BOARD REVIEW FROM MEDSCAPE Case-Based Internal Medicine Self-Assessment Questions CLINICAL ESSENTIALS CARDIOVASCULAR MEDICINE DERMATOLOGY ENDOCRINOLOGY GASTROENTEROLOGY HEMATOLOGY IMMUNOLOGY/ALLERGY INFECTIOUS DISEASE INTERDISCIPLINARY MEDICINE METABOLISM NEPHROLOGY NEUROLOGY ONCOLOGY PSYCHIATRY RESPIRATORY MEDICINE RHEUMATOLOGY www.acpmedicine.com BOARD REVIEW FROM MEDSCAPE Case-Based Internal Medicine Self-Assessment Questions Director of Publishing Director, Electronic Publishing Managing Editor Development Editors Senior Copy Editor Copy Editor Art and Design Editor Electronic Composition Manufacturing Producer Cynthia M Chevins Liz Pope Erin Michael Kelly Nancy Terry, John Heinegg John J Anello David Terry Elizabeth Klarfeld Diane Joiner, Jennifer Smith Derek Nash © 2005 WebMD Inc All rights reserved No part of this book may be reproduced in any form by any means, including photocopying, or translated, transmitted, framed, or stored in a retrieval system other than for personal use without the written permission of the publisher Printed in the United States of America ISBN: 0-9748327-7-4 Published by WebMD Inc Board Review from Medscape WebMD Professional Publishing 111 Eighth Avenue Suite 700, 7th Floor New York, NY 10011 1-800-545-0554 1-203-790-2087 1-203-790-2066 acpmedicine@webmd.net The authors, editors, and publisher have conscientiously and carefully tried to ensure that recommended measures and drug dosages in these pages are accurate and conform to the standards that prevailed at the time of publication The reader is advised, however, to check the product information sheet accompanying each drug to be familiar with any changes in the dosage schedule or in the contraindications This advice should be taken with particular seriousness if the agent to be administered is a new one or one that is infrequently used Board Review from Medscape describes basic principles of diagnosis and therapy Because of the uniqueness of each patient and the need to take into account a number of concurrent considerations, however, this information should be used by physicians only as a general guide to clinical decision making Board Review from Medscape is derived from the ACP Medicine CME program, which is accredited by the University of Alabama School of Medicine and Medscape, both of whom are accredited by the ACCME to provide continuing medical education for physicians Board Review from Medscape is intended for use in self-assessment, not as a way to earn CME credits EDITORIAL BOARD Editor-in-Chief David C Dale, M.D., F.A.C.P Professor of Medicine, University of Washington Medical Center, Seattle, Washington (Hematology, Infectious Disease, and General Internal Medicine) Founding Editor Daniel D Federman, M.D., M.A.C.P The Carl W Walter Distinguished Professor of Medicine and Medical Education and Senior Dean for Alumni Relations and Clinical Teaching, Harvard Medical School, Boston, Massachusetts Associate Editors Karen H Antman, M.D Deputy Director for Translational and Clinical Science, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (Oncology) John P Atkinson, M.D., F.A.C.P Samuel B Grant Professor and Professor of Medicine and Molecular Microbiology, Washington University School of Medicine, St Louis, Missouri (Immunology) Christine K Cassel, M.D., M.A.C.P President, American Board of Internal Medicine, Philadelphia, Pennsylvania (Ethics, Geriatrics, and General Internal Medicine) Mark Feldman, M.D., F.A.C.P William O Tschumy, Jr., M.D., Chair of Internal Medicine and Clinical Professor of Internal Medicine, University of Texas Southwestern Medical School of Dallas; and Director, Internal Medicine Residency Program, Presbyterian Hospital of Dallas, Dallas, Texas (Gastroenterology) Raymond J Gibbons, M.D Director, Nuclear Cardiology Laboratory, The Mayo Clinic, Rochester, Minnesota (Cardiology) Janet B Henrich, M.D Associate Professor of Medicine and Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut (Women’s Health) William L Henrich, M.D., F.A.C.P Professor and Chairman, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland (Nephrology) Michael J Holtzman, M.D Selma and Herman Seldin Professor of Medicine, and Director, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri (Respiratory Medicine) Mark G Lebwohl, M.D Sol and Clara Kest Professor and Chairman, Department of Dermatology, Mount Sinai School of Medicine, New York, New York (Dermatology) Wendy Levinson, M.D., F.A.C.P Vice Chairman, Department of Medicine, The University of Toronto, and Associate Director, Research Administration, Saint Michael’s Hospital, Toronto, Ontario, Canada (Evidence-Based Medicine and General Internal Medicine) D Lynn Loriaux, M.D., Ph.D., M.A.C.P Professor of Medicine and Chair, Department of Medicine, Oregon Health Sciences University, Portland, Oregon (Endocrinology and Metabolism) Shaun Ruddy, M.D., F.A.C.P Elam C Toone Professor of Internal Medicine, Microbiology and Immunology, and Professor Emeritus, Division of Rheumatology, Allergy and Immunology, Medical College of Virginia at Commonwealth University, Richmond, Virginia (Rheumatology) Brian Haynes, M.D., Ph.D., F.A.C.P Professor of Clinical Epidemiology and Medicine and Chair, Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada (Evidence-Based Medicine, Medical Informatics, and General Internal Medicine) Jerry S Wolinsky, M.D The Bartels Family Professor of Neurology, The University of Texas Health Science Center at Houston Medical School, and Attending Neurologist, Hermann Hospital, Houston, Texas (Neurology) CONTENTS EDITORIAL BOARD PREFACE CLINICAL ESSENTIALS Ethical and Social Issues Reducing Risk of Injury and Disease Diet and Exercise Adult Preventive Health Care Health Advice for International Travelers Quantitative Aspects of Clinical Decision Making Palliative Medicine Symptom Management in Palliative Medicine Psych osocial Issues in Term in al Illn essc Complementary and Alternative Medicine 7 11 12 15 17 20 CARDIOVASCULAR MEDICINE Heart Failure Hypertension Atrial Fibrillation Supraventricular Tachycardia Pacemaker Therapy Acute Myocardial Infarction Chronic Stable Anginai Unstable Angina/Non–ST Segment Elevation MI Diseases of the Aorta Pericardium, Cardiac Tumors, and Cardiac Trauma Congenital Heart Disease Peripheral Arterial Disease Venous Thromboembolism 12 14 15 18 25 30 31 35 39 43 45 DERMATOLOGY Cutaneous Manifestations of Systemic Diseases Papulosquamous Disorders Psoriasis Eczem atous Disorders, Atopic Derm atitis, Ich th yoses an d Contact Dermatitis and Related Disorders 11 Cutaneous Adverse Drug Reactions 13 Fungal, Bacterial, and Viral Infections of the Skin 17 Parasitic Infestations 19 Vesiculobullous Diseases 21 Malignant Cutaneous Tumors 23 Benign Cutaneous Tumors 26 Acne Vulgaris and Related Disorders 29 Disorders of Hair 31 Diseases of the Nail 33 Disorders of Pigmentation 35 ENDOCRINOLOGY Testes and Testicular Disorders The Adrenal Calcium Metabolism and Metabolic Bone Disease Genetic Diagnosis and Counseling Hypoglycemia 13 Obesity 15 GASTROENTEROLOGY Esophageal Disorders Peptic Ulcer Diseases Diarrheal Diseases Inflammatory Bowel Disease Diseases of the Pancreas Gallstones and Biliary Tract Disease 11 Gastrointestinal Bleeding 16 Malabsorption and Maldigestion 17 Diverticulosis, Diverticulitis, and Appendicitis 21 Enteral and Parenteral Nutritional Support 22 Gastrointestinal Motility Disorders 24 Liver and Pancreas Transplantation 25 HEMATOLOGY Approach to Hematologic Disorders Red Blood Cell Function and Disorders of Iron Metabolism Anemia: Production Defects Hemoglobinopathies and Hemolytic Anemia 10 The Polycythemias 15 Nonmalignant Disorders of Leukocytes 17 Transfusion Therapy Hematopoietic Cell Transplantation Hemostasis and Its Regulation Hemorrhagic Disorders Thrombotic Disorders 22 26 31 33 35 IMMUNOLOGY/ALLERGY Innate Immunity Histocompatibility Antigens/Immune Response Genes Immunogenetics of Disease Immunologic Tolerance and Autoimmunity Allergic Response Diagnostic and Therapeutic Principles in Allergy Allergic Rhinitis, Conjunctivitis, and Sinusitis Urticaria, Angioedema, and Anaphylaxis Drug Allergies Allergic Reactions to Hymenoptera Food Allergies 10 11 14 16 18 21 INFECTIOUS DISEASE Infections Due to Gram-Positive Cocci Infections Due to Mycobacteria Infections Due to Neisseria Anaerobic Infections Syphilis and Nonvenereal Treponematoses E coli and Other Enteric Gram-Negative Bacilli Campylobacter, Salmonella, Shigella, Yersinia, Vibrio, Helicobacter Haemophilus, Moraxella, Legionella, Bordetella, Pseudomonas Brucella, Francisella, Yersinia Pestis, Bartonella Diseases Due to Chlamydia Antimicrobial Therapy Septic Arthritis Osteomyelitis Rickettsia, Ehrlichia, Coxiella Infective Endocarditis Bacterial Infections of the Upper Respiratory Tract Pneumonia and Other Pulmonary Infections Peritonitis and Intra-abdominal Abscesses Vaginitis and Sexually Transmitted Diseases Urinary Tract Infections Hyperthermia, Fever, and Fever of Undetermined Origin Respiratory Viral Infections Herpesvirus Infections Enteric Viral Infections 14 16 21 24 27 30 33 36 40 45 50 52 54 57 64 72 75 77 79 82 84 88 Measles, Mumps, Rubella, Parvovirus, and Poxvirus 90 Viral Zoonoses 93 Human Retroviral Infections 96 HIV and AIDS 98 Protozoan Infections 103 Bacterial Infections of the Central Nervous System 105 Mycotic Infections 108 INTERDISCIPLINARY MEDICINE Management of Poisoning and Drug Overdose Bites and Stings Cardiac Resuscitation Preoperative Assessment Bioterrorism 12 Assessment of the Geriatric Patient 15 Disorders in Geriatric Patients 18 Rehabilitation of Geriatric Patients 24 METABOLISM Diagnosis and Treatment of Dyslipidemia The Porphyrias Diabetes Mellitus 10 NEPHROLOGY Renal Function and Disorders of Water and Sodium Balance Disorders of Acid-Base and Potassium Balance Approach to the Patient with Renal Disease Management of Chronic Kidney Disease Glomerular Diseases 11 Acute Renal Failure 14 Vascular Diseases of the Kidney 16 Tubulointerstitial Diseases 21 Chronic Renal Failure and Dialysis 24 Renal Transplantation 28 Benign Prostatic Hyperplasia 31 11 NEUROLOGY The Dizzy Patient Diseases of the Peripheral Nervous System Diseases of Muscle and the Neuromuscular Junction Cerebrovascular Disorders 10 Traumatic Brain Injury 14 Neoplastic Disorders 16 Anoxic, Metabolic, and Toxic Encephalopathies 19 Headache 21 Demyelinating Diseases 23 Inherited Ataxias 27 Alzh eim er Disease an d Oth er Dem en tin g Illn esses Major 27 Epilepsy 31 Disorders of Sleep 34 Pain 38 Parkinson Disease and Other Movement Disorders 41 Acute Viral Central Nervous System Diseases 43 Central Nervous System Diseases Due to Slow Viruses and Prions 45 12 ONCOLOGY Cancer Epidemiology and Prevention Molecular Genetics of Cancer Principles of Cancer Treatment Colorectal Cancer Pancreatic, Gastric, and Other Gastrointestinal Cancers 10 Breast Cancer 13 Lung Cancer 18 Prostate Cancer 20 Gynecologic Cancer 26 Oncologic Emergencies 29 Sarcomas of Soft Tissue and Bone 32 Bladder, Renal, and Testicular Cancer 34 Chronic Lymphoid Leukemias and Plasma Cell Disorders 36 Acute Leukemia 38 Chronic Myelogenous Leukemia and Other Myeloproliferative Disorders 42 Head and Neck Cancer 45 13 PSYCHIATRY Depression and Bipolar Disorder Alcohol Abuse and Dependency Drug Abuse and Dependence Schizophrenia Anxiety Disorders 11 14 RESPIRATORY MEDICINE Asthma Chronic Obstructive Diseases of the Lung Focal and Multifocal Lung Disease 14 Chronic Diffuse Infiltrative Lung Disease Ventilatory Control during Wakefulness and Sleep Disorders of the Chest Wall Respiratory Failure Disorders of the Pleura, Hila, and Mediastinum Pulmonary Edema Pulmonary Hypertension, Cor Pulmonale, and Primary Pulmonary Vascular Diseases 16 20 22 26 29 32 35 15 RHEUMATOLOGY Introduction to the Rheumatic Diseases Rheumatoid Arthritis Seronegative Spondyloarthropathies Systemic Lupus Erythematosus Scleroderma and Related Diseases Idiopathic Inflammatory Myopathies Systemic Vasculitis Syndromes Crystal-Induced Joint Disease Osteoarthritis Back Pain and Common Musculoskeletal Problems Fibromyalgia 13 15 16 20 22 26 31 33 15 RHEUMATOLOGY 21 36 A 54-year-old man is brought to the emergency department by his family They report that several days ago, the patient began complaining of arthralgias, myalgias, and subjective fevers He thought that he had the flu and remained home from work Yesterday he developed swelling and a rash on his legs According to his family, yesterday evening the patient started acting funny, and today he has been somewhat confused On physical examination, the patient’s temperature is 99.5° F (37.5° C); his heart rate is 93 beats/min, and his blood pressure is 154/85 mm Hg He is able to answer questions but is easily distracted during the examination Pulmonary, cardiovascular, and abdominal examinations are normal On musculoskeletal examination, petechiae and purpura are noted on the upper and lower extremities, with 1+ pitting edema in the lower extremities Laboratory values reveal a white blood cell count of 24,000, a platelet count of 550,000, and a hematocrit of 35% Blood urea nitrogen and creatinine levels are 120 mg/dl and 4.5 mg/dl, respectively You admit the patient to the hospital for further workup Renal biopsy reveals pauci-immune glomerulonephritis A serum test for perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) with antimyeloperoxidase specificity is positive Which of the following vasculitides is most likely responsible for this man’s illness? ❑ A Polyarteritis nodosa (PAN) ❑ B Allergic granulomatous angiitis ❑ C Microscopic polyangiitis (MPA) ❑ D Wegener granulomatosis (WG) Key Concept/Objective: To know the clinical presentation and laboratory findings for MPA Glomerulonephritis, particularly rapidly progressive glomerulonephritis, and alveolar hemorrhage are common in MPA and absent, by definition, in classic PAN Constitutional symptoms such as fever, asthenia, and myalgias are common in both PAN and MPA Elevated acute-phase reactants, thrombocytosis, leukocytosis, and the anemia of inflammatory disease are common, although they are not uniformly present The diagnosis of MPA and PAN should ideally be based on histopathologic demonstration of arteritis and the clinical pattern of disease A biopsy specimen of clinically involved, nonnecrotic tissue that demonstrates the presence of arteritis of muscular arteries is the ideal supportive finding for the diagnosis of arteritis of a medium-sized vessel, but such a finding is not always possible The presence of serum p-ANCA with antimyeloperoxidase specificity (found in 60% of MPA patients) supports the clinical diagnosis of MPA, but p-ANCA is not specific for this disease ANCAs are not characteristic of PAN The renal biopsy tissue in MPA, as in WG and CSS, does not contain extensive immune complexes on immunofluorescent staining and electron microscopy (so-called pauci-immune glomerulonephritis) (Answer: C— Microscopic polyangiitis [MPA]) 37 A 14-year-old girl is brought in to the emergency department by her parents They report high spiking fevers that began several days ago They also report that the patient has complained of headaches and aching joints and that today she developed a rash On physical examination, the patient’s temperature is 103.2° F (39.5° C), her heart rate is 110 beats/min, and her blood pressure is 125/70 mm Hg You note nonexudative conjunctivitis and an erythematous, dry oropharynx Pulmonary and cardiac examinations are unremarkable except for tachycardia Her distal limbs are notable for mild swelling Skin examination reveals a diffuse, polymorphous rash with some plaques You seriously suspect Kawasaki disease (KD) and begin administration of I.V immunoglobulin and aspirin The morbidity and mortality of KD is associated with which of the following complications? ❑ A Overwhelming sepsis caused by encapsulated organisms ❑ B Central hypertension and stroke ❑ C Glomerulonephritis and renal failure ❑ D Coronary artery aneurysms and thrombosis Key Concept/Objective: To know the life-threatening complications of KD The morbidity and mortality (< 3%) of KD is overwhelmingly associated with the development of inflammatory coronary artery aneurysms, most of which are asymptomatic at the time of formation Aneurysms may be detected by echocardiography Thrombosis can 22 BOARD REVIEW occur in the aneurysms, resulting in direct or embolic coronary artery occlusion Coronary events may occur weeks or even many years after the febrile illness A baseline echocardiogram should be obtained at the time of the acute illness and should be repeated and weeks later Early recognition of the disease and treatment with intravenous immunoglobulin and aspirin have significantly decreased the frequency of aneurysm formation and thrombotic coronary events Renal compromise is distinctly unusual in KD (Answer: D—Coronary artery aneurysms and thrombosis) 38 An 18-year-old woman comes to your clinic complaining of a rash on her legs She reports having crampy abdominal pain and aching joints for several days She also reports that the rash began yesterday evening and was worse this morning, and she complains that her skin is itchy Her medical history is significant only for an upper respiratory infection or weeks ago that resolved spontaneously She is otherwise healthy Physical examination is notable only for trace edema and purpura, noted on both lower extremities You suspect small vessel vasculitis You perform a skin biopsy, which stains positively for IgA-containing immune complexes This biopsy finding is most consistent with which of the following diseases? ❑ A Henoch-Schönlein purpura ❑ B Urticarial vasculitis ❑ C CSS ❑ D WG Key Concept/Objective: To know the clinical presentation and pathologic findings of HenochSchönlein purpura Cutaneous involvement can occur in many of the primary or secondary vasculitic syndromes Large, medium-sized, or small vessel occlusion can cause livedo, Raynaud phenomenon, or necrosis Purpura is the most common manifestation of small vessel vasculitis Small vessel vasculitis, particularly when associated with infections, is frequently associated with immune complex deposition Vasculitis primarily involving the postcapillary venules has been termed hypersensitivity vasculitis in older literature Primary small vessel vasculitis may be limited to the skin or may be associated with visceral involvement, including alveolar hemorrhage; intestinal ischemia or hemorrhage; and glomerulonephritis Purpura tends to occur in recurrent crops of lesions of similar age and is more pronounced in gravity-dependent areas Biopsy is useful in excluding causes of nonvasculitic purpura such as amyloidosis, leukemia cutis, Kaposi sarcoma, T cell lymphomas, and cholesterol or myxomatous emboli Tissue immunofluorescent staining is useful to support the diagnosis of Henoch-Schönlein purpura (specifically, IgA staining), systemic lupus erythematosus, or infection (the percentage of cases with positive results on immunofluorescent staining is not known) Patients with WG and CSS can present with purpura; however, they not exhibit IgA deposits in the immunoflourescence stains Urticarial vasculitis is a disease that affects the skin exclusively; very rarely, patients present with interstitial lung disease but not articular or abdominal complaints, as seen in this patient (Answer: A— Henoch-Schönlein purpura) For more information, see Mandell BF: 15 Rheumatology: VIII Systemic Vasculitis Syndromes ACP Medicine Online (www.acpmedicine.com) Dale DC, Federman DD, Eds WebMD Inc., New York, August 2003 Crystal-Induced Joint Disease 39 A 67-year-old man comes to your clinic to establish care He has a history of hypertension, gout, obesity, and hyperlipidemia He denies alcohol abuse He tells you that he has not had a “gout flare” in several years and takes no medicines for this condition His medications include a dihydropyridine calcium channel blocker and a statin He does not take aspirin You order routine laboratory studies, including assessment of the uric acid level All laboratory results are normal 15 RHEUMATOLOGY 23 For this patient, which of the following statements regarding gout is false? ❑ A Hyperuricemia must be present to make a diagnosis of gout ❑ B This patient likely has secondary gout ❑ C Gout is primarily a disease of middle-aged men ❑ D Obesity, alcohol intake, high blood pressure, and an elevated serum creatinine level correlate with elevation of the serum uric acid level and the development of gout ❑ E In 80% to 90% of patients with primary gout, hyperuricemia is caused by underexcretion of uric acid in the presence of normal renal function Key Concept/Objective: To understand that although hyperuricemia is associated with gout, it does not always lead to the development of gout The development of gout tends to be associated with chronically increased levels of serum uric acid However, a substantial minority of patients with acute gout will have normal uric acid levels, and hyperuricemia does not always lead to the development of gout Gout is often classified as primary or secondary Gout associated with an inborn problem in metabolism or decreased renal excretion without other renal disease is referred to as primary gout, whereas gout associated with an acquired disease or use of a drug is called secondary gout In both primary and secondary gout, chronic hyperuricemia may be the result of overproduction of uric acid caused by increased purine intake, synthesis, or breakdown, or it may be the result of decreased renal excretion of urate Gout is predominantly a disease of middle-aged men, but there is a gradually increasing prevalence in both men and women in older age groups In most studies, the annual incidence of gout in men is one to three per 1,000; the incidence is much lower in women Additional factors that correlate strongly with serum urate levels and the prevalence of gout in the general population include serum creatinine levels, body weight, height, blood pressure, and alcohol intake Hyperuricemia can result from decreased renal excretion or increased production of uric acid In 80% to 90% of patients with primary gout, hyperuricemia is caused by renal underexcretion of uric acid, even though renal function is otherwise normal (Answer: A— Hyperuricemia must be present to make a diagnosis of gout) 40 A 74-year-old man presents to your clinic with a 2-day history of pain in his right great toe You suspect gout and recommend treatment You order laboratory studies, and the patient’s serum uric acid level is found to be elevated Before leaving your office, the patient asks you what he should expect in the future concerning this disease In counseling this patient about the clinical presentation and course of this condition, which of the following statements is false? ❑ A Initial attack of gout is monoarticular in 85% to 90% of cases, and half of these cases will involve the first metatarsophalangeal joint ❑ B The presence of fever and the involvement of multiple joints effectively rules out the diagnosis of gout ❑ C If the patient’s hypouricemia is not treated, there is at least a 75% chance of further attacks within years and a 90% chance within 10 years ❑ D Without treatment for hyperuricemia, the patient will likely develop tophi within 12 years ❑ E Chronic gout eventually progresses to articular destruction, including bony erosions that may have the radiographic appearance of punchedout lesions of periarticular bone, often with an overhanging edge that can be distinguished from rheumatoid arthritis Key Concept/Objective: To understand that gout may involve multiple joints and be associated with fever 24 BOARD REVIEW Acute gouty arthritis is usually characterized by a sudden and dramatic onset of pain and swelling, usually in a single joint This condition occurs most often in lower extremity joints and evolves within hours to marked swelling, warmth, and tenderness The initial attack of gout is monoarticular in 85% to 90% of patients At least half of initial attacks occur in the first metatarsophalangeal joints (a condition known as podagra), but other joints of the foot may be involved simultaneously or in subsequent attacks Other lower extremity joints, including the ankles and knees, are often affected; in more advanced gout, attacks may occur in upper extremity joints, such as the elbow, wrist, and small joints of the fingers Polyarticular gout occurs as the initial manifestation in about 10% to 15% of patients and may be associated with fever After the initial attack of gout subsides, the clinical course may follow one of several patterns A minority of patients never have another attack of gout, and some may not have another attack for several years Most patients, however, have recurrent attacks over the ensuing years In a study conducted before the use of hypouricemic agents, 78% of patients had a second attack within years and 93% had a second attack within 10 years Persistent hyperuricemia with increasingly frequent attacks of gout eventually leads to joint involvement of wider distribution, as well as chronic joint destruction as a result of deposition of massive amounts of urate in and around joints Without therapy to lower serum uric acid levels, the average interval from the first gouty attack to the development of chronic arthritis or tophi is about 12 years Erosive bony lesions may be seen on x-rays as well-defined, punched-out lesions in periarticular bone, often associated with overhanging edges of bone These erosions are usually mm or more in diameter and are larger than those seen in rheumatoid arthritis Bone mineralization appears to be generally normal in chronic tophaceous gout, and periarticular osteopenia, which is seen in rheumatoid arthritis, is usually not present The distribution of destructive joint disease in gout is often asymmetrical and patchy (Answer: B— The presence of fever and the involvement of multiple joints effectively rules out the diagnosis of gout) 41 A 77-year-old male patient of yours presents to your clinic for evaluation of right knee pain He has had recurrent gout in this knee, and his current symptoms are consistent with previous presentations This patient has many medical problems, which include congestive heart failure, chronic kidney disease, and hypertension Three months ago, the patient was admitted to the hospital for upper gastrointestinal bleeding; he was found to have peptic ulcer disease His medications include a daily dose of colchicine, but he admits that he has not taken his medications today because of the pain and mild nausea The patient is noticeably uncomfortable His examination is notable only for marked swelling and erythema of the right knee and the presence of an effusion Which of the following treatment strategies should be prescribed for this patient’s gouty attack? ❑ A Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin ❑ B Colchicine, 0.6 mg to 1.2 mg initially and then 0.6 mg every hours until the flare resolves ❑ C Allopurinol ❑ D Cyclooxygenase-2 inhibitors ❑ E Arthrocentesis followed by administration of an intra-articular steroid to provide immediate relief Key Concept/Objective: To understand the management of acute gouty attacks in patients with multiple comorbidities Treatment of acute gout should be initiated as early in the attack as possible Agents available for terminating the acute attack include colchicine, NSAIDs, adrenocorticotropic hormone (ACTH), and corticosteroids Each agent has a toxicity profile, with advantages and disadvantages applicable to individual circumstances This patient’s overall health and coexistent medical problems, particularly renal and gastrointestinal disease, dictate the choice among these approaches Corticosteroids and ACTH have been used more often in recent years in patients with multiple comorbid conditions, because of the relatively low toxicity profile of these agents Colchicine has been used for centuries to treat acute attacks of gout Given in oral dosages of 0.6 to 1.2 mg initially, followed by 0.6 mg every hours, colchicine begins relieving most attacks of gout within 12 to 24 hours However, most 15 RHEUMATOLOGY 25 patients experience nausea, vomiting, abdominal cramps, and diarrhea with these dosages Colchicine should be given more cautiously in elderly patients and should be avoided in patients with renal or hepatic insufficiency and in patients who are already receiving long-term colchicine therapy NSAIDs are useful in most patients with acute gout and remain the agents of choice for young, healthy patients without comorbid diseases The use of all NSAIDs is limited by the risks of gastric ulceration and gastritis, acute renal failure, fluid retention, interference with antihypertensive therapy, and, in older patients, problems with mentation Cyclooxygenase-2–specific NSAIDs should be useful in treating acute gout and possibly for long-term prophylaxis in patients at risk for gastrointestinal toxicity from the currently available NSAIDs but are not without risk in patients with renal insufficiency and congestive heart failure The use of intra-articular steroids after arthrocentesis is extremely useful in providing relief, particularly in large effusions, in which the initial aspiration of fluid results in rapid relief of pain and tightness in the affected joint The dosage of the steroid triamcinolone depends on the size of the joint; dosages range from to 10 mg for small joints of the hands or feet to 40 to 60 mg for larger joints, such as the knee Systemic corticosteroids may also be useful in patients for whom colchicine or NSAIDs are inadvisable and for patients with polyarticular attacks (Answer: E—Arthrocentesis followed by administration of an intra-articular steroid to provide immediate relief) 42 A 55-year-old man presents with a painful swollen right great toe He reports a previous similar attack months ago The pain is severe, even with minimal pressure from his sock or bed sheet The medical history includes reflux esophagitis, GI bleeding, and COPD Laboratory results include the following: uric acid, 8.8; Ca, 9.3; Na, 144; K, 5.0; BUN, 26; Cr, 2.9; and Glu, 96 What is the best treatment option for this patient? ❑ A Indomethacin, 50 mg p.o., t.i.d ❑ B Prednisone taper ❑ C Rofecoxib, 25 mg p.o., q.d ❑ D Allopurinol, 300 mg p.o., q.d ❑ E Acetaminophen, g p.o., q.i.d Key Concept/Objective: To appreciate comorbid conditions when selecting treatment for acute gout This patient’s acutely painful great toe is suggestive of gout His uric acid level is high, which is consistent with this diagnosis Appropriate treatment would be either oral prednisone or steroids injected into the joint He should not receive NSAIDs because he has renal insufficiency Rofecoxib, a COX-2 inhibitor, can also be detrimental to renal function and should not be used in this setting Allopurinol is not indicated for the acute treatment of gout (Answer: B—Prednisone taper) 43 A 54-year-old man presents with an attack of gout He had his first attack months ago; gout was confirmed by joint aspiration that revealed uric acid crystals Three months later, he had a second attack, which involved his knee and left great toe The medical history includes hypertension, reflux esophagitis, and psoriasis The patient reports drinking one glass of wine once a week Medications include omeprazole, lisinopril, hydrochlorothiazide, and triamcinolone ointment What would you recommend for this patient to prevent future episodes of gout? ❑ A Stop all alcohol use ❑ B Stop hydrochlorothiazide ❑ C Begin allopurinol ❑ D Begin probenecid ❑ E Begin colchicine Key Concept/Objective: To understand that hydrochlorothiazide is a common trigger for elevated uric acid and gout 26 BOARD REVIEW This patient has had several attacks of gout over a 6-month period Hydrochlorothiazide can decrease uric acid excretion and raise uric acid levels, triggering attacks of gout Before considering use of prophylactic medications in this patient, it would be appropriate to withhold the hydrochlorothiazide and see whether the gout attacks stop Alcohol consumption can also precipitate attacks, but this patient’s infrequent alcohol use is unlikely to be the cause of his gout attacks (Answer: B—Stop hydrochlorothiazide) 44 A 51-year-old man presents for primary care He has no major medical problems He brings with him old records that include results of lab testing done a year ago Those results were as follows: Na, 139; K, 4.2; Cl, 100; HCO3, 26; BUN, 12; Cr, 1.0; uric acid, 10.2 Laboratory tests are repeated, and the results are normal, with the exception of a uric acid measurement of 10.4 What would you recommend for this patient? ❑ A No therapy ❑ B Allopurinol ❑ C Probenecid ❑ D Colchicine ❑ E Aspirin Key Concept/Objective: To understand that asymptomatic hyperuricemia does not need therapy This patient has asymptomatic hyperuricemia There is no need to treat asymptomatic patients with hypouricemic agents They should be followed closely for the development of gout or renal stones If either condition develops, it would be appropriate to consider treatment (Answer: A—No therapy) 45 A 61-year-old man presents with a swollen, warm, tender left knee He has had three episodes of gout this year, which were treated successfully with indomethacin He is started on a 1-week course of indomethacin What other therapy would be appropriate to start? ❑ A Prednisone, 40 mg q.d for days ❑ B Probenecid, g p.o., b.i.d ❑ C Colchicine, 0.6 mg p.o., b.i.d ❑ D Allopurinol, 300 mg p.o., q.d ❑ E Acetaminophen, g p.o., b.i.d Key Concept/Objective: To understand how and when to start prophylactic medications for gout This patient presents with an acute attack of gout He has had several episodes in the past year It would be appropriate to treat him with indomethacin for the acute attack and to begin medication to decrease the risk of another attack in the near future Colchicine, 0.6 mg once or twice a day, prevents recurrent attacks in 80% of patients with gout It should be started in conjunction with acute treatment (NSAIDs or steroids) and continued for to months Colchicine should also be used when urate-lowering drug therapy is initiated This patient should not receive allopurinol or probenecid during the acute attack because both of these agents can worsen the acute attack There is no need to add prednisone to the indomethacin being used for acute treatment (Answer: C—Colchicine, 0.6 mg p.o., b.i.d.) For more information, see Wise C: 15 Rheumatology: IX Crystal-Induced Joint Disease ACP Medicine Online (www.acpmedicine.com) Dale DC, Federman DD, Eds WebMD Inc., New York, March 2004 Osteoarthritis 46 A 51-year-old white woman presents to your primary care clinic for evaluation of knee pain She states that the pain has been progressing gradually for at least a year The patient denies having had any trau- 15 RHEUMATOLOGY 27 ma She also states that she has not experienced any erythema, point tenderness, fevers, or chills, nor has she lost the ability to ambulate However, she occasionally notes some swelling of the joint Physical examination is notable for the absence of joint instability, fever, redness, edema, or warmth You suspect that the patient has osteoarthritis Which of the following statements regarding osteoarthritis is false? ❑ A In patients older than 50 years, men are more commonly affected than women ❑ B In most patients with primary osteoarthritis, involvement is limited to one or a small number of joints or joint areas ❑ C Intra-articular fractures and meniscal tears can lead to osteoarthritis years after the injury ❑ D Most patients with radiographic changes consistent with osteoarthritis have few symptoms or functional limitations Key Concept/Objective: To understand the epidemiology and etiology of osteoarthritis Osteoarthritis is a common form of arthritis characterized by degeneration of articular cartilage and reactive changes in surrounding bone and periarticular tissue The disease process results in pain and dysfunction of affected joints and is a major cause of disability in the general population Patients without a specific inflammatory or metabolic condition known to be associated with arthritis who have a history of specific injury or trauma are considered to have primary osteoarthritis In most patients, involvement is limited to one or a small number of joints or joint areas Secondary osteoarthritis has been associated with several conditions that cause damage to articular cartilage through a variety of mechanisms, including mechanical, inflammatory, and metabolic processes Acute trauma, particularly intra-articular fractures and meniscal tears, can result in articular instability or incongruity and can lead to osteoarthritis years after an injury Osteoarthritis is the most common type of arthritis, and it is one of the most common causes of disability and dependence in the United States Fortunately, most patients with radiographic changes found in population-based surveys have few symptoms or functional limitations Men and women tend be affected equally by osteoarthritis in middle age, but after the age of 50 years, women are more commonly affected than men (Answer: A—In patients older than 50 years, men are more commonly affected than women) 47 A 32-year-old man presents to your clinic for management of hypertension He states that his mother and father and many of their siblings have arthritis, and he wants to know if he will get arthritis, too He has no current complaints of arthritis or arthralgias, and his joint examination is normal Which of the following statements regarding risk factors for osteoarthritis is false? ❑ A Age and presence of osteoarthritis are positively correlated ❑ B Despite many well-designed studies, an association between obesity and osteoarthritis has not been established ❑ C Bone mineral density and the presence of osteoarthritis are positively correlated ❑ D A family history of osteoarthritis is common in patients with osteoarthritis Key Concept/Objective: To understand the risk factors for osteoarthritis A number of risk factors are believed to contribute to the development of primary osteoarthritis, including age, obesity, joint malalignment, bone density, hormonal status, nutritional factors, joint dysplasia, trauma, occupational factors, and hereditary factors Age is the factor most strongly associated with radiographic and clinically significant osteoarthritis, with an exponential increase seen in more severely involved joints Obesity is clearly associated with osteoarthritis of the knee The increased load carried by obese persons and the alterations in gait and posture that redistribute the load contribute to cartilage damage A study in young men suggested that each increase in weight of kg results 28 BOARD REVIEW in a 70% increase in the risk of symptomatic arthritis of the knee in later years This association is particularly high in patients with varus malalignment of the knee, and obese patients with malalignment are at risk for more rapid progression of established osteoarthritis in the knee Most of the association of obesity with osteoarthritis of the knee appears to be related to environmental, rather than genetic, factors An association between increased bone density and osteoarthritis has been noted in several studies Women with osteoporosis and hip fractures have a decreased risk of osteoarthritis, and those affected by osteoarthritis have significantly increased bone density This negative association suggests that soft subchondral bone absorbs impact and protects articular cartilage better than dense bone Many patients with osteoarthritis have a family history of the disorder, and multiple genetic factors may be responsible in various forms of osteoarthritis In women, osteoarthritis with finger joint involvement is probably the bestrecognized form of arthritis with familial associations, but hereditary factors are also important in osteoarthritis of the hip (Answer: B—Despite many well-designed studies, an association between obesity and osteoarthritis has not been established) 48 A 64-year-old white woman presents to the clinic with a 3- to 4-month history of worsening right hand pain She denies undergoing any trauma or injury, and she states that her pain is worse at the base of the thumb On physical examination, the patient has bony enlargement of her distal and proximal interphalangeal joints The carpometacarpal joint of the right thumb is exquisitely painful to motion, but there is no overlying erythema or edema Which of the following statements regarding the clinical manifestations and diagnostic tests for osteoarthritis is true? ❑ A The most commonly involved joints are the wrists, the metacarpophalangeal joints, the elbows, the shoulders, and the ankles ❑ B The ESR is usually elevated, and it is common to find an elevated leukocyte count (> 2,000 cells/mm3) in the synovial fluid ❑ C Synovial effusions may be present; erythema and warmth suggest the presence of coexistent crystal-induced inflammation or other conditions ❑ D Morning stiffness can occur with osteoarthritis and typically will last longer than hour Key Concept/Objective: To understand the clinical manifestations of osteoarthritis and the diagnostic tests used in the workup Typical symptoms of osteoarthritis include pain, stiffness, swelling, deformity, and loss of function Pain is usually chronic and localized to the involved joint or joints or referred to nearby areas Pain may be mild or moderate early in the disease but tends to worsen gradually over many years Most of the pain is made worse with activity and improves with rest Morning stiffness is not as prolonged as it is in patients with inflammatory diseases; morning stiffness in patients with osteoarthritis usually lasts less than an hour Physical findings in osteoarthritis include crepitus, pain on motion, bony enlargement, and periarticular tenderness Synovial effusions may be present, particularly in the knee Erythema and warmth are unusual and should suggest the presence of coexistent crystal-induced inflammation or other conditions Osteoarthritis has a characteristic pattern of involvement in most patients Frequently involved joints include the distal and proximal interphalangeal joints and the first carpometacarpal joints in the hands; the cervical and lumbar spine; the hips; the knees; and, less commonly, the small joints of the feet or the acromioclavicular joint The wrists, metacarpophalangeal joints, elbows, shoulders, and ankles are usually not affected unless there is a history of injury to the specific joint, occupational overuse, or an underlying condition that might be a cause of secondary osteoarthritis Characteristic radiographic features are usually considered essential for diagnosis but should be corroborated by the presence of compatible symptoms Laboratory studies are useful in the evaluation of patients with osteoarthritis only in that they help to exclude other diagnoses Thus, the ESR, rheumatoid factor, and routine hematologic and biochemical parameters should be normal in patients with osteoarthritis unless the osteoarthritis is attributable to comorbid conditions Synovial fluid from involved joints is 15 RHEUMATOLOGY 29 noninflammatory, with leukocyte counts of less than 2,000 cells/mm3 in most patients Typical radiographic findings in osteoarthritis include joint space narrowing, subchondral bone sclerosis, subchondral cysts, and osteophytes (bony spurs) (Answer: C—Synovial effusions may be present; erythema and warmth suggest the presence of coexistent crystal-induced inflammation or other conditions) 49 A 46-year-old woman presents with complaint of pain, stiffness, and swelling in her right hand; these symptoms have persisted for several months She denies experiencing any past or recent trauma to her hand or having any other significant medical history On examination, she has tenderness on several of her distal and proximal interphalangeal joints and a Heberden node on the index finger Which of the following is the most likely diagnosis? ❑ A Primary osteoarthritis ❑ B Secondary osteoarthritis ❑ C Erosive osteoarthritis ❑ D Rheumatoid arthritis Key Concept/Objective: To understand the classification of various forms of arthritis Erosive osteoarthritis is characterized by polyarticular involvement of the small joints of the hand and tends to occur more often in middle-aged and elderly women Patients without a specific inflammatory or metabolic condition known to be associated with arthritis and without a history of specific injury or trauma are considered to have primary osteoarthritis Secondary osteoarthritis has been associated with several conditions that cause damage to articular cartilage through a variety of mechanisms, including mechanical, inflammatory, and metabolic processes Rheumatoid arthritis can usually be distinguished from osteoarthritis on the basis of a different pattern of joint disease, more prominent morning stiffness, and soft tissue swelling and warmth on physical examination (Answer: C—Erosive osteoarthritis) 50 A 50-year-old man presents with complaints of right knee pain and swelling of days’ duration He reports no new injury, but several years ago he underwent arthroscopic surgery in that knee for a meniscal tear Since the time of his surgery, he has experienced intermittent pain in his knee when he “overdoes it,” but he has not previously experienced swelling in his knee On examination, there is moderate effusion in the patient’s right knee, and range-of-motion assessment elicits crepitus and pain Which of the following may be found on radiographic examination of this patient’s right knee? ❑ A Joint space narrowing ❑ B Subchondral bone sclerosis ❑ C Osteophytes ❑ D All of the above Key Concept/Objective: To understand the common radiographic findings of osteoarthritis Typical radiographic findings in osteoarthritis include joint space narrowing, subchondral bone sclerosis, subchondral cysts, and osteophytes (bony spurs) Joint space narrowing, resulting from loss of cartilage, is often asymmetrical and may be the only finding early in the disease process In weight-bearing joints such as the knees, narrowing may be seen only in a standing view and may be missed in a film obtained in the recumbent position In more chronic disease, the hypertrophic features of subchondral sclerosis and osteophyte formation become more prominent, and subluxations or fusion of the joint may become apparent in more severely affected joints In the small interphalangeal joints of the fingers, central erosions may be seen within the joint space (Answer: D—All of the above) 51 A 33-year-old morbidly obese man presents for a routine physical examination He reports pain in his knees, which he has been experiencing for several months and for which he takes acetaminophen He denies undergoing any trauma to either knee He also denies having any other past or present medical 30 BOARD REVIEW problems On examination, both knees have crepitus with range-of-motion assessment, and the right knee has a small effusion Which of the following statements regarding this patient is false? ❑ A This patient has an increased risk of osteoarthritis of the knees ❑ B This patient should be counseled regarding dietary vitamin C and D supplementation ❑ C Analysis of the synovial fluid would show an absence of inflammation, with leukocyte counts below 2,000 cells/mm3 ❑ D This patient would be expected to have an elevated erythrocyte sedimentation rate (ESR) Key Concept/Objective: To understand the risk factors for and characteristics of nonpharmacologic measures for osteoarthritis The ESR, rheumatoid factor level, and routine hematologic and biochemical parameters should be normal in patients with osteoarthritis unless the osteoarthritis is attributable to comorbid conditions Laboratory studies are useful in the evaluation of patients with osteoarthritis only in that they help to exclude other diagnoses Synovial fluid from involved joints is noninflammatory, with leukocyte counts being under 2,000 cells/mm3 in most patients A number of risk factors are believed to contribute to the development of primary osteoarthritis, including age, obesity, bone density, hormonal status, nutritional factors, joint dysplasia, trauma, occupational factors, and hereditary factors Obesity is clearly associated with osteoarthritis of the knee The increased load carried by obese patients and the alterations in gait and posture that redistribute the load contribute to cartilage damage Nonpharmacologic measures that have the potential to improve outcomes in osteoarthritis include patient education, physical and occupational therapy assessment and interventions, exercise, weight loss, and dietary vitamin D and C supplementation Epidemiologic studies have suggested a role for adequate dietary vitamin C and D intake in reducing the risk of progression of established osteoarthritis (Answer: D—This patient would be expected to have an elevated erythrocyte sedimentation rate [ESR]) 52 A 67-year-old woman presents with pain and stiffness in various joints of her hands; these symptoms have persisted for several months She denies experiencing any trauma to her hands She also denies having any other relevant medical history She states that she takes aspirin when she has pain On examination, she has swelling on several proximal interphalangeal joints in both hands and has Bouchard nodes in two joints Which of the following is the most appropriate first-line pharmacologic treatment for this patient? ❑ A Acetaminophen ❑ B Opioids ❑ C Steroids ❑ D Cyclooxygenase-2 (COX-2) NSAIDs Key Concept/Objective: To understand the pharmacologic therapies for osteoarthritis Acetaminophen in doses up to 3,000 to 4,000 mg daily should be prescribed initially in most patients with osteoarthritis The primary goal of drug therapy in osteoarthritis is to relieve pain In some patients, simple analgesics may be as effective as NSAIDs Opioids are generally avoided in osteoarthritis but may be useful in selected patients Opioids should be used with caution in elderly patients Tramadol, a centrally acting analgesic with dual mechanisms, may give relief comparable to that achieved with acetaminophen and codeine Topical capsaicin may be useful in some patients, particularly those with involvement of the knees and hands NSAIDs are useful in osteoarthritis mostly for their analgesic effects, although anti-inflammatory effects may have some clinical significance NSAIDs are associated with an increased risk of gastric ulcers and bleeding, particularly in patients with a history of GI disease The recently available COX-2–specific NSAIDs celecoxib and rofecoxib have been shown to reduce endoscopic gastritis and ulcers as well as serious GI 15 RHEUMATOLOGY 31 complications when compared to the previously available nonselective COX inhibitors (Answer: A—Acetaminophen) For more information, see Wise C: 15 Rheumatology: X Osteoarthritis ACP Medicine Online (www.acpmedicine.com) Dale DC, Federman DD, Eds WebMD Inc., New York, January 2005 Back Pain and Common Musculoskeletal Problems 53 A 67-year-old African-American man comes to your office with low back pain He has been experiencing progressive back pain for the past weeks He believes these symptoms started after he lifted a 20-lb box His medical history is unremarkable Review of systems is significant for a weight loss of 10 lb over the past months and urinary hesitancy Physical examination reveals tenderness to percussion over L5 and a nodular, enlarged prostate The neurologic examination is normal Of the following, which is the most appropriate step to take next in the treatment of this patient? ❑ A Start nonsteroidal anti-inflammatory drugs (NSAIDs) and have the patient come back to your clinic only if the pain persists ❑ B Prescribe bed rest for week ❑ C Obtain imaging studies ❑ D Start opiates and muscle relaxants Key Concept/Objective: To be able to identify patients with acute back pain who are at risk for serious underlying conditions For patients with acute back pain, the initial history should be used to identify those who are at risk for serious underlying conditions, such as fracture, infection, tumor, or major neurologic deficit The initial physical examination should include evaluation for areas of localized bony tenderness and assessment of flexion and straight leg raising This patient has symptoms and signs that suggest the presence of a malignancy He has experienced weight loss, and there is bony tenderness and a nodular prostate In this clinical scenario, imaging is indicated to evaluate for the possibility of metastatic disease to the spine For the treatment of acute back pain, NSAIDs and mild analgesics may be useful for symptom control Muscle relaxants and opiates should be used sparingly Spinal manipulation or specific exercise programs may also be effective in acute back pain Over 90% of patients will improve within month Strict bed rest should be kept to a minimum, and continuation of normal activities should be enforced (Answer: C—Obtain imaging studies) 54 A 42-year-old male postal worker presents to your clinic asking for a second opinion regarding the management of his chronic low back pain The pain started months ago The pain is located in his lower back; it does not radiate The patient denies having any weakness or sensory deficits The pain is worse when he walks or when he lifts weights, and it is interfering with his work The patient’s medical history and review of systems are unremarkable He has tried over-the-counter acetaminophen and ibuprofen, without relief Recently, he saw another physician, who ordered a magnetic resonance imaging scan The report describes a bulging disk on L4-5 with no signs of spinal cord compression On the basis of that study, the patient was told he needed surgery On physical examination, there is diffuse tenderness in his lower back, and a leg-raising test is negative The neurologic examination, including sphincter tone, is normal How would you manage this patient? ❑ A Prescribe an NSAID at a higher dosage than previously used, educate the patient about low back pain, and recommend physical therapy ❑ B Order a repeat MRI because the results not fit with the physical examination ❑ C Refer to a neurosurgeon for surgical repair of his herniated disk ❑ D Recommend that the patient apply for disability because of his chronic pain 32 BOARD REVIEW Key Concept/Objective: To understand the management of chronic back pain A herniated lumbar disk should be considered in patients with back pain who have symptoms of radiculopathy, as suggested by pain radiating down the leg with symptoms reproduced by straight leg raising MRI may be necessary to confirm a herniated disk, but findings should be interpreted with caution, because many asymptomatic persons have disk abnormalities This patient has no signs of radiculopathy Also, the MRI reports a bulging disk with no signs of compression: a finding that is frequently seen in healthy persons Surgery would be indicated if there were signs of radiculopathy and the MRI showed a herniated disk with evidence of spinal compression; however, this is not the situation in this case A repeat MRI is not indicated, because it is unlikely that a herniated disk is the cause of this patient’s symptoms, given the clinical evidence The management of chronic back pain is complex Patients should undergo physical therapy, an exercise program, and an education program that emphasizes proper ergonomics for lifting and other activities Light normal activity and a regular walking program should be encouraged Encouraging the patient to apply for disability before trying different therapeutic interventions is not appropriate Judicious use of NSAIDs and mild analgesics may improve patient function and outcome (Answer: A—Prescribe an NSAID at a higher dosage than previously used, educate the patient about low back pain, and recommend physical therapy) 55 A 55-year-old woman with a history of rheumatoid arthritis presents to the emergency department complaining of right elbow pain The pain started days ago and has become progressively worse, to the point where it is now difficult for her to move her elbow She has also felt febrile On physical examination, the patient’s temperature is 98.8° F (37.1° C), there are signs of chronic rheumatoid arthritis on her hands, and there is a × cm area of indurated swelling over the tip of her elbow This area is tender to palpation and is warm and erythematous The passive range of motion of the elbow is preserved What is the appropriate step to take next in the treatment of this patient? ❑ A Start NSAIDs and follow up within a week ❑ B Aspirate the fluid to rule out infection or crystal-induced disease ❑ C Order an MRI to evaluate the degree of joint damage ❑ D Inject steroids to the area Key Concept/Objective: To be able to recognize different causes of olecranon bursitis Olecranon bursitis presents as a discrete swelling with palpable fluid over the tip of the elbow Olecranon bursitis may be secondary to trauma, rheumatoid arthritis, crystalinduced disease (e.g., gout or pseudogout), or infection This patient’s clinical presentation should raise concern about an infectious process She may have had a fever previously On examination, she has an indurated, tender, erythematous area over her elbow The ability to perform passive range of motion of the elbow makes the possibility of synovial infection unlikely; however, aspiration of the bursae is indicated to rule out infection and crystal-induced disease Infectious bursitis, usually caused by gram-positive skin organisms, is accompanied by heat, erythema, and induration When infection is suspected, prompt aspiration and culture of the fluid are mandatory Antibiotics should be started empirically, and the bursae should be reaspirated frequently until the fluid no longer reaccumulates and cultures are negative NSAIDs and steroids should not be started until the fluid has been examined, because of the risk of underlying infection MRI is not indicated at this point, because the clinical picture is consistent with bursitis (Answer: B—Aspirate the fluid to rule out infection or crystal-induced disease) 56 A 31-year-old obese man presents to your clinic with a 2-week history of right foot pain The pain is located on his posterior heel There is no history of trauma The pain is worse when standing in the morning and when walking after sitting down for a period On physical examination, there is tenderness to palpation on the heel area The rest of the physical examination is normal Which of the following is the most likely cause of this patient’s symptoms? 15 RHEUMATOLOGY 33 ❑ A Previous unrecognized traumatic event ❑ B A deformity of the arch of his foot ❑ C Peripheral neuropathy ❑ D Plantar fasciitis Key Concept/Objective: To know the causes of hindfoot pain Plantar fasciitis is one of the most common causes of hindfoot pain Patients report pain over the plantar aspect of the heel and midfoot that worsens with walking Localized tenderness along the plantar fascia or at the insertion of the calcaneus is helpful in diagnosis Plantar fasciitis is associated with obesity, pes planus, and activities that stress the plantar fascia It may also be seen in systemic arthropathies such as ankylosing spondylitis and Reiter syndrome Although radiographic spurs in the affected area are common, they may also be seen in asymptomatic persons and are therefore not diagnostic In this case, the constellation of symptoms, obesity, and physical examination findings are consistent with the diagnosis of plantar fasciitis Careful examination usually helps distinguish between Achilles tendinitis and plantar fasciitis Therapy for plantar fasciitis is usually conservative and includes the use of orthotic devices (heel wedges), stretching exercises, and judicious use of NSAIDs Heel spurs can be seen on plain radiography; however, their role in the pathogenesis of plantar fasciitis is unclear (Answer: D—Plantar fasciitis) For more information, see Wise C: 15 Rheumatology: XII Back Pain and Common Musculoskeletal Problems ACP Medicine Online (www.acpmedicine.com) Dale DC, Federman DD, Eds WebMD Inc., New York, December 2002 Fibromyalgia 57 A 34-year-old woman returns to your office for a routine follow-up visit You diagnosed her as having fibromyalgia years ago, when she presented with multiple tender points of muscle and tendons, marked sleep disturbance, recurrent headaches, fatigue, and chronic generalized pain You have also treated her for generalized anxiety disorder and depression Today, she states that her generalized pain is slightly improved She is sleeping better, and her energy level has improved She remembers that just before her pain syndrome started years ago, she fell down her neighbor’s doorsteps She asks you if you agree that this fall is the likely cause of her current pain syndrome Which of the following statements regarding fibromyalgia is true? ❑ A Fibromyalgia most commonly occurs in middle-aged men ❑ B Fibromyalgia is considered to be a purely somatic disease; social or psychological factors have little bearing on the disease ❑ C The type of pain associated with fibromyalgia is typically nociceptive or neuropathic ❑ D Fibromyalgia patients often have fixed beliefs that minor traumatic events or exposure to pathogens, chemicals, or other physical agents caused their illness Key Concept/Objective: To know the general features of fibromyalgia Fibromyalgia is a chronic syndrome that occurs predominantly in women It is marked by generalized pain, multiple defined tender points, fatigue, disturbed or nonrestorative sleep, and numerous other somatic complaints Fibromyalgia becomes more common after 60 years of age but also occurs in children The cause of fibromyalgia is unknown Despite extensive research, no definitive organic pathology has been identified Psychological factors associated with chronic distress appear to be very important In fibromyalgia, negative psychological elements constituting stress and distress are major contributors to the development of increased pain sensitivity and myriad other symptoms There are four principal categories of pain: nociceptive, neuropathic, psychogenic, and chronic pain of complex etiology Chronic pain of complex etiology is the type of pain 34 BOARD REVIEW characteristic of fibromyalgia Fibromyalgia patients often have fixed beliefs that minor traumatic events, pathogens, chemicals, or other physical agents caused their illness (Answer: D—Fibromyalgia patients often have fixed beliefs that minor traumatic events or exposure to pathogens, chemicals, or other physical agents caused their illness) 58 A 27-year-old woman visits your clinic as a new patient She was in very good health until year ago, when she developed severe neck, shoulder, and hip pain Her primary physician has completed an extensive workup for rheumatologic disorders; the patient has brought the data from that workup with her today The patient is in constant pain and has difficulty sleeping; she also has a “nervous stomach” and chronic diarrhea, and she feels that her “memory is slipping.” Her pains are so constant and severe that she has had to resign her job as a schoolteacher Her social history reveals that she was divorced year ago and is a single parent of three children Which of the following statements regarding the historical diagnosis of fibromyalgia is true? ❑ A Cognitive complaints, such as difficulty with concentration and memory, are notably absent in patients with fibromyalgia ❑ B Fibromyalgia does not lead to functional impairment ❑ C Regional pain syndromes, such as headache, temporomandibular joint syndrome, or irritable bowel syndrome, are uncommon in fibromyalgia ❑ D Pain is the hallmark of fibromyalgia Key Concept/Objective: To understand important historical elements in patients with fibromyalgia Cognitive complaints, such as difficulties with concentration and memory, may be prominent in fibromyalgia Functional impairment is usually present, at least in patients with fibromyalgia who seek care Patients report difficulty performing usual activities of daily living; in addition, they avoid exercise—indeed, patients with fibromyalgia are fearful of exercise Regional pain syndromes, such as headache, temporomandibular joint syndrome, or irritable bowel syndrome, are extremely common in fibromyalgia It is essential that the physician not automatically attribute all such symptoms to fibromyalgia, however, because fibromyalgia frequently coexists with other organically defined disorders Pain is the hallmark of fibromyalgia The pain radiates diffusely from the axial skeleton and is localized to muscles and muscle-tendon junctions of the neck, shoulders, hips, and extremities (Answer: D—Pain is the hallmark of fibromyalgia) 59 A 35-year-old woman presents to your office with the complaints of severe joint pain, joint swelling, muscle aches, insomnia, and severe fatigue All of her symptoms started months ago when she lost her job as an executive assistant She denies having fever or chills, unprotected sexual contact, morning stiffness, or gastrointestinal or urinary symptoms On physical examination, diffuse swelling of the patient’s metacarpophalangeal joints and wrists is noted The patient has an erythematous rash on her face She has significant pain at 12 of the 18 tender points, and there is a mild reduction in strength in all extremities Her physical examination is otherwise normal Which of the following statements regarding the physical examination findings of fibromyalgia is false? ❑ A Evidence of synovitis, objective muscle weakness, or other definite physical or neurologic signs suggests the presence of either a comorbid disease or an alternative diagnosis ❑ B When assessing tender points, palpation is performed with the thumb, using approximately kg of pressure ❑ C For an accurate diagnosis, the examiner must confirm pain at all 18 tender points ❑ D Useful tests in fibromyalgia include antinuclear antibody (ANA), complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), thyroid-stimulating hormone (TSH), creatine kinase (CK), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) 15 RHEUMATOLOGY 35 Key Concept/Objective: To know the important components of the physical examination of a patient with fibromyalgia Evidence of synovitis (e.g., joint effusion, warmth over the joint, pain on joint motion), objective muscle weakness, or other definite physical or neurologic signs suggest the presence of either comorbid disease or an alternative diagnosis Eighteen specific tender points have been identified in fibromyalgia A patient with fibromyalgia will have pain, not just tenderness, on palpation at many of these tender points Palpation is performed with the thumb, using approximately kg of pressure—about the pressure necessary to blanch the examiner’s thumbnail Attempting to confirm pain at all 18 tender points is not necessary for diagnosis and is inconsiderate toward patients, many of whom find tender-point palpation quite distressing Useful tests in fibromyalgia include the following: ANA, CBC, ESR, CRP, TSH, CK, AST, and ALT Tests for Lyme disease, Epstein-Barr virus infection, and endocrinologic status are usually unnecessary (Answer: C—For an accurate diagnosis, the examiner must confirm pain at all 18 tender points) For more information, see Winfield JB: 15 Rheumatology: XIII Fibromyalgia ACP Medicine Online (www.acpmedicine.com) Dale DC, Federman DD, Eds WebMD Inc., New York, July 2004 .. .BOARD REVIEW FROM MEDSCAPE Case-Based Internal Medicine Self-Assessment Questions Director of Publishing Director, Electronic Publishing... clinical decision making Board Review from Medscape is derived from the ACP Medicine CME program, which is accredited by the University of Alabama School of Medicine and Medscape, both of whom... adult internal medicine, possibly with preparation for recertification as a final goal With this idea in mind, we have collected 981 case-based questions and created Board Review from Medscape