A 50-year-old man presents to your office with fatigue and weakness. He first noticed it a few weeks ago while trying to hang pictures with his wife. His legs have begun to ache as he walks up stairs. He has lost about 20 lbs in the last 3 months. Most recently, he has found that he is more constipated and has trouble rising from the commode. Your physical examination reveals modest proximal weakness, no articular swelling, rash, or any other pertinent findings. Blood work from a recent insurance examination revealed: Sodium 142 meq/L; potassium 3.8 meq/L; chloride 107 meq/L; bicarbonate 29 meq/L; BUN 30 mg/dL; Cr 1.6 mg/dL; WBC 6.8; Hgb 13.6 g/dL; HCT 40%; MCV 88.0 m3; platelets 240,000/mm3; AST 200 U/L; ALT 250 U/L; alkaline phosphatase 70 U/L; bilirubin 0.3 mg/dL; ESR 40 mm/h
His CPK is 2400 and an EMG shows fibrillation potentials, positive sleep waves, and myotonic discharges. In addition to addressing his myositis, diagnostic testing should be performed to evaluate for the possibility of which of these?
A. Hodgkin lymphoma
B. testicular cancer
C. multiple myeloma
D. lung cancer
E. prostate cancer
Correct Answer: D Section: (none)
Explanation:
The clinical features presented by the patient suggest a myopathy. It is often forgotten that serum transaminases are found in the muscle as well as the liver. Thus, a significant inflammatory myopathy may present with elevated serum transaminases in addition to symptoms. In this patient with normal alkaline phosphatase and bilirubin, initial measurement of the GGT would help rule out liver pathology and would be more appropriate initially than ultrasonography. Rhabdomyolysis may lead to renal dysfunction or even renal failure and a kidney ultrasound may eventually be appropriate, but a urinalysis would be recommended first. An MRI of the lumbar spine is not needed for this evaluation. It has long been established that there is an association between dermatomyositis, polymyositis, and malignancy. Although the malignancy risk is slightly higher in patients with dermatomyositis than with polymyositis, the malignancy association with both diseases is well established. The overall risk of cancer is highest in the first 3 years after the diagnosis of the myopathy, but it also continues over the individual's lifetime. Cancers most highly associated with inflammatory myopathy include lung, pancreatic, GI tract, non-Hodgkin lymphoma, and ovarian
Question 622:
A 50-year-old man presents to your office with fatigue and weakness. He first noticed it a few weeks ago while trying to hang pictures with his wife. His legs have begun to ache as he walks up stairs. He has lost about 20 lbs in the last 3 months. Most recently, he has found that he is more constipated and has trouble rising from the commode. Your physical examination reveals modest proximal weakness, no articular swelling, rash, or any other pertinent findings. Blood work from a recent insurance examination revealed: Sodium 142 meq/L; potassium 3.8 meq/L; chloride 107 meq/L; bicarbonate 29 meq/L; BUN 30 mg/dL; Cr 1.6 mg/dL; WBC 6.8; Hgb 13.6 g/dL; HCT 40%; MCV 88.0 m3; platelets 240,000/mm3; AST 200 U/L; ALT 250 U/L; alkaline phosphatase 70 U/L; bilirubin 0.3 mg/dL; ESR 40 mm/h. Along with a creatine phosphokinase (CPK), which of the following tests should be ordered first?
A. muscle biopsy
B. gamma glutamyl transferase (GGT)
C. MRI of the lumbar spine
D. ultrasound of the liver and gallbladder
E. kidney ultrasound with renal artery Doppler
Correct Answer: B Section: (none)
Explanation:
The clinical features presented by the patient suggest a myopathy. It is often forgotten that serum transaminases are found in the muscle as well as the liver. Thus, a significant inflammatory myopathy may present with elevated serum transaminases in addition to symptoms. In this patient with normal alkaline phosphatase and bilirubin, initial measurement of the GGT would help rule out liver pathology and would be more appropriate initially than ultrasonography. Rhabdomyolysis may lead to renal dysfunction or even renal failure and a kidney ultrasound may eventually be appropriate, but a urinalysis would be recommended first. An MRI of the lumbar spine is not needed for this evaluation. It has long been established that there is an association between dermatomyositis, polymyositis, and malignancy. Although the malignancy risk is slightly higher in patients with dermatomyositis than with polymyositis, the malignancy association with both diseases is well established. The overall risk of cancer is highest in the first 3 years after the diagnosis of the myopathy, but it also continues over the individual's lifetime. Cancers most highly associated with inflammatory myopathy include lung, pancreatic, GI tract, non-Hodgkin lymphoma, and ovarian.
Question 623:
A 55-year-old woman presents to your office with painful hands, causing difficulty opening jars and turning the key in the ignition of her car. She is fatigued and she notices joint stiffness, but limbers up by lunch. She has trouble getting her rings off because of enlarging knuckles. About a year ago, she tried some OTC ibuprofen, which seemed to help, but led to the development of a bleeding ulcer severe enough to require transfusion and ICU care. Otherwise, her health is good, and her review of systems is negative. Your physical examination reveals tenderness and swelling at the index proximal interphalangeal and metacarpophalangeal joints bilaterally. There are small effusions on both knees. She has tenderness to lateral compression of the forefoot area bilaterally.
The test ordered above is negative and an anticyclic citrullinated peptide (anti-CCP) antibody is strongly positive (600). Which of the following is the probable source of her symptoms?
A. cryoglobulinemia
B. osteoarthritis
C. polymyalgia rheumatica
D. SLE
E. RA
Correct Answer: E Section: (none)
Explanation:
In all likelihood, this patient is presenting with a systemic inflammatory arthritis. Clearly, treatment will need to be initiated. In order to effectively and promptly treat her, you will need to understand the current state of her physiology. Therefore, basic laboratory studies including blood count, full chemistries, and urinalysis should be obtained. At this point, the most likely diagnosis is RA, and the rheumatoid factor and sedimentation rate may be helpful. Theoretically, sarcoidosis can present in this way but, epidemiologically, this is much less likely. Because of this and because the ACE level is fairly nonspecific, it should not be part of the initial workup. Neither joint fluid aspiration nor uric acid levels are likely to be diagnostic. The elevation of serum transaminase in the face of elevated sedimentation rate, moderate or low positive ANA, and rheumatoid factors raise the question about hepatitis C.
About 50% of patients with active hepatitis C will have cryoglobulinemia. Cryoglobulins can produce low moderate positive rheumatoid factors. Therefore, it is extremely important in this circumstance to be certain that hepatitis C is not present. With such a low positive ANA, the likelihood that this is classical Lupus is low, and double-stranded DNA antibodies are not likely to be revealing. C-reactive protein may confirm the presence of inflammation, but it won't provide additional information over the sedimentation rate. Syphilis, "the great imitator," again may occasionally have arthritis as a manifestation--but rarely without other features. The remaining studies while they might be useful later but are unlikely to be helpful as the next most important test obtained. The probable source of the patient's symptoms is RA. Osteoarthritis can produce articular swelling, but on physical examination, there is rarely bogginess in the synovium. Anti-CCP antibody is an antibody directed against the citrullinated portion of fillagen. It has the highest specificity for RA of any antibody known. It is usually present early and may predict more severe disease.
Question 624:
A 55-year-old woman presents to your office with painful hands, causing difficulty opening jars and turning the key in the ignition of her car. She is fatigued and she notices joint stiffness, but limbers up by lunch. She has trouble getting her rings off because of enlarging knuckles. About a year ago, she tried some OTC ibuprofen, which seemed to help, but led to the development of a bleeding ulcer severe enough to require transfusion and ICU care. Otherwise, her health is good, and her review of systems is negative. Your physical examination reveals tenderness and swelling at the index proximal interphalangeal and metacarpophalangeal joints bilaterally. There are small effusions on both knees. She has tenderness to lateral compression of the forefoot area bilaterally.
The following data are obtained: normal CBC; normal basic metabolic panel; ESR 40 mm/h; ALT 90 U/L; AST 110 U/L; alkaline phosphatase 70 U/L; bilirubin 0.2 mg/dL; uric acid 5.1 mg/dL; urinalysis is normal. ACE level is normal. Rheumatoid factor is 60 and ANA is positive 1:40 speckled pattern. The next most important test would be which of the following?
A. hepatitis C antibody
B. anti-double-stranded DNA antibodies
C. serum protein electrophoresis
D. C-reactive protein
E. RPR
Correct Answer: A Section: (none)
Explanation:
In all likelihood, this patient is presenting with a systemic inflammatory arthritis. Clearly, treatment will need to be initiated. In order to effectively and promptly treat her, you will need to understand the current state of her physiology. Therefore, basic laboratory studies including blood count, full chemistries, and urinalysis should be obtained. At this point, the most likely diagnosis is RA, and the rheumatoid factor and sedimentation rate may be helpful. Theoretically, sarcoidosis can present in this way but, epidemiologically, this is much less likely. Because of this and because the ACE level is fairly nonspecific, it should not be part of the initial workup. Neither joint fluid aspiration nor uric acid levels are likely to be diagnostic. The elevation of serum transaminase in the face of elevated sedimentation rate, moderate or low positive ANA, and rheumatoid factors raise the question about hepatitis C. About 50% of patients with active hepatitis C will have cryoglobulinemia. Cryoglobulins can produce low moderate positive rheumatoid factors. Therefore, it is extremely important in this circumstance to be certain that hepatitis C is not present. With such a low positive ANA, the likelihood that this is classical Lupus is low, and double-stranded DNA antibodies are not likely to be revealing. C-reactive protein may confirm the presence of inflammation, but it won't provide additional information over the sedimentation rate. Syphilis, "the great imitator," again may occasionally have arthritis as a manifestation--but rarely without other features. The remaining studies while they might be useful later but are unlikely to be helpful as the next most important test obtained. The probable source of the patient's symptoms is RA. Osteoarthritis can produce articular swelling, but on physical examination, there is rarely bogginess in the synovium. Anti-CCP antibody is an antibody directed against the citrullinated portion of fillagen. It has the highest specificity for RA of any antibody known. It is usually present early and may predict more severe disease.
Question 625:
A 55-year-old woman presents to your office with painful hands, causing difficulty opening jars and turning the key in the ignition of her car. She is fatigued and she notices joint stiffness, but limbers up by lunch. She has trouble getting her rings off because of enlarging knuckles. About a year ago, she tried some OTC ibuprofen, which seemed to help, but led to the development of a bleeding ulcer severe enough to require transfusion and ICU care. Otherwise, her health is good, and her review of systems is negative. Your physical examination reveals tenderness and swelling at the index proximal interphalangeal and metacarpophalangeal joints bilaterally. There are small effusions on both knees. She has tenderness to lateral compression of the forefoot area bilaterally.
Which of the following tests is most likely to result in a diagnosis?
A. joint aspiration
B. ESR
C. serum uric acid
D. rheumatoid factor
E. ACE level
Correct Answer: D Section: (none)
Explanation:
In all likelihood, this patient is presenting with a systemic inflammatory arthritis. Clearly, treatment will need to be initiated. In order to effectively and promptly treat her, you will need to understand the current state of her physiology. Therefore, basic laboratory studies including blood count, full chemistries, and urinalysis should be obtained. At this point, the most likely diagnosis is RA, and the rheumatoid factor and sedimentation rate may be helpful. Theoretically, sarcoidosis can present in this way but, epidemiologically, this is much less likely. Because of this and because the ACE level is fairly nonspecific, it should not be part of the initial workup. Neither joint fluid aspiration nor uric acid levels are likely to be diagnostic. The elevation of serum transaminase in the face of elevated sedimentation rate, moderate or low positive ANA, and rheumatoid factors raise the question about hepatitis C.
About 50% of patients with active hepatitis C will have cryoglobulinemia. Cryoglobulins can produce low moderate positive rheumatoid factors. Therefore, it is extremely important in this circumstance to be certain that hepatitis C is not present. With such a low positive ANA, the likelihood that this is classical Lupus is low, and double-stranded DNA antibodies are not likely to be revealing. C-reactive protein may confirm the presence of inflammation, but it won't provide additional information over the sedimentation rate. Syphilis, "the great imitator," again may occasionally have arthritis as a manifestation--but rarely without other features. The remaining studies while they might be useful later but are unlikely to be helpful as the next most important test obtained. The probable source of the patient's symptoms is RA. Osteoarthritis can produce articular swelling, but on physical examination, there is rarely bogginess in the synovium. Anti-CCP antibody is an antibody directed against the citrullinated portion of fillagen. It has the highest specificity for RA of any antibody known. It is usually present early and may predict more severe disease.
Question 626:
A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable.
Which of the following antibodies can cross the placenta and cause the syndrome of neonatal lupus?
A. anti-double-stranded DNA antibodies
B. antiscleroderma antibodies
C. anticardiolipin antibodies
D. Sjögren syndrome antibodies (SSA/SSB)
E. anticentromere antibody
Correct Answer: D Section: (none)
Explanation:
Vasospasm severe enough to reduce flow and produce cyanosis after exposure to cold is called Raynaud phenomenon. Some make a further distinction between Raynaud syndrome when the phenomenon is associated with another systemic disorder and Raynaud disease when there is no established systemic process. Similarly, Raynaud phenomenon in the absence of a systemic illness may also be referred to as primary Raynaud phenomenon, and Raynaud in the presence of another systemic illness may be termed secondary Raynaud phenomenon. In this case, there is no evidence of another systemic illness. Clinical features suggesting SLE or RA are absent. Subacute bacterial endocarditis likewise would be expected to be associated with fever, which is absent in this patient. In addition, one would expect to see areas of necrosis either in the soft tissue (Janeway spots) or under the fingernails (splinter hemorrhages) were any kind of embolic phenomenon is present. (Harrison's Principles of Internal Medicine, 15th ed., pp. 14381439) Given the patient's age, it is reasonable to explore the possibility of an associated systemic illness. If one were present, basic laboratories such as blood count, urinalysis, and chemistries are important. ANAis a reasonable screening study in this case. It does have a prognostic value increasing the likelihood of the development of a systemic process in the future.
If positive, further serologic studies might then be helpful in establishing a more specific diagnosis. The arterial Doppler with cold stimulation can be a useful test in showing a marked drop in blood flow with cold exposure. Still, with such a classical description, it is hard to imagine how this test would be helpful either diagnostically or therapeutically. Antidouble-stranded DNA antibodies would establish the diagnosis of SLE. Likewise, the antiscleroderma antibodies (anti-Scl-70) would be a very important prognostic marker once the ANA is positive and certainly would occasion a rheumatic disease consultation. Patients with hypercoagulable states, including those with positive cardiolipin antibodies, can often mimic Raynaud's. Given that the patient wants to become pregnant, this would be an important study to obtain. Sjögren antibodies, both SSA and SSB, are important in this case because of the contemplated pregnancy. Sjögren antibodies can cross the placenta and create the syndrome of neonatal lupus (complete heart block, thrombocytopenia, and rash).
Question 627:
A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable. In this patient, which of the following studies would be most likely to describe an increased risk of future systemic disease?
A. echocardiogram
B. nerve conduction study
C. ANA
D. joint aspiration
E. arterial Doppler of the upper limbs with cold stimulation
Correct Answer: C Section: (none)
Explanation:
Vasospasm severe enough to reduce flow and produce cyanosis after exposure to cold is called Raynaud phenomenon. Some make a further distinction between Raynaud syndrome when the phenomenon is associated with another systemic disorder and Raynaud disease when there is no established systemic process. Similarly, Raynaud phenomenon in the absence of a systemic illness may also be referred to as primary Raynaud phenomenon, and Raynaud in the presence of another systemic illness may be termed secondary Raynaud phenomenon. In this case, there is no evidence of another systemic illness. Clinical features suggesting SLE or RA are absent. Subacute bacterial endocarditis likewise would be expected to be associated with fever, which is absent in this patient. In addition, one would expect to see areas of necrosis either in the soft tissue (Janeway spots) or under the fingernails (splinter hemorrhages) were any kind of embolic phenomenon is present. (Harrison's Principles of Internal Medicine, 15th ed., pp. 14381439) Given the patient's age, it is reasonable to explore the possibility of an associated systemic illness. If one were present, basic laboratories such as blood count, urinalysis, and chemistries are important. ANAis a reasonable screening study in this case. It does have a prognostic value increasing the likelihood of the development of a systemic process in the future.
If positive, further serologic studies might then be helpful in establishing a more specific diagnosis. The arterial Doppler with cold stimulation can be a useful test in showing a marked drop in blood flow with cold exposure. Still, with such a classical description, it is hard to imagine how this test would be helpful either diagnostically or therapeutically. Antidouble-stranded DNA antibodies would establish the diagnosis of SLE. Likewise, the antiscleroderma antibodies (anti-Scl-70) would be a very important prognostic marker once the ANA is positive and certainly would occasion a rheumatic disease consultation. Patients with hypercoagulable states, including those with positive cardiolipin antibodies, can often mimic Raynaud's. Given that the patient wants to become pregnant, this would be an important study to obtain. Sjögren antibodies, both SSA and SSB, are important in this case because of the contemplated pregnancy. Sjögren antibodies can cross the placenta and create the syndrome of neonatal lupus (complete heart block, thrombocytopenia, and rash).
Question 628:
A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable.
What condition is she describing?
A. Carpal Tunnel syndrome
B. Raynaud phenomenon
C. subacute bacterial endocarditis with emboli
D. SLE
E. RA
Correct Answer: B Section: (none)
Explanation:
Vasospasm severe enough to reduce flow and produce cyanosis after exposure to cold is called Raynaud phenomenon. Some make a further distinction between Raynaud syndrome when the phenomenon is associated with another systemic disorder and Raynaud disease when there is no established systemic process. Similarly, Raynaud phenomenon in the absence of a systemic illness may also be referred to as primary Raynaud phenomenon, and Raynaud in the presence of another systemic illness may be termed secondary Raynaud phenomenon. In this case, there is no evidence of another systemic illness. Clinical features suggesting SLE or RA are absent. Subacute bacterial endocarditis likewise would be expected to be associated with fever, which is absent in this patient. In addition, one would expect to see areas of necrosis either in the soft tissue (Janeway spots) or under the fingernails (splinter hemorrhages) were any kind of embolic phenomenon is present. (Harrison's Principles of Internal Medicine, 15th ed., pp. 14381439) Given the patient's age, it is reasonable to explore the possibility of an associated systemic illness. If one were present, basic laboratories such as blood count, urinalysis, and chemistries are important. ANAis a reasonable screening study in this case. It does have a prognostic value increasing the likelihood of the development of a systemic process in the future.
If positive, further serologic studies might then be helpful in establishing a more specific diagnosis. The arterial Doppler with cold stimulation can be a useful test in showing a marked drop in blood flow with cold exposure. Still, with such a classical description, it is hard to imagine how this test would be helpful either diagnostically or therapeutically. Antidouble-stranded DNA antibodies would establish the diagnosis of SLE. Likewise, the antiscleroderma antibodies (anti-Scl-70) would be a very important prognostic marker once the ANA is positive and certainly would occasion a rheumatic disease consultation. Patients with hypercoagulable states, including those with positive cardiolipin antibodies, can often mimic Raynaud's. Given that the patient wants to become pregnant, this would be an important study to obtain. Sjögren antibodies, both SSA and SSB, are important in this case because of the contemplated pregnancy. Sjögren antibodies can cross the placenta and create the syndrome of neonatal lupus (complete heart block, thrombocytopenia, and rash).
Question 629:
A45-year-old male presents to the hospital for acute abdominal pain and is found to have acute pancreatitis. He has no past medical history but recently has noticed urinary frequency and muscle weakness. He takes no medications. He denies alcohol use. His liver function tests during the episode are normal and magnetic resonance cholangiopancreatography study (MRCP) demonstrates an absence of stones in the biliary tree as well as a normal pancreatic duct. His serum calcium is found to be markedly elevated during this episode. The patient recovers clinically, and repeat serum calcium is also found to be elevated 1 month after hospital discharge.
What is the most likely cause of his hypercalcemia?
A. metastatic bone disease
B. sarcoidosis
C. vitamin D overdose
D. hyperparathyroidism
E. laboratory error
Correct Answer: D Section: (none)
Explanation:
The patient likely has hyperparathyroidism. Hyperparathyroidism can lead to chronic hypercalcemia, a known cause of acute pancreatitis. Aserum calcium level can be elevated in many patients during acute pancreatitis due to dehydration and should be checked after the event has resolved. Hyperparathyroidism would also explain his urinary frequency and muscle weakness. Laboratory error is unlikely given that the level is elevated on two occasions. Metastatic bone disease and sarcoidosis can also cause hypercalcemia but hyperparathyroidism is more commonly associated with pancreatitis. Vitamin D overdose is unlikely given his lack of medication use.
Question 630:
A 45-year-old female develops fever, dysuria, and back pain and is admitted to the hospital after evaluation in the ER discloses pyelonephritis. The patient is placed on broad-spectrum antibiotics and has a good improvement in her symptoms. On hospital day 4, the patient develops a new fever, leukocytosis, and profuse watery diarrhea. A colonoscopy is performed and the following finding is seen
What is the first-line therapy for treating this disorder?
A. metronidazole
B. vancomycin
C. oral corticosteroids
D. rectal administration of topical corticosteroids
E. sulfasalazine
Correct Answer: A Section: (none)
Explanation:
The colonoscopy image demonstrates the pseudomembranes classically seen in pseudomembranous colitis, also known as Clostridium difficile colitis. C. difficile colitis is commonly encountered in patients on broadspectrum antibiotics, although almost any antibiotic can predispose a patient to this illness. The disease is toxin mediated, and is frequently seen when antibiotics disrupt the normal balance of gut flora, allowing C. difficile to more widely colonize the bowel than it would normally. Crohn colitis and ulcerative colitis would have different patterns of ulceration of the mucosa, which is not seen here. Ischemic colitis would appear as an area or areas of blanched, edematous, or frankly necrotic mucosa due to an interruption of vascular flow. Microscopic colitis, which can cause a chronic form of watery diarrhea, typically has a normal appearance at colonoscopy. The first-line therapy for patients diagnosed with pseudomembranous colitis is typically a course of oral metronidazole. Patients can also receive oral vancomycin, although this is usually reserved for persistent or recurrent infection. Oral vancomycin also carries a much higher cost than metronidazole. Oral or topical= steroids would be contraindicated in the setting of an infection, although these medications are frequently used in patients with IBD such as ulcerative colitis or Crohn colitis. Sulfasalazineis a topical anti-inflammatory agent that is also sed for patients with IBD.
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