(MCQS 310-312):A 75 year old woman complains of weakness and fatigue

Correct Answer: D
This group of disorders is characterized by the development either of a single delusion or of a set of related delusions which are usually persistent and sometimes lifelong. The delusions are highly variable in content. Often they are persecutory, hypochondriacal, or grandiose, but they may be concerned with litigation or jealousy, or express a conviction that the individual's body is misshapen, or that others think that he or she smells or is homosexual. Other psychopathology is characteristically absent, but depressive symptoms may be present intermittently, and olfactory and tactile hallucinations may develop in some cases. Clear and persistent auditory hallucinations (voices), schizophrenic symptoms such as delusions of control and marked blunting of affect, and definite evidence of brain disease are all incompatible with this diagnosis. However, occasional or transitory auditory hallucinations, particularly in elderly patients, do not rule out this diagnosis, provided that they are not typically schizophrenic and form only a small part of the overall clinical picture. Onset is commonly in middle age but sometimes, particularly in the case of beliefs about having a misshapen body, in early adult life. The content of the delusion, and the timing of its emergence, can often be related to the individual's life situation, e.g. persecutory delusions in members of minorities. Apart form actions and attitudes directly related to the delusion or delusional system, affect, speech, and behaviour are normal.
Correct Answer: E
Patients with multiple myeloma or systemic amyloidosis may have light chain deposits in the cutaneous blood vessels. These vessels are particularly fragile, and purpura can occur as a result of minor trauma ('pinch purpura'). The eyelids and periorbital regions are particularly prone to developing purpura. Biopsies of the purpuric lesions demonstrate amyloid deposits in the dermis and subcutaneous tissues, and inflammatory cells are scarce. Bone pain, particularly in the back or chest and less often in the extremities, is present at the time of diagnosis in more than two thirds of patients. The pain is usually induced by movement and does not occur at night except with change of position. The patient's height may be reduced by several inches because of vertebral collapse. Weakness and fatigue are common and often are associated with anemia. Fever is rare and, when present, is usually from an infection. The major symptoms may result from an acute infection, renal insufficiency, hypercalcemia, or amyloidosis. Pallor is the most frequent physical finding. The liver is palpable in about 20% of patients and the spleen in 5%. Occasionally, extramedullary plasmacytomas may appear.A normocytic, normochromic anemia is present initially in two thirds of patients but eventually occurs in nearly every patient with multiple myeloma. The serum protein electrophoretic pattern shows a peak or localized band in 80% of patients, hypogammaglobulinemia in almost 10%, and no apparent abnormality in the remainder. IgG M-protein is found in 53%, IgA in 20%, light chain only (Bence Jones proteinemia) in 17%, IgD in 2%, and biclonal gammopathy in 1%, and 7% have no serum M-protein at diagnosis. Immunofixation of the urine reveals an M-protein in approximately 75% of patients. The kappa/lambda ratio is 2:1. Ninety-eight per cent of patients with multiple myeloma have an M-protein in the serum or urine at the time of diagnosis. Conventional radiographs reveal abnormalities consisting of punched-out lytic lesions , osteoporosis, or fractures in 75% of patients. The vertebrae, skull, thoracic cage, pelvis, and proximal humeri and femora are the most frequent sites of involvement.
Correct Answer: J
The management of documented venous thrombosis and pulmonary embolism is primarily by anticoagulant therapy. Heparin should be administered intravenously by constant infusion. Continuous intravenous infusion provides a more stable level of anticoagulation and a lower incidence of hemorrhage. Blood coagulation is affected by heparin in at least two ways: by preventing the activation of factor IX (Christmas factor) by factor XI (thromboplastin antecedent) in the early coagulation sequence, and by acting as a potent antithrombin in the presence of heparin cofactor. Therefore, heparin inhibits both the intrinsic and the extrinsic coagulation mechanisms by blocking the conversion of fibrinogen to fibrin by thrombin and, in high doses, by preventing the action of thrombin on platelets. Heparin is excreted mainly in the urine, and the enzyme heparinase is present in the liver, the site of some degradation.


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