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A 40-year-old woman comes to the office for follow-up.  The patient has a 4-year history of rheumatoid arthritis and has been taking a disease-modifying therapy.  She reports significant improvement in joint pain and stiffness with treatment and can now perform daily activities without difficulty.  The patient has no other medical conditions and does not use tobacco, alcohol, or illicit drugs.  She consumes a balanced diet and exercises most days of the week.  Vital signs are normal.  Physical examination shows no significant joint swelling, erythema, or tenderness.  Laboratory results are as follows: Complete blood count     Hemoglobin 11.2 g/dL     Mean corpuscular volume 108 µm3     Platelets 226,000/mm3     Leukocytes 7,800/mm3 Serum chemistry     Sodium 140 mmol/L     Potassium 4.0 mmol/L     Bicarbonate 24 mmol/L     Creatinine 70.7 umol/L     Calcium 2.4 mmol/L     Glucose 5.6 mmol/L Laboratory studies were within normal limits 6 months ago.  Which of the following is the most likely additional adverse effect of this patient’s pharmacotherapy? A. Hepatotoxicity B. Neurotoxicity C. Osteoporosis D. Retinal toxicity E. Tuberculosis reactivation

Explanation: Correct Answer Is D This patient with back pain radiating to the thighs has symptoms typical of lumbar spinal stenosis (SS).  SS is caused by narrowing of the spinal canal, leading to compression of one or more spinal roots.  It is primarily seen in degenerative arthritis with osteophyte formation affecting the facet joints (spondylosis).  However, other factors may contribute, including hypertrophy of the ligamentum flavum, bulging of the intervertebral discs, and spondylolisthesis (displacement of one vertebral body relative to another).  Most patients are over age 60. The symptoms of SS are posture-dependent.  Extension of the lumbar spine (eg, standing, walking upright) further narrows the spinal canal and worsens the symptoms, whereas lumbar flexion (eg, walking uphill, leaning on a cane) relieves the pain.  The onset of pain with walking is referred to as “neurogenic claudication” as it may resemble symptoms seen in vascular claudication.  However, vascular claudication causes pain with exertion and relief with rest, whereas neurogenic claudication is relieved by walking while leaning forward (“shopping cart sign”), and exercise with the spine flexed (eg, cycling) does not incite symptoms.  The diagnosis of SS can be confirmed on MRI of the spine.  Most patients are treated conservatively with physical therapy and exercise, although some require surgical intervention. Cervical spondylotic myelopathy presents with weakness, paresthesias, and loss of fine motor control.  Neck and upper extremity symptoms are usually present, and patients will show upper motor neuron signs (eg, hyperreflexia, upgoing plantar reflex). Lumbar disk herniation typically causes acute back pain with unilateral radiation down the sciatic nerve to the foot (sciatica).  It usually follows an inciting event, and lumbar flexion makes the pain worse. Vertebral metastasis presents as dull, non-radiating pain that is worse at night and not related to position or activity.  Patients often have a known malignancy or systemic symptoms (eg, weight loss). Lumbar spinal stenosis is a common cause of back pain in patients age >60.  It is characterized by back pain radiating to the thighs that is worse with lumbar extension and persists while standing still.  Vascular claudication is exertion-dependent and resolves with standing still

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A 65-year-old man comes to the office due to a 4-month history of periodic back pain radiating to his buttocks and thighs. The pain is exacerbated by walking or prolonged standing, although he can tolerate bicycling without significant discomfort. Associated symptoms include occasional tingling and numbness in both lower extremities. Medical history is notable for benign prostatic hyperplasia, hypertension, and hypercholesterolemia, for which he takes appropriate medications. The patient does not use tobacco, alcohol, or illicit drugs. His blood pressure is 140/80 mm Hg, pulse is 76/min, and respirations are 14/min. On examination, distal pulses are full and symmetric. Neurologic examination shows normal motor strength, deep tendon reflexes, and plantar reflexes in the lower extremities bilaterally. Which of the following is the most likely cause of this patient’s condition? A. Cervical spondylotic myelopathy B. Iliac artery atherosclerosis C. Lumbar disk herniation D. Lumbar spinal stenosis E. Metastatic disease

Explanation: Correct Answer Is D This patient has slipped capital femoral epiphysis (SCFE), characterized by anterolateral and superior displacement of the proximal femur along the physis (growth plate).  During periods of accelerated growth (eg, early adolescence), the physis is relatively weak due to its cartilaginous composition and rapid expansion.  Although obesity is a significant risk factor (due to increased mechanical strain on the physis), SCFE can also occur in tall, thin adolescents during a growth spurt (as seen in this patient). Classic presentation is an insidious onset of dull hip pain and limp.  Minor trauma, as seen in this patient, can sometimes exacerbate the pain and prompt the patient to seek medical attention.  On examination, patients hold the affected hip in passive external rotation and exhibit decreased internal rotation, abduction, and flexion.  Hip radiographs (anteroposterior and frog-leg lateral views) are diagnostic.  Bilateral hips should be imaged for comparison and assessed for contralateral displacement.  Treatment is immediate stabilization of the physis with surgical fixation to avoid the risk of avascular necrosis. Femoral neck fracture most commonly occurs in elderly patients with osteopenia.  In children, the fracture is usually secondary to high-impact trauma (eg, motor vehicle collision).  Presentation includes hip pain and decreased range of motion; however, x-ray would show a fracture line, not seen in this case. Legg-Calvé-Perthes disease, or idiopathic avascular necrosis of the hip, most commonly affects boys age 5-7 and presents with insidious onset of hip pain and limp.  X-ray may be normal in early disease or show fragmentation of the femoral head, not displacement of the femoral head. Osteomyelitis typically presents with fever, bony tenderness, and swelling.  Initial x-ray may be normal, but evidence of bony destruction is usually present within 1-2 weeks of symptom onset. Transient synovitis involving the hip is an inflammatory condition that presents in children age 3-8 with hip pain and limp, often after a viral illness.  Symptoms typically improve (not worsen) over weeks, and x-ray is normal or may show joint effusion. Slipped capital femoral epiphysis (SCFE), which causes hip pain and limp, is characterized by displacement of the proximal femur relative to the femoral head along the growth plate.  Obesity is a risk factor, but SCFE may also be seen in tall, thin adolescents during periods of accelerated growth.

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A 13-year-old boy is brought to the clinic by his mother for evaluation of hip pain.  For the past 3 weeks, he has had mild pain in his right hip with an associated limp, which he attributed to a muscle strain from skateboarding.  The patient fell while skateboarding last night, which resulted in worsened pain.  The patient has taken ibuprofen with some improvement in his pain.  He has no chronic medical conditions but did have a runny nose and nasal congestion for a few days last week.  Height and weight are in the 95th and 50th percentiles, respectively.  Temperature is 37 C.  The patient walks with a limp to the examination table, avoiding bearing weight on his right leg.  Examination of the right hip shows limited range of motion with internal rotation.  There is full range of motion on the left side.  Frog-leg lateral x-ray of bilateral hips is shown below. Which of the following is the most likely diagnosis in this patient?   A. Femoral neck fracture B. Legg-Calvé-Perthes disease C. Osteomyelitis D. Slipped capital femoral epiphysis E. Transient synovitis

Correct Answer Is E Adolescent idiopathic scoliosis (AIS) refers to lateral curvature (ie, Cobb angle >10 degrees) of the spine without a specified etiology.  The deformity typically presents in children age ≥10 during periods of rapid growth.  Although poor posture may be noted, AIS is usually asymptomatic and identified during school scoliosis screening or annual physical examination.  Inspection of the back may reveal asymmetry of the shoulders, scapulae, or iliac crest.  Forward bend test shows asymmetric thoracic or lumbar prominence. The first step in evaluating clinically evident spinal asymmetry is x-ray of the spine.  Full-back posteroanterior and lateral radiographs confirm the diagnosis, measure the severity of disease (ie, Cobb angle), and assess skeletal maturity. Management of AIS depends on risk of progression (eg, degree of skeletal maturity) and severity (ie, degree of curvature on x-ray).  Scoliosis typically progresses slower with increasing degrees of bone ossification.  Therefore, patients are at increased risk for progression in early puberty (eg, premenarche). Most curves are mild (ie, Cobb angle 10-30 degrees) and can be monitored clinically every 6 months.  A thoracolumbosacral spinal brace is indicated in a child with growth potential remaining and Cobb angle ≥30 degrees to help reduce curve progression.  Surgical fixation is considered for severe curvature (ie, Cobb angle ≥40-50 degrees) . Scoliosis due to pathologic causes (eg, mass, dysraphism) may present with neurologic symptoms, severe pain, rapid progression, or vertebral abnormalities on x-ray.  MRI of the spine should be performed in such cases but is not indicated in this asymptomatic patient. Adolescent idiopathic scoliosis is defined as lateral curvature of the spine without a known etiology in a child age ≥10.  Forward bend test reveals an asymmetric thoracic or lumbar prominence.  The first step in evaluation is x-ray of the spine to determine the degree of curvature and assess skeletal maturity

A 13-year-old girl is brought to the office by her mother for a preparticipation sports physical.  She is planning to play lacrosse, which she had played the previous school year.  The coach notified the mother that the girl’s posture seemed abnormal.  The patient has no chronic medical conditions and takes no daily medications.  She has not undergone menarche.  BMI is at the 50th percentile.  Physical examination shows a right-sided lumbar prominence during forward bend test, and there is no tenderness of the spine.  The remainder of the examination reveals no abnormalities with normal neurologic function.  Which of the following is the best next step in the management of this patient? A. MRI of the spine B. Reassurance and follow-up in 6 months C. Surgical fixation D. Thoracolumbosacral spinal brace E. X-ray of the spine

Correct Answer Is A This patient has lateral wrist pain consistent with de Quervain tendinopathy (DQT).  DQT is an overuse syndrome involving the tendons of the abductor pollicis longus and extensor pollicis brevis and occurs most prominently at the point where the tendons pass under the extensor retinaculum in the first dorsal compartment.  It most commonly occurs in women age 30-50 and is seen in higher frequencies 4-6 weeks postpartum, possibly because of repetitive thumb abduction and extension when lifting the infant. The diagnosis of DQT is based on clinical features.  Examination typically shows tenderness at the radial side of the wrist at the base of the hand.  In addition, the Finkelstein test (adduction of the wrist with the fingers closed over the thumb in a fist) causes passive stretching of the tendons over the radial styloid; reproduction of the pain in this maneuver is strongly suggestive of DQT.  Conservative management with nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and thumb spica splinting is usually adequate. Flexor carpi radialis tenosynovitis is associated with excessive wrist flexion and characterized by pain and tenderness at the anterior aspect of the wrist.  It is relatively uncommon; overuse of this muscle more commonly causes symptoms at the proximal origin (ie, medial epicondylitis). Osteoarthritis of the first metacarpophalangeal joint causes pain over that joint, not at the carpometacarpal joint.  It would be uncommon in this young patient without a history of significant trauma. Scaphoid fractures typically occur during forceful hyperextension of the wrist (eg, fall on an outstretched hand).  Pain and tenderness typically localize to the anatomic snuffbox. Stenosing tenosynovitis (“trigger thumb”) results in pain over the palmar aspect of the first metacarpophalangeal joint; the pain is associated with a catching sensation during movement or locking of the thumb in flexion. De Quervain tendinopathy presents with lateral wrist pain over the tendons of the abductor pollicis longus and extensor pollicis brevis.  It is most common in women age 30-50, with an increased frequency during the postpartum period.  Examination shows tenderness at the radial side of the wrist and a positive Finkelstein test (reproduction of pain on adduction