Musculoskeletal Pathology, Pathology, USMLE Step 1 - Full Vignette with Extended Explanations

Описание: Several patients present to the clinic within the same hour, each exhibiting acute monoarthritis alongside unique comorbidities such as anticoagulation, renal impairment, poor glycemic control, and recent gastrointestinal bleeding. With limited immediate diagnostic resources and varying underlying risk factors, how should clinicians prioritize management decisions to ensure both efficacy and patient safety? Which clinical features and comorbidity profiles should inform your approach in these challenging acute care scenarios?

VIDEO INFO
Category: Musculoskeletal Pathology, Pathology, USMLE Step 1
Difficulty: Hard - Advanced level - Challenges experienced practitioners
Question Type: Treatment - Evaluate therapeutic interventions and management
Case Type: Multi Patient

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QUESTION
In an internal-medicine run clinic, four patients with acute monoarthritis present during the same hour. Each has a distinct comorbidity pattern, and synovial fluid microscopy will not be available until late evening. All are afebrile with normal hemodynamics and no overlying cellulitis....

OPTIONS
A. For the patient with a warfarinized mechanical valve and septic screen negative monoarthritis limited to one knee, inject intra-articular triamcinolone acetonide 40 mg once under aseptic technique in clinic.
B. For the patient with eGFR 25 mL/min/1.73 m2 on azathioprine, give colchicine 0.6 mg twice daily for 3 days and continue azathioprine at the same dose.
C. For the patient with poorly controlled diabetes and unstable hypertension, start indomethacin 50 mg orally three times daily for 10 days plus a proton pump inhibitor.
D. For the patient two weeks post-upper GI bleed on dual antiplatelet therapy, start naproxen 500 mg orally twice daily for 7 days with misoprostol for protection and no change to antiplatelet therapy.

CORRECT ANSWER
A. For the patient with a warfarinized mechanical valve and septic screen negative monoarthritis limited to one knee, inject intra-articular triamcinolone acetonide 40 mg once under aseptic technique in clinic.

EXPLANATION
Among four simultaneous monoarthritis patients awaiting microscopy, guideline-concordant first-line management must reflect comorbidities. Patient A (warfarinized mechanical valve, single joint, septic screen negative) is best treated with intra-articular triamcinolone acetonide 40 mg once, which is effective and avoids systemic bleeding or renal risks; this aligns with ACR 2020 and NICE NG219. Patient B (eGFR 25 on azathioprine) should avoid colchicine due to accumulation and myelosuppressive interaction with azathioprine. Patient C (poorly controlled diabetes and severe hypertension) should avoid high-dose NSAIDs due to BP, renal, and glycemic risks....


Further reading:

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