American College of Physicians: Internal Medicine — Doctors for Adults ®

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The MKSAP Challenge

From the April ACP Observer, copyright 2005 by the American College of Physicians.

Clinical scenario

A 63-year-old woman with a 30-year history of rheumatoid arthritis is evaluated prior to an elective hip arthoroplasty. She has been noted to have a high-titer rheumatoid factor and the erythrocyte sedimentation rate has never been less than 65 mm/h.

Her hemoglobin has remained stable at 8.5-9.1 g/dL. Her current medications are methotrexate, 20 mg/week; prednisone, 7.5 mg/week; and omeprazole, 20 mg/d. Because of a failed right hip arthroplasty, she has been limited to bed and chair for several years.

She has increasing morning stiffness and fatigue, mild alopecia, shooting pains in her forearms and hands with progressively weak hand grip, and mouth ulcers.

On physical examination, she has multiple joint deformities with arthroplasty scars along with multiple infarcts at the base of her nails and in the finger pulp.

She has weakness of hand grip, hyperreflexia and hypertonia. There are multiple subcutaneous nodules on extensor surfaces.

Which of the following is the most appropriate action at this time?

A. Obtain fluorescent antinuclear antibody, anti-DNA, and anti-Sm antibody titers.
B. Test for cryoglobulins.
C. Add a tumor necrosis factor-alpha inhibitor to the methotrexate and decrease prednisone.
D. Obtain images of the cervical spine.

Answer

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