MKSAP: 21-year-old woman with a rash in the lower extremities
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 21-year-old woman is evaluated for a 3-week history of painful nodules and a rash in the lower extremities, along with pain and swelling of the wrists, knees, and ankles. She reports a low-grade fever and a 2.7-kg (6.0-lb) weight loss since the onset of symptoms. She has taken naproxen with some relief. History is significant for gastroesophageal reflux disease and acne. Medications are over-the-counter famotidine as needed and minocycline.
On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is 110/60 mm Hg, pulse rate is 92/min, and respiration rate is 16/min. BMI is 24. Mild swelling of the wrists, knees, and ankles is noted. There are scattered 1- to 2-cm painful erythematous nodules as well as livedo reticularis in the lower extremities beginning at the thighs. The remainder of the examination is normal.
Laboratory studies:
Antinuclear antibodies
Positive (titer: 1:320)
Anti–double-stranded DNA antibodies
Negative
Anti-Smith antibodies
Negative
Anti-U1-ribonucleoprotein antibodies
Negative
Anti-Ro/SSA antibodies
Negative
Anti-La/SSB antibodies
Negative
Antihistone antibodies
Negative
ANCA
Positive (titer: 1:320) in a perinuclear pattern; negative for myeloperoxidase
Urinalysis
Normal
Chest radiograph is normal.
Which of the following is the most appropriate next step in management?
A: Start azathioprine
B: Star...
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: mksap Tags: Conditions Rheumatology Source Type: blogs
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