[22.11 A 72-year-old man develops severe pain and swelling in both knees, shortly after undergoing an abdominal hernia repair surgery. Physical examination shows warmth and swelling of both knees with large effusions. Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly positive birefringent crystals in the synovial fluid. Gram stain is negative. Which is the most likely diagnosis?
C. Calcium oxalate deposition disease
D. Reactive arthritis
[22.2] A 65-year-old man with a history of chronic hypertension, diabetes mellitus, and degenerative joint disease presents with acute onset of severe pain of the metatarsophalangeal (MTP) joint and swelling of the left first toe. Physical examination shows exquisite tenderness of the joint, with swelling, warmth, and erythema. The patient has no history of trauma or other significant medical problems. Synovial fluid analysis and aspiration is most likely to show which of the following?
A. Hemorrhagic fluid
B. Needle-shaped, negatively birefringent crystals
C. Gram-negative organisms
D. Noninflammatory fluid
E. Rhomboidal, positively birefringent crystals
[22.3] A 17-year-okl sexually active man presents with a 5-day history of fever, chills, and persistent left ankle pain and swelling. On physical examination, maculopapular and pustular skin lesions are noted on the trunk and extremities. He denies any symptoms of genitourinary tract infection. Synovial fluid analysis is most likely to show which of the following?
A. WBCs 75,000/mm3 with 95% polymorphonuclear leukocytes
B. RBCs 100,000/mm3, WBC 1000/mm3
C. WBCs 48,000/mm3 with 80% lymphocytes
D. WBCs 500m/m3 with 25% polymorphonuclear leukocytes
[22.4] A 22-year-old man presents with complaints of low back pain for 3^1 months and stiffness of the lumbar area, which worsen with inactivity. He reports difficulty in getting out of bed in the morning and may have to roll out sideways, trying not to flex or rotate the spine to minimize pain. A lumbosacral (LS) spine x-ray film would most likely show which of the following?
A. Degenerative joint disease with spur formation
B. Sacroiliitis with increased sclerosis around the sacroiliac joints
C. Vertebral body destruction with wedge fractures
D. Osteoporosis with compression fractures of L3-L5
E. Diffuse osteonecrosis of the LS spine
[22.1 ] E. Pseudogout is diagnosed by positive birefringent crystals.
[22.2] B. This is most likely gout, and the synovial fluid is likely to show needle-shaped, negatively birefringent crystals.
[22.3] A. This history is suggestive of gonococcal arthritis, and the rash is suggestive of disseminated gonococcal disease. The synovial fluid would most likely show an acute inflammatory exudate. WBCs 72,000/mm3 with 75% polymorphonuclear cells.
[22.4] B. A young man is not likely to have osteoporosis, osteoarthritis, or compression fractures. His morning stiffness, which worsens with rest, suggests an inflammatory arthritis, such as ankylosing spondylitis, which would include sacroiliitis with increased sclerosis around the sacroiliac joints.
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