Internal-Medicine

Answers: 8–28 193
in the normal portion, whereas the diploe
widens and extends to the outer and inner surfaces
of the calvarium without a change in the
calvarial thickness in the lesion. (Kasper, p. 2279)
19. (C) About 95% of patients will develop musculoskeletal
symptoms during the course of SLE.
Arthralgias and myalgias predominate, but
arthritis, hand deformities, myopathy, and avascular
necrosis of bone also occur. About 85% of
patients will have hematologic disease and 80%
will have skin manifestations. (Kasper, p. 1962)
20. (D) This patient has RA and aspirin or other
nonsteroidal agents are effective medications
for relieving the signs and symptoms of disease.
They do little to modify the course of the
disease, however. The new generation of
NSAIDs that are more specific inhibitors of
cyclooxygenase 2 cause less GI toxicity.
Glucocorticoids are very powerful at suppressing
signs and symptoms of disease and may
alter disease progression. Methotrexate is an
important disease modifying drug (DMRD)
used to prevent joint destruction. Gold and antimalarials
were important DMRDs in the past
before the use of methotrexate and newer
“biological” agents. (Kasper, p. 1974)
21. (D) 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. (Kasper, p. 2008)
22. (C) The major musculoskeletal issue is progressive
scoliosis, which is usually treated with
physiotherapy and mechanical bracing. Only
severe scoliosis is treated with surgery.
Vigorous exercise and pregnancy are felt by
some experts to increase the rate of aortic root
dilatation. (Kasper, p. 2330)
23. (C) The frequency of aortic insufficiency has
been about 4% in ankylosing spondylitis (AS).
Other cardiac valve anomalies are not increased
in incidence. Rarely, congestive heart failure or
third degree heart block can occur as well.
(Kasper, p. 1994)
24. (A) Hydralazine can cause drug-induced lupus
(defined by positive ANA and antihistone antibodies).
About 25–30 % of patients treated chronically
with hydralazine will develop ANA
positivity and about 10–20% of patients with
ANA positivity will develop systemic symptoms
compatible with lupus, particularly arthralgias.
Genetic variation in drug acetylation rates might
be a predisposing factor. (Kasper, p. 1967)
25. (B) This man has a noninflammatory effusion
likely from the trauma caused by the fall. In the
noninflammatory category, the fluid is transparent,
WBC 200–2000/mL (50% PMNs), low glucose,
and high LDH. Common causes for this include
crystal induced arthritis, SLE, and RA. In septic
arthritis, WBC is usually 50,000/mL or more
and often >100,000/mL with >75% PMNs.
Other important tests on synovial fluid include
Gram stain and culture when an inflammatory
effusion is suspected clinically. (Kasper, p. 2032)
27. (D) Renal disease is usually secondary to deposition
of circulating immune complex. Although
most patients with SLE have such deposits,
only half have clinical nephritis as defined by
proteinuria. Renal biopsy can provide both
prognostic and therapeutic information. (Kasper,
p. 1963)
28. (A) This patient has features of rheumatoid
arthritis, and early in RA there may not be any
bony changes seen, except nonspecific findings
of soft tissue swelling and joint effusions. With
longer active inflammation of the joints, loss of
cartilage and bony erosions can be seen. The
value of x-rays is to determine the extent of
bone and cartilage damage. (Kasper, p. 1973)