Lab Final Review

Question 1

You begin seeing patients at a local substance abuse rehab clinic. Your first patient is a 56-year-old male with a history of opioid abuse due to a back injury he sustained at work in his 30s. You learn that he is a diabetic and is a little overweight. He reports pain in his lower back, but says that it has increased in severity recently. As he gets up to leave, you notice that he has a pronounced stomping (slappage) gait when he walks and his foot is slightly everted. You ask your patient if he has noticed any new injuries or pain in his foot, but he says no. When you examine his foot, you notice that he doesn’t have any injuries, but has reduced sensation in his foot.
What is the likely diagnosis?

Answer 1

Neuropathic arthropathy

Question 2

A 5-year-old presents with upper right thigh pain. The parents explain that the child has been experiencing pain for the past several months. You don’t notice any abnormalities in your physical exam and the parents explain that none of the child’s previous exams had produced abnormal findings either. A radiograph is taken and shows a small radiolucent area surrounded by a sclerotic border. Given the lesion’s size and appearance, you and your colleagues suggest that the patient be given a regimen of NSAIDs (aspirin) and this helps relieve the patient’s pain.
Which of the following best describes why NSAIDs relieve the patient’s pain?

• NSAIDs stop the accumulation of serous fluid causing expansion of this lesion, which relieves the patient’s pain
• Lesion contains an overproliferation of vasculature. Elevated PGE2 levels cause vasodilation which results in increased pain. NSAIDs affect the COX pathyway causing vasoconstriction and pain relief
• NSAIDs stop osteogenesis controlling the growth of the lesion
• The lesion is caused by the proliferation of abnormal plasma cells. NSAIDs reduce inflammation leading to necrosis of the plama cells

Answer 2

Lesion contains an overproliferation of vasculature. Elevated PGE2 levels cause vasodilation which results in increased pain. NSAIDs affect the COX pathyway causing vasoconstriction and pain relief

osteoid osteoma

Question 3

Name the six Ds used to describe the impacts on bone observed in this radiograph

Answer 3

• Debris
• Disorganized
• Distension
• Density
• Destruction
• Dislocation

Question 4

Which of the following applies to neuropathic arthropathy?

• Non-inflammatory
• Inflammatory
• Parasitic
• Infectious

Answer 4

Non-inflammatory

Question 5

You are in clinic and a new patient arrives. Sam is a 36-year-old with swelling in his hands. He explains that the pain is fairly constant, and he sometimes has difficulty performing tasks due to the pain and stiffness in his fingers. He also explains that he has been feeling extremely tired lately and is having difficulty staying focused at work. You ask how long he has been experiencing these symptoms and he says that it has been several months, but things have gotten worse over the past month. When you take his temperature, you notice a slight fever. You ask if he remembers seeing a rash or having any digestive issues and he says that he hasn’t noticed anything since his symptoms began.
Based on the case presentation, what is the most likely diagnosis for this patient?

Answer 5

Rheumatoid arthritis

Question 6

You are in clinic and a new patient arrives. Sam is a 36-year-old with swelling in his hands. He explains that the pain is fairly constant, and he sometimes has difficulty performing tasks due to the pain and stiffness in his fingers. He also explains that he has been feeling extremely tired lately and is having difficulty staying focused at work. You ask how long he has been experiencing these symptoms and he says that it has been several months, but things have gotten worse over the past month. When you take his temperature, you notice a slight fever. You ask if he remembers seeing a rash or having any digestive issues and he says that he hasn’t noticed anything since his symptoms began.
What radiographic finding would best support your diagnosis?

• Osseous ankylosis of the interphalangeal and metacarpalphalangeal joints
• Juxta-articular osteoporosis at the interphalangeal and metacarpalphalangeal joint margins
• Reversible subluxations in the interphalangeal and metacarpalphalangeal joints
• Osteophyte formation at the interphalangeal and metacarpalphalangeal joint margins

Answer 6

Juxta-articular osteoporosis at the interphalangeal and metacarpalphalangeal joint margins

rheumatoid arthritis

Question 7

You are in clinic and a new patient arrives. Sam is a 36-year-old with swelling in his hands. He explains that the pain is fairly constant, and he sometimes has difficulty performing tasks due to the pain and stiffness in his fingers. He also explains that he has been feeling extremely tired lately and is having difficulty staying focused at work. You ask how long he has been experiencing these symptoms and he says that it has been several months, but things have gotten worse over the past month. When you take his temperature, you notice a slight fever. You ask if he remembers seeing a rash or having any digestive issues and he says that he hasn’t noticed anything since his symptoms began.
Which blood result would best confirm your diagnosis?

Answer 7

RA factor positive

rheumatoid arthritis

Question 8

This radiograph demonstrates which type of deformity?

Answer 8

Boutonniere deformity

rheumatoid arthritis

Question 9

What cellular events would produce this deformity?

Answer 9

• Synovium becomes inflamed due to autoimmune response, thickens, and becomes hyperplastic, forms panus
• Panus continues to thicken and eventually starts to produce extra protease b enzymes
• Erosion of the bone, lose ligament attachment sites causing subluxations, dislocations, and deformities
• Over time, fibrous bands form around the joint (fibrous ankylosis)

rheumatoid arthritis

Question 10

A 57-year-old male named John has been receiving regular adjustments once a month for several years. You haven’t seen him in over a year due to COVID and the more recent increased workload he is experiencing at his restaurant due to staffing shortages. He reports back pain and states that he has been feeling exhausted lately but assumes it’s related to the additional hours at the restaurant. In the past few weeks, he has really had difficulty managing the business. You notice that he has lost about 15lbs since you last saw him. He says he’s actually eating more. Bloodwork shows that he is slightly anemic and radiographs of his skull, pelvis, and vertebra show multiple small punched out osteolytic lesions.
What diagnosis fits this patient presentation?

Answer 10

Multiple myeloma

Question 11

A 57-year-old male named John has been receiving regular adjustments once a month for several years. You haven’t seen him i over a year due to COVID and the more recent increased workload he is experiencing at his restaurant due to staffing shortages. He reports back pain and states that he has been feeling exhausted lately but assumes it’s related to the additional hours at the restaurant. In the past few weeks, he has really had difficulty managing the business. You notice that he has lost about 15lbs since you last saw him. He says he’s actually eating more. Bloodwork shows that he is slightly anemic and radiographs of his skull, pelvis, and vertebra show multiple small punched out osteolytic lesions.
What lab findings would provide greatest evidence to help confirm your diagnosis?

Answer 11

Bence Jones protein

multiple myeloma

Question 12

A 57-year-old male named John has been receiving regular adjustments once a month for several years. You haven’t seen him in over a year due to COVID and the more recent increased workload he is experiencing at his restaurant due to staffing shortages. He reports back pain and states that he has been feeling exhausted lately but assumes it’s related to the additional hours at the restaurant. In the past few weeks, he has really had difficulty managing the business. You notice that he has lost about 15lbs since you last saw him. He says he’s actually eating more. Bloodwork shows that he is slightly anemic and radiographs of his skull, pelvis, and vertebra show multiple small punched out osteolytic lesions.
What is the most probable sequella for this patient’s condition?

Answer 12

Renal failure

multiple myeloma

Question 13

What is a probable sequela for this patient’s condition?

Answer 13

Renal failure

multiple myeloma

Question 14

Which of the following observations is the most diagnostically relevant characteristic in this radiogaph?

• Soap bubble appearance
• Location of the lesion extending into the epiphyseal region
• Intact cortex
• Radiolucent lesions

Answer 14

Location of the lesion extending into the epiphyseal region

giant cell tumor

Question 15

You start seeing a new patient, Andy, who is a 30-year-old male. He never had medical insurance and hasn’t seen a physician since he was a child. As he walks into your office, you notice his spine has a pronounced kyphosis in the thoracic region. Andy says that he has been experiencing stiffness and pain in his back for years. He finally decided to seek a doctor’s advice because he noticed less flexibility in his spine, which is fairly severe in the morning, but gets a bit better during the day. More recently, he has noticed pain in his feet as well.
What is the most likely diagnosis?

Answer 15

Ankylosing spondylolitis

Question 16

You start seeing a new patient, Andy, who is a 30-year-old male. He never had medical insurance and hasn’t seen a physician since he was a child. As he walks into your office, you notice his spine has a pronounced kyphosis in the thoracic region. Andy says that he has been experiencing stiffness and pain in his back for years. He finally decided to seek a doctor’s advice because he noticed less flexibility in his spine, which is fairly severe in the morning, but gets a bit better during the day. More recently, he has noticed pain in his feet as well.
What lab result would help confirm your diagnosis for this patient?

Answer 16

HLA B27 positive

ankylosing spondylolitis

Question 17

You are providing supportive care to a local high school soccer team. One of the players, a 17 year-old boy, reports pain and swelling in his right knee. He says he hasn’t been experiencing the pain that long, but its getting worse. He explains that it feels like its deep in his leg, just below the knee, and it is keeping him awake at night. He reports using NSAIDs, but they don’t seem to be helping long term. When you ask if he has had any recent injuries he says no.
What is the most likely diagnosis for this patient?

Answer 17

Osteosarcoma

Question 18

Name 2 (or more) pathologies that typically produce the type of ankylosis seen in this radiograph

Answer 18

• Ankylosing Spondylitis
• Enteropathic Spondylitis
• Psoriatic arthritis
• Reiter’s syndrome

swan neck deformity

Question 19

What is the name for the radiolucent lesions visible on the humeral head in the radiograph below showing a case of noniflammatory joint disease?

Answer 19

Geode
(aka subchondral cyst)

osteophyte circled in purple

Question 20

Describe the cellular events leading to this degenerative joint disease

Answer 20

• Chondrocyte death is faster than production
• Synovial fluid fills spaces
• Fibrocartilage plug forms
• Cracks in fibrocartilage plug
• More synovial fluid fills in the cracks
• Cysts form around areas of synovial fluid
• Cysts can be capped by a fibrocartilage plug

subchondral cyst

Question 21

What non-pharmacological treatments would you recommend for the patient with this radiograph showing degenerative joint disease?

Answer 21

Chiropractic care with soft tissue work

subchondral cyst

Question 22

Is this lesion eccentric or eucentric?

Answer 22

Eucentric

Question 23

Name three conditions you should include on your differential diagnosis based on this image

Answer 23

• Multiple myeloma
• Infection
• Mestastatic disease

Question 24

A 25-year old female presents with pain and stiffness in both hands. Examination of her hands demonstrates subluxations of the metacarpal phalangeal and interphalangeal joints but the patient is able to extend these joints with normal joint alignment when they exert downward pressure. A radiograph also shows no lytic changes in the joints.
Based solely on this information, what is the most likely diagnosis for this patient?

Answer 24

Systemic Lupus Erythematosus
(Lupus)

Question 25

This radiograph depicts osteolytic lesions in the foot due to gout.
What causes the osteolytic response observed in this condition?

Answer 25

Uric crystal deposits

gout

Question 26

This radiograph depicts an osteolytic lesion in the foot due to gout.
What term would you use to describe the osteolytic lesion indicated by the blue arrow based on its location?

Answer 26

Periarticular erosions

gout

Question 27

Your clinician hands you the radiograph below and asks you to examine the changes at the distal interphalangeal joint.
What terminology would you use to describe the reactive bone formation surrounding the marginal erosion?

Answer 27

Fluffy periostitis OR mouse ear deformity

psoriatic arthritis

Question 28

True or False:

The corduroy cloth appearance observed in cases of hemangioma can occur in more than one vertebrae, but never all vertebral bodies

Answer 28

True

Question 29

In the image below, the green arrow indicates the fusion of intervertebral joints in the thoracolumbar spine due to the formation of ___, which are ossified or calcified annular intervertebral disk fibers.

Answer 29

Syndesmophytes

Question 30

You have a patient who suffers from degenerative joint disease.
Which of the following would most likely describe this patient’s pain?

• Constant deep achy pain
• Sharp anterior knee pain
• Deep achy pain that may be worse with activity
• No pain but obvious joint destruction present on a physical exam or radiograph

Answer 30

Deep achy pain that may be worse with activity

Question 31

During the pathogenesis of degenerative joint disease bony projections growing off the bone are called ___. These typically start developing ___

• osteophytes; at the joint margins
• syndesmophytes; at the joint margins
• osteophytes; on the articular cartilage
• syndesmophytes; on the subchondral bone

Answer 31

osteophytes; at the joint margins

Question 32

Which of the following best describes the pathology depicted in the gross specimen in the image below?

• Benign
• Malignant
• Cyst
• Non-inflammatory

Answer 32

Malignant

Ewing sarcoma

Question 33

A primary osteosarcoma is a primarily ___ growth, which will appear ___ on radiographs.

• Osteoblastic; radiopaque
• Osteoblastic; radiolucent
• Osteolytic; radiopaque
• Osteolytic; radiolucent

Answer 33

Osteoblastic; radiopaque

Question 34

Which of the following terms best describes the appearance of an aneurysmal bone cyst on a radiograph?

• Multilocular
• Unilocular
• Non-expansile
• Eucentric

Answer 34

Multilocular

Question 35

Which of the following will present as a primarily radiolucent lesion?

• Primary osteosarcoma
• Osteoma
• Osteophyte
• Enchondroma

Answer 35

Enchondroma

Question 36

Which term best describes the neoplastic growth depicted in the image below near the distal femur metaphysis?

• Pedunculated
• Sessile
• Tuberous
• Malignant
• Eucentric

Answer 36

Pedunculated

Question 37

Type I muscle fiber types will have more ___ compared to Type II muscle fiber types.

• numerous mitochondria
• fast conduction motor neurons
• SR pumping capacity
• contraction speed

Answer 37

numerous mitochondria

Question 38

Becker Dystrophy is most likely to effect ___ (fibers).

Answer 38

extrafusal fibers

Question 39

Your patient Gina mentions that her son, who is 3-years-old is demonstrating difficulty standing, walking, and sometimes even crawling. She states that his limbs have always looked a little thin compared to other children his age but didn’t think that was too abnormal until his recent difficulties. You suggest ordering blood work for the child and it returns with elevated levels of creatine kinase but normal c-reactive protein. A histological tissue section also demonstrates that multiple muscles in the body show progressive necrosis and fibrosis, primarily involving Type I muscle fibers.
What is the most likely etiology of the child’s condition?

Answer 39

Gene mutation causing decreased dystrophin production

Duchenne muscular dystrophy

Question 40

What type of tissue is indicated by the purple arrow in this histological tissue section of an osteochondroma?

Answer 40

cartilage

osteochondroma

Question 41

You are handed a file in clinic with no associated information for the case. Immediately you notice that the radiograph shows a mixed osteolytic and osteoblastic response in both os coxae and the left femur. You also notice increased cortical thickness and coarsening of the trabeculae in the left femur with no evidence for periosteal or soft tissue involvement.
Which pathology is most likely?

Answer 41

Paget’s disease

Question 42

You have a 35-year-old female patient who you suspect is suffering from lupus. She frequently experiences a rash on the palms of her hands and face, under her eyes and over the bridge of her nose. Her symptoms and rash are often worse after UV exposure.
Which of the following is most likely the cause of this patient’s rash?

• Necrotizing vasculitis
• Keratin overproduction
• Dermatomyositis
• Keratoderma blennorrhagica

Answer 42

Necrotizing vasculitis
DDx: dermatomyositis

pick both if “select all that apply”

Question 43

What skeletal muscle structure comprising a bundle of muscle fibers is indicated by #5 in this image?

Answer 43

Fascicle

Question 44

What skeletal muscle structure comprising a bundle of muscle fibers is indciated by #4 in this image?

Answer 44

Muscle fiber

Question 45

You see a 63-year old female patient for back pain. While taking her history, you learn that she was diagnosed with rheumatoid arthritis approximately 30 years previously and has been managing her condition well with disease modifying drug therapy and lifetyles changes. You note for her appointment states that she is experiencing back pain but does not give any additional details.
Which region of the spine/pelvis is most likely to be affected by her existing diagnosis?

Answer 45

Cervical region

Question 46

You have a 65-year old male patient named Jim that you have been treating for the past 3 years. Recently, Jim has asked to see you more frequently as he states that he doesn’t receive as much relief from his adjustments. You tell Jim that you would like to take a new set of images just to verify that there haven’t been any changes to the area you are treating. On the radiograph, you notice that L3, L4, and L5 all have portions of the vertebral bodies that are not visualized. Intervetebral disk height is maintained for all lumbar vertebrae. L3, L4, and L5 all have lytic areas with cortical disruption.
Which of the following terms best describes this presentation?

• Osteosarcoma
• Benign
• Non-aggressive
• Aggressive

Answer 46

Aggressive

Question 47

You are providing supportive care to a local high school soccer team. One of the players, a 17 year-old boy, reports pain and swelling in his right knee. He says he hasn’t been experiencing the pain that long, but its getting worse. He explains that it feels like its deep in his leg, just below the knee, and it is keeping him awake at night. He reported using NSAIDs, but they don’t seem to be helping long term. When you asked if he has had any recent injuries he says no.
Which of the following would you most likely observe on a radiograph of this patient’s right knee?

• Short Zone of Transition
• Long Zone of Transition
• Intact cortex
• Unremarkable findings

Answer 47

Long zone of transition

osteosarcoma

Question 48

Which of the following is a true statement about osteochondromas?

• They will grow toward the joint
• They will grow away from the joint
• There are two forms pedicled and surreal
• They will generally elicit pain
• More than 3 is consistent with the multiple hereditary exostosis

Answer 48

They will grow away from the joint

Question 49

What pathology is generally associated with the type of ankylosis shown in the radiograph below?

Answer 49

Rheumatoid arthritis

Question 50

A new patient arrives to the clinic. Sam is a 36-year-old male who presents with pain and swelling in both hands. He explains that the pain is fairly constant and he sometimes has difficulty performing tasks due to the pain and stiffness in his fingers. He also explains that he has been feeling extremely tired lately and is having difficulty staying focused at work. He states that the pain started several months ago but things have gotten progressively worse in the past month. When you take his temperature you notice a slight fever. You ask if he remembers seeing a rash or having any digestive issues and he says that he hasn’t noticed anything since his symptoms began.
Which of the following best describes the pathogenesis of the disease associated with this patient’s condition?

• Damage to articular cartilage leading to inflammation in the joint
• Immune complexes directed at joint tissues lead to pannus formation and the erosion of joint structures
• Crystals accumulating in the joints are being broken down by neutrophils and macrophages resulting in inflammation and the
  erosion of joint structures
• A bacterial infection in the joint prompts synovitis and erosion of the joint structures

Answer 50

Immune complexes directed at joint tissues lead to pannus formation and the erosion of joint structures

rheumatoid arthritis

Question 51

A 46-year old female patient presents with altered gait and swelling in their right knee. An examination reveals that the patient demonstrates a lack of sensation when the affected area is stimulated.
What is the etiology of the pathology depicted in this radiograph?

Answer 51

Biomechanical stress with peripheral nerve damage

neuropathic arthropathy

Question 52

A 46-year old female patient presents with altered gait and swelling in their right knee. An examination reveals that the patient demonstrates a lack of sensation when the affected area is stimulated.
Using the characteristic terminology specific for this disease process, name 2 radiographic observations that could be used to describe the impacts to bone observed in the radiograph.

Answer 52

• Decreased joint space
• Osteoclastic activity [Destruction, Dislocation, Debri, Distension, Disorganization, Density (subchondral sclerosing)]

neuropathic arthropathy

Question 53

A 46-year old female patient presents with altered gait and swelling in their right knee. An examination reveals that the patient demonstrates a lack of sensation when the affected area is stimulated.
Using the characteristic terminology specific for this disease process, name 2 radiographic observations that could be used to describe the impacts to bone observed in the radiograph.

Answer 53

• Decreased joint space
• Osteoclastic activity [Destruction, Dislocation, Debri, Distension, Disorganization, Density (subchondral sclerosing)]

Question 54

A new patient arrives to the clinic. Sam is a 36-year-old male who presents with pain and swelling in both hands. He explains that the pain is fairly constant and he sometimes has difficulty performing tasks due to the pain and stiffness in his fingers. He also explains that he has been feeling extremely tired lately and is having difficulty staying focused at work. He states that the pain started several months ago but things have gotten progressively worse in the past month. When you take his temperature you notice a slight fever. You ask if he remembers seeing a rash or having any digestive issues and he says that he hasn’t noticed anything since his symptoms began.
Which of the following is a potential sequela for Sam’s condition?

• Tenosynovitis
• Renal failure
• CPPD
• Chondrosarcoma

Answer 54

Tenosynovitis

rheumatoid arthritis

Question 55

A new patient, Jim, presents with low back pain. Jim is a 25-year-old male states that his pain started several months ago and has been getting progressively worse. Lately, he is noticing less flexibility in his low back and more recently, he has been experiencing pain in his right knee. When asked about his medical history he reports a recent urinary tract infection, a humerus fracture that occurred 10 months ago, and a severe gastrointestinal infection several months ago. He reports that all of these issues have since been resolved.
Which of the following is the most likely potential sequela of Jim’s condition?

• Tenosynovitis
• Rhemuatoid arthritis
• Systemic Lupus Eyrathematosus
• Renal failure
• Conjuntivitis

Answer 55

Conjunctivitis

Reiter’s syndrome

Question 56

A new patient, Jim, presents with low back pain. Jim is a 25-year-old male states that his pain started several months ago and has been getting progressively worse. Lately, he is noticing less flexibility in his low back and more recently, he has been experiencing pain in his right knee. When asked about his medical history he reports a recent urinary tract infection, a humerus fracture that occurred 10 months ago, and a severe gastrointestinal infection several months ago. He reports that all of these issues have since been resolved.
What is the most likely diagnosis for Jim?

Answer 56

Reiter’s syndrome

Question 57

The osteoblastic activity indicated by the arrow is indicative of changes associated with which pathology?

• Chondromalacia patella
• Degenerative joint disease
• Ankylosing spondylitis
• Osteosarcoma
• Acute osteomyelitis
• Osteoma

Answer 57

Degenerative joint disease

Question 58

A 65-year-old man diagnosed with Paget’s disease presents with an increased amount of Type I collagen biproducts and elevated alkaline phosphatase in his blood.
What does this indicate about the patient’s case (stage)?

Answer 58

The patient is in stage 2 of the disease process

Question 59

Which of the following is used as a common route for hematogenous metastatic spread?

• Vertebral arteries
• Saphenous system
• Lymphatic spread
• Batson’s Venus Plexus

Answer 59

Batson’s Venus Plexus

Question 60

Which pathology best fits this radiograph, which shows evidence of marginal lytic erosion and a periosteal response?

Answer 60

Psoriatic arthritis

Question 61

What type of deformity is demonstrated in the second digit in this radiograph?

Answer 61

Swan neck deformity