First Aid for the USMLE Step 1 2011 EXPRESS workbook

page 133

Musculoskeletal and Connective Tissue

Questions ANATOMY AND PHYSIOLOGY
1. Identify the structures on the image below. (p. 370)

2.

In a case of possible knee injury, abnormal passive abduction indicates a torn __________ (ACL/MCL), and a positive anterior drawer sign indicates a torn __________ (ACL/MCL) (p. 370) A 36-year-old man presents with difficulty abducting his left arm. His left shoulder appears flattened and asymmetric to his right arm. What sensory deficit is most likely? (p. 372) _________________ ______________________________________________________________________________

3.

4.

A 24-year-old woman was in a car accident and suffered a fracture of the midshaft of her humerus. When asked to hold up her arm, her wrist could not be extended and appeared floppy. What sensory deficits is she likely experiencing? (p. 372) _____________________________________

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5.

A 20-year-old man presents with a fracture of his medial epicondyle. When asked to flex his wrist, his hand is radially deviated. Why is this deviation happening? (p. 372) ______________________ ______________________________________________________________________________

6.

In the chart below, describe the characteristics of brachial plexus lesions. (pp. 373-375) Lesion Ape hand Erb-Duchenne palsy Injured Nerve(s) Presentation Affected Muscle(s)

Klumpkes palsy

Median claw

Ulnar claw

7.

A 30-year-old man comes to the physician after being tackled in a football game with his friends. He says he was tackled below the knee. The patient is using a steppage gait. What is the most likely diagnosis, and what sensory deficits are likely? (p. 376) _____________________________ ______________________________________________________________________________

8.

A 42-year-old man presents to the clinic with difficulty adducting his thigh. He had been skiing the previous week. He mentions that his thigh is hurting and that hes not sure what he did to it. What type of injury is most likely? (p. 376) _________________________________________________ ______________________________________________________________________________

9.

A 22-year-old woman has difficulty climbing stairs. What type of mechanical injury would predispose her to this problem? (p. 376) ______________________________________________ ______________________________________________________________________________

10.

A 22-year-old man is brought to the emergency department after a motor vehicle accident. His blood alcohol level is 0.20. He had not been wearing a seatbelt. Physical examination reveals he has difficulty flexing his thigh and substantial difficulty extending his leg. What injury is most likely? (p. 376) ________________________________________________________________________ A 23-year-old woman who was a passenger in a motor vehicle accident is brought to the emergency department. She had been wearing a seat belt. Physical examination reveals trauma to the lateral aspect of the knee. What motor deficit is most likely? (p. 376) ____________________ ______________________________________________________________________________

11.

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PATHOLOGY
12. Indicate whether the lab findings in the chart below are elevated, decreased, or normal. (pp. 379380) Condition Osteitis fibrosa cystica Osteomalacia Osteopetrosis Osteoporosis Pagets disease 13. 14. What are the symptoms of a vertebral crush fracture? (p. 379) _____________________________ In the image below, identify the type of tumor according to its location in the bone. (p. 381) Alkaline Phosphatase Phosphate PTH Serum Ca
2+

15.

A 64-year-old man with no significant medical history has had increasing back pain and right hip pain for the past decade. The pain is worse at the end of the day. Physical examination shows enlargement of the distal interphalangeal joints. What is the most likely diagnosis? (p. 382) ______ ______________________________________________________________________________

16.

A 36-year old woman presents to the clinic with a new complaint of fatigue of several months duration. She also reports stiffness in both hands in the morning, which decreases after showering. Physical examination reveals a low-grade fever, and subcutaneous nodules are palpated along her forearms bilaterally. What type of hypersensitivity reaction is occurring? (p. 383) _______________ What are the three symptoms of Sjgrens syndrome? (p. 383) ____________________________ ______________________________________________________________________________

17.

18.

A 50-year-old obese man comes to the emergency room at 3 a.m. because of a painful great toe. The pain began 5 hours earlier, after he walked home from a bar where he had steak and beer. He is allergic to NSAIDs. What is the most appropriate treatment? (p. 384) ______________________

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19.

In the chart below, compare and contrast gout vs. pseudogout. (p. 384) Gout Sexual predilection Joint most often affected Crystal composition Crystal shape Birefringence Treatment Pseudogout

20. 21.

List three causes of septic arthritis. (p. 384) ____________________________________________ A 27-year-old man presents with a 6-month history of low back pain and stiffness that awakens him during the night and is worse in the morning. He has tenderness over his sacroiliac joints bilaterally and decreased motion of his lumbar spine. What is the most likely diagnosis? (p. 385) _________ ______________________________________________________________________________

22.

A 31-year-old man comes to the emergency room because his eyes have been red and itchy for the past 8 hours. For the past month, he has experienced pain during urination and diffuse joint pain; however, 3 weeks earlier he tested negatively for gonorrhea and chlamydia. Tests are also negative for rheumatoid factor. What is the most likely diagnosis? (p. 385) ___________________ A 17-year-old girl complains of fever and a painful swollen left elbow. In addition, she has had pain in her right knee for the past several days. Her cheeks are slightly red but not tender. Her VDRL test result is positive. She is shocked to learn that she has syphilis because she has no sexual history. What is the most likely explanation for this finding? (p. 385) _________________________ ______________________________________________________________________________

23.

24.

In Lambert-Eaton syndrome, symptoms __________ (improve/worsen) with muscle use. In myasthenia gravis, symptoms __________ (improve/worsen) with muscle use. (p. 386) Acetylcholinesterase inhibition __________ (does/does not) reverse symptoms in Lambert-Eaton syndrome and __________ (does/does not) reverse symptoms in myasthenia gravis. (p. 386) What does CREST stand for? (p. 387) ________________________________________________ Match the dermatologic term with its definition. (p. 387) _____ A. Blister containing pus _____ B. Dried exudates from vesicle, bulla, or pustule _____ C. Elevated skin lesion <1 cm _____ D. Epidermal hyperplasia _____ E. Flat discoloration <1 cm _____ F. Inflammation of skin _____ G. Irregular, raised lesion after scar _____ H. Large, fluid-filled blister _____ I. Macule >1 cm _____ J. Papule >1 cm _____ K. Separation of epidermal cells _____ L. Small, fluid-filled blister _____ M. Transient vesicle Copyright 2011 by MedIQ Learning, LLC 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Acantholysis Acanthosis Bulla Crust Dermatitis Keloid Macule Papule Patch Plaque Pustule Vesicle Wheal

25.

26. 27.

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28.

Match the skin disorder with its defining characteristic(s). (pp. 388-389) _____ A. Associated with hyperinsulinemia _____ B. Auspitz sign _____ C. Bulls-eye lesion _____ D. Decrease in melanocytes _____ E. Genital warts _____ F. Honey-colored crusts _____ G. Horn cysts _____ H. Infection of dermis and subcutaneous tissues _____ I. Infection of stratum granulosum _____ J. Intensely pruritic wheals _____ K. Nikolskys sign negative _____ L. Nikolskys sign positive _____ M. Normal melanocyte number, melanin _____ N. Normal melanocyte number, melanin _____ O. Premalignant lesion 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Acanthosis nigricans Actinic keratosis Albinism Bullous pemphigoid Cellulitis Condylomata acuminata Erythema multiforme Freckle Hives Impetigo Pemphigus vulgaris Psoriasis Seborrheic keratosis Staphylococcal scalded skin Vitiligo

29.

In the chart below, compare and contrast the characteristics of bullous pemphigoid vs. pemphigus vulgaris. (pp. 388-389) Characteristic Pattern of immunofluorescence Location of blisters Oral involvement Nikolskys sign Bullous Pemphigoid Pemphigus Vulgaris

30.

Actinic keratosis is a precursor to _______________ (melanoma/squamous cell carcinoma), while dysplastic nevus is a precursor to _______________ (melanoma/squamous cell carcinoma). (p. 390)

PHARMACOLOGY
31. In the arachidonic acid pathway (p. 391): A. B. C. 32. 33. 34. Phospholipase A2 facilitates the conversion of __________ into _______________________. Lipoxygenase facilitates the conversion of __________ into __________________________. Cyclooxygenase facilitates the conversion of __________ into ________________________.

What is the mechanism of action of aspirin? (p. 391) ____________________________________ What is the mechanism of action of NSAIDs? (p. 391) ___________________________________ Why should a person who takes NSAIDs consider switching to a COX-2 inhibitor? What is the risk of COX-2 inhibitors? (pp. 391-392) __________________________________________________ ______________________________________________________________________________

35. 36.

What is the mechanism of action of acetaminophen? (p. 392) _____________________________ Which TNF- inhibitor can be used to treat Crohns disease? (p. 393) _______________________

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Answers ANATOMY AND PHYSIOLOGY

1.

2. 3. 4. 5.

MCL; ACL. Axillary nerve damage leads to loss of sensation over the shoulder. Radial nerve damage leads to loss of sensation over the posterior arm, dorsal hand, and thumb. This patient likely injured his ulnar nerve. Therefore, he has lost function of the flexors on the ulnar portion of his wrist, and has retained the flexors innervated by the median nerve, which are on the radial aspect of the hand. Hence, when these flexors flex, they cause radial deviation.

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6. Lesion Ape hand Erb-Duchenne palsy Injured Nerve(s) Proximal median nerve Upper trunk, C5-6 nerve roots Lower trunk; C8T1 nerve roots Distal median nerve Presentation Unopposable thumb Limb hangs at side, medially rotated; forearm pronated MCP extended; DIP/PIP flexed Second/third fingers clawed Popes blessing when asked to extend fingers Affected Muscle(s) Opponens pollicis Abductors, lateral rotators, and biceps are paralyzed All lumbricals

Klumpkes palsy

Median claw

Lateral lumbricals

Ulnar claw

Distal ulnar nerve

Medial lumbricals

7.

With injury to the common peroneal nerve, sensory deficit would occur at the anterolateral leg and dorsal aspect of the foot. Anterior hip dislocation causing damage to the obturator nerve. Posterior hip dislocation causing injury to the inferior gluteal nerve. Pelvic fracture causing damage to the femoral nerve. Difficulty with foot inversion and plantar/toe flexion due to damage to the tibial nerve.

8. 9. 10. 11.

PATHOLOGY
12. Condition Osteitis fibrosa cystica Osteomalacia Osteopetrosis Osteoporosis Pagets disease 13. Alkaline Phosphatase normal normal normal Phosphate normal normal normal PTH normal normal normal Serum Ca normal normal normal
2+

Acute back pain, loss of height, and kyphosis.

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14.

15. 16.

Osteoarthritis. The patient has rheumatoid arthritis, which is associated with a type III hypersensitivity (immune complex) reaction. Xerophthalmia, xerostomia, and arthritis. This patient has gout; treat with colchicine if NSAIDs are contraindicated.

17. 18. 19.

Gout Sexual predilection Joint most often affected Crystal composition Crystal shape Birefringence Treatment Men MTP joint of big toe Monosodium urate Needle Negative NSAIDs; if NSAIDs contraindicated, colchicines

Pseudogout None Knee Calcium pyrophosphate Rhomboid Weakly positive None

20. 21. 22. 23.

Staphylococcus aureus, Streptococcus, and Neisseria gonorrhoeae. Ankylosing spondylitis. Reiters syndrome. She has lupus, the great imitator! VDRL results are false-positive due to cross-reaction between antiphospholipid antibodies and the cardiolipin used in the VDRL. Improve; worsen. Does not; does.

24. 25.

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26. 27. 28. 29.

Calcinosis, Raynauds phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. A-11, B-4, C-8, D-2, E-7, F-5, G-6, H-3, I-9, J-10, K-1, L-12, M-13. A-1, B-12, C-7, D-15, E-6, F-10, G-13, H-5, I-14, J-9, K-4, L-11, M-3, N-8, O-2.

Characteristic Pattern of immunofluorescence Location of blisters Oral involvement Nikolskys sign 30.

Bullous Pemphigoid Linear Subepidermal No Negative

Pemphigus Vulgaris Reticular or lacelike Intraepidermal Yes Positive

Squamous cell carcinoma; melanoma.

PHARMACOLOGY
31. A = Phospholipase A2 facilitates the conversion of membrane lipids into arachidonic acid. B = Lipoxygenase facilitates the conversion of arachidonic acid into hydroperoxides (which then get converted into leukotrienes). C = Cyclooxygenase facilitates the conversion of arachidonic acid into endoperoxides (which then get converted into prostacyclin, prostaglandins, and thromboxane). Aspirin causes irreversible inhibition of cyclooxygenase. NSAIDs cause reversible inhibition of cyclooxygenase. Many people who take NSAIDs suffer from gastrointestinal distress and ulcer formation, which can be avoided by using COX-2 inhibitors. COX-2 inhibitors do, however, increase the risk of thrombosis. Acetaminophen causes reversible inhibition of cyclooxygenase. Infliximab.

32. 33. 34.

35. 36.

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Notes
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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