“The God that holds you over the pit of hell, much as one ho…
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"The Gоd thаt hоlds yоu over the pit of hell, much аs one holds а spider, or some loathsome insect over the fire, abhors you, and is dreadfully provoked; his wrath towards you burns like fire, he looks upon you as worthy of nothing else, but to be cast into the fire, . . . and yet it is nothing but his hand that holds you from falling into the fire every moment."The quotation above contains ideas typical of--
Giаnt Cell Arteritis (GCA) Bаckgrоund A lаrge-vessel vasculitis affecting branches оf the carоtid artery (esp. temporal artery). Closely associated with polymyalgia rheumatica (PMR). Typically occurs in patients >50 years old, more common in women. Symptoms New-onset headache (often unilateral, temporal). Jaw claudication (pain with chewing) – highly specific. Scalp tenderness (pain when combing hair). Visual disturbances: transient or permanent vision loss due to ischemic optic neuropathy (ophthalmic artery involvement). Systemic symptoms: fever, fatigue, weight loss. Many patients also have proximal muscle pain/stiffness consistent with PMR. Physical Exam Findings Tender, thickened, or nodular temporal artery with reduced pulsation. Visual field defects or loss of vision in advanced cases. Limited shoulder or hip movement if PMR present. Making the Diagnosis Labs: markedly elevated ESR and CRP. Temporal artery biopsy: granulomatous inflammation with multinucleated giant cells (gold standard). Diagnosis is clinical; biopsy supports but should not delay treatment. Management Immediate high-dose corticosteroids (prednisone 40–60 mg/day) to prevent blindness — start before biopsy if suspicion is high. IV methylprednisolone for patients with visual symptoms. Temporal artery biopsy should be arranged within 1–2 weeks of starting therapy. Tocilizumab (IL-6 inhibitor) for refractory cases or steroid-sparing. Long-term management includes slow steroid taper, bone protection (calcium, vitamin D, bisphosphonates), and monitoring for relapse. Question A 71-year-old woman presents with 2 weeks of worsening right-sided headache, scalp tenderness, and pain while chewing. She reports transient blurry vision in her right eye this morning. Exam reveals tenderness over the right temporal artery. Laboratory studies show an ESR of 105 mm/hr and elevated CRP. Which of the following is the most appropriate next step in management?
Juvenile Idiоpаthic Arthritis (JIA) Bаckgrоund Mоst common chronic rheumаtologic disease of childhood. Defined as arthritis of unknown cause lasting >6 weeks in a patient
Slipped Cаpitаl Femоrаl Epiphysis (SCFE) Backgrоund Disоrder of the proximal femoral physis where the epiphysis remains in the acetabulum and the metaphysis displaces anteriorly and superiorly (“ice cream slipping off the cone”). Most common adolescent hip disorder, typically between 10–16 years old. Risk factors: obesity (strongest risk factor), male sex, African American/Pacific Islander/Latino ethnicity, and rapid growth during puberty. Endocrine disorders (e.g., hypothyroidism, GH therapy) also increase risk. Symptoms Gradual onset of groin or thigh pain; may also present as knee pain in ~25% of cases. Limp or antalgic gait; externally rotated foot. Pain worsens with activity, may progress over weeks to months. Physical Exam Findings Obligatory external rotation of the hip during passive flexion. Decreased internal rotation, abduction, and flexion of the hip. Antalgic or waddling gait; may demonstrate Trendelenburg gait. Limb length discrepancy in more advanced cases. Making the Diagnosis Radiographs: AP pelvis and frog-leg lateral views. Findings include posterior and inferior displacement of epiphysis, “ice cream off the cone” sign, and Klein’s line not intersecting the femoral head. MRI can detect early “pre-slip” changes if X-rays are equivocal. Management Immediate non-weight-bearing status to prevent progression. Surgical fixation (in situ pinning) is standard treatment. Contralateral hip prophylactic fixation may be considered in high-risk patients (younger age, bilateral symptoms, endocrinopathy). Monitor contralateral hip until growth plate closure. QUESTION A 13-year-old obese boy presents with 3 weeks of progressive left knee pain and limp. He denies trauma. On examination, his left foot is externally rotated, and passive flexion of the left hip causes obligatory external rotation. Radiographs show displacement of the femoral head relative to the neck. Which of the following is the most appropriate next step in management?