Rheumatology Main風(fēng)濕病 11-20

Rheumatology Main11-20,Q 1,A 35-year-old man comes to the office for foilow-up of low back pain. He has aching pain in the left lumbar paraspinal area that is worse at the end of the day and relieved overnight with rest. The pain began 3 months ago without any precipitating trauma. The patient was initially treated with intermittent doses of acetaminophen and naproxen but continues to have moderate residual pain. There is no associated fever weight loss: radicular pain, lower extremity weakness, or urinary symptoms. His medical history is unremarkable. The patient is employed as a factory line worker, which requires him to lift 5-7 kg (11-15 lb) several times daily. On physical examination, vital signs are normal and the patient appears comfortable. Cervical and thoracic spine range of motion is normal, but flexion and extension of the lumbar spine elicits pain. Straight leg raising test is normal. There is mild tenderness in the left lumbar paraspinal tissues but no midline tenderness. Upper and lower extremity strength and deep tendon reflexes are normal. Which of the following is the best recommendation for management of this patients pain?A.Discontinue working until the pain is resolved B.Epidural glucocorticoid injection C.Exercise therapy D.Lumbar support brace E.Spinal manipulation therapy,A 1,Correct answer: CThis patient has uncomplicated chronic (12 weeks) low back pain (LBP). Patients with acute (40, and presents with pain and stiffness of the knee joint. Examination findings include crepitus and bony tenderness at the medial joint line. X-ray of the knee will reveal narrowing of the joint space and osteophyte formation.(Choice C) Patellofemoral syndrome causes anterior knee pain and is most common in women. Patients present with perSpatellar pain worsened by activity or prolonged sitting (due to sustained flexion) and may also have crepitus with motion of the patella.(Choice E) Prepatellar bursitis presents with pain and swelling directly over the patella, usually following trauma. Examination shows cystic swelling over the patella with variable signs of inflammation.Educational objective:Pes anserinus pain syndrome presents with sharp, localized pain and tenderness over the anteromedial part of the tibial plateau just below the joint line of the knee. Valgus stress test will not aggravate the painr and x-rays will appear normal.,Q 6,A 43-year-old man comes to the office due to pain in his right hand. He has had symptoms intermittently for the last 5 years: but they have become worse over the last 3 months. The pain radiates to the anterior aspect of the forearm. His medical history is notable for type 2 diabetes mellitus. and his most recent hemoglobin A1c is 8.5%. The patient does not use tobacco, alcohol, or illicit drugs. He works as an assistant manager at a supermarket. Blood pressure is 143/95 mm Hg: pulse is 76/min: and respirations are 12/min. BMI is 32 kg/. On examination, the patient is mildly obese but otherwise appears comfortable. There is weakness of thumb opposition and slightly decreased light touch sensation over the palmar surface of the first 3 digits. Which of the following is the most likely cause of this patients hand symptoms?A. Anatomic compression of nerveB.Glycosylation of proteins in vasa nervorumC.Motor neuron degenerationD. Neuronal destruction in sensory ganglia E T cell-mediated immune response F Vasoconstriction of arterioles,A 6,Correct answer: AThis patient has clinical features of advanced carpal tunnel syndrome (CTS). CTS is caused by compression of the median nerve as it passes deep to the flexor retinaculum in the wrist. Conditions that cause swelling of the flexor tendons or fibrosis or edema of the surrounding soft tissues can reduce the available space for the median nerve and lead to compressive neuropathy. Common risk factors include obesity, diabetes, hypothyroidism, and pregnancy. Although CTS is frequently reported in occupations requiring prolonged typing or computer work, current evidence for a causative link between CTS and light-duty office work is conflicting.Manifestations of CTS include pain/tenderness and numbness/decreased sensation in a median nerve distribution (eg: first 3.5 digits). The pain can radiate to the palm, wrist, and forearm, but because the palmar branch of the median nerve enters the hand outside the carpal tunnel, sensation In the proximal part of the palm (eg. thenar eminence) is intact. In advanced cases, denervation atrophy in the median nerve distribution, including thenar atrophy, can be seen, with weakness of the muscles of the thenar eminence (eg, weakness in thumb abduction and opposition).(Choice B) Diabetic peripheral neuropathy can cause pain in the distal extremities. However, it usually occurs in patients with long-standing, poorly controlled diabetes and typically begins in the feet.(Choice C) Motor neuron degeneration (eg, amyotrophic lateral sclerosis) can cause asymmetric weakness and atrophy in distal muscles. However, pain is not typical, and the course Is most often progressive rather than intermittent.(Choice D) Shingles is due to reactivation of the varicella zoster virus in a dorsal root ganglion, resulting in a vesicular rash in a dermatomal distribution. Patients may develop persistent hypersensitivity of afferent pain fibers (post-herpetic neuralgia), but motor function is normal,(Choice E) Guillain-Barre syndrome is caused by segmental demyelination of peripheral nerves due to infiltrating T lymphocytes and macrophages. Symptoms include symmetrical weakness that starts in the lower extremities and moves upward.(Choice F) Raynaud disease (cold-induced digital vasospasm) causes pain in the hands but is typically associated with sharply demarcated color changes.Educational objective:Carpal tunnel syndrome is caused by compression of the median nerve as it passes deep to the flexor retinaculum in the wrist. Risk factors include obesity, diabetes, hypothyroidism, and pregnancy. Symptoms Include pain and numbness in a median nerve distribution with thenar atroohv in severe cases,Q 7,A 45-year-old woman comes to the office with a several-month history of intermittent pain and numbness in the right hand. The symptoms occur primarily at night and occasionally wake her from sleep. Shaking her hands or holding them in a dependent position briefly relieves the pain. The patients medical history is notable for hypothyroidism, for which she takes L-thyroxine. She works as a scientific editor. The patient has a 20-pack-year smoking history but does not use alcohol or illicit drugs. Vital signs are normal. BMI is 36 kg/. On examination, there is normal range of motion in the wrists and digits.Sensation is decreased to pinprick in the thumb and index finger. Biceps, triceps, and brachioradialis reflexes are normal. There is no muscle atrophy, and the remainder of the examination is normal. Which of the following is the most appropriate next step to confirm the diagnosis in this patient?A.Chest x-ray B.Electromyography C.MRI of the cervical spine D.Nerve conduction studies E.X-ray of the hands,A 7,Correct answer:DThe carpal tunnel is an anatomic space in the wrist defined by the carpal bones and the transverse carpal ligament. It contains the median nerve along with the tendons of the flexor digitorum profundus, flexor digitorum superficial, and flexor pollicis longus. Compression of the median nerve causes carpal tunnel syndrome (CTS), characterized by pain and paresthesias in the first 3 digits and the radial half of the fourth. These symptoms are often worse at night. Motor involvement in severe cases can cause weakness of thumb abduction and opposition, and atrophy of the thenar eminence.This patient has sensory deficits In the distribution of the median nerve and multiple risk factors for CTS (female sex, obesity, and hypothyroidism). The diagnosis is usually made on clinical grounds. During examination, tapping over the median nerve at the wrist (Tinel sign) or holding the wrists in extreme flexion with the dorsum of the hands pressed together (Phalen test) can often reproduce the symptoms. However, if the diagnosis is uncertain (or severe symptoms prompt consideration for surgery), CTS can be confirmed with nerve conduction studies, which will show slowing in the median nerve at the wrist.(Choice A) Superior extension of an apical iung mass can cause a brachial plexopathy, occasionally causing symptoms in a median nerve distribution. However, most cases will have other features, Including shoulder pain or neurologic deficits in additional nerve distributions.(Choice B) Electromyography is not