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Old 09-22-2012
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Arrow Gyrus Daily Questions; Internal Medicine #17

A 43-year-old male presents to your office complaining of weakness in the right hand for 2 days. He reports that he had been in excellent health until 2 months ago, when he was diagnosed with hypertension. Since that diagnosis, he has lost 20 lb unintentionally and complains of frequent headaches and abdominal pain that is worse after eating. He previously was an injection drug
user but now is maintained on methadone. His only medications are hydrochlorothiazide 25 mg/d, methadone 70 mg/d, and lisinopril 5 mg/d. On physical examination, the patient appears well developed and without distress. Blood pressure is 148/94. He is not tachycardic. The examination is otherwise notable only for the inability to extend the right wrist and fingers against gravity. Laboratory studies show an erythrocyte sedimentation rate (ESR) of 88 mm/h, an aspartate aminotransferase (AST) of 154 IU/L, and an alanine aminotransferase (ALT) of 176 IU/L. Which of the following tests is most useful in establishing a diagnosis?

A. Hepatitis B surface antigen
B. Hepatitis C viral load
C. Anticytoplasmic neutrophil antibodies
D. Mesenteric angiography
E. Radial nerve biopsy
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Old 09-22-2012
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Nice question. I am posting this post because I know the answer. I just want to follow this thread to know the correct answer and reasoning
Ya have to answer something
Would go with
C. Anticytoplasmic neutrophil antibodies
As disease looks systemic to me with lot of manifestations


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Old 09-22-2012
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I think E .......bcoz It looks like PAN

Most accurate test is biopsy of involved areas.....
If biopsy cannot be done, then angiography is best test.......
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Old 09-22-2012
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I would say E, this looks like PAN

The question asks "Establishing a diagnosis", which for me looks like "most accurate or definitive test"

If the question would asked: next step in management or first step then P-ANCA would be my choice..

But we never know with USMLE haha
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Old 09-22-2012
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The answer is E.

This patient most likely has polyarteritis nodosa with a symptom complex consisting of abdominal pain, weight loss, hypertension, and mononeuritis. Polyarteritis nodosa (PAN) is an uncommon vasculitis that affects primarily medium- size arteries without the involvement of venules. There are no diagnostic serologic tests for PAN. Up to 30% of patients with PAN are positive for hepatitis B surface antigen.

In cases of PAN associated with hepatitis B, the virus, IgM, and complement can be demonstrated in vessel walls on biopsy. In light of the patientís past history of injection drug use, the presence of hepatitis B should be evaluated. However, demonstration of hepatitis B surface antigen is not diagnostic of PAN. ANCA is rarely positive in PAN patients, and hepatitis C is associated with cryoglobulinemic vasculitis but not with PAN.

With the patientís abdominal pain that is worsened with eating, mesenteric ischemia caused by vasculitis should be considered. On mesenteric angiography, one would expect to find aneurysmal dilatation of the arteries. Again, however, this is not pathognomonic for PAN.

The most definitive way to diagnose PAN is by finding vasculitis on a biopsy of the affected nerve. Therefore, a radial nerve biopsy should be pursued.

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Old 09-22-2012
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OMg I love your explanations and drawings gyrus! keep them coming! haha
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