Case-based MCQ

Explanation: Correct Answer Is B Most cases of acute (ie, <4 weeks) low back pain have a benign etiology and resolve spontaneously; imaging generally does not improve outcomes and is not recommended.  However, spinal imaging is indicated for patients with significant neurologic deficits or red-flag features suggesting increased risk for infection, malignancy, or bony abnormalities (eg, compression fracture). This patient has features that raise concern for malignant back pain, including nocturnal pain and history of malignancy; therefore, she warrants imaging despite her unremarkable neurological examination (given the urgency in treating potential metastatic or bony lesions).  The preferred test is spinal MRI, which has a high sensitivity for lytic bone lesions and metastasis in the surrounding soft tissues.  If MRI cannot be performed, CT scan has good sensitivity for bony disruption and is a reasonable alternate test.  Plain film x-rays have lower sensitivity for bone metastasis, but some guidelines suggest x-ray combined with inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) to increase sensitivity for patients with moderate clinical suspicion for malignancy. Epidural corticosteroid injection is indicated for chronic radicular pain (eg, due to a herniated disc) that has failed noninvasive treatment, but it is not indicated for acute nonradicular pain, as in this patient. Uncomplicated pain with no red-flag features can be managed symptomatically with nonsteroidal anti-inflammatory drugs (NSAIDs).  Opioids are not more effective than NSAIDs, so they are not recommended for initial therapy.  Regardless, this patient requires additional evaluation first. Physical therapy referral for a supervised exercise program is used primarily for patients with persistent (ie, >4 weeks) back pain and can be considered for those with risk factors for chronic pain disorders (eg, poor functional status, psychiatric comorbidity). Most patients with acute low back pain do not require imaging.  However, spinal imaging is indicated for patients with significant neurologic deficits or clinical features suggesting increased risk for infection, malignancy, or bony abnormalities.  The preferred test for patients with a history of malignancy is spinal MRI, which has high sensitivity for lytic bone lesions and metastasis in the surrounding soft tissues

A 61-year-old woman comes to the office due to a 2-week history of low back pain.  The patient has a constant, dull, aching pain that is more pronounced at night and has awakened her on several occasions.  She has had no trauma or other back conditions.  There is no associated fever, chills, bowel or bladder incontinence, or lower extremity weakness or numbness.  Medical history is notable for hypertension and breast cancer at age 55, which was treated with lumpectomy, radiation therapy, and hormone therapy.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 134/86 mm Hg, pulse is 76/min, and respirations are 12/min.  Head and neck, cardiac, lung, breast, and abdominal examinations show no abnormalities.  Spinal examination shows no deformities or focal tenderness.  Lower extremity motor strength and reflexes are normal and symmetric.  Straight-leg raising test is negative.  Which of the following is the most appropriate next step in management of this patient? A. Epidural corticosteroid injection B. Lumbosacral spinal imaging C. Opioid analgesic at bedtime D. Supervised exercise program E. Trial of nonsteroidal anti-inflammatory drugs and follow-up

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Correct Answer Is A This patient with rheumatoid arthritis (RA) is on disease-modifying antirheumatic drug (DMARD) therapy, which improves long-term joint function and is initiated as soon as practical after diagnosis.  Methotrexate is the preferred first-line DMARD for most patients with RA. However, this patient now has macrocytic anemia (mean corpuscular volume >100 µm3), a potential adverse effect of methotrexate.  Methotrexate inhibits dihydrofolate reductase, which can lead to cellular folate depletion.  Hematologic effects can range from mild macrocytosis to severe pancytopenia.  Methotrexate is also associated with hepatotoxicity, especially in patients with comorbid liver disease.  Mild elevations in hepatic transaminases are common, and chronic liver disease and cirrhosis may occur over time.  Other adverse effects of methotrexate include nausea, stomatitis, rash, interstitial lung disease, alopecia, and fever. Therefore, patients on methotrexate should have regular monitoring with complete blood counts and hepatic function markers (eg, serum albumin, transaminases).  Much of the toxicity of methotrexate, including hepatotoxicity, can be mitigated by concurrent administration of folic (or folinic) acid, which does not reduce the effectiveness of the drug.  Due to the risk of hepatotoxicity, patients should avoid alcohol intake while on treatment. Calcineurin inhibitors (eg, cyclosporine, tacrolimus) are associated with neurotoxicity; manifestations include headache, seizures, tremor, encephalopathy, and peripheral pain.  However, these medications do not commonly cause macrocytic anemia and are rarely used for RA. Glucocorticoids (eg, prednisone) are used in acute management of RA.  Major adverse effects include Cushing syndrome, osteoporosis, adrenocortical atrophy, and poor wound healing; however, they do not commonly cause macrocytosis.  Unlike DMARDs, glucocorticoids do not alter the course of joint destruction and are not continued chronically in most patients. Hydroxychloroquine is an antimalarial DMARD that is well tolerated in management of RA and other autoimmune disorders.  It can cause irreversible retinal toxicity and warrants regular ophthalmologic examination.  Hematologic effects are uncommon. Tumor necrosis factor (TNF) inhibitors (eg, etanercept, adalimumab) are large-molecule biologic DMARDs that are very effective in the treatment of RA.  They have potent immunosuppressive qualities and are associated with increased risk for reactivation of latent tuberculosis.  TNF inhibitors commonly cause neutropenia, but macrocytic anemia is not a common effect. Methotrexate is a disease-modifying antirheumatic drug used for rheumatoid arthritis.  Macrocytic anemia and hepatotoxicity are common adverse effects.  The toxicity of methotrexate (including hepatotoxicity) can be mitigated by the administration of folic acid, which does not reduce the effectiveness of the drug.

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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