It's Rheumy in Here
Psychological Thrillers
Ur-ine Good Hands
Win in a Glandslide
Let's Get Physical
100
This environmental factor poses the highest risk for developing rheumatoid arthritis
What is Smoking?
Environmental factors are responsible for 40% of the risk for RA. One of the most provocative environmental factors is smoking.
Smoking can lead to lung inflammation, which activates enzymes (including PADI, the enzyme that deiminates arginine to form citrullinated peptides), and may promote local protein citrullination. Patients who smoke are at increased risk for RA, particularly those with a family history of RA, and should be counseled about smoking cessation. Exposure to silica dust has also been associated with increased risk.
100
A 56-year-old man is evaluated during a routine follow-up appointment. He has schizophrenia treated with olanzapine. Currently, the patient experiences no hallucinations or delusions. He is otherwise healthy. Previous ECGs have been normal.
On physical examination, vital signs are normal. BMI is 27. The examination shows flat affect. Speech is normal, and thoughts appear organized.
A fasting blood glucose measurement is pending.
Which of the following should also be monitored in this patient?
A. Complete blood count
B. Lipid levels
C. Liver chemistries
D. Prolactin level
E. QT interval
D. Lipid levels
The most common adverse effects of second-generation antipsychotic agents are weight gain (and sequelae of weight gain, such as hyperglycemia) and hyperlipidemia. The fasting blood glucose level should be measured upon initial medication initiation and at 3 months. Thereafter, the fasting glucose level should be checked at least annually. More frequent monitoring can be considered in patients with risk factors for diabetes.
Lipid monitoring should be performed at baseline, at 3 months, and at least every 5 years thereafter.
100
Once your patient with ESRD reaches this eGFR, you should consider referral for kidney transplant.
What is eGFR <30 mL/min/1.73 m2?
100
Hypercalcemia due to unregulated conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D may occur in this category of diseases.
*Hint: You will often see suppression of PTH in these cases.
What is Granulomatous Disease
Often associated with fungal infection, tuberculosis, sarcoidosis, and lymphoma. Vitamin D-dependent hypercalcemia is associated with normal to elevated serum phosphorus levels because vitamin D enhances intestinal absorption of phosphorus, and suppressed PTH secretion reduces kidney phosphorus excretion.
100
This physical exam finding can be seen in patients with diabetes.
What is Prayer Sign?
Can be a physical finding of diabetes, related to a condition called diabetic cheiroarthropathy. This results in stiffness of the joints preventing the fingers from opposing each other in a prayer position. This finding can also be seen in patients with sclerodactyly from systemic sclerosis.
200
A 25-year-old woman is evaluated for a 3-year history of joint pain involving her hands with more than 1 hour of morning stiffness. She also has intermittent photosensitive facial rash, fatigue, and intermittent subjective fever. On physical examination, vital signs are normal. There is tenderness to palpation with swelling of the second and third metacarpophalangeal joints bilaterally.
Complete blood count, serum creatinine level, and urinalysis are normal. Erythrocyte sedimentation rate is 35 mm/h (normal <20mm/h). Which of the following is the most appropriate diagnostic test to perform next?
A. Anti–double-stranded DNA antibodies
B. Antinuclear antibodies
C. Anti-Ro/SSA, anti-La/SSB antibodies
D. Anti-Smith antibodies
E. Anti–U1-ribonucleoprotein antibodies
B. Antinuclear antibodies
Antinuclear antibody (ANA) specificity or subserology testing (testing for antibodies to specific nuclear components) should be reserved for patients with a positive ANA result and a clinical syndrome suggesting an underlying connective tissue disease.
200
A 50-year-old man is evaluated for worsening depressive symptoms. He has major depressive disorder, which was previously well controlled with fluoxetine, 20 mg daily.
On physical examination, vital signs are normal. The patient appears anxious and tired. He becomes tearful when discussing his current situation.
Repeat score on PHQ-9 is 15; his previous score was 8. Which of the following is the most important next step in management?
A. Add olanzapine
B. Administer the Mood Disorder Questionnaire
C. Increase fluoxetine
D. Inquire about suicidal ideation
D. Inquire about suicidal ideation
Nearly 40% of patients who attempt suicide report being seen by a physician within 1 week of the attempt; failing to inquire about suicidal ideation is a missed opportunity to intervene in a potentially life-threatening situation. Patients can be screened with validated instruments, such as the Ask Suicide-Screening Questions tool.
Patients with positive or equivocal answers about suicidality require an immediate safety assessment and full mental health evaluation; this patient cannot leave until evaluated for safety.
200
This is the most likely cause of kidney failure following colonoscopy.
What is Phosphate-containing bowel prep (acute calcium phosphate crystal deposition in the kidneys)?
Treat with supportive care (fluids, stop ACE inhibitors, ARBs, NSAIDs)
200
Subclinical hyperthyroidism (suppressed thyroid-stimulating hormone (TSH) level, with normal free thyroxine (T4) and total triiodothyronine (T3) levels) should be treated if the TSH is <____ and if the patient has these features.
TSH levels less than 0.1 μU/mL
Treatment of subclinical hyperthyroidism is recommended for patients with serum TSH levels less than 0.1 μU/mL (0.1 mU/L) and with symptoms, cardiac risk factors, heart disease, or osteoporosis, as well as for postmenopausal women not taking estrogen therapy or bisphosphonates.
200
Young woman presents with fever and sore throat, showing this physical exam finding.
Palatal Petechiae
Highly specific for streptococcal pharyngitis
300
An 18-year-old woman is evaluated for a 1-week history of fever and diffuse myalgia, and pain and swelling in the hands and knees that have progressed over the last month. She also has acne. Current medications are minocycline, topical tretinoin, and an oral contraceptive.
On physical examination, temperature is 38.3 °C (100.9 °F); other vital signs are normal. She has synovitis in her hands and wrists and inflammatory acne on the face and upper back. Test results for antihistone and other specific autoantibodies are negative, and serum complement levels are normal.
Which of the following is the most likely diagnosis?
A. Drug-induced lupus erythematosus
B. Granulomatosis with polyangiitis
C. Rheumatoid arthritis
D. Systemic lupus erythematosus
A. Drug-induced lupus erythematosus
Drug-induced lupus is often milder than idiopathic systemic lupus erythematosus and is characterized by more skin and joint symptoms and a much lower risk for organ involvement or damage. Several medications, including minocycline, can cause drug-induced lupus erythematosus. Patients with drug-induced lupus erythematosus often have transiently positive antinuclear antibodies but may lack typical autoantibodies specific to SLE.
300
A 58-year-old woman is evaluated for follow-up of chronic insomnia. She has participated in cognitive behavioral therapy for insomnia; however, she continues to have difficulties maintaining sleep. After a discussion of risks and benefits and shared decision making, the patient has opted for a limited course of pharmacologic therapy for her insomnia. She has no other medical problems and takes no medications.
Which of the following is the most appropriate treatment?
A. Diphenhydramine
B. Doxepin
C. Trazodone
D. No pharmacologic treatment
B. Doxepin
The 2020 guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense recommends low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists (e.g., zolpidem, zaleplon, eszopiclone) in this situation.
Low-quality evidence shows improvement in subjective sleep latency, total sleep time, and sleep quality outcomes in patients receiving doxepin compared with placebo. For short-term use, there does not seem to be an increase in adverse events in patients taking doxepin compared with placebo.
300
A 42-year-old man is evaluated during a follow-up visit for recently confirmed primary hypertension. Hypertension was confirmed with multiple home blood pressure monitoring readings that averaged 148/98 mm Hg. Chlorthalidone was initiated 1 month ago, and home blood pressure monitoring showed readings above target despite adherence to lifestyle interventions and medication. He has no other medical problems and takes no other medication.
On physical examination, blood pressure is 144/94 mm Hg, and pulse rate is 72/min; other vital signs are normal. BMI is 22. The remainder of the examination is normal. Laboratory studies show a serum creatinine level of 1.0 mg/dL (88.4 µmol/L) and a serum potassium level of 3.5 mEq/L (3.5 mmol/L).
Which of the following is the most appropriate additional treatment?
A. Amlodipine
B. Doxazosin
C. Hydralazine
D. Metoprolol
A. Amlodipine
Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults with hypertension. According to the American College of Cardiology/American Heart Association guideline, four drug classes (thiazide diuretics, CCBs, ACE inhibitors, or ARBs) lower BP and reduce cardiovascular or renal outcomes. Except for the combination of ACE inhibitors and ARBs, regimens containing a combination of these classes are reasonable to achieve the BP target.
300
Screening for complications in patients with type 1 diabetes should begin this many years after diagnosis and should be performed this often thereafter.
Name the four complications you should screen for.
Screening for complications in patients with type 1 diabetes should begin 5 years after diagnosis and should be performed annually thereafter.
retinopathy (comprehensive eye examination)
nephropathy (albumin-to-creatinine ratio)
neuropathy (10 g monofilament, 128-Hz tuning fork, pedal pulses, and ankle reflex)
CVD (BP and fasting lipid profile measurements)
300
This is a previously healthy young man who presented with rapid weight gain (license photo taken 9 months prior), a buffalo hump, abdominal striae, easy bruising, and thin skin is displaying this physical exam finding in the photo below.
What is Moon Facies?
Patient was ultimately diagnosed with Cushing’s syndrome from an ectopic source of ACTH. Despite imaging, the source was never located and the patient ultimately underwent bilateral adrenalectomy.
400
This is the most common organism responsible for reactive arthritis
Chlamydia trachomatis
The most common organism responsible for reactive arthritis is Chlamydia trachomatis; 4% to 8% of infected patients develop reactive arthritis.
Other Pathogens:
Gastrointestinal pathogens include several species of Salmonella and Shigella, Campylobacter jejuni, and Yersinia species; reactive arthritis occurs in approximately 1% of infected individuals. Respiratory pathogens, including Chlamydia pneumoniae and Mycoplasma pneumoniae, are also known causes of reactive arthritis. Clostridioides difficile is an uncommon but important cause of reactive arthritis given its frequency in hospitalized patients. Approximately 1.4% of patients with C. difficile colitis will develop reactive arthritis.
400
A 28-year-old woman is evaluated for a 6-month history of amenorrhea. Medical history is significant for schizophrenia. Her only medication is risperidone.
On physical examination, vital signs are normal. BMI is 28. No breast discharge is evident.
Laboratory studies:
Estradiol 20 pg/mL
Follicle-stimulating hormone 1 mU/mL
Prolactin 150 ng/mL
Thyroid-stimulating hormone 2.2 μU/mL
MRI reveals a normal pituitary gland. Consultation with the patient's psychiatrist confirms that risperidone cannot be discontinued.
Which of the following is the most appropriate management?
A. Begin cabergoline
B. Begin estrogen -progesterone replacement therapy
C. Repeat pituitary MRI in 6 months
D. Repeat prolactin measurement in 6 months
B. Begin estrogen -progesterone replacement therapy
Up to 40% of patients taking typical antipsychotics will develop hyperprolactinemia because of the dopamine antagonist effect. Although medication-induced hyperprolactinemia most often results in prolactin levels of 25 to 100 ng/mL (25-100 μg/L), drugs such as metoclopramide, risperidone, and phenothiazines can lead to prolactin levels greater than 200 ng/mL (200 μg/L). If this patient's hyperprolactinemia remains untreated, she will continue to have amenorrhea and bone loss over time because of estrogen deficiency. Estrogen-progesterone replacement therapy is necessary to avoid the sequelae of estrogen deficiency.
400
This young man with testicular cancer who developed renal failure from cisplastin toxicity, then developed this physical exam finding as a result.
What is Uremic Frost?
A complication of severe azotemia, characterized by the presence of white-yellow crystalline material visualized on the skin. It occurs when urea and other nitrogenous waste that accumulate in sweat crystallize on the skin after evaporation
400
A previously healthy 28-year-old man is found unconscious on the ward where he works. His plasma glucose level is 28 mg/dL. He regains consciousness following IV glucose administration. Serum insulin level is elevated, and serum C-peptide level is low. This is the most likely cause of this episode.
What is surreptitious use of exogenous insulin
Remember, in cases of surreptitious use of oral hypoglycemic agents, patient has access to hypoglycemic agents and serum C-peptide levels are inappropriately elevated at time of hypoglycemia. Perform urine screen for sulfonylurea and meglitinide metabolites.
As opposed to surreptitious use of insulin, where the patient has access to insulin and serum C-peptide levels are low at time of hypoglycemia.
400
This is a middle-aged man with a history of non-Hodgkin’s lymphoma, with these marks on his chest.
What are Radiation Tattoos?
The presence of tattoo markers on the skin can be a helpful clue to previous external beam radiation therapy. Look for blue macules that are around 2-4 mm in size.
500
The American College of Rheumatology (ACR) strongly recommends initiating urate-lowering therapy for patients with a diagnosis of gout and any of the following:
(name at least 3)
- one or more subcutaneous tophi
- evidence of radiographic damage (any modality) attributable to gout (eg bone erosions with overhanging edges and a sclerotic rim; bone proliferation; joint space narrowing, which occurs late in the disease course; and soft-tissue masses, sometimes calcified, corresponding to soft-tissue tophi )
- > two or more flares annually
OR
For patients who are experiencing their first flare and
- have CKD stage 3 or greater
- a serum urate level exceeding 9.0 mg/dL (0.53 mmol/L)
- urolithiasis
500
This intranasal medication is approved as an adjunct to oral antidepressant agents for treatment-resistant* major depressive disorder and major depressive disorder with suicidal ideation.
*i.e. trialed on maximal combination oral therapy with a second-generation antidepressant (SGA) and an antipsychotic agent, as well as psychotherapy
What is Intranasal Esketamine
Esketamine is a glutamate receptor modulator, which offers a novel mechanism of action for depression treatment.
Unlike most other antidepressant therapies, treatment effect is almost immediate; however, there are several barriers to its use. Labeling indications restrict the drug to patients whose symptoms have failed to respond to two courses of appropriately prescribed antidepressant therapy
500
A 54-year-old woman is evaluated for a 4-week history of dyspnea on exertion, malaise, fatigue, and anorexia. History is significant for hypertension, gout, and osteoarthritis. Medications are losartan, hydrochlorothiazide, allopurinol, naproxen, and aspirin. On physical examination, blood pressure is 148/84 mm Hg, and pulse rate is 98/min; other vital signs are normal. Conjunctivae are pale. There is 2+ edema of the ankles.
Hemoglobin 8.0 g/dL (80 g/L)
Albumin 3.0 g/dL (30 g/L)
Creatinine 2.2 mg/dL (194.5 µmol/L); 3 weeks ago: 1.2 mg/dL (106.1 µmol/L)
Total protein 8.4 g/dL (84 g/L)
Urate 7.0 g/dL (0.41 mmol/L)
Urinalysis 1+ protein; 2-5 granular casts/hpf; 1-2 erythrocytes/hpf
Urine protein-creatinine ratio 6100 mg/g
Which of the following is the most likely diagnosis?
A. Light chain cast nephropathy
B. NSAID-induced acute tubular injury
C. Renal sarcoidosis
D. Uric acid nephropathy
A. Light chain cast nephropathy
Clinical clues to the diagnosis of light chain cast nephropathy from multiple myeloma include an elevated urine protein-creatinine ratio with minimal proteinuria by urine dipstick, anemia, and hypercalcemia.
500
Gynecomastia is caused by proliferation of glandular tissues in the male breast because of an increase in the ratio of estrogen to androgen. Diagnosis is confirmed by finding subareolar glandular tissue >0.5 cm in diameter and is usually bilateral. Causes include… (name at least 4)
medications (spironolactone, cimetidine, antiandrogens, 5α-reductase inhibitors, protease inhibitors)
opioid use
cirrhosis, CKD
hypogonadism, hyperthyroidism
germ cell tumors
500
This is a young woman who was admitted to the hospital with delirium following months of fatigue, weight gain and constipation, exhibiting this physical exam finding.
What is Queen Anne’s Sign?
Thinning of the eyebrows, particularly the lateral third (also known as the Sign of Hertoghe) seen in hypothyroidism.