Week 5

Question 1

A 35 year old Japanese woman presents with several months of fever, night sweats, and joint/muscle aches and pains. Her vital signs are normal. Her physical exam is notable for 2+ peripheral pulses in the lower extremities, 1+ radial pulse in the right arm, and no palpable radial pulse in the left arm. Angiography is shown below. Which of the following is a notable feature of this disease?

1. Immune complex mediated vascular inflammation.
2. Improvement with smoking cessation.
3. Granulomatous thickening of the arteries.
4. Necrotizing vasculitis.
5. Perinuclear anti-myeloperoxidase (p-ANCA) staining.

Answer 1

1. Immune complex mediated vascular inflammation. This is seen in polyarteritis nodosa.
2. Improvement with smoking cessation. Buerger disease (thromboangiitis obliterans) improves with smoking cessation.
3. Granulomatous thickening of the arteries. This is the correct answer and seen in the aorta and proximal great arteries in Takayasu arteritis
4. Necrotizing vasculitis. This is granulomatosis with polyangiitis.
5. Perinuclear anti-myeloperoxidase (p-ANCA) staining. This would be seen microscopic polyangiitis or Churg-Strauss syndrome.

Lecture: SM253 Vaculitis

Learning Objective(s): Explain the pathology and pathogenesis of the vasculitides, and the commonalities among them. Distinguish among different vasculitides based on their clinical and laboratory presentations.

Question 2

A 14-year old girl presents with several weeks of left knee pain and a limp. Physical exam shows external rotation of the left hip. Her x-ray is shown below. What is the mechanism of this injury?

1. Avulsion fracture of the left hamstring.
2. Osteomyelitis of the femoral head secondary to avascular necrosis.
3. Crush injury after jumping off of a retaining wall.
4. Slippage of the proximal femoral growth plate.

Answer 2

1. Avulsion fracture of the left hamstring. This may have a more acute presentation.
2. Osteomyelitis of the femoral head secondary to avascular necrosis. This could happen after longstanding, untreated SCFE, but is not evident from this x-ray.
3. Crush injury after jumping off of a retaining wall. Crush injuries can happen after compression of the growth plate, but are not seen here.
4. Slippage of the proximal femoral growth plate. This x-ray shows a SCFE (slipped capital femoral epiphysis) in the left hip.

Lecture: 255-256 Pediatric MSK

Learning objective(s): Identify common pediatric musculoskeletal injuries, including: torus or buckle fractures, greenstick fractures, bowing fractures, toddler’s fractures, Nursemaid’s elbow and slipped capital femoral epiphysis (MKS 1a)

Question 3

A 5-year old boy is brought to the ER after complaining of arm pain. His parents had left him at home with the babysitter all day and she told them that she did not observe any injury. He refuses to move his left arm or allow you to examine it but is otherwise responsive and interactive. What is most likely to have happened?

1. He tripped while on a walk and the babysitter grabbed his arm before he hit the ground.
2. He fell onto an outstretched hand.
3. He pulled a piece of furniture over onto his arm.
4. He caught his arm in his sister’s crib, twisting it as he fell backwards.

Answer 3

1. He tripped while on a walk and the babysitter grabbed his arm before he hit the ground. This could result in a nursemaid’s elbow/radial head subluxation.
2. He fell onto an outstretched hand. This is a compression injury that could result in the buckle fracture seen here.
3. He pulled a piece of furniture over onto his arm. This could result in several types of fracture but not compression in this direction.
4. He caught his arm in his sister’s crib, twisting it as he fell backwards. This might result in another type of fracture, such as a spiral fracture.

Lecture: 256: Pediatric MSK

Learning objective(s): Identify common pediatric musculoskeletal injuries, including: torus or buckle fractures, greenstick fractures, bowing fractures, toddler’s fractures, Nursemaid’s elbow and slipped capital femoral epiphysis (MKS 1a)

Question 4

Which of the following is not a side effect of prolonged glucocorticoid therapy?

1. Hypertension
2. Hyperglycemia
3. Delayed wound healing
4. Cushing’s Syndrome
5. Weight loss.
6. Osteoporosis

Answer 4

1. Hypertension
2. Hyperglycemia
3. Delayed wound healing
4. Cushing’s Syndrome
5. Weight loss. This is the correct answer. Weight gain is an often observed side effect of corticosteroid therapy, through several mechanisms including changes in water and slat retention, metabolism, and the storage of fat.
6. Osteoporosis

Lecture: SM257a Glucocorticoids

Learning objective(s): Explain the Adverse Effects of Glucocorticoids on Human Metabolism and Anatomic Structure (MKS1b)

Question 5

A 28-year old woman presents with several months of join pain. On exam she has an erythematous, non-pruritic rash across both cheeks. Which of the following laboratory findings has the highest specificity for a presumed diagnosis of systemic lupus erythematosus?

1. Elevated ANA.
2. Elevated ESR.
3. Anti-dsDNA antibodies.
4. Anti-SSA/Ro antibodies.
5. c-ANCA.

Answer 5

1. Elevated ANA. ANAs are seen in may autoimmune diseases.
2. Elevated ESR. ESR is elevated in many inflammatory conditions.
3. Anti-dsDNA antibodies. Anti-dsDNA antibodies are highly specific for SLE.
4. Anti-SSA/Ro antibodies. While, seen in SLE, these are not specific for it.
5. c-ANCA. This is sometimes seen in SLE, but not specific for the disease.

Lecture: SM 248 SLE

Learning objective(s): List the spectrum of autoantibodies (MKS 1b, 1e)

Question 6

The majority of cells in the epidermis are:

1. Keratinocytes
2. Basalcytes (made up)
3. Melanocytes (small population, pigmented cells)
4. Langerhans cells (dendritic cells in the skin)
5. Merkel cells (specialized cells for light touch)
6. Fibroblasts (these live within the dermis)

Answer 6

1. Keratinocytes
2. Basalcytes (made up)
3. Melanocytes (small population, pigmented cells)
4. Langerhans cells (dendritic cells in the skin)
5. Merkel cells (specialized cells for light touch)
6. Fibroblasts (these live within the dermis)

Lecture: 258 Structure and Function of the Skin

Learning objective(s): Describe the keratinocyte differentiation process during the formation of the four major layers in epidermis. Explain the character and function of the other major cell types residing in the epidermis.

Question 7

In which layer of the skin can the vascular supply be found?

1. Papillary dermis.
2. Stratum basale
3. Stratum spinosum
4. Stratum granulosum
5. Stratum corneum

Answer 7

1. Papillary dermis. The dermis gives the skin flexibility and strength and provides blood supply and innervation to the skin.
2. Stratum basale
3. Stratum spinosum
4. Stratum granulosum
5. Stratum corneum

Lecture: SM 258 Structure and Function of the Skin

Learning objective(s): Describe the major structural and cellular components of the underlying dermis.

Question 8

A otherwise healthy 70 year old female presents to your clinic, with several spots. She is upset by their appearance on her otherwise clear skin and would like them removed. Physical exam reveals several of these spots across her face and shoulders, several areas across her abdomen, forearms, and neck that have been repeatedly itched, and a mildly distended abdomen. Which of the following is the next best step?

1. Punch biopsy.
2. Shave biopsy.
3. Laser ablation.
4. Liver function tests.
5. 15 minutes daily of bright light.

Answer 8

1. Punch biopsy. These are useful for lesions that require dermal or subcutaneous tissue for diagnosis, which is not needed here.
2. Shave biopsy. These are useful for raised lesions, but again a biopsy is not required here.
3. Laser ablation. Laser therapy can be used to remove spider angiomas, but the presence of angiomas, purities, and possible ascites should raise suspicion for a liver condition.
4. Liver function tests. Given several signs of liver disease, it would be wise to test for liver disease rather than just apply a cosmetic fix. These spider angiomas may resolve with correction of the underlying disorder.
5. 15 minutes daily of bright light is not an appropriate treatment.

Lecture: 259 Dermatologic Manifestations of Diseases

Learning objective(s): Describe the cutaneous manifestations of various systemic diseases. (MKS1d) Recognize specific dermatologic findings that can lead to medical diagnoses in the absence of systemic symptoms. (MKS1d)

Question 9

A child presents to your clinic with several patches of skin she is concerned about. These places are pale in comparison to the rest of the skin, have sharply demarcated borders, and are flat and smooth. Which of the following is the cause of this disease?

1. Ascorbic acid deficiency.
2. Niacin deficiency.
3. IgG antibodies against desmoglein.
4. IgG antibodies against hemidesmosomes.
5. Decreased tyrosinase activity.
6. Autoimmune cellular destruction.
7. Hyperinsulinemia.

Answer 9

1. Ascorbic acid deficiency. Aka scurvy, signs would be gingival bleeding, petechiae, and ecchymoses.
2. Niacin deficiency. Aka pellagra, one might see fissures in the palms and soles, glossitis, and photodistributed erythema.
3. IgG antibodies against desmoglein. In pemphigus, these antibodies lead to blistering.
4. IgG antibodies against hemidesmosomes. In bullous pemphigoid, these antibodies lead to severe blistering.
5. Decreased tyrosinase activity. This is one of several causes of albinism, which is likely result in the entire skin being lighter in color.
6. Autoimmune cellular destruction. This is vitiligo, which is an autoimmune disease resulting in destruction of melanocytes leading to hypopigmentation.
7. Hyperinsulinemia. This can manifest as hyperpigmentation, such as acanthosis nigricans.

Lecture: 259 Dermatologic Manifestations of Diseases

Learning objective(s): Describe the cutaneous manifestations of various systemic diseases. (MKS1d) Recognize specific dermatologic findings that can lead to medical diagnoses in the absence of systemic symptoms. (MKS1d)