AAFP 3 Flashcards
A 55-year-old hospitalized white male with a history of rheumatic aortic and mitral valve disease has a 3-day history of fever, back pain, and myalgias. No definite focus of infection is found on your initial examination. His WBC count is 24,000/mm3(N 4300–10,800) with 40% polymorphonuclear leukocytes and 40% band forms. The following day, two blood cultures have grown gram-positive cocci in clusters.
Until the specific organism sensitivity is known, the most appropriate antibiotic treatment would be:
vancomycin and gentamicin
This patient has endocarditis caused by a gram-positive coccus. Until sensitivities of the organism are known, treatment should include intravenous antibiotic coverage for Enterococcus, Streptococcus, and methicillin-sensitive and methicillin-resistant Staphylococcus. A patient who does not have a prosthetic valve should be started on vancomycin and gentamicin, with monitoring of serum levels. Enterococcus and methicillin-resistant Staphylococcus are often resistant to cephalosporins. If the organism proves to be Staphylococcus sensitive to nafcillin, the patient can be switched to a regimen of nafcillin and gentamicin.
A 40-year-old white female lawyer sees you for the first time. When providing a history, she describes several problems, including anxiety, sleep disorders, fatigue, persistent depressed mood, and decreased libido. These symptoms have been present for several years and are worse prior to menses, although they also occur to some degree during menses and throughout the month. Her menstrual periods are regular for the most part.
The most likely diagnosis at this time is:
dysthymia
Psychological disorders, including anxiety, depression, and dysthymia, are frequently confused with premenstrual syndrome (PMS), and must be ruled out before initiating therapy. Symptoms are cyclic in true PMS. The most accurate way to make the diagnosis is to have the patient keep a menstrual calendar for at least two cycles, carefully recording daily symptoms. Dysthymia consists of a pattern of ongoing, mild depressive symptoms that have been present for 2 years or more and are less severe than those of major depression. This diagnosis is consistent with the findings in the patient described here.
A mother brings her 2-month-old infant to the emergency department because of profuse vomiting and severe diarrhea. The infant is dehydrated, has a cardiac arrhythmia, appears to have ambiguous genitalia, and is in distress.
This presentation suggests a diagnosis of:
congenital adrenal hyperplasia
Congenital adrenal hyperplasia is a family of diseases caused by an inherited deficiency of any of the enzymes necessary for the biosynthesis of cortisol. In patients with the salt-losing variant, symptoms begin shortly after birth with failure to regain birth weight, progressive weight loss, and dehydration. Vomiting is prominent, and anorexia is also present. Disturbances in cardiac rate and rhythm may occur, along with cyanosis and dyspnea. In the male, various degrees of hypospadias may be seen, with or without a bifid scrotum or cryptorchidism.
A 62-year-old African-American female undergoes a workup for pruritus. Laboratory findings include a hematocrit of 55.0% (N 36.0–46.0) and a hemoglobin level of 18.5 g/dL (N 12.0–16.0).
What additional findings would help establish the diagnosis of polycythemia vera?
A platelet count >400,000/mm3
Polycythemia vera should be suspected in African-Americans or white females whose hemoglobin level is >16 g/dL or whose hematocrit is >47%. For white males, the thresholds are 18 g/dL and 52%. It should also be suspected in patients with portal vein thrombosis and splenomegaly, with or without thrombocytosis and leukocytosis. Major criteria include an increased red cell mass, a normal O2 saturation,and the presence ofsplenomegaly. Minor criteria includeelevated vitamin B 12 levels, elevated leukocyte alkaline phosphatase, a platelet count >400,000/mm3 and a WBC count >12,000/mm3 . Patients with polycythemia vera may present with gout and an elevated uric acid level, but neither is considered a criterion for the diagnosis.
Over the last 6 months a developmentally normal 12-year-old white female has experienced intermittent abdominal pain, which has made her quite irritable. She also complains of joint pain and general malaise. She has lost 5 kg (11 lb) and has developed an anal fissure.
What is the most likely cause of these symptoms?
Crohn’s disease
The most common age of onset for inflammatory bowel disease is during adolescence and young adulthood, with a second peak at 50–80 years of age. The manifestations of Crohn’s disease are somewhat dependent on the site of involvement, but systemic signs and symptoms are more common than with ulcerative colitis. Perianal disease is also common in Crohn’s disease. Irritable colon and other functional bowel disorders may mimic symptoms of Crohn’s disease, but objective findings of weight loss and anal lesions are extremely uncommon. This is also true for viral hepatitis and giardiasis. In addition, the historical and epidemiologic findings in this case are not consistent with either of these infections. Celiac disease and giardiasis can produce Crohn’s-like symptoms of diarrhea and weight loss, but are not associated with anal fissures.
Which one of the following is considered first-line therapy for nausea and vomiting of pregnancy?
Vitamin B6
A number of alternative therapies have been used for problems related to pregnancy, although vigorous studies are not always possible. For nausea and vomiting, however, vitamin B6 is considered first-line therapy, sometimes combined with doxylamine. Other measures that have been found to be somewhat useful include ginger and acupressure.
A 45-year-old female presents to your office because she has had a lump on her neck for the past 2 weeks. She has no recent or current respiratory symptoms, fever, weight loss, or other constitutional symptoms. She has a history of well-controlled hypertension, but is otherwise healthy. On examination you note a nontender, 2-cm, soft node in the anterior cervical chain. The remainder of the examination is unremarkable.
What would be most appropriate at this point?
Monitoring clinically for 4–6 weeks, then a biopsy if the node persists or enlarges
There is limited evidence to guide clinicians in the management of an isolated, enlarged cervical lymph node, even though this is a common occurrence. Evaluation and management is guided by the presence or absence of inflammation, the duration and size of the node, and associated patient symptoms. In addition, the presence of risk factors for malignancy should be taken into account.
Immediate biopsy is warranted if the patient does not have inflammatory symptoms and the lymph node is >3 cm, if the node is in the supraclavicular area, or if the patient has coexistent constitutional symptoms such as night sweats or weight loss. Immediate evaluation is also indicated if the patient has risk factors for malignancy. Treatment with antibiotics is warranted in patients who have inflammatory symptoms such as pain, erythema, fever, or a recent infection.
In a patient with no risk factors for malignancy and no concerning symptoms, monitoring the node for 4–6 weeks is recommended. If the node continues to enlarge or persists after this time, then further evaluation is indicated. This may include a biopsy or imaging with CT or ultrasonography. The utility of serial ultrasound examinations to monitor lymph nodes has not been demonstrated.
A 45-year-old male is seen in the emergency department with a 2-hour history of substernal chest pain. An EKG shows an ST-segment elevation of 0.3 mV in leads V4–V6.
In addition to evaluation for reperfusion therapy, which one of the following would be appropriate?
Oral clopidogrel (Plavix)
This patient has an ST-segment elevation myocardial infarction (STEMI). STEMI is defined as an ST-segment elevation of greater than 0.1 mV in at least two contiguous precordial or adjacent limb leads. The most important goal is to begin fibrinolysis less than 30 minutes after the first contact with the health system. The patient should be given oral clopidogrel, and should also chew 162–325 mg of aspirin.
Enteric aspirin has a delayed effect. Intravenous β-blockers such as metoprolol should not be routinely given, and warfarin is not indicated. Delaying treatment until cardiac enzyme results are available in a patient with a definite myocardial infarction is not appropriate.
You see a 68-year-old mechanic for a routine evaluation. He has a 2-year history of hypertension. His weight is normal and he adheres to his medication regimen. His current medications are metoprolol (Lopressor), 100 mg twice daily; olmesartan (Benicar), 40 mg/day; and hydrochlorothiazide, 25 mg/day. His serum glucose levels have always been normal, but his lipid levels are elevated.
A physical examination is unremarkable except for an enlarged prostate and a blood pressure of 150/94 mm Hg. Laboratory studies show a serum creatinine level of 1.6 mg/dL (N 0.6–1.5) and a serum potassium level of 4.9 mmol/L (N 3.5–5.0).
The patient’s record shows blood pressures ranging from 145/80 mm Hg to 148/96 mm Hg over the past year.
What would be the appropriate next step at this point?
Substitute furosemide (Lasix) for hydrochlorothiazide
Resistant or refractory hypertension is defined as a blood pressure ≥140/90 mm Hg, or ≥130/80 mm Hg in patients with diabetes mellitus or renal disease (i.e., with a creatinine level >1.5 mg/dL or urinary protein excretion >300 mg over 24 hours), despite adherence to treatment with full doses of at least three antihypertensive medications, including a diuretic. JNC 7 guidelines suggest adding a loop diuretic if serum creatinine is >1.5 mg/dL in patients with resistant hypertension.
Actinic keratoses of the skin may progress to:
squamous cell cancer
Actinic keratoses are scaly lesions that develop on sun-exposed skin, and are believed to be carcinoma in situ. While most actinic keratoses spontaneously regress, others progress to squamous cell cancers.
A 52-year-old male presents with a small nodule in his palm just proximal to the fourth metacarpophalangeal joint. It has grown larger since it first appeared, and he now has mild flexion of the finger, which he is unable to straighten. He reports that his father had similar problems with his fingers. On examination you note pitting of the skin over the nodule.
The most likely diagnosis is:
Dupuytren’s contracture
Dupuytren’s contracture is characterized by changes in the palmar fascia, with progressive thickening and nodule formation that can progress to a contracture of the associated finger. The fourth finger is most commonly affected. Pitting or dimpling can occur over the nodule because of the connection with the skin.
Degenerative joint disease is not associated with a palmar nodule. Trigger finger is related to the tendon, not the palmar fascia, and causes the finger to lock and release. Ganglions also affect the tendons or joints, are not located in the fascia, and are not associated with contractures. Flexor tenosynovitis, an inflammation, is associated with pain, which is not usually seen with Dupuytren’s contracture.
Which one of the following is NOT considered a first-line treatment for head lice?
A. Lindane 1%
B. Malathion 0.5% (Ovide)
C. Permethrin 1% (Nix)
D. Pyrethrins 0.33%/pipernyl butoxide 4% (RID)
Lindane 1%
Lindane’s efficacy has waned over the years and it is inconsistently ovicidal. Because of its neurotoxicity, lindane carries a black box warning and is specifically recommended only as second-line treatment by the FDA. Pyrethroid resistance is widespread, but permethrin is still considered to be a first-line treatment because of its favorable safety profile. The efficacy of malathion is attributed to its triple action with isopropyl alcohol and terpineol, likely making this a resistance-breaking formulation. The probability of simultaneously developing resistance to all three substances is small. Malathion is both ovicidal and pediculicidal.
What food is a frequent cause of cross-reactive food-allergy symptoms in latex-allergic individuals?
Avocadoes
The majority of patients who are latex-allergic are believed to develop IgE antibodies that cross-react with some proteins in plant-derived foods. These food antigens do not survive the digestive process, and thus lack the capacity to sensitize after oral ingestion in the traditional food-allergy pathway. Antigenic similarity with proteins present in latex, to which an individual has already been sensitized, results in an indirect allergic response limited to the exposure that occurs prior to alteration by digestion, localized primarily in and around the oral cavity. The frequent association with certain fruits has been labeled the “latex-fruit syndrome.” Although many fruits and vegetables have been implicated, fruits most commonly linked to this problem are bananas, avocadoes, and kiwi.
A 42-year-old female is found to have a thyroid nodule during her annual physical examination. Her TSH level is normal. Ultrasonography of her thyroid gland shows a solitary nodule measuring 1.2 cm.
What is the most appropriate next step at this point?
A fine-needle aspiration biopsy of the nodule
All patients who are found to have a thyroid nodule on a physical examination should have their TSH measured. Patients with a suppressed TSH should be evaluated with a radionuclide thyroid scan; nodules that are “hot” (show increased isotope uptake) are almost never malignant and fine-needle aspiration biopsy is not needed. For all other nodules, the next step in the workup is a fine-needle aspiration biopsy to determine whether the lesion is malignant (SOR B).
Treatment with donepezil (Aricept) is associated with an increased risk for :
bradycardia requiring pacemaker implantation
A large population study has established a significant increased risk of bradycardia, syncope, and pacemaker therapy with cholinesterase inhibitor therapy. Elevation of liver enzymes with the potential for hepatic dysfunction has been seen with tacrine, but it has not been noted with the other approved cholinesterase inhibitors. Cataract formation and thrombosis with pulmonary embolism do not increase with this therapy. Although improvement in mental function is often marginal with cholinesterase inhibitor therapy, the therapy has not been shown to increase the need for institutionalization.
An 8-year-old female is brought to your office with a 3-day history of bilateral knee pain. She has had no associated upper respiratory symptoms. On examination she is afebrile. Her knees have full range of motion and no effusion, but she has a purpuric papular rash on both lower extremities.
What is the most likely cause of her symptoms?
Henoch-Schönlein purpura
The combination of arthritis with a typical palpable purpuric rash is consistent with a diagnosis of Henoch-Schönlein purpura. This most often occurs in children from 2 to 8 years old. Arthritis is present in about two-thirds of those affected. Gastrointestinal and renal involvement are also common.
Rocky Mountain spotted fever presents with a rash, but arthralgias are not typical. These patients are usually sick with a fever and headache. Juvenile rheumatoid arthritis is associated with a salmon-pink maculopapular rash, but not purpura. The rash associated with Lyme disease is erythema migrans, which is a bull’s-eye lesion at the site of a tick bite. The rash associated with rheumatic fever is erythema marginatum, which is a pink, raised, macular rash with sharply demarcated borders.
What hospitalized patients are the most appropriate candidate for thromboembolism prophylaxis with enoxaparin (Lovenox)?
example: A 67-year-old female with hemiparesis, admitted for community-acquired pneumonia
Venous thromboembolism is a frequent cause of preventable death and illness in hospitalized patients. Approximately 10%–15% of high-risk patients who do not receive prophylaxis develop venous thrombosis. Pulmonary embolism is thought to be associated with 5%–10% of deaths in hospitalized patients. Anticoagulant prophylaxis significantly reduces the risk of pulmonary embolism and should be used in all high-risk patients.
Prophylaxis is generally recommended for patients over the age of 40 who have limited mobility for 3 days or more and have at least one of the following risk factors: acute infectious disease, New York Heart Association class III or IV heart failure, acute myocardial infarction, acute respiratory disease, stroke, rheumatic disease, inflammatory bowel disease, previous venous thromboembolism, older age (especially >75 years), recent surgery or trauma, immobility or paresis, obesity (BMI >30 kg/m2), central venouscatheterization, inherited or acquired thrombophilic disorders, varicose veins, or estrogen therapy.
Pharmacologic therapy with an anticoagulant such as enoxaparin is clearly indicated in the 67-year-old who has limited mobility secondary to hemiparesis and is being admitted for an acute infectious disease. The patient on chronic anticoagulation, the patient with severe thrombocytopenia, and the patient with coagulopathy are at high risk for bleeding if given anticoagulants, and are better candidates for nonpharmacologic therapies such as foot extension exercises, graduated compression stockings, or pneumatic compression devices. Although the 22-year-old is obese and recently had surgery, his young age and ambulatory status make anticoagulant prophylaxis less necessary.
A 25-year-old white male who has a poorly controlled major seizure disorder and a 6-week history of recurrent fever, anorexia, and persistent, productive coughing visits your office. On physical examination he is noted to have a temperature of 38.3°C (101.0°F), a respiratory rate of 16/min, gingival hyperplasia, and a fetid odor to his breath. Auscultation of the lungs reveals rales in the mid-portion of the right lung posteriorly.
What is most likely to be found on a chest radiograph?
A lung abscess
Anaerobic lung abscesses are most often found in a person predisposed to aspiration who complains of a productive cough associated with fever, anorexia, and weakness. Physical examination usually reveals poor dental hygiene, a fetid odor to the breath and sputum, rales, and pulmonary findings consistent with consolidation. Patients who have sarcoidosis usually do not have a productive cough and have bilateral physical findings. A persistent productive cough is not a striking finding in disseminated tuberculosis, which would be suggested by miliary calcifications on a chest film. The clinical presentation and physical findings are not consistent with a simple mass in the right hilum nor with a right pleural effusion.
What medication should be given intravenously in the initial treatment of status epilepticus?
Lorazepam (Ativan)
Status epilepticus refers to continuous seizures or repetitive, discrete seizures with impaired consciousness in the interictal period. It is an emergency and must be treated immediately, since cardiopulmonary dysfunction, hyperthermia, and metabolic derangement can develop, leading to irreversible neuronal damage. Lorazepam, 0.1–0.15 mg/kg intravenously, should be given as anticonvulsant therapy after cardiopulmonary resuscitation. This is followed by phenytoin, given via a dedicated peripheral intravenous line. Fosphenytoin, midazolam, or phenobarbital can be used if there is no response to lorazepam.
Propofol has been used for refractory status epilepticus to induce general anesthesia when the initial drugs have failed, but reports of fatal propofol infusion syndrome have led to a decline in its use.
According to JNC 7, the risk of cardiovascular disease begins to increase when the systolic blood pressure exceeds a threshold of :
115 mm Hg
According to JNC 7, the risk of both ischemic heart disease and stroke increases progressively when systolic blood pressure exceeds 115 mm Hg and diastolic blood pressure exceeds 75 mm Hg.
A 56-year-old female has been on combined continuous hormone therapy for 6 years. This is associated with a reduced risk for ?
Bone fracture
Hormone replacement therapy that includes estrogen has been shown to decrease osteoporosis and bone fracture risk. The risk for colorectal cancer also is reduced after 5 years of estrogen use. The risk for myocardial infarction, stroke, breast cancer, and venous thromboembolism increases with long-term use.
A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure. Which one of the following would be the most appropriate next step?
Referral for orthopedic consultation
Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities. It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia. Experts are divided with regard to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be helpful after 4-6 months of age, but prior to that time the ossification centers are too immature to be seen. Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. The American Academy of Pediatrics recommends ultrasound screening at 6 weeks for breech girls, breech boys (optional), and girls with a positive family history of developmental dysplasia of the hip. Other countries have recommended universal screening, but a review of the literature has not shown that the benefits of early diagnosis through universal screening outweigh the risks and potential problems of overtreating.
A 55-year-old overweight male presents with a complaint of pain in the left big toe. He recently started jogging 2 miles a day to try to lose weight, but has not changed his diet and says he drinks 4 cans of beer every night. The pain has developed gradually over the last 2 weeks and is worse after running. An examination shows a normal foot with tenderness and swelling of the medial plantar aspect of the left first metatarsophalangeal joint. Passive dorsiflexion of the toe causes pain in that area. Plantar flexion produces no discomfort, and no numbness can be appreciated. Which one of the following is the most likely diagnosis?
Sesamoid fracture
Pain involving the big toe is a common problem. The first metatarsophalangeal (MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of big-toe injuries. Overuse, a sharp blow, and sudden dorsiflexion are the most common mechanisms of injury. Gout commonly involves the first MTP joint, but the onset is sudden, with warmth, redness, and swelling, and pain on movement of the joint is common. Morton’s neuroma commonly occurs between the third and fourth toes, causes numbness involving the digital nerve in the area, and usually is caused by the nerve being pinched between metatarsal heads in the center of the foot. Cellulitis of the foot is common, and can result from inoculation through a subtle crack in the skin. However, there would be redness and swelling, and the process is usually more generalized. Sesamoiditis is often hard to differentiate from a true sesamoid fracture. Radiographs should be obtained, but at times they are nondiagnostic. Treatment, fortunately, is similar, unless the fracture is open or widely displaced. Limiting weight bearing and flexion to control discomfort is the first step. More complex treatments may be needed if the problem does not resolve in 4-6 weeks.
A mother brings in her 2-month-old infant for a routine checkup. The baby is exclusively breastfed, and the mother has no concerns or questions. Which one of the following would you recommend at this time in addition to continued breastfeeding?
Vitamin D supplementation
Although breast milk is the ideal source of nutrition for healthy term infants, supplementation with 200 IU/day of vitamin D is recommended beginning at 2 months of age and continuing until the child is consuming at least 500 mL/day of formula or milk containing vitamin D (SOR B). The purpose of supplementation is to prevent rickets. Unless the baby is anemic or has other deficiencies, neither iron nor a multivitamin is necessary. Parents often mistakenly think babies need additional water, which can be harmful because it decreases milk intake and can cause electrolyte disturbances. Cereal should not be started until 4 to 6 months of age.
A 62-year-old white male complains of fatigue and proximal extremity discomfort without any localized joint pain. Which condition is associated with a consistently normal creatine kinase enzyme level at all phases of disease?
Polymyalgia rheumatica (PMR)
Polymyalgia rheumatica is a disease of the middle-aged and elderly. Discomfort is common in the neck, shoulders, and hip girdle areas. There is an absence of objective joint swelling, and findings tend to be symmetric. Characteristically, the erythrocyte sedimentation rate and C-reactive protein levels are significantly elevated; however, these tests are nonspecific. Occasionally there are mild elevations of liver enzymes, but muscle enzymes, including creatine kinase, are not elevated in this disorder. Elevation of muscle enzymes strongly suggests another diagnosis. Polymyositis and dermatomyositis are associated with variable levels of muscle enzyme elevations during the active phases of the disease. Drug-induced myopathies such as those seen with the cholesterol-lowering statin medications tend to produce some elevation of muscle enzymes during the course of the disorder. Hypothyroidism is associated with creatine kinase elevation. It should be strongly considered in the patient with unexplained, otherwise asymptomatic creatine kinase elevation found on a routine chemistry profile. Hyperthyroidism may cause muscle disease and loss of muscle, but it is not associated with creatine kinase elevation.
What are the risk factors for osteoarthritis of the hip?
Risk factors for osteoarthritis of the hip include obesity, high bone mass, old age, participation in weight-bearing sports, and hypothyroidism.
The daily intake of vitamins and minerals recommended by the Food and Nutrition Board varies according to sex, age, and condition. The recommended daily allowance of vitamin D is greatest for which patient population?
A 75-year-old female
The current Dietary Reference Intake (DRI – which has replaced RDA’s) recommendation for vitamin D is 200 IU/day for all women between the ages of 9 and 50 years; pregnancy or lactation does not affect the recommendation. The DRI doubles to 400 IU daily for women age 51-70 and triples to 600 IU daily for women over the age of 70. The maximum daily oral intake of vitamin D thought to be safe is 2000 IU/day for all females over the age of 12 months.
In addition to calcium and vitamin D supplementation, patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day) should also receive
bisphosphonate therapy
The American College of Rheumatology recommends that patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day), or an equivalent, receive bisphosphonate therapy in addition to calcium and vitamin D supplementation, regardless of their DEXA-scan T score. The other treatments are not recommended for prevention of glucocorticoid-induced osteoporosis.
A 79-year-old male is admitted to the hospital because of a sudden inability to ambulate. He has a past history of gout. On examination his temperature is 38.2°C (100.8°F) and he has bilateral knee effusions. His WBC count is 14,000/mm3 with 82% segs. His serum uric acid level is 8.5 mg/dL (N
Arthrocentesis
Polyarticular arthritis often presents with fever, knee and other joint effusions, and leukocytosis. A 24-hour urine collection is not routine, is difficult for the patient, and typically does not change therapy. Especially in cases where a joint effusion is accompanied by fever, diagnostic arthrocentesis should be performed to help guide therapy. Allopurinol should not be initiated during an acute gouty attack, but may be started after a patient has recovered. Diuretics increase uric acid levels.
An overweight 13-year-old male presents with a 3-week history of right lower thigh pain. He first noticed the pain when jumping while playing basketball, but now it is present even when he is just walking. On examination he can bear his full weight without an obvious limp. There is no localized tenderness, and the patella tracks normally without subluxation. Internal rotation of the hip is limited on the right side compared to the left. Based on the examination alone, which one of the following is the most likely diagnosis?
Slipped capital femoral epiphysis
This is a classic presentation for slipped capital femoral epiphysis (SCFE) in an adolescent male who has probably had a recent growth spurt. Pain with activity is the most common presenting symptom, as opposed to the nighttime pain that is typical of malignancy. Obese males are affected more often. The pain is typically in the anterior thigh, but in a high percentage of patients the pain may be referred to the knee, lower leg, or foot. Limited internal rotation of the hip, especially with the hip in 90°; flexion, is a reliable and specific finding for SCFE and should be looked for in all adolescents with hip, thigh, or knee pain. Meralgia paresthetica is pain in the thigh related to entrapment of the lateral femoral cutaneous nerve, often attributed to excessively tight clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of the femoral head) is more likely to occur between the ages of 4 and 8 years. Juvenile rheumatoid arthritis typically is associated with other constitutional symptoms including stiffness, fever, and pain in at least one other joint, with the pain not necessarily associated with activity.
A 70-year-old female consults you about osteoporosis treatment. Two years ago her DEXA scan T score was -2.6, and she began taking risedronate (Actonel), 35 mg/week. Her BMI is 24 kg/m2, she takes appropriate doses of calcium and vitamin D, and she takes walks almost every day. Her current T score is -2.5, and she is concerned about the minimal change in spite of therapy. She has never had a fracture, but asks if more could be done to reduce her fracture risk. Which one of the following would be the most appropriate recommendation?
continue current therapy
There is not a linear correlation between bone mineral density and fracture risk. Bone architecture may be changed by bisphosphonate therapy, which may result in a decreased fracture risk. This patient has not had a fracture and is on adequate medical therapy that should be continued.
A 36-year-old male presents with pain over the lumbar paraspinal muscles. He says the pain began suddenly while he was shoveling snow. What management recommendations would you give regarding this patients injury?
Continued activity rather than bed rest helps speed recovery
Multiple studies have demonstrated that bed rest is detrimental to recovery from low back pain. Patients should be encouraged to remain as active as possible. Exercises designed specifically for the treatment of low back pain have not been shown to be helpful. Neither opioids nor trigger-point injections have shown superiority over placebo, NSAIDs, or acetaminophen in relieving acute back pain. There is no good evidence to suggest that systemic corticosteroids are effective for low back pain with or without sciatica.
A 44-year-old African-American female reports diffuse aching, especially in her upper legs and shoulders. The aching has increased, and she now has trouble going up and down stairs because of weakness. She has no visual symptoms, and a neurologic examination is normal except for proximal muscle weakness. Laboratory tests reveal elevated levels of serum creatine kinase and aldolase. Her symptoms improve significantly when she is treated with corticosteroids. Which one of the following is the most likely diagnosis?
Polymyositis
The patient described has an inflammatory myopathy of the polymyositis/dermatomyositis group. Proximal muscle involvement and elevation of serum muscle enzymes such as creatine kinase and aldolase are characteristic. Corticosteroids are the accepted treatment of choice. It is extremely unlikely that Duchenne’s muscular dystrophy would present after age 30. In amyotrophic lateral sclerosis, an abnormal neurologic examination with findings of upper motor neuron dysfunction is characteristic. Patients with myasthenia gravis characteristically have optic involvement, often presenting as diplopia. The predominant symptom of aseptic necrosis of the femoral head is pain rather than proximal muscle weakness.
You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with the cosmetic appearance and possible future disability, and request that she be treated. You recommend which one of the following?
Observation
There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8-10 years of age who still have cosmetically unacceptable, dysfunctional gaits. Major complications of surgery occur in approximately 15% of cases, and can include residual in-toeing, out-toeing, avascular necrosis of the femoral head, osteomyelitis, fracture, valgus deformity, and loss of position. Thus, observation alone is appropriate treatment for a 5-year-old with uncomplicated anteversion.
Which medication used to treat rheumatoid arthritis can delay the progression of the disease?
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine, originally developed as an antimalarial drug, is a well-known disease-modifying agent that can slow the progression of rheumatoid arthritis. Aspirin, indomethacin, and ibuprofen are anti-inflammatory agents. They relieve pain and improve mobility, but do not alter the progression of the disease. Capsaicin, a topical substance-P depleter, can relieve pain symptoms.
A 75-year-old white female presents with severe pain of the carpometacarpal joint at the base of her thumb. Examination of her hands also reveals hypertrophic changes of the distal interphalangeal and proximal interphalangeal joints of her fingers. These findings are most consistent with
osteoarthritis
Osteoarthritis causes changes predominantly in the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the hands known as Bouchard’s and Heberden’s nodes respectively, and the carpometacarpal joints of the thumbs. While rheumatoid arthritis commonly causes subluxations in the metacarpophalangeal joints, this patient’s hypertrophic changes are most likely due to osteoarthritis. The other choices are less likely to cause this presentation.
A 60-year-old male presents with an acute onset of pain and swelling in the right big toe. He can recall no mechanism of injury. He has hypertension which is well controlled with hydrochlorothiazide. On examination the area around the base of the toe is reddened, slightly warm, and very tender on palpation. Which medication should be AVOIDED in this patient at this time?
Allopurinol (Zyloprim)
This patient likely has gout. Aspiration should be attempted to get a specific diagnosis. The initial treatment for gout is NSAIDs, colchicine, or cortisone injections (SOR B). Allopurinol should be avoided until the episode of gout is controlled, because it may cause temporary worsening. In addition to medication, recommended management includes addressing risk factors such as obesity, diuretic use, high-purine diet, and alcohol intake (SOR B).
A 55-year-old African-American male with osteoarthritis of the knees asks for advice on improving the function of his knees and controlling arthritis pain. Which one of the following would be appropriate advice?
A therapeutic exercise program will improve both pain and function
A therapeutic exercise program will reduce both pain and disability in patients with osteoarthritis of the knee (SOR A). There is no evidence to support the use of capsaicin cream, but NSAIDs will reduce pain and there are proven therapies that will improve function of the patients knee. While intra-articular corticosteroids are effective in relieving pain in the short term (up to 4 weeks), there is no evidence for long-term efficacy. There is not good evidence to support the use of glucosamine for treating osteoarthritis of the knee. One systematic review found it no more effective than placebo.
An 83-year-old female presents with pain, swelling, and erythema of her left knee. She first noticed this problem last night before going to bed. She is generally healthy and takes no medications. She has not been sexually active since being widowed 15 years ago, and she currently lives with her sister. She states that she developed pain and swelling in her left ankle 2 years ago that lasted only a couple of days and resolved spontaneously. Blood testing shows a very elevated erythrocyte sedimentation rate but a normal rheumatoid factor and uric acid level. What is the most likely diagnosis?
Pseudogout (calcium pyrophosphate disease)
Acute monoarthritis in adults is most commonly caused by infection, trauma, or crystal deposition. Rheumatoid arthritis seldom presents as monoarthritis, and more often has a subacute course with multiple, symmetric joints involved. Although osteoporosis may result in a fracture of the knee joint without trauma at this age, there is no reason to believe that this patient has a torn anterior cruciate ligament. Gonococcal arthritis is one of the most common causes of septic arthritis, but is highly unlikely in this elderly, sexually inactive patient. Nongonococcal septic arthritis (especially due to staphylococcal and streptococcal bacteria) is still a consideration and should be ruled out by aspiration of fluid to be sent for culture. This patient’s presentation is most consistent with pseudogout. Having a normal uric acid level suggests against gout, but does not rule it out. Also, gout is seven times more likely to be seen in males, whereas pseudogout is 1.5 times more frequent in females. Pseudogout most often affects the elderly, and usually affects the knee, wrist, and ankle. Gout presents most commonly in the first metatarsophalangeal joint and insteps of the feet, but also can occur in the knee, wrist, finger, and olecranon bursa. Differentiating between gout and pseudogout can be difficult and is best done by analysis of joint fluid. In patients with gout, this fluid contains highly negative birefringent, needle-shaped urate crystals, whereas in pseudogout the fluid contains rhomboid-shaped, weakly positive birefringent calcium pyrophosphate crystals.
A 35-year-old white female comes to your office with a 3-month history of the gradual onset of pain and tenderness in the wrists and hands. She also complains of 1 hour of morning stiffness. She denies rash, fever, or skin changes. On physical examination she has symmetric swelling of the proximal interphalangeal joints and metacarpophalangeal joints. Motion of these joints is painful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, and a chest film is unremarkable. Her CBC is normal, but the erythrocyte sedimentation rate is elevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclear antibody (ANA) test is negative. The most likely diagnosis in this patient is:
Rheumatoid arthritis
This patient has rheumatoid arthritis (RA) by symptoms and physical findings. A positive latex fixation test for rheumatoid factor is not necessary for the diagnosis. A negative rheumatoid factor does not exclude RA, and a positive rheumatoid factor is not specific. Rheumatoid factor is found in the serum of approximately 85% of adult patients with RA; in subjects without RA, the incidence of positive rheumatoid factor is 1%–5% and increases with age. The ANA test is positive in at least 95% of patients with systemic lupus erythematosus (SLE), but in only about 35% of patients with RA. Elevation of the erythrocyte sedimentation rate is seen in many patients with RA, and the degree of elevation roughly parallels disease activity. A mean of 6 months after the onset of Lyme disease, 60% of patients in the U.S. have brief attacks of asymmetric, oligoarticular arthritis, primarily in the large joints and especially in the knee.
A 40-year-old runner complains of gradually worsening pain on the lateral aspect of his foot. He runs on asphalt, and has increased his mileage from 2 miles/day to 5 miles/day over the last 2 weeks. Palpation causes pain over the lateral 5th metatarsal. The pain is also reproduced when he jumps on the affected leg. When you ask about his shoes he tells you he bought them several years ago. What is the most likely diagnosis?
Stress fracture
Running injuries are primarily caused by overuse due to training errors. Runners should be instructed to increase their mileage gradually, in increments of 10% or less each week. A stress fracture causes localized tenderness and swelling in superficial bones. Pain is reproduced by jumping on the affected leg. Plantar fasciitis causes burning pain in the heel and there is tenderness of the plantar fascia where it inserts onto the medial tubercle of the calcaneus.
What clinical presentation is most consistent with vitamin D deficiency in the aged?
Development of chronic bone pain and weakness in association with bone loss
Vitamin D deficiency is being recognized more frequently among the elderly, especially in the nursing home or other settings where inactivity, nutritional deficiency, and lack of sunlight exposure combine to increase the propensity for deficiency. Vitamin D deficiency has been associated with abnormalities in bone metabolism, primarily osteomalacia. Clinically this can present as muscle weakness, limb pain, and impaired physical function. Bleeding gums and fatigue may be presenting symptoms of scurvy (vitamin C deficiency). High-output cardiac failure with vasodilation, dermatitis, and neuropathy is the clinical presentation of thiamine deficiency. The combination of diarrhea, scaly dermatitis, and dementia is one of the clinical presentations of niacin deficiency.
An anxious and agitated 18-year-old white male presents to your office with a 2-hour history of severe muscle spasms in the neck and back. He was seen 2 days ago in a local emergency department with symptoms of gastroenteritis, treated with intravenous fluids, and sent home with a prescription for prochlorperazine (Compazine) suppositories. The best therapy for this problem is intravenous administration of:
Diphenhydramine (Benadryl)
While rarely life threatening, an acute dystonic reaction can be frightening and painful to the patient and confusing to the treating physician who may be unaware of what medications the patient is taking. Dystonia can be caused by any agent that blocks dopamine, including prochlorperazine, metoclopramide, and typical neuroleptic agents such as haloperidol. The acute treatment of choice is diphenhydramine or benztropine.
For several years, a hypertensive 65-year-old female has been treated with hydrochlorothiazide (HydroDIURIL), 25 mg/day; atenolol (Tenormin), 100 mg/day; and hydralazine (Apresoline), 50 mg 4 times/day. Her blood pressure has been well controlled on this regimen. Over the past 2 months she has experienced malaise, along with diffuse joint pains that involve symmetric sites in the fingers, hands, elbows, and knees. A pleural friction rub is noted on examination. Laboratory testing shows that the patient has mild anemia and leukopenia, with a negative rheumatoid factor and a positive antinuclear antibody (ANA) titer of 1:640. What would be the most appropriate INITIAL treatment?
Discontinue the hydralazine
There are many drugs that can induce a syndrome resembling systemic lupus erythematosus, but the most common offender is procainamide, followed by hydralazine. There is a genetic predisposition for this drug-induced lupus, determined by drug acetylation rates. Polyarthritis and pleuropericarditis occur in half of patients, but fortunately, CNS and renal involvement are rare. While all patients with this condition have positive ANAs and most have antibodies to histones, antibodies to double-stranded DNA and decreased complement levels are rare, which distinguishes drug-induced lupus from idiopathic lupus. The best initial management is to withdraw the drug, and most patients improve in a few weeks. For those with severe symptoms, a short course of corticosteroids is indicated. Once the offending drug is discontinued, symptoms seldom last beyond 6 months
A 37-year-old white female who has had silicone breast implants for 17 years is concerned about the risk of developing joint problems from the implants. You discuss studies concerning risks of connective tissue disease in women who have silicone breast implants and assure her that
Assure her that there is no increased risk of connective tissue disease in women with silicone implants
Despite widespread publicity and legal wrangling, a large meta-analysis of women who have had silicone breast implants has produced no evidence of any significant increase in the risk for connective tissue disease in women who have these implants.
A high incidence of osteonecrosis of the femoral head occurs with: A. Femoral neck fractures B. Intertrochanteric fractures C. Subtrochanteric fractures D. Femoral shaft fractures E. Supracondylar femoral fractures
Femoral neck fractures
Femoral neck fractures disrupt the blood supply to the femoral head, which can lead to osteonecrosis. This does not occur with the other types of fractures.
A 3-year-old white female is brought to your office because she is complaining of pain in her right arm. Her mother tells you the pain began after she pulled her daughter by the arm while the girl was fighting with her brother. You examine the child and diagnose “nursemaid’s elbow.” You recommend which intervention?
Manipulation of the forearm to reduce radial head subluxation
Subluxation of the radial head (nursemaid’s elbow) is a common childhood orthopedic problem. There is conflicting information in various textbooks on the proper technique to reduce the subluxed radial head. However, a study comparing hyperpronation to supination/flexion found that hyperpronation had a higher success rate. If a fracture is diagnosed, then a sling would be helpful. Neither a wrist splint nor a long arm cast is helpful in this situation.
A 91-year-old white male presents with a 6-month history of a painless ulcer on the dorsum of the proximal interphalangeal joint of the second toe. Examination reveals a hallus valgus and a rigid hammer toe of the second digit. His foot has mild to moderate atrophic skin changes and the dorsal and posterior tibial pulses are absent. Appropriate treatment includes:
Custom-made shoes to protect the hammer toe
The treatment of foot problems in the elderly is difficult because of systemic and local infirmities, the most limiting being the poor vascular status of the foot. Conservative, supportive, and palliative therapy replaces definitive reconstructive surgical therapy. Surgical correction of a hammer toe and bunionectomy would be disastrous in an elderly patient with a small ulcer and peripheral vascular disease. The correct approach to this patient is to prescribe custom-made shoes and a protective shield with a central aperture of foam rubber placed over the hammer toe. Metatarsal pads are not useful in the treatment of hallux valgus and a rigid hammer toe
A 67-year-old female is concerned about osteoporosis. The study of choice for determining whether or not she has osteoporosis is:
Dual-energy x-ray absorptiometry (DEXA) of the hip and spine
Dual-energy x-ray absorptiometry (DEXA) of the hip and spine is the method of choice for assessment of bone mineral density. Quantitative CT is the most sensitive method, but results in substantially greater radiation exposure. Plain radiographs are not sensitive enough to diagnose osteoporosis until total bone density has decreased by 50%. The predictive value of DEXA scans and ultrasound examinations of peripheral bones in assessing fracture risk at the hip or vertebrae is not clear.
Which one of the following is consistent with spinal stenosis but not herniated vertebral disk? A. Numbness B. Muscle weakness C. Pain relieved by sitting D. Pain relieved by standing
Pain relieved by sitting
Causes of low back pain include vertebral disk herniation and spinal stenosis. Numbness and muscle weakness may be present in both. Pain in spinal stenosis is relieved by sitting and aggravated by standing. Pain from a herniated disk is aggravated by sitting and relieved by standing.
A 32-year-old white female marathon runner presents with persistent pain and tenderness over the pubic symphysis. With exercise, pain is noted in the lower abdomen and medial thighs. There is no fever. A radiograph shows widening of the pubic symphysis. What is the most likely diagnosis?
Osteitis pubis
Osteitis pubis is characterized by the chronic occurrences of pain in the lower abdomen and medial thighs with exercise. It produces tenderness over the pubic symphysis, and widening of the symphysis is often seen on plain radiographs. Pain from osteomyelitis is similar, but usually presents with fever and systemic symptoms, and does not cause widening of the symphysis. A stress fracture of the pubic ramus may occur in distance athletes, but the pain and tenderness are lateral, located over the posterior ramus. Inguinal hernia should not present with symphysis pain.
A 75-year-old female presents with a 1-month history of pain in her hips and shoulders bilaterally, accompanied by marked stiffness in the mornings. In addition, she reports a 4-lb weight loss and fatigue. She denies fever, chills, sweats, nausea, vomiting, swallowing disturbances, or changes in bowel habits. She specifically denies any visual symptoms or headache. Her physical examination is unremarkable, except for changes suggestive of osteoarthritis in the knees and hands. Laboratory testing reveals a hemoglobin level of 11.8 g/dL (N 13.0–16.0), a hematocrit of 36% (N 40–45), and an erythrocyte sedimentation rate of 84 mm/hr (N
Begin prednisone, 15 mg daily, with no plans for a temporal artery biopsy
It is generally not considered necessary to refer patients with classic polymyalgia rheumatica for a temporal artery biopsy in the absence of symptoms or signs of giant cell arteritis (e.g., headache, visual complaints, jaw claudication, fever, scalp tenderness, abnormal funduscopic exam). Corticosteroids should be started at relatively low doses (10–20 mg daily) and the patient followed for what should be a rapid clinical response.
What is recommended regarding the use of alendronate (Fosamax) for the treatment of osteoporosis in men?
Its effectiveness is similar to that seen in women
In men with hypogonadism, testosterone therapy has limited efficacy, and the efficacy of other therapies for osteoporosis in men has not been evaluated. Bisphosphonates, including alendronate, are indicated for treatment of Paget’s disease. They decrease bone pain, decrease bone resorption, and increase new bone formation. The proportion of men whose height decreased by at least 10 mm over a 2-year period was 13% in the placebo group and 3% in the alendronate group. The frequency of adverse gastrointestinal effects in the two groups was similar despite the fact that 36% of the men in the placebo group and 41% of those in the alendronate group reported taking NSAIDs during the study.
Which one of the following is associated with a reduced risk of postmenopausal osteoporosis? A. Corticosteroid use B. Cigarette smoking C. Diuretic use D. Low BMI E. Asian ethnicity
Diuretic use
Diuretic use is associated with a lower risk of osteoporosis, perhaps due to decreased urinary calcium excretion. Cigarette smoking, low BMI, corticosteroid use, and Asian ethnicity are among the factors associated with increased risk.
The most common stress fracture in children involves which bone?
Tibia
Tibial fractures are the most common lower extremity stress fractures in both children and adults, accounting for about half of all stress fractures.
A 70-year-old white female with osteoporosis sees you for follow-up a few days after an emergency department visit for an acute T12 vertebral compression fracture. The fracture was suspected clinically and on plain films; the diagnosis was confirmed with a bone scan. The emergency department physician prescribed oxycodone (OxyContin) and NSAIDs, but the patient is still experiencing considerable discomfort. In addition to increasing the dosage of oxycodone, which one of the following interventions would you suggest now to reduce the patient’s pain?
Calcitonin (Miacalcin)
Calcitonin, either intranasal or subcutaneous, provides pain relief within a few days in many patients with osteoporotic vertebral compression fractures. The remainder of the choices do not provide acute relief. Vertebroplasty/kyphoplasty procedures are generally reserved for cases in which medical management has failed.
A 78-year-old white female presents with a 3-day history of lower thoracic back pain. She denies any antecedent fall or trauma, and first noted the pain upon arising. Her description of the pain indicates that it is severe, bilateral, and without radiation to the arms or legs. Her past medical history is positive for hypertension and controlled diabetes mellitus. Her medications include hydrochlorothiazide, enalapril (Vasotec), metformin (Glucophage), and a general multivitamin. She is a previous smoker but does not drink alcohol. She underwent menopause at age 50 and took estrogen for “a few months” for hot flashes. Physical examination reveals her to be in moderate pain with a somewhat stooped posture and mild tenderness over T12–L1. She has negative straight-leg raising and normal lower extremity sensation, strength, and reflexes. Which one of the following is true regarding this patient’s likely condition?
Subcutaneous or intranasal calcitonin (Calcimar, Miacalcin) may be very helpful for pain relief
The patient described has a classic presentation of an osteoporotic vertebral compression fracture. The diagnosis should be confirmed with a plain radiograph. Treatment is basically symptomatic, with a period of bed rest as short as possible (to avoid complications of immobility), pain medication, and bracing. Salmon calcitonin (injectable or intranasal) is often helpful in providing pain relief. Long-term management of underlying osteoporosis may help prevent future fractures.
A 59-year-old female with type 2 diabetes develops a 2x1-cm ulcer on the plantar aspect of her right foot. The ulcer is very deep and there is surrounding cellulitis. A plain film is normal. Which one of the following would be the imaging study of choice to rule out osteomyelitis in this patient?
An MRI scan
Although leukocyte scans are sensitive for the diagnosis of foot ulcers, MRI is now considered the imaging study of choice when osteomyelitis is suspected; the sensitivity and specificity of MRI in diabetic patients are 90% or greater.
A 38-year-old male is admitted to the hospital after being found lying on the floor unconscious from a drug overdose. The next morning, he is alert and complains of constant pain in the anterior aspect of his left leg. On examination, you note pain with passive stretching, pain with palpation anteriorly, and a slightly decreased dorsalis pedis pulse on the left. There is no edema or erythema. Radiographs of the lower extremity are normal. What should you do now?
Obtain immediate surgical consultation
The patient has a history and symptoms very suggestive of a compartment syndrome of the anterior compartment of the left leg. A common cause of this serious problem is limb compression during prolonged recumbency related to drug or alcohol overdose. Early diagnosis and treatment are essential in order to avoid permanent, severe disability. The five “P’s” of compartment syndrome are pain, pallor, paresthesias, pulselessness, and paralysis. If distal pulses are reduced, then muscle necrosis has occurred and immediate surgical consultation is necessary. Duplex doppler ultrasonography and impedance plethysmography are used to evaluate for deep venous thrombosis. Given the decreased pulses, however, this diagnosis is much less likely and such testing may needlessly delay urgent surgical treatment. Intravenous antibiotics would be appropriate for cellulitis. This diagnosis is unlikely in this scenario given the absence of fever, erythema, and edema, and the presence of a diminished pulse. Rest, ice, and elevation are inappropriate treatment modalities for compartment syndrome.
A football player sustains a finger injury in a preseason scrimmage. He reports getting his finger caught in another team member’s jersey. His right ring finger is tender on the volar surface, and is swollen around the distal interphalangeal joint. He is unable to flex at the distal interphalangeal joint, but can flex at the proximal interphalangeal joint and at the metacarpophalangeal joint. Radiographs do not show any bony abnormality. You would now:
Splint his finger in a slightly flexed position and urgently refer him to a hand surgeon
This injury is commonly called jersey finger. It is a tendinous rupture, sometimes with a bony avulsion fracture of the flexor digitorum profundus tendon. The tendon usually retracts, which makes nonsurgical treatment unlikely to result in complete healing. Splinting in hyperextension will distract the two ends of the tendon and it will not heal. A cast or flexion splint is unlikely to lend itself to complete healing because the tendon ends are unlikely to reattach to each other.
A 28-year-old white female complains of fatigue, stiffness, and a diffuse aching in her neck, shoulders, and back for several months. She is not sleeping well. A thorough physical examination is unremarkable except for tenderness over the upper trapezius, second costochondral junctions, lateral epicondyles, and medial knees. A CBC, erythrocyte sedimentation rate, and rheumatoid factor are unremarkable. What is the most appropriate management at this time?
Prescribe amitriptyline (Elavil), 10–25 mg every night at bedtime, along with exercise aimed at improving her overall level of fitness
This patient has a classic presentation of fibrositis-fibromyalgia syndrome. In addition to small bedtime doses of amitriptyline or cyclobenzaprine, symptoms are improved by an increase in physical fitness, stress reduction, regulation of sleep schedules, and reassurance. Opiate analgesics and sedative-hypnotics are not recommended for long-term treatment of this disorder.
A 2-year-old white male is seen for a well care visit. His mother is concerned because he is not yet able to walk. The routine physical examination, including an orthopedic evaluation, is unremarkable. Speech and other developmental landmarks seem normal for his age. Which tests would be most appropriate?
A serum creatine kinase level
The diagnosis of Duchenne’s muscular dystrophy, the most common neuromuscular disorder of childhood, is usually not made until the affected individual presents with an established gait abnormality at age 4–5. By then, parents unaware of the X-linked inheritance may have had additional children who would also be at risk. The disease can be diagnosed earlier by testing for elevated creatine kinase in boys who are slow to walk. The mean age for walking in affected boys is 17.2 months, whereas over 75% of normal children in the United States walk by 13.5 months. Massive elevation of creatine kinase (CK) from 20 to 100 times normal occurs in every young infant with the disease. Early detection allows appropriate genetic counseling regarding future pregnancies. Hypothyroidism and phenylketonuria could present as delayed walking. However, these diseases cause significant mental retardation and would be associated with global developmental delay. Furthermore, these disorders are now diagnosed in the neonatal period by routine screening. Disorders of amino acid metabolism present in the newborn period with failure to thrive, poor feeding, and lethargy. Gross chromosomal abnormalities would usually be incompatible with a normal physical examination at 18 months.
A 74-year-old African-American female has moderately severe pain due to osteoarthritis. However, she is also on medication for a seizure disorder. When choosing medications to manage her chronic pain, which one of the following should be used with caution because of her history of seizures?
Tramadol (Ultram)
According to the American Geriatrics Society 2002 clinical practice guidelines for management of persistent pain in older persons, tramadol has efficacy and safety similar to those of equianalgesic doses of codeine and hydrocodone. However, because of the threat of seizures (rare but potential), tramadol should be used with caution in patients with a history of seizure disorder or those taking other medications that lower seizure thresholds.
A 79-year-old white male with a previous history of prostate cancer has a lumbar spine film suggesting osteopenia. Subsequent bone density studies show a T score of –2.7. What would be appropriate therapy?
Alendronate (Fosamax)
The only approved treatments for male osteoporosis are alendronate and recombinant parathyroid hormone. Several drugs have been tested in clinical trials, and more pharmacologic treatments should become available in the future as male osteoporosis is increasingly recognized. Testosterone should not be used in this patient because of his history of prostate cancer.
A 28-year-old white male comes to your office complaining of pain in the right wrist since falling 2 weeks ago. On examination, he is tender in the anatomic snuffbox. A radiograph reveals a fracture of the proximal one-third of the carpal navicular bone (scaphoid).What is the most appropriate management at this time?
A thumb spica cast
Fracture of the scaphoid should be suspected in every “sprained wrist” where there is tenderness in the anatomic snuffbox. Radiographs may be negative initially. The scaphoid circulation enters the bone for the most part through the distal half. Fractures through the proximal third tend to cause loss of circulation and are slower to heal, and should be referred to an orthopedist because of the risk of nonunion and avascular necrosis. Fractures through the middle or distal one-third can be handled by the family physician in consultation with an orthopedist. The fracture is treated with a thumb spica cast for 10–12 weeks. A wrist splint does not provide adequate immobilization. A bone scan is unnecessary, and physical therapy is inappropriate. If there is still no evidence of union after 10 weeks of immobilization, the patient should be referred to an orthopedist for further care.
A 22-year-old male has acute low back pain without paresthesias or other neurologic signs. There is no lower extremity weakness. Which treatment has been shown to be of most benefit initially?
Resumption of physical activity as tolerated
Recent studies have shown superior benefits to allowing patients with acute low back pain, without sciatic involvement, to return to normal activities as tolerated. This was better than either bed rest or a back exercise program. Injections would be considered only if conservative therapy fails.
A 10-year-old male is brought to your office after sustaining a fall on an outstretched hand. Radiographs show a nondisplaced fracture of the middle third of the clavicle. Appropriate management would include:
A figure-of-8 splint or sling support
In treating the midshaft clavicular fracture, the goal is reduction of motion at the fracture site. This rarely requires operative intervention and can be managed by the family physician without orthopedic referral. The fracture site is best stabilized by restricting shoulder motion to less than 45 degree abduction. Either an arm sling or a figure-of-8 clavicular splint holding the shoulder back at the “position of attention” may be used. The figure-of-8 splint offers the advantage of leaving the elbow and hand free for activity. Ice and analgesics are used as needed during the acute stage of injury. Early use of heat may increase the inflammatory response. The patient may use the arm as pain permits, but should not abduct the arm more than 45 degrees for several weeks. The risk of adhesive capsulitis is negligible in children. Repeat radiographs at each follow-up office visit are not necessary, but a final radiograph should be ordered when clinical union has occurred to assess callus formation.
A 20-year-old white male presents to your office after a fall on an outstretched hand while skateboarding. He has pain at the anatomic snuffbox with no abrasion. Radiographs are negative. What would be the most appropriate management?
A thumb spica splint and follow-up radiographs in 2 weeks
This is a classic presentation of a possible scaphoid fracture. This fracture is important to diagnose and treat appropriately because of a high rate of non-union. If radiographs are negative, the patient should be placed in a thumb spica splint and have repeat radiographs in 2 weeks, because initial studies may be negative. An Ace bandage or a sugar tong splint would be inappropriate because they do not immobilize the thumb. A long arm cast for 8 weeks would immobilize the thumb, but could lead to loss of function, and may overtreat the injury if it is not truly a scaphoid fracture.
A 72-year-old white male with known coronary artery disease complains of pain in his back and legs which is increased by standing and walking and relieved by sitting. On examination, deep tendon reflexes in his legs are 0 to 1+ bilaterally. He has mild muscle weakness of his quadriceps and 1+ pedal pulses. He is taking ibuprofen, 800 mg three times a day, and using a back brace without much relief. What would be most likely to relieve his symptoms?
Posterior spinal decompression surgery
This patient’s symptoms are typical of spinal stenosis, as they are present when he is standing and relieved by sitting. He has already failed a trial of NSAIDs and bracing. Spinal decompression surgery is now indicated. Epidural corticosteroid injection might be helpful, but not trigger-point injections. Oral corticosteroids would be helpful if he had a herniated disc. Sympathectomy and bypass surgery are treatments for vascular occlusion.
A 62-year-old white male comes to your office with pain and swelling of the left great toe at the metatarsophalangeal joint. Examination shows it is erythematous, warm, swollen, and tender to touch. The patient has a history of diabetes mellitus controlled by diet, and hypertension. His medications include hydrochlorothiazide, 25 mg/day. A CBC and blood chemistry profile are normal, except for a uric acid level of 9.2 mg/dL (N 3.6–8.5). Which one of the following is true in this situation?
Stopping the hydrochlorothiazide may control the hyperuricemia
This is a typical presentation for gout. Elevated uric acid levels are not necessary for the diagnosis, as there are some patients with normal uric acid levels who still have gout. Conversely, hyperuricemia does not establish the diagnosis of gout. Risk factors for the development of gout include several enzyme deficiencies, renal insufficiency, hypertension, obesity, moonshine ingestion (causing lead exposure), and alcohol abuse. There are several medications that elevate uric acid, including diuretics, low-dose salicylates, niacin, cyclosporine, ethambutol, and pyrazinamide. A typical gout attack such as the one described will resolve spontaneously within 2 weeks without treatment. In patients who have an acute monoarticular arthritis in addition to gout, other diagnoses such as osteoarthritis, pseudogout, and infection must be considered. The diagnosis of gout is established by aspiration of synovial fluid or tophi, with characteristic uric acid crystals detected by polarized light microscopy. Treatment can consist of NSAIDs in healthy individuals. Indomethacin is considered the drug of choice. Corticosteroids can also be used, and are particularly helpful when the patient has renal insufficiency. Intra-articular injections of a corticosteroid such as triamcinolone are useful, and intramuscular corticosteroids may be especially useful in patients with polyarticular gout. Colchicine may be used, but may cause diarrhea. Life style changes such as weight loss, discontinuing alcohol use, and changing antihypertensive therapy is often all that is needed to control the hyperuricemia and thus prevent further attacks. Colchicine can be used for prophylaxis as well, although it does not alter hyperuricemia or prevent tophi from forming. If a patient has more than two attacks per year, urate lowering therapy is indicated. A 24-hour urine collection to identify whether the patient is an under-excretor or an overproducer of uric acid would indicate the correct medication. Overproducers are treated with allopurinol, while under-excretors benefit from probenecid if renal function is normal and there is no history of kidney stones.
A 21-year-old white female presents to the emergency department with a history consistent with a lateral ankle sprain that occurred 2 hours ago while she was playing softball. She complains of pain over the distal anterior talofibular ligament, but is able to bear weight. There is mild swelling, mild black and blue discoloration, and moderate tenderness to palpation over the insertion of the anterior talofibular ligament, but the malleoli are nontender to palpation. Which one of the following statements is true regarding the management of this case?
Early range-of-motion exercises should be initiated to maintain flexibility
This patient has an uncomplicated lateral ankle sprain and requires minimal intervention. The Ottawa ankle rules were developed to determine when radiographs are needed for ankle sprains. In summary, ankle radiographs should be done if the patient has pain at the medial or lateral malleolus and either bone tenderness at the back edge or tip of the lateral or medial malleolus, or an inability to bear weight immediately after the injury or in the emergency department, or both. If the patient complains of midfoot pain and/or bone tenderness at the base of the fifth metatarsal or navicular, or an inability to bear weight, radiographs should be ordered. Sprains can be differentiated from major partial or complete ligamentous tears by anteroposterior, lateral, and 30 degrees internal oblique (mortise view) radiographs. If the joint cleft between either malleolus and the talus is >4 mm, a major ligamentous tear is probable. Stress radiographs in forced inversion are sometimes helpful to demonstrate stability, but ankle instability can be present with a normal stress radiograph. Grade I and II ankle sprains are best treated with RICE (rest, ice, compression, elevation) and an air splint for ambulation. NSAIDs are used for control of pain and inflammation. Heat should not be applied. Early range-of-motion exercises should be initiated to maintain flexibility. Weight bearing is appropriate as tolerated and functional rehabilitation should be started when pain permits. Exercises on a balance board will help develop coordination.
The most serious complication of a slipped capital femoral epiphysis is:
Avascular necrosis
Avascular necrosis is the most serious complication of a slipped capital femoral epiphysis, and leads to more rapid arthritic deterioration. It may require hip fusion and total hip replacement early in adulthood.
