66 years old man with myasthenia gravis is evaluated for progressive weakness while hospitalized . He was admitted 2 days prior due to fever, productive cough and pleuritic chest pain, chest x ray shows right lower lobe consolidation for which he has been receiving IV ceftriaxone and azithromycin. He also has been receiving his outpatient dose of pyridostigmine. In past several hours , he has experienced generalized weakness and difficulty spitting sputum. Temperature 37.6 C(99.8 F), BP 130/70mmhg, pulse 110/min, respiratory rate= 25/min. Oxygen saturation is 89% on 4L oxygen by nasal cannula. Patient is in distress, breathing pattern is rapid and shallow with occasional gurgling sounds. Lung auscultation reveals coarse crackles throughout. There is mild weakness of extremities , but deep tendon reflexes are normal. His vital capacity is now 1.0 L compared to 1.5 L at the time of admission and arterial blood gas shows ph 7.27, pco2 55mm Hg, po2 60 mm Hg. Patient is intubated and moved to ICU. Best next step in management?
- A. Close observation only
- B. Increase pyridostigmine dose
- C. Intravenous atropine
- D. Therapeutic plasma exchange
- E. Thymectomy
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27-year-old African American woman comes to the office due to 6 weeks of pain and swelling of her hands and wrists. The pain
worsens in the morning and is associated with stiffness for 10-15 minutes. She has also had easy fatigability and muscle aches. The
patient has no significant past medical history and does not take any medications. She has been sexually active with a new partner.
Her temperature is 37.9 C (100 2 F), blood pressure is 140/90 mm Hg, and pulse is 76/min. Physical examination reveals slightly
swollen, tender metacarpophalangeal and proximal interphalangeal joints. There is a nontender ulcer on the buccal mucosa. Mild
cervical and axillary lymphadenopathy is present Cardiopulmonary auscultation is normal. The abdomen is soft and nontender. The
tip of the spleen is palpable with exhalation. Laboratory results are as follows:
Hemoglobin 11.0 g/dl
Platelets 90,000/mm3
Leukocytes 4,500/mm3
An x-ray of the hands and wrists reveals no bony erosions. Urinalysis shows 2+ protein and 20-30 red blood cells/hpf Which of the
following is the most likely diagnosis?
- QA Beh(;et disease
- 0 B. Disseminated gonococcal infection
- 0 C. Felty syndrome
- 0 D. Hodgkin disease
- 0 E. Parvovirus B 19 infection
- 0 F Sarcoidosis
- 0 G. Systemic lupus erythematosus
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