Internal-Medicine

182 9: Muscles and Joints
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 P 2
,
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)
(B)
(C)
(D)
(E)
pleuritis
cavitating lesions
intrapulmonary nodules
interstitial fibrosis
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)
(B)
(C)
(D)
(E)
immune complex deposition
arteritis with giant cells
lymphocytic infiltration
type II muscle fiber atrophy
polyphasic potentials on
electromyography (EMG)
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)
(B)
(C)
(D)
(E)
asymmetric migratory polyarthritis
involving the large joints of the arms
and legs
not usually associated with disease
flares
a progressive, crippling course
symmetrical small joint involvement
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?
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 small
joints 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)
(B)
(C)
(D)
(E)
plasmapheresis
steroid therapy alone
combination therapy with steroids and
cyclophosphamide
cyclophosphamide therapy alone
combination therapy with steroids and
methotrexate
(A)
(B)
(C)
(D)
(E)
pericarditis
myocarditis
aortic regurgitation
nonbacterial endocarditis
myocardial vasculitis with infarction
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