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RheumatologyMain51-60Q1A66-year-oldasymptomaticwomancomestothephysicianforaroutinepreventiveexamination.Atherlastvisitayearago;shereceivedaninfluenzaandpneumococcalvaccineandhadanormalmammogram.Fouryearsago:shehadacolonoscopythatshowedonlyinternalhemorrhoids.HermedicalhistoryIssignificantforosteoarthritisandhypertension.Thepatienthadahysterectomywithremovalofthecervix17yearsagoformenorrhagiaandfibroids.Shehasa40-pack-yearsmokinghistoryanddrinkswineoccasionally.Examinationshowsnoabnormalities.Whichofthefollowingisthemostappropriatescreeningtestforthispatient?A.Chestx-rayB.ColonoscopyC.Dual-energyx-rayabsorptiometryofthespineandhipsD.PapsmearE.SerumcalciumandphosphorusF.X-rayofthepelvisandspineA1Correctanswer:CThiswoman,whoatage66hasasignificantsmokinghistoryandpriorhysterectomy,isatriskfordevelopingosteoporosisandshouldbescreenedwithdual-energyx-rayabsorptiometry(DEXA)ofthespineandhips.Byconvention,osteoporosisisdefinedasabonedensity2.5standarddeviationsbelowthemeanforayoungadultatpeakbonedensity(ie，T-score-1to-2.5)andisassociatedwithsignificantbonefragilityandriskoffracture.Abonedensityof1-2.5standarddeviationsbelowthemeanyoungadultreferencefie,T-score-1to-2.5)isconsideredosteopenia.ThemostimportantriskfactorforosteoporosisintheUnitedStatesispost-menopausaistate,withothersignificantriskfactorsincludingpoorcalcium/vitaminDintake,smoking,corticosteroiduserlackofweight-bearingexercise,lowbodymassindex,andheavyalcoholuse.Manyexpertgroups,includingtheUnitedStatesPreventiveServicesTaskForce,recommendinitialDEXAscreeningforosteoporosisInallwomenage≧65years,andscreeningcanbeconsideredforyoungerpatientswhohaveotherriskfactorsforosteoporosis.Recommendationsforfollow-upDEXAandscreeningintervalsvary.(ChoiceA)Chestradiographyhasbeenadvocatedasascreeningtestforlungcancerinpatientswithahistoryofsmokingbutisnolongerrecommendedasitdoesnotimprovesurvival.However,low-dosechestcomputedtomographyhasbeenshowntoimprovetheriskoflungcancerdeathinpatientswithasignificantsmokinghistory.(ChoiceB)Colonoscopyisarecommendedmodalityforcoloncancerscreening.Itshouldstartatage50forpeopleofnormalriskandberepeatedevery10yearsunlessthereIsevidenceofpolyps.Peoplewithhigh-riskpolypsshouldreceivefollow-upcolonoscopiesevery3-5years.Thiswomanhadnopolypsanddoesnotneedarepeatcolonoscopyforanother6years.(ChoiceD)Papsmearsdecreasetheriskofdevelopingcervicalcancerinyoungandmiddle-agedwomen.However,theIncidenceofcervicalcancerdeclineswithage,andwomenage65orwhohavehadtheircervixremovedforareasonotherthancancerdonotneedfurtherPapsmears.(ChoiceE)Serumcalciumandphosphorusarenormalinthevastmajorityofpatientswithosteoporosis.Measurementoftheseelectrolytesisnotusefulforscreeningpurposes.(ChoiceF)X-raysofthepelvisandspinemayrevealsignsofosteopenia,osteoporosis,orvertebralcompressionfractures.However,x-raysarelesssensitiveandspecificthanDEXAanddonotprovidequantitativedatatofollowthecourseofthedisease.Educationalobjective:TheUnitedStatesPreventiveServicesTaskForcerecommendsaone-timescreeningforosteoporosisinallwomenage≧65withdual-energyx-rayabsorptiometryscan.Earlierscreeningcanbeconsideredforwomenwithadditionalriskfactors.Protocolsforrepeatscreeningarenotwellestablished.Q2A65-year-oldmancomestotheclinicduetoleftthighpain.Thepainhasbeenpresentforseveralmonthswithconstantmoderateseverity.Thepatienthasnorecenthistoryoftrauma,andthereisnoassociatedweightchangeorlossofappetite.Medicalhistoryissignificantonlyforhighbloodpressure.Hedoesnotusetobacco,alcohol,orillicitdrugs.Temperatureis37.2℃(93.9℉)，bloodpressureis138/88mmHg，pulseis30/min,andrespirationsare12/min.Onexamination,thelowerbackandhipshavenoapparentdeformity,warmth,orerythema.Thereisnormal,pain-freerangeofmotionatthehip.Hisgaitismildlyantalgic.Lower-extremityreflexes,motorstrength,andsensationarenormal,andthepatienthasfullpedalpulses.Laboratoryresultsareasfollows:X-rayrevealscorticalthickeningintheleftfemur.Bonescintigraphyshowsincreasedradiotraceruptakeinseveralspots,includingtheleftfemur.Thispatientisathighestriskofdevelopingwhichofthefollowingcomplications?A.AcuterenalfailureB.HearinglossC.LivercirrhosisD.PulmonaryhemorrhageE.RenalcellcarcinomaF.SubarachnoidhemorrhageA2Correctanswer:BThispatientwithfocaibonepainandanelevatedalkalinephosphataselevelhastypicalfeaturesofPagetdiseaseofbone;acommondisorderinolderadults.Pagetdiseaseischaracterizedbyabnormalosteoclastactivityleadingtoincreasedboneturnoveranddisorderedboneremodeling.Typicalfindingsonimagingincludecorticalthickeningandosteolyticormixedlytic/scleroticlesionsonx-rayaswellasfocallyincreasedradiotraceruptakeonbonescan.PatientswithPagetdiseasecandevelopsymptomsduetofocalenlargement,weakness,orfractureofbone.Bowingoflongbonesrbonepain,andarthritisinadjacentjointsarecommon.Involvementofcranialbonesmaycausefrontalbossing,increasedhatsize,headaches,andcranialnervepalsies.Hearinglossmayoccurduetoenlargementofthetemporalboneandencroachmentonthecochlea.(ChoiceA)Multiplemyelomacancausebonepainandfocallyticlesions.Potentialcomplicationsincludeacuteandchronickidn