11-01-2009, 07:36 AM
A 28-year-old woman with systemic lupus erythematosus is hospitalized for severe left shoulder pain and low-grade fever. The pain is constant, interferes with her sleep, and has a minimal pleuritic component. At age 18 years, she was diagnosed with lupus nephritis, which was treated with corticosteroids and cyclophosphamide. The last flare of her renal disease occurred 2 years ago, and she is now in remission. She has had two second-trimester miscarriages that occurred 1 and 3 years ago, respectively. Medications are hydroxychloroquine, 200 mg daily; low-dose aspirin; and prednisone, 5 mg every other day.
On physical examination, she is afebrile. There is facial scarring from discoid lupus erythematosus but no active lesions. On musculoskeletal examination, passive and active range of motion of the shoulders and neck are normal and do not elicit pain. Deep tendon reflexes, muscle strength, and neurologic examination of the upper extremities also are normal. The remainder of the examination is unremarkable.
Except for a platelet count of 114,000/µL (114 × 109/L), laboratory studies are unchanged from baseline values measured several months ago. Urinalysis reveals trace protein with no casts. Chest and shoulder radiographs are normal.
Which of the following is the most appropriate next step in this patient's management?
A Increase prednisone dose to 40 mg/d
B CT of the abdomen
C MRI of the left shoulder
D Aspirate the left shoulder joint
On physical examination, she is afebrile. There is facial scarring from discoid lupus erythematosus but no active lesions. On musculoskeletal examination, passive and active range of motion of the shoulders and neck are normal and do not elicit pain. Deep tendon reflexes, muscle strength, and neurologic examination of the upper extremities also are normal. The remainder of the examination is unremarkable.
Except for a platelet count of 114,000/µL (114 × 109/L), laboratory studies are unchanged from baseline values measured several months ago. Urinalysis reveals trace protein with no casts. Chest and shoulder radiographs are normal.
Which of the following is the most appropriate next step in this patient's management?
A Increase prednisone dose to 40 mg/d
B CT of the abdomen
C MRI of the left shoulder
D Aspirate the left shoulder joint