A 23-year-old man complains of lower back pain that began approximately 6 months ago. He is unsure why he is experiencing this pain and notices that this pain is worse in the morning after waking up and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, decreased spinal range of motion, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the most appropriate next test for this patient?
AHLA-B27
BSlit-lamp examination
CMRI sacroiliac joint
DRadiograph sacroiliac joint
EESR
A 46-year-old woman comes to the physician with a 4-month history of lethargy. She has had joint pain for the past 15 years and does not have a primary care physician. Her temperature is 37.4°C (99.3°F), pulse is 97/min, and blood pressure is 132/86 mm Hg. Physical examination shows pallor of the oral mucosa and nontender subcutaneous nodules on both elbows. The distal interphalangeal joints of both hands are flexed and the proximal interphalangeal joints appear hyperextended. Range of motion in the fingers is restricted. The liver span is 6 cm and the spleen tip is palpated 4 cm below the left costal margin. Laboratory studies show: Hematocrit 33% Leukocyte count 1,800/mm3 Segmented neutrophils 35% Lymphocytes 60% Platelet count 130,000/mm3 Increased serum titers of which of the following is most specific for this patient's condition?
AAnti-U1-RNP antibody
BRheumatoid factor
CAntinuclear antibody
DAnti-CCP antibody
EAnti-Sm antibody
A 53-year-old woman presents to her primary care physician with complaints of pain and swelling in her hands and fingers. She states that she has had these symptoms since she was in her 20s, but they have recently become more severe. She states that her wedding ring no longer fits, due to increased swelling of her fingers. She is a 30-pack-year smoker with a body mass index (BMI) of 31 kg/m2. The vital signs include: blood pressure 122/78 mm Hg, heart rate 72/min, and respiratory rate 15/min. On physical exam, a mild systolic murmur is heard over the apex, and her lungs are clear bilaterally. There is swelling of all the digits bilaterally, and a yellow-white plaque is noted beneath 3 of her nail beds. When asked about the plaques, she states that she was given itraconazole for them about 3 weeks ago; however, the plaques did not resolve. When asked further about joint pain, she notes that she has had shoulder and knee pain for the last several years, although she has not sought medical care for this. Which of the following is the best initial step in this patient’s therapeutic management?
AAdminister methotrexate
BAdminister indomethacin
CAdminister indomethacin and methotrexate
DAdminister sulfasalazine
EAdminister indomethacin and sulfasalazine
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