The Quizzes about Muscles and joints – Part 4 (18 cases)

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The Quizzes about Muscles and joints – Part 4 (18 cases)
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Select the ONE answer that is BEST in each case.

A 32-year-old woman complains of having intermittent arthralgias of multiple joints and occasional swelling in both knees. The symptoms started about 6 months ago and usually last for weeks at a time and then improve spontaneously. She reports no morning stiffness or any constitutional symptoms. About 1 year ago, she recalls having a round, red, pruritic skin lesion along her belt line, which resolved on its own. Serologic tests confirm a clinical diagnosis of Lyme disease. Which of the following mechanisms is the most likely cause of this syndrome?

This story is typical of Lyme disease. The spirochete involved (B. burgdorferi) is transmitted by ixodic ticks and is most common in the Northeastern and Midwestern parts of the United States. The host animal varies depending on the exact type of tick.

 

See all quizzes of  the Muscles and joints at here:

Part 1Part 2 | Part 3 | Part 4|

61. A 32-year-old woman complains of having intermittent arthralgias of multiple joints and occasional swelling in both knees. The symptoms started about 6 months ago and usually last for weeks at a time and then improve spontaneously. She reports no morning stiffness or any constitutional symptoms. About 1 year ago, she recalls having a round, red, pruritic skin lesion along her belt line, which resolved on its own. Serologic tests confirm a clinical diagnosis of Lyme disease. Which of the following mechanisms is the most likely cause of this syndrome?

(A) autoimmune

(B) viral infection

(C) spirochetal infection

(D) circulating immune complexes

(E) metabolic (abnormal crystal metabolism)

62. A 74-year-old man presents with a history of increasing frequency of headaches, fatigue, and weight loss for 3 months. He has had migraine headaches in the past, but these are different from them. He is also experiencing back, shoulder, and hip discomfort, which is worse in the morning. His head and neck examination is normal. Range of motion in the shoulders and hips is reduced because of discomfort but there is no active inflammation. Which of the following signs or symptoms is most helpful in the diagnosis?

(A) throat pain on swallowing

(B) pain in the jaw when chewing

(C) malaise

(D) fatigue

(E) sweating

63. A 60-year-old man has pain in his left hand and right knee, which is interfering with his work. The pain came on gradually, first in his hand 6 months ago and now in his knee. It is usually fine when he wakes up, but gets worse as the day progresses. There is no history of any trauma, and he is otherwise well. Taking over-the-counter NSAIDs usually relieves the pain. On examination, there is bony soft tissue swelling of his second and third DIP joints in the left hand and crepitus over the right knee with flexion. There is no erythema or joint effusion. Which of the following characteristics is a risk factor for this condition?

(A) being Chinese

(B) being African

(C) being male

(D) being overweight

(E) hyperthyroidism

64. Which of the following is the most common location for osteoarthritis?

(A) hip

(B) base of thumb

(C) knee

(D) spine

(E) DIP joints of hand

75. A 67-year-old woman develops symptoms of cough and sputum production after an upper respiratory tract infection. A CXR does not show any signs of pneumonia but the report mentions a “pseudofracture” sign (Looser zones) seen in the left scapula compatible with osteomalacia. She has no pain in the scapula. Which of the following best differentiates rickets and osteomalacia?

(A) the mineralization defect is less severe in osteomalacia

(B) osteomalacia is only produced by vitamin D deficiency, unlike rickets

(C) the skeleton is at a different stage when affected

(D) parathyroid hormone levels are only routinely elevated in rickets

(E) rickets always is characterized by hypocalcemia

76. A 72-year-old man is recently found to have hypocalcemia and osteomalacia is suspected based on the decrease in the cortical bone thickness and osteopenia is seen on x-rays. Which of the following is the most likely mechanism of the resistance to the effects of vitamin D?

(A) excess parathyroid hormone secretion

(B) insufficient parathyroid hormone secretion

(C) defective receptors for 25(OH) vitamin D

(D) defective receptors for 1,25(OH)2 vitamin D

(E) mineralocorticoid excess

77. A 66-year-old woman complains of pain in her left hip when walking. Three days ago, she tripped and fell in her apartment. On examination, there is decreased range of motion in the hip, no leg length discrepancy. X-rays of the hip reveal osteopenia. Which of the following is the primary defect in vitamin D metabolism that causes osteopenia associated with aging?

(A) impaired intestinal absorption of vitamin D

(B) impaired liver hydroxylation of vitamin D

(C) impaired renal hydroxylation of 1(OH) vitamin D

(D) low parathyroid hormone levels

(E) low phosphate levels

78. Which of the following clinical findings is characteristic of both osteomalacia and rickets?

(A) frontal bossing in the skull

(B) muscle weakness

(C) prominent costochondral junctions

(D) defects in tooth enamel

(E) knock-knees

79. An 84-year-old man, previously well except for chronic osteoarthritis, develops a hot, red, painful knee. Physical examination reveals an exquisitely tender, swollen knee. Which of the following is the most likely finding on synovial fluid analysis?

(A) staphylococcal infection

(B) gonococcal infection

(C) calcium hydroxyapatite crystals

(D) calcium pyrophosphate crystal deposition

(E) calcium oxalate

80. A 74-year-old man has recurrent attacks of pain, swelling, and redness in his left knee. He has background osteoarthritis of both knees, which require him to take acetaminophen on a regular basis. Joint fluid was removed during one acute episode of knee pain, and synovial fluid analysis revealed calcium pyrophosphate deposition disease crystals (CPPD). Which of the following methods is the most effective prophylaxis for this condition?

(A) allopurinol

(B) continuous NSAIDs

(C) low-dose glucocorticoids

(D) continuous antibiotic therapy

(E) colchicine

81. A 79-year-old woman on chronic hemodialysis presents with severe pain in her left knee. On examination, the knee is warm, swollen, and painful to move. Diagnostic joint aspiration is performed. Which of the following is the most likely finding in her joint fluid?

(A) uric acid crystals

(B) calcium pyrophosphate crystals (CPPD)

(C) calcium hydroxyapatite crystals

(D) calcium oxalate crystals

(E) crystallized urea

82. An 81-year-old woman develops progressive pain and immobility of her right shoulder. A series of x-rays over 8 months reveals destruction of the shoulder joint and an aspiration reveals blood in the effusion. Her only other articular manifestations are mild episodes of pain in her knees. Which of the following is the most likely diagnosis?

(A) a chronic bacterial infection

(B) uric acid deposition

(C) CPPD disease

(D) calcium oxalate deposition

(E) calcium hydroxyapatite deposition

83. A 59-year-old woman with RA, under reasonable control with methotrexate, develops a hot, swollen, red knee. Joint aspiration removes 10 cc of an opaque yellow-colored fluid with a white count of 100,000/µL, predominantly neutrophils. The joint fluid protein is high and glucose is much lower than blood. Which of the following is the most likely diagnosis?

(A) uric acid deposition

(B) CPPD deposition

(C) septic arthritis

(D) reactivation of RA

(E) calcium hydroxyapatite deposition

84. A 48-year-old man presents with 3 weeks of fever, fatigue, and shortness of breath. He has a history of “nasal allergies” and asthma, which have been poorly controlled in the past month. Two days prior to presentation, he developed weakness in his left foot and it now “drags” when he walks. On examination, his blood pressure is 165/90 mm Hg, pulse 100/min, respirations 20/min, and lungs have bilateral expiratory wheezes. There is left foot drop, and the rest of the neurologic examination is normal. Laboratory evaluation reveals ESR of 90 mm/h, WBC of 14,000/mL with 10% eosinophils, and 1+ proteinuria. A CXR shows bilateral pulmonary infiltrates. (SELECT ONE)

(A) polyarteritis nodosa (PAN)

(B) Churg-Strauss disease

(C) Henoch-Schönlein purpura

(D) vasculitis associated with infectious diseases

(E) vasculitis associated with connective tissue diseases

(F) Wegener’s granulomatosis

(G) giant cell arteritis

(H) Kawasaki disease

(I) Behçet’s syndrome

85. A 39-year-old man has had several weeks of fever, weight loss, and lack of energy. Three days prior to the assessment, he developed a left   foot drop. Physical examination confirms left peroneal nerve damage and a bilateral sensory peripheral neuropathy in both legs. Laboratory evaluation reveals ESR of 105 mm/h, neutrophilia of 14,000, and a negative serologic test for ANCA. Eosinophil count is normal. Angiography reveals small aneurysms of the celiac and renal arteries. (SELECT ONE)

(A) polyarteritis nodosa (PAN)

(B) Churg-Strauss disease

(C) Henoch-Schönlein purpura

(D) vasculitis associated with infectious diseases

(E) vasculitis associated with connective tissue diseases

(F) Wegener’s granulomatosis

(G) giant cell arteritis

(H) Kawasaki disease

(I) Behçet’s syndrome

86. A 40-year old man complains of cough, shortness of breath, and nasal ulcers. He was previously well until 1 month ago. He noticed some blood in his sputum on the day of presentation. On examination, his blood pressure is 170/90 mm Hg, pulse 90/min, respirations 22/min, and there are bilateral inspiratory crackles. The oral cavity is normal, but there is a 1-cm nasal septal ulcer. Investigations reveal a positive c-ANCA, 3+ proteinuria with red cell casts, and pulmonary infiltrates on the CXR. His ESR is 110 mm/h and WBC 12,000/mL with normal eosinophils. (SELECT ONE)

(A) polyarteritis nodosa (PAN)

(B) Churg-Strauss disease

(C) Henoch-Schönlein purpura

(D) vasculitis associated with infectious diseases

(E) vasculitis associated with connective tissue diseases

(F) Wegener’s granulomatosis

(G) giant cell arteritis

(H) Kawasaki disease

(I) Behçet’s syndrome

87. A 24-year-old woman presents with abdominal pain, joint discomfort, and lower limb rash. She was well until 1 week before presentation. On examination, she has a palpable purpuric rash on her legs, nonspecific abdominal discomfort, and no active joints. She has 3+ proteinuria, normal WBC, no eosinophils, and elevated creatinine of 1.6 mg/dL. Biopsy of the rash confirms vasculitis with immunoglobulin A (IgA) and C3 (complement 3) deposition on immunofluorescence. (SELECT ONE)

(A) polyarteritis nodosa (PAN)

(B) Churg-Strauss disease

(C) Henoch-Schönlein purpura

(D) vasculitis associated with infectious diseases

(E) vasculitis associated with connective tissue diseases

(F) Wegener’s granulomatosis

(G) giant cell arteritis

(H) Kawasaki disease

(I) Behçet’s syndrome

88. A 34-year-old man has recurrent painful oral and genital ulcers. Recently, he has noticed multiple painful joints and a decrease in his vision. Last year he had deep vein thrombosis that required treatment. On examination, he has multiple small shallow oral ulcers and similar lesions on his scrotum. The left eye is red and tearing, while his left wrist and right knee are warm and inflamed. Laboratory investigations including complete blood count (CBC), biochemistry, and ANCA are all normal. His ESR and C-reactive protein are elevated. (SELECT ONE)

(A) polyarteritis nodosa (PAN)

(B) Churg-Strauss disease

(C) Henoch-Schönlein purpura

(D) vasculitis associated with infectious diseases

(E) vasculitis associated with connective tissue diseases

(F) Wegener’s granulomatosis

(G) giant cell arteritis

(H) Kawasaki disease

(I) Behçet’s syndrome

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