MKSAP: 23-year-old woman with stiffness and achiness of the hands
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 23-year-old woman is evaluated for a 1-year history of morning stiffness and achiness of the hands as well as Raynaud phenomenon. Two months ago, she experienced a sun-induced rash on the chest and back and patches of discoloration on the hands.
On physical examination, temperature is 36.4 °C (97.5 °F), blood pressure is 106/66 mm Hg, pulse rate is 60/min, and respiration rate is 16/min. The lungs are clear. Erythematous, violaceous, clumped papules over the extensor surfaces of the elbows, metacarpophalangeal joints, and proximal interphalangeal joints are present; there are nailfold capillary abnormalities with cuticular hypertrophy. Bilateral proximal upper and lower extremity weakness is noted; there is tenderness of the metacarpophalangeal and proximal interphalangeal joints bilaterally without synovitis.
Laboratory studies reveal an erythrocyte sedimentation rate of 82 mm/h, a serum creatine kinase level of 650 units/L, and an antinuclear antibody titer of 1:160 (speckled pattern).
Chest radiograph is normal. Electromyography shows muscle irritability without evidence of neuropathy.
Which of the following is the most appropriate initial treatment?
A: Intravenous immune globulin
B: Prednisone
C: Prednisone and azathioprine
D: Prednisone and methotrexate
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Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: mksap Tags: Conditions Rheumatology Source Type: blogs
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