QUESTION: 141

A64-year-old female with no significant medical history presents with vague complaints of progressive generalized muscle weakness and fatigue. She denies any history of trauma or drug use and does not take any prescription, OTC or herbal medications. This is a new complaint and she has not had any prior workup. There is no evidence of trauma and a recent TSH was normal. On examination, you find mild muscle tenderness and atrophy. She has difficulty standing from a chair unless she pushes up with her arms at the same time. Her neurologic examination is normal. Which of the following tests would be most helpful in confirming your clinical diagnosis?

complete blood count (CBC)
antinuclear antibody (ANA)
ESR
MRI of spine
aldolase

Answer(s): E

Explanation:

Polymyositis usually presents with patients complaining of gradual muscle weakness and myalgias. The peak incidence occurs in the fifth and sixth decades, with women being affected more commonly than men. Aside from the history and physical examination, laboratory analysis such as elevated muscle enzymes such as CPK and aldolase usually confirm the diagnosis. ESR levels may not be significantly elevated in over 50% of the patients. ANAmay be positive in many patients, however this does not distinguish the condition. EMG may be helpful in making the diagnosis as certain features such as polyphasic potentials, fibrillations, and high-frequency action potentials are more consistent with polymyositis. Muscle biopsy is the most specific test, however the patchy distribution may lead to false negative tests on occasion. Muscle biopsy may reveal endomysial infiltration of the inflammatory infiltrate. Usually, the initial treatment of choice is high-dose steroids, that is, prednisone 60 mg with tapering down after clinical response to the lowest effective dose. If steroids fail, immunosuppressant such as methotrexate or azathioprine may be tried.

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QUESTION: 142

vitamin B12 injections
electromyography (EMG)
trigger point injections
prednisone
cyclobenzaprine

Answer(s): D

Explanation:

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QUESTION: 143

A 67-year-old female with past medical history of rheumatoid arthritis on chronic steroid treatment and past surgical history (PSH) of complete hysterectomy secondary to fibroids presents for routine visit. Patient states that she has had multiple arthralgias worsening over the last 2 years. She had a DEXA scan done that showed a T score of -1.5. She has been taking calcium + vitamin D, and even started an exercise program at her local gym.
She was started on bisphosphonates, which she has tolerated well.

Prior to discharging the patient, how soon would you counsel her to repeat the DEXA scan?

never: although she has risk for osteoporosis, she has already made all the lifestyle changes and is on pharmacotherapy
repeat in 5 years, since she only has osteopenia
6 months
repeat in 1 year
repeat in 2 years

Answer(s): D

Explanation:

Osteoporosis is generally defined as a T score of -2.5 SD or greater on assessment of BMD. Osteopenia is generally defined as a T score between 1 and 2.5 SD below the peak BMD for a healthy young person of the same gender. Osteoporosis screening with an assessment of BMD should be offered to the following groups:
· All women 65 years old or older
· All adult women with a history of a fracture (or fractures) not caused by severe trauma (such as a motor vehicle accident)
· Younger postmenopausal women who have clinical risk factors for fractures · Modifiable risk factors:
current cigarette smoking, low body weight (<127 lbs), estrogen deficiency, premature menopause, excessive thyroid hormone replacement, chronic corticosteroid therapy, low calcium intake (life-long), alcoholism, uncorrected visual impairment, inadequate physical activity, recurrent falls · Nonmodifiable risk factors: personal or family history of fragility, family history of osteoporosis, White or Asian race, age, gender, poor health/frailty, dementia, hypogonadism in males, fracture without substantial trauma Serial assessments for BMD may be useful but one must remember the precision error among the tests. Using DEXA, a BMD must have a 35% difference to be clinically significant. Patients who are on pharmacologic treatment with bisphosphonates may only show this much change in 1 year. Therefore, static BMD or slight reduction should not be regarded as treatment failure. At present, there are no hard evidencebased guidelines for the most efficient use for BMD monitoring. However, the following guidelines are generally accepted:
· For patients with "normal" baseline BMD (T score more than -1.0), consider a followup measurement every 35 years. Patients whose bone density is well above the minimal acceptable level may not need further bone density testing.
· For patients in an osteoporosis prevention program, perform a follow-up measurement every 12 years until bone mass stability is documented. After BMD has stabilized, perform follow-up measurements every 23 years.
· For patients on a therapeutic program, perform a follow-up measurement yearly for 2 years. If bone mass has stabilized after 2 years, perform a follow-up measurement every 2 years. Otherwise, continue with annual follow-up measurements until stability of bone mass is achieved.

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QUESTION: 144

A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before.

Which of the following would be most likely to be seen on an ECG?

Q waves
P-R interval depression diffusely
S-T segment elevation in anterior and inferior leads
S-T segment elevation in anterior leads with reciprocal S-T segment depression in inferior leads
normal ECG

Answer(s): D

Explanation:

The clinical scenario described is classic for an acute MI. The patient has multiple risk factors, including smoking, hypertension, and elevated cholesterol. His symptoms of crushing chest pain radiating to the left arm is commonly seen in this setting. Often the first electrocardiographic sign of acute ischemia is the development of hyperacute T waves. The ECG will usually show S-T segment elevations in the area of the involved occluded vessel, with reciprocal S-T segment depressions in uninvolved areas. This can be followed by the eventual resolution of S-T segment abnormalities and the development of T wave inversions and Q waves. Diffuse P-R depressions are often the initial manifestation of pericarditis, a less common cause of acute chest pain. This often progresses to diffuse S-T segment elevations, the presence of which helps to distinguish pericarditis from the focal S-T elevations more classically associated with a thrombosed coronary artery. Q waves would be unlikely to occur within 1 hour of the onset of symptoms. In this clinical setting, a normal ECG, while possible, would be less likely to occur.

Ventricular arrhythmias, both tachycardia and fibrillation, are recognized complications of acute MI. The presence of ventricular fibrillation or pulseless ventricular tachycardia should lead to the primary "ABCD" survey, as outlined in the American Heart Association's ACLS protocols. The mnemonic stands for airway, breathing, circulation, and defibrillation. Epinephrine, lidocaine, or amiodarone are reserved for the setting where defibrillation is ineffective. Synchronized cardioversion would be used in efforts to convert a patient's rhythm in the setting of a stable tachycardia.

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QUESTION: 141

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QUESTION: 142

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QUESTION: 143

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QUESTION: 144

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