A 64-Year-Old Woman Comes to the Office Due to a Bitemporal

question 1359

Multiple Choice

A 64-year-old woman comes to the office due to a bitemporal headache that has slowly worsened over the past week.  The patient has also had dizziness, blurry vision, and tingling and numbness of her feet.  She has had no fever or jaw pain.  The patient has a history of hypertension, for which she takes lisinopril.  She does not use tobacco or alcohol.  Temperature is 37.2 C (99.0 F) , blood pressure is 140/90 mm Hg, pulse is 70/min, and respirations are 16/min.  Physical examination shows moist mucous membranes, normal tympanic membranes, and no sinus or temporal area tenderness.  Bilateral pupils are equal and reactive.  Visual acuity is decreased in both eyes, and funduscopic examination reveals dilated, segmented, and tortuous retinal veins.  Facial sensation and strength are normal.  Bilateral upper and lower extremity muscle strength is normal.  There is decreased pinprick sensation and loss of ankle reflex bilaterally in the feet.  Laboratory results are as follows: Which of the following is the best next diagnostic study for this patient?

• A)Antineutrophil cytoplasmic antibodies
• B)Hemoglobin A1c level
• C)MRI of the brain
• D)Serum protein electrophoresis
• E)Temporal artery biopsy

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