Rheumatology Case Study: Patient 1
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Questions and Answers

What is the patient's hemoglobin level?

  • 12.8 g/dL (correct)
  • 14.8 g/dL
  • 16.8 g/dL
  • 10.8 g/dL

    • What is the patient's erythrocyte sedimentation rate?

  • 44 mm/h (correct)
  • 39 mm/h
  • 49 mm/h
  • 34 mm/h

    • What is the most likely diagnosis based on the patient's laboratory results?

  • Gout
  • Osteoarthritis
  • Rheumatoid arthritis (correct)
  • Systemic lupus erythematosus

    • What is the patient's serum creatinine level?

    <p>1.1 mg/dL</p> Signup and view all the answers

    What is the patient's alkaline phosphatase level?

    <p>33 U/L</p> Signup and view all the answers

    What is the most appropriate next step in management for the patient?

    <p>Arthrocentesis</p> Signup and view all the answers

    What is the patient's leukocyte count?

    <p>9800/mm3</p> Signup and view all the answers

    What is the most appropriate pharmacotherapy for the 42-year-old woman?

    <p>Hydroxychloroquine</p> Signup and view all the answers

    What is the most likely diagnosis for the 42-year-old woman?

    <p>Rheumatoid arthritis</p> Signup and view all the answers

    What is the patient's hemoglobin level according to the laboratory studies?

    <p>8.2 mg/dL</p> Signup and view all the answers

    What is the patient's serum albumin level?

    <p>2.8 g/dL</p> Signup and view all the answers

    What is the most likely cause of the patient's findings based on the laboratory studies?

    <p>Decreased hepatic albumin production</p> Signup and view all the answers

    What is the patient's total bilirubin level?

    <p>1.0 mg/dL</p> Signup and view all the answers

    What is the patient's urine protein level?

    <p>3+</p> Signup and view all the answers

    What is the most likely diagnosis for the 50-year-old woman's knee pain?

    <p>Gonococcal arthritis</p> Signup and view all the answers

    What is the result of the arthrocentesis of the knee with synovial fluid analysis?

    <p>Greenish, turbid fluid with 68,000 WBC/μL</p> Signup and view all the answers

    What is the patient's temperature?

    <p>38.5°C (101.3°F)</p> Signup and view all the answers

    What is the expected finding on an x-ray of the affected knee?

    <p>Soft tissue swelling</p> Signup and view all the answers

    What is the most likely diagnosis for a patient who is anxious and has a flat affect, with an inability to follow their sequence of thoughts?

    <p>Schizophrenia</p> Signup and view all the answers

    What is the primary concern of a 24-year-old male graduate student who believes he is in danger from strangers on the street?

    <p>Fear of being harmed by strangers</p> Signup and view all the answers

    What is the most likely diagnosis for a patient who has delusional thoughts, but no decline in academic performance?

    <p>Delusional disorder</p> Signup and view all the answers

    What is the primary presentation of a 23-year-old woman who has increasingly isolated herself in college and received poor grades?

    <p>Social withdrawal and poor academic performance</p> Signup and view all the answers

    What is the most likely diagnosis for a patient who is anxious and has a flat affect, but with no evidence of hallucinations?

    <p>Mood disorder with psychotic features</p> Signup and view all the answers

    What is the primary concern of a patient who believes a pedestrian getting hit by a car was a warning sign?

    <p>Fear of being harmed by strangers</p> Signup and view all the answers

    What is the most likely diagnosis for a patient who has repetitive thoughts and anxiety, but with no evidence of hallucinations?

    <p>Obsessive-compulsive disorder</p> Signup and view all the answers

    What is the primary presentation of a patient who is alert and oriented, with organized thought processes and speech?

    <p>Normal mental status</p> Signup and view all the answers

    What is the most likely diagnosis for a patient who has a 2-month history of repetitive thoughts and anxiety, triggered by a traumatic event?

    <p>Post-traumatic stress disorder</p> Signup and view all the answers

    What is the most likely location of the acute myocardial infarction in the 61-year-old man?

    <p>Left coronary artery</p> Signup and view all the answers

    What is the most likely histopathological finding in the affected tissue of the 61-year-old man?

    <p>Neutrophilic infiltration</p> Signup and view all the answers

    What is the most likely cause of death in the 61-year-old man who died 10 minutes after arrival at the hospital?

    <p>Ventricular fibrillation</p> Signup and view all the answers

    What is the most likely cause of the 48-year-old man's dyspnea and productive cough with frothy sputum?

    <p>Cardiac failure</p> Signup and view all the answers

    What is the most likely significance of the Q waves in the anteroseptal leads in the 48-year-old man?

    <p>Indicative of a previous myocardial infarction</p> Signup and view all the answers

    What is the most likely cause of the scratchy sound heard over the left sternal border in the 61-year-old man?

    <p>Pericardial friction rub</p> Signup and view all the answers

    What is the most likely effect of the patient's leaning forward on their symptoms?

    <p>Decreased chest pain</p> Signup and view all the answers

    What is the most likely mechanism of the 61-year-old man's chest pain?

    <p>Pericardial inflammation</p> Signup and view all the answers

    What is the most likely relationship between the patient's pulmonary capillary wedge pressure and their symptoms?

    <p>Increased pulmonary capillary wedge pressure causes increased dyspnea</p> Signup and view all the answers

    What is the patient's hemoglobin level?

    <p>10.1 g/dL</p> Signup and view all the answers

    What is the patient's total bilirubin level?

    <p>2.0 mg/dL</p> Signup and view all the answers

    What is the patient's α-fetoprotein level?

    <p>8 ng/mL</p> Signup and view all the answers

    What is the most likely cause of the patient's skin lesions?

    <p>Increased circulating estrogen</p> Signup and view all the answers

    What is the patient's platelet count?

    <p>89,000/mm3</p> Signup and view all the answers

    What is the patient's leukocyte count?

    <p>4300/mm3</p> Signup and view all the answers

    What is the patient's prothrombin time?

    <p>11 sec</p> Signup and view all the answers

    What is the patient's serum albumin level?

    <p>3 g/dL</p> Signup and view all the answers

    What type of antibody is most likely to be positive in the 42-year-old woman with joint pain and swelling?

    <p>Rheumatoid factor</p> Signup and view all the answers

    What is the most likely explanation for the patient's thrombocytopenia?

    <p>Liver cirrhosis</p> Signup and view all the answers

    What is the most likely diagnosis based on the patient's symptoms and laboratory results?

    <p>Cirrhosis</p> Signup and view all the answers

    What is the most likely cause of the patient's increased carbohydrate-deficient transferrin?

    <p>Alcohol consumption</p> Signup and view all the answers

    What is the most likely effect of the patient's cirrhosis on their cardiovascular system?

    <p>Decreased systemic vascular resistance</p> Signup and view all the answers

    What is the most likely relationship between the patient's liver disease and their cardiac function?

    <p>Liver disease worsens cardiac function</p> Signup and view all the answers

    What is the most likely complication of the patient's cirrhosis?

    <p>Portal hypertension</p> Signup and view all the answers

    What is the primary reason for the physician's advice to perform a comprehensive eye examination in the child?

    <p>To diagnose associated eye abnormalities</p> Signup and view all the answers

    What is the most likely cause of this patient's condition?

    <p>A defect in tyrosinase</p> Signup and view all the answers

    What is the most likely diagnosis for the 52-year-old woman's knee pain?

    <p>Osteoarthritis</p> Signup and view all the answers

    What is the most appropriate next step in the management of the 52-year-old woman's knee pain?

    <p>Weight loss program</p> Signup and view all the answers

    What is the likely underlying cause of the 67-year-old woman's bilateral knee pain?

    <p>Osteoarthritis</p> Signup and view all the answers

    What is the significance of crepitus heard on flexion and extension of the knee joint?

    <p>Indicative of joint degeneration</p> Signup and view all the answers

    What is the likely effect of the 52-year-old woman's hypertension on her knee pain?

    <p>It has no effect on her knee pain</p> Signup and view all the answers

    What is the most likely electrocardiographic finding in a patient with an acute posterior myocardial infarction?

    <p>ST depression in leads V1-V3</p> Signup and view all the answers

    What is the most likely underlying cause of a patient's symptoms with an electrocardiogram showing ST elevation in leads II, III, and aVF?

    <p>Acute inferior myocardial infarction</p> Signup and view all the answers

    What is the most likely cause of a patient's symptoms with a history of type 2 diabetes mellitus and a serum troponin level of 3.0 ng/mL?

    <p>Acute myocardial infarction</p> Signup and view all the answers

    What is the most likely finding on coronary angiography in a patient with an acute myocardial infarction and ST elevation in leads V3-V6?

    <p>Occlusion of the left anterior descending artery</p> Signup and view all the answers

    What is the most likely effect of type 2 diabetes mellitus on the development of coronary artery disease?

    <p>Increased risk of coronary artery disease</p> Signup and view all the answers

    What is the most likely location of the acute myocardial infarction in a patient with ST elevation in leads I and aVL?

    <p>Lateral wall</p> Signup and view all the answers

    What is the most likely significant finding on cardiac catheterization in a patient with an acute myocardial infarction?

    <p>All of the above</p> Signup and view all the answers

    What is the most likely cause of the newborn's condition?

    <p>Defect in intracellular transport of melanosomes</p> Signup and view all the answers

    What type of cells are most likely affected in the patient's current condition?

    <p>Langerhans cells</p> Signup and view all the answers

    Which of the following histopathological features would be most consistent with carcinoma in situ?

    <p>Dysplastic keratinocytes</p> Signup and view all the answers

    What is the most likely diagnosis based on the patient's symptoms and physical examination?

    <p>Viral meningitis</p> Signup and view all the answers

    What is the most likely cause of the patient's skin lesion?

    <p>Squamous cell carcinoma</p> Signup and view all the answers

    What is the most likely type of virus that infected the patient?

    <p>Enveloped, single-stranded, positive-sense RNA virus</p> Signup and view all the answers

    What is the most likely histopathological feature of the patient's skin lesion?

    <p>Dysplastic keratinocytes</p> Signup and view all the answers

    What is the most likely diagnosis for the patient with knee pain and swelling?

    <p>Septic arthritis</p> Signup and view all the answers

    What is the significance of the greenish, turbid fluid in the patient's synovial fluid analysis?

    <p>Indicates the presence of bacteria</p> Signup and view all the answers

    What is the most likely cause of the patient's elevated alkaline phosphatase level?

    <p>Liver disease</p> Signup and view all the answers

    What is the significance of the patient's proteinuria?

    <p>Indicates kidney damage</p> Signup and view all the answers

    What is the most likely cause of the patient's elevated urea level?

    <p>Kidney disease</p> Signup and view all the answers

    What is the significance of the patient's Gram-negative diplococci in the synovial fluid analysis?

    <p>Indicates the presence of Neisseria gonorrhoeae</p> Signup and view all the answers

    What is the most likely explanation for the patient's worsening pain and swelling in the knee?

    <p>Infection of the joint</p> Signup and view all the answers

    What is the likely cause of the patient's jaundice?

    <p>Portal hypertension</p> Signup and view all the answers

    What is the indication for the administration of octreotide in this patient?

    <p>Gastrointestinal bleeding</p> Signup and view all the answers

    What is the likely diagnosis in the 76-year-old woman with upper abdominal pain and dyspnea?

    <p>Myocardial infarction</p> Signup and view all the answers

    What is the purpose of administering aspirin to the 76-year-old woman?

    <p>To prevent myocardial infarction</p> Signup and view all the answers

    What is the likely cause of the patient's abdominal distension and swelling of the legs?

    <p>Portal hypertension</p> Signup and view all the answers

    What is the indication for the administration of ceftriaxone in this patient?

    <p>Sepsis</p> Signup and view all the answers

    What is the likely effect of the patient's diabetes mellitus on their cardiac function?

    <p>Decreased cardiac output</p> Signup and view all the answers

    What is the purpose of placing two large intravenous catheters in the patient?

    <p>To provide fluid resuscitation</p> Signup and view all the answers

    What is the likely diagnosis in the patient with ascites and dilated veins in the periumbilical region?

    <p>Portal hypertension</p> Signup and view all the answers

    What is the purpose of administering metoprolol to the 76-year-old woman?

    <p>To manage hypertension</p> Signup and view all the answers

    Study Notes

    Laboratory Studies

    • Hemoglobin: 12.8 g/dL
    • Leukocyte count: 9800/mm3
    • Erythrocyte sedimentation rate: 44 mm/h
    • Serum:
      • Glucose: 77 mg/dL
      • Creatinine: 1.1 mg/dL
      • Total bilirubin: 0.7 mg/dL
      • Alkaline phosphatase: 33 U/L
      • AST: 24 U/L
      • ALT: 21 U/L
      • Rheumatoid factor: positive

    Patient 1

    • 42-year-old woman with 8-month history of intermittent pain and stiffness in hands and feet
    • Episodes occur 3 times a month, last for approximately 1 hour, and are sometimes accompanied by fever and myalgia
    • Takes ibuprofen for pain relief
    • Sister has systemic lupus erythematosus
    • Vital signs are within normal limits
    • Examination shows mild swelling and tenderness of wrists and proximal interphalangeal joints of both hands

    Patient 2

    • 46-year-old woman with 4-month history of lethargy and joint pain for 15 years
    • Temperature: 37.4°C (99.3°F), pulse: 97/min, blood pressure: 132/86 mm Hg
    • Physical examination shows pallor of oral mucosa and nontender subcutaneous nodules on both elbows
    • Laboratory studies:
      • Hemoglobin: 8.2 mg/dL
      • Prothrombin time: 12 sec
      • Serum:
        • Albumin: 2.8 g/dL
        • Total bilirubin: 1.0 mg/dL
        • Alkaline phosphatase: 80 U/L
        • AST: 20 U/L
        • ALT: 19 U/L
        • Urea: 18 mg/dL
        • Creatinine: 1.2 mg/dL
      • Urine:
        • Protein: 3+
        • WBCs: 5-10/hpf
        • RBCs: negative
        • Bacteria: negative

    Patient 3

    • 50-year-old woman with worsening pain and swelling of left knee
    • For the past year, she has had pain in her knees and hands bilaterally, but never this severe
    • During this period, she has also had difficulty moving around for about an hour in the mornings and has been sweating more than usual, especially at night
    • She has been sexually active with a new partner for the past 4 weeks and they use condoms inconsistently
    • Temperature: 38.5°C (101.3°F), pulse: 92/min, blood pressure: 110/70 mm Hg
    • The left knee is erythematous, swollen, and tender, with restricted movement due to pain
    • There is swelling of the metacarpophalangeal joints and proximal interphalangeal joints bilaterally
    • Arthrocentesis of the knee with synovial fluid analysis shows a greenish, turbid fluid, a cell count of 68,000 WBC/μL, and Gram-negative diplococci

    Patient 4

    • 47-year-old man with alcoholic cirrhosis
    • Examination shows erythema over the thenar and hypothenar eminences of both hands
    • He also has numerous blanching lesions over the trunk and upper extremities that have a central red vessel with thin extensions radiating outwards

    Patient 5

    • 59-year-old man with progressive abdominal swelling and shortness of breath for 1 week
    • He drinks 12 to 13 alcoholic beverages daily
    • He appears emaciated
    • Examination shows pallor, jaundice, hepatomegaly, gynecomastia, and a protuberant abdomen with a fluid wave and shifting dullness

    Patient 6

    • 61-year-old man with acute myocardial infarction
    • He has sharp, substernal chest pain that worsens with inspiration and improves when leaning forward
    • Cardiac examination shows a scratchy sound best heard over the left sternal border

    Patient 7

    • 61-year-old man who died 10 minutes after arrival at the emergency department
    • He was brought to the emergency department by ambulance due to severe retrosternal chest pain and shortness of breath for 30 minutes
    • Paramedics reported that an ECG recorded en route to the hospital showed ST-segment elevation in I, aVL, and the precordial leads

    Patient 8

    • 48-year-old man who develops dyspnea and a productive cough with frothy sputum 72 hours after admission for acute myocardial infarction
    • Physical examination shows coarse crackles in both lungs and a blowing, holosystolic murmur heard best at the apex
    • ECG shows Q waves in the anteroseptal leads
    • Pulmonary capillary wedge pressure is 23 mm Hg

    Patient 9

    • 24-year-old male graduate student with a 2-month history of repetitive thoughts and anxiety that he is going to be harmed by a stranger on the street
    • The anxiety worsened after witnessing a pedestrian getting hit by a car 2 weeks ago
    • He says, “That was a warning sign”
    • On his way to school, he often leaves an hour early to take a detour and hide from people who he believes might hurt him
    • He says his friends are concerned about him but that they do not understand because they were not present at the accident

    Patient 10

    • 23-year-old woman with strange behavior for the past 6 months
    • The father reports that his daughter has increasingly isolated herself in college and received poor grades

    Pediatrics - Dermatology

    • A skin biopsy shows a normal number of epidermal and follicular melanocytes, suggesting a potential diagnosis that may require a comprehensive eye examination and genetic testing.
    • The most likely cause of this patient's condition is a defect in the enzyme tyrosinase (D).

    Family Medicine - Osteoarthritis

    • A 52-year-old woman presents with a 3-week history of knee pain, worse at the end of the day and when walking.
    • Examination shows no tenderness or erythema, but limited range of motion and crepitus.
    • The most appropriate next step in management is a weight loss program (B).

    Family Medicine - Rheumatology

    • A 67-year-old woman presents with bilateral knee pain for the past year, worse with movement and relieved with rest.
    • Rheumatoid factor (D) is a potential test to order for this patient.

    Surgery - Cirrhosis

    • A 44-year-old man presents with increasing fatigue, abdominal distension, and erythema on both palms.
    • Laboratory studies show abnormal liver function tests, including elevated total bilirubin and carbohydrate-deficient transferrin.
    • The most likely explanation for this patient's thrombocytopenia is cirrhosis (c).

    Cardiology

    • A 56-year-old man presents with nausea, shortness of breath, and lightheadedness, with an electrocardiogram showing ST-segment elevation.
    • The most likely underlying cause of this patient's symptoms is an acute inferior myocardial infarction (e).
    • A 54-year-old woman presents with a 2-hour history of nausea and retrosternal chest pain, with an electrocardiogram showing ST-segment elevation.
    • The most likely underlying cause of this patient's symptoms is an acute myocardial infarction (ST-segment elevation in leads I, VR), treated with cardiac catheterization and percutaneous coronary intervention.

    Dermatology - Skin and Skin Appendages

    • A 3400-g newborn presents with pale skin, blond hair, and blue irides, with a defect in the enzyme tyrosinase (D) as the most likely cause of this newborn's condition.
    • A 32-year-old man presents with fever, nausea, headache, and confusion, with an enveloped, single-stranded, positive-sense RNA virus.
    • The cells most likely affected in this patient's condition are analogous to Langerhans cells (F).
    • A 74-year-old man presents with a skin lesion on his right arm, with a biopsy specimen showing carcinoma in situ.
    • A 50-year-old woman presents with worsening pain and swelling of her left knee, with Gram-negative diplococci on synovial fluid analysis.
    • An x-ray of the affected knee is likely to show joint space narrowing and osteophyte formation.

    Gastroenterology - Cirrhosis

    • A 65-year-old man presents with progressive abdominal distension and swelling of his legs, with a history of ulcera ve colitis.
    • The abdominal findings are most likely caused by increased blood flow in the superior epigastric vein (D).

    Medicine - Myocardial Infarction

    • A 76-year-old woman presents with a 1-day history of upper abdominal pain, nausea, and dyspnea, with a recent history of an inferior wall myocardial infarction.
    • She has a history of type 2 diabetes mellitus and recently diagnosed Alzheimer disease.

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    Description

    A 42-year-old woman presents with intermittent pain and stiffness in her hands and feet. Analyze her laboratory results to diagnose and manage her condition.

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