WBR0184

Author	PageAuthor::Mugilan Poongkunran
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Musculoskeletal/Rheumatology
Prompt	[[Prompt::A 72 year old female comes to office with complaints of diffuse aches and pain. These are more pronounced around her shoulder and pelvic girdle muscles. She denies any headache, fever, rash, arthralgia, visual symptoms and difficulty in swallowing. She has hypertension, osteoporosis and hypercholestrolemia. Her medications include simvstatin, enalapril, hydrochlorthiazide and alendronate. She is a non-smoker and non-alcoholic. Her vitals are BP: 120/80 mmHg, pulse: 72/min, temperature: 98F and respirations 14/min. On physical examinations there is tenderness in the pelvic girdle muscles. Rest of the examination is normal. Routine labs are normal except for elevated CPK levels. What is the best next step in her line of management?]]
Answer A	AnswerA::Stop statins
Answer A Explanation	[[AnswerAExp::Incorrect - Statin induced myopathy can present with aches and morning stiffness in the shoulders, hip girdle, and neck. ESR is normal in these patients and stopping statins improves the condition.]]
Answer B	AnswerB::Measure ESR
Answer B Explanation	[[AnswerBExp::Correct - The characteristic laboratory finding in polymyalgia rheumatica (and in GCA) is an erythrocyte sedimentation rate (ESR) that is above 40 mm/h (78 to 93 percent in some series), with some patients having values that can exceed 100 mm/h]]
Answer C	AnswerC::Start prednisone
Answer C Explanation	[[AnswerCExp::Incorrect - Polymyalgia rheumatica patients, usually respond quickly and often note improvement after starting on prednisone dose of 15 mg/day (or equivalent) given orally as a single daily dose. Symptoms are generally substantially better (50 to 70 percent reduction in pain and stiffness) within three days in patients with PMR started on prednisone.]]
Answer D	AnswerD::Start NSAIDS
Answer D Explanation	[[AnswerDExp::Incorrect - NSAIDS may provide some symptomatic relief, however it is not disease modifying and produce side effects in elderly patients.]]
Answer E	AnswerE::Perform muscle biopsy
Answer E Explanation	AnswerEExp::'''Incorrect''' - Muscle biopsy is performed when symptoms persist even after starting appropriate treatment.
Right Answer	RightAnswer::B
Explanation	[[Explanation::Polymyalgia rheumatica (PMR) is an inflammatory rheumatic condition characterized clinically by aching and morning stiffness in the shoulders, hip girdle, and neck. It can be associated with giant cell arteritis (GCA). Statin induced myopathy presents in a smiliar way and ESR is one test which differentiate between these two conditions and determine the line of management. Educational Objective: References: ]]
Approved	Approved::Yes
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