A 64-year-old male with a history of hypertension and tobacco abuse presents for follow-up after a routine physical during which he was found to have 45 red blood cells (RBCs) per high-power field (HPF) on a screening urinalysis. The urinalysis was negative for leukocytes, nitrites, epithelial cells, and ketones. The patient denies any complaints and the review of systems is essentially negative.
What would be your initial approach in the workup of this patient with asymptomatic microscopic hematuria?
A. check PSA and urine culture
B. CT scan with and without contrast of the abdomen and pelvis
C. intravenous pyelography (IVP)
D. observation and reassurance as patient is asymptomatic
E. repeat urinalysis
Correct Answer: E Section: (none)
Explanation:
Asymptomatic microscopic hematuria is defined by the American Urological Association as three or more RBCs per high power field on urinary sediment from two out of three properly collected urinalyses. A proper sample can be a midstream clean-catch specimen. The urine dipstick is roughly 91100% sensitive and 6599% specific for detection of RBCs, Hgb, and myoglobin. Urine dipstick is not reliable in distinguishing myoglobin from Hgb or RBCs. Therefore, urinalysis with microscopy should be ordered to assess the number of RBCs per high power field. Microscopic hematuria is usually an incidental finding but deserves a thorough workup, as 10% can be due to malignancy. The initial approach is to repeat the urinalysis to rule out infection. If the urinalysis suggests infection by the presence of WBCs or nitrites, a culture should be ordered and the patient treated appropriately. If RBCs are present without any leukocytes, nitrites, or epithelial cells on the repeated urinalysis, a proper workup should ensue. After history and physical are done to rule out risk factors, comorbidities, or other etiologies to account for the hematuria, one must look to diagnostic tests. A serum creatinine is useful to assess for renal insufficiency. During the course of the workup, if the urinalysis and serum creatinine suggest a glomerular etiology (casts, elevated creatinine, dysmorphic RBCs) a renal consultation and possible renal biopsy may be warranted. Evaluation of the upper tract with either an IVP or CT scan of the abdomen/pelvis with and without contrast should be ordered to rule out renal cell carcinoma, nephrolithiasis, or aneurysms. Next, the lower tract should be visualized by cystoscopy and washings sent for cytology. If all the above workup is negative, the patient can be reassured and followed with a repeat urinalysis in 6 months.
Question 782:
A54-year-old Asian female with no significant medical history presents with frontal headache, eye pain, nausea, and vomiting. Her abdominal examination shows mild diffuse tenderness but no rebound or guarding. Her mucous membranes are dry. Her vision is blurry in both eyes, her eyes are injected but her extraocular muscles are intact. Her pupils are mid-dilated and fixed
Which of the following is the most likely diagnosis?
A. diabetic ketoacidosis (DKA)
B. appendicitis
C. angle closure glaucoma
D. perforated colon due to inflammatory bowel disease (IBD)
E. cerebellar malignancy
Correct Answer: C Section: (none)
Explanation:
The presence of headache, eye pain, nausea, and vomiting should prompt the consideration of the diagnosis of acute angle closure glaucoma. This is a rare but serious condition in which the aqueous outflow is obstructed, and the intraocular pressure abruptly rises. Susceptible eyes have a narrow anterior chamber and when the pupil becomes dilated, the peripheral iris blocks the outflow via the anterior chamber angle. Edema of the cornea occurs, resulting in cloudiness on examination. Diagnosis is made by measuring the intraocular pressure during an acute attack. Treatment includes medications to induce miosis in an effort to relieve the blockage or, if that fails, surgical intervention. In some patients, the headache or GI symptoms can overshadow the ocular symptoms, resulting in a delay in diagnosis and unnecessary workup for other conditions. In this case, the lack of findings on abdominal examination makes appendicitis or perforated bowel unlikely. DKA can present with primary GI symptoms, but would not explain the ocular symptoms. Similarly, cerebellar or other brain tumors may cause headache, nausea, and vomiting, but would not be causes of a painful, red eye.
Question 783:
A 42-year-old man presents to your clinic with a 1-week history of pain and inflammation involving his right first metatarsophalangeal (MTP) joint. He describes the pain as sudden in onset and worse at night. He denies experiencing any fever or traumatic injury to the joint and states that he has never had this type of pain before. He denies any chronic medical conditions, any prior surgery, and any current medication use. Besides an erythematous and exquisitely tender right first MTP joint, the remainder of his physical examination is unremarkable.
Which of the following is true of the patient's condition?
A. It commonly presents in premenopausal women.
B. It commonly presents as a monoarticular arthritis.
C. Episodes of pain and inflammation become more frequent but resolve more quickly as the disease progresses.
D. The presence of tophi is a common early finding.
E. A blood test is the diagnostic gold standard.
Correct Answer: B Section: (none)
Explanation:
This patient's presentation is consistent with gout. Aspiration of his first MTP joint is likely to reveal the presence of needle-shaped, negatively birefringent crystals. Rhomboid-shaped, positively birefringent crystals are characteristic of calcium pyrophosphate deposition disease, or pseudogout, with the knee being the joint most commonly affected. Nonbirefringent crystals are found in hydroxyapatite crystal deposition disease. The synovial fluid from joints affected by gout typically show evidence of inflammation in the form of leukocytosis with a predominance of polymorphonuclear neutrophils. The presence of bacteria in synovial fluid is characteristic of infection rather than gout, although gout and infectious arthritis may coexist. (Cecil Textbook of Medicine, pp. 17031708) Acute gouty arthritis usually presents in a monoarticular or oligoarticular distribution, with the first MTP joint most commonly affected. The diagnostic gold standard is detection of urate crystals within the synovial fluid of affected joints. It most commonly affects adult men with a peak incidence in the fifth decade of life. While patients with gout typically also have hyperuricemia, only a small fraction of the people with hyperuricemia actually have or will develop gout.
Tophi are primarily seen in patients with long-standing hyperuricemia and is considered a finding of chronic gouty arthritis. As the disease progresses, acute attacks become more frequent and last longer if left untreated. Indomethacin inhibits the prostaglandin synthesis that facilitates the inflammation of acute gout and inhibits the phagocytosis of urate crystals by leukocytes. This inhibits the cell lysis and release of cytotoxic factors that initiate the inflammatory cascade. Allopurinol (an inhibitor of urate synthesis) and probenecid and sulfinpyrazone (promoters of urate excretion) are useful for preventing gout but are not effective during an acute gout attack. Aspirin is inappropriate in the treatment of gout since it can inhibit urate elimination and, therefore, increase hyperuricemia.
Question 784:
A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. The patient's symptoms do not respond to your initial therapeutic management. You suspect that his condition is refractory to treatment. Which of the following should you consider at this time?
A. He may have human immunodeficiency virus (HIV) infection and should be tested.
B. His condition will require high doses of prednisone (60 mg daily) for adequate control.
C. His joints are obviously not infected and should be directly injected with corticosteroids.
D. He must have a disseminated bacterial infection that will require IV antibiotics.
E. He is resistant to indomethacin, so the dose should be doubled to 400 mg daily.
Correct Answer: A Section: (none)
Explanation:
Reactive arthritis consists of a triad of nonspecific urethritis, conjunctivitis, and asymmetric arthritis, usually involving the large joints of the lower extremities. Genitourinary causes of reactive arthritis include Chlamydia or Ureaplasma. GI infections due to Salmonella, Shigella, Yersinia, Klebsiella, and Campylobacter can also cause reactive arthritis. Gout attacks are typically monoarticular and begin abruptly with the affected joint being exquisitely painful, warm, red, and swollen. These attacks often spontaneously resolve in 310 days. While the symptoms from pseudogout may mimic those of gout, they tend to be less painful and take longer to reach peak intensity. Gonococcal arthritis is seen more often in females, is associated with migratory arthralgia, tends to favor the upper limbs and knees and may be associated with cutaneous lesions (pustules). The absence of attacks and joint distribution makes gout and pseudogout less likely. The history of conjunctivitis and association with diarrhea makes the diagnosis of reactive arthritis more likely than resistant gonococcal arthritis. His clinical symptoms do not suggest ankylosing spondylitis, although if he was HLA-B27 positive he would be at increased risk of developing spondylitis. This patient has the classic symptoms and exposure risk (GI infection) to suggest reactive arthritis. For the articular symptoms, reduction of inflammation and restoration of function can be achieved with nonsteroidal antiinflammatories alone. A sufficient number of patients with reactive arthritis will not be HLA-B27 positive, thus rendering this test useless as a screening test. However, it may be useful when the clinical picture is incomplete (such as absence of antecedent infection or lack of extraarticular features). Once an antecedent infection has triggered reactive arthritis, it is unlikely that antibiotics will affect the course of the illness (except in the case of chlamydiaassociated urogenital disease where a trial of prolonged antibiotic therapy may be reasonable).
Systemic corticosteroids are usually ineffective in reactive arthritis, but may be tried for resistant disease or conditions such as AIDS in which cytotoxic therapy is contraindicated. Given the absence of skin lesions, penile discharge, or urogenital symptoms, one would be hard-pressed to challenge the patient's statement that he has not engaged in unprotected sex at the risk of jeopardizing the physicianpatient relationship. Reactive arthritis may be the first manifestation of HIV infection. Therefore, HIV antibody status should be determined when the appropriate risk factors and/or clinical features are present. As mentioned previously, systemic steroids are usually ineffective for reactive arthritis and, with the possibility of joint infection, would necessitate ruling out infection by arthrocentesis of the affected joints. Joint infection cannot be ruled out based on his presentation, and joint sepsis must be excluded prior to corticosteroid injection. The clinical presentation is classic for reactive arthritis, and the absence of systemic symptoms makes the likelihood of disseminated bacterial infection low. Indomethacin, at a dose of 150200 mg/day, is the prototypic NSAID medication for treatment of reactive arthritis. Doses higher than this are associated with significant GI complications and do not improve efficacy in a patient resistant to the standard dose. In the event that the patient does not respond to 200 mg of indomethacin or alternative NSAIDs, disease-modifying antirheumatic drugs (DMARD) such as methotrexate, azathioprine, or sulfasalazine may be used, provided that HIV test results are negative, as these immunosuppressants have been reported to precipitate the onset of AIDS in HIV-positive patients.
Question 785:
A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. What would be the appropriate management for this patient's arthritis?
A. Screen him for the suspected disease with HLA-B27 testing.
B. Treat with daily indomethacin (150200 mg daily).
C. Start him on empiric antibiotics.
D. Start treatment with prednisone 10 mg daily.
E. Assume that the patient is not being honest and perform the appropriate urogenital testing to confirm gonorrhea.
Correct Answer: B Section: (none)
Explanation:
Reactive arthritis consists of a triad of nonspecific urethritis, conjunctivitis, and asymmetric arthritis, usually involving the large joints of the lower extremities. Genitourinary causes of reactive arthritis include Chlamydia or Ureaplasma. GI infections due to Salmonella, Shigella, Yersinia, Klebsiella, and Campylobacter can also cause reactive arthritis. Gout attacks are typically monoarticular and begin abruptly with the affected joint being exquisitely painful, warm, red, and swollen. These attacks often spontaneously resolve in 310 days. While the symptoms from pseudogout may mimic those of gout, they tend to be less painful and take longer to reach peak intensity. Gonococcal arthritis is seen more often in females, is associated with migratory arthralgia, tends to favor the upper limbs and knees and may be associated with cutaneous lesions (pustules). The absence of attacks and joint distribution makes gout and pseudogout less likely. The history of conjunctivitis and association with diarrhea makes the diagnosis of reactive arthritis more likely than resistant gonococcal arthritis. His clinical symptoms do not suggest ankylosing spondylitis, although if he was HLA-B27 positive he would be at increased risk of developing spondylitis. This patient has the classic symptoms and exposure risk (GI infection) to suggest reactive arthritis. For the articular symptoms, reduction of inflammation and restoration of function can be achieved with nonsteroidal antiinflammatories alone. A sufficient number of patients with reactive arthritis will not be HLA-B27 positive, thus rendering this test useless as a screening test. However, it may be useful when the clinical picture is incomplete (such as absence of antecedent infection or lack of extraarticular features). Once an antecedent infection has triggered reactive arthritis, it is unlikely that antibiotics will affect the course of the illness (except in the case of chlamydiaassociated urogenital disease where a trial of prolonged antibiotic therapy may be reasonable).
Systemic corticosteroids are usually ineffective in reactive arthritis, but may be tried for resistant disease or conditions such as AIDS in which cytotoxic therapy is contraindicated. Given the absence of skin lesions, penile discharge, or urogenital symptoms, one would be hard-pressed to challenge the patient's statement that he has not engaged in unprotected sex at the risk of jeopardizing the physicianpatient relationship. Reactive arthritis may be the first manifestation of HIV infection. Therefore, HIV antibody status should be determined when the appropriate risk factors and/or clinical features are present. As mentioned previously, systemic steroids are usually ineffective for reactive arthritis and, with the possibility of joint infection, would necessitate ruling out infection by arthrocentesis of the affected joints. Joint infection cannot be ruled out based on his presentation, and joint sepsis must be excluded prior to corticosteroid injection. The clinical presentation is classic for reactive arthritis, and the absence of systemic symptoms makes the likelihood of disseminated bacterial infection low. Indomethacin, at a dose of 150200 mg/day, is the prototypic NSAID medication for treatment of reactive arthritis. Doses higher than this are associated with significant GI complications and do not improve efficacy in a patient resistant to the standard dose. In the event that the patient does not respond to 200 mg of indomethacin or alternative NSAIDs, disease-modifying antirheumatic drugs (DMARD) such as methotrexate, azathioprine, or sulfasalazine may be used, provided that HIV test results are negative, as these immunosuppressants have been reported to precipitate the onset of AIDS in HIV-positive patients.
Question 786:
A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. Which of the following is the most likely diagnosis?
A. pseudogout
B. gout
C. reactive arthritis
D. resistant gonococcal arthritis
E. ankylosing spondylitis
Correct Answer: C Section: (none)
Explanation:
Reactive arthritis consists of a triad of nonspecific urethritis, conjunctivitis, and asymmetric arthritis, usually involving the large joints of the lower extremities. Genitourinary causes of reactive arthritis include Chlamydia or Ureaplasma. GI infections due to Salmonella, Shigella, Yersinia, Klebsiella, and Campylobacter can also cause reactive arthritis. Gout attacks are typically monoarticular and begin abruptly with the affected joint being exquisitely painful, warm, red, and swollen. These attacks often spontaneously resolve in 310 days. While the symptoms from pseudogout may mimic those of gout, they tend to be less painful and take longer to reach peak intensity. Gonococcal arthritis is seen more often in females, is associated with migratory arthralgia, tends to favor the upper limbs and knees and may be associated with cutaneous lesions (pustules). The absence of attacks and joint distribution makes gout and pseudogout less likely. The history of conjunctivitis and association with diarrhea makes the diagnosis of reactive arthritis more likely than resistant gonococcal arthritis. His clinical symptoms do not suggest ankylosing spondylitis, although if he was HLA-B27 positive he would be at increased risk of developing spondylitis. This patient has the classic symptoms and exposure risk (GI infection) to suggest reactive arthritis. For the articular symptoms, reduction of inflammation and restoration of function can be achieved with nonsteroidal antiinflammatories alone. A sufficient number of patients with reactive arthritis will not be HLA-B27 positive, thus rendering this test useless as a screening test. However, it may be useful when the clinical picture is incomplete (such as absence of antecedent infection or lack of extraarticular features).
Once an antecedent infection has triggered reactive arthritis, it is unlikely that antibiotics will affect the course of the illness (except in the case of chlamydiaassociated urogenital disease where a trial of prolonged antibiotic therapy may be reasonable).
Systemic corticosteroids are usually ineffective in reactive arthritis, but may be tried for resistant disease or conditions such as AIDS in which cytotoxic therapy is contraindicated. Given the absence of skin lesions, penile discharge, or urogenital symptoms, one would be hard-pressed to challenge the patient's statement that he has not engaged in unprotected sex at the risk of jeopardizing the physicianpatient relationship. Reactive arthritis may be the first manifestation of HIV infection. Therefore, HIV antibody status should be determined when the appropriate risk factors and/or clinical features are present. As mentioned previously, systemic steroids are usually ineffective for reactive arthritis and, with the possibility of joint infection, would necessitate ruling out infection by arthrocentesis of the affected joints. Joint infection cannot be ruled out based on his presentation, and joint sepsis must be excluded prior to corticosteroid injection. The clinical presentation is classic for reactive arthritis, and the absence of systemic symptoms makes the likelihood of disseminated bacterial infection low. Indomethacin, at a dose of 150200 mg/day, is the prototypic NSAID medication for treatment of reactive arthritis. Doses higher than this are associated with significant GI complications and do not improve efficacy in a patient resistant to the standard dose. In the event that the patient does not respond to 200 mg of indomethacin or alternative NSAIDs, disease-modifying antirheumatic drugs (DMARD) such as methotrexate, azathioprine, or sulfasalazine may be used, provided that HIV test results are negative, as these immunosuppressants have been reported to precipitate the onset of AIDS in HIV-positive patients.
Question 787:
A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After a thorough discussion with your patient, you determine that pharmacologic intervention would be beneficial given the severity of her osteoporosis. Which of the following is most appropriate for your patient?
A. estrogen replacement therapy
B. combined HRT with estrogen and progestin
C. alendronate
D. calcitonin intranasal spray
E. raloxifene
Correct Answer: C Section: (none)
Explanation:
DEXAis the newest, least expensive, and quickest method of assessing BMD. The precision of DEXAis approximately 12%. Standard radiography is inadequate for accurate bone mass assessment. Single photon absorptiometry is used to scan bone, which is in a superficial location with little adjacent soft tissue (e.g., radius). It may not be an accurate reflector of the density in the spine or hip, which are the sites of greatest potential risk for fracture. The quantitative CT scan and dual photon absorptiometry take more time, expose the patient to more radiation, and, in the case of quantitative CT scanning, significantly increase costs, when compared to DEXA. The major risk factors for osteoporosis are family history, slender body build, fair skin, early menopause, sedentary lifestyle, cigarette smoking, medications (corticosteroids or Lthyroxine), more than two drinks a day of alcohol or caffeine, and low calcium intake. The current recommendation for oral calcium in men and premenopausal women is 1000 mg/day. Postmenopausal women and patients with osteoporosis should have 1500 mg calcium a day and 400800 IU of vitamin D, which promotes intestinal calcium absorption. This patient's intake of calcium and vitamin D is not a risk factor for osteoporosis.
Alendronate is a bisphosphonate, which is approved for the prevention and treatment of postmenopausal osteoporosis. Among the many results of the WHI, it was found that combined estrogen plus progestin therapy was associated with an increased risk of nonfatal MI or death from coronary heart disease (CHD). Consequently, while it is recognized that postmenopausal women who are taking estrogen to alleviate postmenopausal symptoms may also experience skeletal benefits, the prevention of osteoporosis should not be a reason in itself to start estrogen therapy. Calcitonin inhibits osteoclastic bone resorption, but is not sufficiently potent to prevent bone loss in early postmenopausal women (within 5 years of menopause). It is best reserved for use in patients with osteoporosis unresponsive to other therapies. Raloxifene is a selective estrogen receptor modulator (SERM), which is effective for prevention of bone loss in early postmenopausal women and treatment of established osteoporosis, but it also increases the risk of venous thromboembolic disease which makes it an inappropriate choice for this patient
Question 788:
A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After performing the appropriate imaging study, you determine that your patient has osteoporosis. Of the following choices, which is risk factor most likely contributing to her osteoporosis?
A. active lifestyle
B. late menopause
C. cigarette smoking
D. frequency of alcohol intake
E. her intake of calcium and vitamin D
Correct Answer: C Section: (none)
Explanation:
DEXAis the newest, least expensive, and quickest method of assessing BMD. The precision of DEXAis approximately 12%. Standard radiography is inadequate for accurate bone mass assessment. Single photon absorptiometry is used to scan bone, which is in a superficial location with little adjacent soft tissue (e.g., radius). It may not be an accurate reflector of the density in the spine or hip, which are the sites of greatest potential risk for fracture. The quantitative CT scan and dual photon absorptiometry take more time, expose the patient to more radiation, and, in the case of quantitative CT scanning, significantly increase costs, when compared to DEXA. The major risk factors for osteoporosis are family history, slender body build, fair skin, early menopause, sedentary lifestyle, cigarette smoking, medications (corticosteroids or Lthyroxine), more than two drinks a day of alcohol or caffeine, and low calcium intake. The current recommendation for oral calcium in men and premenopausal women is 1000 mg/day. Postmenopausal women and patients with osteoporosis should have 1500 mg calcium a day and 400800 IU of vitamin D, which promotes intestinal calcium absorption. This patient's intake of calcium and vitamin D is not a risk factor for osteoporosis.
Alendronate is a bisphosphonate, which is approved for the prevention and treatment of postmenopausal osteoporosis. Among the many results of the WHI, it was found that combined estrogen plus progestin therapy was associated with an increased risk of nonfatal MI or death from coronary heart disease (CHD). Consequently, while it is recognized that postmenopausal women who are taking estrogen to alleviate postmenopausal symptoms may also experience skeletal benefits, the prevention of osteoporosis should not be a reason in itself to start estrogen therapy. Calcitonin inhibits osteoclastic bone resorption, but is not sufficiently potent to prevent bone loss in early postmenopausal women (within 5 years of menopause). It is best reserved for use in patients with osteoporosis unresponsive to other therapies. Raloxifene is a selective estrogen receptor modulator (SERM), which is effective for prevention of bone loss in early postmenopausal women and treatment of established osteoporosis, but it also increases the risk of venous thromboembolic disease which makes it an inappropriate choice for this patient
Question 789:
A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week.
She reports having had menopause 5 years ago and experiencing a deep venous thrombosis
approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center.
She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk
for osteoporosis.
Which of the following tests is best to detect and monitor osteoporosis?
A. plain film radiography
B. dual photon absorptiometry
C. single photon absorptiometry
D. dual-energy x-ray absorptiometry (DEXA)
E. quantitative CT scan
Correct Answer: D Section: (none)
Explanation:
DEXAis the newest, least expensive, and quickest method of assessing BMD. The precision of DEXAis approximately 12%. Standard radiography is inadequate for accurate bone mass assessment. Single photon absorptiometry is used to scan bone, which is in a superficial location with little adjacent soft tissue (e.g., radius). It may not be an accurate reflector of the density in the spine or hip, which are the sites of greatest potential risk for fracture. The quantitative CT scan and dual photon absorptiometry take more time, expose the patient to more radiation, and, in the case of quantitative CT scanning, significantly increase costs, when compared to DEXA. The major risk factors for osteoporosis are family history, slender body build, fair skin, early menopause, sedentary lifestyle, cigarette smoking, medications (corticosteroids or Lthyroxine), more than two drinks a day of alcohol or caffeine, and low calcium intake. The current recommendation for oral calcium in men and premenopausal women is 1000 mg/day. Postmenopausal women and patients with osteoporosis should have 1500 mg calcium a day and 400800 IU of vitamin D, which promotes intestinal calcium absorption. This patient's intake of calcium and vitamin D is not a risk factor for osteoporosis.
Alendronate is a bisphosphonate, which is approved for the prevention and treatment of postmenopausal osteoporosis. Among the many results of the WHI, it was found that combined estrogen plus progestin therapy was associated with an increased risk of nonfatal MI or death from coronary heart disease (CHD). Consequently, while it is recognized that postmenopausal women who are taking estrogen to alleviate postmenopausal symptoms may also experience skeletal benefits, the prevention of osteoporosis should not be a reason in itself to start estrogen therapy. Calcitonin inhibits osteoclastic bone resorption, but is not sufficiently potent to prevent bone loss in early postmenopausal women (within 5 years of menopause). It is best reserved for use in patients with osteoporosis unresponsive to other therapies. Raloxifene is a selective estrogen receptor modulator (SERM), which is effective for prevention of bone loss in early postmenopausal women and treatment of established osteoporosis, but it also increases the risk of venous thromboembolic disease which makes it an inappropriate choice for this patient.
Question 790:
A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. The patient's abdominal pain worsens and his weight loss progresses despite therapy, and you suspect that he may have a malignancy. If a malignancy was present, which tumor marker would be most likely to be elevated in this patient?
A. carcinoembryonic antigen (CEA)
B. prostate-specific antigen (PSA)
C. cancer antigen (CA)-125
D. -Fetoprotein (AFP)
E. CA-19-9
Correct Answer: E Section: (none)
Explanation:
The patient's history and examination are worrisome for pancreatic disease, and he has strong signs of pancreatic insufficiency. His long history of alcohol use suggests the possibility of chronic pancreatitis or pancreatic cancer. Fecal fat studies would only confirm or quantify his steatorrhea. ACT scan would image the pancreas for changes consistent with chronic pancreatitis (duct dilation, calcifications, pseudocysts) and could look for a neoplasm of the pancreas as well. ERCP is not indicated as a first-line test in patients with abdominal pain given its risk of causing acute pancreatitis. Upper endoscopy would be helpful to rule out peptic ulcer disease and other gastric complaints, but would not provide more global information about the abdomen. The patient has greasy stools and weight loss, findings seen in patients with steatorrhea due to chronic pancreatitis. Patients with steatorrhea malabsorb fat-soluble vitamins (vitamins A, D, E, and K). "Night blindness" (poor night vision) due to vitamin Adeficiency is common among patients with advanced chronic pancreatitis and likely led to this patient's motor vehicle accident. The patient has DM as a consequence of pancreatic endocrine insufficiency, another feature of chronic pancreatitis. Diabetes develops when greater than 8090% of the gland has been destroyed. Patients with chronic pancreatitis have a coexisting loss of glucagon from islet cells and, thus, often become brittle diabetics, with hypoglycemia seen after insulin administration. Vitamin K and B12 deficiency, which the patient may have, do not cause hypoglycemia. The patient was previously noted to eat well, so inadequate oral intake is unlikely. Diabetic education should decrease the rate of chronic insulin overdosage.
The patient has pancreatic exocrine insufficiency and thus cannot produce enough pancreatic enzymes to digest his food. Pancreatic enzyme replacement therapy in tablet form is a mainstay of therapy for chronic pancreatitis. It can rapidly reverse this problem by providing exogenously produced pancreatic enzymes to break down fats, carbohydrates, and proteins for absorption in the small bowel. The patient would not benefit from additional oral feedings without enzyme supplementation and would only worsen his steatorrhea by doing so. He can take food orally, so feeding via gastrostomy, TPN, or PPN are not indicated. The patient's worsening pain and weight loss despite therapy is worrisome for the development of pancreatic cancer. CA-19-9 is frequently (but not universally) elevated in pancreatic cancers, although it can be elevated in cholangiocarcinoma as well. PSA is associated with prostate cancer. CEA is associated with colon cancer. CA-125 is associated with ovarian cancer. AFP is associated with hepatocellular carcinoma.
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