A 45-Year-Old Woman Is Brought to the Emergency Department Due

question 1229

Multiple Choice

A 45-year-old woman is brought to the emergency department due to confusion.  According to her husband, the patient has had fatigue, poor appetite, and fleeting joint pain for 2 weeks.  She has a history of rheumatoid arthritis, which is treated with a tumor necrosis factor-alpha inhibitor.  Temperature is 38.9 C (102 F) , blood pressure is 142/76 mm Hg, and pulse is 101/min and regular.  Two small subconjunctival hemorrhages are noted in the right eye; there is no papilledema.  A 2/6 holosystolic murmur is present at the apex.  The lungs are clear.  There is no swelling or redness of the joints.  The patient is poorly cooperative with neurologic examination but moves all extremities.  MRI of the head is shown in the exhibit.  Which of the following is the best next step in management of this patient?

• A)Antineutrophil cytoplasmic autoantibodies
• B)Echocardiogram
• C)HIV testing
• D)Lumbar puncture
• E)Stereotactic brain biopsy
• F)Toxoplasma antibodies

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