Painful Hand Case! - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 2 CK Forum

USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 06-18-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Question Painful Hand Case!

This 54-year-old woman from the Philippines complains of bumps on her hands that keep getting bigger, and they seem to be spreading. She is very worried. The bumps become painful and red at times. There are also bumps on her toes and elbows. She is postmenopausal and on hydrochlorothiazide for her high blood pressure. Her hands are shown in the figure. What is the best treatment for her condition?

Painful Hand Case!-hand.jpg
click image to enlarge


Answer Choices
A. Allopurinol
B. Colchicine
C. Injection of corticosteroids
D. Prednisone
E. Surgical removal
Reply With Quote Quick reply to this message



  #2  
Old 06-18-2011
aksyonez's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 218
Threads: 74
Thanked 115 Times in 64 Posts
Reputation: 127
Default

Gonna guest A. Allopurinol
Reply With Quote Quick reply to this message
  #3  
Old 06-18-2011
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 132
Threads: 1
Thanked 120 Times in 51 Posts
Reputation: 130
Default

Looks like hyperuricemia caused by the thiazide diuretic,leading to gout.

Since the acute attack involves multiple joints,i would go with oral prednisone.
Reply With Quote Quick reply to this message
  #4  
Old 06-18-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default case 2

A 61-year-old man is brought into the emergency department 2 days after initiating chemotherapy for non-Hodgkin lymphoma. He has a exquisitely painful right ankle that is hot and swollen. It appeared suddenly 3 hours ago and he cannot walk because of it. Arthrocentesis of the ankle joint is performed and reveals monosodium urate crystals. What therapeutic agent would most likely have prevented this patient's present symptoms?

Answer Choices
A. Allopurinol
B. Colchicine
C. Indomethacin
D. Oral prednisone
E. Probenecid
Reply With Quote Quick reply to this message
  #5  
Old 06-18-2011
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 132
Threads: 1
Thanked 120 Times in 51 Posts
Reputation: 130
Default

A. Allopurinol
Reply With Quote Quick reply to this message
  #6  
Old 06-18-2011
USMLE Forums Addict
 
Steps History: Not yet
Posts: 192
Threads: 0
Thanked 47 Times in 40 Posts
Reputation: 57
Default

Steroids taken by mouth may be used for patients who cannot take NSAIDs or colchicine and who have gout in more than one joint..so my option is D
Reply With Quote Quick reply to this message
  #7  
Old 06-18-2011
1TA2B's Avatar
USMLE Forums Guru
 
Steps History: CK Only
Posts: 475
Threads: 39
Thanked 351 Times in 169 Posts
Reputation: 374
Default

This is acute gouty arthritis.

I would go with C. Indomethacin.

General rules are


1. NSAID's first choice
2. Cochicine more specific, more toxic too (anti-inflammatory, not analgesics)
3. Corticosteroids helpful for some

http://www.medscape.com/viewarticle/406509_6
__________________
Skill+Hardwork+Preparation=Success
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

Reply With Quote Quick reply to this message
  #8  
Old 06-18-2011
USMLE Forums Addict
 
Steps History: Not yet
Posts: 192
Threads: 0
Thanked 47 Times in 40 Posts
Reputation: 57
Default

i think allopurinol prevents gout
Reply With Quote Quick reply to this message
  #9  
Old 06-18-2011
1TA2B's Avatar
USMLE Forums Guru
 
Steps History: CK Only
Posts: 475
Threads: 39
Thanked 351 Times in 169 Posts
Reputation: 374
Default

Chronic tophaceous gout.

A. allopurinol
__________________
Skill+Hardwork+Preparation=Success
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

Reply With Quote Quick reply to this message
  #10  
Old 06-18-2011
aksyonez's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 218
Threads: 74
Thanked 115 Times in 64 Posts
Reputation: 127
Default

Case 2

Answer : A
Sounds like Acute tumor lysis syndrome . Allopurinol should have been given as prevention.
Reply With Quote Quick reply to this message
  #11  
Old 06-19-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default

Option A (Allopurinol) is correct. This is the only treatment that will attempt to decrease her uric acid load and melt away the tophi. She should also be taken off the diuretics and treated with something else for her hypertension because diuretics will add to the formation of tophi and gout in this woman.

Option B (Colchicine) is incorrect. This is good for acute gout but does nothing for tophaceous disease.

Option C (Injection of corticosteroids) is incorrect. Corticosteroids may alleviate pain but will not decrease her uric acid load and reduce the tophi. There are too many tophi to inject.

Option D (Prednisone) is incorrect. This will not help with the underlying problem and may present more problems in this postmenopausal hypertensive woman.

Option E (Surgical removal) is incorrect. The tophi will return even after surgery.

High-yield Hit 1
Gout
This acute inflammatory crystal arthropathy is caused by the deposition of urate crystal in joints and soft tissues as a result of hyperuricemia. It affects 0.3% of the population, and it is largely confined to men (90%) although some women develop the condition post menopausally. It can present at any time between the ages of 20 and 60 years of age.
Etiology-Uric acid is normally derived from the breakdown of purines, and it is excreted in the urine. Increased concentrations of serum uric acid (hyperuricemia) can result in gout.
There are two main causes of hyperuricemia:
Underexcretion of uric acid (most common): of uncertain origin but clinically associated with hyperlipidemia, renal failure, lactic acidosis (alcohol, exercise, starvation, vomiting), and thiazide diuretics.
Overproduction of uric acid (least common): a result of either high cell turnover (e.g., leukemia, chemotherapy, severe psoriasis, post trauma, surgery, or severe systemic illness), or rare congenital enzyme defects of purine metabolism.
However, it should be noted that the majority of patients who have a raised blood uric acid level will never develop gout or any of its complications. The condition has a familial tendency, and it is believed to be polygenically inherited.
Pathogenesis-Gout affects the joints, soft tissues, and kidney, as discussed below.
Joints-Urate crystals are deposited in certain joints, forming white powdery deposits on the surface of articular cartilage, beneath which degenerative changes can be seen. Crystal deposition stimulates an acute inflammatory reaction leading to the excruciating pain, edema, and redness seen in the acutely inflamed joint. Microscopically, neutrophil polymorphs can be seen to phagocytose urate crystal in the joint fluid.
Soft tissues-Uric acid crystals are also deposited in the soft tissues around joints, where their presence excites a foreign body, giant cell reaction. These soft tissue masses may enlarge to produce a palpable mass composed of white chalky material (tophi), especially around the pinna of the ear.
Kidney-Urate crystals deposited in the kidney may lead to an interstitial nephritis and to renal calculi composed of uric acid. Precipitation of urates in renal tubules may produce acute tubular necrosis and acute renal failure in leukemic patients, with massive purine release after chemotherapy.
Characteristics of gout are:
Intermittent attacks of excruciating pain, edema, and redness (acute gouty arthritis).
Monoarthropathy (90%); polyarthropathy (two or more affected joints; 10%).
Metatarsophalangeal joint of the big toe is most commonly affected (75%), but gout occasionally affects the ankle, or less commonly the knee and hip.
Recurrent attacks affecting the same joint eventually lead to articular cartilage destruction, chronic synovial thickening, and secondary osteoarthritis-chronic gouty arthritis.
Diagnosis:
Clinical features (as above).
Raised serum urate level (>0.480 μmol/L in adult males; >0.390 μmol/L in adult females).
Presence of crystals of sodium urate in aspirated synovial fluid from joint (detected with polarizing light).
Management-Analgesia for acute attacks: NSAIDs (e.g., indometacin) and colchicine. Preventative measures required for patients with recurrent attacks of gouty arthritis or associated renal disease:
Allopurinol: suppresses uric acid synthesis by inhibiting xanthine oxidase.
Uricosuric agents (e.g., probenecid).
Diet: excessive purine intake and overindulgence in alcohol should be avoided.
Prognosis-Some patients have only a single attack or suffer another only after an interval of many years. More often there is a tendency toward recurrent attacks that increase in frequency and duration so that, eventually, attacks merge and the patient remains in a prolonged state of subacute gout.
Reply With Quote Quick reply to this message
The above post was thanked by:
Abdulhakeem (06-19-2011), Dr.Lacune (08-02-2012), skido (06-20-2011), tangled (06-22-2011)
  #12  
Old 06-19-2011
kemoo's Avatar
USMLE Forums Guru
 
Steps History: 1+CK+CS
Posts: 378
Threads: 161
Thanked 102 Times in 51 Posts
Reputation: 116
Default

Quote:
Originally Posted by miss patho View Post
This 54-year-old woman from the Philippines complains of bumps on her hands that keep getting bigger, and they seem to be spreading. She is very worried. The bumps become painful and red at times. There are also bumps on her toes and elbows. She is postmenopausal and on hydrochlorothiazide for her high blood pressure. Her hands are shown in the figure. What is the best treatment for her condition?

Attachment 1573
click image to enlarge


Answer Choices
A. Allopurinol
B. Colchicine
C. Injection of corticosteroids
D. Prednisone
E. Surgical removal
you mention that bumps painful and red , does this mean acute ??

what about answer also of case number 2??

thanks for these useful questions
Reply With Quote Quick reply to this message
  #13  
Old 06-20-2011
drnirajmavani's Avatar
USMLE Forums Veteran
 
Steps History: Step 1 Only
Posts: 268
Threads: 14
Thanked 103 Times in 69 Posts
Reputation: 113
Question

i agree wid kemoo....i was thinking of colchicine because u mentioned became painful nd red at times....nd isnt colchicine /nsaids r d drugs of choice in acute gouty arthritis...??
Reply With Quote Quick reply to this message
  #14  
Old 06-20-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default

Quote:
Originally Posted by miss patho View Post
A 61-year-old man is brought into the emergency department 2 days after initiating chemotherapy for non-Hodgkin lymphoma. He has a exquisitely painful right ankle that is hot and swollen. It appeared suddenly 3 hours ago and he cannot walk because of it. Arthrocentesis of the ankle joint is performed and reveals monosodium urate crystals. What therapeutic agent would most likely have prevented this patient's present symptoms?

Answer Choices
A. Allopurinol
B. Colchicine
C. Indomethacin
D. Oral prednisone
E. Probenecid
Option A (Allopurinol) is correct. This patient has tumor lysis syndrome causing gout, which can be a common occurrence 48 hours after initiation of chemotherapy for highly sensitive tumors, particularly high-grade non-Hodgkin lymphoma. The lysis of tumor cells causes release of nucleic acid prunes, which are converted to uric acid by xanthine oxidase. Allopurinol is a xanthine oxidase inhibitor, which prevents production of uric acid and is considered first-line prophylaxis against tumor lysis syndrome.

Option B (Colchicine) is incorrect. Colchicine acts by inhibiting leukocyte migration. This can be used to prevent gout, but because the pathophysiologic mechanism is high levels of serum uric acid, the goal is to prevent this, rather than events triggered by high levels of serum uric acid.

Option C (Indomethacin) is incorrect. Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID). It is considered first-line therapy for acute gout because of its ability to act rapidly. Other NSAIDs are also useful in the acute management. They would not necessarily be useful in this particular case, because of the high levels of uric acid in the blood.

Option D (Oral prednisone) is incorrect. Oral steroids are considered secondary therapy for gout and may be useful when there is polyarticular involvement.

Option E (Probenecid) is incorrect. Probenecid is a uricosuric drug that increases renal uric acid excretion. It is used as prophylaxis in patients who under excrete uric acid. In this particular case, the therapeutic principle is to prevent build up of uric acid in the blood, rather than try to eliminate it.

High-yield Hit 1
High-Grade NHL.
The two high-grade subtypes, Burkitt's or small non-cleaved cell and lymphoblastic lymphoma, are quite rare in the adult population. Nonetheless, these subtypes are important because they are potentially curable with appropriate therapy and often require urgent, inpatient treatment at the time of diagnosis because of their highly aggressive nature, rapid growth, and tumor lysis on initiation of therapy. Lymphoblastic lymphoma is an aggressive lymphoma that is closely related to T-cell acute lymphocytic leukemia and readily distinguished from most NHLs by its T-cell immunophenotype and the presence of terminal deoxynucleotide transferase. It usually afflicts young adult males and involves the mediastinum and bone marrow, with a propensity to relapse in the leptomeninges. Burkitt's, or small non-cleaved cell, lymphoma is a rare B-cell lymphoma in adults that is highly aggressive, with a propensity to involve the bone marrow and central nervous system. Burkitt's lymphoma is characterized cytogenetically by the pathognomonic t(8;14) translocation that juxtaposes the Ig locus with the myc oncogene. In central Africa, where Burkitt's lymphoma is endemic in children, it is usually associated with EBV, but in the United States it is uncommon for sporadic Burkitt's lymphoma to be EBV positive. Burkitt's lymphoma and lymphoblastic lymphomas both require treatment with intensive multiagent chemotherapy, including intrathecal chemotherapy to prevent leptomeningeal relapse. These lymphomas undergo rapid tumor lysis on initiation of chemotherapy, and it is imperative that all patients receive prophylaxis against tumor lysis syndrome before and during their first course of chemotherapy. Prophylaxis includes hydration, alkalinization of the urine, and allopurinol.

From Cecil Essentials of Medicine 6E by Andreoli et al
High-yield Hit 2
GOUT
Gout is a disorder caused by the tissue accumulation of excessive amounts of uric acid, an end product of purine metabolism. It is marked by recurrent episodes of acute arthritis, sometimes accompanied by the formation of large crystalline aggregates termed tophi, and chronic joint deformity. All of these result from precipitation of monosodium urate crystals from supersaturated body fluids into the tissues. Although an elevated level of uric acid is an essential component of gout, not all individuals with hyperuricemia develop gout, indicating that factors in addition to hyperuricemia must play some role in the pathogenesis of the disorder. Gout is traditionally divided into primary and secondary forms, accounting for about 90% and 10% of cases, respectively. The term primary gout is used to designate cases in which the basic cause is unknown or, less commonly, when the cause is an inborn metabolic abnormality characterized primarily by hyperuricemia and gout. In the remaining cases, termed secondary gout, the cause of the hyperuricemia is known but gout is not the main or dominant clinical disorder. The major categories of gout are listed in Table 21-3.
Reply With Quote Quick reply to this message
  #15  
Old 08-02-2012
Dr.Lacune's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 207
Threads: 38
Thanked 115 Times in 45 Posts
Reputation: 125
Search

Quote:
Originally Posted by miss patho View Post
Option A (Allopurinol) is correct. This patient has tumor lysis syndrome causing gout, which can be a common occurrence 48 hours after initiation of chemotherapy for highly sensitive tumors, particularly high-grade non-Hodgkin lymphoma. The lysis of tumor cells causes release of nucleic acid prunes, which are converted to uric acid by xanthine oxidase. Allopurinol is a xanthine oxidase inhibitor, which prevents production of uric acid and is considered first-line prophylaxis against tumor lysis syndrome.

Option B (Colchicine) is incorrect. Colchicine acts by inhibiting leukocyte migration. This can be used to prevent gout, but because the pathophysiologic mechanism is high levels of serum uric acid, the goal is to prevent this, rather than events triggered by high levels of serum uric acid.

Option C (Indomethacin) is incorrect. Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID). It is considered first-line therapy for acute gout because of its ability to act rapidly. Other NSAIDs are also useful in the acute management. They would not necessarily be useful in this particular case, because of the high levels of uric acid in the blood.

Option D (Oral prednisone) is incorrect. Oral steroids are considered secondary therapy for gout and may be useful when there is polyarticular involvement.

Option E (Probenecid) is incorrect. Probenecid is a uricosuric drug that increases renal uric acid excretion. It is used as prophylaxis in patients who under excrete uric acid. In this particular case, the therapeutic principle is to prevent build up of uric acid in the blood, rather than try to eliminate it.

High-yield Hit 1
High-Grade NHL.
The two high-grade subtypes, Burkitt's or small non-cleaved cell and lymphoblastic lymphoma, are quite rare in the adult population. Nonetheless, these subtypes are important because they are potentially curable with appropriate therapy and often require urgent, inpatient treatment at the time of diagnosis because of their highly aggressive nature, rapid growth, and tumor lysis on initiation of therapy. Lymphoblastic lymphoma is an aggressive lymphoma that is closely related to T-cell acute lymphocytic leukemia and readily distinguished from most NHLs by its T-cell immunophenotype and the presence of terminal deoxynucleotide transferase. It usually afflicts young adult males and involves the mediastinum and bone marrow, with a propensity to relapse in the leptomeninges. Burkitt's, or small non-cleaved cell, lymphoma is a rare B-cell lymphoma in adults that is highly aggressive, with a propensity to involve the bone marrow and central nervous system. Burkitt's lymphoma is characterized cytogenetically by the pathognomonic t(8;14) translocation that juxtaposes the Ig locus with the myc oncogene. In central Africa, where Burkitt's lymphoma is endemic in children, it is usually associated with EBV, but in the United States it is uncommon for sporadic Burkitt's lymphoma to be EBV positive. Burkitt's lymphoma and lymphoblastic lymphomas both require treatment with intensive multiagent chemotherapy, including intrathecal chemotherapy to prevent leptomeningeal relapse. These lymphomas undergo rapid tumor lysis on initiation of chemotherapy, and it is imperative that all patients receive prophylaxis against tumor lysis syndrome before and during their first course of chemotherapy. Prophylaxis includes hydration, alkalinization of the urine, and allopurinol.

From Cecil Essentials of Medicine 6E by Andreoli et al
High-yield Hit 2
GOUT
Gout is a disorder caused by the tissue accumulation of excessive amounts of uric acid, an end product of purine metabolism. It is marked by recurrent episodes of acute arthritis, sometimes accompanied by the formation of large crystalline aggregates termed tophi, and chronic joint deformity. All of these result from precipitation of monosodium urate crystals from supersaturated body fluids into the tissues. Although an elevated level of uric acid is an essential component of gout, not all individuals with hyperuricemia develop gout, indicating that factors in addition to hyperuricemia must play some role in the pathogenesis of the disorder. Gout is traditionally divided into primary and secondary forms, accounting for about 90% and 10% of cases, respectively. The term primary gout is used to designate cases in which the basic cause is unknown or, less commonly, when the cause is an inborn metabolic abnormality characterized primarily by hyperuricemia and gout. In the remaining cases, termed secondary gout, the cause of the hyperuricemia is known but gout is not the main or dominant clinical disorder. The major categories of gout are listed in Table 21-3.

Thanks for that nice explanation, I totally agree with u that is tumor lysis syndrome, but for the sake of the usmle, I think colchicine is for acute attack no matter the reason. Would you agree?
__________________
IT IS GETTING INTENSE !!
Reply With Quote Quick reply to this message



  #16  
Old 08-04-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 720
Threads: 217
Thanked 551 Times in 308 Posts
Reputation: 561
Default

Allopurinol can be given as treatment of acute goute. ?
Reply With Quote Quick reply to this message



Reply

Tags
Internal-Medicine-, Rheumatology-, Step-2-Questions

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
Painful Area Examination in the CS GVVdoc USMLE Step 2 CS SP Challenges 9 01-22-2014 09:23 PM
X-ray in a case of limpy, painful leg 1TA2B USMLE Step 2 CK Forum 5 04-26-2011 04:01 PM
Painful Breast Lump? mosallam USMLE Step 2 CK Forum 10 02-20-2011 10:19 AM
Painful Vesicle Yallah USMLE Step 1 Forum 2 06-25-2010 07:25 PM
Moving a painful limb Adamu2010 USMLE Step 2 CS Forum 2 03-13-2010 11:40 AM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)