08-17-2014, 09:40 AM
A 45-year-old man comes to the clinic with 4 weeks of rash over his lower legs. He is otherwise healthy and takes no medications except for occasional acetaminophen to treat headache that he attributes to stress at work. He first noticed the rash over his ankles and thinks that it is progressing. It is not pruritic and seems to be more darkly colored at the end of the day. Also, for the past few nights his gums have bled when he flosses his teeth. His family history is unremarkable for rheumatic diseases or bleeding disorders. He does not drink alcohol and has never used illicit drugs. His vital signs are stable, and physical examination is remarkable only for a diffuse petechial rash over his lower ankles and on his hard palate; the rash has not spread to his torso or arms, and he has no hemorrhagic bullae in his oropharynx. A peripheral blood smear shows very rare platelets without any accompanying cell line deficits. Laboratory studies show:
WBC count: 6200/mm³
Hematocrit: 41.3%
Platelet count: 14,000/mm³
Na+: 142 mEq/L
K+: 4.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 25 mEq/L
Blood urea nitrogen: 16 mg/dL
Creatinine: 1.0 mg/dL
Glucose: 100 mg/dL
Partial thromboplastin time: 26 seconds
Prothrombin time: 13 seconds
Results of HIV testing are negative, and liver function tests are normal. He is administered multiple pharmacologic agents, but fails to achieve a response after 4 weeks.
What is the best next intervention before proceeding with surgical management of his disease?
127150 : handeep
A.Acyclovir
B.Danazol
C.Fluconazole daily and trimethoprim-sulfamethoxazole double strength three times per week
D.Pulse dose of cyclophosphamide (oral or intravenous)
E.Vaccinations for pneumococcus, meningococcus, and Haemophilus influenzae
WBC count: 6200/mm³
Hematocrit: 41.3%
Platelet count: 14,000/mm³
Na+: 142 mEq/L
K+: 4.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 25 mEq/L
Blood urea nitrogen: 16 mg/dL
Creatinine: 1.0 mg/dL
Glucose: 100 mg/dL
Partial thromboplastin time: 26 seconds
Prothrombin time: 13 seconds
Results of HIV testing are negative, and liver function tests are normal. He is administered multiple pharmacologic agents, but fails to achieve a response after 4 weeks.
What is the best next intervention before proceeding with surgical management of his disease?
127150 : handeep
A.Acyclovir
B.Danazol
C.Fluconazole daily and trimethoprim-sulfamethoxazole double strength three times per week
D.Pulse dose of cyclophosphamide (oral or intravenous)
E.Vaccinations for pneumococcus, meningococcus, and Haemophilus influenzae