QUESTION: 1

You evaluate a 38-year-old man who complains of muscle weakness. Her appearance is remarkable for a periorbital heliotrope rash with edema and erythema on his upper chest, neck, and face. Which of the following is the most likely diagnosis?

polymyositis
dermatomyositis
spinocerebellar degeneration
vasculitis
rheumatoid arthritis

Answer(s): B

Explanation:

The heliotrope, purple periorbital rash is seen with dermatomyositis and may even precede the muscle involvement. On examination, these patients will usually show proximal muscle weakness and may complain of difficulty getting up from a chair, climbing stairs, and raising the arms over the head. Ataxia may be present with cerebellar lesions. Deep tendon reflexes should be normal and there is no joint inflammation. Polymyalgia rheumatica generally occurs in older people but is not associated with muscle weakness. Spinocerebellar degeneration, vasculitis, and rheumatoid arthritis are not associated with this rash. Creatine phosphokinase is usually markedly elevated and muscle biopsy will confirm the diagnosis.
Serum creatinine, sodium, and potassium should be normal, and the rheumatoid factor should not be elevated.

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QUESTION: 2

Identify the defense mechanisms of a person being afraid of one's rage and anger and presenting as unusually meek and mild

acting out
altruism
displacement
intellectualization
passive-aggressive behavior
projection
rationalization
reaction formation
sublimation
suppression

Answer(s): H

Explanation:

Defense mechanisms provide a means for dealing with anxiety and affect. The mechanisms chosen range from the very narcissistic and immature to mature. In suppression, a person makes a conscious decision to put the conflict aside until it can be dealt with more appropriately. On the other hand, in acting out, there is little or no attempt to contain the affect, and it is directly expressed, as in name calling. Sublimation provides a channel for the indirect expression of a need or affect. Its use is positive and socially acceptable. In reaction formation, the person acts as if the strong need or affect did not exist and acts out the opposing feeling. In projection, unacceptable feelings and thoughts are denied as part of the self and instead are "put on" the other person.

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QUESTION: 3

A 30-year-old woman is visiting you in your primary care office as a new patient. Overall, she is healthy. On taking a family history, you learn that her mother was diagnosed with colorectal cancer at the age of 50. When should this patient start being screened for colorectal cancer?

there is no proven benefit for colorectal cancer screening
at age 40
at age 50
at age 60
at age 30

Answer(s): B

Explanation:

Screening should begin approximately 10 years before the age of diagnosis of colorectal cancer in a first- degree (parent or sibling) relative. Given that this patient's mother was diagnosed at age 50, this patient should start screening at age 40. The natural history of a colon polyp to develop into cancer is thought to be 10 years. Colorectal cancer screening has proven mortality benefit.

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QUESTION: 4

A70-year-old man presents to urgent care complaining of a painful, swollen left knee. He previously has had no problems with this knee. Three days prior to onset, he went out dancing for 23 hours but recalls no specific injury. Examination of the knee reveals a moderatesized effusion and mild pain with any range of motion. Plain x-ray shows no fracture. Which of the following is the best next management?

MRI of knee
aspiration of effusion fluid
rest, ice, and leg elevation
physical therapy referral
arthroscopy

Answer(s): B

Explanation:

The presence of effusion generally signifies significant disease. Aspiration of the effusion will help in evaluation for hemarthrosis, septic arthritis, and inflammatory crystal disease. Each of these is important to identify and treat early. An MRI and/or arthroscopy would be later considerations.
Orthopedic referral likely would be necessary.

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