Large vessel vasculitis — MCQs

A 74-year-old woman with no significant past medical history presents with 1 week of fever, unremitting headache and hip and shoulder stiffness. She denies any vision changes. Physical examination is remarkable for right scalp tenderness and range of motion is limited due to pain and stiffness. Neurological testing is normal. Laboratory studies are significant for an erythrocyte sedimentation rate (ESR) at 75 mm/h (normal range 0-22 mm/h for women). Which of the following is the most appropriate next step in management?

A 72-year-old man presents to his primary care provider complaining of fatigue, mild headache, and discomfort with chewing for roughly 1 week. Before this, he felt well overall, but now he is quite bothered by these symptoms. His medical history is notable for hypertension and hyperlipidemia, both controlled. On examination, he is uncomfortable but nontoxic-appearing. There is mild tenderness to palpation over his right temporal artery, but otherwise the exam is not revealing. Prompt recognition and treatment can prevent which of the following feared complications:

A 58-year-old woman presents to the physician with a throbbing headache. She says she had it for the last year and it’s usually located in the right temporal area. There is localized tenderness over the scalp. During the last 2 weeks, she experienced 3 episodes of transient loss of vision on the right side, without ocular pain. On physical examination, her vital signs are normal. Palpation reveals that the pulsations of the superficial temporal artery on the right side are reduced in amplitude. Laboratory studies show: Blood hemoglobin 10.7 g/dL (6.64 mmol/L) Leukocyte count 8,000/mm3 (8.0 x 109/L) Platelet count 470,000/mm3 (470 x 109/L) Erythrocyte sedimentation rate 60 mm/h (60 mm/h) Which of the following conditions is most likely to co-exist with the presenting complaint in this woman?

A 5-year-old boy presents to his pediatrician for a well-child visit. His mother reports him to be doing well and has no concerns. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. On physical exam, he is noted to have a right upper extremity blood pressure of 150/80 mm Hg. 2+ radial pulses and trace femoral pulses are felt. Cardiac auscultation reveals a regular rate and rhythm with a normal S1 and S2. A 2/6 long systolic murmur with systolic ejection click is heard over left sternal border and back. The point of maximal impulse is normal. Which of the following is the most likely diagnosis?

A 32-year-old woman presents with new left-arm pain. She was previously well but for 2 months has had episodes of low-grade fever, night sweats, and dizziness. She works as a stock assistant and has noticed left arm pain when she stocks shelves. She is taking a multivitamin but no other medications. On physical examination, her blood pressure is 126/72 in her right arm, but it cannot be measured in her left arm. The left radial pulse is not detectable. There is a bruit over the left subclavian area. Femoral and pedal pulses are normal and no abdominal bruits are heard. The left hand is cool but has no other evidence of ischemia. Which of the following is the most likely etiology of this patient’s condition?

A 40-year-old woman comes to the emergency department because of difficulty walking for the past 4 hours. She first noticed her symptoms after getting up this morning and her foot dragging while walking. She feels tired. She has a history of chronic sinusitis. Six months ago, she was diagnosed with asthma. Current medications include an albuterol inhaler and inhaled corticosteroids. Her temperature is 38.9°C (102°F), pulse is 80/min, and her blood pressure is 140/90 mm Hg. Auscultation of her lungs shows diffuse wheezing over bilateral lung fields. Physical examination shows tender subcutaneous nodules on the extensor surfaces of the elbows. There are palpable, non-blanching erythematous lesions on both shins. Dorsiflexion of the right foot is impaired. Sensation to pinprick, light touch, and vibration is decreased over the ulnar aspect of the left forearm. Laboratory studies show: Hemoglobin 11.3 g/dL Leukocyte count 24,500 Segmented neutrophils 48% Eosinophils 29% Lymphocytes 19% Monocytes 4% Platelet count 290,000/mm3 Serum Urea nitrogen 32 mg/dL Creatinine 1.85 mg/dL Urine Blood 2+ Protein 3+ Which of the following is the most likely diagnosis in this patient?

A 62-year-old man presents to the emergency department with hematuria and hemoptysis that started in the morning. He notes that he has had frequent lung infections throughout his adult life, the most recent being 2 weeks ago. He also mentions that he has had hematuria twice before but never as severe as he is having currently. His medical history is otherwise non-significant, and his only medication is acetaminophen as needed. His blood pressure is 136/92 mm Hg, heart rate is 86/min, respiratory rate is 16/min, and temperature is 37.0°C (98.6°F). Chest radiography shows a resolving right middle lobe airspace opacity. His initial laboratory tests are notable for elevated erythrocyte sedimentation rate and C-reactive protein level. While in the examination room, the patient develops a spontaneous nosebleed. What is the most likely diagnosis?

A 27-year-old man presents to his primary care physician with worsening cough and asthma. The patient reports that he was in his usual state of health until 1 month ago, when he developed a cold. Since then his cold has improved, but he continues to have a cough and worsening asthma symptoms. He says that he has been using his rescue inhaler 3 times a day with little improvement. He is studying for an accounting exam and states that his asthma is keeping him up at night and making it hard for him to focus during the day. The patient admits to smoking tobacco. His smoking has increased from a half pack per day since he was 17 years old to 1 pack per day during the past month to cope with the stress of his exam. The patient's temperature is 99°F (37.2°C), blood pressure is 110/74 mmHg, pulse is 75/min, and respirations are 15/min with an oxygen saturation of 97% on room air. Physical examination is notable for mild expiratory wheezes bilaterally. Labs are obtained, as shown below: Serum: Na+: 144 mEq/L Cl-: 95 mEq/L K+: 4.3 mEq/L HCO3-: 23 mEq/L Urea nitrogen: 24 mg/dL Glucose: 100 mg/dL Creatinine: 1.6 mg/dL Leukocyte count and differential: Leukocyte count: 13,000/mm^3 Segmented neutrophils: 63% Eosinophils: 15% Basophils: < 1% Lymphocytes: 20% Monocytes: 1.3% Hemoglobin: 13.5 g/dL Hematocrit: 50% Platelets: 200,000/mm^3 Urinalysis reveals proteinuria and microscopic hematuria. Which of the following is associated with the patient's most likely diagnosis?

A 45-year-old man comes to the physician because of fatigue and joint pain for 8 months. He has pain in both knees, both elbows, and diffuse muscle pain. He does not have dyspnea. He also had several episodes of a nonpruritic rash on his lower extremities. Eight years ago, the patient was diagnosed with hepatitis C. His temperature is 37.9°C (100.2°F), pulse is 90/min, and blood pressure is 140/90 mm Hg. Examination of the lower extremities shows raised purple papules that do not blanch when pressure is applied. Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.9 g/dL Leukocyte count 8,500/mm3 Platelets 160,000/mm3 Serum Creatinine 1.1 mg/dL ALT 123 U/L AST 113 U/L Further evaluation of this patient is most likely to show which of the following findings?

A 32-year-old woman who recently emigrated to the USA from Japan comes to the physician because of a 3-month history of night sweats, malaise, and joint pain. During this time, she has also had a 6-kg (13-lb) weight loss. Physical examination shows weak brachial and radial pulses. There are tender subcutaneous nodules on both legs. Carotid bruits are heard on auscultation bilaterally. Laboratory studies show an erythrocyte sedimentation rate of 96 mm/h. A CT scan of the chest shows thickening and narrowing of the aortic arch. Microscopic examination of the aortic arch is most likely to show which of the following findings?