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Serum levels of bradykinin will be elevated
19%
33/172
Loratadine would best treat her chief complaint
2%
4/172
Beta agonists would relieve this patients symptoms
1%
2/172
Non-caseating granulomas are found on biopsy of mediastinal lymph nodes
73%
125/172
Omeprazole is an appropriate next step in management
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The patient in this vignette most likely has sarcoidosis. Biopsy of mediastinal lymph nodes helps to confirm the diagnosis, and would show non-caseating granulomas. Sarcoidosis is a multi-system granulomatous disease without a known cause that often affects young and middle-aged adults. African-Americans are at increased genetic risk. Classically, patients may present with bilateral hilar lymphadenopathy on chest radiograph with or without pulmonary infiltrates, but this is certainly not universal. Commonly, patients with sarcoidosis present first with ocular and/or skin lesions. While noncaseating granulomas are the histopathological hallmark of sarcoidosis, they are not specific for this condition and ultimately sarcoidosis is a diagnosis of exclusion supported by histopathology. Figure A demonstrates the classic, tender lesion of erythema nodosum which is a panniculitis associated with many rheumatological syndromes. Illustration A displays the classic bilateral, hilar lymphadenopathy seen with sarcoidosis. Incorrect Answers: Answer 1: This patient's new onset cough could be due to the ACE inhibitor she was recently started on which would result in elevated levels of bradykinin. However given her systemic complaints (cough, joint pain, erythema nodosum) and African American race there is more evidence suggesting sarcoidosis as the most likely diagnosis. Answer 2: This patients history of atopic disease (eczema, asthma, seasonal allergies) could suggest that her cough is due to post-nasal drip which could be treated with loratadine. However, post-nasal drip does not cause the other systemic complaints in the case. Answer 3: Asthma is a potential cause of chronic cough, and it could be treated with beta-2 agonists such as albuterol. There are no other symptoms presented that suggest asthma that is poorly controlled (wheezing, shortness of breath). In addition the previously mentioned systemic findings are not found in asthma. Answer 5: Omeprazole is the appropriate management of GERD which this patient likely experiences due to her retrosternal burning pain after meals. That being said, the other systemic signs would not be found in GERD and are more specific for sarcoidosis.
3.3
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