Neuromuscular Block

A 50-year-old woman with a history of Hashimoto thyroiditis presents to the office for evaluation of persistent dry mouth and eyes for the past four months. She thought it was due to allergies and has been taking loratadine daily with no relief. She also has been experiencing painful intercourse and multiple joint pains in her hands. Her temperature is 36.7 C (98.2 F), pulse is 61/min, respirations are 16/min, and blood pressure is 110/60 mmHg. Examination of the patient's mouth shows multiple dental caries. Which of the following is the most appropriate diagnostic test to order?

-Anti-Ro and Anti-La antibodies CORRECT! This patient is presenting with clinical symptoms that are suggestive of Sjogren syndrome, which is a chronic disease characterized by dry eyes and dry mouth, resulting from immunologically mediated destruction of the lacrimal and salivary glands. Antibodies directed against two ribonucleoprotein antigens, SS-A (Ro) and SS-B (La), can be detected in as many as 90% of patients.

A 68-year-old woman with osteoarthritis comes to the physician because of a swollen and painful right knee for the past 2 days. Temperature is 37°C (98.6°F). Examination shows erythema and swelling of the right knee with a normal range of motion. An x-ray of the right knee shows punctate radiodensities in both menisci and in the joint capsule. Arthrocentesis of the right knee joint yields 5 mL of cloudy fluid with a leukocyte count of 27,000/mm3. Which of the following is the most likely underlying mechanism of this patient's knee pain?

-Calcium pyrophosphate dihydrate crystal deposition. This patient has pseudogout, which is caused by calcium pyrophosphate dihydrate crystal deposition within joints leading to episodes of acute inflammatory arthritis. This condition is most common among older adults and often manifests with monoarthritis of the knee that causes swelling, warmth, and tenderness. An x-ray would often show calcium deposits in the cartilage (chondrocalcinosis) as seen here. Arthrocentesis is the gold standard for establishing the diagnosis; examination of synovial fluid typically shows an elevated leukocyte count and rhomboid crystals that are weakly birefringent under polarized light. Certain conditions such as joint trauma, familial chondrocalcinosis, hyperparathyroidism, and hemochromatosis are associated with pseudogout but in most cases, the cause of pseudogout is unknown (primary CPPD disease). Acute treatment for pseudogout includes NSAIDs and intra-articular corticosteroids. Colchicine can be used for prophylaxis.

A 46-year-old woman is admitted to the hospital with increasing dizziness for 1 week. She has a history of systemic lupus erythematosus, taking daily prednisone. Her blood pressure is 92/68 mm Hg, pulse is 106/min, and respirations are 12/min. Physical exam reveals clear lungs, distant heart sounds, and jugular veins appear distended. A chest x-ray shows an enlarged cardiac silhouette. ECG shows diffusely decreased voltage. The urinalysis shows 2-3 red blood cells per high powered field. The serum creatinine is 1.1 mg/dL and her troponin is 0.15 ng/mL (N = <0.3). Which of the following is the most likely diagnosis?

Cardiac Tamponade CORRECT! She has hypotension, jugular venous distension, and diminished ECG voltage and heart sounds. Lupus is a cause of both pericarditis and tamponade. She needs a pericardiocentesis.

Clos. tetani

Clostridium tetani is the causative agent of tetanus, which is more common is third-world countries from inadequate vaccinations. Estimated that more than 1 million cases occur worldwide with mortality rate 30-50%. The various forms include generalized tetanus, cephalic tetanus, local tetanus, and neonatal tetanus. Patients may have severe muscle spasms, opisthotonus, spasms of spinal extensor muscles, risus sardonicus, trismus (lockjaw), facial nerve palsy, and paralysis of extraocular muscles. This organism can release tetanolysin which is an oxygen labile hemolysin and tetanospasmin, which inactivates proteins that regulate release of the inhibitory neurotransmitters GABA and glycine.

A 27-year-old man with known history of diabetes presents to the physician complaining of intermittent chronic pain in his wrist. On exam he has a tender and swollen joint, but no fever. Arthrocentesis reveals positively birefringent rhomboid-shaped crystals with blunt ends and 35,600/mm3 white blood cells. There are no bacteria, blood, or urate crystals present. X-ray reveals chondrocalcinosis of the joint. Which of the following is the most likely diagnosis?

Calcium pyrophosphate dihydrate deposition disease CORRECT! This patient has pseudogout which can be associated with diabetes. It can also be seen in patients with acromegaly, gout, hemochromatosis, hyperparathyroidism, hypomagnesemia, hypothyroidism, recent surgery, and Wilson disease. Patients can be treated with NSAIDs, Intraarticular steroids, and colchicine.

A 17-year-old female presents to her pediatrician with her father due to weakness in her feet, which is progressively getting worse. She has also noticed that her voice seems weaker. Her past medical history is significant for multiple ankle injuries and sleep apnea. On physical examination, the patient appears to be in no distress. Vital signs reveal a heart rate of 95/min, respiratory rate of 16/min and blood pressure of 110/65 mmHg. She is noted on examination of her back to have a slight kyphosis. She has pes cavus bilaterally and a high steppage gait. She has noticeable weakness of the hips, legs, and feet. On electromyogram she is noted to have decreased nerve conduction velocity in her lower extremities on electromyography. Which of the following is the most likely diagnosis?

Charcot-Marie Tooth Disease CORRECT! The patient described most likely suffers from Charcot-Marie-Tooth (CMT). CMT is a demyelinating hereditary motor sensory neuropathy caused by gene mutations (duplication of the gene PMP22 in chromosome 17) that affect myelin. There are 40 different types of this disease. Common features include distal symmetric leg weakness, foot deformities (foot drop, calf atrophy, pes cavus, and hammer toes), and sensory deficits. It can be associated with sleep apnea. CMT is generally diagnosed with nerve conduction studies which would reveal decreased impulse conduction velocity due to the demyelination, and nerve biopsy which would reveal repeated demyelination and remyelination giving off a characteristic onion peel appearance.

A 62-year-old man comes to the physician because of a 1-day history of dull pain and stiffness of the right knee. He takes chlorthalidone for hypertension. Physical examination of the right knee shows a large effusion and mild erythema; range of motion is limited by pain. Arthrocentesis of right knee yields a cloudy aspirate. Gram stain is negative. Analysis of the synovial fluid shows a leukocyte count of 15,000/mm3 and 55% neutrophils. Microscopic examination of the synovial fluid under polarized light shows positively birefringent rods and rhomboid crystals. Further evaluation of this patient is most likely to show which of the following findings?

Examination of the synovial fluid that shows neutrophil-predominant, mild leukocytosis and rhomboid-shaped, positively birefringent crystals indicates an inflammatory arthritis caused by calcium pyrophosphate dihydrate deposition, which is caused by pseudogout (calcium pyrophosphate disease).

Osteoarthritis of right hip

Femoral head is no longer nice, round, and smooth. Osteophytosis is seen, as well as sclerosis and joint space narrowing. Compare to left side which is normal.

A 45-year-old female presents to the clinic with a diagnosis of irritable bowel syndrome and a 6 month history of generalized muscle aches. Her irritable bowel has been with constipation, well-controlled with fiber supplementation and avoidance of excess caffeine. She clarifies that her muscle aches are not specific to one area of her body; they often move, and wax and wane over time. On review of symptoms, she describes fatigue during this same time period, stating that she sleeps but does not feel refreshed the next day. She also describes feeling depressed at times, because she states that she is too tired and achy to participate in her usual social activities. She wants to go to social functions, but declines. She also admits to some difficulty concentrating. She denies any changes to her appetite or weight over the past 6 months. Physical exam is remarkable for some tenderness over trapezius muscles bilaterally and throughout all four extremities (upper & lower). Routine laboratory studies, including CBC, CMP, CK, ESR, & TSH, are all normal. Which of the following is the most likely diagnosis?

Fibromyalgia CORRECT! Fibromyalgia is the most likely diagnosis, as the patient complains of wide-spread muscle pain associated with fatigue and non-restorative sleep. Irritable bowel syndrome often co-exists in patients with fibromyalgia.

Charcot-Marie-Tooth disease

Most common initial presentation is distal weakness and atrophy manifesting with foot drop and pes cavus (high arch)

RA

Most important thing here are the marginal erosions. That's where the synovium gets granulation tissue and inflammatory tissue and starts eroding into the bone

RA Question

Proliferation of granulation tissue -This patient has evidence of advanced rheumatoid arthritis, based on the findings of marginal erosions on imaging. Microscopic evaluation of a synovial biopsy would most likely show granulation tissue with mononuclear cells, also referred to as pannus. Synovial fluid analysis in this patient would be expected to show neutrophilic infiltrate, increased proteins, reduced viscosity, and possibly rheumatoid factor

A 32-year-old previously healthy female presents to the family medicine clinic with concern about color changes in her fingers, which she first noticed at the start of winter. She has also experienced mild joint pain and stiffness in her knees over the last year and sensitivity to sunlight. Past medical history is significant for heartburn. On physical exam, she is noted to have a facial rash, mild knee effusions and oral ulcers. Laboratory investigations reveal a positive antinuclear antibody and rheumatoid factor, as well as positive anti-double stranded DNA (anti-dsDNA) antibodies. Which of the following is the most likely diagnosis?

SLE CORRECT! Systemic lupus erythematosus is the most likely diagnosis in this case. The patient presents with several features of lupus, including Raynaud's phenomenon, arthralgias (commonly in the knees and hips), photosensitivity, malar or discoid rash on the face and oral ulcers. Notably, the patient has a positive anti-dsDNA; while a positive ANA and RF can be found in many autoimmune and connective tissue disorders (including the ones listed as answer options), anti-dsDNA is a very specific autoantibody for lupus.

Syringomyelia

Syringomyelia is an abnormal fluid-filled cavity, or syrinx, that develops within the central canal of the spinal cord due to disrupted cerebrospinal fluid drainage. It is commonly caused by previous trauma or Chiari malformation. It is often asymptomatic but can lead to cape-like distribution (neck, shoulders, and arms) of sensory loss, pain, and muscle atrophy due to compression of the lateral spinothalamic tracts.

A 62-year-old woman comes to the physician because of a 6-month history of progressive pain and stiffness of the fingers of her right hand. The stiffness is worse at the end of the day. She recently retired after working for 28 years as a typist at a data entry firm. Physical examination shows swelling, joint-line tenderness, and decreased range of motion of the first metacarpophalangeal joint and the distal interphalangeal joints of the right hand. Discrete, hard, mildly tender nodules are palpated over the 2nd and 4th distal interphalangeal joints of the right hand. An x-ray of her right hand shows narrowing of the interphalangeal joint spaces with subchondral sclerosis and osteophytes. Which of the following is the most likely underlying mechanism of this patient's condition?

This patient presents with asymmetric, polyarticular arthritis and Heberden nodes (tender nodules over the DIP joints). The osteophytes seen on imaging are consistent with a specific diagnosis.

Advanced RA

erosions are seen, joint space narrowing (symmetrical), dark areas indicate loss of bone

Clostridium tetani

-Obligate anaerobes -spore-forming -Spores found in rusty nails or soil -Risus sardonicus = Evil grin or lock jaw symptoms -Opisthotonus = exaggerated arching of back -Retrograde transport of toxin -Toxin acts by cleaving SNARE proteins -Cleavage of SNARE inhibits release of GABA and Glycine -GABA and Glycine release from Renshaw cells is inhibited -Toxoid vaccine

A 2-month-old male presents to the emergency department because he will not suck on his bottle. The mother states that she is worried because the infant is always wanting to feed. She picked him up from his grandmother's house and does not know if she fed him anything, but said he was constipated but she fixed it. The mother states that she did not have prenatal care, but the infant should have gotten properly vaccinated at the hospital. Upon examination, the infant has drooping eyelids that he has a hard time keeping open. The infant is quiet and does not have a fever. The attending physician explains to the medical student that this patient has most likely been infected by an organism that has a toxin that prevents the release of acetylcholine signals at the neuromuscular junction. Which of the following is the most likely etiologic organism?

-Clostridium botulinum CORRECT! Clostridium species are gram positive rods which are ubiquitous in soil, water, and sewage. They are a part of the normal gastrointestinal flora in animals and humans and are able to survive adverse environmental conditions through spore formation. Clostridium botulinum is the causative agent for botulism. Infants (2-6 months of age typically) can present with poor feeding, constipation, and weakness. Botulinum toxin is a protease that cleaves SNARE (soluble NSF attachment protein) and prevents release of acetylcholine (stimulatory) signals at the neuromuscular junction. It is heat-labile. Infants can be given human-derived antitoxin known as Botulism Immune Globulin (BabyBIG).

A 38-year-old woman presents to the clinic for evaluation of abnormal discoloration of the fingers after exposure to cold weather. When she does not wear gloves in the winter, her fingers change from white to blue then to red. The patient also reports thickening on the skin of her fingers. She also reports a history of gastroesophageal reflux disease for which she takes antacids daily with some relief. On physical exam, she has sclerodactyly of bilateral hands and pitting edema of bilateral lower extremities. The physician also hears crackles on lung examination. The physician suspects an autoimmune disease and orders an autoantibody panel which come back positive for Anti-Scl-70 (anti-DNA topoisomerase I) antibody and anticentromere antibody. Which of the following most accurately describes the patient's condition?

-Currently has no definitive cure CORRECT! The patient most likely has systemic scleroderma affecting the skin and multiple internal organs like lungs (crackles), heart (edema which could be a sign of right-sided heart failure), esophageal dysfunction (gastroesophageal reflux symptoms). Currently, there is no cure for scleroderma. Treatment options are for systemic complications include angiotensin-converting enzyme (ACE) inhibitor for hypertension, bosentan for pulmonary fibrosis, calcium chancel blocker for Raynaud symptoms, cyclophosphamide for pulmonary fibrosis and Proton-pump inhibitors for gastroesophageal reflux. Scleroderma is an autoimmune disorder that destroys healthy tissue resulting in changes to the texture and appearance of the skin due to an overproduction of collagen. Scleroderma, also known as CREST syndrome due to its presentation, is characterized by calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. Typically, diagnosis occurs between 30 and 50 years of age, and women are more susceptible to developing scleroderma than men. The severity of symptoms varies and can affect the blood vessels, muscles, heart, digestive system, lung, and/or kidneys as well as the skin. Treatment includes corticosteroids, immunosuppressants, and/or nonsteroidal anti-inflammatory drugs. If left untreated, complications of scleroderma include heart failure, cancer, kidney failure, and/or high blood pressure.

A 63-year-old man comes to the physician because of a 4-hour history of severe pain in the right knee. His temperature is 38.0°C (100.4°F). Examination shows erythema, edema, and warmth of the right knee; range of motion is limited by pain. Arthrocentesis of the knee joint yields cloudy fluid with a leukocyte count of 24,000/mm3 (74% segmented neutrophils). Polarized light microscopy shows needle-shaped, negatively birefringent crystals. Five hours after treatment with a drug is begun, he develops abdominal cramps, diarrhea, and vomiting. The patient was most likely treated with a drug that predominantly acts on which of the following parts of the cell?

-Cytoskeleton. Colchicine inhibits microtubule polymerization by binding to the cytoskeleton. This leads to disruption of several inflammatory mechanisms, such as phagocytosis of urate crystals, cell chemotaxis, leukocyte activation, and migration. Colchicine is used to treat an acute gout attack, but should be avoided in patients with severe renal or hepatic impairment. Side effects include GI upset as observed in this patient (severe diarrhea, vomiting, abdominal pain), myelosuppression, and hair loss.

A 32-year-old woman comes to the physician because of fatigue and joint pain for the past 4 months. Examination shows erythema with scaling on both cheeks that spares the nasolabial folds and two 1-cm ulcers in the oral cavity. Further evaluation of this patient is most likely to show which of the following findings?

-Decreased lymphocyte count Arthralgia, a malar rash, and oral ulcers in a young, female patient make systemic lupus erythematosus (SLE) the most likely diagnosis. Lymphocytopenia is a typical finding in patients with systemic lupus erythematosus, particularly during active disease, and is presumably caused by autoimmune-mediated cell destruction. Both at diagnosis and throughout the disease, decreased cell counts of all lineages may be present, with anemia being the most common hematological abnormality.

A 7-year-old boy is admitted to the inpatient service with joint pain, pink colored urine, and intermittent colicky abdominal pain. His mother states he had a cold a few weeks ago. On exam his pulse is 114/min, temperature is 99.4 F, respiratory rate is 18/min, and blood pressure is 111/80 mm Hg. He is noted to have multiple petechiae and purpuric lesions on his buttocks and lower extremities. He has some mild abdominal tenderness on exam and slight edema in his lower extremities and scrotum. A urinalysis demonstrates proteinuria and hematuria. A basic metabolic profile shows that his BUN is 7 mg/dL and creatinine is 0.6 mg/dL. Which of the following best describes the pathophysiology of this patient's condition?

-Deposition of IgA, C3, and fibrin deposition within the walls of involved blood vessels CORRECT! Henoch-Schönlein Purpura is an IgA mediated vasculitic disease of small blood vessels. IgA is an antibody that functions predominantly in mucosal immunity which explains the gastrointestinal, kidney, and skin involvement associated with HSP. Immunofluorescence studies show IgA, C3, and fibrin deposition within the walls of involved vessels. Some patients with glomerulonephritis develop chronic kidney failure. This particular patient would be closely evaluated as one of the most significant risks with HSP is the development of intussusception associated with associated bowel edema. HSP is a leukocytoclastic vasculitis that affects the skin on the lower extremities (palpable purpuric rash), the GI tract (nausea, abdominal pain, intussusception), kidneys (vascular IgA nephropathy), and joints (joint pain). Joint pain and abdominal pain are often the first noted symptoms. The effect on the kidneys is less obvious but presents as a nephritic syndrome identical to that of IgA nephropathy. The differentiating factor between the two is the presence of other symptoms typical of HSP.

A 2-year-old boy presents to the pediatrician for a new patient visit. His family is concerned because he does not seem to be learning to talk as easily as his older siblings. He has also recently developed seizures. On examination, the patient's proximal muscles are weak bilaterally in the lower extremities. He can barely push himself from a seated position without assistance. Lab results reveal an elevated lactic acid. He is sent to a geneticist who orders a muscle biopsy, which reveals ragged-appearing muscle fibers containing mild accumulations of glycogen when a Gomori trichrome stain is applied. Which of the following describes the mode of inheritance for this patient's most likely disease?

-Mitochondrial Inheritance CORRECT! This patient has a mitochondrial encephalomyopathy, a heterogenous group of syndromes transmitted through mitochondrial inheritance. Mitochondria are the cellular organelles that are responsible for the production of energy. They are maternally inherited because they are supplied by the egg at fertilization. Mitochondria contain their own DNA and contain genes that are susceptible to mutation. Males and females are equally affected. Leber hereditary optic neuropathy are also inherited through mitochondria.

A 63-year-old male is admitted to the hospital with a one-month history of diarrhea, abdominal pain, and migratory joint pain. He states he has lost 7 pounds in the past month. He has a past medical history significant for hypertension and diabetes mellitus type 2. He takes lisinopril, a daily vitamin, and says he manages his diabetes with diet and exercise. On exam, his blood pressure is 131/85 mmHg, pulse 76/min, and respiratory rate 13/min. His liver span is percussed to be 16 cm and ascites is present. His ALT is 124 U/ and AST is 98 U/L. PCR testing of a lymph node sample subsequently identifies the presence of bacillary Tropheryma whipplei. Which of the following histological findings would be present in this sample?

-Foamy macrophages in the lamina propria with periodic acid-Schiff positive intracellular material CORRECT! Tropheryma whipplei is an intracellular gram positive actinomycete that causes a rare malabsorptive disease known as Whipple disease, which can cause problems associated with the incomplete breakdown of carbohydrates or fat. Patients are typically older men who may present with abdominal pain, diarrhea, steatorrhea, eye complaints, joint pain, seizures, and weight loss. Patients may demonstrate hyperactive bowel sounds, weight loss, ascites, decreased oncotic pressure from hypoproteinemia, dementia, fever, hepatomegaly, lymphadenopathy, and splenomegaly. Pathology will be found in lymph nodes surrounding the affected tissue. The organism is identified using PCR or electron microscopy. The histology will reveal foamy macrophages found within the lamina propria and mesenteric nodes of the intestines and contain periodic acid-Schiff (PAS) positive intracellular material.

A 38-year-old woman comes to the physician because of a 4-day history of swelling and pain in her left knee. She has had similar episodes of swollen joints over the past 3 weeks. Two months ago, she had a rash on her upper back that subsided after a few days. She lives in Pennsylvania and works as a forest ranger. Her temperature is 37.8°C (100°F). Physical examination shows a tender and warm left knee. Arthrocentesis of the knee joint yields cloudy fluid with a leukocyte count of 30,000/mm3 and 80% neutrophils. A Gram stain of synovial fluid does not show any organisms. Which of the following is the most likely cause of this patient's condition?

-Infection with spiral-shaped bacteria Borrelia burgdorferi is a tick-borne spiral-shaped bacteria that causes Lyme disease, which typically begins with a localized rash (i.e., erythema chronicum migrans) and ultimately can cause systemic infection involving the joints, skin, and central nervous system. The incidence of lyme disease is highest in the Northeast and upper Midwest of the US, and outdoor workers (e.g., rangers, landscapers, farmers) are at an increased risk of infection. The nonspecific arthrocentesis findings, i.e., negative Gram stain and leukocytosis with increased neutrophils are consistent with Lyme arthritis. Two-step serological testing is indicated to confirm exposure: The screening test ELISA should be followed by a Western blot test to detect IgG and IgM antibodies against Borrelia. However, positive results only demonstrate exposure to Borrelia, not necessarily current infection. PCR (arthrocentesis) is best for confirming suspected Lyme arthritis in patients who are IgG immunoblot-positive. The treatment for Lyme arthritis in adults is oral doxycycline.

An 8-year-old male presents to the pediatric orthopedic clinic with right leg pain. The patient's mother states that she first noticed her son had a slight limp approximately three weeks ago. While at first the patient denied any right hip or leg pain, his mother says in the last few days he has started complaining of right hip and knee pain with physical activity. The patient says that the pain is relieved by rest. The patient and his mother have noticed no other symptoms. They both deny any history of injury or recent illnesses. Physical exam reveals decreased abduction and internal rotation of the right hip. The patient is also noted to have a Trendelenburg gait. Vital signs are within normal limits and the patient's BMI is 16 kg/m2. An x-ray of the right hip shows femoral head sclerosis and an increased width of the femoral neck. Which of the following is the most likely diagnosis?

-Legg-Calve-Perthes Disease CORRECT! The most likely diagnosis in this patient is Legg-Calve-Perthes. Legg-Calve-Perthes disease is most common in males between the ages of 4 and 8, and classically presents with a painless limp that becomes painful gradually with activity. Physical exam findings consistent with Legg-Calve-Perthes include a Trendelenburg gait, decreased hip motion, guarding during passive motion, and possible muscle atrophy in situations of muscle disuse. This condition is often referred to as avascular necrosis of the femoral head due to under perfusion. The vessel that is commonly compromised is the medial circumflex femoral artery.

A 47-year-old woman presents to the internal medicine clinic complaining of increased muscle fatigue, especially as the day progresses. She recounts trouble chewing at the end of meals, difficulty talking at the end of the day, and double vision in the afternoon. She has also had a small cough and felt slightly short of breath. Exam demonstrates a well-appearing female in no obvious distress. Her pulse is 76/min, respirations 16/min, and blood pressure 108/67 mm Hg. Her neck is soft, nontender without lymphadenopathy. She demonstrates bilateral ptosis and muscle fatigability when asked to repeated open and close her eyelids. Abdominal exam is unremarkable. Which of the following is most likely to be seen in her chest on further diagnostic evaluation?

-Lobulated, smooth mass, projecting over the mediastinum CORRECT! This patient most likely has a thymoma associated with myasthenia gravis. Thymomas contain tumor cells that originate from thymic epithelial cells. They are the most common solitary lesion in mediastinum and anterior mediastinum in adults. The peak age of presentation is 40-60 years of age with an equal sex distribution. Approximately 40 percent of thymomas are associated with a paraneoplastic or autoimmune disorder such as, in this case myasthenia gravis. Our patient has symptoms from both the tumor compressing the airway as well as myasthenia, which can be confirmed with the presence of acetylcholine receptor binding antibodies.

A 2-week-old infant male presents to the pediatrician's office with a rash. His mother did not have prenatal care but had an uncomplicated delivery. Upon exam, the patient is lethargic appearing. Vital signs include a blood pressure of 90/50 mm Hg, pulse 60/min, respirations 48/min, and temperature 98.2 F. The physician notes erythematous, scaly plaques on the face and scalp. A complete blood count shows neutropenia and thrombocytopenia. On further questioning, the infant's mother states that she has experienced dry eyes and dry mouth during and after the pregnancy. After diagnostic testing, the mother shows anti-Ro/SS, anti-La/SSb, and Anti-U1RNP IgG antibodies. Which of the following is the most likely diagnosis?

-Neonatal lupus erythematosus CORRECT! Neonatal lupus erythematosus is a rare, autoimmune disease resulting from transplacental antibodies passed to the infant from a mother with systemic lupus erythematosus (SLE). It presents with bradycardia and rashes. It can be extremely severe and lead to complete heart block. The patient may require an emergent pacemaker.

A 16-year-old female presents to the pediatric orthopedic clinic for evaluation for possible scoliosis. She has no symptoms that she has noticed, but came to the clinic after a scoliosis screening at her high school was abnormal. She is otherwise healthy with no significant medical issues. Physical exam shows slightly unequal height of shoulders when standing upright and a noticeable lateral curvature of the spine when observing her spine when she bends forward. After obtaining a spinal x-ray, the patient is determined to have a curvature of 15° in her lumbar spine. Which of the following is the most likely first-line treatment for this patient's scoliosis?

-Observation CORRECT! Scoliosis is a curvature of the spine. Initial x-ray should include standing, full-length posteroanterior (PA) and lateral views of the spine from C7 to the sacrum and iliac crest. It is defined as a Cobb angle > 10 degrees. The first-line treatment for scoliosis is based on the degree of curvature observed on x-ray. When the curvature is <20 degrees, patients need observation and to have their scoliosis rechecked every 6 months to make sure the scoliosis is not worsening.

A 56-year-old farmer in a rural area injures his foot while cleaning out an old barn. A rusty nail went through the sole of his boot and created a 1 cm puncture wound. He did not clean it until he showered later that night. A week later his wife noted that he was becoming more irritable, sweaty, and drooling. She called an ambulance, which took him to the nearest facility an hour away. On the ambulance ride, the EMS workers noted that he began to have severe jerking movement of his neck and face. Which of the following best describes the organism that is causing the patient's clinical presentation?

-Pathology involves inhibition of the release of GABA and glycine CORRECT! Clostridium species are ubiquitous in soil, water, and sewage. They are a part of the normal gastrointestinal flora in animals and humans and are able to survive adverse environmental conditions through spore formation. Clostridium tetani is the causative agent of tetanus, which is more common is third-world countries from inadequate vaccinations. Estimated that more than 1 million cases occur worldwide with mortality rate 30-50%. Clostridium toxin inactivates proteins that regulate release of the inhibitory neurotransmitters GABA and glycine. This causes unregulated excitatory synaptic activity in motor neurons and spastic paralysis. Binding is irreversible so recovery depends on formation of new axonal terminals.

A 1-day-old female presents to the newborn nursery. This patient was born at a gestational age of 40 weeks via Caesarean section due to breech positioning following an uncomplicated pregnancy. During your physical exam, you observe a "clunk" in the patient's left hip when you attempt to gently abduct the left hip while simultaneously exerting an upward force through the greater trochanter laterally. No abnormality is noted on the patient's right hip. No other abnormalities are noted on physical exam. An ultrasound of the patient's hips confirms the most likely diagnosis for this physical exam finding. Which of the following is the most appropriate management for the patient's most likely diagnosis?

-Pavlik harness with follow-up hip ultrasound CORRECT! The most likely diagnosis causing a positive Ortolani sign in a newborn is developmental dysplasia of the hip (DDH). Following an ultrasound to confirm the diagnosis of DDH, the patient should be treated by being placed into a Pavlik harness. This harness keeps the affected hip reduced in a flexed and abducted position until the hip stabilizes. The patient needs to be followed every few weeks in the pediatric clinic while wearing the Pavlik harness.

A 40-year-old diabetic, overweight female presents to the family medicine clinic with a pain in her left heel. She denies a history of trauma, but states that the pain persists when she walks and is worse when she takes her first steps in the morning. When questioned regarding exercise, you note the patient has a fairly sedentary lifestyle. Her temperature is 100.5 F, blood pressure of 145/92 mm Hg, respiratory rate of 14/min, and pulse of 70/min. Upon examination, you note that the patient's soft tissue over the left heel looks inflamed and red, and she exhibits a negative Tinel sign. When asked to walk, gait is normal despite the heel pain. Which of the following is the most likely diagnosis?

-Plantar fasciitis CORRECT! Fasciitis is the most common cause of pain in the inferior heel among adults. Risk factors include excessive running, obesity, diabetes, and/or occupations that require prolonged standing. Fasciitis may cause decreased dorsiflexion due to tightening of the Achilles tendon after onset. Treatment includes physical therapy, administration of anti-inflammatory agents, use of orthotic devices, and may involve surgery in rare instances. If left untreated, fasciitis may lead to systemic toxicity.

JIA Rx bank

-Systemic JIA Juvenile idiopathic arthritis (JIA) is the most common form of arthritis in children. The systemic form of JIA is characterized by quotidian fevers, arthritis, severe leukocytosis and thrombocytosis, and a classic salmon-pink rash.

A 16-year-old female presents to the pediatrician office for a wellness visit. She does not have any complaints today, and she states that she needs her sports physical form filled out. She has a past medical history significant for Osgood-Schlatter disease. She has been strength training for the basketball team and icing her joints after. This seems to alleviate the soreness. Which of the following bony landmarks serves as the attachment point for the affected tendon in this condition?

-Tibial Tuberosity CORRECT! Osgood-Schlatter Disease is a condition most commonly found in children 9-14 years of age who are involved in jumping sports. It is a result of microfractures at the insertion of the patellar tendon on the tibial tubercle (also known as an apophyseal injury, or traction apophysitis, with the apophysis referring to a site of tendon or ligament attachment). Management includes rest, ice, NSAIDs, and strengthening of hamstrings and quadriceps. Most patients will improve with time but can develop a residual bony deformity.

Costridium botulinum

-Transmitted by improper canning of foods -Spore-forming -Obligate-anaerobe -Flaccid descending paralysis -Early symptoms include ptosis and diplopia -Toxin targets nerves that release ACh -Toxin is a protease that cleaves SNARE proteins -Infant botulism transmitted through ingestion of honey (spores found in honey) or if the baby is laying outside on soil

EDMD

-Typically presents in the first or second decade of life -Early contractures at the elbows, posterior aspect of the neck, entire spine, and the achilles tendons

A 15-year-old male presents to the pediatrics clinic with left knee pain. The patient's mother states that he has been complaining of this pain and had a limp for about one month. Both the patient and his mother deny any acute trauma at the time of initial pain. This pain is not relieved by rest or NSAIDs, and the patient has no other new symptoms. All vital signs are within normal limits. Patient's BMI is 28 kg/m2 which places him at the 97th percentile. Physical exam reveals limited range of motion of the left hip, including loss of abduction, flexion, and internal rotation. Which of the following findings are most likely to be seen on an x-ray of the patient's affected hip?

-Widened physis and the femoral head appearing to have rolled off the shaft of the femur CORRECT! The patient in this question does have slipped capital femoral epiphysis, which is a condition where the head of the femur has slipped off the neck of the femur. The expected x-ray findings in this condition are a widened physis and the femoral head appearing to have rolled off the femoral shaft (referred to as the "melting ice cream cone sign").

An 8-month-old female infant presents to the pediatric clinic for a well-child exam. The patient was born to a 25-year-old, gravida 1 mother at 39 weeks via Caesarean section due to breech position following an uncomplicated pregnancy. On physical exam, you observe a positive Galeazzi sign on the infant's right side, as there is inequality in the height of the infant's knees with both hips and knees flexed. Both the Ortolani test and Barlow maneuvers are negative. No other abnormalities are found on physical exam. Which of the following is the best diagnostic test used to make the diagnosis in this patient?

-X-rays of the hips CORRECT! The patient in this question most likely has developmental dysplasia of the hip on the right side. This is based on the presence of the Galeazzi sign, which is an inequality of the heights of the patient's knees when lying supine and the knees are flexed. Once children are over 6 months of age, plain x-rays can be used to evaluate the relationship between the acetabulum and the femoral head in the child's hips to check for DDH.

Ankylosing spondylitis RX-bank

AS is a type of arthritis that presents in young men with lower back pain and stiffness, due to vertebral fusion of the spine and sacroiliac joints. AS is associated with HLA-B27 and is a seronegative arthropathy. Other HLA-B27-related arthropathies are psoriatic arthritis, reactive arthritis, and arthritis associated with inflammatory bowel disease. Mnemonic: PAIR A young patient most likely has ankylosing spondylitis (AS). AS is characterized by lower back pain and stiffness, plus sacroiliac fusion on x-ray (see image). This patient also presents with blurry vision and photophobia, suggesting associated uveitis. AS may also present with pain or stiffness in the hip, shoulder, joints around the ribcage and sternum, fingers, and at the attachment of the Achilles tendon to the heel (enthesitis). The pain typically improves with exercise.

A 35-year-old woman presents to the family medicine clinic complaining of increased muscle fatigue especially as the day progresses. She recounts trouble chewing at the end of meals, difficulty talking at the end of the day and double vision in the afternoon. Exam demonstrates bilateral ptosis and muscle fatigability. Antibodies to which of the following are most likely to be found in her blood work?

Acetylcholine receptors CORRECT! This patient has myasthenia gravis. Myasthenia gravis (Latin= myo- muscle, asthenia-weakness, gravis- severe) is a chronic autoimmune disease that causes muscle weakness. The disease is most commonly due to antibodies which attack nicotinic acetylcholine receptors at the neuromuscular junction. A smaller percentage of individuals have antibodies that attack muscle-specific receptor kinase.

A 40-year-old woman presents to the clinic for evaluation of progressively worsening muscle weakness. Patient reports that she has noticed increased difficulty when she gets up from a chair or when she brushes her hair in the morning. She denies any recent injury or similar symptoms in the past. She does note a history of rheumatoid arthritis in her mother. Physical exam shows symmetric weakness in the muscles of her shoulders, upper arms, hips and thighs. Her neurologic exam is normal including normal deep tendon reflexes. A muscle biopsy reveals endomysial inflammation. Which of the following could also be seen on biopsy?

CD8+ T cell infiltrates CORRECT! This women has polymyositis, an immune-mediated inflammatory myopathy that causes low onset proximal muscle weakness and is characterized by endomysial inflammation. Myofiber injury appears to be mediated directly by CD8+ cytotoxic T lymphocytes that surround and invade myofibers. Macrophages and myeloid dendritic cells are also usually present. Immunosuppressants help relieve symptoms but do bot provide a cure.

A 50-year-old male who has been diagnosed with psoriatic arthritis presents to the clinic complaining of left ankle, right knee and 3rd digit right foot pain. He has been participating in daily exercise and has been taking ibuprofen over-the-counter for his joint pain. It worked pretty well for a number of years, but stopped relieving his pain approximately 2 months ago. He has a previous history of psoriasis of the skin, which responded well to topical corticosteroids. His complete metabolic profile and complete blood count are within normal limits. Which of the following medications should be considered next in the treatment of his psoriatic arthritis?

CORRECT! Methotrexate is the preferred second-line treatment (after exercise plus NSAIDs/ibuprofen) for patients with psoriatic arthritis. The relatively low dosage utilized is not associated with significant immunosuppression and rarely results in elevations in liver enzymes. Folic acid is provided concurrently with methotrexate to reduce the likelihood of gastrointestinal and mucosal side effects.

A 32-year-old male presents to the outpatient clinic with a chief complaint of joint pain. He denies fever, chills, vision changes or weight loss. He admits to a burning sensation while urinating, which started around the same time as the joint pain about 2 days ago when he had a new sexual partner. He admits to having frequent unprotected sex with females. His past medical history is significant for ulcerative colitis. On exam, he is well appearing. His blood pressure is 124/80 mm Hg, pulse 70/min, and a respiration rate 19/min. His temperature is 98.4 F. Inflammation of the conjunctiva and uvea are seen on ocular exam. He has vesicular rashes on the palms and soles of his feet as well as red macules on his glans penis. Which of the following is the most likely diagnosis?

CORRECT! Reactive arthritis is defined as arthritis that arises following an infection with a constellation of joint pain, nongonococcal urethritis, and eye inflammation. This patients admits to unprotected sex, so he might have contracted a sexually transmitted disease such as a Chlamydia trachomatis infection. On exam, the patient has balanitis circinata and keratoderma blennorrhagicum. Reactive arthritis is also the most common cause of asymmetric arthritis in young men.

A 42-year-old female with a past medical history of rheumatoid arthritis presents to her primary care physician with a 6-month history of increased water intake. Review of systems reveals blurry vision, dysphagia, occasional fatigue, and arthralgia. Her husband, who accompanies her, states that his wife's cheeks appear bigger than usual. Upon further questioning, she admits to recent dental work. She denies fevers, shortness of breath, muscle weakness, paresthesia, changes in urine output or peripheral edema. On physical examination, she is well appearing with a temperature of 37.5 C (99.6 F), blood pressure of 122/80 mm Hg, heart rate of 72/min and a respiratory rate of 18/min. There is bilateral erythema of her sclera that the patient attributes to constant rubbing. Upon inspection of the mouth, there are small grooves on the dorsal surface of the tongue. She has bilateral parotid gland enlargement appreciated on palpation. Heart and lung examination are normal. A basic metabolic profile is normal. A Schirmer test results in less than 5 mm of wetting in 5 minutes. Serologic testing demonstrates a positive ANA and anti-Ro antibody. Which of the following is the most likely diagnosis?

CORRECT! Sjogren syndrome (SS) is a chronic autoimmune disease where lymphocytes infiltrate and destroy the lacrimal and salivary glands. Disease is most common in females 40 to 60 years of age. Primary Sjogren syndrome is characterized by dry eyes and dry mouth (keratoconjunctivitis sicca and salivary hypofunction, respectively) with no history of another rheumatologic disease. Secondary Sjogren syndrome involves the same symptoms as primary Sjogren and a positive history of a connective tissue disease (rheumatoid arthritis, systemic lupus erythematosus, scleroderma). As a result of the salivary gland destruction, SS patients have an increased risk of dental caries. They can also complain of parotid gland swelling, arthralgia, and fatigue. Non-Hodgkin lymphoma is one of the most serious complications of SS and most common cause of death. Therefore, a thorough physical examination assessing for lymphadenopathy and hepatosplenomegaly is of importance. Clinical diagnosis is made based on clinical history and laboratory findings of specific serologic tests (anti-Ro/SSA antibodies with or without anti-La/SSB antibodies, rheumatoid factor, and ANA.) Schirmer test may be used to measure aqueous tear production with sterile filter paper. A positive result is less than 5mm of wetting in 5 minutes.

A 32-year-old previously healthy female presents to the family medicine clinic with concern about color changes in her fingers, which she first noticed at the start of winter. She has also experienced mild joint pain and stiffness in her knees over the last year and sensitivity to sunlight. Past medical history is significant for heartburn. On physical exam, she is noted to have a facial rash, mild knee effusions and oral ulcers. Laboratory investigations reveal a positive antinuclear antibody and rheumatoid factor, as well as positive anti-double stranded DNA (anti-dsDNA) antibodies and anti-smith antibodies. Which of the following is the most likely diagnosis?

CORRECT! Systemic lupus erythematosus is the most likely diagnosis in this case. The patient presents with several features of lupus, including Raynaud's phenomenon, arthralgias (commonly in the knees and hips), photosensitivity, malar or discoid rash on the face and oral ulcers. Notably, the patient has a positive anti-dsDNA; while a positive ANA and RF can be found in many autoimmune and connective tissue disorders (including the ones listed as answer options), anti-dsDNA is a very specific autoantibody for lupus.

A 35 year-old woman presents to the emergency department with a concern of lower abdominal pain for the past three days after returning from a mission trip in South America. She describes the pain as crampy on her lower abdomen and notices she is having more daily bowel movements that are loose with mucous and blood in the toilet. She reports recent onset of fevers and nausea without vomiting. On exam, her abdomen is tender to palpation in the lower quadrants without rigidity, guarding, or masses. She is admitted and treated for her condition without incident. On follow-up with her doctor two weeks later, she reports having developed pain of her left heel and swelling of her right knee. She has noticed some annular scaling and skin changes to the bottom of her feet as well. When she uses the bathroom, she has discomfort on urination and her co-workers recently told her that her eyes looked bloodshot. Which of the following conditions shares an HLA association with the complication the patient has developed?

CORRECT! Ulcerative colitis (UC) is an autoimmune inflammatory bowel disease of unknown pathogenesis, but believed to be associated with p-ANCA antibodies. It is classically a disease with a bimodal age distribution in the 20s and 60s. Its classic presentation is rapid onset diarrhea, hematochezia, mucus in stools, tenesmus, and abdominal pain. The inflammation is always involving the rectosigmoid colon and extends proximally in a contiguous fashion. The inflammation is not transmural and microscopically there are crypt abscesses and absence of granuloma formation. The colon grossly shows ulcerations and bleeding with possible pseudopolyp formation. Extraintestinal manifestations with UC are common and may include pyoderma gangrenosum, primary sclerosing cholangitis, uveitis, ankylosing spondylitis, and aphthous ulcers. The patient described above is having asymmetrical enthesitis and arthritis, urethritis, and suspected uveitis consistent with reactive arthritis after a bacterial infection causing dysentery, likely from shigella. Reactive arthritis has an association with HLA subtype B27. UC and Crohn disease share an association with HLA subtype B27.

A 4-year-old boy is referred to the pediatric neurologist for increasingly abnormal gait, weakness, and falls. He has been developmentally normal up to this point. He is otherwise healthy and all of his immunizations are up to date. He has not yet received his kindergarten age immunizations. On exam he is well appearing with no facial dysmorphisms. He is in no acute distress. He is noted to have a slight lumbar lordosis and decreased hip strength. His calves are noted to be prominent. When the physician has him lay on his abdomen on the floor and asks him to stand up he walks his hands up his thighs in order to fully stand. Which of the following is the most likely diagnosis?

Duchenne muscular dystrophy CORRECT! Muscular dystrophy is a disorder of muscle weakness linked to the loss of the dystrophin protein. Patients with Duchenne muscular dystrophy present around age 3-5 years with new onset difficulty walking or frequent falls. They can begin with a limp, waddling gait or have trouble standing. The DMD gene produces dystrophin, which accounts for 0.002% of striated muscle protein mass. It is localized on the cytoplasmic side of the muscle cell membrane. It is a large multi-domain protein which plays a critical role in the structural integrity of muscle cell membrane, sarcolemma, and stabilizes the membrane against mechanical forces involved in muscle contraction. Mutations in the dystrophin gene resulting in DMD are frameshift, resulting in no dystrophin production. Some mutations result in amino acid substitutions that disrupt the folding of particular domains within the dystrophin protein leading to aggregation and subsequent degradation of the misfolded protein.

A 45-year-old female presents with a well-established diagnosis of fibromyalgia for the past 5 years. She is being treated with ibuprofen, cyclobenzaprine, and hydrocodone as needed. She still complains of non-restorative sleep and irritability. She exercises, as able, and tries to embrace a healthy lifestyle. She believes she could exercise more, if her fibromyalgia was better. Screenings for depression and anxiety are negative. Which of the following medication additions is the best option for this patient?

Duloxetine CORRECT! Duloxetine (Cymbalta) is a serotonin norepinephrine reuptake inhibitor antidepressant FDA-approved for the treatment of fibromyalgia. It is especially good at targeting symptoms of sleep and mood disturbance, as seen in this patient.

A 9-year-old boy presents to the pediatric clinic complaining of arm pain after he fell from his bike. The physician orders an upper arm x-ray after concerning finding's are found on exam. The mother indicates that the boy has "always wanted to be a doctor" and asks the physician to review the boy's x-ray with him when the results return. Which of the following descriptions most accurately depicts normal bone anatomy where the patient's injury occurred?

Epiphyseal growth plate is housed in metaphysis of the bone

Strep pyogenes

Glass capsule = encapsulated, H and A in Hot Apple stand for hyaluronic acid capsule B bulb = Beta-hemolytic Honey crusted pie = Impetigo (honey crusted lesions) Red handkerchief = Pharyngitis Big red mittens = cellulitis and erysipelas Scarlet fever (guy on left) 1.) strawberry tongue 2.) pharyngitis 3.) Diffuse rash that spares the face (look at gingerbread man) S. pyogenes can cause necrotizing fasciitis (from s, pyogenes exotoxin SpeB) *SpeA and SpeC cause toxic shock syndrome Rheumatic fever 1.) M protein inhibits opsonization so its anti-phagocytic (guy from behind trying to steal cupcakes, preventing him from eating, aka anti-phagocytosis) 2.) Mitral valve damaged in RF *RF occurs after pharyngitis but NOT after skin infections and it also doesn't occur if pharyngitis is promptly treated 3.) JONES Criteria: Joints (polyarthritis), O (shape of heart), Nodules, Erythema marginatum, Sydenham's chorea PSGN 1.) Type III HSR 2.) Facial edema 3.) Cola-colored urine 4.) PSGN occurs 2 weeks after the onset of strep infection (indicated by calendar) **PSGN can occur after pharyngitis or a superficial skin infection Treatment: Penicillin Streptolysin O (doughnuts) Streptokinase (cupcakes) = converts plasminogen to plasmin S. pyogenes is Bacitracin sensitive

A 68-year-old male presents to the clinic with a complaint of difficulty climbing up the stairs. He has recently retired and attributes his recent difficulties in mobility to older age. His daughter told him to go to the clinic because he now has a rash around his eyes. On exam, he appears well in no acute distress. His blood pressure is 120/80 mm Hg, heart rate 89/min and respirations 20/min. He exhibits weakness in his proximal arms and thighs. Rashes are found in other areas of his body and Violaceous patches with scale are found on the metacarpophalangeal proximal interphalangeal joints of both hands. His diagnostic labs are positive for elevated CRP levels and anti-Jo antibodies. Based on the most likely diagnosis, which of the following is an appropriate next step in management?

Immunosuppressive agents CORRECT! Immunosuppresive agents such as azathioprine and mycophenolate mofetil can help manage the symptoms of dermatomyositis which is the most likely diagnosis. Dermatomyositis is an idiopathic inflammatory myopathy which affects multiple other organs, including skin, heart, and lungs. It distinguishing features include the patient complaint of difficulty climbing the stairs along with a rash around the eyes (heliotrope rash). The physician may also recommend physical therapy.

A 3-year-old boy is admitted to the inpatient service with 7 days of continuous fevers up to 104.1 F. The mother states that she has been giving his acetaminophen which helps a little, but the fever just won't go away. He denies sore throat, cough, abdominal pain, vomiting, or diarrhea. His eyes have been red, but are not draining anything. She recently noticed a faint rash on his trunk. He was previously healthy. On exam he is tired appearing. His pulse is 105/min, respirations 20/min, blood pressure 96/77 mm g, and temperature 101.9 F. His tongue is bright red, with accentuated taste buds. He is noted to have bilateral injected sclera. An erythematous rash is present on his trunk. Cervical lymphadenopathy is present bilaterally. There is mild swelling of his feet. Lab work reveals a white blood cell count of 18,600/mm3 and an ESR of 105 m/hr. Which of the following is the most likely diagnosis?

Kawasaki disease CORRECT! This patient is exhibiting all of the classical findings. Kawasaki disease (KD) is a condition of unknown etiology, in which there is widespread inflammation of the vasculature also known as mucocutaneous lymph node syndrome. Patients are typically under eight years of age who present with fever for at least five days can be less in atypical KD) anorexia, diarrhea, fatigue, rash, red eyes and lips. Patients have elevated inflammatory markers and leukocytosis. Treatment is with a combination of IVIG and aspirin. Untreated patients are at risk for coronary artery aneurysms.

An 18-year-old female presents to the emergency department with a suspected broken leg. She states that she fell during a soccer game today, and her right lower leg immediately began hurting and she could not bear weight on that side. Her mom brought her to the hospital immediately after the incident. She is in severe pain that she rates as a 10 out of 10. The physician suspects a long bone fracture of the diaphysis of the tibia. On physical examination, the physician notes significant pallor and coolness of the skin. The right leg is swollen beneath the knee making it significantly larger than the left leg. Dorsalis pedis pulse is 2+ on the left foot and 1+ on the right foot. Which of the following complications of a long bone fracture should the physician consider?

Limb compartment syndrome CORRECT! Acute limb compartment syndrome is a painful EMERGENT condition caused by swelling or bleeding within a myofascial compartment, which places significant interstitial tissue pressure on the vessels, nerves, and muscles within the compartment. Once the circulation is compromised, serious consequences can result for the ischemic tissue. Patients may demonstrate: Significant pain with passive stretching, paresthesia or hypoesthesia, pallor, poikilothermia (coolness), and swelling. It commonly occurs due to long bone fracture as seen in this case. True acute compartment syndrome is a surgical emergency requiring fasciotomy.

A 32-year-old female presents to her physician with fatigue and arthralgias. She has no prior medical problems except for intermittent arthritis, for which she takes aspirin as needed. Her blood pressure is 148/100 mm Hg, temperature 37.1 C. The exam is notable for a red rash on the cheeks, 1+ ankle edema, bruising on the legs, and swollen and tender wrists. Lab studies show: Urine: 3+ protein, 4+ heme, numerous erythrocytes Serum: Creatinine 1.8 mg/dL Blood: Hematocrit 32%, WBC 10,000/mcL, platelets 62,000/mcL; blood smear is normal. Which of the following is the most likely diagnosis?

Lupus nephritis CORRECT! She has a rash, arthralgias, thrombocytopenia, anemia, and renal failure with hematuria, all characteristic a systemic lupus erythematosus signs.

Borrellia Burgdorferi

Lyme disease is common in northeast and midwest. White-footed mouse is main reservoir of tick and the white tail deer is the obligatory host -Wrights stain and giemsa stain Stage 1 -Bulls eye rash -Flu-like symptoms Stage 2 -Heart block caused by myocarditis -May have bilateral Bell's Palsy or unilateral Stage 3 -Migratory polyarthritis -Encephalopathy Treatment: Doxycycline, or even ceftriaxone in severe cases

A 45-year-old male is admitted to the hospital with a one-month history of diarrhea, abdominal pain, and migratory joint pain. He states he has lost 7 pounds in the past month. He has a past medical history significant for hypertension and diabetes mellitus type 2. He takes lisinopril, a daily vitamin, and says he manages his diabetes with diet and exercise. On exam, his blood pressure is 126/90 mmHg, pulse 86/min, and respiratory rate 14/min. His liver span is percussed to be 16 cm and ascites is present. Liver function tests are elevated. A sample from an enlarged lymph node is taken contains PAS-positive intracellular material. PCR subsequently identifies the presence of bacillary Tropheryma whipplei. Which of the following medications should be started first?

Meropenem CORRECT! This patient has Whipple disease, which causes weight loss, diarrhea, and joint and abdominal pain. Whipple disease affects multiple organ systems including the gastrointestinal, musculoskeletal, ocular, cardiac, renal, and neurologic systems. Patients may have hepatosplenomegaly and ascites on exam. Liver function tests may be elevated. The organism lives in lymph nodes and can be identified using PCR. Macrophages within the lamina propria of the affected tissue will contain PAS-positive intracellular material. Patients can be treated with IV ceftriaxone or meropenem followed by one year of trimethoprim-sulfamethoxazole.

A 14-year-old male presents to the pediatrics clinic with left knee pain. The patient's mother states that she first noticed her son had a slight limp approximately one month ago. At this same time, the patient began to complain of pain in his left knee. The patient says that the pain is not relieved by rest and did not improve after taking ibuprofen. The patient and his mother have noticed no other symptoms. They both deny any history of injury at the time the pain started or any recent illnesses. Physical exam reveals limited range of motion of the left hip, including loss of abduction, flexion, and internal rotation. The patient keeps his left leg externally rotated when standing. All vital signs are within normal limits. The patient is 5'6" and weighs 170 lbs with a BMI of 27.4 kg/m2, placing him in the 96th percentile for his age. Which of the following is the most likely diagnosis?

Slipped Capital Femoral Epiphysis CORRECT! Slipped capital femoral epiphysis (SCFE) is a fracture through the growth plate resulting from instability of the proximal femoral growth plate leading to the femoral head slipping. This condition most commonly presents in male ages 10-17 years with a BMI > 95th percentile for their age. Patients commonly present with a limp and knee pain on the side of the affected hip that is not relieved with rest or pain medications. Physical exam will show loss of range of motion of the affected hip and pain in the hip from passive abduction and internal rotation. Based on this patient's history and physical exam, SCFE is the most likely diagnosis.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is caused by the compression of the posterior tibial nerve within the fibro-osseous canal and usually results from inflammatory arthritis, fibrosis, ganglionic cysts, fractures, or ankle edema. Patients with hypothyroidism are susceptible to tarsal tunnel syndrome due to perineural mucin deposits. Tarsal tunnel syndrome presents with pain in the plantar medial heel that can extend along the plantar surface until the toes. Pain including burning and tingling is worse when the patient stands or walks, but usually persists during rest. A positive Tinel's sign indicates tarsal tunnel syndrome. Other risk factors include obesity, diabetes, ankle sprain, hindfoot valgus, and scar tissue

A 25-year-old male is admitted to the inpatient service with a three-month history of intermittent diarrhea, cramping abdominal pain, and 10 pound weight loss. He also reports intermittent subjective fever and chills, but never took his temperature. Vital signs include pulse 70/min, blood pressure 115/85 mm Hg, respiratory rate 15/min, and temperature 37 C (98 F). Lungs are clear to auscultation bilaterally. Cardiac exam shows regular rate and rhythm. Abdominal exam reveals tenderness to palpation in all four quadrants without rebound or involuntary guarding. Rectal exam shows no lesions with normal sphincter tone. Stool is hemoccult negative. Colonoscopy shows intermittent changes in mucosa resembling cobblestone beginning at the ileocecal valve, and multiple biopsies are taken. Which of the following is expected on biopsy?

Transmural inflammation with lymphoid aggregates CORRECT! This patient is a classic presentation of Crohn's disease, with chronic abdominal pain, diarrhea, weight loss, and intermittent subjective fevers. Colonoscopy reveals skip lesions and cobblestoning of the mucosa. Biopsy will most often show transmural inflammation with lymphoid aggregates, but can also show granulomas and crypt abscesses dominated by lymphocytes.

A 45-year-old women presents with a 4 week history of severely painful toes on her right foot. She denies any trauma; she also denies any fever or chills. She has a past medical history of moderate psoriasis on her elbows and knees bilaterally, which has responded to topical corticosteroids and calcipotriene. She also has a history of irritable bowel disease, for which she is on fiber supplements. On physical exam, her 2nd and 3rd digits of the right foot are swollen and tender to palpation throughout. Erythema and swelling is noted over the length of the two toes, each resembling a sausage. Range of motion of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints in the right foot 2nd and 3rd digits is greatly reduced. Additionally it is noted that her vital signs are normal and that there is evidence of minimal hyperkeratosis on her bilateral elbows and knees. Which diagnostic test is the most likely to be helpful in the diagnosis of psoriatic arthritis?

X-RAY of the foot CORRECT! An x-ray of the foot could show the features typical of psoriatic arthritis: enthesitis resulting in peri-articular erosions and/or "pencil-in-cup" deformities.