A 35-year-old woman presents to your office complaining of fatigue and global achiness. She states that she has "not been myself" since she developed a bad whiplash after a motor vehicle accident. Her health has otherwise been good. About 3 years ago, she saw a cardiologist for chest pain. A full evaluation ensued including heart catheterization that showed no coronary disease, although her cholesterol levels were elevated and a statin was prescribed. She sleeps poorly and notes that she has gained a considerable amount of weight. She has seen a gastroenterologist who has told her that her abdominal pain and alternating constipation and diarrhea are because of irritable bowel syndrome. Physical examination shows that her height is 5 ft 2 in. and her weight is 240 lb. Blood pressure is 126/78. Pulse is 86 and regular. Heart and lung examinations are completely normal. Her pharynx is normal and she has no lymphadenopathy. Abdominal examination shows diffuse mild tenderness, but no masses, rebound, guarding, or organomegaly. Rectal and pelvic examinations are normal. Muscular strength is 4/5 distally and proximally, but there is a considerable give way secondary to pain. She is tender bilaterally at the occiput across the trapezius, iliac crest at the greater trochanteric, anserine bursae bilaterally, and at the second intercostal space bilaterally.In this patient, which of the following conditions may also be exacerbating her symptoms?
Answer(s): A
The most likely diagnosis in this case is fibromyalgia. Occasionally, hypothyroidism can present in this way, and a low-grade myopathy can create many of these symptoms. A reasonable workup would include chemistries, TSH, and CPK. The usefulness of Epstein-Barr virus titers in this case is minimal. Epidemiologic studies reveal that about 90% of Americans over the age of 20 have been exposed to Epstein-Barr virus even if they never had a clinical scenario of mononucleosis. Your physical examination did not show any question of acute infectious mononucleosis. Findings of elevated IgG antibodies to Epstein-Barr virus would only reveal the fact that she has had the disease in the past. Absent titers might assure you that there was no evidence of a previous infection, but it is unclear how that would help you sort out the current situation.
An 82-year-old woman schedules an appointment to see you for neck and back pain. At age 50, she had an L4-L5 diskectomy and laminectomy. She also has long-standing hypothyroidism for which she takes levothyroxine 0.1 mg daily. Over the past few months, she has become more fatigued and describes pain in both of her arms, her low back, and the front of her thighs. She notes that the tops of her shoulders are also achy. She decided to call for an appointment because of worsening headache. She tells you that she has an appointment later this afternoon with her ophthalmologist, because she noticed some flickering of the vision in her left eye. Upon further questioning, she does acknowledge that she has cut her telephone conversation short with her daughter because her jaw begins to ache if she talks too long. Physical examination shows that she has normal vital signs. She has diffuse scalp tenderness. The oral mucosa is normal without aphthous ulcers and the salivary pool is normal. Her pupils are equal, round, and reactive to light and accommodation, and extraocular muscles are intact. The funduscopic examination appears normal for her age. Neck motion is slightly reduced to lateral flexion and rotation. Her trapezii are tender to palpation, but there is no significant loss of range of motion in her shoulders. Her supraspinatus and infraspinatus tendons appear intact. Her quadriceps are mildly tender, but her gastrocnemius muscles are normal. Her strength is normal for age. Her reflexes are normal and symmetrical.The most likely diagnosis is which of the following?
Answer(s): E
The diagnosis is almost certainly temporal arteritis. Age over 70, headache with scalp tenderness, jaw claudication, and visual disturbance would suggest the diagnosis even if the sedimentation rate came back within the normal range. Since the patient's supraspinatus and infraspinatus strength are normal, complete rotator cuff tear seems unlikely. Rotator cuff tears would also not explain the leg component. Osteoarthritis of the neck and back could explain many of her clinical features, particularly if spinal stenosis is present, but would not account for the jaw claudication or the headaches with scalp tenderness. Many patients with temporal arteritis have features of polymyalgia rheumatica, but in this case, temporal arteritis is the best working diagnosis.Temporal arteritis is one of the few unequivocal rheumatic disease emergencies. The patient should be given large doses of prednisone immediately. An ESR should be obtained, but as noted above, even a normal study would not prevent the prednisone from being prescribed at this point. You should also contact the ophthalmologist because there can be retinal clues not picked up on standard office funduscopy. In addition, many ophthalmologists now will do the temporal artery biopsy in their patients. This is a very reasonable next step for the patient and will unequivocally establish the diagnosis.Temporal arteritis may have skip lesions, and thus, a fairly significant length of the temporal artery should be taken by the surgeon. MRI of the brain, even with MRA, will not help establish a diagnosis of temporal arteritis and will needlessly delay diagnosis, possibly causing the patient to lose vision.
An 82-year-old woman schedules an appointment to see you for neck and back pain. At age 50, she had an L4-L5 diskectomy and laminectomy. She also has long-standing hypothyroidism for which she takes levothyroxine 0.1 mg daily. Over the past few months, she has become more fatigued and describes pain in both of her arms, her low back, and the front of her thighs. She notes that the tops of her shoulders are also achy. She decided to call for an appointment because of worsening headache. She tells you that she has an appointment later this afternoon with her ophthalmologist, because she noticed some flickering of the vision in her left eye. Upon further questioning, she does acknowledge that she has cut her telephone conversation short with her daughter because her jaw begins to ache if she talks too long. Physical examination shows that she has normal vital signs. She has diffuse scalp tenderness. The oral mucosa is normal without aphthous ulcers and the salivary pool is normal. Her pupils are equal, round, and reactive to light and accommodation, and extraocular muscles are intact. The funduscopic examination appears normal for her age. Neck motion is slightly reduced to lateral flexion and rotation. Her trapezii are tender to palpation, but there is no significant loss of range of motion in her shoulders. Her supraspinatus and infraspinatus tendons appear intact. Her quadriceps are mildly tender, but her gastrocnemius muscles are normal. Her strength is normal for age. Her reflexes are normal and symmetrical.Which of the following should be done next?
A 32-year-old man comes to the office for his annual checkup. He is asymptomatic and his physical exam is normal. He reports that his father died of colon cancer at age 46 and his older brother was recently diagnosed with colon cancer at age 37. His paternal aunt was previously diagnosed and treated for endometrial cancer. He is concerned about his family history of malignancy and wants to discuss cancer screening.What would be the most appropriate recommendation at this time?
Answer(s): C
The patient appears to be at risk for hereditaty nonpolyposis colon cancer (HNPCC) or Lynch syndrome. This autosomally dominant inherited cancer predisposition is characterized by colorectal cancer involving at least two generations, with one or more cases being diagnosed before age 50, and patients may have multiple primary cancers (affected women often also have endometrial or ovarian cancer). It is recommended that HNPCC family members undergo screening colonoscopy every two years beginning at age 25. The colon cancers in HNPCC often involve the proximal colon, so flexible sigmoidoscopy would be an insufficient tool for screening the at-risk bowel. HNPCC should be differentiated from familial adenomatous polyposis (FAP), another inherited colon cancer predisposition. This wellstudied and described autosomal dominant inherited condition is much less common than HNPCC. Affected patients develop thousands of adenomatous premalignant polyps, which are generally evenly distributed from cecum to anus and usually become evident between puberty and age 25. Because the polyps are so widespread and evenly distributed, proctosigmoidoscopy is usually a sufficient screening procedure for at- risk family members. When diagnosed with FAP, it is recommended that patients under prophylactic colectomy. If not treated surgically, almost all patients will develop colorectal cancer by age 40. Colonoscopy beginning at age 50 would be recommended for persons at average risk for colon cancer.
Which of the following risk factors has the strongest association with the development of malignant melanoma?
History of excess sun exposure and sunburn early in life is associated with increased incidence of skin cancers, including melanoma, but the highest risk would be the development of a suspicious pigmented lesion. Clinicians can be guided by the "ABCD" rules: asymmetry, irregular borders, color variegation within the same lesion, and diameter >6 mm. Other risk factors for melanoma would include fair skin and hair with tendency to burn easily and a family history of melanoma. Actinic keratoses are premalignant lesions, but can develop into cutaneous squamous cell malignancies, not melanoma.
Post your Comments and Discuss USMLE STEP3 exam prep with other Community members:
Our website is free, but we have to fight against AI bots and content theft. We're sorry for the inconvenience caused by these security measures. You can access the rest of the STEP3 content, but please register or login to continue.