الخميس، 4 أبريل 2013

MCQs in Pediatric RHeumatology

Q 1:

A 12-year-old girl who has juvenile idiopathic arthritis (juvenile rheumatoid arthritis) presents with
a history of chronic anemia. Her current medications include ibuprofen, methotrexate, and folic
acid. Physical examination demonstrates tenderness to palpation of the upper abdomen and a
left knee effusion. The stool is positive for occult blood. Results of laboratory studies include a
hematocrit of 28% (0.28), mean cell volume of 72 fL, reticulocyte count of 1%, white blood cell
count of 4.2x103/mcL (4.2x109/L), serum iron concentration of 14 mcg/dL (2.5 mcmol/L), and
total iron binding capacity of 400 mcg/dL (71.6 mcmol/L). Transaminases, bilirubin, amylase, and
lipase values are normal. You initiate iron therapy.
Of the following, the MOST appropriate diagnostic test at this time is

A. abdominal ultrasonography
B. abdominal spiral computed tomography scan
C. mesenteric angiography
D. radionuclide tagged red cell study
E. upper endoscopy with biopsy

Answer

E


The patient described in the vignette presents with iron deficiency anemia and guaiac-positive
stool, which suggest the presence of inflammation and bleeding of the gastrointestinal tract. It is
unlikely that she has an acute gastrointestinal hemorrhage because she is hemodynamically
stable. The differential diagnosis of chronic gastrointestinal bleeding and anemia in this patient is
broad and includes Helicobacter pylori infection, celiac disease, and Crohn disease. However,
her chronic use of ibuprofen points toward gastritis and ulcer disease due to chronic use of
nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen). Upper endoscopy is indicated to
establish a diagnosis of NSAID gastropathy and to exclude other conditions.


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