NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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January 14, 2025
MKSAP 19 General Internal Medicine 2, Question 26
Stem:
A 45-year-old woman is evaluated for 4-month history of persistent rhinorrhea, frontal headache, loss of smell, and malaise. She has self-treated with saline irrigation and antihistamine/decongestants.
On physical examination, vital signs are normal. Nasal turbinates are swollen, and thick yellow nasal discharge is noted. Maxillae and forehead are tender to palpation. The remainder of the examination is normal.
Which of the following is the most appropriate diagnostic test to perform next?
A. CT of the sinuses
B. MRI of the sinuses
C. Nasal swabbing for culture
D. Plain radiography of the sinuses
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: A. CT of the sinuses
Educational Objective:
Evaluate a patient with suspected chronic sinusitis.
The most appropriate diagnostic test to perform next is CT of the sinuses (Option A). Chronic sinusitis manifests with at least 12 weeks of nasal congestion with purulent drainage, diminished sense of smell, or facial pain/pressure. It may be associated with nasal polyposis (with a strong association with asthma). Demonstration of mucosal involvement by nasal endoscopy or imaging (typically CT) is necessary for diagnosis. The findings most commonly seen on CT scan include mucosal thickening, sinus ostial obstruction, polyps, and sinus opacification. Treatment includes glucocorticoids and antibiotics. CT without contrast is the most commonly used imaging modality for the diagnosis of chronic sinusitis.
Although mucosal disease can be demonstrated with MRI (Option B), CT has higher resolution and better diagnostic accuracy for mucosal disease and sinus ostial occlusion. In addition, MRI is more costly than CT and does not provide a more accurate diagnosis. MRI should be considered when there is suspicion for infection or inflammation that extends beyond the sinus cavities.
The possibility of infection with unusual or resistant organisms is suggested by the persistence of symptoms despite previous antibiotic therapy. In this case, it is important to obtain bacterial and/or fungal cultures directly from the sinus via nasal endoscopy or by sinus puncture. Nasal swabs (Option C) are inadequate because they do not accurately predict the infecting organism and cannot be used to guide therapy. This patient has no indication for bacterial and/or fungal culture at this time.
Findings on CT may suggest the need for more aggressive evaluation.
Plain radiography of the sinuses (Option D) may show changes suggestive of chronic sinusitis, including sinus opacification and mucosal thickening. These findings, however, are nonspecific. Furthermore, plain radiography lacks sufficient sensitivity to determine the presence or extent of potential bony erosion by infection.
Key Points
Patients with chronic sinusitis, characterized by nasal congestion, purulent rhinorrhea, and headache for more than 12 weeks, should undergo either nasal endoscopy or CT of the sinuses for diagnostic purposes.
In patients with chronic sinusitis, the findings most commonly seen on CT include mucosal thickening, sinus ostial obstruction, polyps, and sinus opacification.
Bibliography
Kwah JH, Peters AT. Nasal polyps and rhinosinusitis. Allergy Asthma Proc. 2019;40:380-4. PMID: 31690375 doi:10.2500/aap.2019.40.4252
Copyright 2019, American College of Physicians.
December 31, 2024
MKSAP 18 Rheumatology Question 35
Stem:
A 73-year-old woman is evaluated for a 10-year history of osteoarthritis affecting multiple joints over the years, including the distal joints of her fingers, bases of the thumbs, knees, and cervical and lower lumbar spines. She has chronic daily pain in at least one joint. She has tried nonpharmacologic measures, and she had minimal benefit from intra-articular glucocorticoid and hyaluronic acid injections to her knees. She was recently diagnosed with peptic ulcer disease. History is also significant for coronary artery disease, diabetes mellitus, and hypertension. Medications are enalapril, carvedilol, metformin, atorvastatin, pantoprazole, and low-dose aspirin.
On physical examination, vital signs are normal. Heberden nodes and squaring of the bilateral carpometacarpal joints are present. Crepitus and limited extension of the cervical spine are noted. Bilateral knee varus deformity and bony enlargement are present, with crepitus on range of motion.
Which of the following is the most appropriate treatment?
A. Duloxetine
B. Gabapentin
C. Ibuprofen
D. Topical capsaicin
Responses Received from Members (769 Responses):
The Correct Answer is: A. Duloxetine
Educational Objective
Treat osteoarthritis with duloxetine.
Critique
Duloxetine, a serotonin and norepinephrine reuptake inhibitor with central nervous system effects, is a good treatment option for this patient with generalized osteoarthritis (OA). Duloxetine is FDA approved for chronic musculoskeletal pain and has been shown to have analgesic efficacy for chronic low back pain and knee OA pain, implicating the role of central sensitization in OA pain modulation. This patient has already tried multiple nonpharmacologic measures, as well as intra-articular glucocorticoid and hyaluronic injections, all with insufficient symptomatic relief. Duloxetine is a reasonable choice given the patient's comorbidities and generalized musculoskeletal pain.
Gabapentin and pregabalin are more effective than placebo in the treatment of neuropathic pain conditions such as postherpetic neuralgia and diabetic neuropathy. These drugs are expensive and both are associated with dose-dependent dizziness and sedation. There is no evidence of their effectiveness specifically for chronic OA pain.
NSAIDs inhibit cyclooxygenase (COX) enzymes, blocking the generation of the lipid prostaglandin E2 (PGE2). PGE2 stimulates inflammation, vasodilation, smooth muscle contraction, pain, and fever. However, PGE2 also maintains gastric mucosa and promotes kidney sodium excretion and glomerular filtration. Other COX products include thromboxane A2, a prothrombotic regulator of platelets, and prostacyclin, an antithrombotic and vasodilatory lipid. Because NSAIDs inhibit all of these, the consequences of COX inhibition are complex and accompanied by multiple potential side effects. Side-effect risk is increased in older patients and those with preexisting comorbidities. Therefore, ibuprofen is not an advisable choice in an elderly patient with peptic ulcer disease, hypertension, and heart disease.
Topical capsaicin may benefit localized OA (for example, knee only) but is impractical in this case given the multiple areas of involvement. Furthermore, duloxetine is more likely to be efficacious given how many treatments this patient has tried and failed.
Key Points
Duloxetine is FDA approved for chronic musculoskeletal pain and has been shown to have analgesic efficacy for chronic low back pain and knee osteoarthritis pain.
McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22:363-88. PMID: 24462672 doi:10.1016/j.joca.2014.01.003
Copyright 2018, American College of Physicians.