MSS2 Exam 2 Practice Questions

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Which of the following movements will cause the radial head to glide anterior? A. Pronation of the forearm. B. Supination of the forearm. C. Flexion of the wrist. D. Extension of the wrist. E. Extension of the elbow.

Which structure prevents hyperextension of the knee? A. The posterior cruciate ligament. B. The anterior cruciate ligament. C. The medial meniscus. D. The medial collateral ligament. E. The lateral collateral ligament.

Winging of the scapula can be caused by damage to which nerve? A. Axillary. B. Long thoracic. C. Suprascapular. D. Lower subscapular. E. Thoracodorsal.

All of the following muscles make up the rotator cuff EXCEPT: A. Supraspinatus. B. Infraspinatus. C. Teres major. D. Teres minor. E. Subscapularis.

The treatment for lateral femoral patella tracking is focused on strengthening which muscle (s)? A. Rectus femoris. B. Vastus lateralis. C. Vastus medialis. D. The hamstrings. E. Gastrocnemius.

Which muscle is considered to be the primary flexor of the hip? A. Gluteus medius. B. Gluteus maximus. C. Iliopsoas. D. Quadriceps. E. Hamstrings.

All of the following is associated with abduction of the ulna somatic dysfunction EXCEPT: A. Cubitis valgus. B. An increased carrying angle. C. Adduction of the wrist. D. Lateral glide of the olecranon.

The origin of the brachial artery is located at : A. The superior border of pectoralis minor. B. The lateral border of the first rib. C. The superior border of teres minor. D. The inferior border of teres minor. E. The inferior/lateral border of the clavicle.

All of the following may cause psoas syndrome EXCEPT: A. Ureter dysfunction B. Salpingitis C. Sigmoid colon dysfunction D. Appendicitis E. Cystitis

All of the following is true regarding a posterior fibular head dysfunction EXCE P T: A. It often occurs following a supination ankle sprain. B. The talus will be externally rotated on the affected side. C. The distal fibular head may be anterior. D. Dorsiflexion of the ankle will be restricted on the affected side.

An injury to a ligament, in which a portion of the fiber is disrupted, is referred to as which of the following types of strains? A. 1st degree sprain B. 2nd degree sprain C. 3rd degree sprain D. 4th degree sprain

Humeral dislocation is most likely to occur in which position? A. Inferior and posterior. B. Anterior and inferior. C. Superior and anterior. D. Superior. E. Posterior.

The condition in which there is a decrease in the angle between the neck and the shaft of the femur is called: A. Coxa valga. B. Coxa vara. C. Genu varum. D. Genu valgum. E. A decreased Q angle.

Thoracic outlet syndrome is due to compression of the neurovascular bundle (subclavian artery and vein and brachial plexus). This compression can occur in all of the following locations EXCEPT: A. Between the anterior and middle scalene muscles. B. Between joint of Luschka and facet joint. C. Between the pectoralis minor and the upper ribs. D. Between the clavicle and the first rib.

Which compartment of the lower leg is most often effected in "compartment syndrome"? A. The lateral compartment. B. The anterior compartment. C. The deep posterior compartment. D. The superficial posterior compartment.

Which nerve root exits the intervertebral foramen between the L4 and L5 vertebrae? A. L3. B. L4. C. L5. D. S1.

Which one of the following muscles is the primary internal rotator of the humerus? A. Teres minor. B. Subscapularis. C. Infraspinatus. D. Pectoralis minor. E. Deltoid.

A 60-year-old woman with arthritis suffers a massive stroke and expires. At autopsy, the proximal phalangeal joint tis- sue shows pannus, synovial cell hyperplasia, and lymphoid follicles. Which of the following best describes the pathogen- esis of pannus formation in this patient? (A) Calcification of the synovium (B) Chronic inflammation of synovium (C) Degeneration of cartilage (D) Dislocation of a portion of bone (E) Necrosis of fibroadipose tissue

B. Chronic inflammation of the synovium Rheumatoid arthritis (RA) is a systemic, chronic inflammatory dis- ease in which chronic polyarthritis involves diarthrodial joints symmetrically and bilaterally. Synovial lining cells undergo hyperplasia. The result is a synovial lining thrown into numer- ous villi and frond-like folds that fill the peripheral recesses of the joint. As the synovium undergoes hyperplasia and hyper- trophy, it creeps over the surface of the articular cartilage and adjacent structures. This inflammatory synovium is termed a pannus (cloak). The pannus covers the articular cartilage and isolates it from the synovial fluid. Synovial calcification (choice A) does not occur in RA. Pannus may destroy cartilage by depriving it of nourishment. Dx: RA

A 21 y/o R handed minor league pitcher presents to your office with right shoulder pain. The pain has increased gradually over the past month, and worsens with pitching. Ice and ibuprofen seem to decrease the pain. On examination, you notice tenderness at the tip of the acromion. He has full range of motion of the right shoulder, but has pain with abduction, especially from 60° - 120°. He has a positive drop arm test. Neurological examination of the upper extremity is within normal limits. The most likely cause of his pain is? A. Bicipital tenosynovitis. B. Adhesive capsulitis. C. Supraspinatus tendonitis. D. Complete rupture of the supraspinatus tendon. E. A cervical rib.

A 31 y/o F presents to your office with neck pain following a MVA 2 days ago. She states that her pain is a dull ache on the right side of her neck that radiates into her arm. On examination, you notice a right anterior scalene tenderpoint and positive Adson's test. Neurological exam reveals no sensory deficits, 5/5 muscle strength, and normal deep tendon reflexes. Your most likely diagnosis is? A. Bicipital tenosynovitis. B. A rotator cuff tear. C. Thoracic outlet syndrome. D. Supraspinatus tendonitis. E. Herniated nucleus propulsis of the cervical spine.

A decreased Q angle is associated with which one of the following conditions? A. Genu valgum. B. Patella-femoral syndrome. C. A bow-legged appearance. D. Coxa vara.

A posteriolateral disc herniation of the intervertebral disc of L4/L5 is most likely to compress which nerve root? A. L3. B. L4. C. L5. D. S1.

A posterior herniation of the meninges and the nerve roots through a defect in a lumbar vertebral body is called? A. Spina bifida occulta. B. Spina bifida meningocele. C. Spina bifida meningomyelocele D. Spondylolisthesis. E. Spondylosis.

All of the following is true concerning lateral femoral patella tracking EXCEPT: A. It is associated with accelerated wearing on the posterior surface of the patella. B. It occurs most often in women. C. It is associated with a positive Lachman's test. D. The patient may complain of deep knee pain that worsens when climbing stairs.

All of the following may be seen in a patient with a right sided psoas syndrome EXCEPT? A. A positive Thomas test. B. Tenderpoint medial to the ASIS C. Pelvis shifted to the right D. A somatic dysfunction of the upper lumbar segments.

Tennis elbow is often associated with tenderness at which anatomical landmark? A. The olecrenon. B. The bicipital aponeurosis. C. The lateral epicondyle. D. The medial epicondyle. E. The humeral condyles

The anterior displacement of one vertebral body in relation to the one below is known as: A. Spondylosis. B. Spondylolysis. C. Spondylolisthesis. D. Spina bifida. E. Spinal stenosis.

A 15 year old female presents to your office with left wrist and elbow pain. The pain started one week ago. On examination, you notice tenderpoints at the elbow and wrist, she has an increased carrying angle on her left side. Her wrist appears to be restricted in abduction. And X-rays show no evidence of any fractures. Assuming she has somatic dysfunction at her left elbow, which choice is the most likely diagnosis? A. Posterior radial head. B. Anterior radial head. C. Adduction of the ulna. D. Abduction of the ulna.

A 35 year old female presents with numbness and tingling over the palmar surface of her right thumb. She states symptoms often radiates into her first and middle fingers. It started six months ago and has gotten increasingly worse. Tylenol and Advil seem to alleviate the symptoms somewhat. On examination, you notice a decreased sensation at the pads of the first and middle fingers, and decreased grip strength of the right hand. Tinel's test at the wrist is positive. The most likely cause of her pain is? A. Thoracic outlet syndrome. B. Syphilis. C. A scaphoid fracture. D. Carpal tunnel syndrome.

All of the following concerning cauda equina syndrome is true EXCEPT: A. It can be due to a large central herniation on the cauda equina. B. It may result in a weakness in both legs. C. It is a surgical emergency. D. Paralysis may occur rapidly, but does not usually effect the bladder or rectum. E. A decreased sensation to the medial aspect of the thighs and groin, often called "saddle anesthesia" can occur.

All of the following is true regarding spondylolisthesis EXCEPT: A. HVLA at the lumbosacral spine in contraindicated B. 30% of the vertebral displacement is considered a grade II spondylolisthesis C. Patients often walk stiffed-legged with a waddling type of gait D. Pain is relieved with extension based exercises E. The patient often has normal sensation in both lower extremities

The ankle is most stable in which of the following positions? A. Supination. B. Inversion. C. Plantar flexion D. Dorsiflexion.

Which one of the following statements is true concerning the radial artery? A. It branches directly from the profunda (deep) brachial artery and accompanies the radial nerve in the posterior course of the radial groove. B. It branches directly from the axillary artery to supply the lateral aspect of the forearm. C. It branches directly from the axillary artery to supply the medial aspect of the forearm. D. It forms most of the deep palmar arch of the hand.

Spurling Test positive

simultaneous extension, rotation to affected side, lateral bend, and vertical compression reproduces symptoms in ipsilateral arm used to dx cervical foraminal stenosis

Which of the following carpal bones is located most medially? A. Scaphoid B. Trapezoid C. Trapezium D. Capitate E. Hamate

Which of the following nerves only carries fibers from the C5 nerve root? A. Musculocutaneous B. Lateral Pectoral C. Suprascapular D. Long Thoracic E. Dorsal scapular

Wrist drop deformity is associated with damage to which one of the following structures? A. Median nerve. B. Wrist flexor muscles. C. Flexor retinaculum. D. Ulnar nerve. E. Radial nerve.

A 6-year-old child with mild hydrocephalus suffers chronic infections and dies of intractable chronic anemia. At autopsy, his bones are dense and misshapen. The femur, in particular, shows obliteration of the marrow space. Histologically, the bones dem- onstrate disorganization of bony trabeculae by retention of pri- mary spongiosa and further obliteration of the marrow spaces by secondary spongiosa (shown in the image). Hematopoietic bone marrow cells are sparse. The disorder is caused by muta- tions in genes that regulate which of the following cell types? (A) Fibroblasts (B) Myofibroblasts (C) Normoblasts (D) Osteoblasts (E) Osteoclasts

E. Osteoclasts Osteopetrosis, also known as "marble bone" disease or Albers-Schönberg disease, is a group of rare, inherited disorders. The most common autosomal recessive form is a severe, sometimes fatal dis- ease affecting infants and children. The sclerotic skeleton of osteopetrosis is the result of failed osteoclastic bone resorp- tion. The disease is caused by mutations in genes that govern osteoclast formation or function. Because osteoclast function is arrested, osteopetrosis is characterized by (1) the reten- tion of the primary spongiosum with its cartilage cores, (2) lack of funnelization of the metaphysis, and (3) a thick- ened cortex. The result is short, block-like, radiodense bones, and hence the term marble bone disease. Choices A, B, and C do not regulate bone organization. Increased osteoblast activity (choice D) has not been demonstrated in patients with osteopetrosis. Diagnosis: Osteopetrosis, Albers-Schönberg disease

A 17-year-old girl suffers a spiral fracture of her right tibia, and the leg is casted. Unfortunately, the fracture does not heal cor- rectly due to excessive motion and interposition of soft tissue at the fracture site. Which of the following represents the most likely complication of nonunion in this patient? (A) Codman triangle formation (B) Cup-shaped epiphysis (C) Involucrumformation (D) Osteomyelitis (E) Pseudoarthrosis

E. Pseudoarthrosis If a fracture site does not heal, the condition is termed nonunion. Causes of non- union include interposition of soft tissues at the fracture site, excessive motion, infection, poor blood supply, and other factors mentioned in the question. Continued movement at the unhealed fracture site may also lead to pseudoarthrosis, a condition in which joint-like tissue is formed. In such cases, the fracture never heals, and the joint-like material must be removed surgically for the fracture to heal properly. Codman triangle (choice A) is an X-ray finding of a bone involved in osteosarcoma, where, an incomplete rim of reactive bone adja- cent to tumor is lifted from the cortical surface. Involucrum (choice C) is the viable bone that surrounds necrotic bone (sequestrum) in osteomyelitis. Osteomyelitis (choice D) is an uncommon complication of a closed fracture. Diagnosis: Nonunion of healing fracture

What is the correct sequence of nerve divisions leaving the spinal cord to form the brachial plexus? A. Roots, trunks, branches, cords, divisions. B. Roots, divisions, trunks, cords, branches. C. Roots, trunks, cords, branches, divisions. D. Roots, cords, trunks, branches, divisions. E. Roots, trunks, divisions, cords, branches.

E. Roots, trunks, divisions, cords, branches.

A 35-year-old woman has multiple cartilaginous lesions in her long and short bones. A radiograph of the hand (shown in the image) reveals bulbous swellings. A biopsy shows abnormally arranged hyaline cartilage, with scattered zones of proliferation. This patient is at risk for which of the following bone diseases? (A) Chondrosarcoma (B) Giant cell tumor of bone (C) Osteosarcoma (D) Histocyticlymphoma (E) Synovial sarcoma

(A) Chondrosarcoma Enchondromatosis, also termed Ollier disease, is a bone disorder characterized by the development of numerous cartilaginous masses that lead to bony deformities. The condition is not strictly a disease of delayed maturation of bone, but one in which residual hyaline cartilage, anlage cartilage, or cartilage from the growth plate does not undergo endochondral ossification and remains in the bones. As a consequence, the bones show multiple, tumor-like masses of abnormally arranged hyaline cartilage (enchondromas), with zones of proliferative and hypertro- phied cartilage. Enchondromas exhibit a strong tendency to undergo malignant change into chondrosarcomas in adult life. None of the other choices are related to cartilaginous tumors. Diagnosis: Enchondromatosis, Ollier disease

A 40-year-old woman complains of morning stiffness in her hands. On physical examination, her finger joints are painful, swollen, and warm. X-ray examination of the hands shows narrowing of the joint spaces and erosion of joint surfaces of the metacarpal/phalangeal joints. The adjacent bones show osteoporosis. A synovial biopsy reveals prominent lymphoid follicles, synovial hyperplasia, and villous folds (shown in the image). Laboratory studies conducted on a blood sample from this patient will most likely show polyclonal antibodies directed against which of the following proteins? (A) Double-strandedDNA (B) Fab2 portion of IgM (C) Fc portion of IgG (D) Ribonucleoprotein (E) Topoisomerase I

(C) Fc portion of IgG Immunologic mechanisms play an important role in the pathogenesis of rheumatoid arthritis (RA). Lymphocytes and plasma cells accumulate in the synovium, where they produce immunoglobulins, mainly of the IgG class. Some 80% of patients with classic RA are positive for rheumatoid factor (RF). This factor actually repre- sents multiple antibodies, principally IgM, but sometimes IgG or IgA, directed against the Fc fragment of IgG. Significant titers of RF are also found in patients with related collagen vascular diseases, such as systemic lupus erythematosus, scle- roderma, and dermatomyositis. The presence of RF in high titer is associated with severe and unremitting disease, many systemic complications, and a serious prognosis. Antibodies against choices A, D, and E are seen in patients with other collagen vascular/systemic autoimmune diseases. Diagnosis: Rheumatoid arthritis

A 30-year-old man with dwarfism is admitted to the hospital for hip replacement due to severe osteoarthritis. He has short arms and legs and a relatively large head. His parents do not show signs of this congenital disease. This patient most likely has a spontaneous mutation in the gene encoding which of the following proteins? (A) Collagen type I (B) Dystrophin (C) Fibroblast growth factor receptor (D) Growth hormone receptor (E) Insulin-like growth factor

(C) Fibroblast growth factor receptor Achondroplasia refers to a syndrome of short-limbed dwarfism and macrocephaly and represents a failure of normal epiphyseal cartilage formation. It is the most common genetic form of dwarfism and is inherited as an autosomal dominant trait. However, most cases represent new mutations. Achondro- plasia is caused by an activating mutation in the fibroblast growth factor-3 receptor. This mutation negatively regulates chondrocyte proliferation and differentiation and arrests the development of the growth plate. A defective growth hormone receptor (choice D) is responsible for rare cases of dwarfism (Laron dwarfism). Mutations in dystrophin (choice B) are encountered in cases of Duchenne muscular dystrophy. Con- genital deficiency of insulin-like growth factor (choice E) has not been reported as a cause of achondroplasia. Diagnosis: Achondroplasia

A 33-year-old woman presents with a spontaneous fracture of her femoral head. She has suffered from Crohn disease for 20 years. Multiple surgical procedures have resulted in the removal of much of her small bowel. She has had profound weight loss over the last 10 years. The bone is pinned. Histo- logically, the resected femoral head shows bony trabeculae that are covered by a thicker-than-normal layer of osteoid (shown in the image). In this section, the osteoid is stained red, and mineralized bone is stained black. Which of the following best describes the pathogenesis of this lesion? (A) Degenerative changes in the subchondral bone (B) Enhanced osteoblast activity (C) Impaired mineralization of osteoid (D) Inflammatory synovium with pannus formation (E) Subperiosteal bone resorption

(C) Impaired mineralization of osteoid Osteomalacia (soft bones) is a disorder of adults characterized by inad- equate mineralization of newly formed bone matrix. Diverse conditions associated with osteomalacia and rickets include abnormalities in vitamin D metabolism, phosphate deficiency states, and defects in the mineralization process itself. In osteomalacia, the bony trabeculae are rimmed by broad layers of osteoid, whereas the bone spicules in osteoporosis are thin but normally mineralized. Intrinsic diseases of the small intes- tine, cholestatic disorders of the liver, biliary obstruction, and chronic pancreatic insufficiency are the most frequent causes of osteomalacia in the United States. Malabsorption of vita- min D and calcium complicates a number of small intestinal diseases, including celiac disease, Crohn disease, and sclero- derma. Enhanced osteoblast activity (choice B) is encountered in new bone formation. Inflammatory synovium with pannus formation is a feature of RA. Dx: Osteomalacia

A 24-year-old man on chronic corticosteroid therapy for severe asthma presents with a 6-month history of increasing hip pain. This patient most likely exhibits symptoms of which of the following metabolic bone diseases? (A) Gaucher disease (B) Osteomalacia (C) Osteopetrosis (D) Osteoporosis (E) Paget disease

(D) Osteoporosis Risk factors for osteoporosis include smoking, vitamin D deficiency, low body mass index, hypogonadism, a sedentary lifestyle, and glucocorti- coid therapy (seen in this patient). Bone loss and fractures are the hallmarks of osteoporosis, regardless of the underly- ing cause. Choices A and C are congenital disorders that are not related to corticosteroid therapy. Choices B and E are acquired conditions but they are not related to corticosteroid therapy. Diagnosis: Osteoporosis

A 9-year-old boy complains of 2 weeks of pain in the hip. His temperature is 38°C (101°F). Laboratory studies show an elevated erythrocyte sedimentation rate. An X-ray reveals a mottled radiolucent defect in the upper femur, with abun- dant periosteal new bone formation. Fine-needle aspiration returns numerous neutrophils and cocci. Staphylococcus aureus is cultured from the bone lesion. A biopsy shows a fragment of necrotic bone embedded in fibrinopurulent exudate. Which of the following terms best describes the necrotic bone? (A) Brodieabscess (B) Cloaca (C) Involucrum (D) Osteophyte (E) Sequestrum

(E) Sequestrum Sequestrum. Infectious organisms may reach the bone through the bloodstream. If the infection is not contained, pus and bacteria extend into the endosteal vascular channels that supply the cortex and spread through- out the Volkmann and Haversian canals of the cortex. Even- tually, pus forms underneath the periosteum, shearing off the perforating arteries of the periosteum and further devitaliz- ing the cortex. This expansion may shear off the perforating arteries that supply the cortex with blood, leading to necro- sis of the cortex. The necrotic bone is called a sequestrum. Brodie abscess (choice A) consists of reactive bone from the periosteum and the endosteum that surrounds and con- tains the infection. Cloaca (choice B) is the hole found in the bone during formation of a draining sinus. Involucrum (choice C) refers to a lesion in which periosteal new bone formation forms a sheath around the necrotic sequestrum. Osteophytes (choice D) are bone nodules appearing on the peripheral portion of the joint surface that are complications of osteoarthritis. Diagnosis: Osteomyelitis

A 40-year-old woman presents with pain and swelling in her left elbow that has lasted 6 months. Physical examination reveals a 0.5-cm soft tissue mass. Biopsy of the mass discloses a biphasic histologic pattern consisting of cuboidal epithelial and spindle-shaped mesenchymal cells. Which of the follow- ing is the most likely diagnosis? (A) Liposarcoma (B) Malignant fibrous histiocytoma (C) Nodularfasciitis (D) Rhabdomyosarcoma (E) Synovial sarcoma

(E) Synovial Sarcoma

A 50-year-old man complains of fever and severe pain in his great toe of 24 hours in duration. The pain developed in the morning and became so severe that he could not walk. Labora- tory findings include leukocytosis, hyperuricemia, and hyper- lipidemia. An X-ray of the affected joint reveals punched-out lesions in the juxta-articular bone. An aspirate of joint fluid returns urate crystals and neutrophils. Which of the following would be the most likely pathologic finding within the periar- ticular soft tissue of this patient? (A) Osteophyte (B) Pannus (C) Reactive bone (D) Rheumatoidnodule (E) Tophus

(E) Tophus Chronic accumulation of uric acid crystals leads to the formation of nodules (tophi) that contain granuloma-like aggregates of macrophages. These granulo- ma-like areas are found in cartilage, in any of the soft tissues around joints, and even in the subchondral bone marrow adjacent to joints. Osteophytes (choice A) are a complication of osteoarthritis. Pannus (choice B) is featured in rheumatoid arthritis. Rheumatoid nodules (choice D) are found in extra- articular locations. Diagnosis: Gout

A 35-year-old female presents for evaluation of new onset lumbar spine pain. Which of the following physical exam findings is indicative of an organic cause of low back pain symptoms? 1. Positive straight-leg raise with patient distraction 2. Pain with axial loading of the spine 3. Diffuse tenderness with palpation of the paraspinal lumbar musculature 4. Lower extremity numbness in a non-dermatomal pattern 5. Pain with simulated rotation of the lumbar spine

1. Positive straight-leg raise with patient distraction Non-organic signs of low back pain (ie. Waddell Signs) include superficial and non-anatomic tenderness, pain with axial compression or simulated rotation of the lumbar spine, negative straight-leg raise with patient distraction, regional disturbances which do not follow a logical dermatomal pattern, and overreaction to physical examination. Waddell et al described and standardized these non-organic signs of low-back pain in 350 North American and British patients. They divided them into 5 categories (tenderness tests, simulation tests, distraction tests, regional disturbances, and overreaction), and found that when three or more categories were positive, the finding was considered clinically significant. This was also correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory (MMPI).

In a patient with arm pain and paresthesias, which of the following symptoms or physical exam findings supports a cervical radiculopathy as opposed to a peripheral neuropathy. 1. Relief of pain when holding the arm above the head 2. Reproduction of pain with tilting head to affected side and rotating head to contralateral side 3. Compensatory inter-phalangeal joint flexion of the thumb when attempting to pinch 4. Patient is unable to make "AOK" sign with index finger and thumb 5. Forearm pain with resisted wrist extension

1. Relief of pain when holding the arm above the head Relief of pain when holding the arm above the head is indicative of a cervical radiculopathy instead of a peripheral neuropathy. Davidson et al found that in 22 patients requiring myelography for unremitting radicular pain, 15 experienced relief of pain with shoulder abduction. Of the 15 with this physical exam finding, 13 patients achieved a good result with cervical surgery. In conclusion, they argue this exam finding has value as an indicator for cervical radicular compressive disease and postulate that the maneuver seems to occur by decreasing tension on the nerve root. Incorrect Answers: Answer 2: Reproduction of pain with tilting head to the affected side and rotating head to the ipsilateral (not contralateral) side is called the Spurling's sign and also indicates cervical pathology. Answer 3: Compensatory inter-phalangeal joint flexion of the thumb when attempting to pinch (Froment's sign) is seen with a peripheral ulnar neuropathy. Answer 4: Inability to make an "A-OK" sign with index finger and thumb is seen with a peripheral AIN compressive neuropathy. Answer 5: Forearm pain with resisted wrist extension is seen with lateral epicondylitis (tennis elbow).

Which of the following physical exam findings supports the diagnosis of cervical radiculopathy? 1. Shoulder abduction test 2. Lateral forearm pain with resisted extension of the long fingers 3. Intrinsic wasting 4. Hoffman Sign 5. Inverted brachioradialis reflex

1. Shoulder abduction test The shoulder abduction test is a maneuver that has been found to be specific for the diagnosis of cervical radiculopathy. Two helpful tests for diagnosing cervical radiculopathy include the Spurling test and the shoulder abduction test. Patients with a positive shoulder abduction sign will have improvement of their symptoms with elevation of the arm above the head. This is an important test to distinguish cervical pathology from other sources of shoulder/arm pain. Rhee et al. note that cervical nerve roots course at 45-degree angles when entering the neural foramina. This occurs in a ventro-lateral direction across compressive lesions. They postulate that abduction of the shoulder may cause relief as a result of decreased tensile stresses in the nerve root adjacent to the compressive lesion. Viikari-Juntura et al. investigated validity of the shoulder abduction test in the diagnosis of cervical radiculopathy. They found this test was highly specific but had low sensitivity. Thus, they recommend this test as a valuable aid in the clinical examination of a patient with neck and arm pain. Illustration A shows an example of a patient demonstrating the shoulder abduction sign. Incorrect Answers: Answer 2: Lateral forearm pain with resisted extension of the long fingers is consistent with a diagnosis of lateral epicondylitis Answer 3: Intrinsic wasting is most consistent with ulnar neuropathy, not cervical radiculopathy. Answer 4: A Hoffman sign is indicative of an upper motor neurologic disorder. It is noted to be positive when the there is flexion of the other digits after flicking the distal phalanx of the long digit. This may be seen in cervical myelopathy. Answer 5: An inverted brachioradialis reflex is seen when tapping of the distal brachioradialis leads to a reflexive contraction of the finger flexors, despite a diminished brachioradialis reflex. This is consistent with cervical myelopathy.

A 29-year-old male reports a 2-day history of atraumatic low back pain. He denies constitutional symptoms. He denies any bowel or bladder difficulties and physical examination reveals full motor strength and sensation. No pathologic reflexes are detected. All of the following are appropriate at the initial visit EXCEPT? 1. Limited oral analgesia 2. Radiographs of lumbar spine 3. Schedule outpatient follow-up visit within 4 weeks 4. Early range of motion exercises 5. Reassurance

2. Radiographs of lumbar spine A previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. This patient had no "red flags" during the history (recent trauma or constitutional symptoms), and physical examination was normal without focal neurologic deficits. The appropriate treatment for acute onset lower back pain is solely symptomatic treatment. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller et al found the use of radiographs can lead to better patient satisfaction but not better outcomes. Chou et al peformed a metanalysis that also concluded that lumbar imaging without indication of serious underlying condition does not improve clinical outcomes.

A 32-year-old manual laborer has work-related chronic musculoskeletal back pain for several years. Which of the following is the strongest negative predictor for a successful clinical outcome with non-operative treatment? 1. Race 2. Smoking status 3. High Visual Analog Scale (VAS) scores prior to treatment 4. Type of occupation 5. Gender

3. High Visual Analog Scale (VAS) scores prior to treatment In patients with chronic disabling work-related musculoskeletal disorders, high pre-rehabilitation ratings of pain intensity, as measured by high Visual Analog Scale (VAS) scores, is a negative predictor for a successful outcomes. McGeary et al evaluated the ability of pain intensity ratings in 3,106 patients with chronic disabling occupational musculoskeletal disorders to predict the rehabilitation outcomes and identify patients at risk for poor outcomes. High pain intensity prior to rehabilitation was linearly associated with declining rates of program completion and higher rates of self-reported depression and disability after rehabilitation. The authors did not find any correlation between poor clinical outcomes and race, smoking, gender, or type of occupation. Proctor et al "found that about 25% of patients with a chronic disabling work-related musculoskeletal disorder pursue new health-care services after completing a course of treatment, and this subgroup accounts for a significant proportion of lost worker productivity, unremitting disability payments, and excess health-care consumption."

A 57-year old male presents with right arm pain of 4 weeks duration. He reports the pain began following a tennis match and has not improved with time. He describes the pain as an aching sensation that affects his lateral forearm that improves when he abducts the shoulder. He also describe a sensation of numbness in this right thumb. Reflex exam shows he has 1+ right biceps reflexes and 2+ right triceps reflexes which are both symmetric with the left side. Sensory exam shows paresthesias in the distribution of the right thumb. Motor exam shows no evidence of radial deviation with active wrist extension. Motor exam on the right shows 5/5 deltoid, 5/5 elbow flexion with the palms facing upward, 4/5 wrist extension, and 5/5 elbow extension, and 5/5 wrist flexion. What is the most likely etiology of his symptoms? 1. Tendinosis and inflammation at origin of ECRB 2. Compression of the posterior interosseous nerve by the proximal edge of supinator 3. Compression of the ulnar nerve in Guyon's canal 4. A paracentral cervical disc herniation at C5/6 5. A foraminal disc herniation at C6/7

4. A paracentral cervical disc herniation at C5/6 The clinical presentation is most consistent with a C6 radiculopathy. This would be cause by a a paracentral cervical disc herniation at C5/6. The differential diagnosis for neuropathic pain in the upper extremity includes peripheral neuropathies, cervical radiculopathy, and peripheral musculoskeletal conditions. Cervical radiculopathy is characterized by unilateral dermatomal distribution of pain which often improves with abduction of the shoulder. A C6 radiculopathy is characterized by weakness to brachioradialis (elbow flexion weakness at a midpoint between supination and pronation), ECRL weakness (wrist extension weakness), sensory changes in the thumb, and a diminished brachioradialis reflex. Rhee et al. report the differential diagnosis of cervical radiculopathy includes peripheral nerve entrapment syndromes; brachial plexus injury; Parsonage-Turner's syndrome; and tendinopathies of the shoulder, elbow, and wrist. They report that selective cervical nerve root injections can be useful in confirming the source of symptoms if they improve for a time after the injection, and that electromyography and nerve conduction tests may help differentiate radiculopathy from peripheral entrapment disorders. Viikari-Juntura et al. investigated validity of the shoulder abduction test in the diagnosis of cervical radiculopathy. They found this test was highly specific but had low sensitivity. Thus, the recommend this test as a valuable aid in the clinical examination of a patient with neck and arm pain. Illustration A shows the dermatomal distribution of C6. Illustration B shows some key differences between the cervical spine and lumbar spine nerve root anatomy. It shows that in the cervical spine the nerve root travels above the corresponding pedicle whereas in the lumbar spine it travels below the corresponding pedicle. In addition, due to the direct lateral trajectory of the cervical nerve root, both a central and foraminal disc affect the same nerve root. This differs in the lumbar spine where due to the descending path of the nerve root, a paracentral and foraminal (far lateral) disc often affect different nerve roots. Incorrect Answers: Answer 1: Lateral epicondylitis, caused by tendinosis and inflammation at origin of ECRB, present with lateral forearm pain and weakness to wrist extension. However, pain relieved by shoulder abduction and paresthesias of the thumb are not characteristic of tennis elbow. Answer 2: Compression of the posterior interosseous nerve by the proximal edge of supinator is a common cause of PIN compression syndrome. This condition is characterized by painless weakness to wrist extension with noticeable radial deviation. Answer 3: Compression of the ulnar nerve in Guyon's canal is cause of ulnar tunnel syndrome. This condition is characterized by paresthesias in ulnar 1-1/2 digits and clawing of the ring and little fingers. Answer 5: A foraminal disc herniation at C6/7 would lead to a C7 radiculopathy. This would be characterized by decreased triceps reflexes, weakness of elbow extension and wrist flexion, and paresthesias of the index and middle finger.

A 59 year-old man complains of acute pain radiating from the neck down the right upper extremity. Physical exam demonstrates right arm triceps weakness, decreased triceps reflex, and diminished sensation of the middle finger. A cervical disk herniation will likely be found at which level? 1. C3-4 2. C4-5 3. C5-6 4. C6-7 5. C7-T1

4. C6-7 The exam findings are consistent with a C7 radiculopathy which is commonly caused by a C6-7 cervical disk herniation. A cervical spine herniated disk causes impingement on the exiting nerve root at the herniation level. In the cervical spine the nerve roots exit ABOVE the pedicle of the numbered level. For example, the C7 nerve root exits above the C7 pedicle at the C6-7 level. Heller et al. describes the characteristic findings of cervical radiculopathies and myelopathy. A C7 radiculopathy affects the motor strength of the triceps and wrist flexion, has a diminished triceps reflex, and diminished sensation in the middle finger distribution. Illustration A shows the two key difference between cervical and lumbar spine with respect to pathology and level affected.

A 50-year-old diabetic woman describes left arm pain and tingling in the ulnar side of her hand and wrist. She denies weakness or trouble with fine motor tasks. Her symptoms are worse when she is sleeping without a pillow on her left side, and with her left elbow in an extended position. Sleeping with her left hand above her head seems to improve her symptoms. What is the most likely diagnosis? 1. Guyon's canal syndrome 2. Cubital tunnel syndrome 3. Diabetic neuropathy 4. Cervical radiculopathy 5. Cervical myelopathy

4. Cervical radiculopathy The patient is describing cervical radiculopathy symptoms that are alleviated with shoulder abduction, which removes tension on the cervical roots, and are worsened with sleeping with her neck bent laterally in a position similar to the Spurling compression test. The reference by Vikari-Juntura et al describes the high specificity of cervical exam maneuvers like the Spurling compression test, shoulder abduction test, and axial traction test but found low sensitivity (25-50%) of these tests in diagnosing cervical radiculopathy. Incorrect Answers: Answer 1: Guyon's canal syndrome would not affect sensation in the dorsal wrist area. Answer 2: Cubital tunnel syndrome is typically worse with elbow flexion and improved with extension. Answer 3: Diabetic neuropathy is typically in a glove and stocking distribution and is rarely painful. Answer 5: Myelopathy typically has upper motor findings and difficulty with fine motor tasks.

A 38-year-old male presents with a cervical disc herniation at the C7/T1 level with associated foraminal stenosis, but no significant central stenosis. What would be the expected symptoms and physical exam findings. 1. Numbness of the lateral shoulder and deltoid weakness 2. Numbness of 2nd and 3rd fingers and triceps weakness 3. Numbness of the thumb with weakness to wrist extension 4. Numbness of 5th finger with weakness to long flexor function in all digits and thumb 5. Numbness of the medial elbow and weakness to long finger flexion of the 4th and 5th digits only

4. Numbness of 5th finger with weakness to long flexor function in all digits and thumb A disc hernation at the C7/T1 level will most likely affect the C8 nerve root. A C8 radiculopathy usually presents with sensory symptoms in the medial border of the forearm and hand, and weakness in long flexor function in all digits and thumb. It is important to differentiate a C8 radiculopathy from a peripheral ulnar neuropathy which also presents with sensory symptoms in the ulnar hand and finger. One way to do so is to test DIP flexion of the middle and index finger. The function of the flexor digitorum profundus in the index and middle fingers can be affected by 8th cervical radiculopathy, but they are not affected by ulnar nerve entrapment. The reference by Rao is a review of the pathoanatomy of cervical spondylosis and the different clinical manifestations. They recommend a simplified clinical approach of dividing the presenting findings into the categories of axial neck pain, radiculopathy, myelopathy, or some combination of these three.

A 28-year-old man presents with pain in the distribution shown in Figure A, and numbness in the middle finger. After performing a complete neurological exam, his surgeon orders an MRI of his cervical spine. Which of the following motor exam findings and MRI findings are consistent with the symptoms present? 1. Biceps weakness, posterolateral C5-6 disc herniation 2. Hand intrinsic weakness, C8-T1 foraminal stenosis from an uncovertebral osteophyte 3. Shoulder abduction weakness, posterolateral C4-5 disc herniation 4. Wrist flexion weakness, C6-7 foraminal stenosis from an uncovertebral osteophyte 5. Wrist extension weakness, posterolateral C6-7 disc herniation

4. Wrist flexion weakness, C6-7 foraminal stenosis from an uncovertebral osteophyte The distribution of pain and numbness is consistent with C7 radiculopathy. Characteristic motor findings in C7 radiculopathy include middle finger pain, weak triceps (elbow extension) and wrist flexion, and diminished triceps reflex. In the cervical spine, nerve roots exit ABOVE their correspondingly numbered pedicles. Thus C7 root exits between C6-7. In comparison, in the lumbar spine, nerve roots exit BELOW their correspondingly numbered pedicles. And posterolateral pathologies impinge on TRAVERSING roots, while foraminal pathologies impinge on EXITING roots. Rhee et al. reviewed cervical radiculopathy. They state that acute cervical radiculopathy has 75% rate of spontaneous improvement with nonsurgical treatment. If surgery is necessary, either anterior cervical discectomy and fusion (ACDF) or posterior laminoforaminotomy is warranted. Caridi et al. also reviewed cervical radiculopathy. Advantages of ACDF include increased fusion rates (with graft insertion in the disc space) and decompression of the neural foramina by increasing its cephalocaudal dimension. On the other hand, the posterior approach maintains spinal alignment and does not require fusion, but increases risk of neck pain (from posterior muscle dissection). Figure A shows the distribution of pain in C7 radiculopathy. Illustration A shows the distribution of pain in C5-C8 radiculopathies (A, C5; B, C6; C, C7; D, C8). Illustration B shows the spectrum of signs with different cervical radiculopathy patterns. Illustration C shows root positions with respect to the intervertebral disc at cervical and lumbar levels. Incorrect Answers: Answer 1: Biceps weakness indicates C5 or C6 radiculopathy. The bicep is served by nerve roots C5 and C6. C5-6 disc herniation leads to C6 radiculopathy. Answer 2: Hand intrinsic weakness indicates T1 radiculopathy. C7-T1 foraminal stenosis from an uncovertebral osteophyte leads to C8 radiculopathy (same as posterolateral C7-T1 disc herniation). There is no C8 vertebra. Answer 3: Shoulder abduction (deltoid) weakness indicates C5 radiculopathy. Posterolateral C4-5 disc herniation leads to C5 radiculopathy. Answer 5: Wrist extension weakness indicates C6 radiculopathy. Posterolateral C6-7 disc herniation leads to compression on the exiting root (C7), same as foraminal compression (also C7 root).

A 55 y/o M presents to your office with LBP radiating to his lower extremities. He states that yesterday his feet felt numb and weak, and now this feeling has progressed into his thighs. Neurological examination of his lower extremities reveals: 0/4 deep tendon reflexes; 3/5 muscle strength in his ankle plantar flexors; 3/5 in ankle dorsiflexors; and 3/5 in knee flexors and extensors. You also notice a decreased rectal tone. Which one of the following statements describes the correct course of treatment? A. Immediate transportation by EMS to the hospital for neurosurgical evaluation. B. Indirect OMT techniques initially to decrease restrictions, followed by direct techniques such as muscle energy, one week later. C. Physical modalities, such as ultrasound and electrical stimulation to the low back. D. NSAIDS and referral to MRI clinic if pain not improved in one week. E. Referral to neurosurgical specialist for evaluation.

All of the following are components of the lateral longitudinal arch EXCEPT: A. Navicular. B. Cuboid. C. Fourth metatarsal. D. Fifth metatarsal. E. Calcaneus.

Degenerative changes within the intervertebral disc and ankylosing of adjacent vertebral bodies is known as: A. Spondylosis. B. Spondylolysis. C. Spondylolisthesis. D. Spina bifida. E. Spinal stenosis.

Pronators of the forearm are primarily innervated by which one of the following nerves? A. Median. B. Ulnar. C. Radial. D. Musculocutaneous.

The ligament most often injured in supination ankle sprain is: A. The anterior talofibular ligament. B. The calcaneonavicular ligament. C. The calcaneofibular ligament. D. The posterior talofibular ligament.

The main motion of the lumbar spine is? A. Flexion/extension. B. Sidebending. C. Rotation. D. Sidebending and rotation.

Which nerve is most likely to be effected in the above question? A. Median nerve. B. Ulnar nerve. C. Radial nerve. D. Musculocutaneous nerve.

Which of the following findings is most likely to be present in a patient that suffers from a lower motor neuron injury affecting the C5 and C6 nerve roots? A. A decreased biceps reflex. B. An increased triceps reflex. C. Weak finger flexors. D. Decreased sensation over the ring and little fingers. E. Decreased sensation over the medial epicondyle.

A 2-year-old boy is treated for recurrent fractures of his long bones. Physical examination reveals blue sclerae, loose joints, abnormal teeth, and poor hearing. Molecular diagnostic stud- ies will most likely demonstrate a mutation in the gene encod- ing which of the following proteins? (A) Collagen (B) Dystrophin (C) Lysylhydroxylase (D) Fibrillin (E) Fibroblast growth factor receptor

A Osteogenesis imperfecta (OI) refers to a group of mainly autosomal dominant, heritable disorders of connective tissue, caused by mutations in the gene for type I collagen; this affects the skeleton, joints, ears, ligaments, teeth, sclerae, and skin. The pathogenesis of OI involves mutations of COL1A1 and COL1A2 genes, which encode the a1 and a2 chains of type I procollagen, the major structural protein of bone. Mutations in lysyl hydroxylase gene (choice C) are seen in patients with Ehlers-Danlos syndrome, and mutations in the fibrillin gene (choice D) account for Marfan syndrome. Mutations in the dystrophin gene (choice B) cause Duchenne muscular dystrophy. Mutations in the fibroblast growth factor receptor gene (choice E) may result in achondroplasia. Diagnosis: Osteogenesis imperfecta

A 25-year-old woman complains of weakness and easy fatigability, which is most pronounced in the late afternoon. She describes difficulty reading and tiredness while watch- ing television. She has problems chewing and swallowing and loses her voice while talking. Physical examination reveals ptosis and diplopia. Laboratory studies would most likely demonstrate serum autoantibodies directed against which of the following proteins? (A) Acetylcholine receptor (B) Phosphodiesterase (C) Desmin (D) Dystrophin (E) Troponin

A. ACh receptor Myasthenia gravis is an acquired autoimmune disease characterized by abnormal muscular fatigability. It is caused by circulating antibodies to the acetylcholine receptor at the myoneural junction (motor endplate). Antibodies to the acetylcholine receptor can be demonstrated in the serum of most patients with myasthenia gravis and localized in muscle biopsies by immunohistochem- istry. The clinical severity of the condition is variable, and symptoms tend to wax and wane. The other choices are not related to myasthenia gravis. Diagnosis: Myasthenia gravis

A 10-year-old boy complains of increasing pain in his left hip. He began limping shortly after playing a baseball game at school. He is afebrile. An X-ray of the femoral head shows a fracture and irregular densities of the cancellous bone. You make a diagnosis of Legg-Calvé-Perthes disease. Which of the following best describes the pathologic findings in this patient? (A) Avascular osteonecrosis (B) Chondroma (C) Fibrousdysplasia (D) Osteitis fibrosa cystica (E) Osteopetrosis

A. Avascular osteonecrosis Osteonecrosis, also known as avascular necrosis, refers to the death of bone and marrow in the absence of infection. Such bone infarcts may be caused by a variety of conditions, such as trauma, thrombi, emboli, and corticosteroids. Growing bones of children and adolescents are often affected, and in most instances, the cause of such infarctions is not evident. Legg-Calvé-Perthes disease refers to osteonecrosis in the femoral head in children. Collapse of the femoral head may lead to joint incongruity and severe osteoarthritis. Chondroma (choice B) is a benign, intraosseous tumor composed of well-differentiated hyaline cartilage. Fibrous dysplasia (choice C) is a developmental abnormality of the skeleton, characterized by a disorganized mixture of fibrous and osseous elements in the interior of the affected bones. Osteitis fibrosa cystica (choice D) occurs in primary hyperparathyroidism. Diagnosis: Avascular osteonecrosis

A 17-year-old boy fractures his left tibia in a skiing accident. One year later, an X-ray of the leg discloses reactive bone for- mation in the calf muscle at the site of injury. Which of the following is the most likely diagnosis? (A) Myositis ossificans (B) Fibrous dysplasia (C) Malignant fibrous histiocytoma (D) Nodularfasciitis (E) Synovial sarcoma

A. Myositis ossificans Myositis ossificans affects young persons and, although it is entirely benign, often mimics a malignant neoplasm. The lesion typically results from blunt trauma to the muscle and soft tissues, usually of the lower limb. Peripheral neovascularization of the resulting hematoma leads in a short time to the formation of bone spic- ules in the soft tissue because the local environment is similar to that of an initial hematoma in a healing fracture. Because myositis ossificans often occurs near a bone, on radiography, it may be misdiagnosed as a malignant bone-forming tumor. The other choices are unrelated to prior trauma.

A type II supination ankle sprain implies that there is injury to which of the following ligaments? A. The anterior talofibular ligament. B. The anterior talofibular and the calcaneofibular ligament. C. The anterior talofibular the calcaneofibular, and the posterior talofibular ligament. D. The posterior talofibular and the calcaneofibular ligament. E. The deltoid ligament.

A 16-year-old boy presents with a swelling on his left tibia. An X-ray of the leg shows a destructive process, with indis- tinct borders and an "onion-skin" pattern of periosteal bone. Histologic examination of a biopsy reveals uniform small cells with round, dark blue nuclei (shown in the image). A PAS stain demonstrates abundant intracellular glycogen. Immunohistochemistry for leukocyte common antigen is negative. Which of the following is the most likely chromo- somal abnormality in this tumor? (A) t(11;22) (B) t(14;18) (C) t(8;14) (D) t(9;22) (E) t(3;16)

A. t(11;22) Ewing sarcoma (EWS) is an uncom- mon malignant bone tumor composed of small, uniform, round cells. It represents only 5% of all bone tumors and is found in children and adolescents. EWS is thought to arise from primi- tive marrow elements or immature mesenchymal cells. Virtu- ally all of these tumors have a reciprocal translocation between chromosomes 11 and 22, which results in the fusion of the amino terminus of the EWS1 gene to the FLI-1 gene, which encodes a nuclear transcription factor. Chromosomal translo- cation t(14;18) (choice B) is found in follicular lymphomas; t(8;14) (choice C) is present in Burkitt lymphoma; and t(9;22) (choice D) occurs in chronic myelogenous leukemia. Diagnosis: Ewing sarcoma

A fracture of the proximal fibular head is most likely to effect which nerve? A. Sciatic nerve. B. Common fibular nerve. C. Tibial nerve. D. Sural nerve. E. Femoral nerve.

All of the following are lateral stabilizers of the ankle (ligaments that prevent excessive supination) except: A. anterior talofibular ligament B. The calcaneonavicular ligament. C. The calcaneofibular ligament. D. The posterior talofibular ligament.

A 74-year-old, obese woman (BMI = 33 kg/m2) complains of chronic pain in her back, knees, and fingers. The pain typi- cally subsides at rest. On physical examination, the distal interphalangeal joints are enlarged and tender. Which of the following best describes the pathogenesis of joint pain in this patient? (A) Acute inflammation of the ligaments (B) Degeneration of articular cartilage (C) Degenerative changes of cortical bone (D) Inflammatory synovium with pannus formation (E) Reduction of the volume of synovial fluid

B. Degeneration of articular cartilage Osteoar- thritis is a slowly progressive destruction of the articular carti- lage that is manifested in the weight-bearing joints and fingers of older persons or in the joints of younger persons subjected to trauma. Osteoarthritis is the single most common form of joint disease. The disorder is not a single nosologic entity but rather a group of conditions that have in common the mechanical destruction of a joint. Inflammation of synovium with pannus formation (choice D) occurs in patients with rheumatoid arthritis. Dx: OA

Upper arm paralysis caused by an injury to the C5 and C6 nerve roots usually during childbirth is also known as? A. Klumpke's palsy. B. Erb-Duchenne's palsy. C. Stick palsy. D. Long thoracic nerve palsy. E. Bell's palsy.

B. Erb-Duchenne's palsy.

A 50-year-old woman presents with lower back pain of 3 weeks in duration. Radiologic studies reveal several dis- crete lytic lesions in the lumbar back and pelvis. Laboratory studies show elevated serum levels of alkaline phosphatase. Serum calcium, serum protein, and peripheral blood smears are normal. Aspiration biopsy of a pelvic lesion shows keratin- positive cells. Which of the following is the most likely diagnosis? (A) Chondrosarcoma (B) Metastatic carcinoma (C) Osteochondroma (D) Osteosarcoma (E) Plasmacytoma

B. Metastatic carcinoma Multiple lytic lesions associated with keratin-positive cells strongly suggest meta- static bone cancer. Metastatic carcinoma is the most common tumor of bone, and skeletal metastases are found in at least 85% of cancer cases that have run their full clinical course. The vertebral column is the most commonly affected bony structure. Tumor cells usually arrive in the bone by way of the bloodstream. Some tumors (thyroid, gastrointestinal tract, kidney, neuroblastoma) produce mostly lytic lesions. A few neoplasms (prostate, breast, lung, stomach) stimulate osteo- blastic components to make bone. The other choices are not keratin positive. Diagnosis: Metastatic bone cancer

A 33-year-old male presents with neck and left arm pain. He denies symptoms in his right arm. Based on the MRI image shown in Fig A, what findings would be expected on physical exam? A. weakness to shoulder shrug B. weakness to shoulder abduction and elbow flexion C. weakness to elbow flexion and wrist extension D. weakness to elbow extension and wrist flexion E. weakness to finger abduction

B. weakness to shoulder abduction and elbow flexion The MRI shows an axial T2-weighted image with a left sided disc herniation causing foraminal stenosis at the C4/5 level. This would affect the C5 nerve root, and lead to deltoid (shoulder abduction) and biceps (elbow flexion) weakness. In the cervical spine, the nerve root runs above the corresponding pedicle in a horizontal manner. Therefore, the inferior nerve root is affected (C4/5 would affect C5) with both a central and foraminal disc herniation. This is in contrast to the lumbar spine where the nerve root runs below the corresponding pedicle. In addition, in the lumbar spine the nerve root runs in a vertical descending direction before exiting. For this reason, at each level in the lumbar spine you can find both a descending and exiting nerve root. This explains why in the lumbar spine a foraminal disc affects the exiting nerve root (L4 with a L4/5 foraminal disc) and a paracentral disc affects the descending nerve root (L5 with a L4/5 paracentral disc). Figure A shows a left side disc-osteophyte complex affecting the C5 nerve root. Illustration A shows the primary differences between the cervical and lumbar spine with regard to nerve root anatomy.

A 23-year-old man complains of stiffness and pain in his lower back that causes him to awaken at night. He first noticed morning stiffness in his lower back during his college years. He also describes occasional pain in his right eye and sensitiv- ity to light. An X-ray of the sacroiliac region shows fusion of the small joint spaces in the posterior spine and ossification of the intervertebral discs. Serologic tests for rheumatoid fac- tor and antinuclear antibodies are negative. This patient most likely expresses which of the following human leukocyte anti- gen (HLA) haplotypes? (A) B15 (B) B19 (C) B27 (D) B31 (E) B9

C. B27 Ankylosing spondylitis is an inflamma- tory arthropathy of the vertebral column and sacroiliac joints. It may be accompanied by asymmetric, peripheral arthritis (30% of patients) and systemic manifestations. Ankylosing spondylitis is most common in young men, and the peak inci- dence is at age 20 years. More than 90% of patients are posi- tive for human leukocyte antigen-B27 (HLA-B27), although the disorder affects only 1% of persons with this haplotype. None of the other haplotypes are related to the pathogenesis of ankylosing spondylitis.

Molecular diagnostic assays performed on muscle biopsy from the patient described in Question 1 would show alterations in the length of the primary transcript for which of the following muscle-associated proteins? (A) Creatinekinase (B) Desmin (C) Dystrophin (D) Glycogenphosphorylase (E) Myosin

C. Dystrophin Duchenne muscular dystrophy is caused by mutations of a large gene on the short arm of the X chromosome (Xp21). This gene codes for dystrophin, a protein localized to the inner surface of the sarcolemma. Dystrophin links the subsarcolemmal cytoskeleton to the exte- rior of the cell through a transmembrane complex of proteins and glycoproteins that binds to laminin. Dystrophin-deficient muscle fibers thus lack the normal interaction between the sarcolemma and the extracellular matrix. This disruption may be responsible for the observed increased osmotic fragility of dystrophic muscle, the excessive influx of calcium ions, and the release of soluble muscle enzymes such as creatine kinase into the serum. The other proteins are not altered in patients with Duchenne muscular dystrophy. Diagnosis: Duchenne muscular dystrophy

A 2-year-old boy presents with a rash. On physical examina- tion, he has a crusty, red skin lesion at the hairline and on the extensor surfaces of his extremities and abdomen. Exophthal- mos is noted. An X-ray film of the head shows multiple, radio- lucent lesions in the skull. A biopsy of one of the skull lesions shows large, plump cells with pale, eosinophilic, foamy cyto- plasm and convoluted nuclei (shown in the image). What is the most likely diagnosis? (A) Ewing sarcoma (B) Giant cell tumor of bone (C) Hand-Schiller-Christian disease (D) Large B-cell lymphoma (E) Multiple myeloma

C. Hand-Schuller Christian disease Hand-Schüller-Christian disease. Langerhans cell histiocytosis is a generic term for three entities characterized by the proliferation of Langerhans cells in vari- ous tissues: (1) eosinophilic granuloma, a localized form; (2) Hand-Schüller-Christian disease, a disseminated variant; and (3) Letterer-Siwe disease, a fulminant and often fatal gen- eralized disease. Hand-Schüller-Christian disease occurs in younger children (age 2 to 5 years). Radiolucent bony lesions characterize the disorder and occur most frequently in the calvaria, ribs, pelvis, and scapulae. A lesion may infiltrate the retro-orbital space, producing exophthalmos. Infiltration of the stalk of the hypothalamus by the proliferated Langer- hans cells leads to diabetes insipidus. Crusty, red, weepy skin lesions occur at the hairline and on the extensor surfaces of the extremities, abdomen, and occasionally soles of the feet.

A 55-year-old man presents with pain in the left arm. Labo- ratory studies show elevated serum levels of calcium and parathyroid hormone. An X-ray of the left arm reveals mul- tiple small bone cysts and pathologic fractures. Biopsy of the affected bone discloses numerous giant cells in a cellu- lar and fibrous stroma. The patient undergoes removal of a parathyroid adenoma. Which of the following best describes the pathogenesis of bone pain and pathologic fractures in this patient? (A) Enhanced osteoblast activity (B) Impaired mineralization of osteoid (C) Increased bone resorption (D) Increased mineralization of bone (E) Osteoporosis

C. Increased bone resorption In patients with primary hyperparathyroidism, osteoclasts are stimulated to resorb bone. From the subperiosteal and endosteal surfaces, osteoclasts bore their way into the cortex as cutting cones. This process is termed dissecting osteitis. As the disease pro- gresses, the trabecular bone is resorbed, and the marrow is replaced by loose fibrosis. Cystic degeneration ultimately occurs, leading to areas of fibrosis that contain reactive woven bone, and hemosiderin-laden macrophages often dis- play many giant cells, which are actually osteoclasts. Because of its macroscopic appearance, this lesion has been termed a brown tumor. This is not a true tumor, but rather a repair reaction. Impaired mineralization of osteoid (choice B) is a feature of osteomalacia. Osteoporosis (choice E) is charac- terized by decreased but otherwise normally mineralized bone. Dx: Hyperparathyroidism, osteitis fibrosis cystic

A 10-year-old boy complains of pain in his hands and feet. His temperature is 38°C (101°F). Physical examination reveals a faint pericardial friction rub. His spleen, liver, and axillary lymph nodes are enlarged. Which of the following is the most likely diagnosis? (A) Gaucher disease (B) Gout (C) Juvenile arthritis (D) Psoriatic arthritis (E) Reiter syndrome

C. Juvenile arthritis Juvenile arthritis (Still disease) refers to a number of different chronic arthritic condi- tions in children. Twenty percent of children with polyarticu- lar juvenile arthritis have prominent systemic symptoms that include fever, rash, hepatosplenomegaly, lymphadenopathy, pleuritis, and anemia. Many children with juvenile arthritis develop rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and other connective tissue diseases. Gout (choice B) is a disease mainly of adult men and does not cause organo- megaly. Reiter syndrome (choice E) occurs almost exclusively in men and usually follows venereal exposure. Psoriatic arthri- tis (choice D) is excluded by lack of psoriasis. Diagnosis: Juvenile arthritis

A 68-year-old woman presents with a lump in the soft tissue of her neck. Physical examination reveals a 0.5-cm subcutane- ous tumor. Biopsy of the mass shows a benign neoplasm. The patient is told that she has the most common soft tissue tumor. What is the appropriate diagnosis? (A) Fibroma (B) Leiomyoma (C) Lipoma (D) Pleomorphic adenoma (E) Rhabdomyosarcoma

C. Lipoma Lipoma is composed of well- differentiated adipocytes and is the most common soft tis- sue mass. This benign, circumscribed tumor can originate at any site in the body that contains adipose tissue, but most appear in the subcutaneous tissues of the upper half of the body, especially on the trunk and neck. Lipomas are encoun- tered mainly in adults. Histologically, a lipoma is often indis- tinguishable from normal adipose tissue. Fibroma (choice A) and leiomyoma (choice B) are benign neoplasms of fibroblasts and smooth muscle cells, respectively. Pleomorphic adenoma (choice D) is a mixed neoplasm of the salivary gland.

A 56-year-old woman receives high-dose radiation therapy for thyroid carcinoma. One year later, the patient presents with a subcutaneous mass at the site of irradiation. A photomi- crograph of the biopsy is shown in the image. Which of the following is the most likely diagnosis? (A) Hodgkinlymphoma (B) Leiomyosarcoma (C) Malignant fibrous histiocytoma (D) Rhabdomyosarcoma (E) Synovial sarcoma

C. Malignant fibrous histiocytoma Malignant fibrous histiocytoma (MFH) is a soft tissue tumor that con- tains foci of histiocytic (macrophage) differentiation and is the most frequent sarcoma encountered after radiation therapy. Histologically, MFH displays a highly variable morphologic pattern, with areas of spindle-shaped tumor cells arrayed in an irregularly whorled (storiform) pattern adjacent to pleo- morphic fields. The spindle cells tend to be well differentiated and resemble fibroblasts. The other choices do not typically arise as a consequence of radiation treatment.

A 67-year-old man from England develops bow-legs and leg pain over a period of 5 years. He also complains of progres- sive hearing loss over the last 2 years. A bone biopsy shows a mosaic pattern with prominent cement lines and increased osteoblastic and osteoclastic activity. Serum electrolyte levels are normal. This patient is at increased risk for developing which of the following diseases? (A) Amyloidosis (B) Multiple myeloma (C) Osteogenic sarcoma (D) Pulmonary embolism (E) Renal failure

C. Osteogenic sarcoma Paget disease is a chronic condition characterized by lesions of bone resulting from disordered remodeling, in which excessive bone resorp- tion initially results in lytic lesions, followed by disorganized and excessive bone formation. The diagnostic hallmark in late disease is an abnormal arrangement of lamellar bone, in which islands of irregular bone formation, resembling pieces of a jig- saw puzzle, are separated by prominent cement lines. Persons of English descent have a high incidence of this disease. Neo- plastic transformation may occur in a focus of Paget disease, usually in the femur, humerus, or pelvis. This complication occurs in less than 1% of all cases; however, the incidence of osteogenic sarcoma is still 1,000 times higher than that in the general population. The other choices are not associated with disorganized bone.

Which of the following may be of therapeutic benefit to the patient described in Question 4? (A) Adrenalectomy (B) Parathyroidectomy (C) Thymectomy (D) Thyroidectomy (E) Vagotomy

C. Thymectomy The thymus clearly plays an important role in the pathogenesis of myasthenia gravis. Up to 40% of patients with thymoma develop myasthenia gravis, and surgical removal of the tumor is often curative. Other patients with myasthenia gravis have thymic hyperplasia, and in such cases, thymectomy is often an effective treatment. Acetylcho- line receptors have been demonstrated on the surface of some thymic cells in both thymoma and thymic hyperplasia. None of the other choices are curative for myasthenia gravis. Abnor- malities of the other organs are not associated with myasthenia gravis. Dx: M. gravis

A 49-year-old male presents with left arm pain of four weeks duration. A T2-weighted axial MRI is shown in Figure A. Which of the following statements would most accurately describe his diagnosis and physical exam findings? A. A C5 radiculopathy leading to deltoid and biceps weakness. B. A C5 radiculopathy leading to brachioradialis and wrist extension weakness. C. A C5 radiculopathy leading to triceps and wrist flexion weakness. D. A C6 radiculopathy leading to brachioradialis and wrist extension weakness. E. A C6 radiculopathy leading to finger flexion weakness.

D. A C6 radiculopathy leading to brachioradialis and wrist extension weakness. The MRI is consistent with a posterolateral disc herniation at C5/6. This would lead to a C6 radiculopathy, which is most likely presents with dermatomal arm pain, paresthesias in the thumb, weakness to brachioradialis and wrist extension, and a diminished brachioradialis reflex. Eubanks reviews the pathophysiology of cervical radiculopathy. They describe that unlike the lumbar spine, the cervical spine has cervical nerve roots that exit above the level of the corresponding pedicle. For instance, the C6 nerve root exits at the C5-C6 disk space, and a C5-C6 disk herniation typically leads to C6 radiculopathy. Heller emphasizes separating patterns of symptomatic degenerative cervical disease from other causes of neck, shoulder, and arm symptoms rests on an awareness of the broad spectrum of subjective complaints, a thorough physical examination, and confirmatory diagnostic studies. Clear delineation of the etiology will increase the likelihood of successful treatment. Incorrect Answers: Answer A & B: A C5 radiculopathy leads to deltoid and biceps weakness, and would be caused by a posterolateral disc herniation at C4/5. Answer C: A C7 radiculopathy leads to triceps and wrist flexion weakness, and would be caused by a posterolateral disc herniation at C6/7. Answer E: A C8 radiculopathy leads to finger flexion weakness, and would be caused by a posterolateral disc herniation at C7/T1.

A 10-year-old girl complains of persistent redness of the skin over her knuckles and around the nail beds. She describes easy fatigability and can rise only with difficulty from a squatting position. Physical examination reveals erythema over the knuckles and a heliotropic rash. A muscle biopsy shows infiltrates of B and T lymphocytes around blood ves- sels and in connective tissue of the perimysium. Elevated serum levels of which of the following would be expected in this patient? (A) Alkalinephosphatase (B) Alpha-fetoprotein (C) Carcinoembryonic antigen (D) Creatine kinase (E) Urea-nitrogen

D. Creatine kinase The inflammatory myopa- thies represent a heterogeneous group of acquired disorders, all of which feature symmetric proximal muscle weakness, increased serum levels of muscle-derived enzymes, and non- suppurative inflammation of skeletal muscle. They are thought to have an autoimmune origin. The most common morpho- logic characteristics in the inflammatory myopathies are (1) inflammatory cells, (2) necrosis and phagocytosis of mus- cle fibers, (3) a mixture of regenerating and atrophic fibers, and (4) fibrosis. Dermatomyositis is distinguished from the other myopathies (i.e., polymyositis and inclusion body myo- sitis) by the presence of a characteristic heliotropic rash on the upper eyelids, face, and trunk. Patients with inflammatory myopathies have increased serum levels of creatine kinase and other muscle enzymes. Elevated serum alkaline phosphatase (choice A) is associated with liver and bone disease. Alpha- fetoprotein and carcinoembryonic antigen (choices B and C) are markers of neoplasia. Elevated blood urea-nitrogen (choice E) is associated with renal disease.

A 60-year-old man with a history of gout presents with mul- tiple rubbery nodules on his hands (shown in the image). Which of the following best explains the pathogenesis of this patient's underlying condition? (A) Autoimmune relapsing polychondritis (B) High dietary intake of purine-rich foods (C) Hypercalcemia and chondrocalcinosis (D) Impaired renal excretion of uric acid (E) Increased calcium hydroxyapatite deposition

D. Impaired renal excretion of uric acid Impaired renal excretion of uric acid. Gout is a heterogeneous group of diseases in which the common denominator is an increased serum uric acid level and depo- sition of urate crystals in the joints and kidneys. A tophus (shown in the photograph) is an extracellular soft tissue deposit of urate crystals surrounded by foreign-body giant cells and mononuclear cells. Most cases (85%) of idiopathic gout result from an as yet unexplained impairment of uric acid excretion by the kidneys. When sodium urate crystals precipi- tate from supersaturated body fluids, they absorb fibronectin, complement, and a number of other proteins on their surfaces. Neutrophils that have ingested urate crystals release activated oxygen species and lysosomal enzymes, which mediate tissue injury and promote an inflammatory response. A high dietary intake of purine-rich foods (choice B) does not lead to gout, although endogenous overproduction of purines is associated with this condition.

A 58-year-old woman fractures her hip after slipping on an icy sidewalk. An X-ray shows generalized osteopenia. A bone biopsy reveals attenuated bony trabeculae and a normal ratio of mineral-to-matrix. Serum calcium and phosphorus levels are normal. Which of the following best explains the pathogenesis of osteopenia in this postmeno- pausal woman? (A) Impaired mineralization of osteoid (B) Increased osteoblast activity (C) Increased mineralization of bone (D) Increased osteoclast activity (E) Mosaic bone formation

D. Increased osteoclast activity Osteoporosis is a metabolic bone disease characterized by diffuse skeletal lesions in which normally mineralized bone is decreased in mass to the point that it no longer provides adequate mechani- cal support. The remaining bone exhibits a normal ratio of mineralized to nonmineralized (osteoid) matrix (therefore, not choices A and C). Bone loss and eventually fractures are the hallmarks of osteoporosis. Primary osteoporosis occurs principally in postmenopausal women (type 1) and elderly persons of both sexes (type 2). Type 1 primary osteoporosis is due to an absolute increase in osteoclast activity. The increased number of osteoclasts that appear in the early postmenopausal skeleton is the direct result of estrogen withdrawal. Type 2 osteoporosis reflects decreased osteoblast activity (therefore, not choice B). Mosaic bone formation (choice E) is a feature of Paget disease.

A 50-year-old man presents with a 2-day history of left leg pain. His temperature is 38.7°C (103°F). He has a harsh systolic murmur and echocardiographic evidence of bacterial endocarditis. If this patient has developed hematogenous osteomyelitis, his bone infection would most likely be found in which of the following anatomic locations? (A) Body of a flat bone (B) Diaphysis of a long bone (C) Epiphysis of a long bone (D) Metaphysis of a long bone (E) Periosteum of a long bone

D. Metaphysis of a long bone Hematogenous osteomyelitis primarily affects the metaphyseal area of the long bones (knee, ankle, hip) because of the unique vascular supply in this region. Normally, arterioles enter the calcified portion of the growth plate, form a loop, and then drain into the med- ullary cavity without establishing a capillary bed. This vascu- lar loop permits slowing and sludging of blood flow, allowing bacteria time to penetrate the walls of the blood vessels and establish an infective focus within the bone marrow. Osteo- myelitis may break into the periosteum (choice E) but does not originate there. Vascular loops do not reach the epiphysis Dx: Osteomyelitis

A 16-year-old boy presents with a 2-week history of pain in his right leg. He says that he has been taking aspirin to relieve the pain. An X-ray of the leg shows a 1-cm sharply demarcated, radiolucent lesion in the diaphysis of the tibia surrounded by dense, sclerotic bone. The lesion is surgically removed, and the gross specimen is shown in the image. Microscopically, the tumor shows irregular trabeculae of woven bone surrounded by osteoblasts, osteoclasts, and fibrovascular marrow. What is the appropriate diagnosis? (A) Chondroblastoma (B) Giant cell tumor of bone (C) Osteoblastoma (D) Osteoid osteoma (E) Solitary chondroma

D. Osteoid osteoma Osteoid osteoma is a small, painful, benign lesion of bone composed of osseous tis- sue (the nidus) and surrounded by a halo of reactive bone for- mation. The tumor typically occurs in young persons ranging in age from 5 to 25 years. Osteoid osteoma frequently arises in the cortex of the diaphysis of the tubular bones of the lower extremity. Osteoid osteoma is a spherical, hyperemic tumor of about 1 cm in diameter that is considerably softer than the surrounding bone and easily enucleated at surgery. Reactive, sclerotic bone surrounds the nidus. Chondroblastoma (choice A) features primitive chondroblasts and cartilage matrix. Giant cell tumor (choice B) of bone is a locally aggressive neoplasm composed of multinucleated, osteoclastic giant cells. Osteo- blastoma (choice C) is a benign neoplasm that is histologically similar to osteoid osteoma but larger and not accompanied by nocturnal pain relieved by aspirin. Solitary chondroma (choice E) is a benign, intraosseous tumor composed of well- differentiated hyaline cartilage.

A 60-year-old man recovering from a "flu" complains of marked fatigability. He reports that he cannot climb stairs two at a time as he used to. He also describes pain in his thighs. A muscle biopsy (shown in the image) demonstrates a mono- nuclear inflammatory cell infiltrate chiefly in the endomysium. Immunostaining shows that most of these inflammatory cells are CD8+ T lymphocytes. What is the appropriate diagnosis? (A) Dermatomyositis (B) Myasthenia gravis (C) Myotonicdystrophy (D) Polymyositis (E) Werdnig-Hoffman disease

D. Polymyositis Polymyositis is related to direct muscle cell damage produced by cytotoxic T cells. Healthy muscle fibers are initially surrounded by CD8+ T lymphocytes and macrophages (see photomicrograph), after which muscle fibers degenerate. There is a frequent association between polymyositis and anti-Jo-1, an antibody against histidyl-tRNA synthetase, with the concomitant presence of interstitial lung disease, Raynaud phenomenon, and nonero- sive arthritis. Although viral infections (e.g., influenza) may trigger polymyositis, muscle tissue has not yielded a virus on culture. An inflammatory myopathy indistinguishable from polymyositis occurs in many cases of HIV infection, but the role of the lentivirus is unclear. None of the other choices are associated with an infiltrate of cytotoxic T lymphocytes.

A 9-year-old boy is evaluated for signs of precocious puberty. Laboratory tests demonstrate a 21-hydroxylase deficiency and increased serum levels of androgens. A CT scan reveals enlargement of the adrenal glands bilaterally. If this patient is untreated, short stature will result as a consequence of which of the following mechanisms of disease? (A) Decreased growth hormone production (B) End-organ resistance to androgens (C) Impaired osteoblast activity (D) Premature epiphyseal plate closure (E) Unresponsiveness to bone morphogenetic protein

D. Premature epiphyseal plate closure. Congenital deficiency of 21-hydroxylase results in adrenogen- ital syndrome, which is associated with virilization of external genitalia in female infants (pseudohermaphroditism). Males exhibit precocious puberty. Eventually, high levels of adrenal androgens lead to premature closure of the epiphyses and stunted growth. The other choices are not related to the adre- nogenital syndrome. Diagnosis: Adrenogenital syndrome, adrenal cortical hyperplasia

An 85-year-old man presents with a 3-week history of pain- ful swelling of his right knee. Aspiration of joint fluid returns numerous neutrophils and crystals, which are described as rhomboid and "coffin-like." Chemical analysis shows that these crystals are composed of calcium pyrophosphate. Which of the following is the most likely diagnosis? (A) Ankylosing spondylitis (B) Gout (C) Infectious arthritis (D) Pseudogout (E) Rheumatoid arthritis

D. Pseudogout Pseudogout. Calcium pyrophosphate dihydrate (CPPD)-deposition disease refers to the accumulation of this compound in synovial membranes (pseudogout), joint cartilage (chondrocalcinosis), ligaments, and tendons. CPPD- deposition disease is principally a condition of old age, with half of the population older than 85 years being afflicted. Pseudog- out refers to self-limited attacks of acute arthritis lasting from 1 day to 4 weeks and involving one or two joints. Some 25% of patients with CPPD-deposition disease have an acute onset of gout-like symptoms, manifesting as inflammation and swell- ing of the knees, ankles, wrists, elbows, hips, or shoulders. The synovial fluid exhibits abundant leukocytes containing CPPD crystals. Gout (choice B) features deposition of urate crystals. Crystal deposition does not occur in rheumatoid arthritis (choice E). Diagnosis: Chondrocalcinosis, pseudogout

An 18-year-old man presents with bone pain about his knee that he has had for 6 weeks. Radiologic studies reveal a lytic lesion of the distal end of the femur, which arises in the meta- physis, extends into the proximal diaphysis, and elevates the periosteum. Serum levels of alkaline phosphatase are mark- edly elevated. The lesion is removed, and the cut surface of the surgical specimen is shown in the image. Molecular studies of this tumor would most likely reveal a mutation in the gene encoding which of the following proteins? (A) CyclinA (B) Cyclin D (C) Fibroblast growth factor receptor (D) Rb tumor suppressor protein (E) Stimulatory guanine nucleotide-binding protein

D. Rb tumor suppressor protein Osteosarcoma is a highly malignant bone tumor characterized by formation of bone tissue by tumor cells. It is most frequent in adoles- cents between the ages of 10 and 20 years. Almost two thirds of cases of osteosarcoma exhibit mutations in the retinoblas- toma (Rb) gene, and many tumors also contain mutations in p53. Often, the periosteum produces an incomplete rim of reactive bone adjacent to the site where it is lifted from the cortical surface by the tumor. When this appears on an X-ray as a shell of bone intersecting the cortex at one end and open at the other end, it is referred to as Codman triangle. A "sunburst" periosteal reaction is often superimposed. Muta- tions in the fibroblast growth factor receptor gene (choice C) are a cause of achondroplasia. Deregulation of cyclins (choices A and B) and cyclin-dependent kinases are associated with several neoplasms. Dx: Osteosarcoma

A 28-year-old man complains of burning pain on urination, as well as pain in his fingers and left eye. He also relates a recent episode of bacillary diarrhea contracted during a visit to Mexico. Physical examination confirms arthritis and conjunctivitis. The patient responds well to treatment with NSAIDs. Which of the following is the most likely diagnosis? (A) Ankylosing spondylitis (B) Infectious arthritis (C) Osteomyelitis (D) Reiter syndrome (E) Rheumatoid arthritis

D. Reiter syndrome Reiter syndrome is a triad that includes (1) seronegative polyarthritis, (2) conjunctivitis, and (3) nonspecific urethritis. The disorder is almost exclu- sively encountered in men and usually follows venereal expo- sure or an episode of bacillary dysentery. As in ankylosing spondylitis, Reiter syndrome is associated with HLA-B27 anti- gen in up to 90% of patients. In fact, after an attack of dysen- tery, 20% of HLA-B27-positive men develop Reiter syndrome. The pathologic features of Reiter arthritis are comparable to those of rheumatoid arthritis. The other choices do not typically affect the eye.

A 4-year-old boy is brought to the physician by his parents because he falls a lot, cannot jump, and tires easily. Physical examination reveals weakness in the pelvic and shoulder gir- dles and enlargement of the child's calf muscles. The serum level of creatine kinase is elevated. A biopsy of calf muscle reveals marked variation in size and shape of muscle fibers. There are foci of muscle fiber necrosis, myophagocytosis, regenerating fibers, and fibrosis. Which of the following is the most likely cause of death expected in this patient? (A) Dissecting aortic aneurysm (B) Disseminated intravascular coagulation (C) Pulmonaryembolism (D) Respiratoryinsufficiency (E) Rhabdomyosarcoma

D. Respiratory insufficiency Duchenne muscular dystrophy is a severe, progressive, X-linked, inher- ited condition characterized by progressive degeneration of muscles, particularly those of the pelvic and shoulder girdles. The weakness is noted mainly around the pelvic and shoul- der girdles (proximal muscle weakness) and is relentlessly progressive. "Pseudohypertrophy" (enlargement of a muscle due to abundant replacement of muscle fibers by fibroadipose tissue) of the calf muscles eventually develops. Patients are usually wheelchair bound by the age of 10 years and bedrid- den by age 15 years. The most common causes of death are complications of respiratory insufficiency caused by muscular weakness or cardiac arrhythmia due to myocardial involve- ment. The other choices are not complications of Duchenne muscular dystrophy. Diagnosis: Duchenne muscular dystrophy

An insult to the knee often referred to as "O' Donahue's triad", "the terrible triad", or "the unhappy triad" results in injury to which of the following structures? A. The medial meniscus, the anterior cruciate ligament and the lateral collateral ligament. B. The lateral meniscus, the anterior cruciate ligament and the medial collateral ligament. C. The medial meniscus, the anterior cruciate ligament and the lateral meniscus. D. The medial meniscus, the anterior cruciate ligament and the medial collateral ligament. E. The medial meniscus, the posterior cruciate ligament and the lateral collateral ligament.

D. The medial meniscus, the anterior cruciate ligament and the medial collateral ligament.

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