Case-based MCQ

A 56-year-old woman comes to the office with her daughter to discuss knee pain, which has been ongoing for several years.  The patient has a high tolerance for pain and has previously refused to see a doctor for her condition.  Lately, the pain has been affecting the patient’s daily activities, and she spends most of the day sitting in a chair.  The knee pain and stiffness are more pronounced on the right side and are worse in the morning but gradually improve by the afternoon.  She takes no medications.  Review of systems is positive for fatigue.  Vital signs are within normal limits.  BMI is 31 kg/m2.  Lower extremity examination shows that both knees are swollen and tender but more so on the right side.  The patient is unable to fully flex or extend the right knee.  There is mild, bilateral atrophy of the quadriceps.  Radiographs of the knees reveal osteopenia of the distal femur, multiple periarticular erosions, and soft tissue swelling.  Which of the following is the best long-term management for the most likely diagnosis in this patient? A. Antifolate immunosuppressant B. Knee braces and weight loss C. Systemic glucocorticoid D. Total knee replacement E. Urate-lowering therapy

Correct Answer Is C This patient’s low body weight (BMI <18.5 kg/m2), stress fracture, and distress in response to the recommendation to limit his physical activity are concerning for anorexia nervosa (AN).  Although AN is more common in female patients, male patients are also affected and at risk for bone loss.  Decreased bone mineral density, which is caused by a number of factors (eg, endocrine abnormalities, hypercortisolism, growth hormone resistance), results in an increased risk of bone fractures.  Other medical complications associated with AN include bradycardia, hypotension, and cardiac atrophy. The most important next step in management of this patient is to obtain a comprehensive dietary history.  Caloric intake and meal patterns, attitudes about food and weight, and history of bingeing and efforts to control weight with compensatory behaviors (eg, exercise, fasting, self-induced vomiting, misuse of laxatives, diuretics) should be assessed.  In addition, AN in male patients may present with a focus on muscularity rather than thinness.  In these cases, dietary history may reveal dietary restrictions aimed at muscle building and the use of protein supplements at the expense of balanced nutrition. Advising participation in another sport would not treat an underlying eating disorder. Although exogenous steroid use (eg, androgen) can predispose to decreased bone mineral density and fractures, it is typically associated with increased muscle strength and mass, and other typical signs of steroid use could be seen (eg, hypertension, acne, gynecomastia, testicular shrinkage).  Obtaining a dietary history would take priority in this patient with significantly low body weight and no other signs of steroid use. Hyperthyroidism can result in decreased bone mineral density and weight loss.  However, these symptoms are typically accompanied by increased appetite and signs of sympathetic hyperstimulation such as tachycardia, hypertension, heat intolerance, tremor, and hyperreflexia, which are not evident in this patient.  Hyperthyroidism would not explain this man’s distress at having to limit his physical activity. The initial management of small tibial stress fractures includes rest, analgesia, and stabilization with a splint or brace if necessary.  Surgical intervention could be considered for severe fractures or for lack of healing or severe pain despite conservative treatment. A dietary history to assess for anorexia nervosa should be obtained in any patient with a stress fracture, low body weight, and distress at having to limit physical activity.  Patients with anorexia nervosa are at risk for stress fractures due to decreased bone mineral density.

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A 20-year-old man comes to the emergency department due to worsening right leg pain.  The patient runs 10 km daily, but several weeks ago, he began having dull pain at the right lower shin during runs.  Now, the pain occurs even with light walking.  He has had no trauma, fever, chills, or redness in the affected area.  The patient has no prior medical conditions and takes no medications.  Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, pulse is 56/min, and respirations are 16/min.  BMI is 17 kg/m2.  Physical examination reveals tenderness of the right lower anterior tibia.  X-ray of the right lower extremity reveals a small tibial stress fracture.  When the findings are explained and treatment with analgesics and limited physical activity is discussed, the patient becomes distressed that he has to stop running.  Which of the following is the most appropriate next step in management of this patient? A. Advise participation in different sports B. Inquire about exogenous steroid use C. Obtain comprehensive dietary history D. Order thyroid function studies E. Refer for surgical intervention

Correct Answer Is A Septic bursitis This patient’s presentation is concerning for septic bursitis.  The prepatellar bursa is a fluid-filled synovial sac between the patella and the skin that alleviates friction.  Infection of the bursa can occur due to penetrating trauma, superficial abrasions (eg, from working while kneeling), or extension from local cellulitis.  Gram-positive skin floras (eg, Staphylococcus aureus) account for most cases, and the risk is greater in patients with immunocompromising conditions (eg, diabetes mellitus). Septic bursitis is characterized by boggy swelling of the bursa associated with erythema, warmth, pain, and fever, although fever may be less prominent in patients age ≥65.  Aspiration of bursal fluid is necessary to confirm the diagnosis; the fluid should be sent for cell count and differential, Gram stain, and culture.  Treatment includes systemic antibiotics; drainage is indicated when the bursitis fails to improve after 36-48 hours of antibiotic therapy or compressive symptoms (eg, neurovascular compromise) are present. Knee joint (rather than bursal fluid) aspiration is indicated for suspected septic arthritis, which presents with knee effusion and severely painful, reduced range of motion.  This patient has intact range of motion of the knee with little pain, indicating that the pathology is extraarticular. Gout can cause an inflammatory bursitis resembling septic bursitis, and bursa fluid is often sent for crystal microscopy.  However, gouty bursitis is significantly less common than septic bursitis, and infection should be ruled out before empirical treatment for gout (eg, colchicine) is initiated. A knee compression wrap and ice application are used to treat noninflammatory bursitis due to overuse.  This patient’s erythema and warmth are atypical for noninflammatory bursitis.  In some patients, it may be hard to differentiate septic from noninflammatory bursitis.  Therefore, aspiration should be performed to rule out infection. Knee x-ray may show nonspecific bursal swelling but does not rule out infection.  X-ray is most helpful if a concurrent fracture (eg, due to a fall) or foreign body is suspected. Septic prepatellar bursitis is characterized by acute erythema, warmth, and pain accompanying bursal swelling.  It is usually caused by skin breakage that allows entry of skin floras (eg, Staphylococcus).  Bursal fluid analysis is needed to confirm the diagnosis.  Treatment includes systemic antibiotics

A 68-year-old man comes to the office due to right knee pain and swelling.  Three days ago, the patient spent most of the day on his knees while replacing the kitchen floor.  The next day, the right knee started to become increasingly red and painful.  Medical history includes hypertension and type 2 diabetes mellitus.  Temperature is 37.8 C (100 F), blood pressure is 130/80 mm Hg, and pulse is 92/min.  On examination, erythema and warmth are present at the anterior right knee, as shown in the image below.  Palpation reveals a 5-cm, tender, fluctuant swelling just anterior to the patella.  Range of motion of the knee is intact but produces mild pain at the end-range of flexion and extension.  Pedal pulses are 2+, and sensation in the lower extremities is intact.  Gait is normal.  Which of the following is the most appropriate next step in management of this patient? A. Aspiration of the bursal fluid B. Aspiration of the knee joint C. Empiric colchicine therapy D. Knee compression wrap and ice application E. X-ray of the knee

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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