A1

A 26-year-old male presents to the hospital with history of stiffness of the back
and low back pain since last two years. The pain is worse on getting up in the
morning and it improves as the day progresses. For last few weeks, he has had
episodes of bloody diarrhea that last for 1-2 days. On examination, movements of
back are restricted and painful. Some erythematous nodules are present in skin
over the tibial bones. X-ray of the spine shows erosion and sclerosis of sacro-iliac
joints. Laboratory investigations reveal a positive p-ANCA test, normocytic
normochromic anemia, raised ESR, Thrombocytosis and negative stool cultures.
Which of the following is the most likely diagnosis in this case?

Answers:

A. Reactive arthritis from infectious diarrhea

B. Inflammatory bowel disease
C. Tropheryma whippeli infection
D. Gluten-sensitive enteropathy
E. Infection with Giardia lamblia

Explanation:

This patient described is most likely suffering from inflammatory bowel disease
(IBD).specifically ulcerative colitis (UC), given his young age. History of acute-onset
bandy diarrhea, anemia and negative stool cultures. IBD typically presents in
patients during their second of third decade, and the presenting symptoms of UC
often include bloody' diarrhea, lower abdominal pain and temesum Common
extracolonic Manifestations include Skin findings such as erythema nodosum (as
described in this patient) and pyoderma gangrenosum, Episcleritis arthritis and
cholangitis p-ANCA is positive in ulcerative colitis. Presentation of arthritis is
similar to arthritis is similar rto ankylosing spondylitis
Choice A: Reactive arthritis may follow diarrhea caused by shigella, salmonella,
yersinia and campylobacter or C. difficile infection. Reiter syndrome is
characterized by malaise, urethritis, conjunctivitis/uveitis, arthritis and
characteristic cutaneous findings (keratoderma blennorrhagica and balanitis
circinata).

Choice C: Infection by Tropheryma whippelli causes Whipple’s disease. This

disorder is characterized most commonly by chronic malabsorptive diarrhea,
weight loss, migratory non-deforming arthritis, lymphadenopathy and low-grade
fever

Choice D: Gluten sensitive enteropathy is an autoimmune disease characterized by

malabsorptive diarrhea. Serologic invetigation shows presence of anti-endomysial
and anti-transglutaminase antibodies. Characteristic cutaneous lesion that may be
seen in this disease is dermatitis herpetiformis

Choice E: Infection by the protozoan Giardia lamblia typically produces a frothy,

foul-smelling steatorhea due to malabsorption caused by the infecting organism.
Bloody diarrhea is uncommon.

Educational Objective:

Inflammatory bowel disease may occur in association with an inflammatory

arthritis. Ankylosing spondylitis and lBD are both associated with HLA-B27 and
may occur in association with one another Both conditions may also be associated
with a positive the absence of vasculitis in both conditions
A2

A 45-year-old man presents to your clinic with history of pain and swelling of the
right knee following a minor trauma. He had a similar problem about two years
back, which resolved on intake of OTC analgesics. His personal history is non-
contributory. On examination, his pulse, temperature and blood pressure are
normal. Right knee joint shows decreased mobility, swelling and redness. Other
joints are normal. Synovial fluid analysis shows presence of positive birefringent
crystals. Gram stain is negative. Nature of these crystals is most likely to be.

Answers:

A. Hydroxyapatite

B. Monosodium orate

C. Calcium pyrophosphate

D. Calcium oxalate

E. Ammonium phosphate

Explanation

This patient's history and synovial fluid analysis are suggestive of pseudogout. the
acute form of calcium pyrophosphate dihydratee (CPPD) crystal disease. Attacks of
pseudogout often occur in the setting of trauma surgery or medical illness This
patients lineetrauma was the likely precipitant of his ccctition Patients with
pseudogout present both acute pain, smelling, redness, and limited motion all the
motion of the involved joint being most commonly affected (>50% of cases).
Fever, leukocytosis with a left shift and Chondrocalcinosis (calcified articular
cartilage) may also occur in pseudogout While this patients history is Consistent
with pseudogout gout and septic arthritis may present similarly There fore, the
diagnosis cannot he made based on history and examination alone. Synovial fluid
analysis is critical for distinguishing between these conditions The identification of
rhomboid. positively birefringent crystals on Synovial fluid analysis is diagnostic of
pseudogout
Choice A: Calcium is deposited in teeth and bones as calcium hydroxyapatite.
However, it can also be found in cartilage of patients with degenerative joint
diseases like osteoarthritis and may be isolated from synovial fluid of such
patients.

Choice B: Deposition of monosodium urate crystals is seen in gout. These crystals

are needle-shaped and negatively birefringent when seen with a polarizing
microscope.

Choice D: Calcium oxalate is the most common crystal found in renal calculi
Calcium oxalate crystals are not isolated from synovial fluid.

Choice E: Struvite (magnesium ammonium phosphate) may be found in the renal

calculi of patient with urinary tract infection caused by urease-producing
organisms like klebsilla and proteus

Educational Objective:

Pseudogout cannot be distinguished reliably from gout and septic arthritis based
on history and physical examination alone. It is diagnosed by presence of
rhomboid, positively birefringent crystals on synovial fluid analysis along with
radiographic evidence of chondrocalcinosis
Qno-49

A 84.year.old male comes to the physician's office because of increasng pain is his
right groin for the past several months The pain increases with, activity and is
rellieved rest. he also has difficulty moving after a period of rest He denies any
trauma or falls. He has no fever, weight loss or loss of appetie. He has had lumbar
disk herniation in the past but denies any correct bask pain he has no other active
medical problems. His vital signs are within normal limits He weighs 95 kg
(210ib)and is 168cm(66 in) tall. Examination shores pain on passive internal
rotation of right hip joint. Direct pressure over the groin did not increase the pain
His reflexes are 2+, and there are no sensory deficlts Muscle hulk, tone and power
are within normal limits. Pulses are 2+ in both legs. Which of the following Is the
most likely cause of his hip pain ?

A. Cutaneous nerve compression

B. Inflammation of trochanteric bursa

C. Degenerative joint disease

D. Disruption of bone vasculature

E Referred pain from the lumbosacral area

Explanation:

The patient described is most likely suffiering from degenerative joint disease
(osteoarthnitis wear and tear' arthritis) Osteoarthritis typically presents indolently
in patients over 40 years or age with progressive anterior a consistent feature but
in contrast to rheumatoid arthritis the moming stiffness of osteoarhritis lasts less
exam tendemess to palpation and systemic sytmptoms are characteristically
absent in osteoarthritis and destruction of the articular cartilage leading to nbone
on none frction and the formatrion of osteophytes qsteoarthritis is the most
comman joint disease predisposing factors are advanced age and obesity
particularly for hip and knee arthnitis

(Choice A) Cutaneous nerve compression may cause hip pain in meralgia

parestirelca, a condition where compression of the lateral femoral Cutaneous
nerve Causal lateral hip paresthesia unaffected by motion or Palpation.

(Choice B) inflammation of the trochanteric bursa( trochanteric bursitis) is caused

by friction between the tendons of the gluteus medius and tensor fascia lata over
the greater trochanter of the femur pain is localized over the lateral hip and is
worsened by palpation. Pain caused by pressure on the lateral hip may interfere
with sleeping in patients with this Condition

(Choice D) Disruption of bone vasculature may cause osteonecrosis Osteonecrosis

of the femoral head is typically associated with Chronic corticosteroid use while
this condition may also present with chronic progressive anterior hip/groin pain
there is no history of chronic vorticosteroid use

(Choice E)Referred pain from the lumbosacral area can cause pasterior hip or
gluteal pain and when impingement of the lumbar nerve roots occurs pain may
radiate laterally down the thigh Such parents typically have no limitation of hip
mobility but will exhibit positive findings on a straight leg raise maneuver

Educational objective:
Degenerative joint desease (osteoarthnitis)presents in .adults over age 40 with
indolent progressive anterior hip pain worsened by activity and relieved by rest.
The hip is not tender and systemic symptoms are absent. Short-lived morning
stiffness may occur.
Qno-50

A 45 year old man complains of sudden pain and swelling in his left first
metatarsophalangeal joint he is undergoing hign dose Induction chemotherapy
for acute leukemia Joint fluid aspiration reveals negative bireferrgent crystals and
elevated white cell count. Which of the following prophylactic measures would
most likely have prevented this condition?

A. Urine acidification

B. N-acetycysteine

C. Allopurinol

D. Mesna

E Adequate hydration

Explanation_

This patient presents with a classic case of acute gouty(arthritis Gout results from
either overproduction or underexcretion of uric acid In this patients case
overproduction due to rapid tumor cell lysis is the most likely mechanism
Induction chemotherapy causes rapid tumor destructon, or lysis This process
releases uric acid a byproduct of DNA, into the circulation and resutts in an
elevated serum uric acid level that can predispose to gout attacks. Acute,
monoarticular arthritis affecting the first metatarsophalangeal.joint (prodagra) is
the most common presentation of a gout attack Definitive diagnosis is achieved by
joint aspiration with demonstration of neekie shaped negatively birefringent urate
cuystais and a white blood cell count of 2,000-50,000-mm3 Allopurinol a xanthine
oxidase inhibitor is often used to prevent gout attacks it works by decreasing uric
acid production

(Choice A) Urine acidification is helpful in eliminating amphetamines but not in

eliminating uric acid. In fact, Urine akalinization increases uric acid excretion and
will decrease uric acid renal stones Acidiflcation will increase gouty attacks
additionally uricosuric drugs (e.g probencid) are used to prevent gout attacks and
work by increasing urinary excretion &uric acid There is some risk of inducing uric
acid renal stones with probenecid so allopurinol is the first line agent for
prevention of gout during chemotherapy.

(Choice B) N-acetylcysteine is used as an antidote for acetaminophen overdose

and as a nephroprotective agent to prevent radiocontrast indued nephropathy
however it has no role in prevention of gout

(Choice D) mesna is used to prevent hemorrhagic cystitis caused by certain.

chemotherapeutic agents (cyclophosphamide)

(Choice E) Hydration is recommended to decrease the risk of developing uric acid

induction kidney stones In relation to gout. adequate hydration is recommended
during prohenecid therapy to prevent the formation of uric acid kidney stones
Hydration is not sufficient to treat complications of hyperuricemia from
chemotherapy however so allopurinol must be used

Educational Objective:

Gout Can result from overproduction or underexcretion of uric acid. Induction

chemotherapy results in rapid tumor cell lysis and releases uric acid into the
circulation. It is important to distinguish between the prevention and treatment of
gout for prevention asllopurinol and dprobenecid ard used swhile colchicine
NSAIDs and steroids are used during acute attacks
Qno-51

A 27.year old male presents to the physician's office because of pain on the
medial side of the tibia just below the knee The pain does not radiate and is
continuous He relates the onset of his pain to falling on the ground while playing
football two weeks ago. He denies fever, malaise and weight loss. his past medical
history is not significant On examination. a well-defined area of tenderness is
present on the upper tibia below the medial knee joint. There is no redness,
warmth or swellng. Hs gait is normal. A valgus stress test has no effect on his pain
X-ray of the knee and tibia shows no abnormalities. Which of the following is the
most likely cause of his current symptoms?

A. Anserine bursitis

B. Prepatellar bursitis

C. Medial collateral ligament strain

D. Medial compartment osteoarthritis

E. Patellofemoral syndrome

Explanation:

The patient described is most likely experiencing anserine bursitis The anserine
bursa is located anteromedially over the tibial plateau just below the joint line of
the knee. Inflammation of the anserine bursa can be the result of an abnormal
gait. overuse or trauma Patients typical' present complaining of localized pain over
the anterornedial tibia. the pain is otter present ceernight as pressure from the
knees making contact with one another while the patient lies on their side can
exacerbate the pain. Examination reveals a well-detnen area of tenderness over
the mediationl plateau just below the joint line A valgus stress test does not
aggravate the pain indicating that disease or the medial collateral ligament is
absent. X-ray of the this is normal in this condition Treatment is with rest, ice and
maneuvers to reduce pressure on the bursa Corticosteroid reactions into the
teens are also helfull

(Choice B) Prepatelar bursitis presents with pain and swelling. directly over the
patella Examination shows cystic swelling over the patella with variable singns of
inflammation the most common cause is trauma

(Choice C) Medial collateral ligament injury presents with pain along the medial
Joint line and is aggravated by walking it is caused by valgus stress applied on the
lateral aspect of the knee when it is partially flexed The knee pain in this condition
is aggravated by valgus stress tesing

(Cholas D) Medial compartment ostenarthits presents with pain or medial joint

line typically in patients older than 40 Other clinical features include moming
stiffness of less than 30 minutes, crepitus and bony tenderness on examination
X.ray of the knee shows narrowing of the joint space and ostecophyte formation.
Anserine bursitis may accompany medial campartrrem osteasrthnias due to the
chronic gait abnormality caused by the arthritic pain

(Choice E) Patellofemoral syndrome is a common overuse pain syndrome of the

knee Patients present with penpatellar pain worsened by actrviby or prolonged
sitting(due to sustained flexion) and may also complain of crepitus with motion of
the patella.
Educational Objective

Anserine bursrtis presents with sharpy localized pain over the anteromedial part
of the tibial plateau Just below the joint line of the knee valgus stress test fails to
reproduce the pain thereby ruling out damage to the medial colateral ligament
and radiographs are classically normal
Qno-52

A 27-year-old African-American woman presents with several complaints. She has

had pain and swelling of her hands and wrists for the past few days She also
complains of easy fatigabilty and frequent mouth

ulcers She Has no signiflcant past medial history.and does not take any medication
Her temperature is

37 1•C (98 9f), blood pressure is 140/90mmHg, and pulse is 76/min Examination
reveals svollen, tender metacarpophalangeal and proximal interphalangeal joints
There are superficial ulcers on her buccal

mucosa. X-ray of hands and 'wrists shows no bony erosions. Laboratory studies
show

Hemoglobin 11.0 g/L

Platelets 90,000/mm3

Leukocyte count 4,500/mm3

Unnalysis shows 2+ protein and red tblood cell casts which of the following is the
most likely cause of her joint pains

A.Systmic lupus erythematosus

B. Dermatomyositis

C .sarcoidosis

D. Neuropathir joint disease

E. Systemic joint disease

F. Degenerative joint disease

G Psonatil arthdis

H Polymyalgia rheumatica

I. Rheumatoid aarthritis

Explanation:

The patients presentation is strongly suggestive.of systemic lupus erythematosus

(SLE) Young, African American woman aged 20-40 years are at greatest risk of
developping SLE fatigue painless oral ulcers, non-deforming arthritis, and
hematologic abricrmalities are common findings in SLE. These patients may also
Present with log-grade fever. weight loss. rash (malar or discoid) serositis and
proteinuria Arthritis affects 90% of patents with SLE and is often the preserving
symptom lupus arthritis, like rheumatoid adhntis (RA), most corrrnony aeons the
metacarpophalangeal (MCP) and prownal interphalangeal (PIP) joint. but differs In
that it is non,deforming Hematologic ahnormanbes may include anemia,
thiorrencyropenia and leumapenia

(Choice B) Dermatomyositis presents with proximal rnusole weakness.. rash cf the

shoulders and hack, and scales on the hangs. Hematologic abnormalities arthnitis
and oral ulcers are not expected in dermatomyositis

(Choice C)sarcoidosis rs most Common in young, black females Cough and

erytnema nodosum are common findings. Abnormal chest x-ray, hypercalcemia,
elevated ACE levels, and non-resealing granulomas on biopsy also point to
sarcoidosis
(Choice D)Neuropathic joint disease most commonly affects the feet and ankles.
Systemic symptoms of fatigue oral ulcers and hematologic abnormahties are not
expected

(Choice E) Systemic iron overload is the hallmark of hemochromatosis It can lead

to arthropathy of the MCP joint bronzed skin, diabetes, hepatomegaly and heart
failure

(Choice F) Degenerative joint disease_ also known as osteoarthrtis_ often affects

the distal interrnalangeal (DIP) joints X ray show osteophytes. narrowed joint
spaces, and subcriondral bone cysts. OA is a non-inflammatory arthritis and is not
associated with systemic symptoms

(Choice G) Psoriatic arthnitis occurs in 5-30% of patients with psariasis though it

can occur without skin changes The DIP joints are prominently involved and
actylitis(sausage digit) is characteristic nail pitting and psoriatic plaques are
common

(Choice H) Polymyalgia rheumatic is characterized by, stiffiness and pain of the

shoulders and pelvic girdle Systemic symptoms of fever and weight loss are also
common It is strongly associated with giant cell arteritis

(Choice I) RA like SLE, presents with arthntis of the MCP and PIP joint. However, X-
ray in RA may show joint space erosions,juxta articular demineralization. and soft
lassue swelling Furthermore while RA may present with hematologic
ahnicrmalities and fatigue. the oral ulcers and renal disease observed in this case
more strongly suggest SLE.
Educational Objective:

SLE is an autommune disease that most commonly affects African-American

women aged 20-40 years Systemic manifestations include fatigue. fever. weight
loss. non.deforming arthritis_ Oral ulcers sernsitrs, hematologic abnormalities.
prateinuna. and rash. Greater than 9O% of patients have arthritis most commonly
affecting the MCP .and PIP joints of the hands
Qno-53

A 24 year.old Caucasian female complains of weakness skin rash, low, grade fever
and joint pain She descnbes pain and swelling of the hand joints and pain in her
kness. Her mother suffers from rheumatoid arthrftis. Her blood pressure is 145/90
mmHg, and her heart rate is Oalrnin. Her hem:armpit is 40% and ESR is 43mm/hr
Urinalysis is 2+ for protein. Which of the- following is the best statement about
this patient's joint symptoms?

A. Excessive bony growth is characteristic

B.Permanent deformity is uncommon

C. Subluxation and tendon damage cause permanent deformity

D. Cartilage degradatal and muscle atrophy cause deformity

E. Bone resorption of the distal phalanges may result

Explanation

this patients presentation is suggestive of systemic lupus erythematosus (SLE).

Young women and indiyiduals with a family history of autommune disease are at
most correnony affected by SLE Common presentations of hs systemic disease
include low-grade /fever weakness weight loss, rash (malar buterfly, annular.
discoid), arthralgiasiarthitis. protenina and hemataxgc abnormalities. This
patient's elevated ESR. while non-specfic suggests systemic inflammation and is
consistent with a diagnosis of SLE. Arthntis affects 90 percent of patients with SLE,
and most commanly occurs in the hand or knee it is a migratory arthritis with pain
that is often disproportionate to objective physical finding the arthritis of SLE is
has a lower incidence of erosion synovial abnormality and permanent joint
deformity than that of rheumatoid arthritis therefore SLE is consdered a non
deforming arthritis.
(Choice A) Osteoptytes are dony growths that develop in the joints of patients
with osteoarthritis. This patent's age, family history and systemic tens are far
more suggestive of SLE.

(Choice C)Subluxstion of the cervical vertebrae and tendon damage in the hands
may occur In rheumatoid arthris (RA).

(Choice D) cartilage degradation is the pathogenesis of deteoarthritis (OA). OA

patients May develop muscle atrophy from Iimitations of joint movement.

(Choice E) Bone resorption does not occur in SLE Distal phalangeal resorption is
prominent in the arthritis mutlans variant of psoriatic arthrtis leading to classic
'pencil, in- cup' deformities

Educational Objective:

Systemic lupus erythematosus (SLE) is an autoimmune disease that is most

commonly diagnosed in young females. Systems manifestations include fever,
faugue , weight loss, proteinuria, rash, arthralgias old anemia. Greater than 90%
of patients have joint involvement most commaly affecting the hands joint pain is
common but the arthritis induced by SLE is considered non deforming
Qno-54

A 51.year old Caucasian female complains of low-back pain radiating to the

buttocks. She also complains persistent muscle pain that gets worse with exercise
Physical examination reveals normal muscle strength. Her jonts are not swollen.
but palpation over the outer upper quadrants of the buttocks and the medial
aspect of the knees elicits tenderness Her ESR is 12 mm/hr Which of the following
is the most likely diagnosis?

A Seronegative spondyloarthropathy

B Polymyalgia rheumatica

C. Polymyositis

D. Rheumatoid arthritis

E.fibromyalgia

F. Polyarteritis nodosa

G. Giant cell arterits

Explanadom

The presence of diffuse musculoskeietal pain in the absence of joint swelling.

muscle weakness or laboratory abnormalites is suggestive of fibrorriolgra.
Fexcinwalgia is the most common cause of generalized musculoskeletal pain in
women ages 20-55. The pathogenesis of fibromyalgia is poonly understood but n
is believed to be a disorder of pain regulation The diagnosis is made based on the
presence ohaidespread musculosleketal pain and excessive tenderness on
palpation of at least 11 of 18 predefined soft tissue locations during physical
examination. These sites include-the upper quadrants of the buttocks and medail
aspect at the knees (as in this patients) as well as the Stemdcleidomastoid and
trapezius muscles The absence of joint swelling or muscle weakness is also
characcenstic of fibrompigia, as is the eersening of sytmptoms with exercise

(Choice A)Seronegative spoeyloarthropathies(SA)do commonly cause low back

pain. Although the rheumatoid factor is negative in this patient, an elevated ESR
would be expected in arty of the SAs The pain of spondytoarihmpatfry improves
with exercise, unlike that of fibrornyalgia

(Choice B) Polymyalgia rheimatica (PMR) is most common in women and patients

over 50 Patents present with pain and stiffness of the shoulders and pelvic girdle
The ESR is almost always elevated PMR is commonly associated with ternporal
arteritis

(Choice C) Polymyositis is Characterized by symmetric proximal muscle weakness

and mild pain, This patient showed no weakness on exam Elevation of CK and
inflammation factor occurs in polymyositis

(Choice D)Risk factors for reheumatoid arthritis include female gender and middle
age swelling of the wrist and hand joints (MCPand PIP), morning stiffness and an
elevated rheumatoid factor and ESR are common

Educational Objective:
The pain associated with fibromyalgia worsens with exercise. Fatigue, imtable
bowel syndrome and depression are common in these patents. while
inflammation, joint sweing and muscle weakness are absent. Radiographic.
Laboratory and histologic studies typically show no abnormalities
Qno-55

A 54.year old woman comes to the physician's office complaining of chronic,

bilateral knee and hip pain The pain increases with activity and is relleved by rest
She denies fever chills or weight loss. The review ofsystems is unremarkable she
currently weight 80kg(180ib) and is 146cm(59in)tall her knee joints are lender but
there is no warmth, erythema or effusion X ray show narrow joint space
subchondral bone cysts and bony spurs in both knees which of the following
interventions would provide the greatest long term benefit to this patient

A. muscle strengthering exercise

B.Non steroidal antinflammatory agents

C.weight loss

D.Chondroitin sulfate

E.Acetarnmcchen with codeine

Explanation;

This patients presentation is most consistent with ostedarthritis (OA). Studies have
shown a particularly strong link obesity and knee CA. Based on a height of 59
inches and a neighs or 180 pounds, this patient has a EMI of 36. indicating
rroderate obesity. Patients with OA typically present with brief rooming stffness (<
30 minutes) and exertional joint pain Unlike autionmune atritides. systemic
symptoms such at fever and weight lass are generally absent. Plain films Of an
osteoarthritic knee reveal a narrowed joint space. osteophytes. and subc hondral
scleroses or cysts. Obesity is the most readily modifiable risk factor for OA Weight
loss has been shown to ozia progression of the OA and imcrwe font pan and
function Hence. weight loss is the most effective measure in slowing progression
of OA.

(Choice A) As part of an overall physical therapy program, muscle strengthening

exercises play an integral role in OA therapy They reduce pain and improving
mobilitybut muscle seengthening does not slow the progression of OA

(Choice B,D and E) NSAIDs. acetaminophen. and chondroitin sulfate each play a
role in the
phamiacotherapy of OA They provide effective. temporary pain relief but to red
slow the progression of OA

Educational Objective:

Plain films of an osteoarthrtic knee reveal nerrowed joint space,osteophytes and

suhchondral sclerosis or cysts Obesity is the most readily macdifiable risk factor
for OA and weight loss decreases joint pain increases function and shows
progression of the disease Pharmacologic threpy and exercise also play integral
roles in OA therapy.

Qno-56

A 65.year•old man complains of periodic back pain radiating to his thigh and
buttock The pain is related to Walking or climbing the stairs but is promptly-
relieved by leaning forward. He also has noticed tingling and numbness in both
lower extremities He has a history of hypertension and takes hydrochlorothiazide.
He does not use tobacco. alcohol. or illicit drugs. His pulse is 76/min respirations
are 1/min and blood pressure in 140/80mmhg Lumbar extension reproduces the
pain, and tingling, while lumber flexion releves the symptoms. which of the
following is the most likely cause of this patient's condition?

A. lliac artery atherosclerosis

B. Abdominal aortic aneurysm

C. Degenerative central stenosis

D. Lumbar disk herniation

E. Spina bifida occulta

F.Metastatic disease

G Seronegative spondylarthnitis

Explanation

Lumber spinal stenosis is a degmeratrve condition where the spinal canal is

narrowed resulting in cimpression of one or more of the spinal roots. It most
commonly results from a combination of two factors enlarging Osteophytes the
facet joint and hypertrophy of the ligamentum flavum most affected patients are
over age 60. Patients experience back pain that radiaters to the buttocks and
thighs Numbness and paresthesias may occur Symptoms are typically worse
during walking and lumber extension, while lumbar flexion alienates the
symptoms Pedal pulses should remain normal, as arterial perfusion is not
affected. The diagnosis is confirmed with MRI

(Choice A) lliac artery atherosclerois causes claudication in the buttocks and thighs
This pain tylpically occurs during activity as in relieved by rest The key clinical
difference between illac artery atherosclerosis and lumbar spinal stenosis are that
the former is not affected by lumbar extension or-flexion and does not cause back
pain
(Choice B) Abdominal aortic aneurysms (AAA) are usually asymptomatic but can
present with severe back or abdominal pain and hypotension upon rupture.

(Choice D) Lumbar disk herniation typicaly presents with the acute onset of back
pain with or without radiation down one leg Patents usually recall an inciting
event As with lumbar spinal stenosis. the pain may be radiating and he associated
with neurologic symptoms However. In disc hermiation lumbar flexion and sitting
will make the pain worse

(Choice E) Spina bittla occulta is a Congenital derect of the vertebral arch that
does not involve protrusion of the cord or dura. It is typically asymptomatic and
diagnosed as an incidental radiographic finding.

(Choice F) Metastatic disease of the vertebrae typically presents as pain that is

chronic dull worse at night. and changes little with activity The pain is usually non-
radiatng.

(Choice G) Seronegative spandylarthritis (e.g., ankylosing spondyltis) is

characterized by progressive limitation of back motion it most often occurs in
young men Back pain and stffness are typically- worst in the morning and improve
as the day progresses

Educational Objective:
Lumbar spinal stenosis is a common cause of back pain in patients over 60 year
old age it is Characterized back pain radiating to the buttocks and thighs that
interferes with walking and lumbar extention
Qno-57

A 35year-old white female presents with pain and steness of her wrist and hand
joints for the last several months Her morning stiffness lasts for more than an
hour. She also complains of redness and joint swilling her past medical history is
significant only tar a similar episode one war ago That episode res.:lived with over
the counter ibuprofen. Examination of her Joints show redness, warmth swelling
arid terrierness of proximal nterphalangeal joints. metacarpophalangeal joints and
wrists X ray shrews penarticular osteopenia and erosions retire proxrnal
interphalangeal and metacarpophalangeal pile started taking indomethacin voth
good relief. Which of the following is the most appropriate next step in the
management of this patent?

A. Glucocrticoids
B. Metnetroxate
C. Celecoxib
D. Azathioprine
E Etanercept

F. Infliximab

G. No additional treatment

Explanation:

The above patient is most likely suffering from rheumatoid arthritis (RA). The key
clinical features of RA include symmetric polyarthrlis. characteristic joint
deformities ulnar deviation, swan neck and Louronnibre) and morning stiffness
lasting longer than one hour. Systemic sins such as fewer, yomet lass and malaise
may also be present Laboratory testng classically cereals the presence of
rheumatoid facto- and arrti-cyclic cituilinated peptide while radiographic studies
may reveal joiint erosions juxta,..articular osteoporosis and narrowing or the joint
spaces In the hand. the proximal interphalangeal and the metacarpophalangeal
joints are most commonly. affected

Once the diagnosis of RA is certain, therapy with disease modifying anti-rheumatic

drugs (DMAROs) is indicated. DMARDs should be used early in the course of the
disease en RA is a chronic medical problem and the goal of therapy is induction of
a remission followed by maintenance of that remission The first-line DMARD used
in the treatment of Rd methotrexate due to ifs long history of efficacy and safety
when used at a weekly pulse. Other as a weekly pulse other DMARDs include
hydroxychloroquine sulfasalazine,leflunomide. Etanercept infliximab and
azataroprine.

(Choice A)Glucocorticoids offer rapid improvement in the clinical and radiographic

Fritangs of RA, but due to their signfficant adverse effects they are typically not
used for long term management

(Choice C) Celecoxib is a selective COX-2 iiabstor and its anti-inflammatory and

analgesic action is comparable an conventional NSAIDs In contrast to
conventional NSAIDs, celecuhe does not affect hernostasis and does not produce
GI side effects COX-2 inhibitors are avoided currently due to their ability to cause
an increased risk of heart disease.

(Choice D) Alathioprine is a pulre analog that is used at an ommunosuppressrve

and a DMARD. It it not as Efficacious as methotrexate; therefore,it is not used as
afirst-line agent in RA
(Choices E & F.) Etarercept and inflximab are tumor necrosis factor (TNF) They are
very effective in patents who have disease sefractory to methetrexate. These
agents, however_ are very expensivr and do not have the long safety record that
methotrexate has because they are

new Reports of increased risk of lyrnphoma, tuberculosis reaclivarlion CHF and

dernyelinaling disease have been associated with these agents. They are not yet
indicated as first-line treatment.

(Choice G) Leaving this patient untreated is inappropriate as RA is a progressive

disease with effective available treatments

Educational Objective:

Erosive joint disease in rheumatoid arthnitis is a clear-cut indication for the use of
diseases modifying anti-rheumatic drugs (DMARDs).methotrexate is the initial
drug of choice tor this purpose.
Qno-58

A 68.year old AfricanAmerican woman presents to the ER in acute distress She

complwis of a sudden onset of complete visual loss in her right eye. Her vision had
been blurry for the past few days and acutely worsened one hour ago. She also
describes right-sided headaches of two months duration for which she has taken
ibuprofen without relief She has no nausea or vomiting She has diabetes.
hypertension. and

degeneratrve dnease. Her temperature is 37. 2’(98.9F)and blood pressure is

144/86 mmHg. Examination reveals complete loss of vision in the right eye. Her
putrls are 4 mm bilaterally. Fundoscopy shows a swollen pale disc with blurred
margins A bruit is heard in the right subclavicular area Motor and Sensory
examination is within normal 'limits Which of the following is the most
appropriate next step in management?

A.Temporal artery biopsy.

B. Low dose prednisone

C. Methotrexate therapy

D. MRI of the brain with contrast

E. High dose acetazolaide

F. High dose prednisone

Explanadon;
This patients presentation is highly suggestive of temporal. or giant cell. artellis
Temporal relents should be suspend in any patiem over 50 years or age with a
new-headache, Jaw claudication, scab pain, visual loss msymptoms of polyrnolgia
rheurnatca. Temporal arterbis is a form of large vessel wasculifis that affects me
aorta and its cranial artenat branches. ['ince texnnoral anteritis is strongly
suspected co clinical grounds, imrnediter empiric treahment with high dose
steroids is paramount. Visual loss is one or the most feared complications of
temporal antis. affecting up to 20% of patients Prompt systemic stems
administration Kindicanity lowers the rate of Astral compkcations and decreases
re likelihood of visual kiss in this patient's unaffected eye. The ESR will be elevated
in this pattern and temporal arte ry biopsy will provide definitive diagnosis

(Choice A) Temporal artery biopsy is indicated to confirm diagnosis of temporal

aetentis in this

patent However, biopsy is non-emergent and empiric treatment with high dose
steroids takes prionty in clinically temporal arteries.

(Choice B) Low dose steroids may be used to treat patients with patients with
polymyalgia rheurnalica This condition presents with Stiffness and Pain of the
Shoulders pelvic girkle These patients are at increased risk of developing temporal
attends and should be screened for this disease.

(Choice C) methotrexate is less effective them high dose steroids in treating

temporal artels and should not be used.

(Choice D)MRI of the brain with contrast does carry some diagnostic and
prognostic value in temporal arterdis However. empiric treahment takes
precedence in this patient and temporal artery biopsy rerruerti the definitive
method for diagnosis.
(Choice E) Acetazolamide is used to treat open-angle glaucoma .and benign
intracranial hypertension.

Educational Objactive:

Temporal artentis should be suspected in patierils over 50 years of age with new-
onset temporal headache. jaw claudication vision loss or suymptoms of
polymyalgia once the diagnosis is suspected immediate initiation of high dose
steroids is indicated to prevent damage to the retinal artery and other vessels the
ESR is elevated in temporal arteries and the claghnsis is corilrmed by ternioral
artery biopsy.