A 54-year-old woman is evaluated in the outpatient continuity clinic for a 4-month history of worsening fatigue, joint stiffness in her hands, and a recurrent rash on her lower legs. The rash consists of small, raised, red-to-purple spots that do not blanch when pressed. She also notes intermittent "pins and needles" sensations in her toes.
Medical history is significant for hypertension and hypothyroidism. Surgical history includes an open reduction and internal fixation of a femur fracture following a severe motor vehicle collision in 1989. She takes lisinopril and levothyroxine. She does not use tobacco or illicit drugs and drinks 1-2 glasses of wine weekly.
Vital signs are within normal limits. Skin examination reveals palpable purpura over the bilateral distal lower extremities. The metacarpophalangeal joints are mildly tender without frank swelling. Neurologic examination shows decreased pinprick sensation in the bilateral toes. The liver edge is palpated 3 cm below the right costal margin.
Laboratory results are as follows:
White blood cell count:
Hemoglobin:
Platelets:
Aspartate aminotransferase (AST):
Alanine aminotransferase (ALT):
Creatinine:
Urinalysis: 2+ protein, 10-15 RBCs/hpf
Rheumatoid factor: Positive
Complement C3: Normal
Complement C4: Low
Which of the following additional historical questions is most essential to establishing the underlying etiology of this patient's current condition?
- "Did you receive any blood products during your trauma surgery in 1989?"Cevap
- B"Do you have a family history of systemic lupus erythematosus or other connective tissue diseases?"
- C"Have you recently noticed any changes in the amount of urine you produce or foaming in the toilet?"
- D"Have you recently initiated any new over-the-counter pain medications or herbal supplements?"
- E"Have you traveled to a wooded area endemic for tick-borne illnesses in the past six months?"