Undifferentiated Symptoms — MCQs
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A 55-year-old woman presents with a 3-month history of unintentional weight loss of 8kg and persistent fatigue. She reports intermittent loose stools but no rectal bleeding. She has a 30 pack-year smoking history. Examination reveals mild conjunctival pallor and a palpable left supraclavicular lymph node. Blood tests show Hb 102 g/L (normal 115-165), MCV 78 fL, and normal thyroid function. What is the most appropriate next investigation?
A 44-year-old woman presents with a 12-week history of profound fatigue, difficulty concentrating, and 4kg weight loss. She works as a teacher and reports finding it increasingly difficult to cope with work. She has intermittent low-grade fevers. Examination is unremarkable. Initial blood tests show: Hb 132 g/L, WCC 4.8 × 10⁹/L, platelets 245 × 10⁹/L, ESR 8 mm/hr, CRP <5 mg/L, normal thyroid function, liver function, and renal function. What factor in this presentation would most strongly suggest an underlying organic cause rather than a primary psychological cause?
A 29-year-old woman presents with widespread pain affecting her neck, shoulders, back, and legs for 8 months. She describes the pain as constant and aching, with no clear precipitating factors. She also reports poor sleep, fatigue, and difficulty concentrating. Examination reveals multiple tender points but no joint swelling or objective weakness. Blood tests including FBC, CRP, ESR, thyroid function, and vitamin D are all normal. What is the most appropriate management approach?
A 65-year-old man with advanced COPD presents with worsening breathlessness and chest tightness. He describes the breathlessness as severely limiting his daily activities. He is already on maximum inhaler therapy. On examination, oxygen saturations are 89% on air, respiratory rate 22/min. Which pain and symptom assessment tool would be most appropriate to assess his symptom burden and guide management?
A 33-year-old man presents with a 5-day history of severe right-sided abdominal pain. He describes the pain as constant, scoring it 8/10 in intensity. He has had multiple previous attendances for various pains and has requested strong painkillers. Examination reveals tenderness in the right upper quadrant but no guarding or rebound. Vital signs are normal. Blood tests including FBC, CRP, liver function, and amylase are all normal. Urinalysis is normal. What is the most appropriate next step in management?
A 76-year-old woman presents with a 3-month history of fatigue, 6kg weight loss, and jaw pain when chewing. She also reports a dull headache over her right temple and some scalp tenderness when brushing her hair. Blood tests show: Hb 105 g/L, WCC 8.5 × 10⁹/L, platelets 425 × 10⁹/L, ESR 94 mm/hr, CRP 68 mg/L. What is the most appropriate immediate management?
A 42-year-old woman presents with persistent lower back pain for 6 weeks. The pain is worse in the morning and improves with activity. She reports stiffness lasting over an hour each morning. She is otherwise well with no red flag symptoms. Examination shows reduced lumbar spine flexion. What is the most appropriate initial investigation to support the suspected diagnosis?
Which of the following features would classify a fever of unknown origin (FUO) according to classical diagnostic criteria?
A 58-year-old man presents with a 2-week history of fever (up to 38.8°C), malaise, and a painful rash on his legs. He has a history of ulcerative colitis managed with mesalazine. Examination reveals tender, erythematous nodules on both shins. Blood tests show: Hb 118 g/L, WCC 11.2 × 10⁹/L, CRP 72 mg/L, ESR 68 mm/hr. Chest X-ray shows bilateral hilar lymphadenopathy. Which investigation would best establish the underlying diagnosis?
A 52-year-old woman with rheumatoid arthritis presents with 4 weeks of fever (38-39°C), night sweats, and fatigue. She takes methotrexate 15mg weekly and has done so for 2 years without problems. Blood tests show: Hb 108 g/L, WCC 3.2 × 10⁹/L (neutrophils 1.1 × 10⁹/L), platelets 165 × 10⁹/L, CRP 85 mg/L. Chest X-ray shows patchy bilateral infiltrates. What is the most appropriate immediate management?
Undifferentiated Symptoms UK Medical PG Practice Questions and MCQs
Question 151: A 55-year-old woman presents with a 3-month history of unintentional weight loss of 8kg and persistent fatigue. She reports intermittent loose stools but no rectal bleeding. She has a 30 pack-year smoking history. Examination reveals mild conjunctival pallor and a palpable left supraclavicular lymph node. Blood tests show Hb 102 g/L (normal 115-165), MCV 78 fL, and normal thyroid function. What is the most appropriate next investigation?
- A. Fine needle aspiration of the lymph node (Correct Answer)
- B. Urgent chest X-ray
- C. Colonoscopy within 2 weeks
- D. CT chest, abdomen and pelvis
- E. Upper gastrointestinal endoscopy within 2 weeks
Explanation: ***Fine needle aspiration of the lymph node*** - A palpable **left supraclavicular lymph node (Virchow’s node)** in a patient with **unexplained weight loss** and **microcytic anemia** is highly suspicious for metastatic malignancy, often originating from **thoracic or abdominal primary sites**. - **Fine needle aspiration (FNA)** or biopsy of this easily accessible node is the most appropriate next step to obtain a **histological diagnosis**, which is crucial for confirming malignancy and guiding further management. *Urgent chest X-ray* - While the patient has a significant **smoking history**, a chest X-ray has limited sensitivity for detecting small primary tumors and will not provide the **histological diagnosis** needed from the palpable node. - This investigation might miss **sub-diaphragmatic pathologies** or small primary lesions that are better evaluated through other means after tissue confirmation. *Colonoscopy within 2 weeks* - **Loose stools** and **microcytic anemia** are suggestive of **gastrointestinal blood loss** and potentially a **right-sided colonic malignancy**. - However, investigating a specific primary site without first obtaining a **tissue diagnosis** from the readily accessible **Virchow's node** is less efficient and could delay the definitive diagnosis, as the primary could be elsewhere. *CT chest, abdomen and pelvis* - **CT imaging** is essential for **staging** a confirmed malignancy and attempting to locate the **primary tumor**, providing a roadmap for further investigation. - However, it does not provide the **histological confirmation** of malignancy, which is the immediate priority to guide treatment decisions and is best obtained from the palpable node. *Upper gastrointestinal endoscopy within 2 weeks* - A **Virchow’s node** is classically associated with **gastric cancer** (Troisier's sign), making an upper GI endoscopy a relevant consideration for a primary source. - Like colonoscopy, performing this invasive procedure before obtaining a **histological diagnosis** from the accessible **lymph node aspiration** might delay the overall diagnostic process for the confirmed malignancy.
Question 152: A 44-year-old woman presents with a 12-week history of profound fatigue, difficulty concentrating, and 4kg weight loss. She works as a teacher and reports finding it increasingly difficult to cope with work. She has intermittent low-grade fevers. Examination is unremarkable. Initial blood tests show: Hb 132 g/L, WCC 4.8 × 10⁹/L, platelets 245 × 10⁹/L, ESR 8 mm/hr, CRP <5 mg/L, normal thyroid function, liver function, and renal function. What factor in this presentation would most strongly suggest an underlying organic cause rather than a primary psychological cause?
- A. The unintentional weight loss of 4kg (Correct Answer)
- B. The intermittent low-grade fevers
- C. The profound fatigue lasting 12 weeks
- D. The normal inflammatory markers
- E. The difficulty concentrating
Explanation: ***The unintentional weight loss of 4kg*** - **Unintentional weight loss** is a significant **red flag** feature that strongly suggests an underlying **organic pathology**, such as malignancy, chronic infection, or metabolic disorders. - A quantifiable loss of 4kg within a relatively short timeframe, especially when unintended, is a more compelling indicator of a physical disease process than many symptoms that can be psychosomatic. *The intermittent low-grade fevers* - **Low-grade fevers** can be subjective or intermittently present in various conditions, including some psychological states or functional syndromes, and are often non-specific without objective documentation. - While fevers can indicate infection or inflammation, they are less definitive than documented unintentional weight loss in strongly distinguishing an organic from a psychological cause in this context. *The profound fatigue lasting 12 weeks* - **Chronic fatigue** is a hallmark symptom of many **psychological conditions**, such as depression and anxiety disorders, and is also central to **functional syndromes** like Chronic Fatigue Syndrome. - Although fatigue can be a symptom of numerous organic diseases, its duration alone is not a strong discriminator for an organic cause due to its high prevalence in mental health conditions. *The normal inflammatory markers* - **Normal ESR and CRP** levels indicate the absence of significant acute inflammation, which tends to make acute infectious or active inflammatory diseases less likely. - This finding is often consistent with **psychological causes** or **functional syndromes** where systemic inflammation is not a primary feature, rather than strongly suggesting an organic pathology. *The difficulty concentrating* - **Difficulty concentrating**, often described as "brain fog," is a very common symptom in both **psychological disorders** (e.g., depression, anxiety, stress) and **sleep disturbances**. - This symptom is highly non-specific and frequently overlaps between psychological distress and various organic conditions, making it a poor sole indicator for an organic cause.
Question 153: A 29-year-old woman presents with widespread pain affecting her neck, shoulders, back, and legs for 8 months. She describes the pain as constant and aching, with no clear precipitating factors. She also reports poor sleep, fatigue, and difficulty concentrating. Examination reveals multiple tender points but no joint swelling or objective weakness. Blood tests including FBC, CRP, ESR, thyroid function, and vitamin D are all normal. What is the most appropriate management approach?
- A. Explain the likely diagnosis of fibromyalgia, discuss management strategies including graded exercise and CBT, and consider amitriptyline (Correct Answer)
- B. Refer to rheumatology under 2-week wait pathway
- C. Arrange MRI spine to exclude structural pathology
- D. Prescribe prednisolone 20mg daily for 2 weeks
- E. Prescribe morphine sulfate modified-release for pain management
Explanation: ***Explain the likely diagnosis of fibromyalgia, discuss management strategies including graded exercise and CBT, and consider amitriptyline*** - This patient displays the classic triad of **fibromyalgia**: chronic widespread pain, **fatigue**, and **sleep disturbance** with normal inflammatory markers (**ESR/CRP**). - Management focuses on a **multidisciplinary approach** including patient education, **Cognitive Behavioral Therapy (CBT)**, and low-dose **tricyclic antidepressants** like amitriptyline to improve sleep architecture. *Refer to rheumatology under 2-week wait pathway* - A **2-week wait (urgent)** referral is reserved for suspected **malignancy** or rapidly progressive inflammatory conditions, which are not suggested by normal blood tests. - Fibromyalgia is a clinical diagnosis that should ideally be managed in **primary care** once inflammatory mimics are excluded. *Arrange MRI spine to exclude structural pathology* - MRI is not indicated as the pain is **widespread (systemic)** rather than localized to a specific dermatome or spinal segment. - Ordering imaging for chronic widespread pain often reveals **incidental findings** that can lead to unnecessary anxiety and medicalization. *Prescribe prednisolone 20mg daily for 2 weeks* - **Corticosteroids** are used for inflammatory conditions like **Polymyalgia Rheumatica (PMR)**, which is unlikely given the patient's young age and **normal ESR/CRP**. - Steroids have no role in the pathophysiology of **fibromyalgia** and carry significant side effects with no clinical benefit in this context. *Prescribe morphine sulfate modified-release for pain management* - **Opioids** are explicitly not recommended for fibromyalgia because they are largely **ineffective** for central sensitization pain. - Long-term use of strong opioids carries a high risk of **dependence**, addiction, and **opioid-induced hyperalgesia**.
Question 154: A 65-year-old man with advanced COPD presents with worsening breathlessness and chest tightness. He describes the breathlessness as severely limiting his daily activities. He is already on maximum inhaler therapy. On examination, oxygen saturations are 89% on air, respiratory rate 22/min. Which pain and symptom assessment tool would be most appropriate to assess his symptom burden and guide management?
- A. McGill Pain Questionnaire
- B. Numeric Rating Scale (NRS) for pain
- C. Edmonton Symptom Assessment System (ESAS) (Correct Answer)
- D. Brief Pain Inventory (BPI)
- E. Visual Analogue Scale (VAS) for pain
Explanation: ***Edmonton Symptom Assessment System (ESAS)*** - The **ESAS** is a validated multidimensional tool that assesses nine common symptoms, including **breathlessness**, pain, and anxiety, making it ideal for the holistic management of **advanced COPD**. - It allows clinicians to monitor the **total symptom burden** over time and is particularly useful in **palliative care** settings to guide complex symptom management beyond just pain. *McGill Pain Questionnaire* - This tool is specifically designed to evaluate the **quality and intensity of pain** using descriptive adjectives, which is not the primary concern for this patient whose main issue is breathlessness. - It lacks the components to assess **respiratory distress** or other non-pain symptoms associated with chronic lung disease like **fatigue** or **anxiety**. *Numeric Rating Scale (NRS) for pain* - The **NRS** is a unidimensional scale focusing exclusively on **pain intensity** on a 0–10 scale. - It is insufficient for this patient because it cannot capture the severity of **dyspnea** or the functional impact of his COPD, nor other associated symptoms. *Brief Pain Inventory (BPI)* - The **BPI** primarily assesses the **severity of pain** and its impact on daily functions; it is not designed to measure **respiratory symptoms**. - While it helps in understanding disability related to pain, it ignores the **multidimensional symptom profile** required for advanced chronic disease management. *Visual Analogue Scale (VAS) for pain* - The **VAS** is a subjective scale used to measure **pain intensity** along a continuous line, which is too narrow for a patient with multiple systemic symptoms like severe breathlessness. - It does not provide data on **breathlessness**, tiredness, or psychological well-being, which are critical for guiding therapy in **advanced COPD**.
Question 155: A 33-year-old man presents with a 5-day history of severe right-sided abdominal pain. He describes the pain as constant, scoring it 8/10 in intensity. He has had multiple previous attendances for various pains and has requested strong painkillers. Examination reveals tenderness in the right upper quadrant but no guarding or rebound. Vital signs are normal. Blood tests including FBC, CRP, liver function, and amylase are all normal. Urinalysis is normal. What is the most appropriate next step in management?
- A. Prescribe codeine phosphate 30mg four times daily and review in 1 week
- B. Arrange urgent ultrasound abdomen and review with results (Correct Answer)
- C. Explain the normal investigation results, offer simple analgesia, and arrange follow-up to reassess
- D. Refer to general surgery for same-day assessment
- E. Arrange urgent CT abdomen and pelvis
Explanation: ***Arrange urgent ultrasound abdomen and review with results*** - The patient presents with severe, persistent right upper quadrant pain, which, despite normal blood tests and stable vital signs, necessitates investigation to rule out organic pathology such as **biliary colic** or **cholecystitis**. - An **abdominal ultrasound** is the gold-standard first-line imaging for the hepatobiliary system, highly effective for detecting **gallstones** and assessing the gallbladder, with no radiation exposure. *Prescribe codeine phosphate 30mg four times daily and review in 1 week* - Initiating potent **opioid analgesia** without a definitive diagnosis, especially with a history of frequent attendances for pain and requests for strong painkillers, is inappropriate and risks **masking symptoms**. - This approach fails to identify and treat the underlying cause of the pain and could reinforce potential **drug-seeking behavior**. *Explain the normal investigation results, offer simple analgesia, and arrange follow-up to reassess* - Despite normal blood tests, severe 8/10 right upper quadrant pain for 5 days cannot be dismissed without further diagnostic steps, particularly **imaging** to exclude structural causes. - Normal **vital signs** and inflammatory markers reduce the urgency but do not rule out conditions like **cholelithiasis** which can cause significant pain and require specific management. *Refer to general surgery for same-day assessment* - Emergency surgical referral is not indicated as the patient is **haemodynamically stable** and lacks signs of **peritonitis** (no guarding or rebound tenderness). - In the absence of acute complications, initial diagnostic workup including imaging should be completed before a surgical consult, which might then be appropriate based on findings. *Arrange urgent CT abdomen and pelvis* - **CT imaging** involves significant ionising radiation and is less sensitive than ultrasound for detecting **gallstones** or evaluating the biliary tree. - CT is typically reserved for suspected complications such as **perforation**, appendicitis, or when ultrasound findings are inconclusive.
Question 156: A 76-year-old woman presents with a 3-month history of fatigue, 6kg weight loss, and jaw pain when chewing. She also reports a dull headache over her right temple and some scalp tenderness when brushing her hair. Blood tests show: Hb 105 g/L, WCC 8.5 × 10⁹/L, platelets 425 × 10⁹/L, ESR 94 mm/hr, CRP 68 mg/L. What is the most appropriate immediate management?
- A. Start prednisolone 60mg daily immediately and arrange urgent temporal artery biopsy (Correct Answer)
- B. Arrange urgent temporal artery ultrasound before starting treatment
- C. Refer urgently to ophthalmology for assessment
- D. Arrange urgent temporal artery biopsy before starting treatment
- E. Start prednisolone 15mg daily and review in 1 week
Explanation: ***Start prednisolone 60mg daily immediately and arrange urgent temporal artery biopsy*** - The patient's symptoms including **jaw claudication**, **temporal headache**, **scalp tenderness**, and significantly elevated **ESR and CRP** are classic for **Giant Cell Arteritis (GCA)**. - Immediate high-dose **corticosteroid therapy** (e.g., prednisolone 60mg daily) is crucial to prevent irreversible **vision loss**, which is an urgent complication, while the biopsy can be performed within 7-14 days. *Arrange urgent temporal artery ultrasound before starting treatment* - While a **temporal artery ultrasound** revealing a 'halo sign' can support the diagnosis, it should never **delay the immediate initiation of steroids** in suspected GCA due to the risk of permanent blindness. - Diagnostic imaging and biopsy should ideally be performed urgently but concurrently with or after starting treatment. *Refer urgently to ophthalmology for assessment* - An **ophthalmology referral** is important, especially if visual symptoms are present or developing, but it is not the primary immediate management step in GCA. - The critical first step is to administer **high-dose systemic steroids** to protect the optic nerve from ischemia and prevent permanent visual impairment. *Arrange urgent temporal artery biopsy before starting treatment* - Delaying **steroid treatment** to wait for a **temporal artery biopsy (TAB)** is incorrect and dangerous, significantly increasing the risk of severe ischemic complications like **stroke or blindness**. - The characteristic histological changes of vasculitis in the temporal artery persist for at least 1 to 2 weeks after starting steroids, allowing the biopsy to be performed after treatment begins. *Start prednisolone 15mg daily and review in 1 week* - A daily dose of **15mg prednisolone** is typically appropriate for **Polymyalgia Rheumatica (PMR)**, which is a different condition although it can coexist with GCA. - This dose is **insufficient** to treat active GCA and prevent its severe complications, and waiting a week for review leaves a critical window open for **irreversible vision loss**.
Question 157: A 42-year-old woman presents with persistent lower back pain for 6 weeks. The pain is worse in the morning and improves with activity. She reports stiffness lasting over an hour each morning. She is otherwise well with no red flag symptoms. Examination shows reduced lumbar spine flexion. What is the most appropriate initial investigation to support the suspected diagnosis?
- A. MRI lumbar spine
- B. HLA-B27 testing and inflammatory markers (ESR, CRP) (Correct Answer)
- C. Plain radiographs of sacroiliac joints and lumbar spine
- D. Bone scan
- E. CT lumbar spine
Explanation: ***HLA-B27 testing and inflammatory markers (ESR, CRP)*** - The patient's symptoms (persistent lower back pain, morning stiffness > 1 hour, improvement with activity) are highly characteristic of **inflammatory back pain**, suggesting a **spondyloarthropathy**. - Initial investigation with **HLA-B27** (a genetic marker) and **inflammatory markers** like **ESR** and **CRP** (indicating systemic inflammation) provides strong, cost-effective, and non-invasive evidence to support this suspected diagnosis. *MRI lumbar spine* - While **MRI** is highly sensitive for detecting **early sacroiliitis** (bone marrow edema) which is crucial for diagnosing axial spondyloarthritis, it is typically reserved as a **second-line investigation** after initial clinical and laboratory screening. - It is often more expensive and less readily available in primary care settings compared to blood tests, making it not the *most appropriate initial* step. *Plain radiographs of sacroiliac joints and lumbar spine* - **Plain radiographs** often appear **normal in early stages** of spondyloarthropathies, as bony changes like erosions, sclerosis, or fusion (sacroiliitis) can take years to become evident. - For symptoms present for only 6 weeks, X-rays lack the sensitivity to detect acute inflammation and would likely yield a false negative result. *Bone scan* - A **bone scan** (scintigraphy) is highly sensitive to increased bone turnover but is **non-specific**, meaning it cannot differentiate well between various causes of increased uptake such as infection, malignancy, or different types of inflammation. - It is not a standard or appropriate initial investigation for suspected inflammatory back pain due to its low specificity in this context. *CT lumbar spine* - **CT scans** provide excellent detail of bone but involve significant **ionizing radiation** and are less effective than MRI for visualizing early soft tissue or bone marrow inflammation characteristic of spondyloarthropathies. - It is generally not used as an initial diagnostic tool for inflammatory back pain and is more suited for evaluating advanced bony changes or complex anatomical issues.
Question 158: Which of the following features would classify a fever of unknown origin (FUO) according to classical diagnostic criteria?
- A. Temperature >38.3°C on several occasions, duration >3 weeks, no diagnosis after 3 outpatient visits or 3 days of hospital investigation (Correct Answer)
- B. Temperature >37.8°C on several occasions, duration >2 weeks, no diagnosis after appropriate investigation
- C. Temperature >38.5°C on several occasions, duration >4 weeks, no diagnosis after 1 week of hospital investigation
- D. Temperature >38.3°C continuously for >2 weeks, no diagnosis after appropriate investigation including CT imaging
- E. Temperature >38.0°C continuously for >1 week, no diagnosis after initial blood tests and chest X-ray
Explanation: ***Temperature >38.3°C on several occasions, duration >3 weeks, no diagnosis after 3 outpatient visits or 3 days of hospital investigation***- The classical definition of **Fever of Unknown Origin (FUO)**, established by Petersdorf and Beeson, precisely states a temperature of **>38.3°C (101°F)** on several occasions.- This definition also requires a prolonged duration of **more than 3 weeks** and a thorough diagnostic work-up without a diagnosis after **3 outpatient visits** or **3 days of hospital investigation*.*Temperature >37.8°C on several occasions, duration >2 weeks, no diagnosis after appropriate investigation*- The temperature threshold of **>37.8°C** is too low; the classical definition specifically requires **>38.3°C**.- A duration of **>2 weeks** is also insufficient, as the classical criteria mandate a fever lasting for **>3 weeks*.*Temperature >38.5°C on several occasions, duration >4 weeks, no diagnosis after 1 week of hospital investigation*- While **>38.5°C** is a significant fever, it is not the exact **>38.3°C** specified in the classical FUO definition.- The investigation period specified as **1 week of hospital investigation** is inconsistent with the classical criteria of **3 days of hospital investigation** or 3 outpatient visits*.*Temperature >38.3°C continuously for >2 weeks, no diagnosis after appropriate investigation including CT imaging*- The classical definition requires fever on **several occasions**, not necessarily continuously, distinguishing it from persistent fever patterns.- A duration of **>2 weeks** is insufficient; the classical criteria require the fever to last for **>3 weeks*.*Temperature >38.0°C continuously for >1 week, no diagnosis after initial blood tests and chest X-ray*- The temperature threshold of **>38.0°C** is not precise enough for the classical definition, which specifies **>38.3°C**.- A duration of **>1 week** is significantly shorter than the **>3 weeks** required by the classical FUO criteria, and initial tests do not meet the work-up duration.
Question 159: A 58-year-old man presents with a 2-week history of fever (up to 38.8°C), malaise, and a painful rash on his legs. He has a history of ulcerative colitis managed with mesalazine. Examination reveals tender, erythematous nodules on both shins. Blood tests show: Hb 118 g/L, WCC 11.2 × 10⁹/L, CRP 72 mg/L, ESR 68 mm/hr. Chest X-ray shows bilateral hilar lymphadenopathy. Which investigation would best establish the underlying diagnosis?
- A. CT chest with contrast
- B. Anti-neutrophil cytoplasmic antibodies (ANCA)
- C. Serum angiotensin-converting enzyme (ACE) level (Correct Answer)
- D. Skin biopsy of the leg lesions
- E. Colonoscopy
Explanation: ***Serum angiotensin-converting enzyme (ACE) level*** - The patient presents with **Löfgren’s syndrome**, a classic triad of **erythema nodosum**, **bilateral hilar lymphadenopathy (BHL)**, and fever, which is a specific acute form of **sarcoidosis**. - Elevated **serum ACE** levels are found in approximately 60% of patients with active sarcoidosis and support the diagnosis when combined with characteristic radiographic and clinical findings. *CT chest with contrast* - While a CT can provide higher resolution of the **mediastinal and hilar lymphadenopathy**, it is not the most specific diagnostic tool when the CXR already clearly shows characteristic BHL. - Imaging alone helps visualize anatomical changes but does not offer the biochemical support for **sarcoidosis** activity that serum ACE provides in this constellation of symptoms. *Anti-neutrophil cytoplasmic antibodies (ANCA)* - **ANCA** testing is primarily used to screen for small-vessel **vasculitides** such as Granulomatosis with Polyangiitis, which typically involves the upper/lower respiratory tracts and kidneys. - The absence of renal symptoms, airway necrosis, or cavitating lung lesions makes vasculitis less likely than a sarcoid-related process. *Skin biopsy of the leg lesions* - A biopsy of **erythema nodosum** typically shows **septal panniculitis** without granulomas, which is a non-specific finding common to many triggers. - Since these skin lesions are a reactive manifestation rather than a primary site of the disease process, they do not provide the definitive underlying diagnosis of **sarcoidosis**. *Colonoscopy* - While **erythema nodosum** can be an extra-intestinal manifestation of **Ulcerative Colitis**, it does not explain the **bilateral hilar lymphadenopathy** found on the CXR. - A colonoscopy would assess the activity of the patient's known colitis but would fail to investigate the multi-system involvement suggested by the chest findings.
Question 160: A 52-year-old woman with rheumatoid arthritis presents with 4 weeks of fever (38-39°C), night sweats, and fatigue. She takes methotrexate 15mg weekly and has done so for 2 years without problems. Blood tests show: Hb 108 g/L, WCC 3.2 × 10⁹/L (neutrophils 1.1 × 10⁹/L), platelets 165 × 10⁹/L, CRP 85 mg/L. Chest X-ray shows patchy bilateral infiltrates. What is the most appropriate immediate management?
- A. Admit to hospital immediately for investigation and management (Correct Answer)
- B. Stop methotrexate and prescribe folic acid 5mg daily
- C. Prescribe oral amoxicillin 500mg three times daily
- D. Arrange outpatient CT chest and review in 1 week
- E. Prescribe oral prednisolone 30mg daily and review in 48 hours
Explanation: ***Admit to hospital immediately for investigation and management*** - The patient presents with **neutropenic sepsis** (neutrophils <1.5 × 10⁹/L and fever) while on **immunosuppressive methotrexate**, which is a life-threatening medical emergency. - Immediate hospitalization is required for **intravenous antibiotics**, cultures, and monitoring of **pulmonary infiltrates**, which may represent severe infection or drug-induced **pneumonitis**. *Stop methotrexate and prescribe folic acid 5mg daily* - While **methotrexate** must be discontinued due to **bone marrow suppression**, this supportive measure alone does not address the acute risk of sepsis. - Folic acid is used for chronic side effects, whereas the urgent priority is treating the **neutropenia-associated infection**. *Prescribe oral amoxicillin 500mg three times daily* - **Oral antibiotics** are insufficient for a patient with systemic symptoms, **neutropenia**, and bilateral lung infiltrates who requires **broad-spectrum IV therapy**. - Amoxicillin does not provide adequate coverage for potential **atypical pathogens** or opportunistic infections like **Pneumocystis jirovecii**. *Arrange outpatient CT chest and review in 1 week* - Delaying care for an outpatient scan is dangerous given the high risk of rapid deterioration in **immunocompromised patients** with fever. - Diagnostic imaging and intervention must occur **emergently** in an inpatient setting to prevent further septic decline. *Prescribe oral prednisolone 30mg daily and review in 48 hours* - Starting **corticosteroids** empirically is contraindicated before excluding an active infection, as it could severely worsen **neutropenic sepsis**. - A 48-hour delay for review is inappropriate for a patient already showing signs of **hematologic toxicity** and systemic illness.
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