Question of the week # 480

A 32-year-old man comes in regularly because his back hurts. You suspect malingering because he continually requests narcotic pain relievers and imaging studies of his spine. He has come 5 times in the last 6 months with the same problem, typically stating that the pain improves with exercise and leaning forward but is worse at night; pain also occurs at times in his buttocks and does not improve with rest. On physical examination you find no abnormalities of the spine besides inflexibility of the lower spine when he leans forward. Neurological examination is normal, including the absence of pain on a straight-leg raise test. X-ray of the spine and sacroiliac joint is normal. All blood tests including rheumatoid factor, ESR, and C-reactive protein are normal. Today, he again claims to have only minimal improvement with ibuprofen. He is requesting narcotics and a “doctor’s note to get out of work.” What is the next best step in management?

A. MRI of the sacroiliac joint
B. Anti-cyclic citrullinated peptide (anti-CCP)
C. HLA-B27 testing
D. Methotrexate
E. Report to employer for malingering

Question of the Week # 467

A 32-year-old man comes in regularly because his back hurts. You suspect malingering because he continually requests narcotic pain relievers and imaging studies of his spine. He has come 5 times in the last 6 months with the same problem, typically stating that the pain improves with exercise and leaning forward but is worse at night; pain also occurs at times in his buttocks and does not improve with rest. On physical examination you find no abnormalities of the spine besides inflexibility of the lower spine when he leans forward. Neurological examination is normal, including the absence of pain on a straight-leg raise test. X-ray of the spine and sacroiliac joint is normal. All blood tests including rheumatoid factor, ESR, and C-reactive protein are normal. Today, he again claims to have only minimal improvement with ibuprofen. He is requesting narcotics and a “doctor’s note to get out of work.” What is the next best step in management?
A. MRI of the sacroiliac joint
B. Anti-cyclic citrullinated peptide (anti-CCP)
C. HLA-B27 testing
D. Methotrexate
E. Report to employer for malingering

Question of the Week # 466

466. A 60-year-old woman presents to the office with hoarseness, shortness of breath, cough, and bilateral ear pain for the past 3 days. She has experienced similar, but less severe symptoms in the past week. Her past medical history is significant for moderate arthritis of the knees ankles, and wrists for the past 20 years Vital signs are:
temperature 37 C (98.6 F)
blood pressure 120/90 mm Hg
pulse 82/min
Respirations 12 breaths/min

On physical examination, the external ears are tender to touch with the exception of the lobule of the ear. There is no hearing loss. There is a saddle-nose deformity. The lungs have minimal bibasilar rhonchi. Abdominal examination reveals a normal-size spleen and liver. The ankle and knee joints are tender but not erythematous. Chest x-ray demonstrates focal tracheal narrowing. Which of the following is the most appropriate management for this patient at this time?

A An arthrocentesis of the knee joint
B Order knee and ankle x-rays
C Prescribe corticosteroids
D Prescribe nonsteroidal anti-inflammatory drugs
E Schedule a bronchoscopy

Question of the Week # 446

446) A 64 year old woman presents to your office with productive cough and fever for the past three days. About two months ago, she was admitted for pneumonia. Past medical history is significant for Rheumatoid arthritis. Her medications include hydroxychloroquine and prednisone. Previously, she was treated with Azathiprine for about 6 years.

On examination, temperature is 101F, blood pressure 120/80 and heart rate of 106/min.  Chest examination reveals decreased breath sounds at left lower lobe. No hepatomegaly, spleen tip is palpable. Chest X-Ray reveals left lower lobe consolidation  Labs reveal WBC 1000/µl with differential count showing neutrophils of 30% and Hemoglobin 9.9 gm%

Which of the following is the most likely explanation for the patient’s presentation?

A) Hypogammaglobulinemia from Rheumatoid arthritis

B) Marrow suppression by Hydroxychloroquine

C) Marrow toxicity by Azathiprine

D) Myeloproliferative disorder

E) Felty Syndrome

Question of the Week # 331

331) A 16 year old girl is evaluated in the office for mild to moderate pain in her left ankle.  She reports that she heard a pop sound followed by the pain when she was about to walk briskly on her way to college. She is unable to walk normally and cannot lift up on to her toes while weight bearing. Her past medical history is significant for recurrent episodes of urinary tract infections. On examination, she is afebrile. There is no bruising or swelling in her left foot. There is tenderness at the back of her left foot about 2 cm above the posterior calcaneus.  Squeezing of the left calf muscle fails to result in passive plantar flexion at the ankle.  Which of the following element if obtained from the patient’s history would help in determining the cause of her presentation?

A) Eating habits

B) Menstrual History

C) Sexual History

D) Recent antibiotic use

E) Family history of Muscular Dystrophy

Question of the Week # 324

324)  A 45 year old woman with history of Rheumatoid Arthritis presents to the emergency room increasing pain and swelling in her joints. She reports progressively increasing pain and stiffness of her bilateral wrist joints over the past two weeks. She now developed rapidly increasing pain and swelling in her right knee which prompted this Emergency Room visit. Her medications include Ibuprofen and Methotrexate. On examination, she is afebrile. There is mild swelling and tenderness in bilateral wrist joints. Right knee is warm, swollen and tender. Flexion and extension of the right knee  are severely painful.  Laboratory investigations are as follows:

WBC 9.0k/µl

Differential: Neutrophils 65%, Lymphocytes 24%, Monocytes 7%

Hemoglobin 11.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 510k/µl ( Normal 180 to 350k⁄μl )

ESR : 70 mm/hr

Which of the following is the most appropriate next step in management?

A)  Pulse Methyl Prednisolone

B)  Oral Prednsione

C) Arthrocentesis

D) Discontinue Methotrexate and start Infliximab

E) Intra-articular Glucocorticoids

Question of the week # 313

313) A 54 year old man is evaluated in your office for swelling of bilateral wrists and ankles. He also describes pain in his wrists and ankles as well as in the lower legs. Symptoms started 2  months ago and have been progressively worse. He reports limitation in walking because of extreme pain. He denies any stiffness. His past medical history is significant for chronic obstructive pulmonary disease for which he uses Tiotropium inhaler. He recently quit smoking but reports having smoked about 2 packs per day for 35 years. On physical examination, his vitals are within normal limits. Musculoskeletal exam reveals swelling and tenderness in bilateral wrists and ankles. There is an associated grade 3 clubbing in the fingers. There also tenderness all over the tibiae.  Overlying skin is thickened and erythematous. An erythrocyte sedimentation rate is elevated at 30 mm/hr. An x-ray of his upper extremity is shown below:

Which of the following investigations should be ordered next?

A) Arterial Doppler

B) Rheumatoid Factor

C) Hepatitis C serology

D) CT Scan of the Chest

E) Anti-Citrullin Peptide

Question of the week # 277

277) A 32 year old woman with history of Systemic Lupus Erythematosus is evaluated during a routine antenatal visit. Her last menstrual period was 18 weeks ago. She is using prenatal pills and has no complaints. She is being maintained on prednisone.  Physical examination is benign and her blood pressure is normal. Her laboratory investigations show positive ANA, Anti-Ds DNA and Anti-SSA (Anti-Ro) antibodies in high titers. Anticardiolipin antibodies and Lupus anticoagulant testing is negative.  She is concerned about the risk to her baby because she heard that her antibodies can cross the placenta. Which of the following conditions is most likely to occur in the baby due to passive transfer of maternal antibodies?

A) Lupus Nephritis

B) Aplastic anemia

C) No risk with passive transfer

D) Complete Heart Block

E) Hydrops fetalis

Question of the Week # 269

269 )  A 42 year old man is evaluated in the Emergency room for sudden onset pain and swelling in the right knee. He denies any trauma. His past medical history is significant for chronic alcohol abuse, diabetes and stage III chronic kidney disease.  On physical examination, temperature is 100.5F and heart rate 110. Right knee is grossly swollen, warm, tender and erythematous. Rest of the physical examination is within normal limits. Arthrocentesis is performed and results reveal polymorphonuclear leucocytes of 50,000/µl and intra-cellular negatively birefringent needle shaped crystals under polarized microscopy. Synovial fluid gram stain is negative and bacterial cultures are pending. Complete blood count shows a white blood cell count of 18,000/µl with left shift. Which of the following is the most appropriate management recommendation?

A) Colchicine

B) Indometacin

C) Oral Prednisone

D) Broad spectrum antibiotics

E) Intra-articular Triamcinolone

Question of the Week # 161

161) A 42 year old man is evaluated in your office for pain in his left hand. He has a chronic history of biciptal tendinopathy in his left upper extremity and Gastro-esophageal Reflux disease. He denies any history of recent trauma. He reports sudden onset of pain in his left hand that is associated with burning sensation. On physical examination, the left hand is swollen, pal, cool and tender to touch. Radial and ulnar pulses are intact. The image of his hands is shown below:

 

 

 

 

 

 

Most likely diagnosis of this patient’s presentation

A)     Scleroderma

B)      Raynaud’s phenomenon

C)      Complex regional pain syndrome

D)     Acute arterial occlusion

E)      Carpal Tunnel Syndrome

F)      Compartment Syndrome

Question of the Week # 155

155)  A 55 year old man presents to the clinic for progressive right hip pain. He has a history of hearing impairment. He reports pain in the right hip when walking more than 1 block and also, has difficulty putting shoes on his right foot. On examination, the range of motion is significantly limited in the right hip. An X-ray of the right hip reveals significant loss of cartilage, subchondral sclerosis and sub-chondral cysts. X-ray also reveals pagetoid changes in the right iliac wing and right femoral neck. Serum alkaline phosphatase level is 432 IU/L (n = 20 to 140 IU/L). The most appropriate initial step in managing this patient is:

A)           Bisphosphanates

B)            Acetaminophen

C)            Bisphosphanates and Acetaminoiphen

D)           Calcitonin Intranasally

E)           Oral prednisone

Question of the Week # 154

154) A 68 year old man presents to the clinic for progressive right hip pain.  He reports pain in the right hip when walking more than 1 block and also, has difficulty putting shoes on his right foot. On examination, the range of motion is significantly limited in the right hip. An X-ray of the right hip reveals significant loss of cartilage, subchondral sclerosis and sub-chondral cysts. The patient is diagnosed with Right Hip Osteoarthritis and is started on Acetaminophen. Which of the following exercises should not be recommended to this patient at this time:

A) Stair climbing

B) Quadriceps strtengthening

C) Tai-Chi

D) Swimming

E) Bicycling

Question of the Week # 153

153) A 68 year old man presents to the clinic for progressive right hip pain. He has a history of hearing impairment. He reports pain in the right hip when walking more than 1 block and also, has difficulty putting shoes on his right foot. On examination, the range of motion is significantly limited in the right hip. An X-ray of the right hip reveals significant loss of cartilage, subchondral sclerosis and sub-chondral cysts. X-ray also reveals pagetoid changes in the right liac wing and right femoral neck. Serum alkaline phosphatase level is normal. The most appropriate initial step in managing this patient is:

A) Bisphosphanates

B) Acetaminophen, Quadriceps strtengthening and Tai-Chi

C) Bisphosphanates and Acetaminoiphen

D) Calcitonin

E) Oral prednisone

Question of the Week # 152

152) A 34 year old woman with history of recently diagnosed Rheumatoid Arthritis presents to your office for follow up. She reports much improvement in her symptoms after starting Ibuprofen for pain. She was also started on Hydroxychloroquine 3 weeks ago. Which of the following is most appropriate in monitoring her therapy?

A)     Liver function tests every month

B)      Complete Blood Count every 3 months

C)      Serum Creatinine every week

D)     Ophthalmologic evaluation every year

E)      Hydroxychloroquine serum levels every month

%d bloggers like this: