A 70-year-old man comes to the physician due to generalized weakness and headaches. He has also had intermittent episodes of blurry vision and a 6.8-kg (15-lb) weight loss over the past 3 months. His other medical problems include hypertension, congestive heart failure, type 2 diabetes mellitus, and hypercholesterolemia. The patient underwent coronary artery bypass surgery for triple-vessel disease 4 years ago. His medications include insulin detemir, ramipril, simvastatin, low-dose aspirin, metoprolol, furosemide, and naproxen as needed for headaches.
The patient's temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, and pulse is 73/min. Eye examination is normal. He has decreased breath sounds at the left lung base. The liver edge is palpable at the costal margin. There is no adenopathy. There is trace peripheral edema bilaterally. The prostate is mildly enlarged, soft, and nontender on rectal examination. Fecal occult blood testing is negative.
Laboratory results are as follows:

Chest x-ray reveals cardiomegaly and a left-sided pleural effusion

Question

A 70-year-old man comes to the physician due to generalized weakness and headaches.  He has also had intermittent episodes of blurry vision and a 6.8-kg (15-lb) weight loss over the past 3 months.  His other medical problems include hypertension, congestive heart failure, type 2 diabetes mellitus, and hypercholesterolemia.  The patient underwent coronary artery bypass surgery for triple-vessel disease 4 years ago.  His medications include insulin detemir, ramipril, simvastatin, low-dose aspirin, metoprolol, furosemide, and naproxen as needed for headaches.
The patient's temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, and pulse is 73/min.  Eye examination is normal.  He has decreased breath sounds at the left lung base.  The liver edge is palpable at the costal margin.  There is no adenopathy.  There is trace peripheral edema bilaterally.  The prostate is mildly enlarged, soft, and nontender on rectal examination.  Fecal occult blood testing is negative.
Laboratory results are as follows:

Chest x-ray reveals cardiomegaly and a left-sided pleural effusion <1 cm.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9919_6a61_853d_151ca57bbb5e_MD0002_00 This patient is >50 years old and has headaches, blurry vision, and constitutional symptoms (generalized weakness, weight loss) with a significantly elevated erythrocyte sedimentation rate. This is consistent with giant cell arteritis (GCA), a chronic vasculitis of large and medium-sized vessels. New headache is a cardinal feature and can be localized to the temporal area or generalized. Visual symptoms vary; amaurosis fugax (transient blurry vision, partial visual field defect, or monocular blindness) and anterior ischemic optic neuropathy are common and can progress to blindness. Patients with GCA often have normocytic anemia, reactive thrombocytosis, and mildly decreased albumin. In up to 1/3 of patients, liver enzymes can be elevated but usually revert to normal with therapy. Criteria useful in distinguishing GCA from other vasculitides are summarized in the table. GCA can cause permanent vision loss and glucocorticoids should be initiated if GCA is suspected. Diagnosis is confirmed with temporal artery biopsy, but treatment should be initiated immediately while awaiting biopsy results. (Choice B) Increased ferritin levels can suggest hemochromatosis, but ferritin is also an acute-phase reactant that can be elevated in inflammatory disorders such as GCA. This patient's normal transaminases make hemochromatosis less likely. (Choice C) A prostate-specific antigen test and a bone scan may help diagnose metastatic prostate cancer, which is usually associated with an asymmetric and indurated prostatic nodule on rectal examination. However, this patient's examination findings are more consistent with benign prostatic hyperplasia. (Choice D) The patient has a left-sided pleural effusion <1 cm that could be due to heart failure (cardiomegaly, trace lower extremity edema) and/or naproxen therapy. He is otherwise hemodynamically stable with no respiratory problems. There is no indication for urgent thoracentesis. Corticosteroid therapy for GCA is the first priority. (Choice E) Triple-phase abdominal CT scan helps to diagnose and differentiate between various space-occupying liver lesions (eg, hepatoma) enhanced during the arterial vascular phase. A triple-phase CT would not be the best next step in management of this patient who fits criteria for GCA and has normal liver function tests. Educational objective: Criteria effective for distinguishing giant cell arteritis from other vasculitides include age >50, localized new-onset headache, erythrocyte sedimentation rate >50 mm/h, and temporal artery tenderness. Diagnosis is confirmed with temporal artery biopsy, but treatment with glucocorticoids should be initiated immediately. __________ References: Temporal arteritis presenting with gastrointestinal symptoms in a middle aged man. (http://www.ncbi.nlm.nih.gov/pubmed/16808762) Laboratory investigations including liver in polymyalgia rheumatica/giant cell arteritis (http://www.ncbi.nlm.nih.gov/pubmed/1807822)

A 70-Year-Old Man Comes to the Physician Due to Generalized