A 25-year-old man comes to the clinic due to a 3-month history of right shoulder pain. He also has swelling and pain at his heels. The patient has tried using a topical "arthritis cream" without improvement, although over-the-counter analgesics have provided some relief. Medical history includes influenza pneumonia at age 12, but he has otherwise been healthy and takes no regular medications. The patient does not use tobacco, alcohol, or illicit drugs. His temperature is 37.3 C (99.2 F), blood pressure is 115/75 mm Hg, pulse is 56/min and regular, and respirations are 12/min. On examination, there is pain with resisted abduction at the shoulder and tenderness at the acromioclavicular junction. Palpation over the heels, iliac crests, and tibial tuberosities also elicits tenderness. Which of the following additional findings is most likely in this patient?

Question

A 25-year-old man comes to the clinic due to a 3-month history of right shoulder pain.  He also has swelling and pain at his heels.  The patient has tried using a topical "arthritis cream" without improvement, although over-the-counter analgesics have provided some relief.  Medical history includes influenza pneumonia at age 12, but he has otherwise been healthy and takes no regular medications.  The patient does not use tobacco, alcohol, or illicit drugs.  His temperature is 37.3 C (99.2 F), blood pressure is 115/75 mm Hg, pulse is 56/min and regular, and respirations are 12/min.  On examination, there is pain with resisted abduction at the shoulder and tenderness at the acromioclavicular junction.  Palpation over the heels, iliac crests, and tibial tuberosities also elicits tenderness.  Which of the following additional findings is most likely in this patient?

Quizplus · Accepted Answer

11ec25c8_d117_8832_bc81_bbcf04b065c6_MD0003_00 Enthesitis is characterized by inflammation and pain at sites where tendons and ligaments attach to bone. It is commonly due to tendon or ligament stress and can manifest as acute swelling and pain. Examination findings include tenderness at tendon insertion sites. Enthesitis at the insertion of the Achilles tendon at the heel is often the most prominent presentation. However, enthesitis can also be seen at the costosternal junction, shoulders, elbows, hips, iliac crests, tibial tuberosities, and other locations. Chronic complications of enthesitis include fibrosis and calcification. insertion of the Achilles tendon Enthesitis may occur as an isolated disorder (eg, plantar fasciitis) but is a characteristic finding in the spondyloarthropathies such as ankylosing spondylitis (AS), psoriatic arthritis, and reactive arthritis. It may manifest with isolated heel pain at the insertion of the Achilles tendon, but can also involve multiple regions as in this case. Low back pain (that classically improves with activity), loss of spinal mobility, and peripheral arthritis are other common musculoskeletal manifestations of AS. (Choices A, C, and E) Rheumatoid arthritis (RA) is characterized by chronic synovitis leading to hand joint deformities (eg, ulnar deviation of the fingers, swan-neck and boutonnière deformities). Many patients have a positive rheumatoid factor, and some will have painless, slow-growing subcutaneous nodules. Enthesitis is not a prominent feature of RA. Enthesitis can be seen with psoriatic arthritis, which can lead to sausage digits; however, this patient has no history of skin problems to suggest psoriasis. (Choice D) Proteinuria and arthritis are common manifestations of systemic lupus erythematosus. Lupus is a systemic illness that is likely to present with other findings, including weight loss, fatigue, rash, serositis, and neurological symptoms. Enthesitis is not expected. Educational objective: Enthesitis is characterized by inflammation and pain at sites of tendon and ligament attachment to bone. It is a common finding in ankylosing spondylitis and other spondyloarthropathies. References: Enthesitis: The clue to the pathogenesis of spondyloarthritis? (http://www.ncbi.nlm.nih.gov/pubmed/26431931)

A 25-Year-Old Man Comes to the Clinic Due to a 3-Month