
24
25 (Choice B) The characteristic radiographic findings of hemochromatosis-associated arthropathy include
26 squared-off bone ends and hook-like osteophytes in the second and third MCP joints.
27
28 (Choice D) Reactive arthritis typically follow s an infectious illness and is manifested by asymmetric
29 oligoarthritis.
30
31 (Choice E) Rheumatoid arthritis classically spares the DIP joints and involves the MCP and PIP joints.
32
(Choice F) Systemic lupus erythematosus can also affect the hand joints. However, it is unlikely to present
33
at such an advanced age and w ithout other systemic manifestations.
34
35 Educational objective:
36 Osteoarthritis predominantly involves the distal interphalangeal joints. The major radiographic features include
37 joint space narrow ing, subchondral sclerosis, osteophytes, and subchondral cysts.
38
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A 33-year-old tennis player comes to you w ith a complaint of pain in his right shoulder. He says that the pain
7 is absent at rest but present w hen he lifts his arm over his head. The pain is compromising his play. On
8 examination, active motion at right shoulder is limited due to pain. Pain is most severe on passive internal
9 rotation and flexion at the right shoulder. No atrophy of the shoulder muscle is seen. W hich of the follow ing is
10 the most likely diagnosis in this patient?
11
12
- A. Tear of long head of bicep tendon [12%]
13
14 B. Tennis elbow [4%]
15 ~ C. Subacromial bursitis [74%]
16
D. Anterior dislocation of shoulder [7%]
17
18 ~ E . Axillary nerve palsy [3%]
19
20
Explanation: User ld:
21
22 The patient described is suffering from subacromial bursitis. The subacromial bursa lies between the
23 acromion and the tendon of the supraspinatus muscle. Inflammation of the subacromial bursa typically
18 occurs in the setting of chronic microtrauma to the supraspinatus tendon caused by overhead w ork and
19 repeated overhead movements of the arm during w ork or sporting activities. The tendon is traumatized by
20 compression between the acromion and the humeral head, and its vascular supply may be temporarily
21 compromised during such episodes of compression. The physical examination in subacromial bursitis
22 reveals pain w ith active range of motion of the shoulder, tenderness in the shoulder w hen the arm is internally
23 rotated and forward flexed at the shoulder (Neer impingement sign) and no signs of deltoid atrophy.
24
25 (Choices A & D) A tear of the proximal end of the long head of bicep tendon is associated w ith rotator cuff
26 injury and typically occurs during forceful flexion of the arm. Patients present w ith a prominent bulge in the
27 midportion of the upper arm. Axillary nerve injury may occur as a result of anterior dislocation of the humerus
28 out of the glenoid fossa .
29
30 (Choice B) Tennis elbow causes chronic nagging pain over the lateral epicondyle (lateral epicondylitis).
31
(Choice E) The axillary nerve supplies the deltoid and the teres minor w ith motor innervation. Palsy of this
32
nerve w ould result in paralysis and ultimately denervation atrophy of these muscles.
33
34 Educational objective:
35 Subacromial bursitis is the result of repetitive overhead motions. Patients complain of pain w ith active range
36 of motion of the shoulder, and passive internal rotation and forward flexion at the shoulder also elicits
37 tenderness.
38
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6 A 67 -year-old male hospitalized after elective hernia repair complains of severe right knee pain . Physical
examination reveals redness and swelling of the right knee with limited motion due to pain. His temperature is
8 39.9 C (102 F), blood pressure is 160/ 110 mm Hg, pulse is 80/min, and respirations are 16/min. Synovial
9 fluid analysis reveals the following findings:
10 3
11 WBC count 30,000mm
12 Neutrophils 90%
13 Crystals rhomboid-shaped, positively birefringent
14 Gram stain negative
15
16 Which of the following is most likely associated with this patient's current condition?
17
18 A. Tophi [1 7%1
19
B. Transient bacteremia [8%1
20
21 .; C. Chondrocalcinosis [68%1
22 D. Rheumatoid factor [2%1
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E. Heberden nodes [3%1
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25 r.... F. Chlamydia! infection [2%1
26
?.7
Explanation: User ld:
18
19 Pseudogout is a form of acute arthritis induced by the release of calcium pyrophosphate dehydrate (CPPD}
20 crystals from sites of chondrocalcinosis (calcification of articular cartilage} into the joint space. It often occurs
21 in the setting of recent surgery or medical illness. Patients present with acute pain, swelling, redness and
22 limited motion of the involved joint(s}, with the knee being most commonly affected. Fever, leukocy1osis and a
23 left shift may occur in pseudogout, although the presence of these findings is not required for diagnosis. The
24 crystals of CPPD can be difficult to detect on synovial fluid analysis, but the identification of rhomboid-shaped,
25 positively birefringent crystals is diagnostic.
26
?.7 (Choice A) Tophi are collections of urate crystals which form firm, yellowish nodules at the sites of involved
18 joints in patients with chronic gout. The presentation of gout and pseudogout can be similar, but gout is
19 distinguished by needle-shaped, negatively birefringent crystals.
20
21 (Choice B) Transient bacteremia could lead to septic arthritis causing acute pain and swelling of the knee in
?.? the setting of fever and leukocy1osis. How ever, the negative gram stain and presence of rhomboid-shaped,
18 positively birefringent crystals in this case make pseudogout the more likely explanation. S. aureus is the most
19 common cause of septic arthritis.
20
21 (Choice D) Positive rheumatoid factor (RF} is characteristic of rheumatoid arthritis (RA}, but finding a positive
22 RF does not necessarily make the diagnosis of RA as it can occur in many other conditions. RA presents
23 with gradual onset symmetric arthritis; fever may be present. This patient's acute onset of pain, recent
24 surgery and crystals in the synovial fluid are more consistent with pseudogout.
25
26 (Choice E) Heberden nodes occur in the DIP joints in osteoarthritis and form from calcified cartilaginous
27 spurs. Osteoarthritis may predispose to pseudogout, but osteoarthritis alone cannot account for the acute
28 onset, inflammation, fever and synovial fluid analysis in this case.
29
(Choice F) Chlamydia! infection can result in reactive arthritis. The triad of urethritis, conjunctivitis and
30
arthritis compose the classic presentation. Lower extremity oligoarthritis and enthesopathy (inflammation at
31
tendon and ligament insertions} account for musculoskeletal complaints.
32
33 Educational objective:
34 Acute inflammatory arthritis caused by CPPD crystals is called pseudogout. It often occurs in the setting of
35 recent surgery or medical illness. Pseudogout is diagnosed by the presence of rhomboid-shaped, positively
36 birefringent crystals on joint aspiration microscopy and radiographic evidence of chondrocalcinosis (calcified
37 articular cartilage}.
38
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6 A 70-year-old man comes to the physician for pain and stiffness of his neck, shoulders, and hips for the last 3
7 months. His stiffness is w orse in the morning and lasts 1-2 hours. He also complains of general malaise and
a recent w eight loss of 3.17 kg (7 lb). The patient has no headache, scalp tenderness, visual symptoms, or
9 jaw claudication. Examination show s no overt synovitis at the joints, with normal passive range of motion.
10 The arteries of the scalp, neck, and ex1remities are normal on palpation without tenderness. Laboratory
11 results are as follow s:
12 Leukocytes 7500/~L
13 Hematocrit 31%
14 Platelets 450,000/~L
15 Erythrocyte sedimentation rate 85 mm/h
16 Thyroid-stimulating hormone 1.8 ~U/mL
17 Creatine kinase 33 U/L
18
19
Which of the following is the most appropriate nex1 step in management of this patient?
20
21
22 .~ A Measure antinuclear antibodies and rheumatoid factor levels [32%]
23 B. Recommend low-impact aerobic exercise [7%]
24
C. Temporal artery biopsy [4%]
25
26 .; D. Treatment with low -dose prednisone [40%]
?.7 E. Treatment with nonsteroidal anti-inflammatory drug [1 7%]
18
19
20
21
Explanation: User ld: I
22 Polymyalgia rheumatica
23
24
25 Clinical
26 Findings
features
?,7
18
19 Age >50
20 Bilateral pain & morning stiffness >1 month
21 Involvement of 2 of following:
22 Symptoms o Neck or torso
23 o Shoulders or proximal arms
24
o Proximal thigh or hip
25
26
o Constitutional (fever, malaise, weight loss)
?.7
18 Physical
19 Decreased active ROM in shoulders, neck & hips
examination
20
21
22 ESR >40 mm/h, sometimes >100 mm/h
23 Laboratory Elevated CRP
24
studies Normocytic anemia possible
25
26 - 20% can have normal studies
?,7
18 Treatment Response to glucocorticoids
19
20 CRP= C-reactive protein; ESR = erythrocyte sedimentation rate; ROM = range of motion.
21
@UWOI1d
22
23
24 This patient has the following characteristic features of polymyalgia rheumatic a (PMR):
25 Age >50
26 Subacute-to-chronic (>1 month) pain in the shoulder and hip girdles
?.7 Morning stiffness lasting > 1 hour
18 Constitutional symptoms
19 Elevated erythrocyte sedimentation rate >40 mm/h
20 No other apparent explanation for symptoms
21
22
23 In PMR, the physical examination is frequently unremarkable with patients having no focal tenderness or pain
24 with active or passive range of motion. Signs of inflammation in the joints are absent. When asked to identify
25 the location of their pain, patients typically indicate the soft tissues and not the joints.
26
?,7 Low -dose glucocorticoids are the treatment of choice for PMR (eg, prednisone 10-20 mg daily). Rapid and
thorough relief of symptoms is expected, and failure to improve rapidly on prednisone should call the
18
diagnosis into question. PMR is frequently associated with giant cell arteritis (GCA), also known as temporal
19
20 arteritis. Symptoms of GCA include headache, jaw claudication, vision loss, or tenderness over the temporal
artery. If GCA is suspected, patients should be considered for an expedited temporal artery biopsy (Choice
21
C) and receive significantly higher doses of glucocorticoids (eg, prednisone 40-60 mg or higher daily).
22
23 (Choice A) Antinuclear antibody and rheumatoid factor are screening tests for systemic lupus erythematosus
24
and rheumatoid arthritis, respectively, and are frequently positive in a number of other inflammatory and
25 autoimmune conditions. These tests have poor specificity in the absence of characteristic symptoms (eg, I
18 malar rash, metacarpophalangeal synovitis) and w ould be unlikely to change management in this patient.
19
20 (Choice B) Fibromyalgia (FM) most commonly presents in young to middle-aged women with widespread
21 pain, fatigue, and cognitive/mood disturbances. Patients have point muscle tenderness in areas such as the
22 mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. Regular aerobic
23 exercise and good sleep hygiene are recommended for FM. How ever, constitutional symptoms (eg, w eight
24 loss) or elevated erythrocyte sedimentation rate are not present in FM.
25
26 (Choice E) Nonsteroidal anti-inflammatory drugs are occasionally useful in PMR for mild breakthrough
27 discomfort or minor relapse of symptoms while tapering glucocorticoids. How ever, they are much less
28 effective than glucocorticoids for initial management and are not recommended .
29
Educational objective:
30
Polymyalgia rheumatic a (PMR) affects patients age >50 and is characterized by pain and stiffness in the
31
neck, shoulders, and pelvic girdle, along with an elevated erythrocyte sedimentation rate. The treatment of
32
choice for uncomplicated PMR is low-dose prednisone, which results in rapid relief of symptoms.
33
34
35 References:
36 1. Recognition and management of polymyalgia rheumatica and giant cell arteritis.
37
38
39
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6 A 52-year-old w oman complains of difficulty gripping her cup of coffee in the morning. She likes to solve
7 crossw ord puzzles but is unable to hold a pen properly due to stiffness in her right hand. Her symptoms
8 gradually improve during the day and she is "fully functional" by late afternoon. Examination show s nontender
nodules near the elbow s over the back of her forearm. The erythrocyte sedimentation rate is 45 mm/hr.
10 W hich of the following w ould most likely be involved during the course of this patient's disease?
11
12
~ A Cervical spine [51%]
13
14 B. Lumbar spine [9%]
15 C. Sacral spine [2%]
16
D. Sacroiliac joints [33%]
17
18 E. Thoracic spine [4%]
19
20
Explanation: User ld:
21
22
23
24 Clinical features of rheumatoid arthritis
25
26 Symptoms
?.7
18 Insidious onset, multiple joint pain, stiffness & swelling
19 Morning stiffness lasting hours, improves with activity
20
21 Small joints (eg, PIP, MCP, MTP) commonly involved
22 Monoarthritis (eg, knees, elbows) can also occur later
23
24 Sp ares the DIP joint, unlike osteoarthritis
Clinical
25 presentation Examination
26
?,7
Affected joints are tender to the touch, swollen, with limited range
18
of motion
19 Tenosynovitis of the palms ~ "trigger finger"
20 Rheumatoid nodules (especially on elbows)
21
22 Cervical joint involvement can lead to spine subluxation ~ spinal
23 cord compression
24
25
26 Positive anti-CCP antibodies (diagnostic testing)
Labo ratory/
?.7 High lgM rheumatoid factor
imaging
18
studies High C-reactive protein & ESR correlate with disease activity
19 X-ray: Soft-tissue swelling, joint space narrowing & bony erosions
20
21 Anti-CCP =anti-cyclic citrullinated peptide; DIP = distal interphalangeal joints;
22 ESR =erythrocyte sedimentation rate; lgM = Immunoglobulin M; MCP = metacarpophalangeal;
23 MTP = metatarsophalangeal.
24 UWor1d
25
26 This patient's presentation (morning stiffness, metacarpophalangeal j oint involvement, nontender nodules on
?,7 the elbow, high erythrocyte sedimentation rate) suggests rheumatoid arthritis (RA). RA is a chronic systemic
18 inflammatory disorder that involves synovial inflammation leading to joint damage. W omen are affected 2-3
19 times more frequently than men, with a peak incidence at age 50-75.
20
21 RA primarily involves peripheral joints and most commonly affects the metacarpophalangeal (MCP) and
22 proximal interphalangeal (PIP) joints of the fingers, metatarsophalangeal (MTP) joints of the toes, and the wrist
23 joints in the early phases. How ever, the distal interphalangeal (DIP) joints are not involved. The disease
24 eventually can involve larger joints such as the knees, elbow s, ankles, and shoulders. Symptoms include
25 pain, swelling, and morning stiffness that improve with increased movement and during the course of the day.
26 Reduced grip strength can occur occasionally and is a sensitive sign of early disease.
?.7
18 Rheumatoid nodules can occur in up to 30%-40% of patients and present as firm and nontender
19 subcutaneous nodules usually close to pressure points (eg, elbow s). RA most commonly affects the cervical
spine joints in the axial skeleton and can lead to cervical spine subluxation, which can also cause spinal cord
:?9
compression. Patients with cervical spine involvement often complain of neck pain, stiffness, and radicular
18
pain in the upper extremity. Subluxation with spinal cord compression can present with hyperreflexia or
19
upgoing toes on Babinski testing.
20
21 (Choices B, C, 0, and E) RA does not affect the thoracic, lumbar, or sacral spine or sacroiliac joints. The
22 thoracic spine has great stability and is rarely affected by arthritis, disc herniation, or other spinal disorders.
23 The lumbar spine is the most common site of disc herniation and spinal stenosis. The sacroiliac joints are
24 commonly affected in seronegative spondyloarthropathies (eg, ankylosing spondylitis, reactive arthritis, and
25 psoriatic arthritis).
26
27 Educational objective:
28 Rheumatoid arthritis (RA) presents as progressive and symmetrical involvement of the peripheral joints. The
29 common sites of early involvement include metacarpophalangeal and proximal interphalangeal joints of the
30 fingers, metatarsophalangeal joints of the toes, and the wrist joints. RA most commonly affects the cervical
31 spine joints in the axial skeleton and can cause spinal subluxation and spinal cord compression .
32
33 References:
34
35 1. Rheumatoid arthritis.
36 2. Rheumatoid arthritis of the cervical spine--clinical considerations.
37
38
39
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6 A 28-year-old w oman comes to the clinician with pain and numbness of both hands over the last 6 months.
7 Cold temperatures seem to precipitate these episodes. Medical history includes exercise-induced asthma,
8 lower back pain, and hypothyroidism . The patient takes levothyroxine daily. She does not use alcohol or illicit
9 drugs but has a 10-pack-year smoking history. l aboratory studies show normal complete blood count and
chemistry panel. TSH is 4.71-JU/ml. Antinuclear antibody screen is negative. Physical examination findings
11 are shown in the image below.
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
?.7
18
19
20
21
22
23
24
25
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?.7
18
19
20
I
21 In addition to smoking cessation, which of the following is the best initial therapy for this patient?
22
23 ..; A. Amlodipine [7 4%1
24 B. Clonidine [11 %1
25
26 C. Increase in levothyroxine dose [6%1
?.7 D. lisinopril [2% 1
18 ~ E. Metoprolol [7%1
19
20
21 Explanation: User ld:
22
23
24 Secondary Raynaud
25
Primary Raynaud phenomenon
pheno menon
26
?.7
18 Connective tissue diseases
19 (eg, systemic lupus
20 erythematosus, scleroderma)
21
22 Occlusive vascular conditions
23 (eg, Buerger's disease)
24
25 Etiology Sympathomimetic drug use
No underlying cause
26 (eg, ephedrine, epinephrine)
?.7
18 Use of vibrating tools (eg,
19 jackhammer, power drill)
20 Hyperviscosity syndromes
21
22 (eg, cryoglobulinemia,
23 paraproteinemias)
24
25
Usually men age >40
26
?.7
Usually women age <30 Asymmetrical attacks
18 Possible prevalence in multiple Presence of systemic
19 family members symptoms or symptoms of
20
21 Symmetrical episodic attacks another disease
22 Clinical No tissue injury or digital pitting Painful episodes with tissue
23 features injury or digital ulcers
24 Negative nailfold capillary
25 examination Abnormal nailfold capillary
26 Negative antinuclear examination
?.7 antibodies, erythrocyte Abnormal laboratory studies
18 sedimentation rate for vascular or autoimmune
19
disease
20
21
22 Evaluation & treatment for
23 underlying etiology
I
24 No further evaluation
25 Calcium channel blockers for
26 Treatment/ Avoidance of aggravating persistent symptoms; aspirin
?.7 evaluati on factors added in patients with risk for
18 Calcium channel blockers for digital ulceration
19 persistent symptoms Chemical or surgical
20
sympathectomy for severe
21
22
ischemia
23 USMLEWorld, UC
24
25 Clinical features suggest that this patient has primary Raynaud phenomenon (RP), an increased vascular
26 response to cold temperature or emotional stress without an underlying cause. Primary RP occurs usually in
?.7 w omen age <30 with symptoms of symmetrical episodic attacks and without evidence of peripheral vascular
18 disease, connective tissue disease, tissue injury, or abnormal nailfold capillary examination. Abnormalities
19 such as dilated or dropout vessels in the nailfold capillaries are predictive for future development or the
20 presence of a connective tissue disease. Episodes can also involve tingling, numbness, and pain with skin
21 color changes of pallor (white attack) or cyanosis (blue attack). l aboratory studies (eg, antinuclear
22 antibodies, erythrocyte sedimentation rate) are usually negative.
23
24 Primary RP does not require further evaluation. Treatment mainly involves avoiding aggravating factors
18 (ie, cold stimuli, emotional stress). Dihydropyridine calcium channel blockers (eg, nifedipine, amlodipine)
19 are the drugs of choice for continuing symptoms.
20
(Choices B, D, and E) Clonidine, angiotensin II converting enzyme inhibitors, and beta blockers are not
21
helpful for treatment of RP. In fact, some studies have shown that nonselective beta blockers may w orsen
22
the condition.
23
24 (Choice C) Although hypothyroidism can lead to generalized cold intolerance, sharply demarcated digit color
25 changes are not typical of cold-induced vasospasm caused by hypothyroidism .
26
27 Educational objective:
28 Primary Raynaud phenomenon is an increased vascular response to cold temperature or emotional stress. It
29 is usually found in women age <30 with symptoms of symmetrical episodic attacks without evidence of
30 peripheral vascular disease, tissue injury, or abnormal nailfold capillary examination. Treatment involves
31 mainly calcium channel blockers (eg, nifedipine, amlodipine) and avoiding aggravating factors.
32
33 References:
34
35 1. Current medical and surgical management of Raynaud's syndrome.
36 2. The association of Raynaud syndrome with ?-blockers: a meta-analysis.
37
38
39
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6 A 24-year-old w oman comes to the physician complaining of a skin rash and pain in her w rists, ankles and
7 elbow s over the past 4 days. She has also had a fever and sw eats, but denies headache, nausea or
8 vomiting . She has no significant past medical history and does not take any medications. She recently took a
9 vacation w ith her new boyfriend. She denies any previous sexually transmitted diseases but acknow ledges
10 having unprotected sex w ith her new boyfriend. She does not use tobacco, alcohol or illicit drugs. Her
temperature is 38.5 C (101 .3 F) and her pulse is 98/min. Her oropharynx is clear and there is no thrush or
12 lymphadenopathy. Her abdomen is benign and the pelvic examination is w ithin normal limits. She has pain
13 along the tendon sheaths w ith active and passive hand movement. A photo of her skin rash is show n below .
14
15
16
17
18
19
20
21
22
23
24
25
26
?.7 Dlployod wltll perm/nlon from Current Medklne Group LLC@ 2000.
18
19 W hich of the follow ing is the most likely cause of her symptoms?
20
21 A. Lyme disease [12%]
22
23 B. Syphilis [8%]
24 ~ C. Gonococcemia [68%]
25 D. Meningococcemia [3%]
26
?.7 E. Acute HIV infection [4%]
18 F. Acute rheumatic fever [4%]
19
20
21 Explanation: User ld:
22
23 This patient has the classic triad of polyarthralgia, tenosynovitis, and painless vesiculopustular skin lesions for
24 disseminated gonococcal infection. Her complaints of w rist, elbow and ankle pain are consistent w ith
25 gonococcal polyarthralgias, and her pain elicited along the tendon sheaths suggests tenosynovitis. The
26 lesions show n in the photograph are typical vesiculopustular lesions of disseminated gonococcal infection;
?.7 they tend to number from two to ten and may be dismissed as furuncles or pimples. Fevers and chills may
18 be present. A history of recent unprotected sex w ith a new partner is frequently associated w ith disseminated
19 gonococcal infection, w hile symptoms of symptomatic venereal disease are most often absent.
20
(Choice A) Arthritis and rash are associated w ith Lyme disease. The rash (erythema migrans} of Lyme
21
disease occurs early on in illness, w hile arthritis, typically monoarticular knee pain, does not occur until
22
months later. Erythema migrans occurs at the site of a tick bite, and has a "bulls eye" appearance.
23
Tenosynovitis is not typical of Lyme disease.
18
19 (Choice B) The skin findings of syphilis include a painless ulcer of the genitalia that occurs in the primary
20 stage of infection, and a maculopapular rash of the palms and soles in the secondary stage.
21
22 (Choice D) Meningococcemia presents w ith a petechial rash, high fever, headache, nausea/vomiting, stiff
23 neck, and photophobia . This patient specifically denies many of these symptoms. Furthermore, arthritis,
24 tenosynovitis, and the rash in the image are not consistent w ith meningococcemia.
25
26 (Choice E) The symptoms of acute HIV infection include fever, arthralgias, sore throat, lymphadenopathy,
27 mucocutaneous lesions, diarrhea, and w eight loss. Her symptoms are more consistent w ith disseminated
28 gonococcal infection. All patients w ith disseminated gonococcal infection, how ever, should undergo HIV
29 screening.
30
(Choice F) An episode of pharyngitis typically precedes the onset of acute rheumatic fever by 2-4 w eeks.
31
Symptoms of acute rheumatic fever include migratory arthritis of the large joints, erythema marginatum
32
(raised ring-shaped lesions over the trunk and extremities}, subcutaneous nodules, carditis, and Sydenham
33
34 chorea .
35 Educational objective:
36 Disseminated gonococcal infection often presents w ith a triad of polyarthralgias, tenosynovitis, and
37 vesiculopustular skin lesions.
38
39
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6 A 45-year-old tennis player comes to your office w ith a complaint of pain over the lateral side of the right
7 elbow. He has been a professional tennis player for 15 years but has never had this kind of pain before.
8 Range of motion at both elbow s is normal. There is point tenderness over the lateral side of the distal end of
9 right humerus. Pain is exacerbated by extension of w rist against resistance. The rest of the physical
10 examination is normal. W hich of the follow ing is the most likely diagnosis in this patient?
11
I
24 slow taper over several months. Immediate therapy with systemic corticosteroids reduces the progression of
25 visual complications in the affected and unaffected eyes; it should be started promptly while awaiting
26 confirmation of the diagnosis.
?.7
18 (Choice A) Acetazolamide is used to treat open-angle glaucoma and benign intracranial hypertension. ~ has
19 no role in the management of patients with suspected GCA.
20
21 (Choice C) Initial therapy with low -dose prednisone (10-20 mg daily) is recommended for patients with
22 polymyalgia rheumatica without evidence of GCA. Higher-dose oral prednisone (40-60 mg/day) is
23 recommended only in patients with uncomplicated GCA without associated symptoms or signs of end-organ
24 damage.
25
00
18
19
(Choice D) Methotrexate is less effective than high-dose glucocorticoids in treating temporal arteritis. It is
used primarily as a steroid-sparing agent for patients who develop significant adverse effects with systemic
glucocorticoids.
-
20
21 (Choice E) MRI with contrast enhancement can identify vessel w all edema and provide a noninvasive
22 method of diagnosis in patients with suspected GCA. How ever, immediate empiric treatment takes
23 precedence in this patient, and temporal artery biopsy remains the definitive method for diagnosis.
24
25 (Choice F) Temporal artery biopsy is indicated to confirm the diagnosis of GCA. How ever, therapy with
26 systemic glucocorticoids should be started immediately when the diagnosis is suspected and should not be
27 withheld while awaiting confirmation with temporal artery biopsy.
28
Educational objective:
29
Giant cell arteritis (temporal arteritis) should be suspected in patients with temporal headaches, jaw
30
claudication, and vision loss. Patients with suspected giant cell arteritis who have visual symptoms should be
31
started immediately on high-dose systemic glucocorticoids to reduce the progression of visual complications.
32
33
34 References:
35 1. Visual improvement with corticosteroid therapy in giant cell arteritis. Report of a large
36 study and review of literature.
37
38
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6 A 22-year-old Caucasian female comes to your office complaining of difficulty swallow ing. She says that solid
7 food sticks in the middle of her chest, and that's w hy she prefers liquids. She has lost 10 pounds over the last
8 3 months. She also complains of recent severe heartburn that does not respond w ell to over-the-counter
9 antacids. On review of systems, she denies cough, shortness of breath and palpitations. She has noticed
10 occasional sw elling and pain in her small finger joints. Her fingers turn blue upon cold exposure, and she
11 always w ears gloves to keep them w arm . She does not smoke or drink alcohol. She denies illegal drug use.
12 W hich of the follow ing is the most likely diagnosis?
13
24
25 (Choice C) Osteitis fibrosa cystic a (Von Recklinghausen disease of bone), which presents with bony pain, is
18 characterized by excessive osteoclastic resorption of bone, leading to replacement with fibrous tissue (brown
19 tumors). It is very rare and is seen primarily in patients with parathyroid carcinoma. It can also occur in
20 primary and secondary/tertiary (advanced renal disease) hyperparathyroidism. Renal injury may occur in RA
21 (from use of nonsteroidal anti-inflammatory drugs and some disease-modifying agents or from amyloidosis
22 due to inflammation), but the risk of osteoporosis is far greater than the risk of osteitis fibrosa cystic a.
23
24 (Choice E) Osteosarcoma is a primary malignant bone tumor. Risk factors include Paget disease and
25 radiation and chemotherapy exposure.
26
Educational objective:
27
Patients with rheumatoid arthritis are at increased risk of developing osteopenia, osteoporosis, and bone
28
fractures, especially if additional risk factors for osteoporosis are present. Management includes adequate
29
physical activity, optimization of calcium and vitamin D intake, minimization of corticosteroid therapy, and
30
consideration for bisphosphonate treatment.
31
32
33 References:
34 1. Clinical decision rules in rheumatoid arthritis: do they identify patients at high risk for
35 osteoporosis? Testing clinical criteria in a population based cohort of patients with
36 rheumatoid arthritis recruited from the Oslo Rheumatoid Arthritis Register.
37
38
39
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6 A 44-year-old w hite male presents w ith a long history of joint pains in several joints. He has seen a physician
7 before but no diagnosis w as made. He has been taking ibuprofen w ith partial relief. He has now developed
8 fever, diarrhea and w eight loss. He denies any genitourinary or eye symptoms. He does not use tobacco,
9 alcohol or drugs. He is a farmer. On examination, he has generalized lymphadenopathy and non-deforming
10 arthritis. Small intestinal biopsy reveals periodic acid-Schiff (PAS}-positive macrophages. W hich of the
11 follow ing is the most likely diagnosis?
12
13
14 A. Reactive arthritis [4%1
15 B. Sarcoidosis [3%1
16 C. Inflammatory bow el disease [6%1
19 I
20
Disseminated gonococcal infection
21
22
23 Purulent arthritis without skin lesions
24
25 OR
26 Clinical Triad of:
?.7 presentation Tenosynovitis (eg, wrist, ankles, fingers & knees)
19 Dermatitis (pustules, maculas, papules & bullae)
20
Migratory asymmetric polyarthralgia without purulent arthritis
21
22
23 Blood cultures (2 sets) but may be negative
24
25 Synovial fluid analysis may show up to 50,000 cells/mm 3
26 Diagnosis Urethral, cervical, pharyngeal or rectal cultures
?.7
Recommend HIV & syphilis screen
19 Recurrent DGI: check terminal complement activity
20
21
22 IV ceftriaxone 1 g/day for 7-14 days, switch to PO (cefixime)
23 when clinically improved
24
Joint drainage for purulent arthritis
25 Treatment
26 Empiric azithromycin (single 1-g dose) OR doxycycline for
?.7 7 days for concomitant chlamydia! infection
19 Treat sexual partners
20
21 OGI = disseminated gonococcal infection; HIV = human immunodeficiency virus; IV = intravenous; PO = orally.
22 @UWorld
23
24 The fever, knee pain, and white blood cell (WBC) count of 50,000/mm' on synovial fluid analysis strongly
25 suggest septic arthritis. Septic arthritis in a young, sexually active individual is most often caused by
26 N eisseria gonorrhoeae (75% of cases).
?.7
Gonococcal septic arthritis may present with asymmetric polyarthralgias (most often associated with
19 tenosynovitis and skin rash) or an isolated purulent mono- or oligoarthritis. In some patients, asymmetric
20 polyarthralgias may precede purulent monoarthritis. Roughly 75% of cases are "silent," meaning that the
21 preceding genitourinary or pharyngeal infection goes unnoticed.
22
23 For this patient, migratory asymmetric polyarthralgias of the right wrist and left ankle preceded purulent
24 monoarthritis of the left knee. Although skin rash and tenosynovitis are not present in this patient, purulent
25 arthritis in a sexually active individual is gonococcal arthritis until proven otherwise. Synovial fluid
26 white blood cell count is about 50,000/mm' (slightly low er than other septic arthritides). Gram stain of the
?.7 synovial fluid (positive in 25% of cases), blood cultures (positive in 20%-50% of cases), and genital/pharyngeal
mucosal nucleic acid amplification tests (positive in 90% of cases) are used to confirm the diagnosis.
19 Treatment is ceftriaxone or cefotaxime.
20
21 (Choice A) Symptoms of acute HIV infection tend to present 2-4 w eeks after exposure to the virus. The
22 symptoms are nonspecific and include fever, arthralgias, sore throat, lymphadenopathy, mucocutaneous
23 lesions, diarrhea, and w eight loss.
I
24
(Choice B) Acute rheumatic fever generally occurs 2-4 w eeks after pharyngitis caused by Group A
25
Streptococcus. Symptoms of acute rheumatic fever include migratory arthritis of the large joints, erythema
26
marginatum rash, subcutaneous nodules, carditis, and Sydenham chorea .
?.7
(Choice C) Crystal-induced arthritis often presents with a w arm, painful, swollen joint accompanied by
19 low -grade fever. Synovial fluid analysis show s a WBC count of 5,000-80,000/mm' and characteristic crystals
20 under polarized light.
21
~4 (Choice E) Arthritis is not a prominent symptom of infective endocarditis. Fever, a new heart murmur, Osier
nodes (nodules on finger and toe pads), Roth spots (retinal hemorrhages), and Janew ay lesions (small
19 hemorrhages on extremities) are classic.
20
21 (Choice F) Non-gonococcal septic arthritis is less likely than gonococcal arthritis in a young, sexually active
22 patient. A more classic profile for non-gonococcal arthritis w ould be an adu~ with a chronic disease (eg,
23 diabetes, osteoarthritis) who generally has single-joint involvement (rather than migratory polyarthralgias) and
24 fever. Gram stain and blood cultures are necessary for definitive diagnosis.
25
26 (Choice G) Reactive arthritis may be caused by genitourinary infection with Chlamydia trachoma/is or by
27 certain gastrointestinal infections. It presents with a triad of arthritis, conjunctivitis, and urethritis.
28
Educational objective:
29
N eisseria gonorrhoeae is the most common cause of septic arthritis in young, sexually active patients.
30
Gonococcal septic arthritis may present with asymmetric polyarthralgias (often associated with tenosynovitis
31
and skin rash) or as an isolated purulent mono- or polyarthritis. Diagnosis may be confirmed by Gram stain of
32
the synovial fluid, blood cultures, and genital/pharyngeal mucosal nucleic acid amplification tests.
33
34
35 References:
36 1. Gonococcal and nongonococcal arthritis.
37
38
39
Time Spent: 2 seconds Copyright UW orld Last updated: [1 0/30/2014]
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Media Exhibit
Translucent or
Fl uid clarity Clear Clear Opaque
opaque
50,000-
WBCs/mm3 < 200 200-2,000 2,000-1 00,000
150,000
Often >
PMNs < 25% 25% Often> 50%
80-90%
USMlEWorld.. LLC
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4
5
6 A 51-year-old w oman comes to the clinic w ith 6 months of fatigue and low back pain radiating to the buttocks.
7 She also complains of persistent muscle pain in her arms and shoulders that w orsens acutely after exercise.
8 Physical examination show s normal muscle strength. Her joints are not sw ollen, but palpation over the outer
9 upper quadrants of the buttocks and the medial aspect of the knees elicits tenderness. Her erythrocyte
10 sedimentation rate is 12 mm/hr. W hich of the following is the most likely diagnosis?
11
12
13 >1 A. Fibromyalgia [61%1
14 B. Giant-cell arteritis [0%1
15 C. Polyarteritis nodosa [1 %1
16
17 D. Polym yalgia rheumatic a [21 %1
18 E. Polym yositis [1 0%1
F. Rheumatoid arthritis [0%1
20
21 G. Seronegative spondyloarthropathy [6%1
22
23 Explanation: User ld:
24
25
26 Condition Distinguishing clinical features Laboratory/diagnosis
?.7
18
20
21
. Usually young-to-midd le-aged women . No abnormal laboratory studies
. Widespread musculoskeletal pain in . Possible tender points on physical I
both sides of body, above & below waist examination (eg, mid trapezius,
22
23
. Fatigue when arising from sleep & mid- lateral epicondyle, costochondral
24 Fibromyalgia afternoon junction)
25 . Cognitive difficulties (eg, attention/tasks . Symptoms >3 months with
26
requiring rapid thought changes) increased widespread pain index
?,7
18
. Nonspecific gastrointestinal symptoms or symptom severity score
(eg, diarrhea, constipation)
20
21
22
. Symmetrical proximal muscle weakness . Elevated muscle enzymes
23 . Increasing d ifficulty climbing stairs, (eg, creatine kinase, aldolase,
24 getting up from a chair, carrying heavy lactate dehydrogenase, aspartate
25 Polymyositis
groceries aminotransferase)
26
. Less prominent hip/shoulder . Possible autoantibodies
?.7
18 involvement . Electromyography abnormal
20 . Age usually >50 . Clinical diagnosis
21
22
. Aching & morning stiffness >pain in . Significantly elevated eryth rocyte
23 shoulders, hips, neck, torso sedimentation rate
24
Polymyalgia
. Synovitis, bursitis, decreased range of . Symptoms improve with
25 rheumatica
motion corticosteroids
26
?,7
. No significant muscle tenderness
18 . Possible systemic symptoms
) USMLEV/01Id, llC
20
21
This patient's presentation is consistent w ith likely fibromyalgia (FM). FM presents most commonly in
22
young-to-middle-aged w omen w ith w idespread pain, fatigue, and cognitive/mood disturbances. Patients tend
23
to have a fairly normal physical examination except for point muscle tenderness in areas such as mid
24
trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. Patients perceive
25
that their pain and fatigue w orsen acutely after exercise. How ever, studies show that gradual and incremental
26
low -impact exercises (eg, fast w alking, sw imming, w ater aerobics) can improve pain and fatigue and provide
?.7
long-term benefit.
18
FM has no specific diagnostic laboratory findings and the diagnosis is primarily based on history and exam
20 findings. Symptoms frequently overlap w ith those of other disorders (eg, chronic fatigue syndrome, irritable
21 bow el syndrome). Revised 2010 American College of Rheumatology criteria suggest using the widespread
22 pain index and symptom severity score rather than trigger points for FM diagnosis. The index and score
23 better emphasize cognitive problems, fatigue, and severity of somatic symptoms.
24
25 (Choice B) Giant-cell arteritis (temporal arteritis) usually occurs in association w ith polym yalgia rheumatic a
26 and presents w ith systemic symptoms, headache, jaw claudication, visual disturbances, and a significantly
?,7 elevated erythrocyte sedimentation rate (ESR). This patient's absence of these findings makes this less likely.
18
(Choice C) Polyarteritis nodosa typically presents w ith systemic symptoms, skin findings (eg, livedo
20 reticularis, purpura), kidney disease, abdominal pain, and muscle aches or w eakness. ESR is usually
21 elevated, w hich is not seen in this patient.
22
23 (Choice D) Polym yalgia rheumatic a almost alw ays occurs in patients age >50. Patients develop pain and
24 stiffness of the shoulders and pelvic girdle but do not have significant muscle tenderness. ESR is usually
25
26
?.7
18
significantly elevated. Polym yalgia rheumatic a is commonly associated w ith temporal arteritis.
(Choice E) Polym yositis usually presents w ith symmetrical proximal muscle w eakness, mild pain, and
elevated muscle enzymes (eg, creatine kinase, aspartate aminotransferase, lactate dehydrogenase,
aldolase). However, there is usually less prominent hip or shoulder involvement, as seen in this patient. In
I
addition, this patient's absence of muscle w eakness makes polym yositis unlikely.
20
21 (Choice F) Rheumatoid arthritis occurs most commonly in middle-aged w omen. T ypical findings include
22 swelling of the w rist and hand joints (metacarpophalangeal and proximal interphalangeal}, morning stiffness,
23 and elevated rheumatoid factor and ESR.
24
25 (Choice G) Seronegative spondyloarthropathies (SA) commonly cause low back pain . Although the
26 rheumatoid factor is negative, an elevated ESR w ould be expected in any of the SAs. In contrast to
27 fibromyalgia, exercise usually improves pain in SA.
28
Educational objective:
29
Fibromyalgia presents commonly in young-to-middle-aged w omen w ith w idespread pain, fatigue, and
30
cognitive/mood disturbances. Diagnosis is made clinically using w idespread pain index and symptom
31
severity score, w hich emphasize cognitive problems, fatigue, and severity of somatic symptoms.
32
33
34 References:
35 1. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia
36 and measurement of symptom severity.
37
38
39
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40
Media Exhibit
21 This patient's presentation is most consistent w ith osteoarthritis (OA). OA is a noninflammatory arthritis that
22 most commonly affects the hands and w eight-bearing joints. Increasing age is the leading risk factor for OA.
23 Patients typically present w ith mild morning stiffness (< 30 minutes) and pain that is exacerbated by exercise
24 and relieved by rest. Unlike autoimmune diseases, systemic symptoms are generally absent. Effusions may
25 occur in OA but the joint w ill remain cool to the touch. Bony crepitus, bony enlargement, and painful or
26 decreased range of motion are also common on exam. Synovial fluid analysis w ill reveal a w hite blood cell
?.7 count of 200-2000/ml (as opposed to 0-200/ml in a normal joint, 2,000-50,000/ml in an inflammatory condition,
18 and >50,000/ml in septic arthritis). Plain films of an osteoarthritic knee w ill reveal a narrow ed joint space w ith
19 osteophyte formation, and subchondral sclerosis/cysts.
(Choice A) Punched out erosions w ith a rim of cortical bone are the characteristic x-ray finding in gouty
arthritis. Gout causes acute joint pain and synovial fluid analysis w ill demonstrate a white blood cell count of
2,000-50,000/ml and needle-shaped, negatively birefringent crystals.
21 (Choice B) The x-ray findings of periarticular osteopenia and joint margin erosions are classic for rheumatoid
22 arthritis (RA). RA is an inflammatory arthritis presenting w ith morning stiffness (> 30 minutes) and systemic
23 symptoms of fever, malaise, and w eight loss. W hite blood cell count of 2,000-50,000/ml on synovial fluid
24 analysis is characteristic. W rists, MCP and PIP joints are commonly involved. The joints w ill be w arm to the
25 touch .
26
27 (Choice D) Normal joint space w ith soft tissue sw elling is seen on radiography in patients w ith infectious
28 arthritis. Cell count of >50,000/ml is typical on synovial fluid analysis and the gram stain is often positive.
29
(Choice E) Calcification of cartilaginous structures (chondrocalcinosis) is typical of pseudogout, or calcium
30
pyrophosphate dihydrate (CPPD) deposition. The typical presentation involves acute sw elling, stiffness, and
31
pain of the knee after surgery or medical illness. Synovial fluid analysis demonstrates a cell count of
32
2,000-50,000/ml w ith rhomboid, positively birefringent crystals.
33
34 Educational objective:
35 Osteoarthritis is a non-inflammatory arthritis presenting w ith pain that is w orse w ith activity and improved w ith
36 rest. X-ray findings include joint space narrow ing and osteophytes. Synovial fluid analysis w ill reveal few er
37 than 2000 WBC/ml, no organisms, and no crystals.
38
39
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6 A 42-year-old male presents to your office complaining of back pain that started two days ago after carrying
7 heavy packages. He denies any weakness or sensory changes in his legs. His past medical history is
8 insignificant. He is not taking any medications and denies drug abuse. His temperature is 36.r C (98 F),
9 blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals
10 paravertebral tenderness. Lower extremity power is 5/5 and the deep tendon reflexes are 2+. Babinski's sign
11 is negative. Straight-leg raising test is negative at 90 degrees. What is the most probable diagnosis in this
12 patient?
13
14
A. Multiple myeloma [1 %1
15
16 B. Ankylosing spondylitis [1 %1
17 C. Compression fracture of the vertebrae [3%1
18
"' D. Lumbosacral strain [88%1
19
20 E. Herniated disk [4%1
F. Metastatic tumor [0%1
22
G. Increased lumbar lordosis [1 %1
23
24 H. Spondylolisthesis [1 %1
25 I. Epidural abscess [0%1
26
J. Spinal stenosis [1 %1
?.7
18 K. Abdominal aortic aneurysm [0%1
19 L. Cauda equina syndrome [0%1
20
M. Transverse myelitis [0%1
22 N. Vertebral body osteomyelitis [1 %1
23
24
Explanation: User ld:
~?
18 Lumbosacral strain is the most common cause of back pain. It is estimated that the lifetime risk of
19 lumbosacral strain is close to 80%. The clinical scenario described is typical. The pain starts acutely after
20 physical exertion, and it is concentrated in the lumbar area, usually without radiation to the thighs. Physical
examination reveals local tenderness and contraction of the paraspinal muscles. A straight-leg raising test
22 and neurologic examination are typically normal. The treatment includes NSAIDs and early mobilization.
23
24 A herniated disk (Choice E) is characterized by acute pain that radiates to the thighs and typically below the
25 knee. Straight-leg raising test is positive.
26
27 A compression fracture of the vertebrae (Choice C) presents as acute intense pain, and local spinal
28 tenderness is usually observed. Predisposing factors are usually obvious (postmenopausal or senile
29 osteoporosis, steroid treatment).
30
31 Ankylosing spondylitis (Choice B) and multiple myeloma (Choice A) are characterized by chronic back pain.
32
A metastatic or primary tumor (Choice F) is not likely in this case.
33
34 Educational objective:
35 Lumbosacral strain is the most common cause of acute back pain. The typical clinical scenario includes
36 acute onset of the back pain after physical exertion, absence of radiation, presence of paravertebral
37 tenderness, negative straight-leg raising test, and normal neurologic examination.
38
39
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6 A 66-year-old man comes to the physician complaining of progressive low er back pain. The pain is
7 associated with bilateral leg pain, which is precipitated by w alking. The pain improves with leaning on a cane
8 or sitting. Over-the-counter ibuprofen has provided moderate relief. The patient has no pain at night and no
9 problems with bow el or bladder function. He underwent coronary artery bypass grafting 6 years ago for
10 3-vessel coronary artery disease. Physical examination show s normal strength, reflexes, and sensation in his
11 legs. A straight leg raise test does not reproduce the pain. X-rays of the lumbosacral spine show
12 degenerative changes. Ankle brachial index is 1.1 on the right and 1.2 on the left. Which of the following is
13 most likely responsible for his current condition?
14
15
.~ A. Atherosclerosis [15%]
16
17 B. Disc herniation [4%]
18 .; C. Spinal canal narrowing [63%]
19
20 D. Spinal cord compression [6%]
21 E. Spondyloarthropathy [ 12%]
F. Vertebral metastasis [0%]
23
24
25 Explanation: User ld:
26
?.7
18
19
20
21
Neurogenic & vascular claudication
Neurogenic claudication
(pseudoclaudication)
Vascular claudication
I
23 Posture-dependent pain Exertion ally-dependent pain
24
Lumbar extension worsens Pain relieved with rest,
25
pain (eg, walking downhill) but not with bending forward
26
?,7 Lumbar flexion relieves pain while walking
18 (eg, walking while bent Lower-extremity
19
Symptoms forward) cramping/tightness
20 Lower-extremity numbness No significant lower-extremity
21 & tingling weakness
23 Lower-extremity weakness Possible buttock, thigh, calf,
24 Low back pain or foot pain
25
26 Decreased pulses
?.7 Normal pulses
18 Cool extremities
Examination Frequently nonrnal
19 Decreased hair growth
20 examination
Pallor with leg elevation
21
23 (Choice F) Vertebral metastasis should be suspected in patients with low back pain in conjunction with
24 history of malignancy, w eight loss, failure to improve with conservative therapy, and constant dull pain.
25 Symptoms are often nocturnal.
26
Educational objective:
27
Lumbar spinal stenosis is most commonly caused by degenerative changes in the spine and presents with
28
low back and leg pain. The leg pain of neurogenic claudication is position-dependent (exacerbated by lumbar
29
extension) and persists while standing still. Vascular claudication is exertion-dependent and resolves with
30
standing still. Arterial pulses and ankle-brachial index can differentiate between vascular and neurogenic
31
claudication .
32
33
34 References:
35 1. The reliability of differentiating neurogenic claudication from vascular claudication based
36 on symptomatic presentation.
37
38
39
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6 A 75-year-old w hite male comes to the physician's office for his routine health maintenance examination . He
7 has no symptoms. He has a past medical history significant for hypertension and hyperlipidemia . He takes
8 aspirin, hydrochlorothiazide and simvastatin. He does not smoke and consumes 1-2 beers on w eekends. He
9 w alks 2 miles every morning and eats a balanced diet. His vital signs are w ithin normal limits. His chest is
10 clear to auscultation, and his abdomen is soft and nontender. Rectal examination show s a diffusely enlarged,
11 firm prostate w ithout nodules. Stool for occult blood is negative. The distal interphalangeal joints are
12 enlarged, and his gait is normal. His labs are as follow s:
13 Total bilirubin 1.0 mg/dl
14 Alkaline phosphatase 420 U/L
15 Aspartate aminotransferase (SGOT) 20 U/L
16 Alanine aminotransferase (SGPT) 25 U/L
17 Serum creatinine 0.8 mg/dl
18 Calcium 8.8 mg/dl
19 Serum PSA 2.1 ng/ml
20
21
W hich of the follow ing is the most likely cause of the elevated alkaline phosphatase in this patient?
22
24 Elevation of alkaline phosphatase can result from many conditions. Most commonly, elevations of this
25 enzyme are seen in hepatobiliary disorders or diseases of bone causing increased bone turnover. The single
26 most common cause of asymptomatic isolated elevation of alkaline phosphatase in an elderly patient is
?.7 Paget's disease of bone (osteitis deformans). Paget's disease of bone is most commonly diagnosed in
18 asymptomatic individuals w hen an isolated elevated alkaline phosphatase is incidentally discovered on routine
19 blood tests. Bone lesions in this condition are the result of defective osteoid formation at sites of high bone
20 turnover resulting in hypertrophy of bone. The most commonly affected bones are the skull, clavicles, pelvis
21 and long bones. Pathologic fractures, pain, osteosarcoma and neurologic symptoms are possible
22 complications of this condition .
(Choice A) In patients w ith prostate cancer, prostate-specific antigen (PSA) is usually greater than 4 ng/ml.
24
Prostate cancer w ith bone metastasis may cause elevation of serum alkaline phosphatase but it w ill also
18 typically cause bone pain, osteoblastic bone lesions on radiographic studies and hypercalcemia due to some
19 degree of bone resorption despite the blastic nature of the lesions.
20
21 (Choice B) Patients of multiple m yeloma w ill have bone pain and hypercalcemia due to osteolysis as w ell as
22 monoclonal immunoglobulin proteins in the serum and urine. W eakness, fatigue, w eight loss, renal disease
and amyloidosis are also not uncommonly observed in this condition.
24
25 (Choice C) Statin drugs, such as simvastatin are not know n to cause isolated elevation of serum alkaline
26 phosphatase. They may, how ever, cause an elevation of the aminotransferases (Al T and AST) or
27 rhabdomyolysis leading to m yoglobinuria and renal failure.
28
(Choice E) Alcoholic liver disease causes elevations of the serum alanine aminotransferase (ALT), serum
29
aspartate aminotransferase (AST) and gamma glutamyl transferase (GGT). Elevation of the serum AST is
30
disproportionately higher than the serum ALT and the AST to ALT ratio is typically greater than 2 in liver
31
disease due to alcohol use.
32
33 Educational objective:
34 The most common cause of asymptomatic elevation of alkaline phosphatase in an elderly patient is Paget's
35 disease of bone (osteitis deformans). Patients w ith this condition are typically asymptomatic at the time of
36 diagnosis; the diagnosis is made by incidentally finding an isolated elevated alkaline phosphatase on routine
37 laboratory testing .
38
39
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6 A 38-year-old male w ith steroid-dependent sarcoidosis presents to the physician's office because of
7 progressive right hip pain . He localizes the pain to the right groin and states that the pain is present on w eight
8 bearing and at rest. His temperature is 37.2 C (98.9 F) and blood pressure is 156/86 mm Hg. Examination
9 show s decreased range of motion due to pain. He also has a round face and fullness in supraclavicular
10 area. Purple striae are present on skin. Muscle pow er is slightly decreased in the proximal thigh muscles in
11 both legs. Reflexes are 2+, and there are no sensory deficits. Plain films of the right hip show no significant
12 abnormalities. ESR is 10 mm/hr. W hich of the follow ing is the most likely cause of his hip pain?
13
14
A. Inflammatory arthritis [5%]
15
16 B . Cartilage degeneration [26%]
17 ~ C. Disruption of bone vasculature [59%]
18
D. Inflammation of the trochanteric bursa [5%]
19
20 E. Aortoiliac occlusion [4%]
21
22
Explanation: User ld:
23
The patient described is most likely experiencing corticosteroid-related osteonecrosis of his right femoral
25 head. Osteonecrosis is also referred to as aseptic necrosis, avascular necrosis, ischemic necrosis and
26 osteochondritis dessicans. There are numerous factors that are believed to play an etiologic role in this
?.7 condition. This process, how ever, proceeds through a common pathw ay regardless of the suspected
18 etiology. In all cases, the vasculature to the affected bone is disrupted causing bone and bone marrow
19 infarction. Subsequently, the bone is unable to remodel and trabecular thinning occurs ultimately leading to
20 collapse of the affected bone. This process may take months to years, on occasion, to occur. Clinically, the
21 patient experiences progressive pain during this time. In the case of osteonecrosis of the femoral head,
22 patients experience anterior hip pain w orsened by activity and relieved by rest w ith progressive limitation of
23 range of motion. Progression of disease w ill ultimately cause joint instability and pain at rest. In the first few
months of symptoms, x-rays w ill often fail to demonstrate an abnormality. MRI is the most sensitive test for
25 this condition. Precipitating factors other than chronic corticosteroid use include chronic alcohol use, trauma
26 and the antiphospholipid syndrome.
?.7
1? (Choice A) There are several forms of inflammatory arthritis including rheumatoid arthritis, gout, pseudogout,
18 psoriatic arthritis, ankylosing spondylitis, lupus and ochronosis among others. Each has a unique
19 presentation, but the case described is most consistent w ith osteonecrosis related to chronic corticosteroid
20 use.
21
22 (Choice B) Cartilage degeneration occurs in osteoarthritis. This condition typically affects patients over 40
23 years of age, though such patients may also present w ith anterior hip pain w orsened by activity. This patient's
clinical scenario is more suggestive of osteonecrosis due to the history of chronic corticosteroid use.
25
26 (Choice D) Inflammation of the trochanteric bursa (trochanteric bursitis) is caused by friction between the
27 tendons of the gluteus medius and tensor fascia lata over the greater trochanter of the femur. Pain is
28 localized over the lateral hip and is w orsened by palpation . Pain caused by pressure on the lateral hip may
29 interfere w ith sleeping in patients w ith this condition.
30
(Choice E) Male patients w ith aortoiliac occlusion (Leriche syndrome) classically present w ith low back, hip,
31
buttock and thigh claudication accompanied by impotence and atrophy of the low er extremities. Femoral
32
pulses are typically w eak and a bruit may be heard over the iliac and femoral arteries.
33
34 Educational objective:
35 Chronic corticosteroid use and chronic excessive ingestion of alcohol account for over 90% of cases of
36 avascular necrosis of bone (osteonecrosis). In the hip, patients present w ith slow ly progressive anterior hip
37 pain w ith limitation of range of motion.
38
39
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6 A 54-year-old w oman comes to the physician's office complaining of chronic, bilateral knee and hip pain . The
7 pain increases w ith activity and is relieved by rest. She denies fever, chills or w eight loss. The review of
8 systems is unremarkable. She currently w eighs 80 kg (180 lb) and is 146 em (59 in) tall. Her knee joints are
9 tender but there is no w armth, erythema or effusion. X-rays show narrow joint space, subchondral bone
10 cysts, and bony spurs in both knees. W hich of the follow ing interventions w ould provide the greatest long-
11 term benefit to this patient?
12
13
14 A. Muscle strengthening exercise [3%]
15 B. Non steroidal antiinflammatory agents [5%]
16 ~ C. Weight loss [88%]
17
18 D. Chondroitin sulfate [3%]
19 E. Acetaminophen w ith codeine [1 %]
20
21
22 Explanation: User ld:
18 This patient's presentation is most consistent w ith osteoarthritis (OA). Studies have show n a particularly
19 strong link between obesity and knee OA. Based on a height of 59 inches and a w eight of 180 pounds, this
20 patient has a BMI of 36, indicating moderate obesity. Patients w ith OA typically present w ith brief morning
21 stiffness (< 30 minutes) and exertional joint pain. Unlike autoimmune arthritides, systemic symptoms such as
22 fever and w eight loss are generally absent. Plain films of an osteoarthritic knee reveal a narrow ed joint space,
23 osteophytes, and subchondral sclerosis or cysts. Obesity is the most readily modifiable risk factor for
24 OA. W eight loss has been show n to slow progression of the OA and improve joint pain and function. Hence,
w eight loss is the most effective measure in slow ing progression of OA.
26
27 (Choice A) As part of an overall physical therapy program, muscle strengthening exercises play an integral
28 role in OA therapy. They reduce pain and improve mobility, but muscle strengthening does not slow the
29 progression of OA.
30
(Choice B, 0, and E) NSAIDs, acetaminophen, and chondroitin sulfate each play a role in the
31
pharmacotherapy of OA. They provide effective, temporary pain relief but do not slow the progression of OA.
32
33 Educational objective:
34 Plain films of an osteoarthritic knee reveal narrow ed joint space, osteophytes, and subchondral sclerosis or
35 cysts. Obesity is the most readily modifiable risk factor for OA, and w eight loss decreases joint pain,
36 increases function, and slow s progression of the disease. Pharmacologic therapy and exercise also play
37 integral roles in OA therapy.
38
39
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6 A 72-year-old Caucasian female complains of frequent headaches, fatigue and recent w eight loss. Her
7 shoulder muscles feel stiff in the morning. A tender cord is palpated in the right temporal area . Her ESR is 85
8 mm/hr. W hich of the follow ing is the most likely complication of this patient's condition?
9
10
11 <:: A. Chronic lymphocytic leukemia [12%]
12 B. Hypothyroidism [11 %]
13 .; C. Aortic aneurysm [41 %]
14
15 D. Ulcerative colitis [9%]
16 : E . Membranous glomerulonephritis [26%]
17
18
19 Explanation: User ld:
20
The patient described in the vignette has typical features of giant cell arteritis. Symptoms include headache,
21
jaw claudication, muscle fatigue, and visual disturbance. On examination, patients have scalp tenderness
~?
and a decreased temporal artery pulse. The erythrocyte sedimentation rate (ESR) is generally more than 50
18 mm/hr.
19
20 As giant cell arteritis can involve the branches of aorta, an aortic aneurysm is a w ell-know n complication . For
21 this reason, patients should be follow ed w ith serial chest x-rays.
22
23 (Choice A) Chronic lymphocytic leukemia is the most common form of leukemia in older individuals. The
24 presentation is very insidious. Although the exact etiology is unclear, certain chromosomal abnormalities can
25 predispose individuals to this condition.
27 (Choice B) The most common cause of hypothyroidism is chronic lymphocytic thyroiditis (Hashimoto's
28 disease). Radiation to the thyroid region predisposes to the development of hypothyroidism .
29
30 (Choice D) Ulcerative colitis is an inflammatory bow el disease involving the large intestine. It is more
31 common in Jew s, and those w ith a positive family history.
32
(Choice E) Important causes of membranous glomerulonephritis include hepatitis B and C, syphilis, gold,
33
penicillamine, SLE and rheumatoid arthritis. Many patients have no predisposing factors.
34
35 Educational objective:
36 Aortic aneurysms are w ell-know n complications of giant cell or temporal arteritis due to the involvement of the
37 branches of the aorta . For this reason, patients should be follow ed w ith serial chest x-rays.
38
39
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6 A 23-year-old w hite w oman presents complaining of 6 months of progressive low back pain. She complains
7 of morning stiffness that lasts one hour, and says her symptoms improve w ith physical activity. She denies
8 rash, eye pain, urinary problems, and diarrhea. Her past medical history is significant only for an
9 appendectomy at the age of 16 years. She has been taking birth control pills for the past l\'l'o years. She is
10 afebrile w ith normal w eight and height. Examination reveals reduced forward flexion of the lumbar spine and
11 tenderness over the sacroiliac joints. The remainder of the physical examination is normal. W hich of the
12 follow ing is the most appropriate next step in the management of this patient?
13
14
15 <::' A. HLA-B27 testing [30%]
16 B. ANA and rheumatoid factor levels [11 %]
17 C. Bone scan [1 %]
18
19 D. MRI of the spine [7%]
20 .; '.::' E . X-ray of the sacro-iliac joints [51%]
21
22
23 Explanation: User ld:
24
Ankylosing spondylitis (AS) is the most likely diagnosis in this patient. The highest incidence of AS occurs in
25
the second and third decades of life, and it has a male:female ratio of approximately 2:1. Any young patient
26
presenting w ith progressive low back pain and spinal stiffness of >3 months duration should be investigated
for this condition . Patients often complain of morning stiffness lasting >30 minutes, and their back pain
18
typically improves w ith exercise. Decreased lumbar spinal mobility and tenderness over the sacroiliac joints
19
are common exam findings. Anteroposterior x-ray of the sacroiliac joints is used to confirm the diagnosis in
20
the setting of a suggestive history and physical. Fusion of the sacroiliac joints and/or bamboo spine is
18 diagnostic.
19
20 (Choice A) There is a strong association bel\'Veen HLA-B27 and ankylosing spondylitis. W hile greater than
21 90% of patients w ith AS have HLA-B27, only 5% of patients w ith HLA-B27 have AS . Therefore, HLA-B27 is not
22 specific for AS and testing for it is not necessary for diagnosis. On the other hand, demonstrating
23 radiographic changes of the lumbar spine is necessary for diagnosis.
24
25 (Choice B) AS belongs to the category of seronegative spondyloarthropathies, so named because patients
26 are negative for rheumatoid factor and ANA.
28 (Choice C) Bone scan is not recommended for diagnosing ankylosing spondylitis. It is best for identifying
29 osteomyelitis, suspected fractures, and neoplasms.
30
(Choice D) W hen AS is strongly suspected clinically and lumbar spine x-ray findings are negative or
31
equivocal, MRI is recommended. MRI is highly sensitive and specific for sacroiliitis and may be diagnostic in
32
such cases. How ever, the effectiveness and low er cost of x-ray make it a logical first step.
33
34 Educational objective:
35 Ankylosing spondylitis is a seronegative spondyloarthropathy that presents w ith progressive inflammatory
36 back pain and stiffness. In the setting of suggestive findings on history and physical, AS is confirmed by plain
37 film x-ray demonstrating fused sacroiliac joints and/or bamboo spine.
38
39
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5
6 A 22-year-old soccer player comes to the emergency department with knee pain . During practice earlier that
7 day, she tried to run around another player on the right and felt a popping sensation in her right knee follow ed
8 by pain and rapid sw elling. The patient has no other injury to the knee. She has had no significant prior knee
9 injuries. Her past medical history is unremarkable. On physical examination, the right knee is significantly
10 sw ollen and tender. Ambulation appears awkward, and the patient hesitates to bear w eight on the right leg.
11 Aspiration of the knee yields grossly bloody joint fluid. Which of the following is the most likely diagnosis?
12
13
~ A Anterior cruciate ligament injury [46%]
14
15 B. Medial collateral ligament injury [14%]
16 C. Meniscal injury [28%]
17
D. Patellofemoral pain syndrome [1 %]
18
19 E. Popliteal cyst rupture [7%]
20 F. Stress fracture of the tibial plateau [3%]
21
22
23 Explanation: User ld:
24
25
26
Features of ant erior cruciate ligament injury
?.7
I
18 Injury Rapid deceleration or direction changes
19
20 mechanisms . Pivoting on lower extremity with foot planted
21
22
23 Pain: rapid onset, may be severe
24 A "popping" sensation at the time of injury
25 Symptoms
Significant swelling (effusion/ h emarthrosis)
26
?,7 Joint instability
18
19
Examination Anterior laxity of tibia relative to femur
20
21 findings (anterior drawer test, Lachman test)
22
23
24 Magnetic resonance imaging
25 Diagnosis
26
?.7 RICE (rest, ice, compression, elevation) measures
18 Treatment
19 +I- Surgery
20
@ USMLEWorld, LLC
21
22
23 Injuries to the anterior cruciate ligament (ACL) are common in young athletes, especially in w omen
24 participating in sports requiring rapid direction changes or pivots on the low er extremity (eg, soccer,
25 basketball, tennis}. ACL tears can also occur in high-contact sports or injuries involving a blow to the knee or
26 significant twisting force. Patients with partial- or full-thickness ACL tears typically experience a "popping"
?,7 sensation in their knee during the injury follow ed by rapid onset of hemarthrosis and a feeling of instability
18 when bearing w eight on the affected side.
19
20 Patients with an ACL tear will show laxity at the knee with the tibia able to be pulled forward relative to the
21 femur. Tw o such maneuvers -the Lachman test and the anterior drawer sign - are highly sensitive
22 (>90%} and specific for ACL injuries. In addition, there is usually a significant knee effusion due to
23 hemarthrosis. The diagnosis is usually confirmed on MRI.
24
(Choice B) Medial collateral ligament (MCL) tears may also occur in pivoting/twisting injuries or if the knee
25
is struck from the lateral side with the foot planted. Examination show s tenderness at the medial knee, and
26
laxity when the foot is gently forced into abduction with the knee stationary (valgus stress test}. How ever,
?.7
MCL injuries are not usually associated with significant hemarthrosis unless there is a concurrent ACL injury.
18
19 (Choice C) Meniscal tears are possible in athletes subjected to rapid direction changes and are
20 characterized by a subacute or chronic locking or popping sensation in the knee. How ever, immediate
21 symptoms at the time of the injury may be mild. Effusions are possible but typically develop slowly, and
22 hemarthrosis is rare.
23
24 (Choice D) Patellofemoral pain is commonly seen in young female athletes with chronic overuse rather
25 than acute trauma to the knee. Patients usually develop pain over the anterior knee that is reproduced by
26 extending the knee while compressing the patella (patellofemoral compression test}. Although the anterior
?,7 knee may have sw elling, true knee effusions and hemarthrosis are not seen.
18
(Choice E) Rupture of a popliteal cyst (Baker cyst} may cause posterior knee pain. How ever, this is more
19
common in older adults and is often associated with osteoarthritis of the knee. Patients may have sw elling at
20
the posterior knee and calf resembling deep venous thrombosis. Knee effusions and hemarthrosis are
21
usually not present.
22
23 (Choice F) Stress fractures of the tibial plateau may occur in female athletes, especially following abrupt
24 initiation or changes in exercise regimen . How ever, stress fractures typically present with progressively
25 w orsening pain and are much less common than ligament injuries.
26
27 Educational objective:
Anterior cruciate ligament (ACL} injuries are common, especially in young athletes in sports requiring rapid
29 direction changes or twisting movements of the low er extremity. ACL injuries usually present with rapid onset
30 of pain and sw elling with hemarthrosis. Examination findings include laxity of anterior motion of the tibia
31 relative to the femur.
32
33 References:
34
35 1. Anterior cruciate ligament rupture: differences between males and females .
36 2. Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management.
37
38
39
Time Spent: 3 seconds Copyright UW orld Last updated: [2/ 12/2015]
40
Media Exhibit
ACL tear
ACL tear
Femur
Anterior
cruciate
ligament
Articular
cartilage
Lateral
collateral ....._
ligament Posterior
1 _____. cruciate
Popliteus
tendon
--k"l
y __., ,______..--- 1i gament
-----..__Medial
meniscus
Lateral
meniscus
Transverse
ligament
'-.....Medial ACL
Media Exhibit
Thessaly test
'
Patient stands on 1 leg with knee flexed 20 degrees
Pain or locking with internal &/or external knee rotation
suggests meniscal tear
Apl ey test
~
ACL =anterior cruciate ligamen~ LCL = lateral collateral ligamen~ MCL = medial collateral ligament;
PCL = posterior cruciate ligament.
UWorld
"
~
Media Exhibit
Femur------':-- - -
Direction ---tb~
ofimpact Ill"
Medial
- 7----collateral
ligament
- - - - -Tibia
@ USMLEWortd. LlC
Media Exhibit
Femur - - - - -
Patellar
- --,--
ligament
18 (Choice B) Abdominal aortic aneurysms (AAA) are usually asymptomatic but can present w ith severe back or
19 abdominal pain and hypotension upon rupture.
20
21 (Choice D) Lumbar disk herniation typically presents w ith the acute onset of back pain w ith or w ithout
22 radiation dow n one leg. Patients usually recall an inciting event. As w ith lumbar spinal stenosis, the pain may
23 be radiating and be associated w ith neurologic symptoms. How ever, in disc herniation, lumbar flexion and
24 sitting w ill make the pain w orse.
25
26 (Choice E) Spina bifida occulta is a congenital defect of the vertebral arch that does not involve protrusion of
27 the cord or dura. It is typically asymptomatic and diagnosed as an incidental radiographic finding.
28
29 (Choice F) Metastatic disease of the vertebrae typically presents as pain that is chronic, dull, w orse at night,
30 and changes little w ith activity. The pain is usually non-radiating.
31
(Choice G) Seronegative spondylarthritis (e.g., ankylosing spondylitis) is characterized by progressive
32
limitation of back motion. It most often occurs in young men. Back pain and stiffness are typically w orst in the
33
morning and improve as the day progresses.
34
35 Educational Objective:
Lumbar spinal stenosis is a common cause of back pain in patients over 60 years of age. It is characterized
37 by back pain radiating to the buttocks and thighs that interferes w ith w alking and lumbar extension.
38
39
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6 A 23-year-old man complains of progressive low back pain for the past several months. He has morning
7 stiffness that lasts for one hour. He has no history of trauma to his back and denies any recent illness. He
8 had an episode of pain, blurring, and photophobia of his right eye two years ago that required ophthalmology
9 evaluation . His vital signs are w ithin normal limits. Examination show s tenderness in both sacroiliac joints
10 and reduced range of motion of the low er back. If measured, w hich of the follow ing is most likely to be
11 present in this patient?
12
13
14 A. Rheumatoid factor [2%]
15 B. Anti-cyclic citrullinated peptide (CCP} antibodies [2%]
16 C. Anti dsDNA antibodies [1 %]
17
18 v D. HLA B 27 positivity [93%]
19 E. Glutamic acid decarboxylase antibodies [1 %]
20 F. Acetylcholine receptor antibodies [1 %]
21
22
23 Explanation: User ld:
24
25 Ankylosing spondylitis (AS} is most common in men aged 20-30 years, and presents w ith progressive back
26 pain and morning stiffness of greater than 3 months duration. Although there are no pathognomonic signs of
?.7 AS on exam, reduced range of motion in the low er back and sacroiliac tenderness support the diagnosis. In a
18 patient w ith suggestive signs and symptoms, the diagnosis may be confirmed by a plain film demonstrating
sacroiliitis. In addition to skeletal involvement, patients w ith AS may develop extraarticular manifestations.
18 Anterior uveitis is the most common extraarticular manifestation, occurring in 25- 40% of patients. It presents
19 w ith monocular pain, blurring and photophobia . There is a strong correlation between HLA-827 and AS, w ith
20 HLA-827 positivity occurring in 90% of all patients afflicted by the disease.
21
22 (Choices A and B) Positive rheumatoid factor and anti-CCP antibodies are typically seen in rheumatoid
23 arthritis. AS belongs to the seronegative spondyloarthropathies, so named because they test negative for
24 these serologic markers.
25
26 (Choice C) Anti-dsDNA antibodies are highly specific for systemic lupus erythematosus. This disease may
27 present w ith arthritis, rash, renal disease, and systemic symptoms, but sacroiliac inflammation is uncommon.
28
29 (Choice E) Glutamic acid decarboxylase antibodies are seen in 70% of type I diabetics at the time of
30 diagnosis.
31
(Choice F) Acetylcholine receptor antibodies are seen in m yasthenia gravis.
32
33 Educational objective:
34 Ankylosing spondylitis (AS} is a seronegative spondyloarthropathy associated w ith HLA-827. It is most
35 common in young men and presents w ith progressive, inflammatory back pain and stiffness. Reduced low er
36 back range of motion and sacroiliac tenderness are typical on exam. The most common extraarticular
manifestation is anterior uveitis.
38
39
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6 A 35-year-old w oman comes to the physician with pain and stiffness of her w rists and hand joints for the last
7 several months. Her morning stiffness lasts for more than an hour. She also complains of joint sw elling. Her
8 past medical history is significant only for a similar episode a year ago, which resolved with over-the-counter
9 ibuprofen. Joint examination show s mild redness, w armth, sw elling, and tenderness in the proximal
10 interphalangeal and metacarpophalangeal joints and wrists. X-rays show periarticular osteopenia and
11 erosions of the proximal interphalangeal and metacarpophalangeal joints. The patient began taking
12 indomethacin, which provides good relief, but symptoms recur if she skips a dose. Which of the following is
13 the most appropriate next step in management of this patient?
14
15
16 A Azathioprine [1 %1
17 B. Celecoxib [3%1
18 C. Etanercept [2%1
19
20 D. Glucocorticoids [9%1
21 E. lnfliximab [3%1
22 .; F. Methotrexate [70%1
23
24 G. No additional treatment [11 %1
25
26 Explanation: User ld:
?.7
18
19
20
21
22
This patient's presentation is consistent with moderate-to-severe rheumatoid arthritis (RA). RA is a chronic,
systemic inflammatory disorder with progressive erosion of the bone and cartilage and significant joint
destruction and deformity. Patients typically present with joint findings (eg, pain, stiffness, swelling), morning
stiffness, involvement of proximal interphalangeal and metacarpophalangeal joints, and radiographic evidence
I
of erosions and/or periarticular osteopenia . Treatment goals in RA are to induce and maintain early
23 remission, control synovitis, and prevent progression of joint damage.
24
25
26 Rheumatoid arthritis
?,7
18
19
20
21 Methotrexate
22
23
24
25
26 Persistent symptoms for> 6 months
?.7
18 I
19
20
21
+ Inadequate
Step-up therapy Parallel therapy
22 response
23 Add b iologic agent Add another non-biologic agent
24 (e.g., TNF inhibitor) (e.g., sulfasalazine, hydroxychloroquine)
25
26
?,7
18
19 Inadequate response
20
21
22
23
24 Switch to alternative TNF inhibitor
25
& continue methotrexate
26
?.7
18 <;) USMLEWorld, l lC
19
20 All patients diagnosed with RA should be started on disease-modifying antirheumatic agents (DMARDs) as
21 soon as possible as joint damage begins early in its course (Choice G). Nonsteroidal anti-inflammatory
22 drugs and COX-2 inhibitors (eg, celecoxib) are adjunctive therapies for symptomatic relief but do not reduce
23 disease progression. Glucocorticoids can also relieve symptoms and short-term radiographic progression
24 but are also not effective in preventing eventual joint destruction. In fact, they can result in generalized bone
25 loss (ie, osteoporosis).
26
?,7 DMARDs include nonbiologic agents (eg, methotrexate, hydroxychloroquine, sulfasalazine, leflunomide,
18 azathioprine) and biologic agents (eg, etanercept, infliximab, adalimumab, tocilizumab, rituximab).
19 Methotrexate is the preferred initial DMARD in patients with moderately to severely active RA due to its
20 efficacy and long-term safety profile. Patients should be tested for hepatitis B and C and tuberculosis
21 before starting therapy. Methotrexate should not be used in patients who are pregnant or are planning to
22 become pregnant in the near future and those with severe renal insufficiency, liver disease, or excessive
~9
alcohol intake. Patients who do not respond after 6 months may require biologic DMARDs such as tumor
18 necrosis factor-alpha inhibitors (eg, etanercept, infliximab) as step-up therapy (Choices C and E).
19
(Choice A) Azathioprine is an immunosuppressive agent that has been used to treat RA. How ever, it is not
20
as efficacious as other DMARDs and is associated with significant hematologic and gastrointestinal toxicity.
21
22 (Choices B and D) This patient notes improvement with indomethacin and does not require additional
23 symptomatic treatment with celecoxib or glucocorticoids.
24
25 Educational objective:
26 All rheumatoid arthritis (RA) patients should receive disease-modifying antirheumatic drugs (DMARDs) as
27 early as possible in the disease course. Methotrexate is the initial DMARD of choice in most patients with
28 active RA. Nonsteroidal anti-inflammatory drugs or glucocorticoids should be used for initial temporary
29 symptomatic relief while aw aiting response to DMARD therapy.
30
31 References:
32
33 1. In the clinic. rheumatoid arthritis.
34 2. 2012 update of the 2008 American College of Rheumatology recommendations for the use
35 of disease-modifying antirheumatic drugs and biologic agents in the treatment of
36 rheumatoid arthritis.
37
! 13 - 13164) Medicine Rheumatology/Orthopedics & Sp. . Temporal Arteritis And Vision Loss
I 16- [4572) Medicine Rheumatology/Orthopedics & Sp. . Rheumatoid Arthritis And Osteop...
! 35 - 14264) Medicine Rheumatology/Orthopedics & Sp... Acute Lower Lumoar Back Pain
...
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