A 49-year-old, female with a 5-year history of diabetes

mellitus type 2, presents for an initial visit. She has no known

complications of diabetes. She
takes metformine, glibenclamide , and aspirin. On
examination, you find a pleasant, obese female in no distress.
Her blood pressure is 136/86 mm Hg. As you discuss
monitoring her diabetes, you recommend screening for early
kidney disease.
Which of the following approaches is the recommended way to screen for diabetic kidney disease?

A-Obtain a 24-hour urine collection for albumin now and again in 3 years.

B-Obtain a spot urine albumin every year.

C-Obtain a spot urine albumin/creatinine ratio every year.

D-Obtain a urinalysis every year.

E-Obtain a serum creatinine every year.

 The correct answer is "C."

The best test to evaluate for

Moderately increased albuminuria Some of you may have chosen
moderately increased albuminuria
(previously known by the "B." A "spot microalbumin" (now
is the urine albumin/creatinine
misnomer "microalbuminuria") is a spot albumin) is a common but
ratio. Its advantages include ease
a marker for increased risk of less accurate way to provide
of use, relatively low cost, and
future kidney disease in diabetic screening and may still be in use in
good correlation with 24-hour
patients. some areas..
urine collections.
As a practical matter, many physicians use urine albumin alone as a method of
screening, but this method does not allow for corrections for variations in urine
volume and dilution.

A random spot urine albumin/creatinine ratio is normally less than 30 mg/g.

Values above 30 mg/g are consistent with 24-hour measures showing abnormal
amounts of albumin. Answers "D" and "E" offer measures of kidney function
that simply are not sensitive enough to use for screening purposes
the correct answer is "A."
Verification by repeat urine albumin/creatinine ratio is sufficient for a diagnosis of
moderately increased albuminuria, so 24-hour urine collections need not be performed for
confirmation. Of note, the diagnosis of moderately increased albuminuria requires 2 of 3
urine specimens showing >30 mg/g albumin/creatinine over a 6-month period.

Since protein excretion must exceed 300 to 500 mg/day for a urine dipstick to detect
proteinuria, urinalysis ("B") is not sensitive enough to be diagnostic.
Serum creatinine elevation may be a marker for diabetic kidney disease, but it would develop
late in the process. Nephrology referral is premature—you went to medical school; you can
do this!
Which of the following can cause a false-negative albumin/creatinine ratio?

A-Vigorous exercise.

B-Fever.

C-Cachexia.

D-Poor glycemic control.

E-Large muscle mass.

The correct answer is "E."
Patients with a large muscle mass have a high rate of creatinine excretion, which
may result in a falsely negative albumin/creatinine ratio (as the urine creatinine goes
up, the ratio obviously goes down). Cachectic patients have the opposite problem,
with low amounts of creatinine excretion, resulting in false-positive
albumin/creatinine ratio.

Fever, vigorous exercise, heart failure, and poor glycemic control can cause transient
increases in albuminuria, potentially resulting in false-positive albumin/creatinine
ratios.
Your patient's other laboratory studies reveal the following:
hemoglobin A1c 6.4%, serum creatinine 1.4 mg/dL, and normal
electrolytes.

A month later, your patient returns. Her blood pressure is 138/84

mm Hg. Her urine albumin/creatinine remains elevated on a second
measurement. According to an eye examination yesterday, she has
nonproliferative diabetic retinopathy.
Because your patient has type 2 diabetes mellitus and moderately increased albuminuria, you realize that her likelihood of
progressing to overt nephropathy is:

A-Almost zero.

B-About half that of a similar patient with type 1 diabetes.

C-Nearly equal to that of a similar patient with type 1 diabetes.

D-More than twice that of a similar patient with type 1 diabetes.

E-Absolutely certain (100% chance).

The correct answer is "C."
Although earlier studies showed a greater progression to
overt nephropathy in type 1 diabetics, more recent studies
demonstrate a nearly equal rate of progression in types 1
and 2.

About 20% to 40% of Caucasian patients with diabetes type 2

and moderately increased albuminuria will progress to
diabetic nephropathy. The rate of progression to nephropathy
in non-Caucasian populations is even higher.
What is the most appropriate next step in the evaluation and management of this patient's moderately increased
albuminuria?

A-Start an angiotensin-converting enzyme (ACE) inhibitor.

B-Start an angiotensin receptor blocker (ARB).

C-Order renal ultrasound with Doppler of the renal arteries.

D-Start insulin .

E-Order a 24-hour urine collection for total protein.

 The correct answer is "A."
ACE inhibitors should be the first-choice drugs unless there is a contraindication to
their use.

"B," an ARB, should be second-line choice in the event that the patient cannot
tolerate an ACE inhibitor.

"C," a renal ultrasound, is not indicated at this point in time.

"D" is also incorrect. Your patient already has good glucose control (HbA1c of 6.4%).
As previously stated, a 24-hour urine collection is not necessary for diagnosis.
 What further investigations must your patient undergo
to eliminate other potential causes of proteinuria?

A-Renal biopsy.

B-Renal ultrasound with Doppler of the

renal arteries.
The patient has a full
urinalysis to rule out renal
inflammation (e.g., C-ANA, ESR, CRP.
nephritis) and overt
proteinuria (nephrotic
syndrome). The urinalysis D-All of the above.
is entirely negative.
E-None of the above.
The correct answer is "E."
case 2
A 5-year-old boy presents with acute onset of left
anterior thigh and hip pain that began 2 days ago with
no known prior trauma. He reports that it initially
"loosened-up" after he had been out of bed for a few
hours but has become worse again by afternoon. His
pain is exacerbated by weight bearing and active or
passive range of motion (ROM)
. His mother notes that he had a cold 7 to 10 days
ago, but has been asymptomatic until he complained
of thigh pain two nights ago. She also notes that he
has had a low-grade fever. He has no other
significant constitutional symptoms and appears to
be in some pain, but otherwise he appears well.
Based on the information obtained thus far, which of the following is the most
likely diagnosis?

A-Osteomyelitis.

B-Rheumatic fever.

C-Slipped capital femoral epiphysis (SCFE).

D-Legg–Calve–Perthes disease (LCPD).

E-Transient (toxic) synovitis.

 The correct answer is "E."
This presentation is classic for transient (toxic) synovitis. This is the most common
cause of hip pain in children aged 3 to 10 years, with peak occurrence in ages 5 to 6
years.

It is more commonly seen in boys (male:female ratio of 2–3:1) and is often preceded
by a viral respiratory infection, although numerous studies have failed to demonstrate
a specific viral or bacterial agent.

Physical examination reveals a limp or refusal to walk and complaint of pain over the
groin and/or proximal thigh. There is pain with ROM testing, especially during
abduction. Most children will be afebrile with a temperature of ≤38°C.
 Appropriate diagnostic work-up might include which of the following?

A-Joint aspiration.

B-Plain film radiographs.

C-Inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

D-CBC with differential.

E-All of the above.

 The correct answer is "E."

All of the above may be appropriate as transient synovitis is a diagnosis of exclusion. Patients with
mild symptoms may be observed without further investigation.

However, if the pain is significant, ROM is significantly impaired, or the temperature is >37.5°C,
further diagnostic work-up is indicated. Laboratory findings consistent with transient synovitis
include: clear joint fluid aspirate, normal CBC, and a mildly increased ESR.

Blood cultures, antistreptolysin O (ASO) titer, bone scan, and MRI may also be of benefit to rule
out other possibilities (e.g., septic arthritis, rheumatic fever, and SCFE).
It is of extreme importance to differentiate transient synovitis from septic arthritis.
Unfortunately, there is no combination of physical findings and laboratory tests short of
joint fluid that will definitively rule out septic arthritis.

There are published clinical decision tools, but these are generally based on observational
data and often have conflicting results. It requires clinical judgment; decide which patients
you are worried enough about that you want to commit them to hip joint aspiration.
A-Open fixation.

B-Immobilization.

C-Antibiotics.

D-Surgical decompression.

E-Ibuprofen and rest.

The correct answer is "E."
Conservative treatment is
warranted: the appropriate
initial treatment is rest,
weight bearing as tolerated,
and observation.
Transient synovitis generally responds well
to oral NSAIDs. Home care is acceptable;
however, admission is indicated if the
diagnosis is equivocal or if significant pain
management is required.
For septic arthritis, prompt administration
of an intravenous (IV) antibiotic—directed
at the most likely infecting pathogen and
altered as necessary based on culture
results—is indicated.
Surgical irrigation of
the joint is often
necessary and early
orthopedic consultation
is needed.
A 15-year-old female cross-country runner presents to your clinic with the chief complaint of
bilateral knee pain. She describes a gradual increase in her symptoms during the first 3 weeks of the
season. She wants to run varsity this year and has done extra running and hill training after practice
each day. She describes anterior knee pain in the patellar region with little or no swelling, but
complains of crepitus and pain exacerbated by running, squatting, stair climbing, and prolonged
sitting with the knee bent.

The most likely diagnosis for the condition described is:

A-Osgood–Schlatter disease.

B-Chondromalacia patellae.

C-Patellofemoral pain syndrome (PFPS).

D-Femoral stress fracture.

E-Jogger's joints.
The correct answer is "C."

This condition is due to

forces across the knee that
PFPS is a common overuse syndrome Maltracking and malalignment of the
lead to biomechanical
seen more frequently in runners and patellofemoral joint can contribute to
overload of the
female athletes (thus the moniker this overload, as can training errors,
patellofemoral joint and
"runner's knee"). core weakness, and muscle imbalance.
other anterior knee
structures.
"A," Osgood–Schlatter disease, is also related
to overuse but is 2 to 3 times more common
in males, particularly in athletes engaging in
repetitive jumping. The pain of Osgood–
Schlatter is generally well localized to the
tibial tubercle. Radiographic evidence of
fragmentation of the epiphysis or heterotopic
ossification anterior to the tubercle may be
seen but is not necessary for diagnosis.
 B," chondromalacia patella, is
softening of the articular cartilage of
the patella as seen on arthroscopy
Femoral stress fracture ("D") would "E" is not a real thing but has nice
and may be a result of long-term
be unlikely to present bilaterally. alliteration.
patellofemoral dysfunction. This is a
surgical diagnosis and the term
should be avoided clinically.
 B-Decreased
activity level
along with and C-Evaluation E-
A-Arthroscopic D-Casting or
quadriceps and for "Female Corticosteroid
debridement. immobilization.
hip Athlete Triad." injection.
strengthening
exercises.
The correct answer is "B."
The most effective treatment modality is a combined physical therapy regimen
consisting of strength training of the hip abductors and quadriceps, as well as
quadriceps stretching. Quadriceps strengthening is usually initiated by resisted
straight leg raises (SLRs) to minimize patellofemoral compressive forces. NSAIDs,
cross-training, and core strengthening may also be of benefit.

Adjunctive trials of therapeutic modalities such as orthotics may be considered, but

should not be used in isolation. Recalcitrant cases and patients with recurrent
dislocation/subluxation should be referred to your friendly neighborhood orthopedic
surgeon for consideration of surgical intervention.
Three months later, the same patient presents complaining
of unilateral right knee pain over the medial knee joint.
Again, this pain is exacerbated by knee flexion and she notes
popping and snapping when she stands from sitting. She
notes that the pain is worse after prolonged sitting or going
up or downstairs. Your examination shows tenderness about
1 cm medial to the patella with palpable fullness in the area.
 B-Medial
D-Recalcitrant
A-Osteosarcoma collateral ligament C-Plica syndrome E-Meniscal tear
PFPS
(MCL) strain
The correct answer is "C."

Plicae are synovial

remnants that did not Treatment includes
resorb properly during Typical symptoms rest, Ice ,quadriceps
development. They can include popping or strengthening, and
This is the typical be irritated, usually snapping sensation with NSAIDs. If
presentation of plica chronically or knee flexion; there may conservative
syndrome. subacutely, especially in also be knee locking management fails,
sports that require and catching as well as steroid injection or
repeated flexion of the having the knee "give." arthroscopy may
knee (e.g., rowing, alleviate the symptoms.
cycling, running etc.).
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