MSK/Rheum

Question 1

most common cause of elevated Alk Phos in an elderly patient

Answer 1

Paget disease - osteoclastic dysfunction with defective osteoid formation, increase bone remodeling and focal hypertrophy

Question 2

Pain with resisted extension and passive flexion of the wrist in an airport baggage handler

Answer 2

Lateral epicondylitis

Question 3

Child with leg pain, polyuria, hypernatremia, rash on truck and groin. Skeletal survey shows well-defined, lytic distal femoral lesion

Answer 3

Langerhans cell histiocytosis

Question 4

Inflammatory arthritis, splenomegaly, neutropenia

Answer 4

Felty syndrome

Question 5

Patient presents with stroke like symptoms and positive ANA

Answer 5

Antiphospholipid antibody syndrome

• pt presents with a thrombotic event (DVT or arterial) or pregnancy morbidity
• Common in people with lupus
• Lupus anticoagulant causes prolonged PTT (not reversed on mixing studies)
• anticardiolipin antibody or anti-beta2-glycoprotein-1 antibody

Question 6

female patient presents with difficulty rising from a seated position, erythematous rash on chest, periorbital edema

Answer 6

Dermatomyositis

• Proximal muscle weakness, UE=LE
• Gottron’s papules - violaceous, slighty scaly papules
• Heliotrope rash - periorbital edema
• elevated CPK
• anti-Jo-1 and anti-Mi-2
• internal malignancies are more common***

Question 7

Methotrexate side effects

Answer 7

oral ulcers
transaminitis
alopecia
pulm toxicity
bone marrow suppresion
(MTX is a folate antimetabolite)

Question 8

Child with fever, conjunctivitis, red mouth and tongue, an enlarged anterior cervical lymph node. Recently returned from Japan

Answer 8

Kawasaki disease

- will also have extremity edema, desquamation of hands and feet, polymorphous rash

Question 9

Patient with foot pain. Clicking sensation when palpating space between 3rd and 4th toes while squeezing the metatarsal joints (mulder sign)

Answer 9

Morton neuroma - mechanically induced neuropathic degeneration of the interdigital nerves

Question 10

immune markers: SLE

Answer 10

ANA, anti-dsDNA, anti-Sm

*false-positive RPR or VDRL

Question 11

immune markers: drug-induced lupus

Answer 11

antihistone antibodies, ANA

Question 12

immune markers: RA

Answer 12

RF, anti-citrullinated peptide antibodies, ANA, HLA-DR4

Question 13

immune markers: polymyositis or dermatomyositis

Answer 13

ANA, anti-Jo-1 antibodies

Question 14

immune markers: ankylosing spondylitis

Answer 14

HLA-B27

Question 15

immune markers: psoriatic arthritis

Answer 15

possible HLA-B27

Question 16

immune markers: scleroderma

Answer 16

anti-scl-70

Question 17

Teenager has progressive facial weakness, difficulty relaxing muscles after contraction (especially thenar and hypothenar), testicular volume is small for age, and difficulty swallowing

Answer 17

Myotonic muscular dystrophy

• autosomal dominant expansion of CTG repeats
• appears in teenagers
• can also have cataracts, arrhythmias, baldness

Question 18

Enthesis (tenderness at tendon insertion sites) is a characteristic finding of

Answer 18

ankylosing spondylitis

Question 19

Pt with long standing hx of joint pain in the hands with morning stiffness that lasts several hours. Sausage digits present (dactylitis), red demarcated patches on hands, and nail involvement (onycholysis - seperation from nail bed)

Answer 19

Psoriatic arthritis

Question 20

Pt whose hard hat no longer fits. Elevated alk phos. CT show increased thickening of cranium with mixed lytic and osteoblastic lesions. Normal Ca and Phos. Nuclear bone scan shows increased uptake in skull and tibia

Answer 20

Paget disease of bone

- tx: bisphosphonates

Question 21

9 month old with dorsal swelling of both hands and feet. Pt has a temp of 101.

Answer 21

Vaso-occlusive disease/early manifestation of sickle sell disease

Question 22

teenage girl with point tenderness over anterior right shin. She is underweight with irregular menses

Answer 22

Stress fracture

Question 23

Pt with pmhx of sarcoidodis who was recently on steroids presents with unilateral hip pain. Pain is worse with abduction and internal rotation.

Answer 23

Avascular necrosis of femoral head

Question 24

immune markers: CREST syndrome

Answer 24

anticentromere antibodies

Question 25

immune markers: mixed connective tissue disease

Answer 25

anti-RNP ANA

Question 26

immune markers: sjogren syndrome

Answer 26

anti-Ro (ant-SSA) ANA | anti-La (anti-SSB) ANA

Question 27

Pt presents with left LE pain. Sprained her ankle 1 month ago. Now has increased swelling, burning pain, pain with light palpation and x-ray shows patchy areas of osteopenia

Answer 27

Complex regional pain syndrome

Question 28

Pt with DM develops increased foot and ankle pain. Both foot and ankle are deformed. X-ray shows bone loss, large osteophytes, several extraarticular bone fragments

Answer 28

Charcot joint due to diabetic neuropathy

Question 29

Displaced supracondylar fractures of the humerus are at risk for damaging

Answer 29

Median nerve and brachial artery

Question 30

Sensation of the foot

Answer 30

``` Dorsal surface: superficial peroneal 1st web space: deep peroneal Medial: saphenous Lateral: sural Sole: tibial ```

Question 31

MOA of dantrolene

Answer 31

inhibiting calcium ion release from the sarcoplasmic reticulum, and thereby interfering with muscular contraction

Question 32

Labs for polymyositis

Answer 32

increased creatine kinase, increased aldolase, anti-Jo-1 antibodies - 50-70 year old lady with progressive weakness

Question 33

saddle nose deformity and bilateral auricular inflammation who may have been treated on multiple occasions with antibiotics

Answer 33

Relapsing polychondritis | - cartilaginous inflammation

Question 34

muscle that opens the vocal cords

Answer 34

posterior cricoarytenoid muscle

Question 35

29 year old female with knee pain and a bone lesion in the epiphysis. Has a soap bubble appearance

Answer 35

Giant cell tumor (osteoclastoma)

Question 36

Anterior shoulder dislocation *ext rotation and abduction) damages the

Answer 36

axillary nerve causing weakness in abduction (deltoid)

Question 37

Muscle affected in lateral epicondylitis (tennis elbow)

Answer 37

extensor carpi radialis brevis

Question 38

Muscle affected in medial epicondylitis (golfer's elbow)

Answer 38

flexor carpi radialis

Question 39

Osteosarcoma mets to

Answer 39

lungs - get a CT lung

Question 40

Tx of acute gout in CKD 3 pt

Answer 40

steroids

Question 41

16 year old with small round lucency on distal femur. Leg pain is worse at night and unrelated to activity

Answer 41

osteoid osteoma | - benign, bone-forming tumor usually in teenage boys

Question 42

86 year old woman with history of right leg pain. x-ray of skull reveals areas of bone resorbtion and sclerosis. x-ray of the leg reveals cortical thickening with mild bowing.

Answer 42

Paget disease of bone - normal calcium and phosphorus - elevated alk phos and PINP/urine hydroxyproline - giant cell tumor or osteosarcoma - tx: bisphosphonates

Question 43

SE of hydroxychloroquine (DMARD for lupus)

Answer 43

retinopathy

Question 44

tx of hepatic encephalopathy (flapping tremor)

Answer 44

- fluids and abx | - decrease blood ammonia concentration with lactulose and rifaximin

Question 45

70 year old male with pain and stiffness of neck, shoulders and hips. ESR of 85 and normocytic anemia

Answer 45

polymyalgia rheumatica | - tx: glucocorticoids

Question 46

features of SLE, systemic sclerosis, and/or polymyositis with anti-U1 RNP antibodies

Answer 46

Mixed connective tissue disease

Question 47

patient presents with white tongue, drooling, dysphasia with severe pain after ingesting an unknown substance

Answer 47

caustic ingestion

Question 48

complex regional pain syndrome

Answer 48

Weakness of the affected side, autonomic disturbances (altered skin temperature, altered skin blood flow causing cyanosis or mottling, or increased sweating), and trophic changes (reduced hair or nail growth, skin atrophy)