Step 1 Express 2018-Musculoskeletal Skin and Connective Tissue

First Aid Express 2018 workbook: MUSCULOSKELETAL

page 1

Mus uscu culo losk ske eleta letal, l, Ski Skin, n, and Con onnecti nective ve Tis issu sue e Questions ANATOMY AN ATOMY AND PHYSIOLOGY PHYSIOL OGY 1.

A 36-year-old man presents with difficulty abducting abducting his left arm arm above 15 degrees. His left shoulder appears flattened and asymmetric to his right arm. What sensory deficit is most likely? Which nerve is likely involved? (p 437) ___________________________________________________________

______________________________________________________________________________ 2.

A 24-year-old 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? Which nerve is most likely affected? (p 437) _______________ ______________________________________________________________________________

3.

A 20-year-old 20-year-old man presents with with a fracture of his medial epicondyle. When asked to flex his wrist, wrist, his hand is radially deviated. Why is this deviation happening? (p 437) ______________________ ______________________________________________________________________________

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page 2 4.

In the chart below, describe the characteristics of brachial plexus lesions. (pp 436-439) Lesion

Injured Nerve(s)

Presentation

Affected Muscle(s)

Ape hand

Erb palsy

Klumpke palsy

Median claw

Ulnar claw

5.

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 440)

6.

What ligaments are torn in the unhappy triad? (p 441) ___________________________________

7.

An injury to which ligament represents the most common type of ankle sprain? (p 441) ___________ ______________________________________________________________________________

8.

A 30-year-old man comes to the physician after being tackled below the knee in a football game with his friends. The patient is using a steppage gait. W hat is the most likely diagnosis, and what sensory deficits are likely? (p 442) _________________________________________________________ ______________________________________________________________________________

9.

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 he’s not sure what he did to it. What type of injury is most likely? (p 442) _________________________________________________ ______________________________________________________________________________

10.

A 22-year-old woman has difficulty climbing stairs. What type of mechanical injury would pre-dispose her to this problem? (p 443) _______________________________________________________ ______________________________________________________________________________



11.

page 3

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 442) _________________________________________________________________________

12.

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 442) _____________________________

______________________________________________________________________________ 13.

What causes medial tibial stress syndrome (shin splints)? (p 444) __________________________ ______________________________________________________________________________

14.

How is developmental dysplasia of the hip diagnosed in newborns? (p 444) __________________ ______________________________________________________________________________

15.

What artery is paired with the long thoracic nerve? (p 445) _ ______________________________

16.

What nerve and artery are located in the popliteal fossa? (p 445) __________________________

17.

__________ (Type 1/Type 2) muscle is associated with increased oxidative phosphorylation, whereas ___________ (type 1/type 2) muscle is associated with increased anaerobic glycolysis. (p 447)

18.

How do osteoblasts build bone? How do osteoclasts dissolve bone? (p 448) ___________________ ______________________________________________________________________________

19.

What are the effects of PTH on bone? (p 448) _________________________________________



page 4

PATHOLOGY 20.

Indicate whether the lab findings in the chart below are elevated, decreased, or normal. (p 451)

Al kal in e Phosphatase

Condition

Phosp hate

PTH

Serum Ca2+

Osteitis fibrosa cystica, primary hyperparathyroidism Osteitis fibrosa cystica, secondary hyperparathyroidism Osteomalacia Osteopetrosis Osteoporosis Paget disease 21.

What disease is associated with increased risk of osteosarcoma? (p 452) ____________________



page 5

22.

In the image below, identify the type of tumor according to its location in the bone. (p 453)

23.

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 454) ______ ______________________________________________________________________________

24.

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 454) _______________ ______________________________________________________________________________ ______________________________________________________________________________



page 6 25.

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 455) ______________________ ______________________________________________________________________________

26.

In the chart below, compare and contrast gout and calcium pyrophosphate deposition disease (previously called pseudogout). (p 455) Gout

Pseudogout

Sexual predilection Joint most often affected Crystal composition Crystal shape Birefringence Treatment 27.

An 11-year-old boy presents with pain in his knees and ankles, along with daily spiking fevers, a salmon-pink macular rash on his trunk, and uveitis. What is a likely diagnosis? (p 456) ____________ ______________________________________________________________________________

28.

What are the four symptoms of Sjögren syndrome? What are the two common autoantibodies found in these patients? (p 456) _________________________________________________________ ______________________________________________________________________________

29.

List three causes of septic arthritis. (p 456) _____________________________________________ ______________________________________________________________________________

30.

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 457) __________ ______________________________________________________________________________

31.

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 c hlamydia. Tests are also negative for rheumatoid factor. What is the most likely diagnosis? (p 457) _____________________________



32.

page 7

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 p ast several days. Her cheeks are slightl y 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 458) _______________________________ ______________________________________________________________________________

33.

In Lambert-Eaton myasthenic syndrome, symptoms __________ (improve/worsen) with muscle use. In myasthenia gravis, symptoms ______________ (improve/worsen) with muscle use. (p 459)

34.

Acetylcholinesterase inhibition __________ (does/does not) reverse symptoms in Lambert-Eaton myasthenic syndrome and __________ (does/does not) reverse symptoms in myasthenia gravis (p 459)

35.

What does CREST stand for, and with what antibody is it associated? (p 460) ________________ ______________________________________________________________________________ ______________________________________________________________________________



page 8

DERMATOLOGY 36.

Identify the structures on the image below. (p 461)

37.

Match the dermatologic term with its definition. (pp 462, 464) _____ A. Blister containing pus

1. Acantholysis

_____ B. Dried exudates from vesicle, bulla, or pustule

2. Acanthosis

_____ C. Elevated skin lesion <1 cm

3. Bulla

_____ D. Epidermal hyperplasia

4. Crust

_____ E. Flat discoloration <1 cm

5. Dermatitis

_____ F. Inflammation of skin

6. Macule

_____ G. Large, fluid-filled blister

7. Papule

_____ H. Macule >1 cm

8. Patch

_____ I. Papule >1 cm

9. Plaque

_____ J. Separation of epidermal cells

10. Pustule

_____ K. Small, fluid-filled blister

11. Vesicle

_____ L. Transient smooth papule or plaque

12. Wheal



page 9

38.

With what disease is seborrheic dermatitis associated? (p 463) _____________________________

39.

Match the skin disorder with its defining characteristic(s). (pp 463-468) _____ A. Areas of complete depigmentation

1. Acanthosis nigricans

_____ B. Associated with insulin resistance

2. Actinic keratosis

_____ C. Auspitz sign

3. Albinism

_____ D. Genital warts

4. Bullous pemphigoid

_____ E. Honey-colored crusts

5. Cellulitis

_____ F. Horn cysts

6. Condyloma acuminatum

_____ G. Infection of dermis and subcutaneous tissues

7. Eczema

_____ H. Infection of stratum granulosum

8. Erythema multiforme

_____ I. Intensely pruritic wheals

9. Hives

_____ J. Nikolsky sign negative

10. Impetigo

_____ K. Normal melanocyte number, ↓ melanin

11. Pemphigus vulgaris

_____ L. Potentially fatal

12. Psoriasis

_____ M. Premalignant lesion

13. Seborrheic keratosis

_____ N. Target lesion

14. Staphylococcal scalded skin

_____ O. Pruritic eruptions in antecubital fossa

15. Vitiligo

40.

With which GI disease is dermatitis herpetiformis associated? (p 467) _______________________

41.

In the chart below, compare and contrast the characteristics of bullous pemphigoid and pemphigus vulgaris. (p 467) Characteristi c

Bullo us Pemphigoid

Pemphig us Vulgaris

Pattern of immunofluorescence Location of blisters Oral involvement Nikolsky sign 42.

Second-degree burns occur ___________ (with/without) pain and heal _________ (with/without) scarring, while third-degree burns occur ___________ (with/without) pain and heal _________ (with/without) scarring. (p 468)

43.

Actinic keratosis is a precursor to _________________ (melanoma/squamous cell carcinoma), while dysplastic nevus is a precursor to ___________________ (melanoma/squamous cell carcinoma). (p 469)

44.

What is the most common type of skin cancer? (p 469) __________________________________



page 10 45.

Name a tumor marker of melanoma. (p 469) __________________________________________

46.

What type of skin cancer may benefit from vemurafenib? (p 469) __________________________

PHARMACOLOGY 47.

In the arachidonic acid pathway (p 470): A.

Phospholipase A2 facilitates the conversion of _____________ into ____________________

______________________________________________________________________________ B.

Lipoxygenase facilitates the conversion of _____________ into _______________________

______________________________________________________________________________ C.

Cyclooxygenase facilitates the conversion of _____________ into _____________________

______________________________________________________________________________ 48.

What is the mechanism of action of acetaminophen? (p 470) _____________________________

49.

What is the mechanism of action of aspirin? (p 471) ____________________________________

50.

What is the mechanism of action of NSAIDs? (p 471) ___________________________________

51.

Why should a person who takes NSAIDs consider switching to a COX-2 inhibitor? What is the risk of COX-2 inhibitors? (p 471) _________________________________________________________ ______________________________________________________________________________

52.

What is the mechanism of action of bisphosphonates? (p 471) ____________________________ ______________________________________________________________________________



page 11

An swers ANATOMY AND PHYSIOLOGY 1.

Axillary nerve damage leads to loss of sensation over the shoulder.

2.

Radial nerve damage leads to loss of sensation over the posterior arm, dorsal hand, and thumb.

3.

This patient likely injured his ulnar nerve. Therefore, he has lost function of the flexors on the ulnar portion of his wrist, but 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.

4. Lesion

Injured Nerve(s)

Presentation

Affected Muscle(s)

Recurrent branch, median nerve

Unopposable thumb

Opponens pollicis

Erb palsy

Upper trunk, C5C6 nerve roots

Limb hangs at side, medially rotated; forearm pronated

Abductors, lateral rotators, and biceps are paralyzed

Klumpke palsy

Lower trunk; C8T1 nerve roots

MCP extended; DIP/PIP flexed

All lumbricals

Median claw

Distal median nerve

Second/third fingers clawed

Lateral lumbricals

Distal ulnar nerve

“Pope’s blessing” when asked to extend fingers

Medial lumbricals

Ape hand

Ulnar claw

5.

MCL; ACL.

6.

Medial meniscus, ACL, MCL.

7.

Anterior talofibular ligament.

8.

With injury to the common peroneal nerve, sensory deficit would occur at the anterolateral leg and dorsal aspect of the foot.

9. 10.

Anterior hip dislocation, causing damage to the obturator nerve. Posterior hip dislocation, causing injury to the inferior gluteal nerve.



page 12 11.

Pelvic fracture, causing damage to the femoral nerve.

12.

Difficulty with foot inversion and plantar/toe flexion due to damage to the tibial nerve.

13.

Bone resorption that outpaces bone formation in tibial cortex.

14.

Developmental dysplasia of the hip is tested with Ortolani and Barlow maneuvers, as the manipulation of newborn hip reveals a “clunk.” Diagnosis is confirmed via an u ltrasound. An X-ray would not be used, as cartilage is not ossiffed before the ne wborn is 4-6 months old.

15.

Lateral thoracic artery.

16.

The tibial nerve and popliteal artery.

17.

Type 1; type 2.

18.

They catalyze mineralization by secreting collagen; they dissolve bone by secreting acid and collagenases.

19.

Catabolic effects, including osteitis fibrosa cystica.

PATHOLOGY 20. Al kal in e Phosphatase

Phosp hate

↑

↓

↑

↑

↑

↑

↑

↓

↑

↓

↑

↓

Osteopetrosis

Normal

Normal

Normal

Normal/↓

Osteoporosis

Normal

Normal

Normal

Normal

Paget disease

↑

Normal

Normal

Normal

Condition

Osteitis fibrosa cystica, primary hyperparathyroidism Osteitis fibrosa cystica, secondary hyperparathyroidism Osteomalacia

21.

Serum Ca2+

PTH

Paget disease.



page 13

22.

23.

Osteoarthritis.

24.

The patient has rheumatoid arthritis, which is associated with a type III hypersensitivity (immune complex) reaction.

25.

This patient has gout; treat with colchicine if NSAIDs are contraindicated.

26. Gout

Pseudogout

Sexual predilection

Men

None

Joint most often affected

MTP joint of big toe

Knee

Crystal composition

Monosodium urate

Calcium pyrophosphate

Crystal shape

Needle

Rhomboid

Birefringence Treatment

Negative

Weakly positive NSAIDs, colchicine, glucocorticoids

NSAIDs; if NSAIDs contraindicated, colchicine

27.

Systemic juvenile idiopathic arthritis.

28.

Inflammatory joint pain, keratoconjunctivitis sicca, xerostomia, and bilateral parotid enlargement. SS-A (Ro) and SS-B (La).



page 14 29.

Staphylococcus aureus, Streptococcus , and Neisseria gonorrhoeae.

30.

Ankylosing spondylitis.

31.

Reactive arthritis (Reiter syndrome).

32.

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.

33.

Improve; worsen.

34.

Does not; does.

35.

Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Associated with anticentromere antibody.



page 15

DERMATOLOGY 36.

37.

A-10, B-4, C-7, D-2, E-6, F-5, G-3, H-8, I-9, J-1, K-11, L-12.

38.

Parkinson disease.

39.

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

40.

Celiac disease.

41. Characteristi c

Bullo us Pemphigoid

Pemphig us Vulgaris

Pattern of immunofluorescence

Linear

Reticular or lacelike

Location of blisters

Subepidermal

Intraepidermal

Oral involvement

No

Yes

Nikolsky sign

Negative

Positive

42.

With, without; without, with.

43.

Squamous cell carcinoma; melanoma.

44.

Basal cell carcinoma.



page 16 45.

S-100 tumor marker.

46.

Melanoma patients with unresectable or metastatic disease with BRAF V600E mutation.

PHARMACOLOGY 47.

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).

48.

Acetaminophen causes reversible inhibition of cyclooxygenase.

49.

Aspirin causes irreversible inhibition of cyclooxygenase.

50.

NSAIDs cause reversible inhibition of cyclooxygenase.

51.

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 ri sk of thrombosis.

52.

Bind hydroxyapatite in bone to inhibit osteoclast activity.


Step 1 Express 2018-Musculoskeletal Skin and Connective Tissue

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