#Rheumatology#Internal_Medicine#Clinical_USMLE_Step2#Lecturio

A 55-year-old woman presents to the clinic because of joint pain and swelling of her hands. She reports that the pain lasts for at least an hour in the morning and improves as her joints "loosen up." The hand pain has been bothering her for almost 2 years but has recently started affecting her daily routine. Her past medical history is significant for hypertension and she takes hydrochlorothiazide daily. Her grandmother and aunt both had rheumatoid arthritis (RA). She has smoked half of a pack of cigarettes a day for the last 35 years. Vital signs are temperature 37.0°C (98.6°F), heart rate 90/min, respiratory rate 16/min, and blood pressure 125/85 mm Hg. Physical examination reveals tender, swollen joints in her hands and wrists. Her left knee is warm and swollen with a significant effusion. Laboratory studies show:

A 64-year-old woman presents to an urgent care clinic with swelling of her lips and difficulty breathing. She had multiple root canal procedures earlier today and started to notice swelling of her lips 2 hours ago. She has had similar episodes after minor procedures but has never had full-blown anaphylaxis. Her blood pressure is 118/76 mm Hg, heart rate is 84/min, and respiratory rate is 16/min. Physical examination is remarkable for edema of her lips and mild inspiratory stridor. The laboratory results are remarkable for a low level of C1 esterase inhibitor. What is the most likely diagnosis?

A 52-year-old thoracic surgeon presents to her primary care provider with eczematous dermatitis on her hands and forearms. She has recently started using a new type of surgical gloves. She washes her hands frequently but has never had issues with skin irritation before. On physical examination, there are erythematous plaques with areas of vesicles on both hands and dorsal forearms. What is the next best step in diagnosing this patient's skin condition?

A 51-year-old woman presents to her primary care provider because of symptoms of dry mouth and dry eyes for several months. It has become so severe that she has difficulty swallowing food. She has a history of hypertension, for which she takes hydrochlorothiazide (HCTZ), but she has no other medical problems. Family history is significant for her grandmother with systemic lupus erythematosus. Her blood pressure is 118/76 mm Hg, heart rate is 78/min, and respiratory rate is 14/min. On physical exam, she has tender parotid glands bilaterally and dry mucous membranes. The presence of serum anti-Ro and anti-La autoantibodies is confirmed at high titers. In addition to her primary diagnosis, what is this patient at risk for developing in the future?

A 34-year-old man presents to his family physician because of ongoing joint pain for several months. Prior to the onset of his arthritis in his right hip, knee, and ankle, he had a gastrointestinal infection that caused bloody diarrhea but it resolved on its own after 2 days. He recovered well but a few weeks later the joint pain started. He took over-the-counter naproxen for a month, then had an aspiration of joint fluid and glucocorticoid injection in his right knee but he still has pain in several joints. The synovial fluid showed inflammation but no crystals or infection. He had temporary relief for 2 weeks, then the pain recurred. A 2-week taper of oral prednisone did not help much; he had significant side effects and does not want to take that again. He has no significant past medical or family history. Review of systems is negative for any GI or genitourinary complaints, and recent lab testing for sexually transmitted infections was all negative. X-rays of the knee and ankle show no specific findings. Today, his vital signs are normal and his right knee and ankle are tender with signs of inflammation. What is the next therapy for this patient's chronic reactive arthritis?

A 62-year-old woman presents to the emergency department because of intense right knee pain that started 12 hours ago. Her past medical history is significant for hemochromatosis, managed with biweekly phlebotomy. Vital signs are blood pressure 130/70 mm Hg, heart rate 82/min, respiratory rate 18/min, and temperature 36.5°C (97.7°F). Physical examination reveals an erythematous, warm, and very tender right knee with decreased range of motion. An arthrocentesis is performed, and synovial fluid analysis is significant for a neutrophil count of 3,200 cells/μL, a negative Gram stain, and the following result under polarized light microscopy (see image). Which of the following additional findings would you expect in this patient?

A 28-year-old woman presents to the office for a follow-up visit. Three months ago, she was evaluated for fatigue, facial rash, swollen hands, and lower extremity edema, and she was diagnosed with systemic lupus erythematosus (SLE) based on clinical findings and abnormal lab results with elevated antinuclear, anti-Sm, and anti-dsDNA antibodies. Therapy with hydroxychloroquine and prednisone was started. She takes her medications reliably and has responded to these medications. Her provider decides to taper prednisone and start a steroid-sparing immunosuppressive agent. Which of the following tests should be done before this patient is started on methotrexate?

A 38-year-old woman is being evaluated by her primary care physician for chronic, widespread pain that started around 5 months ago. This pain has been accompanied by sleeping issues. Her friend recommended that she try yoga to relieve the pain, but she says this has not helped her at all. She says the symptoms have begun to impact her daily functions and keep her from doing things she used to enjoy. Past medical history includes generalized anxiety disorder, for which she currently takes no medication. The patient had been previously successfully medicated with paroxetine for 5 years. On physical examination, several points of tenderness are found on the occipital region, elbows, and medial surface of both knees. A laboratory workup is unremarkable. What is the best treatment option for the most likely diagnosis in this patient?

A 43-year-old man is brought to the emergency department following a work-related accident resulting in the amputation of both arms. The patient lost a substantial amount of blood before arrival, and his bleeding is difficult to control due to arterial damage and wound contamination with debris. His complete blood count (CBC) is significant for a hemoglobin (Hgb) level of 5.3 g/dL. The trauma surgery resident initiates the massive transfusion protocol with O negative whole blood, and the patient receives 6 units. He subsequently develops a fever, chills, hematuria, and pulmonary edema. Several hours later, the patient goes into hemodynamic shock requiring emergent vasopressors. Of the following options, which hypersensitivity reaction occurred?

A 16-year-old boy presents to the emergency department because of the sudden-onset right knee pain. He describes it as the worst pain he has ever felt. He denies any recent trauma or injury to the knee. He is otherwise healthy and has no family history of connective tissue disorders. Vital signs are temperature is 39.1°C (102.4°F), heart rate 104/min, respiratory rate 16/min, and blood pressure 124/82 mm Hg. On physical examination, the right knee is tender with erythema and edema. Which of the following will most likely be found in this patient’s synovial fluid analysis? (WBC = white blood cells, PMNL = polymorphonuclear leukocytes)

A 55-year-old man with a history of fatigue and exertional dyspnea presents to the urgent care clinic following an acute upper respiratory illness. On physical examination, his pulses are bounding, his complexion is very pale, and scleral icterus is apparent. The spleen is moderately enlarged. Oxygen saturation is 79% on room air and he is now requiring oxygen at 9 L by a non-rebreather mask to keep his sats above 92%. Laboratory analysis results show a hemoglobin level of 6.8 g/dL and elevated bilirubin. What type of hypersensitivity reaction does his condition represent?

A 54-year-old man presents with fever, rash, and rectal bleeding that started 3 days ago. He noticed a rash on his legs when he woke up this morning. His past medical history is significant for IV drug abuse. He is not currently taking any medications. The review of systems is significant for  6 kg (13 lb) involuntary weight loss in the last month, and morning joint stiffness and arthralgias. Vital signs are temperature 38.1°C (100.6°F), blood pressure 160/80 mm Hg, heart rate 80/min, respiratory rate 14/min, and oxygen saturation 99% on room air. On physical examination, the patient appears ill and diaphoretic. Cardiac and lung examinations are normal. Abdominal exam is significant for moderate periumbilical and RLQ tenderness without rebound or guarding. Stool guaiac test is positive. A lace-like, erythematous, non-blanching rash is present on the lower extremities bilaterally (see image). Laboratory test results are as follows:

#Rheumatology#Internal_Medicine#Clinical_USMLE_Step2#Lecturio

A 67-year-old man with a long history of joint pain presents to the office for right knee pain and swelling that started this morning. His left ankle was swollen a few weeks ago, but this has improved with ice and ibuprofen. He also has chronic low back pain that makes it difficult for him to be active during the day and significantly worsens after periods of prolonged sitting. Family history is negative for connective tissue disease or malignancy. On review of systems, he has a flaky scalp that is not improving with dandruff shampoo. Physical examination is remarkable for pitting of his nails and a scaly scalp rash on the occipital area and neck. Which of the following is the most likely diagnosis?

A 68-year-old woman presents to the office after receiving a bone mineral density screening test result with a T score of -3.1. She is diagnosed with osteoporosis. Her medical history reveals that she took estrogen-containing oral contraceptive pills for 20 years. She takes ranitidine several times a week for GERD symptoms and lithium for bipolar disorder, which works well for her. She took prednisone for many years as a teen and in her 20s and 30s for asthma but is now doing well with only inhaled medications since she quit smoking at age 40. About 5 years ago, she was diagnosed with hypertension and was started on low-dose hydrochlorothiazide. Which of her medications most likely contributed to the development of her osteoporosis?

A 34-year-old man presents with back pain for the past 6 months. His pain is associated with morning stiffness, and it actually improves with exercise but not with rest. His back pain bothers him most at night. He also has pain in his left ankle. Family history is negative for rheumatologic diseases. On physical examination, there is swelling and warmth over his left Achilles tendon. He has increased spinal kyphosis and tenderness over both sacroiliac joints. Imaging of his SI joints reveals narrowing of the joint spaces and sclerosis of the endplates on the iliac side. What condition does this patient most likely have?

A 64-year-old woman presents to her physician because of a fever and sore throat for 2 days. She was diagnosed with rheumatoid arthritis 15 years ago and has had several flares necessitating admission to the hospital in recent years. She has developed joint deformities despite aggressive therapy and is a candidate for surgical correction. Her temperature is 38.2°C (100.9°F), and the rest of her vital signs are normal. Physical examination of the hands reveals multiple swan-neck and boutonniere deformities and ulnar deviation. There are 3 firm, nontender nodules palpated around the right elbow and one on the left Achilles tendon. Her feet are pronated. The spleen is palpable 5 cm below the costal margin with a percussion span of 15 cm. There is no lymphadenopathy. X-rays of the hands show erosive joint disease. The laboratory test results show:

A 55-year-old man presents to a rheumatologist with bilateral wrist and knee pain that has slowly progressed over the last 10 years. His joint pain gets worse with use and improves a little with rest. He also notes morning stiffness that lasts approximately 20 minutes. The patient was a professional athlete who retired at age 50. He denies joint swelling, color changes in his digits, dryness of mucous membranes, and constitutional symptoms such as fever and chills. On physical exam, the physician notes several non-tender nodules on the left 1st, 3rd, and 4th distal interphalangeal (DIP) joints. There is also tenderness to palpation at the base of both thumbs. The patient’s knees are enlarged, bilaterally, and he has pain and crepitus on passive range of motion. What is the most likely diagnosis?

A 60-year-old-man presents with worsening myalgias and new symptoms of fatigue, muscle weakness, and drooping eyelids. His medical history is significant for gout, hypertension, hypercholesterolemia, and type 2 diabetes mellitus. He had surgery as a teenager for a pilocytic astrocytoma that was completely resected. He is a non-smoker and drinks a 6-pack of beer per day. His vital signs are temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 88/min, and respiratory rate 14/min. Physical examination is significant for minimal bibasilar rales, a grade 2/6 holosystolic murmur, and 3/5 motor strength in all 4 extremities. A test for acetylcholine receptor (AChR) antibodies is positive. Why is a chest CT or MRI scan necessary for this patient?

A 6-year-old boy presents with joint pain in the legs, generalized abdominal pain, poor appetite, headache, and rash for the past 2 days. His mother reports the patient does not have any fever, chills, or past similar symptoms but he did have strep throat 2 weeks ago and took antibiotics. He has no other current medications. The patient is meeting all appropriate developmental milestones, and his vaccinations are up to date. Vital signs are temperature 38.5°C (101.3°F), blood pressure 100/65 mm Hg, pulse 92/min, respiratory rate 20/min, and oxygen saturation 99% on room air. The physical examination is significant for moderate periumbilical tenderness without rebound or guarding. There is palpable purpura present on both lower extremities (see image). Both knees and ankles are warm and tender but without erythema or effusions. Lab results show:

A 48-year-old man presents to establish care with a new family physician as he has been having worsening hand joint pain for the past year. He has not had any regular medical care in the last 20 years. At first, he attributed his pain to his job as a mechanic, but he is mainly supervising now, and recently the pain has gotten worse in the mornings before work. He has associated stiffness for at least an hour and swelling. His knees also hurt, particularly upon standing from a seated position. He no longer gets relief with over-the-counter analgesics. His family history is unknown. He has been a smoker for 23 years. Review of systems is negative for respiratory, CV, GI, or urinary complaints. On physical examination, his wrists and proximal interphalangeal (PIP) joints are warm and swollen. The knees are without effusions. He has no skin rash or other abnormal findings. There is no hepatosplenomegaly. A genital exam is normal. What is the next best step in this patient’s management?

An 18-year-old man is hospitalized after his 6th suicide attempt in the last 5 years; he was admitted to the hospital’s psychiatric unit. He was diagnosed with depression five years ago and takes fluoxetine. He sustained minor injuries, primarily abrasions to his arms and knees, but was ambulatory and X-rays revealed no fractures on admission. A few days into his hospitalization, he develops severe and worsening left knee swelling and pain after his suicide attempt by jumping out of his second-story bedroom window. His blood pressure is 110/72 mm Hg, heart rate is 88/min, and temperature is 38°C (100.4°F). On examination, the knee is erythematous and warm with an effusion. The effusion is drained by needle aspiration, and the fluid shows a leukocyte count of 60,000/µL with 95% neutrophils. The patient’s serum lab studies reveal a hemoglobin level of 11.9 g/dL, leukocyte count of 11,200/µL, and a platelet count of 301,000/µL. What is the most appropriate next step in the management of this patient?

A 31-year-old woman presents with redness and painful swelling of her fingers. Her right knee has also been stiff and slightly swollen for the past 6 weeks. She is overall fatigued and has difficulty moving around but has not sought medical attention until now. On physical examination, the distal interphalangeal (DIP) joints are swollen, warm, and painful; her nails are pitted and cracked. There are also rough, erythematous skin patches with silvery scale on her elbows and knees; these have been present for the last few months. She reports that her father has similar symptoms. They both use hydrating creams and topical glucocorticoids with moderate benefit. What is the most likely cause of her joint pain?

An 8-year-old girl presents to the emergency department with respiratory distress, facial edema, and a skin rash after eating a buffet dinner with her family. Her parents say they were eating at a seafood buffet when the girl suddenly started coughing and complaining of shortness of breath. She has never had this happen before. The patient has a history of seasonal allergies for which she occasionally takes cetirizine. Her blood pressure is 96/60 mm Hg, heart rate is 122/min. and respiratory rate is 22/min. On physical examination, the patient has severe edema over her face and audible stridor. What is the most appropriate next step in the management of this patient?

A 33-year-old African American woman presents to the clinic with a 5-month history of hand and wrist pain and swelling. The symptoms are worse in the morning and are associated with stiffness that lasts for about 15 minutes. She also complains of profound fatigue and decreased appetite. She is sexually active and is in a monogamous relationship. Her past medical history is unremarkable, and she is taking oral contraceptives. She smokes 1–2 cigarettes per day and drinks alcohol socially on weekends. Her temperature is 37.2°C (99.1°F), blood pressure is 130/82 mm Hg, pulse is 76/min, and respirations are 12/min. Physical examination reveals wrists that are tender to palpation, warm, and mildly swollen. Several metacarpophalangeal and proximal interphalangeal joints on both hands are also tender. Hand and wrist strength is 5/5 bilaterally. A non-tender ulcer on the buccal mucosa is also noted. When asked about the ulcer, the patient reports that she has had it for several months and that it does not bother her. Laboratory results are as follows:

A 53-year-old woman presents to her primary care physician for gradually worsening pain in both wrists that began several months ago. The pain has recently affected her daily functioning and has made it difficult to tend to her rose garden. The early morning stiffness in her hands is severe. Ibuprofen has not helped her pain much at all. Her medical history is significant for diabetes mellitus and major depressive disorder. She is currently taking insulin, sertraline, and a daily multivitamin. Her blood pressure is 126/84 mm Hg, heart rate is 82/min, and temperature is 37.0°C (98.6°F). On physical exam, her wrists and metacarpophalangeal joints are edematous, tender, erythematous, and warm to the touch. There are no nodules or vasculitic lesions. Which of the following antibodies is most specific to this patient’s condition?

A 45-year-old man presents to the emergency department because of pain and swelling in his right great toe. The pain is so severe that it woke him up from sleep this morning and he has never had this before. The patient smokes a pack of cigarettes daily for the last 25 years and drinks alcohol heavily each weekend. He has no medical problems requiring medication. His mother died of pancreatic cancer at age 55, and his father died of a stroke 2 years ago. Vital signs are temperature 37.0°C (98.6°F), blood pressure 140/70 mm Hg, heart rate 104/min, respiratory rate 20/min, and BMI 25 kg/m2. The patient is in significant distress due to pain. On examination, the right first metatarsophalangeal (MTP) joint is very tender, swollen, warm, and slightly erythematous. Laboratory studies show:

A 7-year-old boy presents to an urgent care clinic from his friend’s birthday party after experiencing trouble breathing. His father explains that the patient had eaten peanut butter at the party, and soon after, he developed facial flushing and began scratching his face and neck. He has never had this happen before, but his father says they have avoided peanuts and peanut butter because they were worried about their son having an allergic reaction. The patient has no significant medical history and takes no medications. His blood pressure is 94/62 mm Hg, heart rate is 125/min, and respiratory rate is 22/min. On physical examination, his lips are edematous, and he has severe audible stridor. What type of hypersensitivity reaction is this patient most likely experiencing?

A 72-year-old woman presents to the emergency department with complaints of a new-onset, right-sided throbbing headache that becomes markedly worse when eating. The daughter also reports that her mother has recently had difficulties with performing daily activities, such as climbing stairs or standing up. Past medical history is significant for a lower extremity deep vein thrombosis (DVT). Her blood pressure is 124/78 mm Hg, heart rate 72/min, and respiratory rate 15/min. The physical examination is unremarkable except for a right visual field defect. Laboratory studies show:

A 63-year-old African American man with a history of hypertension and dyslipidemia presents to the emergency department with facial swelling and difficulty breathing. His symptoms began suddenly this morning and continued to worsen. He started taking lisinopril several weeks ago. His blood pressure is 110/74 mm Hg, heart rate is 94/min, and respiratory rate is 20/min. Physical examination is notable for swelling of his lips and inspiratory stridor. Clinical lab results show a normal C1 esterase inhibitor level. What is the most likely diagnosis?

A 46-year-old man presents to the emergency department because of severe pain in his right big toe that started 4 hours ago. The pain is so intense that it woke him up from sleep this morning, and it is so uncomfortable that he cannot even let the bed sheets rest on his foot. The patient has smoked 1 pack of cigarettes daily for the last 25 years and drinks alcohol occasionally with friends. He was diagnosed with hypertension a year ago and started taking chlorthalidone. His temperature is 37.0°C (98.6°F), blood pressure is 130/70 mm Hg, heart rate is 100/min, respiratory rate is 18/min, and BMI is 31 kg/m2. The patient is in moderate distress due to the pain. On examination, his right first metatarsophalangeal (MTP) joint is exquisitely tender to light palpation. It is edematous, warm, and erythematous. What test is most helpful in making the diagnosis?

A 28-year-old woman presents to the emergency department complaining of abdominal pain and bloody vaginal discharge with clots. Her last menstrual period was 7 weeks ago. She has been sexually active with a new partner for 3 months and uses condoms inconsistently. She does not smoke cigarettes or drink alcohol. Past medical history is significant for a deep vein thrombosis one year ago treated with anticoagulation for 6 months. She has had 2 miscarriages in the past 3 years. Family history is significant for her mother who died of a stroke at age 50. Vital signs are temperature 38.0°C (100.4°F), blood pressure 110/70 mm Hg, heart rate 98/min, and respiratory rate 16/min. On examination, her lower abdomen is tender over the suprapubic area and vaginal examination reveals an open cervical os with blood pooling in the vagina. Laboratory studies show:

A 4-year-old boy is brought by his mother to the emergency department because of an itchy rash on his trunk, malaise, and fever up to 38.5°C (101.3°F) for the past week. The patient’s mother gave him acetaminophen with little improvement. Birth history was by spontaneous vaginal delivery at full term. The patient’s vaccinations are up-to-date and he has met all developmental milestones. On physical examination, his lips are cracking and he has painful cervical lymphadenopathy. The rash is morbilliform and involves his trunk, palms, and the soles of his feet. There is fine desquamation of the skin of the perianal region. What test should be performed as soon as this patient's diagnosis is suspected?

A 25-year-old woman presents to an urgent care center following a “bee sting” while at a picnic with her friends. She immediately developed a skin rash and swelling over her arms and face and has diffuse itching. She denies any episodes similar to this and has no significant medical history. Her father has a severe allergy to peanuts. Her blood pressure is 92/54 mm Hg, heart rate is 118/min, and respiratory rate is 18/min. On physical examination, the patient has severe facial edema and inspiratory stridor. Which type of hypersensitivity reaction is this patient most likely experiencing?

A 60-year-old man presents to the clinic because of left knee pain and severe swelling for the past few days. He has a history of gout, but it has only affected his foot in the past, and he stopped drinking all alcohol a year ago. He has mild joint pain in his other knee and shoulders, but the left knee is very swollen with fluid. His family history is remarkable for rheumatoid arthritis in his mother. His medications are metformin for diabetes and hydrochlorothiazide for hypertension. Vital signs are temperature 37.6°C (99.8°F), blood pressure 132/65 mm Hg, heart rate 90/min, respiratory rate 14/min, and BMI 32 kg/m2. On examination, his left knee is swollen, warm, tender, and has a significant joint effusion. There is a healing skin abrasion on his left knee that does not appear infected. Cardiopulmonary and abdominal examinations are normal. What is the best test to help clarify the diagnosis in this patient?

A 22-year-old woman with no significant past medical history presents with a 3-day history of knee pain. She denies any recent injury or trauma. She has had 3 sexual partners over the last year and does not use condoms regularly. Her last period was a week ago, and she has no concerns about pregnancy. On physical examination, her knee is warm, erythematous, and has pain with flexion. Vital signs are blood pressure 124/85 mmHg, heart rate 76/min, and temperature 38.3℃ (101.0℉). Joint aspiration is performed, and the Gram stain shows growth of gram-negative diplococci and culture confirms N. gonorrhoeae. What is the recommended treatment for this patient?

A 40-year-old woman presents to her primary care physician with a 2-month history of joint pain and morning stiffness that improves through the course of the day. She reports that her left knee also sometimes bothers her. She has taken ibuprofen and acetaminophen without relief, and the pain is starting to upset her daily routine. On physical examination, the joints of her fingers and wrists are swollen and tender. Her left knee feels warmer than the right. Grip strength is reduced in both hands but sensation is intact. Heart and lung exams are unremarkable. Laboratory studies show:

A 38-year-old woman presents with a rash and progressive muscle weakness over the past couple of weeks. She hasn’t been able to lift her arms to comb her hair for the past few days. She has no significant past medical history and does not take any regular medications. Family history is significant for her mother with scleroderma and an aunt with systemic lupus erythematosus (SLE). On physical examination, motor strength is 3 out of 5 in the upper extremities bilaterally. There is an erythematous area of alternating hypopigmentation and hyperpigmentation with telangiectasias on the extensor surfaces of the arms (see image), the upper chest, and the neck in a "V-shaped" distribution. Laboratory tests are significant for a positive antinuclear antibody (ANA) and elevated creatine kinase. What is the most appropriate initial treatment for this patient?

A 51-year-old man was bitten by a cottonmouth viper and successfully treated with Fab antivenom (sheep immunoglobulin fragments). One week later, the patient returns to the emergency department with an itchy rash on his abdomen and severe pain in his joints. His vital signs are temperature 40.0°C (104.0°F), blood pressure 126/74 mm Hg, heart rate 110/min, and respiratory rate 24/min. His heart and lungs are normal on physical exam except for tachycardia. The skin exam shows a pruritic erythematous patchy rash with serpiginous borders on his abdomen, back, upper trunk, and extremities. What is the next best step in this patient's management?

A 37-year-old woman presents to the occupational health clinic for a new employee health screening. She has limited medical records before immigrating to the US several years ago. She denies any current illness or significant medical history. A purified protein derivative (PPD) test is placed on her forearm for tuberculosis (TB) screening. Approximately 48 hours later, the patient returns for her PPD test reading and has induration measuring 15 mm in diameter at the site of the PPD test placement. Of the following options, which is the mechanism of her reaction?

A 46-year-old woman presents to the clinic complaining of eye irritation. Her eyes are itchy and red. The discomfort has been relatively constant for the last 6 months, and nothing makes it better or worse. Past medical history is significant for hypertension, hyperlipidemia, and aggressive tooth decay, requiring several root canals and the removal and replacement of several teeth. She takes chlorthalidone, atorvastatin, and ibuprofen for tooth pain. She has smoked a pack of cigarettes daily since age 20 and drinks alcohol on the weekends. She does not use illicit drugs. Her family history is unknown as she was adopted. Her temperature is 36.7°C (98°F), blood pressure is 135/65 mm Hg, heart rate is 82/min, and  respiratory rate is 14/min. A slit-lamp eye exam shows no foreign objects. Both eyes appear erythematous and dry. A Schirmer test is abnormal.

A 70-year-old woman visits the office because of dry mouth and dry eyes for several months. She states that she has recently been having difficulty wearing her dentures on account of her dry mouth. She also says that her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food. Her eyes have also been burning, and she has had to use over-the-counter eye drops often. The patient has a history of hypertension, for which she takes lisinopril. On physical exam, mild bilateral enlargement of the parotid glands is noted, and an oral examination reveals a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa. What is the best first step in this patient’s management?

#Rheumatology#Internal_Medicine#Clinical_USMLE_Step2#Lecturio