Pharmacology · patient case question
Which of the following findings in this patient is most directly related to his medication?
Patient case: Elderly patient with unexplained bruising
Patient: Male, 85 years old
Chief complaint: Presents for a routine recall examination, accompanied by his son and daughter-in-law.
History: Rheumatoid arthritis, managed with ADALIMUMAB and ASPIRIN. Lives with his son. During the appointment the son answers most questions for the patient, is visibly angry and speaks to him harshly.
Findings: The patient is withdrawn and quiet, offering little spontaneous speech. Several bruises of differing ages are visible on both forearms. Oral examination is otherwise unremarkable for his age.
Show answer and explanation
Correct answer: D. Easy bruising and prolonged bleeding
- A. Secondary (AA) amyloidosis is a complication of LONG-STANDING UNCONTROLLED rheumatoid inflammation — that is, of the DISEASE, not of the drugs. Effective treatment with a TNF-α inhibitor such as adalimumab actually REDUCES that risk.
- B. Neither aspirin nor adalimumab is a recognised cause of xerostomia. Secondary Sjögren syndrome in a rheumatoid patient would be the explanation if dry mouth were present.
- C. Rheumatoid arthritis and its associated inflammatory burden are linked to periodontitis, but again this is a disease association rather than a drug effect. Adalimumab suppresses TNF-α and would be expected to dampen, not drive, periodontal inflammation.
- D. CORRECT. ASPIRIN irreversibly acetylates cyclo-oxygenase-1 in platelets, abolishing thromboxane A2 production for the platelet's 7–10 day lifespan. The result is impaired platelet aggregation, easy bruising and prolonged bleeding time — which is the medication-related explanation for the bruises on his arms.
Note: The recall listed only two options here (amyloidosis / periodontal disease), neither of which is a drug effect. The clinically defensible link between this patient's medications and his presentation is aspirin-related bruising. The second medication matters too: adalimumab is a TNF-α inhibitor, so this patient is immunosuppressed and carries an elevated risk of infection and of reactivating latent tuberculosis.