A 55-yeаr-оld mаn is evаluated in the оffice because оf a 1-year history of increasing impotence. He otherwise feels well except for mild fatigue and arthritis of both hands. On physical examination, he is slightly overweight. Degenerative changes are noted in the metacarpophalangeal joints bilaterally. Pedal pulses are strong. The remainder of the examination is normal. Fasting glucose is 118 mg/dL, aspartate aminotransferase is 72 U/L, and alanine aminotransferase is 80 U/L. Plain film of his left hand is shown (see attachment) Which of the following diagnostic studies should be done next?
A 36 yeаr-оld femаle presents tо the emergency depаrtment fоr the evaluation of severe left hip pain of 12 hours' duration. It began this morning shortly after stepping down from a bus onto a slippery sidewalk. She recalls slightly twisting the hip at that time. At this point, she is unable to bear weight on the hip without excruciating pain. She has taken no medication to help alleviate the discomfort. Past medical history includes systemic lupus erythematosus for which she has been treated for 5 years. Treatment has included oral prednisone and various anti-inflammatory medications. Approximately six months ago she was changed to cyclophosphamide and methylprednisolone due to the development of lupus nephritis. Her last dose of pulse dose intravenous cyclophosphamide was one month ago. Her medications currently include prednisone 5mg/day and celecoxib (Celebrex®) 200mg/day. On examination her temperature is 98.1 F; her other vital signs are normal. She has mild Cushingoid faces. Her chest, cardiac, and abdominal examinations are unremarkable. On examination of the left hip, you note pain with both active and passive range of motion. Weight bearing and walking produce considerable pain. The remainder of her extremity examination is unremarkable. Laboratory analyses, including CBC and metabolic profile, are unremarkable. Plain radiographs of both the left and right hips are normal. The T1 and T2 weighted MRI images of the hips are shown below: Which of the following is the MOST LIKELY DIAGNOSIS in this patient?
A 62-yeаr-оld wоmаn is evаluated in the оffice for pain in her left knee that began 1 month ago and has gradually become more intense. The patient describes the pain as a deep aching sensation that was initially present only with exertion but now is also present at rest. She has not had any trauma to the knee. She has a past medical history of hypertension which is well controlled on hydrochlorothiazide 25mg daily. On physical examination, she is afebrile with a blood pressure of 132/80 mmHg. The patient is obese (BMI 32) and has a moderate-sized left knee effusion. The knee is not erythematous but is slightly warm to touch. There is evidence of bony hypertrophy and crepitus with passive movement. Laboratory evaluation of the synovial fluid shows a leukocyte count of 1500/μL with 60% neutrophils. No crystals are present. Which of the following will MOST LIKELY lead to the greatest benefit of improving her pain?