SRX quiz 2

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Production of a modified penicillin-binding protein MRSA resists B-lactams by altering PBP2, which lowers its affinity for these drugs

A 50-year-old man comes to the emergency department with pain and swelling in his right leg after scraping his right calf against a park bench. He is prescribed cephalexin. Three days later, he returns with worsening swelling, pain, and a tender, fluctuant mass at the injury site. Tissue culture reveals methicillin-resistant Staphylococcus aureus (MRSA). Which of the following bacterial mechanisms best explains why the patient's infection does not respond to cephalexin? A Modification of a ribosomal binding site B Mutated DNA gyrase C Production of β-lactamase D Production of a modified pencillin-binding protein E Reduced permeability of bacterial cells

Mycosis Fungoides MF is a cutaneous T cell lymphoma, can cause large plaques or patches with pruritis and atypical lymphocytes at the DEJ or within the epidermis; it develops from a malignant clone of CD4+ memory T cells

A 55-year-old man comes to the physician because of a large, itchy, red area on his lower back that has been present for the past year and has not been relieved by topical antihistamines and antifungals. On physical examination, an erythematous plaque measuring 8 by 9 cm is seen on the right lower back. A skin biopsy specimen shows atypical lymphocytes at the dermal-epidermal junction, with small collections of atypical lymphocytes in the epidermis. Which of the following is this patient's most likely diagnosis? A Mycosis fungoides B Pemphigus vulgaris C Pityriasis rosea D Psoriasis E Secondary syphilis

HLA-DR4 RA presents with morning stiffness and symmetric erosive arthritis, particularly of the MCP and PIP joints. HLA-DR4 is strongly associated with RA

A 55-year-old woman comes to the physician because of pain and stiffness in the joints of her hands. She says these symptoms are worse in the morning. On physical examination, there is swelling and limited range of motion bilaterally in the metacarpophalangeal and proximal interphalangeal joints with ulnar deviation. Which of the following human leukocyte antigen (HLA) subtypes is most associated with this condition? A HLA-B27 B HLA-B8 C HLA-BW22 D HLA-DR3 E HLA-DR4

Polymyositis Polymyositis is characterized by bilateral proximal muscle weakness and increased erythrocyte sedimentation rate and creatinine phosphokinase

A 56-year-old woman comes to the physician after having difficulty lifting boxes at her job. Over the past year, she has had increased difficulty lifting and standing up from a seated position. Vital signs are normal. Physical examination shows normal deep tendon reflexes and weakness on flexion of the deltoids and quadriceps muscles. Blood and serum studies show a creatine kinase of 920 U/L and erythrocyte sedimentation rate of 90 mm/hr. Which of the following is the most likely diagnosis? A Amyotrophic lateral sclerosis B Cushing syndrome C Dermatomyositis D Fibromyalgia E Hypothyroid myopathy F Polymyositis

Septic arthritis Staphylococcus Aureus is a common cause of prosthetic joint infection. The WBC count in joint fluid in prosthetic joint infection/septic arthritis is typically >20,000/mm3. The WBC count could reach higher than 50,000/mm3 with staphylococcal septic arthritis

A 70-year-old woman comes to the emergency department because of a 1-day history of acute-onset left knee pain. She underwent arthroplasty of the same knee 2 weeks ago. Temperature is 38.2°C (100.8°F). Physical examination shows swelling, erythema, and decreased range of motion in the left knee. The joint fluid shows 62,000 WBCs/mm3. Which of the following is the cause of this patient's symptoms? A Gouty arthritis B Osteoarthritis C Rheumatoid arthritis D Septic arthritis E Systemic lupus erythematosus

Lower trunk the lower trunk of the brachial plexus arises from the C8-T1 nerve roots. Injury to the lower trunk (Klumpke palsy) may result from accidents that stretch the lower trunks of the brachial plexus, leading to a claw-hand deformity and other symptoms

A 17-year-old boy is brought to the clinic with shooting pain in his right hand following a snowboarding accident, in which he directly struck a tree with his arms raised. On physical examination, the right fingers are held in flexion at the proximal and distal interphalangeal joints. The patient also has decreased sensation over the medial aspect of his right palm, atrophy of the hypothenar eminence, and inability to maintain finger abduction against resistance. Which of the following parts of the brachial plexus is most likely injured in this patient? A Lateral cord B Lower trunk C Middle trunk D Posterior cord E Upper trunk

Median nerve Proximal median nerve injury classically presents with inability to flex the second and third MCP joints

A 19-year-old man comes to the emergency department with a severely dislocated left elbow after a snowboarding accident. He is sedated and undergoes manual reduction for dislocation. Two weeks later, he reports difficulty making a fist with his left hand. Physical examination reveals difficulty flexing the metacarpophalangeal joints of the second and third digits of the left hand. Sensation is intact on the dorsal hand but is lost over the palmar aspect of the first three digits. Which of the following nerves has most likely been injured in this patient? A Axillary nerve B Median nerve C Musculocutaneous nerve D Radial nerve E Ulnar nerve

Endochondral ossification Achondroplasia is caused by an AD mutation of the FGFR3 gene leading to short stature and macrocephaly

A 2-month-old boy is brought to the clinic by his parents for a well-child checkup. He was born at full term and is developing appropriately. The growth chart shows significantly short stature for his age group. On physical examination, he has a large head with a prominent forehead, a long narrow trunk, and short extremities. Which of the following processes is defective in this child's most likely disorder? A Defective osteoclast resorption B Endochondral ossification C Excessive resorption of cartilage D Mineralization of cartilaginous growth plates E Secretion of osteoid by osteoblasts without a hyaline cartilage model

Anterior talofibular ligament A lateral ankle sprain can result from overinversion of a plantar-flexed foot and can present with ecchymosis and tenderness over the lateral ligaments, of which the anterior talofibular ligament is the weakest and thus most likely to be damaged

A 16-year-old gymnast is brought to the emergency department for ankle pain after she felt the sole of her foot roll inwards after she landed from the uneven bars. On physical examination, there are swelling and bruising over the lateral aspect of the joint. There is tenderness to palpation at the anterolateral aspect of the ankle joint. Which of the following ligaments has the patient most likely injured? A Anterior talofibular ligament B Calcaneofibular ligament C Talonavicular ligament D Tibiocalcaneal ligament E Tibiotalar ligament

Anterior talofibular ligament Ankle sprains involve inversion injuries of the ankle, injuring lateral ligaments. The AFTL is the ligament most commonly affected in ankle sprains

A 17-year-old boy comes to the emergency department with pain and swelling in his left ankle after landing awkwardly on a teammate's foot while playing basketball. On physical examination, there is pain, swelling, and a limited range of motion in his left ankle. X-rays reveal no fractures. Which of the following ligaments is most likely injured in this patient? A Anterior inferior tibiofibular ligament B Anterior talofibular ligament C Calcaneofibular ligament D Deltoid ligament E Posterior talofibular ligament

Methylprednisolone Avascular necrosis of the femoral head may present with hip pain and tenderness with femoral head lucency on plain radiographs. Long-term adverse effects of oral or intravenous CCS, such as methylprednisolone, are a risk factor for the development of avascular necrosis of bone

A 25-year-old woman comes to the clinic with a 4-week history of hip pain. She recalls no injury to the hip. Her past medical history is notable for ulcerative colitis requiring several hospital admissions for flares. The patient is afebrile. On physical examination, there is tenderness of her right hip. X-ray of the hip is shown. Which of the following medications most likely contributed to the patient's symptoms? A Cyclosporine B Fluticasone C Mesalamine D Methotrexate E Methylprednisolone

Chondrocytes Achondroplasia usually manifests with short stature and decreased limb length; the majority of cases are due to a gain-of-function mutation in the FGFR3 gene, which activates the FGFR3 receptor, inhibiting chondrocyte proliferation

A 25-year-old woman comes to the office for genetic counseling prior to having children. She has had a short stature since childhood. On physical examination, the patient measures 102 cm (3 ft 4 in) tall. Her limbs are shortened relative to the length of her torso and head. Decreased proliferation of which cell type is most likely responsible for this patient's disorder? A Chondrocytes B Fibroblasts C Osteoblasts D Osteoclasts E Somatotrophic cells

Desmosomes Patients with SSSS present with diffuse erythema and fever and subsequently develop flaccid bullae. SSSS is due to S aureus, which produces exotoxins that bind to desmoglein 1 (desmosomes)

A 4-day-old girl is brought to the pediatrician with a rash. Yesterday, she had purulent umbilical discharge with fever, irritability, and diffuse flushing. Today, she has developed blisters. Physical examination shows widely distributed bullae that rupture easily, resulting in tender erosions. Bacterial culture of the purulent discharge grows the exotoxin-producing organism shown. Image courtesy of CDC/Dr. Richard Facklam The skin findings in this patient are most likely due to exotoxins binding to which of the following structures? A Adherens junctions B Desmosomes C Gap junctions D Hemidesmosomes E Tight junctions

Septic arthritis Staphylococcus Aureus is a common cause of prosthetic joint infection. The WBC count in joint fluid prosthetic joint infection/septic arthritis is typically >20,000/mm3. The WBC count could reach higher than 50,000mm3 with staphylococcal septic arthritis

Furosemide Gout presents as an acute monoarticular arthritis, usually in the great toe, ankle, or knee. Furosemide is a loop diuretic that can reduce the renal clearance or uric acid, causing hyperuricemia, a risk factor for gout

A 73-year-old man comes to the clinic with a painful, swollen right great toe. He also has hypertension and congestive heart failure and was started on multiple medications for these disorders at the last clinic visit. Which of the following medications is the most likely cause of his new symptoms? A Digoxin B Enalapril C Furosemide D Metoprolol E Spironolactone F Verapamil

A Axillary nerve is susceptible to injury with fractures to the surgical neck of the humerus and is responsible for motor and sensory abnormalities in the shoulder

A 74-year-old man is brought to the emergency department with left shoulder pain after being involved in a motor vehicle accident. Physical examination reveals difficulty abducting the left shoulder. Passive movement of the shoulder elicits severe pain. There are mild sensory deficits over the inferior aspect of the deltoid muscle. The patient has good hand grip with active motion. X-ray of the left shoulder discloses a fracture of the surgical neck of the humerus. An injury to which of the labeled locations in the image would most likely explain this patient's physical findings? A A B B C C D D E E

Obturator nerve The obturator nerve may become compressed by the muscles of the medial compartment of the thigh, causing weakness and/or atrophy with thigh adduction

A 25-year-old track athlete comes to the clinic because of right groin pain and lower extremity weakness for the past 2 months. He notes worsening of symptoms with exercise. On examination, the patient has atrophy of the medial compartment of the right thigh with weakened adduction. Injury to which of the following nerves is the most likely cause of this patient's presentation? A Femoral nerve B Inferior gluteal nerve C Obturator nerve D Sciatic nerve E Tibial nerve

Right C6-C7 disc herniation C6-C7 disk herniation causes C7 radiculopathy, resulting in motor defects of the triceps and sensory abnormalities of the middle finger

A 30-year-old man comes to the clinic because of right-sided neck pain and tingling that radiates down to the middle finger of his right hand. He sustained a neck injury during a skiing accident 1 year ago. Neurologic examination reveals weakness of the right triceps and an absent right triceps reflex. Which of the following is the most likely cause of his symptoms? A Right C4-C5 disc herniation B Right C5-C6 disc herniation C Right C6-C7 disc herniation D Right axillary nerve compression E Right radial nerve compression F Right ulnar nerve compression H

Supraspinatus A supraspinatus injury causes inability to initiate shoulder abduction

A 50-year-old man comes to the emergency department because of severe right shoulder pain after a skiing accident. Physical examination reveals tenderness over the anterior and superior aspects of the right glenohumeral joint. He is unable to initiate abduction of the right shoulder. However, when assistance is provided for the first 20 degrees of abduction the patient is able to complete the motion without discomfort. Which of the following muscles is most likely injured in this patient? A Deltoid B Infraspinatus C Serratus anterior D Supraspinatus E Teres minor

Posterior cord The posterior cord of the brachial plexus gives rise to the axillary and radial nerves. An injury to this structure will manifest as an inability to perform shoulder abduction and wrist extension in the affected arm

A 10-year-old boy is brought to the pediatrician because of a 4-day history of fever, fatigue, and right shoulder pain. His temperature is 38.6°C (101.5°F). On physical examination, he has right shoulder tenderness, worse at the right axillary region, and painful and weak abduction. On palpation, a swollen mass in the axillary region is noted. He also has wrist-extension weakness and triceps hyporeflexia in the same limb. Sensory examination reveals absent sensation to light touch over the right shoulder and lateral and posterior arm. Imaging identifies an abscess in the right axillary region. The most likely diagnosis is an abscess. Which of the following structures is most likely being compressed by the abscess? A Axillary nerve B Lateral cord of the brachial plexus C Medial cord of the brachial plexus D Posterior cord of brachial plexus E Radial nerve

Osteonecrosis Scaphoid fracture may be complicated by avascular necrosis (osteonecrosis) of the proximal part of the bone; can be seen on x-ray as hyperdensity and sclerosis

A 12-year-old boy is brought to the clinic for right hand pain. He was evaluated in the emergency department 2 weeks ago after falling on his outstretched right hand. X-ray of the hand at that time showed no obvious fracture, and the patient was discharged home with a splint. On today's physical examination, there is tenderness to palpation of the anatomic snuffbox. Repeat x-ray of his right hand is shown. Which of the following is the most likely diagnosis? A Osteoarthritis B Osteomyelitis C Osteonecrosis D Osteoporosis E Perilunate dislocation

Pain in the wrists, knees, and hips Systemic JIA, the most common pediatric arthritis, often presents with polyarticular arthritis, spiking fevers, rash, hepatosplenomegaly, lymphadenopathy, elevated WBC and platelets, and anemia. SLE should be ruled out by a negative ANA test. Systemic JIA shows polyarticular arthritis in 85% to 90% of cases, but can be absent early in the disease

A 12-year-old boy is brought to the clinic with periodic high spiking fevers for the past 3 weeks and a rash that comes and goes. His temperature is 38.0°C (100.4°F). On physical examination, there is a macular rash with small, pink spots present on his trunk. His liver and spleen are enlarged and there are palpable cervical, axillary, and inguinal nodes. The complete blood cell count shows anemia and increased leukocytes and platelets. Antinuclear antibodies are negative, and the erythrocyte sedimentation rate is elevated. An x-ray of the chest shows a small left pleural effusion. Which of the following findings is most likely to develop in this patient? A Hematuria, proteinuria, and elevated serum IgA B Mucosal and submucosal inflammation of the gastrointestinal tract C Pain in the wrists, knees, and hips D Parasitic protozoa inside erythrocytes E Rash on cheeks and bridge of nose F Transmural inflammation of the gastrointestinal tract

Median nerve Supracondylar fractures of the humerus most commonly occur from falling onto an outstretched hand with hyperextension of the elbow and may result in median nerve injury. Supracondylar fractures can injure the median nerve, which can present as loss of wrist flexion, thumb opposition, or lateral finger flexion

A 12-year-old boy is brought to the emergency department because of pain and weakness along the left forearm and wrist after falling 2 days ago. Physical examination shows decreased grip strength, inability to make a fist, and difficulty with pronation of the forearm all on the left. Sensation is diminished in the left thumb and lateral three fingers of the left hand. X-ray of the left arm is shown. Which of the following nerves is most likely injured? A Axillary nerve B Median nerve C Musculocutaneous nerve D Radial nerve E Recurrent branch of median nerve F Ulnar nerve

Common fibular (peroneal) nerve Common fibular (peroneal) nerve injuries can occur with fracture to the fibular neck. Patients present with an inability to dorsiflex and evert. Patients often have a steppage gait as a result of foot drop and may present with pain and paresthesia in the lateral leg and dorsum of the foot

A 15-year-old boy is brought to the emergency department after falling off his skateboard. He reports numbness on the outside of his right leg. Physical examination reveals a swollen right knee. He is unable to dorsiflex or evert the right ankle. In addition, there is decreased sensation to the lateral leg and dorsum of the right foot. While walking, he raises the right leg high off the ground, and his foot subsequently slaps the ground. X-ray of the right lower leg shows a fracture. Which of the following nerves is most likely to be compromised by the fracture? A Common fibular (peroneal) nerve B Deep peroneal nerve C Femoral nerve D Superficial peroneal nerve E Tibial nerve

Popliteal artery Occlusion or severing of the popliteal artery can occur due to knee dislocation following posterior knee trauma and can present with lack of pulses in the lower leg and severe leg pain. Toes on the affected leg may appear dusky

A 16-year-old boy is brought to the emergency department by ambulance for severe leg pain after sustaining an injury during a football game. He was tackled from behind by another player and was hit in the back of his knee, landing with his knee bent. Physical examination is limited due to pain, but reveals a swollen extended right knee, a hypermobile patella, and no palpable pulses at the dorsalis pedis or posterior tibial artery. The toes are dusky red and decreased sensation over the lower leg is noted. Which of the following structures was most likely injured in this patient? A Anterior tibial artery B Common femoral artery C Deep femoral artery D Fibular artery E Popliteal artery F Posterior tibial artery

C5-C6 nerve roots Erb Palsy presents with tenderness to palpation over the shoulder, loss of upper arm abduction and flexion, loss of forearm supination and flexion, and numbness in the lateral forearm. It is associated with "waiter's tip" hand. An injury to the upper trunk of the brachial plexus, most specifically the C5-C6 nerve roots, can lead to Erb Palsy

A 16-year-old boy is brought to the emergency department for severe arm pain after he fell out of a tree. Physical examination reveals tenderness to palpation over the left shoulder. There is limited range of motion at the shoulder including loss of abduction and decreased flexion. His arm dangles at his side, with the forearm pronated and extended. Sensation is absent along his left lateral forearm. Which of the following structures is most likely injured in this patient? A Axillary nerve B C5-C6 nerve roots C C8-T1 roots D Long thoracic nerve E Lower trunk F Radial nerve G Ulnar nerve

Medial collateral ligament, anterior cruciate ligament, medial meniscus An "unhappy triad" is when a lateral blow to the knee on a planted foot causes rupture to the MCL, ACL, and medial meniscus

A 20-year-old man is brought to the student health clinic after sustaining a knee injury during rugby practice. He says he landed with a planted knee and was kicked by another player on the lateral side of the knee. On examination of the injured knee, the tibia is displaced anteriorly from the femur in the flexed position; there is laxity of the knee with valgus stress at 0 degrees of flexion; and a click is heard when the patient's knee is externally rotated and passively extended from 90 degrees to 0 degree. Which of the following structures are most likely injured? A Lateral collateral ligament, anterior cruciate ligament, medial meniscus B Lateral collateral ligament, posterior cruciate ligament, lateral meniscus C Medial collateral ligament, anterior cruciate ligament, medial meniscus D Medial collateral ligament, posterior cruciate ligament, lateral meniscus E Medial collateral ligament, posterior cruciate ligament, medial meniscus

Adductor pollicis The ulnar nerve can be damaged by ventromedial wrist lacerations. It provides sensation over the medial 1 1/2 digits and hypothenar eminence and has a deep motor branch that supplies most of the intrinsic muscles of the hand, including the adductor pollicis muscle

A 20-year-old woman is brought to the emergency department after cutting her wrists in a suicide attempt. Physical examination reveals several superficial lacerations on the medial side of the ventral left wrist. She has some sensory loss over the left fifth digit. Surgical exploration of the wounds reveals a nerve injury. The function of which of the following muscles is most likely affected by this patient's nerve injury? A Abductor pollicis brevis B Adductor pollicis C Extensor pollicis brevis D Lumbricals (1 and 2) E Opponens pollicis

Adductor pollicis The ulnar nerve can be damaged by ventromedial wrist lacerations; provides sensation of the medial 1 1/2 digits and the hypothenar eminence and has a deep motor branch that supplies most of the intrinsic muscles of the hand, including the adductor pollicis muscle

Shoulder abduction Anterior shoulder dislocation may occur after a direct trauma to an abducted and externally rotated shoulder (throwing motion); may lead to axillary nerve injury due to its close proximity to the joint; may result in the loss of action of the deltoid muscle and consequent inability to abduct the shoulder, as well as sensory deficits in the lateral arm

A 21-year-old man comes to the emergency department because of severe pain in his left shoulder and numbness in the lateral aspect of the arm. This occurred after being tackled from behind as he was throwing a football. An x-ray of his shoulder is shown. He is found to have a nerve injury. Weakness in which of the following motions would be most likely in this patient? A Forearm pronation B Shoulder abduction C Shoulder internal rotation D Wrist dorsal flexion E Wrist volar flexion

FGFR3 mutation Achondroplasia is a disorder that results in the formation of abnormal cartilage and connective tissue; it stems from a mutation in FGFR3

A 22-year-old man comes to a primary care physician to establish care. He has markedly short stature, prominent forehead with a large head, and a disproportionately long trunk with shortening of the arms and legs. His maternal grandfather had a similar appearance, whereas neither of his paternal grandparents was affected. Which of the following is the most likely explanation for these findings? A Deletion of the 5p gene B FGFR3 gene mutation C Mutation of a gene on chromosome 11 D Mutation of a gene on chromosome 17 E Triplet repeats on chromosome 9

Biceps brachii Erb Palsy presents with a pronated forearm, a flexed wrist ("waiter's tip" hand), an internally rotated shoulder, and an inability to abduct the arm at the shoulder. Erb palsy is due to injury of the nerves arising from C5 and C6 (the upper trunk). Lesions affect the deltoid, supraspinatus, infraspinatus, and biceps brachii

A 22-year-old man comes to the clinic because he is unable to raise his left arm. He is an avid horseback rider and was recently thrown off his horse, landing on the outside of his left shoulder. On physical examination, the patient has 1/5 strength in shoulder abduction, and the patient's arm is hanging at his side with his forearm pronated. In addition to the abductors at the shoulder, which of the following muscles is most likely to be affected by this injury? A Biceps brachii B Diaphragm C Extensor carpii radialis D Interossei E Pronator teres

2/3 of the outer palmar side of the hand, including 3 and one half fingers Sensation between the PIP and DIP joints of the second digit is provided by the median nerve which also provides sensation in the palmar side of the hand

A 24-year-old man comes to the emergency department because of a laceration over the palmar surface of the middle section of his left index finger. A subcutaneous local block is used to numb the area with lidocaine so that it can be sutured. The nerve that the physician is most likely targeting also provides cutaneous innervation to which of the following areas? A 2/3 of the outer palmar side of the hand, including 3 and one-half fingers B The lateral aspect of the forearm C The medial surface of the forearm D The radial aspect of the wrist E The ulnar aspect of the wrist

Arteries of deep and superficial palmar arch The superficial arch (a continuation of the ulnar artery) and the deep arch (a continuation of the radial artery) ensure good collateral flow to the hand when the radial or ulnar artery becomes occluded

A 24-year-old man comes to the emergency department for hand pain after falling on an outstretched hand. Physical examination reveals tenderness over the scaphoid tubercle, significant bruising, and an absent radial pulse. On simultaneous occlusion of the radial and ulnar arteries, the hand turns pale. When the ulnar artery compression is released, the color returns to the hand. Which of the following arteries have most likely ensured adequate collateral arterial flow in this patient's hand despite his injury? A Anterior and posterior interosseous arteries B Arcuate artery C Arteries of deep and superficial palmar arch D Common and proper palmar digital arteries E Radial collateral and recurrent radial arteries

Fusion of lumbar vertebrae AS is one of the seronegative arthropathies and is most commonly diagnosed in young men aged 20 to 40. It is characterized by back pain with decreased range of motion and stiffness of the lower back. X-rays usually show fusion of the SI joints and IV joints ("bamboo spine")

A 26-year-old man comes to the clinic because of several years of back pain. He reports stiffness upon waking that improves with exercise. He also reports occasional hip pain. On physical examination, hip flexion, hip extension, and flexion of the lower back are limited. There is tenderness on palpation over the lumbar spine and sacroiliac joints. Which of the following is the most likely finding on diagnostic imaging? A Fusion of lumbar vertebrae B Lateral curvature of the spine C Lumbar disc herniation D Osteophytes in the intervertebral joints E Pannus formation F Vertebral compression fractures

Fusion of lumbar vertebrae Ankylosing spondylosis is one of the seronegative arthropathies and is most commonly diagnosed in young men aged 20 to 40. It is characterized by back pain with decreased range of motion and stiffness of the lower back. X-rays usually show fusion of the sacroiliac and intervertebral joints ("bamboo spine")

HLA-B27 AS (ankylosing spondylitis) is a chronic inflammatory disease of the spine and SI joints, with a peak age of onset in young adults between 20 and 30 years old. There may also be uveitis, with eye pain and blurred vision. Most patients with AS are positive for HLA-B27

A 27-year-old man comes to the clinic because of pain and blurry vision in his right eye for the past week. He also notes a 3-month history of progressive low back and hip pain and stiffness. The pain wakes him up at night, feels worse in the morning, and improves with activity. On physical examination, the right eye is erythematous, with decreased visual acuity. There is decreased range of motion when bending at the waist. Which of the following human leukocyte antigen (HLA) subtypes would most likely be present in this patient's cells? A HLA-B27 B HLA-B8 C HLA-DQ8 D HLA-DR2 E HLA-DR4

Dactylitis Reactive arthritis, a seronegative spondyloarthropathy, is a reaction to either a gastrointestinal or genitourinary infection and develops within 1 to 4 weeks of infection. Patients may also present with keratoderma blennorrhagica. Other findings associated with reactive arthritis are dactylitis, sacroiliitis, conjunctivitis, urethritis, and balanitis

A 27-year-old man comes to the physician because of pain and swelling of his right knee and left ankle, and a new skin rash on the soles of his feet. He had a diarrheal illness 3 weeks ago. His father has psoriasis. On physical examination, the knee appears erythematous with a mild effusion. There are scaly plaques with an erythematous base on the soles of the feet (shown). Synovial fluid analysis from his right knee reveals no crystals or bacteria and 10,000 WBC/mm3 with 65% polymorphonuclear leukocytes. Image courtesy of CDC/ Dr. M. F. Rein Which of the following additional findings is most likely in this patient? A Dactylitis B Discoid rash C Heberden nodes D Malar rash E Ulnar deviation of fingers

Weakness in wrist extension Midshaft fractures of the humerus can cause radial nerve injury; radial nerve injury results in "wrist drop" which is weakness in wrist extension

A 27-year-old man is brought to the emergency department after falling off a ladder from the height of the roof. An x-ray of the patient's right arm is shown. Which of the following neurologic deficits is most likely to occur as a result of his fracture? A A protruding scapula B Inability to abduct the arm fully C Inability to hold a piece of paper between the fingers D Pain over the palmar aspects of the first three and a half digits E Weakness in wrist extension

Injectable drug use Osteomyelitis presents with bone pain and fever and can result from hematogenous seeding or spread from adjacent tissue. Injectable drug use is a major risk factor for osteomyelitis caused by P aeruginosa

A 27-year-old man presents with a 5-day history of fever, right arm pain, erythema, and swelling. MRI reveals diffuse soft tissue and bone inflammation in the right humerus. Bone biopsy is performed (see image). Blood culture grows an aerobic, gram-negative, oxidase-positive rod. Which of the following is the strongest risk factor for the patient's likely diagnosis? A Corticosteroid use B Injectable drug use C Miliary tuberculosis D Multiple sexual partners E Sickle cell anemia

Immune response to Chlamydia trachomatis Reactive arthritis is a postinfectious process characterized by arthritis, enthesitis, dactylitis, and low back pain; joint aspirates of synovial fluid are usually uninfected, differentiating this illness from septic arthritis. The cause appears to be a cytokine-mediated immune reaction against pathogens such as C. trachomatis

A 27-year-old woman comes to the physician with pain in the right knee, right elbow, and lower back for the past 2 days. She also reports a tender left heel at the insertion of the Achilles tendon. She has a past history of uncomplicated cystitis, allergic sinusitis, and urethritis. She is afebrile. Physical examination reveals tenderness, erythema, and decreased range of motion in the right knee and right elbow and a diffusely swollen and red right third toe. The knee synovial aspirate shows 20,000 WBC/mm3, but is negative for bacterial growth. The rheumatoid factor and antinuclear antibodies are negative. Which of the following is the most likely cause of this patient's current condition? A Anti-Ro and anti-La antibodies B Double-stranded DNA antibodies C IgM antibodies against IgG D Immune response to Chlamydia trachomatis E Immune response to gonococci

Enthesitis Reactive Arthritis can be preceded by a GU infection with Chlamydia or enteritis with Salmonella, Shigella, Yersinia, or Campylobater. It presents with an oligoarticular arthritis. Additional findings in reactive arthritis include enthesitis, conjunctivitis, sacroiliac inflammation, dactylitis, balanitis, and a rash on the soles or palms

A 28-year-old man comes to the clinic because of a 2-day history of redness in his right eye and joint pains in his right knee and right ankle. He was treated for a chlamydial urethritis with doxycycline 10 days ago; urethral discharge initially resolved but now has returned. Which of the following additional findings is most likely to develop in this patient? A Anti-dsDNA antibodies B Elevated creatine phosphokinase C Enthesitis D Joint fluid crystals E Painless skin pustules and diffuse tendonitis

Toxin-induced cross-linking of MHC II with T cell receptors Toxic shock syndrome presents with high fever, headache, vomiting, diarrhea, myalgias, and an erythematous rash; toxic shock syndrome is caused by exotoxins produced by S aureus or group A streptococcus that are capable of directly cross-linking MHC class II molecules on antigen presenting cells with the B chain of T cell receptors

A 30-year-old woman presents to the emergency department with a diffuse, blotchy, red rash on her abdomen for the past 2 days. The patient also has lightheadedness, headache, vomiting, and muscle pain. She had nasal packing 4 days ago for a nosebleed that would not stop. On physical examination, her temperature is 102.1°F (38.9°C), blood pressure is 91/51 mm Hg, pulse is 109/min, and respirations are 18/min. Nasal packing is in place, and there are no oral or mucosal lesions. Which of the following mechanisms is responsible for this patient's most likely diagnosis? A Cross-linking of IgE on mast cells and basophils B Cross-reactivity between pathogen and host proteins C Excess cytokine release by B-cell activation D Small immune complex activation of complement E Toxin-induced cross-linking of MHC II with T-cell receptors

Adductor pollicis The medial portion of the FDP, which performs flexion of the fourth and fifth digits is innervated by the ulnar nerve which also innervates the adductor pollicis, interossei, and the FDP, in addition to the muscles of the fifth digit (digiti minimi)

A 32-year-old man comes to the emergency department because of increasing numbness and tingling on the side of his right hand. Two days ago he sustained a crush injury to the right forearm at work. The initial injury was x-rayed and no fractures were found, and the pain in the forearm is now well controlled with ibuprofen. Neurologic examination reveals weakness of flexion in the fourth and fifth fingers and decreased grip strength. Which of the following structures is innervated by the most likely injured nerve? A Adductor pollicis B Extensor digiti minimi C Lateral portion of the flexor digitorum profundus D Skin of the lateral forearm E Skin of the palmar middle finger

Psoriatic arthritis AS is a type of arthritis that presents in young men with lower back pain and stiffness, due to vertebral fusion of the spine and SI joints. AS is associated with HLA-B27 and is a seronegative reactive arthritis, and arthritis associated with inflammatory bowel disease

A 33-year-old man comes to the clinic because of years of gradually increasing lower back pain and morning stiffness. The pain radiates to the right groin and has been present for several years. Review of systems reveals episodic blurry vision and photophobia. Physical examination shows mild tenderness at the insertion of the Achilles tendon. A lumbar x-ray is obtained and is shown. Courtesy of Wikimedia Commons. The human leukocyte antigen marker commonly associated with this man's disease is also associated with which of the following disorders? A Behçet disease B Graves disease C Multiple sclerosis D Psoriatic arthritis E Rheumatoid arthritis

Ulnar Ulnar neuropathy at the elbow presents with paresthesia over digits 4 and 5, weakness of the flexor muscles of the forearm (wrist and finger flexion), and weakness of the intrinsic muscles of the hand (hand grip)

A 34-year-old woman comes to the physician with right hand weakness for the last 3 months. She has had progressive difficulty opening jars with her right hand. She does not recall any trauma. She has no significant medical history and is not on medication. On physical examination there is diminished sensation to light touch over digits 4 and 5 on the right hand. Strength is 3/5 in the right hand involving the following muscle groups: attempted abduction of the index finger, wrist flexion, and flexion of the fourth and fifth digits. Damage or compression of which of the following nerves is most likely in this patient? A Axillary B Median C Musculocutaneous D Radial E Ulnar

Plantarflexion of foot Patients with herniated disks experience back pain radiating into the lower extremity, often caused by heavy lifting. The straight leg raise test is very sensitive (95%) for clinically significant disk herniation at the L4-L5 or the L5-S1 level. Herniation of the L5-S1 disk with resultant radiculopathy of the S1 nerve root causes decreased sensation in the posterior leg and the lateral foot, diminished ankle jerk reflex, weak plantarflexion of the foot, and back pain radiating to the lower extremity

A 35-year-old sanitation worker comes to the clinic with severe lower back pain that began suddenly as he was lifting a heavy load. He describes the pain as sharp and radiating down his left leg and foot. He does not report bowel or urinary incontinence. The pain is reproduced when the patient's left leg is lifted at a 30-degree angle. Ankle jerk reflex testing reveals 1+ on the left side and 2+ on the right side. Sensation to pinprick is diminished markedly on the lateral portion of his left foot. This patient will most likely experience weakness in which of the following movements? A Dorsiflexion of foot B Hip flexion C Knee extension D Plantarflexion of foot E Toe extension

Polymyositis Polymyositis, an inflammatory myopathy, presents with symmetrical, proximal muscle weakness, without cancerous involvement

A 35-year-old woman comes to the clinic because of progressive weakness in the shoulders and legs for the past 3 months, along with an intermittent inability to swallow food. She has been having difficulty combing her hair, buttoning her blouses, walking upstairs, lifting objects, and getting up from the seated position. It does not seem to change throughout the day or with repeated efforts, and she has mild pain over her shoulders and hip. Physical examination shows a symmetrical weakness of the proximal muscles in both the upper and lower extremities. Skin examination is unremarkable. Which of the following is the most likely diagnosis? A Dermatomyositis B Guillain-Barré syndrome C Lambert-Eaton myasthenic syndrome D Myasthenia gravis E Polymyalgia rheumatica F Polymyositis G Systemic sclerosis

Antinuclear antibodies Dermatomyositis manifests with proximal muscle weakness, heliotrope eyelid rash, and elevated muscle enzymes. It is associated with a positive antinuclear antibodies

A 38-year-old woman comes to the clinic with increasing upper arm and neck weakness and increasing dyspnea for 1 month. On physical examination, deltoid and quadriceps strength are 2/5 bilaterally and she has an erythematous rash on both eyelids (shown). There are diffuse fine crackles on lung examination. © 2008 Dhoble et al; licensee BioMed Central Ltd Which of the following serum studies is most likely to be elevated in this patient? A Anti-double-stranded DNA antibodies B Anti-IgG antibodies C Anticentromere antibodies D Antimicrosomal antibodies E Antimitochondrial antibodies

X-linked recessive Duchenne muscular dystrophy is associated with proximal muscle weakness, abnormal gait, gastrocneumius pseudohypertrophy, and Gower sign, among other symptoms; Duchenne muscular dystrophy's inheritance pattern is XLR

A 4-year-old boy is brought to the clinic because of abnormal gait. Over the past year, he has had increased difficulty standing from a seated position and needs his arms to support himself while getting up. His mother's brother had similar issues and died at a very young age. On physical examination, his gait is unsteady and there is bilateral diminished strength in his lower extremities. His gastrocnemius muscles are prominent and firm. Which of the following is the inheritance pattern of this patient's most likely disorder? A Autosomal dominant B Autosomal recessive C Mitochondrial D X-linked dominant E X-linked recessive

Calcium deposits on the elbow CREST syndrome is associated with sclerodactyly, Raynaud phenomenon, and esophageal dysmotility. Calcinosis cutis is the deposition of calcium within the skin at points of trauma or injury. This is primarily seen on the fingers, elbows, and knees

A 40-year-old woman comes to the clinic because of pain in her fingers, which is worse during cold weather. She reports difficulty grabbing objects because her skin has become progressively "tight." She has occasional difficulty swallowing food. Physical examination reveals discoloration of the fingertips with areas of ulceration, along with skin findings like those shown. © 2007 Russo and Katsicas; licensee BioMed Central Ltd. This patient is most likely to have which of the following additional findings? A Calcium deposits on the elbow B Cholesterol deposits around the eyelid C Erythematous rash on the bilateral upper eyelids D Firm, nontender nodules along the forearm E Rash on the cheekbones and the bridge of the nose F Silver-white scaling plaques on the knees

Enzyme-linked immunosorbent assay RA is an autoimmune disease that presents with joint pain and swelling accompanied by morning stiffness and weakened grip strength. Detection of autoantibodies, particularly anti-CCP antibody, provides important diagnostic information for RA. Anti-CCP can be detected with an ELISA assay

A 40-year-old woman comes to the outpatient clinic because of a 2-month history of pain, stiffness, and swelling in the wrists and finger joints of both hands causing difficulty grasping objects. The pain lasts more than 30 minutes in the morning and decreases with movement. Her temperature is 37.4°C (99.3°F). X-rays of the metacarpophalangeal joints and wrists show soft tissue swelling and joint space narrowing. Which of the following describes the test that offers the greatest specificity for the patient's most likely diagnosis? A Enzyme-linked immunosorbent assay B Fluorescence in situ hybridization C Karyotyping D Polymerase chain reaction E Western blot

Diminished ankle-jerk reflex S1 nerve radiculopathy is associated with decreased sensation of the posterior leg and lateral foot, diminished ankle-jerk reflex, and weakness of plantarflexion, toe flexion, and foot eversion

A 42-year-old man comes to the emergency department because of severe lower back pain that started abruptly as he was lifting a piano while helping his daughter move into a new apartment. He describes the pain as sharp and shooting and says it radiates down his right leg. On physical examination, the pain is exacerbated with the patient supine while slowly lifting the leg while it is straight at the knee. MRI of the spine reveals a laterally herniated disk at the L5-S1 level. Which of the following additional physical examination findings is most likely in this patient? A Babinski sign B Diminished ankle-jerk reflex C Diminished knee-jerk reflex D Diminished sensation to the medial aspect of foot E Weakness to knee extension

Antibodies against the Fc portion of IgG RA presents with morning stiffness and symmetric erosive polyarthritis, especially of the MCP and PIP joints. Most cases of RA involve the accumulation of rheumatoid factor (IgM anti-IgG) which prompts an influx of inflammatory cells into the synovium

A 42-year-old woman comes to the clinic for pain and swelling of the joints in her hands and feet for the past few years. Her pain is associated with stiffness and is worse for the first hour in the morning. These symptoms interfere with common household tasks. On physical examination, she has symmetric swelling of the joints of her hands and feet. An x-ray of both wrists is obtained and shown in the image. Image courtesy of William Scott, MD Which of the following would most likely be found in this patient? A Antibodies against double-stranded DNA B Antibodies against the Fc portion of IgG C Antibodies against the nuclear enzymes that unwind DNA D Antibodies against the nuclear protein that links sister chromatids E Cell-surface human leukocyte antigen B27

Hydrochlorothiazide Gout flares occur due to hyperuricemia and the accumulation of monosodium urate crystal deposition in joints, most often in the big toe. Thizaides (and sometimes loop diuretics) can cause hyperuricemia by inhibiting uric acid secretion and promoting of uric acid reabsorption in the kidney. As a result, they can cause gout symptoms

A 44-year-old man comes to the clinic using crutches due to the abrupt onset of an exquisitely painful, swollen, erythematous, and warm right metatarsophalangeal. Two months ago, he developed mild peripheral edema and was started on a new medication that may cause decreased urine calcium excretion. On physical examination, his right toe is tender, erythematous, and warm to the touch. Which of the following antihypertensive medications was most likely responsible for this patient's findings? A Clonidine B Furosemide C Hydrochlorothiazide D Lisinopril E Nifedipine F Prazosin

Citrullinated protein RA presents with morning stiffness and erosive arthritis, particularly of the metacarpal and proximal interphalangeal joints. Anti-CCP is the most specific finding for RA

A 44-year-old woman comes to the clinic for evaluation of pain and swelling in her hands, wrists, and elbows for the past 18 months. She says the pain is worse in the morning. She notes an unintentional 2.26-kg (5-lb) weight loss. Physical examination reveals tenderness and edema of the bilateral metacarpal and proximal interphalangeal joints, wrists, and elbows. An x-ray of her hand is shown. Courtesy of Wikimedia Commons The presence of serum antibodies against which of the following is most specific in diagnosing this patient's likely disease? A Centromeres B Citrullinated protein C Contents of the cell nucleus D Fc portion of human IgG E Ro antigen F Small nuclear ribonucleotide proteins

B Osteoporosis is characterized by loss of bone mass despite normal bone mineralization. Low bone mass can be caused by age-related changes, genetic factors, and in women, postmenopausal states such as decreased estrogen production

An 87-year-old woman visits her primary care physician for routine follow-up care. She has a history of a hip fracture following a minor fall 2 years ago. She has a 35-pack-year history of smoking. X-ray studies show bone cortical thinning and increased radiolucency. Which pattern of serum values in the table would be most likely in this patient? A A B B C C D D E E

Brunner glands Symptoms of duodenal ulcers include epigastric abdominal pain that worsens after periods of starvation and vomiting, fatigue, a history of smoking, and overuse of NSAIDs. Doudenal ulcers are associated with hyperplasia of Brunner glands

A 44-year-old woman comes to the physician because of epigastric abdominal pain, vomiting, fatigue, and weight gain over the past month. The abdominal pain sometimes wakes her at night, and the pain improves with meals. She has a long-standing history of osteoarthritis, which is treated with ibuprofen, and she smoked one pack of cigarettes daily for 20 years. Physical examination reveals epigastric and right upper quadrant tenderness to deep palpation. A biopsy of the affected tissue is most likely to show hyperplasia of which of the following structures? A Brunner glands B Mucosa of the antrum of the stomach C Muscularis layers in the gastrointestinal tract D Peyer patches E Tubular glands in the fundus of the stomach

Scaphoid A fracture of the scaphoid is associated with pain and tenderness at the anatomic snuffbox and is associated with increased risk for osteonecrosis following the fracture due to retrograde blood supply

A 45-year-old woman comes to clinic because of left wrist pain after landing on her outstretched left hand to break a fall 1 day ago. On physical examination, she has tenderness in the dorsum of the left hand between the tendons of extensor pollicis longus and brevis. This patient most likely fractured which of the following bones? A Capitate B Hamate C Lunate D Pisiform E Scaphoid F Trapezium G Trapezoid

Elicitation of symptoms by tapping on the median nerve CTS is caused by compression of the median nerve at the wrist; tapping of the median nerve at the wrist may elicit a tingling sensation in the distribution of the nerve

A 45-year-old woman comes to the clinic for pain and a tingling sensation in both of her hands that started 3 weeks ago. She is a pianist and reports that the symptoms worsen at night and are sometimes relieved by shaking her hands vigorously. On physical examination, her thenar muscles appear atrophied, and there is a loss of sensation on the palmar aspect of the first and second digits of both hands. Which of the following additional physical examination findings is most likely in this patient? A Atrophied hypothenar eminence of the hands B Elicitation of symptoms by tapping on the median nerve C Loss of sensation in the ventral aspect of the medial wrist D Loss of sensation of skin overlying the anatomic snuffbox E Loss of sensation of the medial aspect of the fourth digit F Loss of wrist extension

Tyrosine Alkaptonuria presents with darkly pigmented cartilage and sclera, urine that turns black upon standing, and painful arthropathy. There may be renal and prostate calculi and calcification of vertebral disks and cardiac valves. Alkaptonuria is due to pathogenic mutations in the homogentisate 1,2 dioxygenase enzyme in the tyrosine catabolism pathway, leading to homogentisic acid accumulation

A 46-year-old man comes to the clinic for a repair of his right anterior cruciate ligament after an injury. His medical history includes presumed knee osteoarthritis. On arthroscopy, his cartilage appears black. Urinalysis is notable for urine that turns black after several minutes but is otherwise normal. This patient has an abnormal enzyme that is involved in the degradation of which of the following amino acids? A Cystine B Homocysteine C Leucine D Methionine E Tyrosine F Valine

Inhibition of the organic anion transporter Probenecid is a medication used to prevent gout; it functions by inhibiting urate absorption in the proximal tubule. It also inhibits the organic anion transporter in the kidneys, reducing the excretion of several drugs, such as penicillin, and raising their serum levels

A 48-year-old man comes to the clinic because of a 4-day history of pain in the left ear. His medical history is significant for gout, for which he takes ibuprofen, allopurinol, and probenecid. Otoscopy shows an erythematous, bulging left tympanic membrane. He is prescribed amoxicillin at a reduced dose. Which of the following drug mechanisms best explains why amoxicillin is prescribed at a reduced dose in this patient? A Competitive inhibition of xanthine oxidase B Decreased glomerular filtration rate C Increased tubular reabsorption of antibiotics D Induction of cytochrome P450 E Inhibition of the organic anion transporter

Subscapularis the function of the subscapularis muscles is to internally rotate and adduct the shoulder, injury to this muscle or to the upper and lower subscapular nerves can result in weakness in these movements

A 49-year-old man comes to the emergency department because of pain in his right shoulder. He was lifting a heavy box onto a shelf several hours ago when he experienced a sudden tearing sensation in his shoulder. Physical examination reveals tenderness to the shoulder on palpation, weakness on internal rotation, and pain with adduction. Which of the following muscles is most likely injured? A Deltoid B Infraspinatus C Subscapularis D Supraspinatus E Teres minor

Irreversible COX-1 and COX2 inhibitor Aspirin, which acts as an irreversible COX-1/2 inhibitor, reduces the formation of thromboxane A2 and prostaglandins. Aspirin adverse effects include gastritis and tinnitus

A 49-year-old man comes to the outpatient clinic because of a 3-week history of ringing in his ears, stomach pain, and nausea. His past medical history is significant for chronic back pain, for which he takes an unknown analgesic agent. The physical examination shows epigastric tenderness. Which of the following describes the mechanism of action of this patient's most likely prescribed pain medication? A Binding to central nervous system m-receptors B Inhibition of cyclooxygenase (COX)-1, COX-2, and phospholipase A2 C Irreversible cyclooxygenase (COX)-1 and COX-2 inhibitor D Reversible cyclooxygenase-2 inhibitor E Reversible inhibition of cyclooxygenase (COX)-1 and COX-2

Gram-positive, catalase positive, coagulase positive Osteomyelitis presents with bone pain, fever, and positive blood cultures. X-ray may show lytic bone destruction. S. Aureus is the most common causative pathogen of osteomyelitis. S. Aureus is a gram-positive, catalase positive, coagulase positive coccus

A 50-year-old man comes to the emergency department because of a 3-day history of fever, chills, malaise, and new low back pain. He has a history of injectable drug use. His temperature is 38.8°C (101.8°F). On physical examination, his lumbar spine is tender to palpation. Courtesy of Chen C-H, Chen WL, Yen H-C. et al. J Ophthalmic Vis Res. 2013;6:529. doi:10.1186/1756-0500-6-529. Blood cultures will most likely recover a bacterium with which of the following characteristics? A Acid-fast positive B Gram-negative diplococci, aerobic C Gram-negative, lactose non-fermenter, oxidase negative, positive hydrogen sulfide production D Gram-positive, catalase positive, coagulase negative E Gram-positive, catalase positive, coagulase positive

Prevents hyperflexion of the knee The posterior drawer test checks for PCL tears or instability. The PCL is responsible for preventing hyperflexion of the knee and excessive posterior translation of the tibia on the femur

A 50-year-old man is brought to the emergency department after being involved in a motor vehicle collision in which the dashboard of the car was pushed back into the patient's knees. He has pain in the anterior left knee and is unable to bear weight on the knee. During the physical examination, the patient is supine on the table and flexes his hip and knees to 90° with his feet flat. The physician places his hands on the sides of the left knee and finds the joint line. On applying an anterior-to-posterior force on the proximal tibia, there is an abnormally large posterior translation of the tibia on the femur. The right knee is normal. The ligament most likely injured in this patient has which of the following functions? A Decreases friction between tibial and femoral joint surfaces B Limits leg abduction C Maintains proper alignment of the patella D Prevents anterior displacement of the tibia on the femur E Prevents hyperflexion of the knee

Opponens pollicis In CTS, median nerve compression leads to numbness and tingling in the hands and decreased sensation in the fingers, which can be triggered by wrist flexion; the recurrent branch of the median nerve innervates the opponens pollicis, the sole muscle responsible for opposition of the thumb. With progressive median nerve compression, this muscle will become weakened

A 50-year-old woman comes to the clinic because of numbness and tingling in her hands. Physical examination reveals bilateral decreased sensation in the thenar eminence and all of her fingers except the fifth fingers. Muscle strength is intact, and range of motion is normal. Flexion of the hand at the wrist reproduces the numbness and tingling. Which of the following muscles will most likely become weakened in this patient? A Adductor pollicis B Dorsal interossei C Opponens digiti minimi D Opponens pollicis E Third and fourth lumbricals

Macrophages OA causes joint pain, stiffness, and swelling in the fingers, back, hip, and knee. Symptoms typically worsen late in the day or after activity but can be present on rising. OA stems from joint trauma and wear, leading to the innate immune response with macrophages and cytokines

A 50-year-old woman comes to the clinic with knee pain for 2 months. Her pain is worse at the end of the day and is relieved with rest and ibuprofen. She works as a clerk and is mostly sedentary. The patient is 170 cm (5'7") tall and 93 kg (205 lb); for a body mass index of 32.1 kg/m2. X-ray of the knee is shown. ©ScholarRx Which of the following cell types is most involved in the pathogenesis of the patient's disease? A B cells B Eosinophils C Macrophages D Neutrophils E T cells

OA causes joint pain, stiffness, and swelling in the fingers, back, hip, and knee. Symptoms typically worsen late in the day or after activity but can be present on rising. OA stems from joint trauma and wear, leading to the innate immune response with macrophages and cytokines

Prednisone The CCS prednisone is metabolized to prednisolone, the active form of the drug

A 52-year-old man develops peripheral edema, and is found to have hematuria and proteinuria. A renal biopsy shows membranous nephropathy, and he is begun on immunosuppressive drugs, including a synthetic corticosteroid that requires enzymatic bioactivation in order to be effective. Which of the following corticosteroids was the patient most likely prescribed? A Betamethasone B Budesonide C Dexamethasone D Hydrocortisone E Prednisone

Loss of sensation in the lateral forearm The musculocutaneous nerve supplies the coracobrachialis, brachialis, and biceps brachii muscles. Injury to the musculocutaneous nerve may lead to weak forearm flexion, loss of the biceps tendon reflex, and sensory loss over the lateral forearm.

A 52-year-old woman who works in construction comes to the emergency department after being shot in the right arm with a nail gun. On physical examination, she has a clean puncture wound on her right upper arm. Biceps reflex is absent. Assuming the patient sustained a nerve injury, which of the following sensory deficits is most likely to accompany this injury? A Loss of sensation in the dorsal thumb B Loss of sensation in the hypothenar eminence C Loss of sensation in the lateral forearm D Loss of sensation on the palmar aspect of the third finger E Loss of sensation over the deltoid muscle

Diet Hyperuricemia with elevated urinary uric acid can be idiopathic or due to rhabdomylolysis, tumor lysis, or diet. A high intake of meat or seafood can lead to high purine ingestion; purines are metabolized to uric acid, resulting in hyperuricemia and increased urinary uric acid

A 54-year-old man comes to his primary care physician for a routine examination. He feels well. He has hypertension, managed with chlorthalidone. He mentions that his dietary habits include daily meat consumption and a glass of beer three times a week. His blood pressure today is 126/86 mm Hg. Physical examination is normal. Serum studies are abnormal only for a uric acid concentration of 8.5 mg/dL. Urine uric acid levels are increased. The urinalysis shows no cells or crystals. Which of the following is the most likely cause of this patient's hyperuricemia and elevated urinary uric acid? A Chlorthalidone B Diet C Elevated ADH D Gout E Muscle breakdown F Urate nephropathy

Leukotriene B4 Adverse effects of aspirin include heartburn, ulcers, gastrointestinal bleeding, and rash. Aspirin is an inhibitor of COX. Inhibition decreases proinflammatory end products such as prostacyclin, prostaglandin E2, and thromboxane A2 and shunts arachidonic acid metabolism to the lipoxygenase pathway, resultsing in the production of leukotriene B4

A 54-year-old man comes to the physician with worsening of his chronic osteoarthritis pain. He is taking an over-the-counter medication, which, if overdosed, may cause combined metabolic acidosis and respiratory alkalosis. Which of the following molecules is most likely increased in the serum of this patient while taking this medication? A Leukotriene B4 B Prostacyclin C Prostaglandin D2 D Prostaglandin E2 E Thromboxane A2

Deviation of the fingers toward the fifth digit RA commonly presents with bilateral swelling, stiffness, and pain of the MCP, PIP, wrist, and knee joints that is associated with morning stiffness lasting longer than an hour. A common finding in RA is ulnar deviation

A 57-year-old woman comes to the clinic because of joint pain and stiffness for the past several years. Her symptoms have worsened during the past 2 months and are at their worst upon waking; both wrists and knees are stiff for over an hour each morning. Findings on physical examination are shown. Which of the following additional findings is most likely to be associated with this patient's condition? A Clubbing of the fingers and toes B Dactylitis C Deviation of the fingers toward the fifth digit D Skin nodules composed of uric acid E Swelling of the distal interphalangeal joints F Tenderness over the sacroiliac joints

Interstitial lung disease RA presents with morning stiffness and symmetric erosive arthritis, particularly of the MCP and PIP joints. Rheumatoid nodules are the most common cutaneous manifestation of RA; such nodules can occur in multiple organ systems, including the lungs

A 57-year-old woman comes to the clinic because of months of pain and stiffness in multiple joints. Her left forearm is shown. The observed lesions are firm and nonfluctuant. Which of the following complications is most likely in this patient? A Elevated total creatine phosphokinase B Fusion of sacroiliac joints C Hyperuricemia D Hypocomplementemia E Interstitial lung disease F Sialadenitis

Synovitis of the C1-C2 vertebral joint RA commonly presents with early morning stiffness lasting longer than an hour as well as swelling and pain in the bilateral PIP, metacarpophalangeal, and wrist joints. Anti-cyclic citrullinated peptide will be positive. Involvement of the cervical spine in RA can present with neck pain and stiffness similar to other joints, but can progress to potentially life-threatening misalignment of the C1-C2 vertebrae (atlanto-axial subluxation)

A 58-year-old woman comes to the clinic because of neck pain and stiffness over the past few months. She has had many years of hand and wrist pain and stiffness and never sought care. It takes her over an hour to get up in the morning due to stiffness in her hands and neck. Laboratory studies show serum anticyclic citrullinated peptide antibodies. Which of the following is a complication of this patient's most likely diagnosis? A Compression fracture of the T10 vertebral body B Development of uric acid containing nodules C Osteosarcoma of the femur D Round-shaped skin lesions E Synovitis of the C1-C2 vertebral joint F Unilateral blindness

Osteophyte formation OA is a common arthritis in which articular cartilage is damaged as a result of multiple factors that include aging, mechanical trauma, genetics, and innate immune system activation. Pathological findings include the formation of bony outgrowths known as osteophytes

A 58-year-old woman comes to the clinic for pain and stiffness in her hands. It is in most of her fingers, progressively worsens during the day, and is relieved by rest and ibuprofen. Physical examination reveals tenderness at the proximal interphalangeal and distal interphalangeal joints bilaterally with limited flexion. Which of the following is the most likely pathologic finding in this patient? A Juxta-articular erosions B Negatively birefringent joint crystals C Osteophyte formation D Positively birefringent crystal deposition E Resorption of the phalangeal bones

Radial nerve Midshaft humerus fracture may occur after a direct blow or fall; the radial nerve may be injured with a midshaft humerus fracture. Patients present with weakened wrist and finger extension and decreased sensation on the posterior forearm and the thumb, index, middle, and (half of) ring fingers

A 58-year-old woman comes to the emergency department because of severe left arm pain after slipping and falling on ice on her driveway. On physical examination, she has tenderness and deformity over the lateral side of the middle of her left arm. She is unable to move her left shoulder due to pain. Examination of her wrist and hand reveals weakness with wrist and finger extension of her left hand. An x-ray of her left humerus is shown. Which of the following nerves is most likely injured? A Axillary nerve B Median nerve C Musculocutaneous nerve D Radial nerve E Ulnar nerve

Binding and activation of intracellular receptors Nonselective NSAIDs, such as naproxen and ibuprofen, significantly increase the risk for peptic ulcer disease and upper GI bleeding. This risk is increased by adding glucocorticoids in the treatment. Inhibition of COX-1 by nonselective NSAIDs reduces production of prostaglandins in the GI tract, which compromises the protective gastric mucosal layer and can lead to ulceration and gastritis. Glucocorticoids activate intracellular glucocorticoid receptors and suppress the immune system response

A 60-year-old man comes to his primary care physician because of abdominal pain and dark stools for the past 3 days. He has a history of gout and osteoarthritis that is managed with allopurinol and ibuprofen as needed. Two weeks ago, he was given prednisone for a short period to control a flare of gout. Abdominal examination reveals mild epigastric tenderness. Stool is heme positive. Upper gastrointestinal endoscopy reveals hyperemia of the gastric mucosa and the presence of numerous linear ulcerations with evidence of bleeding. The medication that increased the risk for the patient's gastric findings has which of the following mechanisms of action? A Binding and activation of intracellular receptors B Inhibition of β-tubulin polymerization into microtubules C Inhibition of the H+/K+-ATPase pump D Inhibition of the Na+/K+-ATPase pump E Inhibition of xanthine oxidase

Right superior gluteal nerve The superior gluteal nerve innervates the gluteus medius and minimus, which abduct and medially rotate the thigh and keep the pelvis level. Injury to this nerve causes the hip contralateral to the injured nerve to drop when an individual leans on the affected side

A 60-year-old man visits a new physician to establish care. He reports one major illness as a child, after which he developed a limp. On physical examination, the patient stands on his right leg and subsequently the left hip drops and his trunk leans slightly toward the right. No abnormalities are seen when the patient stands on his left leg. Which of the following nerves is most likely injured in this patient? A Left femoral nerve B Left superior gluteal nerve C Right obturator nerve D Right superior gluteal nerve E Ventral rami of L2 and L3 F Ventral rami of S1 and S2

Intervertebral foramina Cervical radiculopathy is compression of the cervical nerve root due to spondylosis or degenerative or nondegenerative changes. It causes radiating arm pain, weakness, sensory changes, or decreased reflexes. The spinal nerves exit the spinal canal intervertebral foramina and bony growth in this area may cause compression of the nerve roots

A 62-year-old woman with a history of osteoarthritis comes to the physician because of neck pain. The pain is constant, sharp, and radiates down her right arm. There is a "pins and needles" sensation in her right hand. There is no history of trauma. On examination, the right arm is weaker than the left. There is decreased sensation to light touch in the right hand. Degenerative changes in which of the following areas are the most likely causes of these symptoms? A Intervertebral foramina B Spinous process C Superior articular process D Transverse foramen E Vertebral body

S1 radiculopathy S1 radiculopathy presents as pain that radiates to the posterior leg and as motor weakness of plantar flexion, hip extension, and/or knee flexion

A 64-year-old man comes to the physician because of back pain. The patient says the pain started 1 year ago and has progressively become more severe. The pain is currently 7/10, radiates down the posterior aspect of the left leg, and is exacerbated with physical activity. He has a history of osteoarthritis and is not taking any medications. On physical examination, he has 3/5 strength for hip extension and knee flexion on the left leg, 5/5 strength for both on the right leg, and an absent Achilles reflex on the left. Which of the following is the most likely diagnosis? A L4 radiculopathy B L5 radiculopathy C S1 radiculopathy D S4 radiculopathy E Spinal stenosis

Osteoarthritis OA causes joint stiffness and swelling in the fingers, back, hip, and knee. It is associated with joint trauma, obesity, and aging

A 64-year-old woman comes to her primary care physician because of pain in her fingers, back, and right hip. The pain has been present for many years and persists through most of the day. On physical examination, she has limited range of motion in her hips. A photograph of her hands is shown. Courtesy of Wikimedia Commons. Which of the following diseases is most likely the cause of this patient's symptoms? A Gout B Osteoarthritis C Pseudogout D Reactive arthritis E Rheumatoid arthritis

Inclusion body myositis Inclusion body myositis is a chronic progressive inflammatory myopathy that presents with weakness of the quadricep and distal finger flexor muscles. Lab studies will be remarkable for elevated CK and abnormal ESR/CRP, and muscle biopsy for rimmed vacuoles and mononuclear cell (CD8+ T cells) infiltrate

A 65-year-old man comes to the physician because of insidious onset and worsening weakness over the past several months. He says he has difficulty climbing stairs and opening jars. He eats a normal diet. When asked to stand, he uses his hands to lift off the chair. Serum studies show potassium of 5 mg/dL, thyroid-stimulating hormone of 4 mIU/L, and creatine kinase of 500 U/L. Erythrocyte sedimentation rate is 15 mm/hr, and C-reactive protein is 32 mg/dL (reference range: 0.8-100 mg/dL). Biopsy specimen of the quadriceps muscle shows rimmed vacuoles, endomysial inflammation, and myofiber degeneration with amyloid deposition. The patient is unresponsive to immunosuppressive therapy. Which of the following is the most likely diagnosis? A Drug-induced myopathy B Hypothyroid myopathy C Inclusion body myositis D Necrotizing myopathy E Polymyositis

Perimysial inflammation with perifascicular atrophy Dermatomyositis leads to proximal muscle weakness, eyelid heliotrope rash, and elevated muscle enzymes. The pathology of dermatomyositis is perimysial inflammation with perifascicular atrophy

Naproxen Muscular and ligamentous strain of the back may cause acute mechanical low back pain. Acute mechanical back pain is treated conservatively with NSAIDS (e.g. naproxen)

A 65-year-old man comes to the urgent care clinic because of a 2-week history of persistent back pain. The pain began after he moved heavy boxes in his garage. He has no history of major medical illness. Vital signs are within normal limits. Physical examination of the back reveals limited range of motion due to pain and tenderness to the lumbar paraspinal muscles. He is prescribed a medication that decreases glomerular capillary hydrostatic pressure. Which of the following is the drug that was most likely prescribed for the patient's back pain? A Baclofen B Fentanyl patch C Hydrocodone D Naproxen E Prednisone

Parasympathetic nerves from S2 to S4 Erectile dysfunction may arise after pelvic surgery, leading to damage to nerves. The nervous innervation of erections comes from parasympathetic fibers in S2 to S4

A 66-year-old man comes to the office reporting erectile dysfunction following surgery for prostate cancer. He does not have morning erections. His erections were normal before surgery, and he is otherwise healthy. His physical examination is normal. Damage to which of the following is most likely responsible for this patient's symptoms? A Hypogastric nerve from T10 to L2 B Parasympathetic axons from L1 to L2 C Parasympathetic nerves from S2 to S4 D Pudendal nerves from S2 to S4 E Somatic nerves from L5 to S1 F Sympathetic nerves from S2 to S4

Increased afferent arteriolar tone In the setting of NSAID use, increased BUN and creatinine may be indicative of AKI (acute kidney injury), NSAIDs reverse the afferent arteriole vasodilation that maintain GFR in the face of volume depletion, leading to mild acute kidney injury

A 67-year-old man comes to the office for a follow-up examination. He has a history of systolic heart failure, well-controlled with enalapril and metoprolol, as well as osteoarthritis, for which he takes ibuprofen daily. Physical examination is normal. Laboratory tests reveal a blood urea nitrogen level of 60 mg/dL and creatinine of 2.9 mg/dL. These values were normal 6 months ago. Urinalysis is normal. Which of the following is the most likely mechanism by which ibuprofen is causing the patient's abnormal laboratory values? A Crystal-induced tubular obstruction B Decreased afferent arteriolar tone C Decreased efferent arteriolar tone D Glomerular inflammation E Increased afferent arteriolar tone F Increased glomerular capillary oncotic pressure

Presence of protein A on the bacterial surface Fever, productive cough secondary to a viral infection, and a sputum sample showing gram-positive cocci in clusters are suggestive of bacterial pneumonia due to S aureus. S aureus has surface protein A, which binds the Fc portion of antibodies, blocking opsonization

A 68-year-old woman comes to her physician because of a 5-day history of fever, difficulty breathing, productive cough, and muscle aches. She recently recovered from the flu. Temperature is 38.5°C (101.3°F), and respirations are 25/min. X-ray of the chest shows patchy infiltrates in the middle lobe of the right lung. The patient's Gram-stained sputum sample is shown. Image courtesy of Y Tambe. Which of the following is a characteristic of the most likely causal organism? A α-Hemolysis on blood agar B Exists as elementary body between hosts C IgA protease D Lack of a cell wall E Presence of protein A on the bacterial surface

Dislodged pieces of cartilage and subchondral bone OA causes joint stiffness and swelling in the fingers, back, hip, and knee and is associated with joint trauma, obesity and aging. In joint degeneration associated with OA, pieces of cartilage and bone are broken off into the joint space, causing pain and restriction of joint movement

A 68-year-old woman comes to the clinic because of pain in both knees that is worse on the right. The pain increases with activity and is relieved by rest and ibuprofen. She has a history of obesity and osteoporosis. Physical examination is remarkable for crepitus in the right knee; mild tenderness, small effusions, and decreased range of motion are noted bilaterally but are more severe on the right. Which of the following pathologic findings is most likely present in this patient's knees? A A fibrocellular mass of synovium and granulation tissue B Dislodged pieces of cartilage and subchondral bone C Needle-shaped crystals in neutrophil cytoplasm D Neutrophils and dense, proteinaceous debris E Positively birefringent crystals

Dislodged pieces of cartilage and subchondral bone OA causes joint stiffness and swelling in the fingers, back, hip, and knee and is associated with joint trauma, obesity, and aging. In joint degeneration associated with OA, pieces of cartilage and bone are broken off into the joint space, causing pain and restriction of joint movement

Piriformis and superior gemellus Sciatica, a condition of the sciatic nerve containing L4 through S3 nerve roots, presents with shooting pain from the back/buttock to the leg, numbness, weakness, and a positive straight leg raise test. The sciatic nerve passes between the piriformis and superior gemellus muscles after leaving its origin and before traveling down the leg

A 69-year-old man comes to the office because of pain in his right leg. The pain starts in his lower back and right buttock and shoots down his leg. It is worse when he tries to bend over. On physical examination, a straight leg raise on the right reproduces the pain. Active dorsiflexion is weaker in the right foot. Flexion of the hip against resistance is normal. There is decreased sensation in the plantar aspect of the right foot. The nerve most likely affected in this patient passes between which of the following two muscles as it leaves its origin? A Gastrocnemius and soleus B Gluteus maximus and gluteus medius C Gluteus maximus and obturator internus D Peroneus longus and extensor digitorum longus E Piriformis and superior gemellus

Afferent arteriolar constriction NSAIDs may cause AKI (acute kidney injury) by reversible hemodynamic changes in glomerular capillary hydrostatic pressure. NSAIDs reduce vasodilating prostaglandins, causing afferent arteriole constriction

A 70-year-old man comes to his physician for routine follow-up care. He has osteoarthritis, for which he was recently started on ibuprofen because of worsening joint pain. He also has stable systolic heart failure treated with metoprolol and furosemide. Two weeks after ibuprofen was started, his serum creatinine is noted to have risen from 1.5 mg/dL to 2.9 mg/dL. His vital signs and physical examination are normal except for unchanged joint stiffness and swelling in his fingers and elbows. His urinalysis is normal. Which of the following best explains the recent rise in his serum creatinine concentration? A Afferent arteriolar constriction B Afferent arteriolar dilation C Decreased glomerular capillary oncotic pressure D Efferent arteriolar constriction E Increased glomerular capillary hydrostatic pressure

Medial femoral circumflex artery Femoral fractures have an increased association with osteonecrosis of the femoral head. The osteonecrosis occurs because of injury to the medial femoral circumflex artery, which supplies blood to the femoral head

A 70-year-old woman comes to her physician because of increasing right hip pain. Two years ago she underwent open operative reduction and pinning of a right femoral head fracture after a fall. The surgery was uncomplicated, as was the postoperative recovery. On examination, there is limited motion of the right hip with severe pain during active and passive motion. An MRI scan shows areas of bone infarction and bony destruction in the femoral head. Injury to which of the following arteries is most likely responsible for this patient's current findings? A Deep femoral artery B Inferior gluteal artery C Lateral femoral circumflex artery D Medial femoral circumflex artery E Obturator artery

CD8+ T cell inflammation The clinical features of polymyositis, an inflammatory disorder of the skeletal muscle, include bilateral proximal muscle weakness and elevated creatine kinase and erythrocyte sedimentation rate. Histologically, polymyositis demonstrates endomysial CD8+ T cell inflammation with necrotic muscle fibers

A 74-year-old man presents to his physician after noticing weakness at the gym, particularly with bicep curls. Physical examination is normal except for weakness on flexion of the biceps brachii and quadriceps muscles. He has rheumatoid arthritis, well controlled with methotrexate and prednisone. Laboratory test studies show a creatinine kinase level of 299 U/L and an erythrocyte sedimentation rate of 36 mm/hr. Electromyography shows increased fibrillation potentials with positive sharp waves and polyphasic motor unit action potentials of short duration and low amplitude. Which of the following pathologic features is most likely in this patient's biceps muscles? A CD4+ T-cell inflammation B CD8+ T-cell inflammation C Endomysial inflammation with inclusion bodies D Motor neuron degeneration E Myofibrillar protein degradation

Inferior gluteal nerve Gluteus maximus weakness results in difficulty standing from a seated position and climbing the stairs. It can be injured through damage of the inferior gluteal nerve in posterior hip dislocations, especially if the dislocation is treated with posterior approach hip arthroplasty

A 75-year-old man in physical rehabilitation is evaluated at the clinic for weakness. He has difficulty rising from a seated position and requires assistance when ascending stairs. Six weeks earlier, he fell at home, resulting in a left hip dislocation that required arthroplasty. On physical examination of his gait, his hips remain level, but he leans back slightly when his left heel strikes the ground in front of him. Which of the following nerves is most likely injured in this patient? A Common fibular nerve B Deep fibular nerve C Femoral nerve D Inferior gluteal nerve E Superior gluteal nerve

Systemic juvenile idiopathic arthritis JIA is the most common form of arthritis in children. The systemic form of JIA is characterized byquotidian fevers, arthritis, severe leukocytosis, and thrombocytosis and a classic salmon pink rash

A 9-year-old girl is brought to the clinic for a 2-month history of daily fevers that spike to a temperature of 38.3°C (101°F) then return to normal. She traveled to Southeast Asia last week with her family. She has a rash on her trunk and joint pains in her right wrist, elbows, both knees, and both ankles. Temperature is 38.2°C (100.8°F). Physical examination reveals tenderness, erythema, and swelling in her right wrist and both knees and a mild, macular salmon-pink rash across her waist. Laboratory tests reveal elevated transaminases and ferritin levels. The complete blood cell count shows:WBC: 25,000/mm3Hemoglobin: 11 gm/dLMean corpuscular volume: 85 fLPlatelets: 1,200,000/mm3 Which of the following is the most likely diagnosis? A Acute rheumatic fever B Malaria C Parvovirus infection D Septic arthritis E Systemic juvenile idiopathic arthritis F Systemic lupus erythematosus

Lesser trochanter of the femur Iliopsoas tendinopathy is an inflammatory injury seen in repetitive hip flexion that causes an achy pain worse with activity and a popping noise with hip extension and internal rotation. The iliopsoas is a complex of the psoas major and iliacus muscles that insets on the lesser trochanter of the femur via the psoas tendon

An 18-year-old woman comes to the clinic because of a 1-week history of right hip pain. She runs track and reports that she first noticed the pain after jumping hurdles. The pain is achy, on the anterior of the right hip, and worse with activity. She also has noticed a popping noise in her hip. On physical examination, there is tenderness to deep palpation over the anterior hip. The hip is passively extended and internally rotated, which reproduces the pain and popping noise. Hip flexion against resistance also reproduces the pain. Which of the following is the insertion site of the muscle most likely involved in this patient's condition? A Greater trochanter of the femur B Ischial spine C Lesser trochanter of the femur D Patellar tendon E Pes anserinus

Capsule Bone pain, redness, and swelling in a patient with sickle cell disease are suggestive of bacterial osteomyelitis. Patients with sickle cell disease are vulnerable to encapsulated bacteria, such as Salmonella and E coli, because their loss of splenic function

An 8-year-old boy is brought to the pediatrician by his mother because of a 10-day history of right leg pain. The patient says that it has become difficult to put weight on that leg. He has a history of sickle cell disease with painful swollen fingers as a toddler. Temperature is 39°C (102.2°F). Physical examination shows swelling and erythema in the area over his right tibia. A culture of infected bone reveals a gram-negative organism. Which of the following bacterial virulence factors most likely predisposes this patient to his current infection? A Capsule B Hyaluronidase C Immunoglobulin proteases D Mycolic acids E Teichoic acid

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