A 63-year-old woman is evaluated during a follow-up visit for a 4-week history of fatigue; pain in the proximal interphalangeal joints, knees, and hips; and low-grade fever. She has not had joint swelling, chest pain, or shortness of breath. Over the past 4 years, she has had progressive dryness of the eyes and mouth. She has a 5-month history of Raynaud phenomenon, which has been less symptomatic since beginning nifedipine 4 months ago.
On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is 125/72 mm Hg, pulse rate is 74/min, and respiration rate is 18/min. Cardiac examination is normal, and the lungs are clear. She has bilateral parotid gland enlargement, a firm 4-cm left axillary lymph node, and a shotty 0.3-cm left anterior cervical lymph node. Musculoskeletal examination reveals bilateral crepitus of the knees. There is no joint swelling.
Hemoglobin 11.6 g/dL (116 g/L)
Leukocyte count 3400/µL (3.4 × 109/L)
Platelet count 120,000/µL (120 × 109/L)
Rheumatoid factor 76 U/mL (76 kU/L)
Antinuclear antibodies Positive
Anti-Ro/SSA antibodies Positive
Anti-La/SSB antibodies Positive
Blood cultures No growth
A chest radiograph and mammogram are normal.
Which of the following is the next best step in this patient’s management?
A) Excisional axillary lymph node biopsy
B) Minor salivary gland biopsy
D) Transthoracic echocardiography
clue: إدراكك بأن الحالة typical يساعدك في معرفة الجواب.