The Quizzes about Muscles and joints – Part 2 (20 cases)

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The Quizzes about Muscles and joints – Part 2 (20 cases)
5 (100%) 1 vote

Select the ONE answer that is BEST in each case.

A 55-year-old woman has had several weeks of fever, abdominal pain, weight loss, and lack of energy. Three days prior to the assessment, she developed a left foot drop. Her blood pressure is 160/90 mm Hg, pulse 80/min, and physical examination confirms left peroneal nerve damage and a bilateral sensory peripheral neuropathy in both legs. There are no skin rashes. Laboratory evaluation reveals ESR of 105 mm/h, WBC of 14,000/mL, and negative serologic tests for antineutrophil cytoplasmic antibody (ANCA) and ANA. The eosinophil count is normal, and urinalysis is negative for casts, protein, and red cells. Which of the following is the most likely mechanism for renal injury in this condition?

This patient has polyarteritis nodosa (PAN) and in classic PAN, unlike microscopic polyangiitis, both small and medium vessels are involved. The renal lesions are ischemic secondary to fibrinoid necrosis of the vessels. In microscopic polyangiitis, a diffuse glomerulonephritis is frequently present. The most common organ systems involved are the kidneys, musculoskeletal system, and peripheral nervous system.

 

See all quizzes of  the Muscles and joints at here:

Part 1Part 2 | Part 3 | Part 4|

 

21. A 55-year-old woman has had several weeks of fever, abdominal pain, weight loss, and lack of energy. Three days prior to the assessment, she developed a left foot drop. Her blood pressure is 160/90 mm Hg, pulse 80/min, and physical examination confirms left peroneal nerve damage and a bilateral sensory peripheral neuropathy in both legs. There are no skin rashes. Laboratory evaluation reveals ESR of 105 mm/h, WBC of 14,000/mL, and negative serologic tests for antineutrophil cytoplasmic antibody (ANCA) and ANA. The eosinophil count is normal, and urinalysis is negative for casts, protein, and red cells. Which of the following is the most likely mechanism for renal injury in this condition?

(A) nephrotic syndrome

(B) diffuse glomerulonephritis

(C) granuloma formation

(D) necrotizing vasculitis of vessels

(E) exclusively small vessel involvement

22. A 20-year-old man with Marfan syndrome is having back pain. On examination, there is a curvature of his thoracic spine to the left. Which of the following is the most appropriate next step in management?

(A) a vigorous exercise program

(B) bisphosphate therapy

(C) mechanical back bracing

(D) a prophylactic surgical procedure

(E) appropriate footwear

23. A 27-year-old man has a history of low back pain and stiffness. Recently, he has noticed more severe stiffness at night and hip pain. The symptoms improve in the morning after doing some “stretching” exercises. On physical examination, there is paravertebral muscle and sacroiliac joint tenderness with limited flexion of the lumbar spine. A 2/6 diastolic murmur is also heard at the left sternal border radiating to the apex. Which of the following is the most likely diagnosis for the diastolic murmur?

(A) mitral stenosis

(B) tricuspid stenosis

(C) aortic insufficiency

(D) pulmonic insufficiency

(E) tetralogy of Fallot

24. A 35-year-old woman notices a red rash over her cheeks, and pain and swelling in both knees as well as several small joints in her hands. She has a history of hypertension and 2 months ago was started on a new medication to control her blood pressure. Her ANA and antihistone antibodies are positive. Which of the following medications is most likely to cause her condition?

(A) hydralazine

(B) hydrochlorothiazide

(C) ramipril

(D) nifedipine

(E) methyldopa

25. A 57-year-old man presents with a swollen, painful left knee. He fell on the knee 3 days ago while hurrying up the stairs. On examination, there is a swollen knee with palpable effusion and decreased range of motion. A diagnostic tap is preformed and 5 cc of transparent fluid is removed. The WBC count is 1000/mL (20% polymorphonuclear neutrophils [PMNs]), glucose is equal to plasma, viscosity is high, and lactate dehydrogenase (LDH) is low. (SELECT ONE)

(A) normal synovial fluid

(B) noninflammatory effusion

(C) inflammatory effusion

(D) septic arthritis

(E) hemorrhagic effusion

26. A 77-year-old woman presents with a swollen, painful right knee. She fell on the knee 3 days ago while hurrying up the stairs. On examination, there is a swollen knee with palpable effusion and decreased range of motion. A diagnostic tap is preformed and 5 cc of opaque fluid is removed. The WBC count is 20,000/mL (50% PMNs), glucose is lower than plasma, viscosity is low, and the LDH is high. (SELECT ONE)

(A) normal synovial fluid

(B) noninflammatory effusion

(C) inflammatory effusion

(D) septic arthritis

(E) hemorrhagic effusion

27. A 27-year-old woman presents with a red rash over her cheeks, and pain and swelling in both knees as well as several small joints in her hands. She notes that the rash is worse with sun exposure. Medical evaluation reveals oral ulceration, positive ANA, and 3+ proteinuria. Which of the following is the most likely mechanism for the renal damage in this condition?

(A) vasculitis

(B) microemboli

(C) antibasement membrane antibodies

(D) deposition of circulating immune complexes

(E) primary tubular atrophy

28. A 50-year-old man develops fatigue and painful swelling of both hands. He is also very stiff in the morning and requires longer time to get ready for work. Physical examination reveals erythema, swelling, and tenderness on palpation of the proximal interphalangeal joints and MCP joints. Plain x-rays of the hand are taken. Which of the following x-ray findings is characteristic of this condition?

(A) loss of articular cartilage and bone erosion

(B) normal

(C) osteolytic changes

(D) osteosclerotic changes

(E) osteolytic and osteosclerotic changes together

29. A 23-year-old man notices new low back pain, stiffness, and left eye discomfort. Sunlight also bothers his eyes. The back pain is worse at night and described as a dull ache in the back and buttock area. On physical examination, there is paravertebral muscle, iliac crest, and ischial tuberosity tenderness with limited flexion of the lumbar spine. His eye is inflamed and the pupil is constricted. Pelvic x-rays show sacroiliitis. Which of the following is the most likely diagnosis for his eye symptoms (it is the most common extra-articular manifestation of this condition)?

(A) glaucoma

(B) acute anterior uveitis

(C) keratitis

(D) conjunctivitis

(E) episcleritis

30. A 24-year-old man presents with shortness of breath on exertion. He is tall and thin,  visual acuity is poor with his glasses off, the jugular venous pressure (JVP) is 4 cm, first heart sound is normal, second sound is soft, a 3/6 early diastolic murmur is heard at the right second intercostal space radiating to the apex. The pulses are bounding, lungs are clear, and his arms are quite long in comparison to his total length. Which of the following is the most likely diagnosis for his cardiac murmur?

(A) aortic root dilatation and aortic stenosis

(B) left ventricular dilatation and mitral valve prolapse

(C) aortic root dilatation and aortic regurgitation

(D) aortic dissection

(E) mitral stenosis

31. A 40-year-old woman complains of being very “stiff” in the morning, in addition to having sore hands and wrists. The symptoms have come on very gradually and she can not recall exactly when they started. Her only other complaint is that of being fatigued. Physical examination reveals involvement of the proximal interphalangeal joints, MCP joints, and wrist joints in a symmetrical fashion. She also has nodules over both elbows. Which of the following is predictive of developing extraarticular features of her condition?

(A) her knees are involved early

(B) there is a poor articular response to disease-suppressing medication

(C) humoral immunity is suppressed

(D) cellular immunity is suppressed

(E) she develops an antibody to her own immunoglobulin (RF)

32. A 24-year-old is referred for assessment of a low white cell count. She has no past medical history and is not on any medications. Her only symptoms are of joint discomfort in her hands, and occasional sharp chest pains that change with breathing. On examination, there is inflammation of some MCP and DIP joints in both hands, and the rest of the examination is normal. Her WBC is 3500/mL and the lymphocytes are low (15%) and PMNs are normal. Which of the following is the most likely diagnosis?

(A) periarteritis nodosa

(B) SLE

(C) scleroderma

(D) DM

(E) osteoarthritis

33. A 69-year-old man develops clubbing of his fingers. Which of the following is most likely associated with this condition?

(A) RF

(B) aortic stenosis

(C) periosteal inflammation

(D) crystal-induced arthritis

(E) diffuse osteoarthritis

34. A 30-year-old woman develops painful swelling of her hands, pleuritic chest pain, and shortness of breath on exertion. She is also very stiff in the morning. Physical examination reveals involvement of the proximal interphalangeal joints and MCP joints. Air entry is decreased to the right lower lobe and the area is dull on percussion. Her RF is elevated and a CXR reveals a pleural effusion. A diagnostic tap is performed, and 500 cc of a straw-colored fluid is removed. Which of the following biochemical patterns is consistent with a pleural effusion due to her primary condition?

(A) exudate protein and LDH ratios with low glucose

(B) exudate protein and LDH ratios with high glucose

(C) transudate protein and LDH ratios with high glucose

(D) transudate protein and LDH ratios with low glucose

(E) normal pleural fluid

35. A 67-year-old man has a long history of symmetrical small joint arthritis with deformities. He now develops shortness of breath on exertion with a dry cough, but no sputum or chest discomfort. His heart sounds have a loud P2, and the lungs have fine bibasilar crackles. Which of the following is the most likely diagnosis of the pulmonary condition associated with his arthritis?

(A) pleuritis

(B) cavitating lesions

(C) intrapulmonary nodules

(D) interstitial fibrosis

(E) diffuse pneumonitis

36. A 71-year-old woman comes to the office with a history of headaches, fatigue, and weight loss for 3 months. The headaches are new for her, and usually not very severe. Her jaw also hurts when she is chewing food. Two days prior, she had briefly lost partial vision in her left eye. There were no other neurologic symptoms at the time. On examination, her neck is supple to flexion, fundi and neurologic examinations are normal. She is started on prednisone 60 mg/day and a biopsy is performed to confirm the diagnosis. Which of the following is the most likely change seen on the biopsy to confirm the diagnosis?

(A) immune complex deposition

(B) arteritis with giant cells

(C) lymphocytic infiltration

(D) type II muscle fiber atrophy

(E) polyphasic potentials on

electromyography (EMG)

37. A 30-year-old woman develops a rash over her cheeks, nose, and ears. She also has pain and swelling in her wrists as well as several smalljoints in her hands. Medical evaluation reveals oral ulceration and 3+ proteinuria. Her ANA is positive. Which of the following is the most likely cardiac manifestation of her disease?

(A) pericarditis

(B) myocarditis

(C) aortic regurgitation

(D) nonbacterial endocarditis

(E) myocardial vasculitis with infarction

38. A 32-year-old woman has a long history of intermittent bloody diarrhea and crampy abdominal pain. Recently, her bowel symptoms have increased and she is having 4–6 bowel movements a day with mucus and blood in the stool. She now has a low-grade fever, loss of appetite, and new musculoskeletal symptoms. Which of the following is the best description of this patient’s accompanying arthritis?

(A) asymmetric migratory polyarthritis involving the large joints of the arms and legs

(B) not usually associated with disease flares

(C) a progressive, crippling course

(D) symmetrical small joint involvement

(E) seropositive

39. A 42-year-old woman has had several weeks of fever, abdominal pain, weight loss, and lack of energy. Three days prior to assessment, she developed a left foot drop and rash on her legs. Her blood pressure is 160/90 mm Hg, pulse 80/min, and physical examination confirms left peroneal nerve damage and a bilateral sensory peripheral neuropathy in both legs. The rash looks like livedo reticularis. Laboratory evaluation reveals ESR of 105 mm/h, WBC of 14,000/mL, and negative serologic tests for ANCA and ANA. Eosinophil count is normal, and urinalysis is negative for casts, protein, and red cells. Biopsy of the skin rash shows inflammation of the small blood vessels. Which of the following is the most appropriate next step in management?

(A) plasmapheresis

(B) steroid therapy alone

(C) combination therapy with steroids and cyclophosphamide

(D) cyclophosphamide therapy alone

(E) combination therapy with steroids and methotrexate

40. A 67-year-old man complains of frequent headaches that are new for him. They are usually not very severe, and relieved with acetaminophen. He also has some back, shoulder, and hip discomfort, which is worse in the morning as well he feels quite fatigued and does not have his usual energy level. On examination, his neck is supple to flexion, fundi and thyroid examination are normal. Range of motion in the shoulders and hips is reduced because of discomfort but there is no active inflammation. There are no focal deficits on screening neurologic examination. Which of the following is the most appropriate initial diagnostic test?

(A) immunoelectrophoresis

(B) c-ANCA levels

(C) ESR

(D) creatine phosphokinase (CPK)

(E) hemoglobin and red cell indices

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