Questions from lecture

Question 1

A 62 y/o male complains of low back pain that radiates from his back down into his buttock and into his right leg. On PE, you note sensory loss on the lateral aspect of the right foot, decreased ability to perform a toe walk on the right side and a decreased Achilles reflex. The straight leg raise test elicits pain at 45% elevation. On the basis of this information, between which pair of vertebrae is the disc herniation most likely to have occurred?

L2-L3
L3-L4
L4-L5
L5-S1
S1-S2

Answer 1

E

Question 2

A 24-year-old presents with low back pain of 2 days duration. The patient is a manual laborer and reports lifting a heavy box while at work the previous day. Initially, the patient had no complaints, but the following day, stiffness and pain began. The patient denies radiation of the pain, numbness or difficulty with urination. On exam, there is paravertebral muscle spasm and slight decrease in range of motion of the spine. Deep tendon reflexes are equal bilaterally, and no sensory defects are noted. Which of the following is the most appropriate intervention?

a) MRI of lumbar spine
b) Plan x-rays of lumbar spine
c) Return the patient to work with no limitations
d) Refer the patient for trigger point injections
e) Initiate a short period of rest, analgesia, and progressive functional use

Answer 2

E

Question 3

Which of the following clinical manifestations is most characteristic of polymyalgia rheumatica (PMR)?

a) Subcutaneous inflammatory lesions
b) Abrupt onset of proximal muscle pain + stiffness in shoulder and pelvic girdle
c) Insidious onset of symmetrical joint involvement
d) Widespread musculoskeletal pain and tender points
e) Symmetrical weakness initially in the legs that progresses caudally

Answer 3

B

NOT A: this is erythema nodosum
NOT C: insidious= RA
NOT D: widespread and trigger points=fibromyalgia
NOT E: GB

Question 4

Which of the following conditions is strongly associated with systemic sclerosis (scleroderma)?

a) Polymyositis
b) Reactive arthritis
c) Dermatomyositis
d) Sjogren’s disease
e) Raynaud’s phenomenon

Answer 4

E

Question 5

Patients diagnosed with Sjogren syndrome should be counseled to avoid which of the following classes of medications?

A) Penicillins
B) Decongestants 
C) Antihistamines
D) Corticosteroids
E) Fluoroquinolones

Answer 5

B–bc decongestants will decrease saliva

Question 6

The diagnosis of SLE is reported by a positive initial antibody screen; however, the test is not specific. Which of the following tests is most specific in the diagnostic eval of SLE?

a) Gliadin antibody
b) Anti-dsDNA
c) Antinuclear antibody (ANA)
d) Anticentromere antibody
e) Antiribosomal P antibody

Answer 6

B
**anti-smith antibodies also specific for SLE

NOT ANA because that is not specific to SLE

Question 7

Which of the following clinical manifestations is associated with systemic disorders that are HLA-B27 related, including ankylosing spondylitis, reactive arthritis, psoriasis and Bechet syndrome?

a) Uveitis
b) Dysentery
c) Vasculitis
d) Hyperuricemia
e) Thoracic involvement

Answer 7

A

Question 8

A 40-year-old female has a 2-year history of Raynaud’s phenomenon. She now has heartburn and dysphagia to both solids and liquids. Vital signs are normal. Examination shows thickening of the skin of the fingers with loss of the creases. Which of the following is the most likely diagnosis?

a) Sjogren’s syndrome
b) Achalasia
c) Squamous cell carcinoma of the esophagus
d) Carcinoma of the lung with paraneoplastic syndrome
e) Scleroderma

Answer 8

E

Question 9

A 52-year-old male has a 4-month history of progressive exertional breathlessness without associated cough or angina pectoris. He now has dysphagia to both solids and liquids. Blood pressure is 140/90 Hg sitting; pulse, 96 / min / regular; and respiratory rate, 28 / min. Examination shows thickening of the skin of the face and hands. Telangiectasia are noted on the face. Chest radiograph shows diffuse pulmonary fibrosis. Which of the following is the most likely diagnosis?

Sarcoidosis
Chronic pulmonary embolic disease
Asbestosis
Scleroderma
Silo-Filler’s disease

Answer 9

Scleroderma

Question 10

A patient with systemic lupus erythematosus has a rash in the malar area and on the extremities. Which of the following is the appropriate counseling to be given to the patient?

Apply coal tar and salicylate gel topically on a weekly basis
Avoid direct sunlight
Avoid sunscreen preparations
Take weekly cornstarch bath
Avoid hydrocortisone topical medications

Answer 10

avoid direct sunlight

Question 11

In a neonate, unequal thigh folds may indicate which of the following?

A. Coxa vara
B. Legg-Calve-Perthes disease
C. Developmental hip dysplasia
D. Slipped capital femoral epiphysis

Answer 11

C

NOT B– thats a painless limp kids 4-10 YO due to avasc necrosis
NOT D= SCFE fx primarily in adolescents obese

Question 12

An obese 15-year-old male presents with complaint of a limp and right knee pain for two weeks. He denies recent trauma or history of previous injury. Physical examination of the right knee is unremarkable. Examination of the right hip reveals pain with passive range of motion and limited internal rotation and abduction. Flexion of the hip results in external rotation of the thigh. Gait is antalgic with the right hip externally rotated. Which of the following radiographic findings supports the most likely diagnosis?

Displacement of the femoral epiphysis
Irregularity and fragmentation of the joint space
Capsular swelling of the joint
Dislocation of the hip

Answer 12

Displacement of the femoral epiphysis

— bc this PT has a SCFE

Question 13

A 14-year-old male who is overweight presents with complaints of left knee and anteromedial thigh pain for the past month. He states the pain gets better with rest and denies any known trauma. On examination of the gait, a slight limp is noted. X-ray films of the left knee are normal. The most likely diagnosis is:

Genu valgum
Legg-Calve-Perthes disease
Osgood-Schlatter disease
Slipped capital femoral epiphysis

Answer 13

SCFE

Question 14

A 12-year-old male has been limping for the past 2 months. Exam reveals a moderately obese young male in no acute distress who complains of pain in his left hip region. There is a limitation of internal rotation of the hip with a 2-cm left limb discrepancy as compared to the right. What is the most appropriate diagnostic test?

A. AP and lateral radiographs of the left hip
B. AP pelvic films
C. frog leg view of both hips
D. weight-bearing MRI of the left hip

Answer 14

C–frog leg

Question 15

A 14-year-old male presents with anterior knee pain and swelling that gets worse after soccer games. The patient reports no trauma to the knee. On exam, knee range of motion is normal but the patient is tender to palpation over the tibial tubercle. What is the most likely diagnosis?

A. Chondromalacia patella
B. Medial collateral ligament tear
C. Osgood-Schlatter disease
D. Prepatellar bursitis

Answer 15

C

Question 16

A 25 y/o man was involved in a MVA and complains of right leg pain. At the time of the accident, he was sitting in the passenger side of the front seat. The force of the collision caused the dashboard to be driven back against the patient’s knees. On the basis of the mechanism of injury, what would you expect to find when you inspect the right leg?

Flexed, abducted and externally rotated
Shortened, abducted and externally rotated
Shortened, abducted and internally rotated
Shortened and externally rotated
Shortened, adducted, and internally rotated

Answer 16

E— bc its a hip dislocation

***hip fx=shortened, abducted and externally rotated

Question 17

What is a typical radiographic finding that supports a diagnosis of a Lisfranc dislocation-fracture?

Answer 17

An AP view which reveals lateral shift of the second metatarsal off the middle cuneiform

Question 18

Do boys or girls typically develop slipped capital femoral epiphysis at a younger age?

Answer 18

girls. Girls typically present at a younger age (10-14) versus boys (12-16)

Question 19

A 59-year-old man presents to your ED with severe left knee pain that started the previous evening and became worse overnight, waking him up early this morning. He denies having anything like this before. He denies any trauma to the knee or onset with activity. He states he drinks a glass of whiskey daily and enjoys red meat. The knee is swollen, red, exquisitely warm, and has a limited range of motion in both passive and active phases. Vital signs are within normal limits.
ESR and CRP are slightly elevated. You decide to tap the knee for synovial fluid, which shows a white count of 40,000 with neutrophil predominance and negatively birefringent crystals in polarizing light microscopy. Gram stain of the fluid is negative and culture is pending. Given these findings, which of the following treatments should be initiated next?

A) Allopurinol
B) Joint aspiration and intra-articular triamcinolone
C) Oral colchicine
D) Oral indomethacin
E) Oral prednisone

Answer 19

D
CRYSTAL ARTHROPATHY
Acute Treatment
1. NSAIDS (not ASA)
2. Corticosteroids (if refractory to NSAIDS or NSAIDS contraindicated). Can be injected into joint OR oral
3. Colchicine (if NSAIDS and steroids don’t work)

Prophylaxis

• Avoid purine rich foods
• Allopurinol -> decreased uric acid production
• Uricosuric drugs (Probenecid) -> increased urine excretion of uric acid
• Colchicine (lower doses)

Question 20

A 37-year-old woman has been taking prednisone for 4 years as therapy for rheumatoid arthritis. Bone density study now shows significant osteopenia. In addition to oral calcium supplementation, which of the following is recommended?

Initiate therapy with a thiazide diuretic
Initiate therapy with fluoride
Initiate therapy with a bisphosphonate
Obtain 24-hour urinary calcium level
Initiate high-protein diet

Answer 20

Initiate therapy with a bisphosphonate

Question 21

A 57-year-old female is to begin alendronate as treatment for osteoporosis. Which of the following instructions should be given to the patient?

Take the medication at bedtime
Do not eat for 60 minutes after taking the medication
Take medication with an aluminum-containing antacid
Stand or sit upright for 30 minutes after taking the medication
Check daily for signs of purpura

Answer 21

Stand or sit upright for 30 minutes after taking the medication
**why? because this drug can cause bad esophagitis

Question 22

A 13 year-old girl reports two weeks of worsening right knee pain with no history of antecedent injury or recent trauma. She reports frequent episodes of nighttime awakening with knee pain in the past two weeks. Examination of the knee reveals edema and a tender mass over the anterior proximal right tibia. Her knee exam is otherwise within normal limits. Radiographs of the right knee show a lytic mass with a multi-laminated periosteal reaction involving the proximal anterior tibia. What is the most likely diagnosis?

Ewing sarcoma
Osteochondroma
Multiple myeloma
Osteoid osteoma

Answer 22

Ewing sarcoma

-xray findings explain onion skin

Question 23

A 12 year-old male presents with pain in his left leg that is worse at night. NSAIDs relieve the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a slight limp that favors the left leg. Radiographs show a 1 cm radiolucent nidus surrounded by osteosclerosis. Which of the following is the most likely diagnosis?

Osteosarcoma
Legg-Calve-Perthes disease
Osgood-Schlatter disease
Osteoid osteoma

Answer 23

Osteoid Osteoma

Question 24

Physical exam findings in a 4 year-old child that include blue sclerae and recurrent fractures indicates which of the following?

Ehlers-Danlos syndrome
Marfan syndrome
Achondroplasia
Osteogenesis imperfecta

Answer 24

Osteogenesis imperfecta

Question 25

In what age group are physeal

injuries most common?

Answer 25

12-15 boys

9-12 girls

Question 26

What is the classic description of ankylosing spondylitis?

Answer 26

insidious onset of bilateral buttock pain (sacroiliitis), thoracolumbar pain (enthesitis), and morning lumbar stiffness that lessens with exercise. Most commonly seen in young men.