Internal-Medicine

Answers: 17–33 297
more evidence of cor pulmonale and pulmonary
hypertension. (Kasper, p. 1551)
25. (E) Muscle weakness in RA is common and can
occur within weeks of onset of RA. It is most
apparent in muscles adjacent to involved joints.
There is not usually a vasculitis present,
although a mononuclear infiltrate may be present.
The most common finding on biopsy is
type II fiber atrophy and muscle fiber necrosis.
(Kasper, pp. 1970–1971)
26. (A) Alpha-thalassemia involves a decrease in
alpha-chain production and leads to the formation
of beta-globin tetramers known as
hemoglobin H. Individuals normally inherit
four alpha-chain genes. The clinical syndrome
depends on how many genes are deleted.
Deletion of one gene results in a silent carrier
state. Deletion of all four is the most severe and
presents as hydrops fetalis. This condition is
incompatible with life. (Kasper, p. 599)
27. (A) Diabetic neuropathy usually presents as
peripheral polyneuropathy, usually bilateral,
including symptoms of numbness, paresthesia,
severe hyperesthesia, and pain. Impairment
of proprioceptive fibers can lead to gait abnormalities
and Charcot’s joints. Mononeuropathy
is less common and is often spontaneously
reversible. Common syndromes include wrist
or foot drop and third, fourth, or sixth cranial
nerve palsies. Autonomic neuropathy may
cause gastroesophageal dysfunction, bladder
dysfunction, and orthostatic hypotension.
(Kasper, pp. 2165–2166)
28. (D) Uricosuric drugs and allopurinol have no
role in the treatment of acute gouty arthritis.
Salicylates are also not used in the treatment of
gout. The treatments of choice are colchicine,
NSAIDs, and intra-articular steroid injection.
Response is best when initiated early in the
disease. Colchicine can be given intravenously
to avoid GI distress. A short course of systemic
corticosteroids is also quite effective therapy.
Allopurinol is started only when all inflammation
is gone and colchicine prophylaxis has
been started. It is not always required. (Kasper,
pp. 2046–2047)
29. (B) The two broad categories of ischemic stroke
are embolic and thrombotic. Emboli can originate
from an arterial atheroma (e.g., common
carotid bifurcation) or from the heart. In the
latter case, anticoagulants are often indicated.
On occasion, emboli occur without obvious
source (e.g., hypercoagulable states, malignancy,
eclampsia). (Kasper, pp. 2375–2376)
30. (C) Screening for antibodies to hepatitis C has
reduced the incidence of this infection, but
numerous chronic cases remain. Treatment
options include interferon and ribavirin. The
hepatitis C virus is a linear, single-stranded
ribonucleic acid (RNA) virus. There are at least
six distinct genotypes. (Kasper, pp. 666–667)
31. (E) Causes of acute glomerulonephritis include
infectious diseases, especially Streptococcus,
vasculitides, and primary glomerular disease.
The acute nephritic syndrome consists of the
abrupt onset of hematuria and proteinuria,
often accompanied by azotemia and renal salt
and water retention. Oliguria may be present.
(Kasper, pp. 1679–1680)
32. (A) The pain may be described as sharp, burning,
or gnawing, usually 90 minutes to 3 hours
after eating, relieved by food or antacids. The
pain frequently awakens the patient at night.
Symptoms are usually episodic and recurrent.
Periods of remission are usually longer than
periods with pain. The ulcer crater can recur or
persist in the absence of pain. Only a minority
of patients with dyspepsia are found to have an
ulcer on endoscopy. (Kasper, pp. 1751–1752)
33. (C) Intravascular hemolysis from blood transfusion
is usually due to ABO incompatibility,
often from human error. Symptoms of intravascular
hemolysis include flushing, pain at the
infusion site, chest or back pain, restlessness,
anxiety, nausea, and diarrhea. Signs include
fever and chills, shock, and renal failure. In
comatose patients, hemoglobulinuria or bleeding
from disseminated intravascular coagulation
can be the first sign. Management is
supportive. Acute hemolysis can also result
from antibodies directed against other RBC