what is the next step here? - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 2 CK Forum

USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 05-27-2012
tyagee's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,365
Threads: 648
Thanked 584 Times in 354 Posts
Reputation: 594
Question what is the next step here?

A 69-year-old woman is evaluated for a progressive 6-month history of fatigue and weakness. She has had painful paresthesias on the dorsum of the right foot for the past 10 days and weakness in the right wrist for the past 2 days. She also has had fever and night sweats accompanied by arthralgia and myalgia. She has had a 4.1-kg (9-lb) weight loss during this time and over the past month has developed anorexia and nausea. Colonoscopy, mammography, and Pap smear performed 2 months ago were normal. Her medical history is otherwise unremarkable, and she takes no medications.
On physical examination, temperature is normal, blood pressure is 155/115 mm Hg, pulse rate is 102/min, and respiration rate is 18/min. BMI is 28. There is jugular venous distention. Cardiac examination reveals a summation gallop. Left and right renal bruits are heard during systole and diastole. The lungs are clear to auscultation. She is unable to dorsiflex the right foot, and extension of the right wrist is weak. There is 2+ ankle edema bilaterally. There are no skin lesions and no evidence of synovitis.

Hemoglobin 10 g/dL (100 g/L)
Erythrocyte sedimentation rate 98 mm/h
Blood urea nitrogen 30 mg/dL (10.7 mmol/L)
Serum creatinine 1.2 mg/dL (106.0 μmol/L)
Antinuclear antibodies Negative
Rheumatoid factor Negative
c-ANCA Negative
p-ANCA Negative
C3 and C4 Normal
Urinalysis 2+ protein; no casts
Urine protein-creatinine ratio 0.36 mg/mg
Serum and urine electrophoreses are negative. Blood cultures are pending. Echocardiography
is negative for valvular disease, valvular vegetation, or tumor. On kidney ultrasound, the
kidneys are 11 cm bilaterally. There is no hydronephrosis.

Which of the following studies is most likely to yield a definitive diagnosis?

(A) Abdominal fat pad aspiration
(B) Angiography of the renal arteries
(C) Kidney biopsy
(D) Skin biopsy
Reply With Quote Quick reply to this message
The above post was thanked by:
yarasara77 (07-13-2012)



  #2  
Old 05-27-2012
USMLE Forums Veteran
 
Steps History: 1+CK+CS+3
Posts: 246
Threads: 18
Thanked 142 Times in 86 Posts
Reputation: 152
Default

Quote:
Originally Posted by tyagee View Post
(A) Abdominal fat pad aspiration
(B) Angiography of the renal arteries
(C) Kidney biopsy
(D) Skin biopsy
agree, amyloidosis picture
peripheral neuropathy , Cardiac failure, Nephrosis, + picture of hidden infection ,inflammation or malignancy

Quote:
fat pad aspiration as the initial biopsy technique for patients with other than single organ involvement, because fat pad aspiration biopsy is less likely than liver, renal, or even rectal biopsy to be complicated by serious bleeding.
UpToDate
Reply With Quote Quick reply to this message
The above post was thanked by:
um aala (05-27-2012)
  #3  
Old 05-27-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,867
Threads: 149
Thanked 2,086 Times in 1,046 Posts
Reputation: 2106
Default

Two things against Amyloidosis:
1. Normal Electrophoresis.
2. Normal Kidney size--Amyloidosis usually causes increase in kidney size.
Reply With Quote Quick reply to this message
The above post was thanked by:
tyagee (05-27-2012)
  #4  
Old 05-27-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,867
Threads: 149
Thanked 2,086 Times in 1,046 Posts
Reputation: 2106
Default

My answer is (B) Angiography of the renal arteries

She has features suggestive of vasculitis+ raised ESR+ Hypertension+ Renal failure + negative ANCAs

The study to most likely to yield a definitive diagnosis is Angiography.

Skin Biopsy will be low yield since she does not have skin lesions.

Kidney Biopsy is dangerous in PAN.

Angiography should be considered if clinically involved tissue is inaccessible.

Quote:
Features of PAN
The American College of Rheumatology (ACR) established criteria for research purposes in order to differentiate PAN from other forms of vasculitis.[6] A committee of ACR physicians selected 10 disease features of PAN; in order for PAN to be diagnosed, at least 3 of the 10 ACR criteria should be present when radiographic or pathological diagnosis of vasculitis is made[6] (See Clinical and Workup.):

Weight loss of 4 kg or more
Livedo reticularis
Testicular pain/tenderness
Myalgia or leg weakness/tenderness
Mononeuropathy or polyneuropathy
Diastolic blood pressure greater than 90 mm/Hg
Elevated blood urea nitrogen (BUN) or creatinine level unrelated to dehydration or obstruction
Presence of hepatitis B surface antigen or antibody in serum
Arteriogram demonstrating aneurysms or occlusions of the visceral arteries
Biopsy of small- or medium-sized artery containing polymorphonuclear neutrophils
Reply With Quote Quick reply to this message
The above post was thanked by:
shyangel18 (05-28-2012), yarasara77 (07-13-2012)
  #5  
Old 05-27-2012
tyagee's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,365
Threads: 648
Thanked 584 Times in 354 Posts
Reputation: 594
Default

what to do when there are characterstic skin lesions? then also, ans is angiography?
Reply With Quote Quick reply to this message
  #6  
Old 05-27-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,867
Threads: 149
Thanked 2,086 Times in 1,046 Posts
Reputation: 2106
Default

Quote:
Originally Posted by tyagee View Post
what to do when there are characterstic skin lesions? then also, ans is angiography?
In that case:
Skin Biopsy--Most accurate test.
Angiography-- Best initial test.
Reply With Quote Quick reply to this message
The above post was thanked by:
bisho (05-28-2012), tyagee (05-28-2012), yarasara77 (07-13-2012)
  #7  
Old 05-28-2012
USMLE Forums Veteran
 
Steps History: 1+CK+CS+3
Posts: 246
Threads: 18
Thanked 142 Times in 86 Posts
Reputation: 152
Default

Daam. This is the 2ed PAN question im missing.
If they give us HBs Ag shall we consider that as initial test or Angio/CT angio is better
Reply With Quote Quick reply to this message
  #8  
Old 05-28-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,867
Threads: 149
Thanked 2,086 Times in 1,046 Posts
Reputation: 2106
Default

Quote:
Originally Posted by bisho View Post
Daam. This is the 2ed PAN question im missing.
If they give us HBs Ag shall we consider that as initial test or Angio/CT angio is better
Best Initial test is always Angio

Most accurate test is Biopsy unless you don't have anything reliable to biopsy (as in this question). Biopsy of the kidney won't give you much but the trouble (you might hit a micro-aneurysm and cause bleeding) since the pathology lies in the arteries NOT the renal parenchyma.
Reply With Quote Quick reply to this message



Reply

Tags
Internal-Medicine-, Rheumatology-, Step-2-Questions

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)