A 35-year-old pharmacist complains of "hurting all over." Her pain is particularly bad in her upper back and shoulders, and she notes morning stiffness. On examination, her joints are not inflamed, but she has symmetric "tender points" in the posterior neck, anterior chest, lateral buttocks, medial knees, and lateral elbows. You make a preliminary diagnosis of fibromyalgia.Which one of the following diagnostic tests should you order?
Answer(s): C
Sleep disturbance is a characteristic symptom associated with fibromyalgia. Patients awaken feeling tired.The examination, other than tenderness in 14 specific, symmetrical points, is usually normal. Fever, rash on the extremities, muscle weakness, and migratory joint inflammation point to Lyme disease or other rheumatologic disorders. Asedimentation rate should be normal. If elevated, it may point to another diagnosis. Lyme titers are not indicated unless the patient has symptoms or history suggestive of the disease. Electromyelography and spine radiographs are typically normal and unnecessary for help in establishing the diagnosis.Depression can be associated with pain, but screening for it early on does not make sense and might offend the patient. Low-dose antidepressants often help to correct the sleep pattern and result in relief of pain. Nonsteroidal anti-inflammatory agents can also be used as needed; low-dose steroid is not indicated.Exercise is also helpful, and patients should be encouraged to stay physically active. Amoxicillin is not used for fibromyalgia. Benzodiazepines have addictive potential and lose their effectiveness for sleep after a few weeks.
A 35-year-old pharmacist complains of "hurting all over." Her pain is particularly bad in her upper back and shoulders, and she notes morning stiffness. On examination, her joints are not inflamed, but she has symmetric "tender points" in the posterior neck, anterior chest, lateral buttocks, medial knees, and lateral elbows. You make a preliminary diagnosis of fibromyalgia.Which of the following is the most appropriate therapeutic recommendation?
Answer(s): E
A 62-year-old man is undergoing neurologic evaluation. His arteriogram demonstrates the lesion shown in the figure below. Which of the following deficits is compatible with this lesion?
Answer(s): B
The cerebral arteriogram shown in Figure reveals severe stenosis of the common carotid artery proximal to its bifurcation, as well as small lesions in the more distal vessels. Common manifestations are transient monocular blindness (amaurosis fugax), hemiparesis, hemisensory loss, aphasia, and homonymous visual field defects. Ataxia would be an unusual feature of carotid disease and, if present, would suggest involvement of the vertebrobasilar arteries, which results in dysarthria, diplopia, and vertigo.
A 30-year-old woman who has been human immunodeficiency virus (HIV) positive for 4 years was recently diagnosed with AIDS.Which of the following immunologic abnormalities would be expected?
The new case definition for AIDS in 1993 added pulmonary tuberculosis, invasive cervical cancer, and recurrent pneumonia. This CDC classification system is divided into three categories: category A is symptomatic infection with HIV and includes acute illness and persistent lymphadenopathy; category B includes conditions attributed to HIV infection, such as oral thrush, herpes zoster, and peripheral neuropathy; category C is the AIDS surveillance cases. Anergy to common skin test antigens is a common finding with HIV infection. There is a decline in CD4 cell numbers, a relative increase in the number of T8 cells, which results in a decreased T4:T8 ratio of less than 1. Functional abnormalities occur in both B cells and natural killer cells, which accounts for the increase in certain bacterial infections seen in advanced HIV disease. Elevation of beta2 submicroglobulin, a serologic finding reflecting immunologic dysfunction, is a fairly reliable marker of progressive immunologic decline and the subsequent development of AIDS.
When you examine the back of an elderly gentleman, you note multiple brown papules and nodules having a "stuck on" appearance. These are shown in Figure. The patient tells you they have been there for years.Which of the following is the most likely diagnosis?
This man has multiple seborrheic keratoses, which are very common, benign pigmented tumors that occur after age 30, especially on the trunk and face. Melanocytic nevi are usually small, circumscribed, pigmented macules or papules, rather than large "stuck-on" nodules. Actinic keratoses are red, scaly (not dark) lesions on the face and arms that are from suninduced damage. Seborrheic dermatitis is a red, scaly rash along the scalp, eyebrows, and nasolabial folds. Malignant melanoma would be in the differential if it were a single lesion.
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