Answer:USMLE step 2 Mcq 110:A 26 year old woman presents with a severe headache and bilateral severe pain in her hands




Correct Answer: C

The triad of fever, joint pain, and rash in a woman of child-bearing age should suggest the diagnosis of SLE; however, the disease ranges from mild illness with cutaneous abnormalities to severe life-threatening complications such as renal failure and lupus cerebritis. Almost all patients with SLE have arthralgias and myalgias at some time during their disease. Like rheumatoid arthritis, the inflammation of the hands, specifically the proximal interphalangeal and the metacarpalphalangeal joints, is symmetric. Although the initial presentation can mimic rheumatoid arthritis, joint deformities are less common. Thirty percent of patients develop hitchhiker's thumb, a hyperextension of the interphalangeal joint of the thumb. The cutaneous manifestations include the characteristic but uncommon malar or butterfly rash of acute cutaneous SLE. The facial eruption may be the first sign of SLE or may accompany flares of the disease. It can be exacerbated by exposure to ultraviolet light. Discoid lupus is an erythematous raised plaque with scales usually on the face, head, or neck. This can be associated with alopecia. Mucous membrane lesions can be seen with small, shallow ulcerations. Lastly, vasculitic lesions such as ulcerations, purpura, and digital infarcts may occur. Clinical nephritis, defined as persistent proteinuria, is seen in approximately 50% of patients, although immunoglobulin deposition is seen in almost all patients with SLE. Most patients have no symptoms from their lupus nephritis until it progresses to nephrotic syndrome or frank renal failure. Serum creatinine is an insensitive indicator of early renal disease because many nephrons need to be involved before there is any elevation of serum creatinine. In patients with renal disease, the urinalysis shows hematuria, proteinuria, and red blood cell casts.


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