12-12-2008, 11:16 AM
A 55-year-old man is evaluated in the emergency department for a several-day history of weakness in his hands and a painful, bluish discoloration of several fingers on both hands. He has also had a 4.5-kg (10-lb) weight loss and intermittent low-grade fever over the past 2 weeks.
His history includes seropositive rheumatoid arthritis that was diagnosed 7 years ago and hypertension. In addition to methotrexate therapy for his rheumatoid arthritis, his medications include naproxen, prednisone, hydrochlorothiazide, and atenolol. He does not smoke and rarely drinks alcohol.
On physical examination, his blood pressure is 120/80 mm Hg, respiration rate is 14/min, pulse rate is 105/min, and temperature is 37.7 °C (99.8 °F). His radial and ulnar pulses are intact, but his hand grip is weak on the left, and he has a right-wrist drop. He also has foot dorsiflexion weakness bilaterally, which is greater in the right foot than in the left foot. Plantar flexion appears intact. The remainder of the musculoskeletal examination shows chronic rheumatoid deformities of the small joints of the hands and feet, slight elbow flexion contractures, and rheumatoid nodules on the extensor surfaces of the forearms.
Which of the following is the most likely cause of this patient's symptoms?
( A ) Buerger's disease
( B ) Rheumatoid vasculitis
( C ) Excessive β-blockade
( D ) Atherosclerosis
( E ) Cholesterol emboli syndrome
His history includes seropositive rheumatoid arthritis that was diagnosed 7 years ago and hypertension. In addition to methotrexate therapy for his rheumatoid arthritis, his medications include naproxen, prednisone, hydrochlorothiazide, and atenolol. He does not smoke and rarely drinks alcohol.
On physical examination, his blood pressure is 120/80 mm Hg, respiration rate is 14/min, pulse rate is 105/min, and temperature is 37.7 °C (99.8 °F). His radial and ulnar pulses are intact, but his hand grip is weak on the left, and he has a right-wrist drop. He also has foot dorsiflexion weakness bilaterally, which is greater in the right foot than in the left foot. Plantar flexion appears intact. The remainder of the musculoskeletal examination shows chronic rheumatoid deformities of the small joints of the hands and feet, slight elbow flexion contractures, and rheumatoid nodules on the extensor surfaces of the forearms.
Which of the following is the most likely cause of this patient's symptoms?
( A ) Buerger's disease
( B ) Rheumatoid vasculitis
( C ) Excessive β-blockade
( D ) Atherosclerosis
( E ) Cholesterol emboli syndrome