A 33-year-old Caucasian female presents to your office with a six-month history of cold intolerance.  When the weather is cold, her third and fourth fingers on both hands get numb and turn blue.  She says, ‘I wear gloves to keep my hands warm, but it does not always work’.  Her past medical history is significant for non-ulcer dyspepsia treated with omeprazole.  She does not smoke or consume alcohol, and denies any recreational drug use.  She has no known drug allergies.  She works as a nurse at a local hospital and considers her job moderately stressful.  She is sexually active with her husband and uses condoms for contraception.  Physical examination findings are within normal limits.

Item 1of 2

Which of the following medications is the best initial treatment for this patient?

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The patient returns in one month and complains that the treatment ‘does not help much.’  In addition, she has started to experience periodic joint and muscle pain.  She says that she has been adherent to the medication and has tried to avoid going out in cold weather as much as possible.  Her husband even gave up smoking because you had warned her that passive smoking may worsen her condition.  Which of the following is the best next step in the management of this patient?

A 61-year-old man comes to the emergency department because of severe pain in his right knee over the last 12 hours.  He also has had malaise and low-grade fever.  He has not had any trauma.  He has peptic ulcer disease, type 2 diabetes mellitus, hypertension, and chronic renal insufficiency.  He was hospitalized one year ago for upper gastrointestinal bleeding that required a blood transfusion.  He has smoked one pack of cigarettes daily for 40 years.  He describes himself as a “heavy drinker.”  Temperature is 37.9 C (100.1 F), blood pressure is 152/87 mm Hg, and pulse is 96/min.  BMI is 32 kg/m².  Examination shows a swollen, warm, and tender right knee.  Laboratory results are as follows:

Aspiration of the knee joint is performed.  Compensated, polarized, light microscopic analysis of the aspirate shows intracellular needle-shaped, negatively birefringent crystals.  Gram staining of the synovial fluid shows no bacteria.  Which of the following is the most appropriate next step in management?

A 45-year-old woman comes to the office due to progressive stiffness, pain, and swelling of the joints in the hands and wrists for the past 3 months.  The symptoms are worse when she wakes up and gradually improve after several hours.  The patient also feels fatigued but has had no skin rashes, oral lesions, or fever.  She recently began taking chlorthalidone for hypertension and takes no other medications.  She works in a daycare center.  The patient drinks alcohol occasionally and does not use tobacco or illicit drugs.  Her mother had “arthritis” in her older age, and her sister has systemic lupus erythematosus.  Temperature and other vital signs are within normal limits.  Physical examination shows warmth, swelling, and tenderness of the second and third proximal interphalangeal joints, the metacarpophalangeal joints, and the wrists of both hands.  The remainder of the examination shows no abnormalities.

Item 1 of 3

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 3

A week later, the patient returns to the office and says that her symptoms have improved with the prescribed treatment.  Laboratory results are as follows:

Hand x-rays reveal mild periarticular osteopenia and early erosions of the proximal interphalangeal and metacarpophalangeal joints.  Which of the following is the most appropriate next step in management of this patient?

Item 3 of 3

Additional laboratory results show normal hepatic aminotransferase levels.  The patient is advised to avoid alcohol consumption.  She receives appropriate immunizations, and methotrexate therapy is begun.  Which of the following additional interventions is the most appropriate in this patient?

A healthy 75-year-old African-American man comes to the physician because of persistent lower back pain for the past six months.  The pain disappears when he sits down, improves when he bends over his knees, and gets worse when he extends his back.  A couple of times before, when he was walking, he had a sudden onset of intense pain radiating from his back to his thighs.  His other medical problems include hypertension, gastroesophageal reflux disease and rheumatoid arthritis.  He does not use tobacco, alcohol, or drugs.  He lives in a house with his wife.  His medications include aspirin, atenolol, lansoprazole, and naproxen.  He has no known drug allergies.  On physical examination, straight-leg raising to 90 degrees is negative.  Hyperextension of the lumbar spine produces lumbar pain radiating to the gluteal region.  His pedal pulses are palpable and full.

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Which of the following is the most likely diagnosis?

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Which of the following is the most helpful in establishing the patient’s diagnosis?

A 53-year-old man comes to the office due to progressive pain and stiffness in his hands for the past several months.  The patient’s symptoms are worse in the morning, and he has difficulty shaving or holding a coffee cup.  The stiffness lasts for about 15 minutes and the pain gradually improves through the course of the day, but he often has to take acetaminophen for complete relief.  For the past 3 weeks, he has experienced pain in the left knee, especially after prolonged rest.  The patient has also had progressive fatigue over the past year.  Medical history is notable for type 2 diabetes mellitus, which was diagnosed 6 months ago and is treated with metformin.  He works as a sales representative and does not use tobacco, alcohol, or illicit drugs.  Family history is remarkable for diabetes mellitus in his father.  Temperature is 37.1 C (98.8 F), blood pressure is 126/78 mm Hg, and pulse is 82/min.  Physical examination shows normal jugular venous pressure, clear lung fields, and normal heart sounds.  The abdomen is nondistended, soft, and nontender.  The liver is palpable 1 cm below the right costal margin.  There is moderate swelling, warmth, and mild tenderness and decreased range of motion of the second and third metacarpophalangeal joints in both hands.  A small effusion and tenderness of the left knee is present without any redness.  Radiography of the hand reveals narrowing of the joint space, particularly of the second and third metacarpophalangeal joints, along with subchondral sclerosis, curved osteophytes, subchondral cysts, and osteopenia.  An arthrocentesis of the knee is performed, and the synovial fluid analysis shows a leukocyte count of 20,000 cells/mm³ with 80% neutrophils.  Gram stain shows no organisms, and polarization microscopy reveals positively birefringent rhomboid-shaped crystals.

Item 1 of 2

Which of the following is the most likely cause of this patient’s joint pain?

Item 2 of 2

Additional studies are performed and the diagnosis is established.  If this patient’s current condition remains untreated, he is at greatest risk for which of the following?

A 52-year-old man comes to the office due to difficulty using his left hand.  Over the last year, he has had progressive stiffness at the palm and third and fourth digits, which has led to difficulty doing yard work and typing at his computer.  The patient has tried splints and warm compresses without relief.  He has no history of trauma to the hand and no other musculoskeletal issues.  On examination, the patient has decreased extension at the left third and fourth metacarpophalangeal joints.  Findings of the left hand examination are shown below:

Which of the following is most closely associated with this patient’s condition?