Vasculitides
A 72-year-old man presents with new-onset headache, scalp tenderness, jaw claudication, and visual disturbances. What is the diagnosis, lab abnormality and treatment?
GCA, ESR (high) and you will start high-dose corticosteroids immediately and obtain a temporal artery biopsy for definitive diagnosis.
A 35-year-old man with a history of psoriasis presents with pain and swelling in his distal interphalangeal joints and nail pitting. He also reports morning stiffness that lasts for over 30 minutes.
The most likely diagnosis is psoriatic arthritis. Imaging findings might include periostitis, "pencil-in-cup" deformity of the phalanges, and asymmetric joint involvement.
A 40-year-old woman presents with widespread musculoskeletal pain, fatigue, and sleep disturbances for the past year. Physical examination reveals multiple tender points.
Fibromyalgia. The cornerstone of management includes patient education, regular physical activity, cognitive-behavioral therapy, and medications such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), or serotonin-norepinephrine reuptake inhibitors (SNRIs).
A 48-year-old woman presents with progressive muscle weakness over the past few months, particularly in her proximal muscles. She has difficulty climbing stairs and rising from a seated position. Laboratory tests reveal elevated creatine kinase (CK) levels.What is the most likely diagnosis, and what diagnostic test would confirm it?
The most likely diagnosis is polymyositis. The diagnostic test to confirm it would be a muscle biopsy showing endomysial inflammation.
A 72-year-old woman is brought to the emergency department 1 hour after the sudden onset of right facial droop and weakness of the right arm and leg. She takes captopril for hypertension and daily aspirin. Her pulse is 80/min, respirations are 16/min, and blood pressure is 150/90 mm Hg. Examination shows a left carotid bruit and right central facial paralysis. There is moderate expressive aphasia. A CT scan of the head shows no abnormalities. Which of the following is the most appropriate initial pharmacotherapy? (A) Oral ticlopidine (B) Oral warfarin (C) Sublingual nifedipine (D) Intravenous nitroprusside (E) Intravenous tissue plasminogen activator
E
A 25-year-old woman presents with fatigue, weight loss, and claudication of her upper extremities. On physical examination, you note diminished pulses in her radial arteries. What is the most likely diagnosis, and what imaging study would you use to confirm it?
The most likely diagnosis is Takayasu arteritis. The imaging study to confirm it would be magnetic resonance angiography (MRA) or computed tomography angiography (CTA) to visualize large vessel involvement, especially in the aorta and its branches.
A 55-year-old woman presents with dry eyes and dry mouth for the past year. She also reports fatigue and joint pain. Schirmer’s test is positive.
The most likely diagnosis is Sjogren's syndrome. Autoantibodies to test for include anti-Ro/SSA and anti-La/SSB antibodies.
A 40-year-old woman presents with tight, shiny skin on her fingers and hands, Raynaud’s phenomenon, and difficulty swallowing. She has also noticed skin thickening on her face.
The most likely diagnosis is systemic sclerosis (scleroderma). A serologic test that would help in confirming the diagnosis is the anti-centromere antibody (for limited cutaneous systemic sclerosis) or anti-topoisomerase I (Scl-70) antibody (for diffuse cutaneous systemic sclerosis)
A 55-year-old man presents with a rash on his eyelids (heliotrope rash) and knuckles (Gottron's papules), along with proximal muscle weakness. Laboratory tests show elevated CK levels.
The most likely diagnosis is dermatomyositis. Given the risk of associated malignancy, a thorough malignancy workup should be considered, including age-appropriate cancer screenings such as mammography, colonoscopy, and CT scans of the chest, abdomen, and pelvis.
A 45-year-old man presents with epigastric pain that is worse with meals and at night. He has a history of chronic NSAID use for osteoarthritis. On examination, there is tenderness in the epigastric region.
A) Abdominal ultrasound
B) H. pylori stool antigen test
C) Upper endoscopy
D) Serum gastrin level
E) Barium swallow
upper scope
A 40-year-old man presents with chronic sinusitis, hemoptysis, and hematuria. Laboratory tests reveal a positive c-ANCA (anti-proteinase-3) test. What is the most likely diagnosis, and what is the next step in management?
The most likely diagnosis is granulomatosis with polyangiitis. The next step in management is to start immunosuppressive therapy with corticosteroids and cyclophosphamide or rituximab, and to confirm the diagnosis with a biopsy of an affected organ, typically showing necrotizing granulomatous inflammation.
A 45-year-old man presents with sudden onset of severe pain, redness, and swelling in the first metatarsophalangeal joint of his right foot. He has a history of hypertension and is on diuretics.
The most likely diagnosis is gout. On joint aspiration, you would expect to find monosodium urate crystals that are needle-shaped and negatively birefringent under polarized light microscopy. Intra-joint steroids, NSAIDs, colchicine, PO pred
A 70-year-old woman presents with bilateral shoulder and hip pain and stiffness, especially in the morning, lasting for more than 30 minutes. She has difficulty getting out of bed and lifting her arms.
The most likely diagnosis is polymyalgia rheumatica. The first-line treatment is low-dose corticosteroids, such as prednisone.
A 30-year-old man presents with conjunctivitis, urethritis, and arthritis following a recent gastrointestinal infection. He also reports heel pain. What is the most likely diagnosis?
The most likely diagnosis is reactive arthritis. The typical triad of symptoms associated with this condition includes conjunctivitis, urethritis, and arthritis.
A 58-year-old woman with type 2 diabetes mellitus presents for a follow-up visit. Her current medications include metformin 1000 mg twice daily. Her HbA1c is 8.5%. She has no history of cardiovascular disease. Her BMI is 32 kg/m².
Question: What is the most appropriate next step in management?
A) Add glipizide
B) Add sitagliptin
C) Add liraglutide
D) Add insulin glargine
E) Increase metformin dose
A 52-year-old woman presents with a three-month history of fatigue, weight loss, and muscle aches. She reports experiencing recurrent abdominal pain after meals and has noticed a rash on her legs. On physical examination, you observe livedo reticularis and palpable purpura on her lower extremities. Blood pressure is 160/100 mmHg. Laboratory tests reveal elevated ESR and CRP, mild anemia, and a positive hepatitis B surface antigen.
What is the most likely diagnosis, and what is the recommended initial treatment?
Polyarteritis nodosa; corticosteroids and antiviral therapy
A 30-year-old man presents with chronic lower back pain and stiffness that improves with exercise but worsens with rest. He also reports pain in his heels and intermittent eye redness.
The most likely diagnosis is ankylosing spondylitis. The most helpful imaging study would be an X-ray of the sacroiliac joints, which may show sacroiliitis. MRI can be more sensitive in early disease.
A 28-year-old woman presents with a rash on her cheeks and nose, fatigue, joint pain, and photosensitivity. Laboratory tests reveal a positive ANA and anti-dsDNA antibodies.
The most likely diagnosis is systemic lupus erythematosus. Additional tests to assess organ involvement include complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis, complement levels (C3, C4), anti-Smith antibodies, and anti-phospholipid antibodies.
A 40-year-old man presents with a history of recurrent oral and genital ulcers, along with uveitis. He also reports skin lesions that look like acne. What condition should you suspect and what criteria are used for diagnosis?
Diagnostic criteria: International Criteria for Behçet's Disease (ICBD), which includes oral aphthosis, genital aphthosis, ocular lesions, skin lesions, vascular manifestations, and positive pathergy test
A 62-year-old woman with a history of hypertension and diabetes mellitus presents with a 3-month history of fatigue and swelling of the lower extremities. Laboratory results reveal a serum creatinine of 2.5 mg/dL, estimated glomerular filtration rate (eGFR) of 28 mL/min/1.73 m², and 2+ proteinuria on urinalysis.
Question: What is the most appropriate next step in management?
A) Increase insulin dose
B) Add losartan
C) Start hemodialysis
D) Add hydrochlorothiazide
E) Refer to nephrology
B
A 50-year-old woman presents with a four-month history of weight loss, fever, and severe muscle pain. She also reports experiencing numbness and tingling in her hands and feet. Physical examination reveals livedo reticularis and ulcerations on her legs. Laboratory tests show elevated ESR and CRP, and negative ANCA. Electromyography (EMG) confirms mononeuritis multiplex.
What is the most likely diagnosis, and what is the recommended initial treatment?
Polyarteritis nodosa; corticosteroids and immunosuppressive agents
A 52-year-old woman presents with a 6-month history of morning stiffness lasting over an hour and symmetrical swelling of her metacarpophalangeal and proximal interphalangeal joints. She reports significant fatigue and difficulty performing daily tasks.
The most likely diagnosis is rheumatoid arthritis. Initial laboratory tests would include rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
A 45-year-old woman with known diffuse systemic sclerosis presents with new-onset hypertension, headache, and acute kidney injury. What is the most likely diagnosis, and what is the first-line treatment?
The most likely diagnosis is scleroderma renal crisis. The first-line treatment is the initiation of an ACE inhibitor, such as captopril, to control blood pressure and renal function.
A 30-year-old woman presents with recurrent miscarriages and a history of deep vein thrombosis. She has a positive lupus anticoagulant test. What condition should you suspect and what is the mainstay of treatment?
APLAS. Warfarin or heparin
One day after undergoing cholecystectomy, a 37-year-old man becomes increasingly tremulous and anxious. He is irritable with the staff and moves around restlessly in bed. He has no previous history of serious medical illness and takes no medications. He does not smoke. His temperature is 37.4°C (99.4°F), pulse is 120/min, and blood pressure is 160/100 mm Hg. Physical examination shows a well-healing incision without erythema. He is oriented to person but not to place or time. Administration of which of the following is the most appropriate next step in management?(A) Intravenous ceftriaxone (B) Oral buspirone (C) Oral diazepam (D) Oral naltrexone (E) Oral phentolamine (F) Oral sertraline
c