04-07-2015, 03:15 PM
A 62-year-old white man comes to the physician because of an 8-month history of progressive pain and stiffness of
his hands. The stiffness is worse at the end of the day. He has a 1-year history of fatigue and increased urination. He
has no history of serious illness and takes no medications. His last visit to a physician was 10 years ago. He does not
smoke or drink alcohol. He is 185 cm (6 ft 1 in) tall and weighs 82 kg (180 lb); BMI is 24 kg/m2. His pulse is
84/min, and blood pressure is 136/82 mm Hg. Examination shows dark brown skin. S1 and S2 are normal. An S3 is
heard at the apex. There is mild tenderness over the second and third metacarpophalangeal joints bilaterally without
synovial thickening. Heberden nodes are present over the distal interphalangeal joints of the index and ring fingers
bilaterally. Laboratory studies show:
Hemoglobin 16 g/dL
Leukocyte count 7700/mm3
Platelet count 332,000/mm3
Serum
Glucose 182 mg/dL
Albumin 3.4 g/dL
Total bilirubin 1.1 mg/dL
Alkaline phosphatase 52 U/L
AST 55 U/L
ALT 68 U/L
Hepatitis B surface antigen negative
Hepatitis C antibody negative
Rheumatoid factor negative
Which of the following is most likely to have prevented this patient's condition?
(A) Calcium supplementation
(B) Enalapril therapy
© Metformin therapy
(D) Methotrexate therapy
(E) Phlebotomy
his hands. The stiffness is worse at the end of the day. He has a 1-year history of fatigue and increased urination. He
has no history of serious illness and takes no medications. His last visit to a physician was 10 years ago. He does not
smoke or drink alcohol. He is 185 cm (6 ft 1 in) tall and weighs 82 kg (180 lb); BMI is 24 kg/m2. His pulse is
84/min, and blood pressure is 136/82 mm Hg. Examination shows dark brown skin. S1 and S2 are normal. An S3 is
heard at the apex. There is mild tenderness over the second and third metacarpophalangeal joints bilaterally without
synovial thickening. Heberden nodes are present over the distal interphalangeal joints of the index and ring fingers
bilaterally. Laboratory studies show:
Hemoglobin 16 g/dL
Leukocyte count 7700/mm3
Platelet count 332,000/mm3
Serum
Glucose 182 mg/dL
Albumin 3.4 g/dL
Total bilirubin 1.1 mg/dL
Alkaline phosphatase 52 U/L
AST 55 U/L
ALT 68 U/L
Hepatitis B surface antigen negative
Hepatitis C antibody negative
Rheumatoid factor negative
Which of the following is most likely to have prevented this patient's condition?
(A) Calcium supplementation
(B) Enalapril therapy
© Metformin therapy
(D) Methotrexate therapy
(E) Phlebotomy