All right, so fifty high old MSK questions bunch of demonics in there to
help you remember the stuff that you need to know for your exam. Thank
you as always for the support the really nice comments. I truly do appreciate
it. If you want to check out the YouTube channel if you want some
visuals to go along with the audio, let's cram the pants on YouTube.
All right, let's go ahead and get started. Question one, forty two
year old female presents to the office today complaining of a burning pain in the
ball of her foot radiating to the third and fourth toe. She states the
burning sensation is worse after a long day of standing on her feet, especially
when she wears high heels. Physical examination reveals tenderness in the plantar aspect of
the distal foot over the third intermeda tarsal space. What is the most likely
diagnosis in this patient? So that is going to be a morton neuroma,
So mort neuroma, which is a compressive neuropathy. When it comes to morton
neuroma, there's three things that you need to know for the exam that will
be in the vignette. It will be a woman. They will likely describe
a tight fitting shoe, often high heels, as overpronation of the foot can
cause this condition and the paristhesias, the numbness burning is set that these patients
feel is going to be most common in the third intermetatarsal space. The way
that I used to remember these three key things for the vignette is by focusing
on the M in more neuroma. If you turn an M on its side,
it's a three that helps remember the third intermetatarsal space is the most common
area to be affected. If you turn the M upside down, it's a
W that helps you remember women are approximately five times more likely than males to
develop more neuroma. And then the M it also looks like the spike of
two heels. Las it does to me and that helps me remember this is
often caused from tight fitting shoes or high heels from the overpronation of the foot.
So remember from more neuroma third intermetatarsal space way more common in women.
And then the M tight fitting shoes like high heels looks like the spike of
high heels, all right. Question two. A sixty three year old female
presents the office to review the results of her bone density test. She has
a history of vertebral fractures, and her recent bone density test reveals a T
score of negative two point eight. The treating physician decides to start the patient
on reloxifen. The what is likely positive in this page as pathematical history that
would influence the decision to start her on reloxofen rather than alternative osteoporosis agents.
So that is going to be breast cancer. So reloxofin orloxophene is a selective
estrogen receptor modulator, and while it does not work as well as bisphosphonates,
the unique thing about this drug is that, in addition to treating osteoporosis,
it also reduces the risk of breast cancer, so it's usually reserved for osteoporosis
patients when there's also a need for breast cancer prophylaxis. It's really the only
thing you need to know for this med So how can you remember that,
Well, there's a much more commonly used med for breast cancer prophylaxis slash treatment
they probably have heard of in the same class, and that's tamoxifen, tomoxifen
orloxofin, so it sounds very similar. So remember reloxofin is in the same
class as tamoxifen, and in addition to training osteoporosis, it can also be
used for breast cancer prophylaxis. Question three. Forty two year old female presents
to the office complaining of heartburn, small white lumps on her fingers as well
as a tight feeling in her hands that makes it difficult to make a fist.
On physical exam, clangiectasias on the palms and face. Labs are positive
for both anti nuclear antibodies as well as anti centromere antibodies. What diagnosis should
be suspected in this patient? So that is going to be limited systemic sclerosis
aka Crest syndrome. So this patient has a very classic presentation and has a
number of the manifestations of crests syndrome. Remember CREST stands for calcinosis, cutis
ray nood phenomenon, soft geodysmotility, sclerodactylly, and talangiectasia. So we see
the calcinosis cutas those are those small calcium deposits in her hands. She has
heartburn, which is from the esophageal dysmotility disorder. Clangiectasias as well as the
tightening of the skin of the hands which can progress to sclerodactyly where we have
this claw like appearance of the hands. So this is classic limited systemic sclerosis
aka Crest syndrome, which we know will generally have a positive ANA and most
importantly a positive anti centromere antibody test which I used to remember as anti crestomere
instead to help me remember this antibody is positive in Cress syndrome. So if
you see a positive anti centromere instead think of anti crustomere and think of crest
syndrome which is associated with limited systemic sclerosis. Question four. A sixty three
year old female presents to her physician's office complaining of pain and stiffness in her
shoulders, hip, and neck. She states the symptoms are very severe in
the morning, sometimes limiting her activity, and as the day goes on there
is moderate improvement. Physical exam reveals normal muscle strength and slightly reduce range of
motion. Labs reveal elevated erythrocyte sedimentation rate and C reactive protein cierum rheumatoid factor
as well as creating kindase are normal, the patient is diagnosed with polymylogio romatica
and started on cortico steroids. Clinical assessment for the presence of what other associated
condition should also be considered in this patient. So that is going to be
giant cell arduritis. So remember giant cell arditis is associated with polymyogi romatica.
You have to know that anywhere from five to thirty percent of patients with PMR
will have giant cell ardoritis. This always shows up on exam quest and you
don't want to miss this diagnosis in real life because it can lead to blindness
if it's not treated. So if you make the diagnosis of PMR and a
patient, make sure you're asking the patient about headaches, jaw claudication, transi
A vision laws to make sure they don't need a work up for giant cell
So the way that I used to remember that Paul E. Myalger romatica is
associated with giant cell arturitis is by instead of remembering it as Paul E myalgio
romatica, instead remember it as Paul B. Myalgia romatica Paul B as in
Paul Bunny and the Giant from those kids books. And then you'll always remember
this is associated with giant cell arderitis. Question five, What is the most
common type of osteoporotic fracture? So that is going to be vertebral fractures.
So vertebral fractures are the most common type of osteoporotic fracture. These types of
fractures can sometimes be a symptomatics or remember to assess for loss of height or
kyphosis, as these are sometimes the only indicator of a vertebral compression fracture in
an osteoporotic patient. Question six. Sixty two year old Mail presents the emergency
department after being involved in a motor vehicle accident, is complaining of severe pain
in his right hip. On physical exam, you know what. The right
leg is internally rotated and adducted. X ray reveal a dislocation of the right
hip. What type of dislocation did this patient likely suffer? Remember, his
leg is internally rotated and adducted, so that is going to be a posterior
hip dislocation. So why a posterior hip dislocation? First? Posterior Hip dislocations
are the most common type of hip dislocation, counting for almost ninety percent of
all types of hip dislocations. And then the second reason why this is likely
a posterior dislocation is because on physical exam, the patient's leg is internally rotated
and adducted, which is the classic presentation for posterior dislocations where anterior are classically
externally rotated and abducted. Question seven. Forty six year old Mail presents to
the office complaining of severe lower back pain radiating into both legs, as well
as numbness in his inner thighs and buttocks that started after moving some furniture.
He also reports difficulty with urination. Physical exam reveals lower extremity, weakness,
saddle parastesia, and loss of rectal tone. What is the diagnostic test of
choice for the likely diagnosis in this patient? So that is going to be
an MRI. So this patient very likely has called a quina syndrome. They
have the classic clinical manifestations lower back pain radiating to the legs, saddle parastesia,
urinary in continence, loss of rectal tone. All of these areas are
affected because cata quina syndrome is severe compression of multiple lumbo sacral nerve roots that
innervate these regions. So when cataquina syndrome is suspected, you're going to order
an MRI. Generally, this is with contrast, and this is going to
be your diagnostic test of choice. Really in any situation where there's suspicion for
a localized process within the spinal cord, and RI is going to be your
test of choice. All right. Question eight. Anterior dislocation aka forward slippage
of one vertebral body with respect to the one beneath it is known as so
that is going to be spondulolis thesis. So forward slipping of a vertebral body
relative to an adjacent inferior vertebral body. That's sponded Lo list thesis. Thirty
to fifty percent of the time. This is a consequent of spondalo lisis.
Anyways, how do you remember spondal lolist thesis is forward slippage of a vertebral
body. Well, I have this little trick that worked for me. Maybe
it'll work for you, maybe not. But when I saw spond lo list
thesis at the end of the word, it has list thesis in it,
like list your thesis statement. So when I see sponded lost thesis, I
think of the sentence, list your thesis statement on the slip of paper and
pass it forward, like you're in class and your teacher asks you to pass
the your thesis statement forward. So when you see spondal lost thesis right away,
think list thesis and then what are you going to do with your thesis.
You're gonna list it on a slip of paper and pass it forward.
And that slip of paper being passed forward helps you remember the vertebral body slips
forward and spond A low list thesis a little weird, but it definitely worked
for me. Question nine. Thirty two year old female presents to the office
complaining of fatigue, weakness, fever, and a rash for the past two
months. On physical exam, you note are a thema over the cheeks and
nose bearing the nasalabial folds. You suspect lupus and order and anti nuclear antibody
which comes back positive. Which additional lab test listed below would be most appropriate
to order next to assist in making the diagnosis answer A anticentromere antibody answer B
ant tissue transglutaminase antibody C anti smith antibody, D anti cyclic sutrilinated peptide antibody
again, A anticentromere b ant tissue transglutaminase C anti Smith, d anti cyclic
cutrilinated peptide. So the answer is going to be C anti Smith antibody,
all right, So let's talk about why it's not the other ones. First,
A anti centrimere anibodies. As we discuss before, this is most commonly
used in the diagnosis of limitous systemic sclerosis subtype aka Crests syndrome. B anti
tissue transglutaminase body that's used for the diagnosis of celiac disease. And finally,
anti cyclic cutrilinated peptide anibody or anti CCP. It's most commonly used for diagnosis
of rheumatoid us right, And while it can be elevated and lupus, it
is in no way the best lab tests listed here. The best lab to
order out of these four is by far the anti Smith antibodies. Anti Smith
antibodies as well as anti double stranded DNA are the most specific lab tests you
can use for lupus, so those are really the two that you need to
know for lupus. I used to remember the word lupus sounds like Lou,
like the name Lou, and piss like taking a piss, So Lou piss
and I used to remember a guy named Lou taking a piss on his Smith
and Wesson double barrel shotgun. Anytime I saw the word lupas just created this
very weird visual of Lou taking a piss on a Smith and Wesson double barrel
shotgun. You won't forget it. It's such a weird visual. So Smith
and Wesson helped me remember the anti smith antibodies, and double barrel shotgun helped
me remember the anti double stranded DNA antibodies. So remember when you see lupas.
I want you to think of Lou taking a piss on his Smith and
Wesson double barrel shotgun. Create that visual in your head and you'll remember the
two main specific labs you need to know for lupas, anti smith and anti
double stranded DNA. Question T. A three year old boy presents at the
office company by his mother with with reports of acute right elbow pain and limited
use of the right upper extremity. The mother states this all started after she
witnessed his older brother swinging the boy by his arms as they were playing.
The mother denies any other witness trauma to the elbow, and physical exam,
no focal bony tenderness, bruising, deformity, or swelling is found. Radiographs
are negative for fracture. What is the most likely diagnosis in this patient,
So that is going to be a radial head sub luxation aka a nurse made
elbow. So this one's pretty straightforward. We have a young child under five,
It's typically the age you'll be looking for with some sort of pulling injury
to the elbow. When this happens in young children, the annular ligament is
not thick or strong enough to resist the traction, and a portion of the
annular ligament slips over the head of the radius and slides into the radio humeral
joint and it gets stuck there until it's reduced. You always want to make
sure you do a really good physical exam in these children and make sure there
is no signs of fracture. They shouldn't have any focal bony tenderness, rusing
deformity. And while the vignette I added in a negative X ray finding just
to help solidify the answer in real life. If everything is normal, on
the physical exam and they fit the classic picture for radiohead subluxation. X rays
are generally not indicated. Question eleven, a fifty one year old female presents
at the office today complaining of muscle weakness. She describes difficulty combing her hair
and rising from a chair. And physical exam you note a rash around the
eyes, violacious papules over the dorsal aspect of both hands, as well as
erathema across the shoulders, upper back, and upper chest. Labs are drawn
which reveal an elevated creating kindness level as well as positive antime to antibodies.
What treatment should be initiated in this patient for the suspected diagnosis that is going
to be glucocorticoids. So this patient has drmato myocytis, She has the gotron
papules, heliotrope, brash, decreased muscle strength, the Shaw sign plus elevated
CK in antime to antibodies. That's about as clear cut as you can get,
and then we know for drmato myosis. Glucocorda choids are the cornerstone of
your initial therapy. This is usually pret in his own at a dose of
one milligram per kilogram per day. Now Dermato myycitius has a few very high
yield findings in the way that I used to remember all the high old stuff
foror dermato myocytis was. Instead of remembering dermato myocytis, I used to remember
it as permato myocytis. So all you do is replaced the D with a
P, and now you have perm prm permato myocytis. So why PERM,
Because whenever you think of this disease, we need to think of a lady
getting a PERM. She's sitting in the chair, her hair is in the
perm helmet thing, and she's getting the work. She's getting her nails done,
her eyebrows wax, and she's got the cape or shawl over her shoulders
as you're normally wearing a salon or a barbershop. She's just relaxing and having
some me time, me time spelled within m I. It's very hard visual,
so check out the YouTube channel if you need one. It's hard visual
to create just by kind of saying it out loud, but that's a visually
you need to create. Lady in a chair getting her hair permed, getting
her nails done, eyebrows wax with the cape or shawl thing that you were
in the salon having some meat time. Now, how does that remember?
How does that help you remember what you need to know. Well, she's
getting her eyebrows wax, and that helps remember the heliotrope rash that's common around
the eyes, upper eyelids especially. She's getting her fingernails done. That helps
remember the gotron papules that are the most common on the top of the fingers.
And she's wearing the cape or shawl, which helps you remember the shaw
sign or photo distributed poikilo derma, which is most common in the upper back,
neck and upper chest, exactly where the cape is distributed when you wear
it anytime you get your hair done. And then remember she's having some me
time, me time spelled am I. That helps you remember the anti me
too antibodies which are highly specific for dermato myocytis. So remember changed the D
to a P and you have permato myocytis. Lady getting a perm having some
metime, eyebrows wax, getting her nails done, and wearing a cape.
Question twelve fifty two year old mail presents in the emergency department complaining of severe
pain in his first metatar sophalangeal joint. He denied trauma to the area and
states it started suddenly. Arthurs sentisis is performed, which displays negatively by her
farringent needle shaped crystals. Patient has a history of hypertension, type two diabetes,
hyperlipidemia, and current medications include hydrochlorothiside, metformin, glyposide, and resuvastatin,
which medication that the patient is currently taking is the most likely culprit leading
to its current clinical manifestations. Again, those meds or hydrochlorothiside, metformin,
glyposide and rsuvastatin. The med is going to be hydrochloro thyside, all right,
So this is about as clear cut a case of gout as you can
get severe pain. First tone, negatively biofur engine needle shaped crystals on arthur
sentesis. So I have to remembers which meds can cause gaut flares and in
this case is hydrochlorothyside. Remember thyside Diuretics like hydrochlor thizide increase urate reabsorption at
the proxymorhinal tubule, which can elevate uric acid levels and precipitate Gaut flares.
So one of the many meds that can cause gautflares. So, how do
you remember the main meds that can cause gaut So? I used to remember
if you put too much seafood on your plate, you'll get gaut. Plate
stands for purizenamide, loop diuretics, aspirin, thisides like hydrochlor thizide, and
then fambutal. So again plate plat pierzenamide, loop diuretics, aspirin, thiasides,
Fambutall that helps you remember the main meds that you need to know that
can lead to Gaut flares. Question thirteen. Seventy two year old female presents
at the office today for routine checkup. Path medical history includes hypertension, hyperlipidemium.
She says she has concerns about osteoporosis as her mother was diagnosed with it
in her sixties and wound up with a hip fracture. A Deexis scan is
ordered, which reveals a T score of negative two point six. Is decided
that the patient will be started on the first line medication class for osteoporosis.
What important instructions need to be provided to the patient about the proper way to
take the medication before she takes her first dose, so that is going to
be to avoid recumbency for at least thirty minutes and take with sixty eight ounces
of water. So first you need to know the first line medication for osteoporosis,
that of course is bisphosphonates, and one of the most important adverse drug
reactions from bisphosphonates that you have to know is esophagitis. This can be avoided
by making sure the patient stays upright for at least thirty minutes after taking the
medication and taking it with at least sixty eight ounces of water. It's actually
a contraindication listed on all the bisphosphonates to give these to a patient who cannot
remain upright for at least thirty minutes. It's also important for them to remain
npo thirty minutes after the dose, so no other food or mead for thirty
minutes. But by far the most important thing to know that they will test
you on is avoiding recumbreency for at least thirty minutes. All right, Question
fourteen, Twenty seven year old Mail presents to the office with pain and swelling
of his left knee he was playing soccer with friends and as he was running,
he stopped short to change directions and felt a pop in his left knee,
followed by pain and swelling. A Lockman test is performed, which demonstrates
increased interior translation of the tibia with no distinct endpoint. What type of injury
did this patient likely sustain? So that is going to be an anterior cruciate
ligament injury. So first the history hop in the knee followed by immediate swelling.
That swelling that hemarthrosis is a very common presentation for an ACL tear.
Up to seventy seven percent of patients with acute hemarthrosis after injury of the knee
have an acel tear. And then you have the positive Lockman test, which
we know is the most sensitive test for an ACL tear. And you can
remember that the Lockman tests is the most sensitive test for ACL tears because the
first three letters of Lockman are ACL rearranged. So in this patient, all
signs point to an ACL tear. Question fifteen. Fourteen year old boy presents
the office company by his mother complaining of right knee and thigh pain. He
denies trauma to the area He ascribes the pain a severe and deep in his
leg, and he often finds the pain keeps him up at night. Smother
states he has no medical conditions and is not currently taking any prescription medications,
and denies any other symptoms such as fever or weight loss. On physical exam,
a tender soft tissue mass is palpated on the distal femur. X rays
reveal a soft tissue mass in a radial or sunburst pattern. What is the
most likely diagnosis in this patient? So that is going to be in osteosarcoma.
So why osteosarcoma? Well, in real life you're going to need a
biopsy to say for sure, But for the sake of an exam question,
there's a few key areas that point to osteosarcoma. First, osteosarcoma is the
most common primary malignancy of bone in children and young adults, so that alone
is helpful, but not enough of course. Second clue is the location of
the mass, which is at the distal femur, and that's the most common
site of osteosarcoma and children thirty two percent of all patients. And then finally,
the sun burst pattern to the mass. While this can be seen in
other bone malignancies like ewing sarcoma, it's most common in osteosarcoma. And then
also ewing sarcoma will most often be described as having an onion skin or mothi
in appearance on X ray, and then euing sarcoma often will also have systemic
symptoms fever and malaise, etc. Which is generally absent in osteosarcoma as we
can see in this patient. So in this case, most likely diagnosis is
going to be an osteosarcoma. Question sixteen, Which of the following drugs have
been associated with a high risk of causing drug induced lupus? A procanamide,
B, metformin C, A, zythromycin, D, gabapentin, E,
L prazen LAMB. So I could be a second to think about that,
that's going to be a procanamide. So there's a bunch of drugs that can
cause lupus, close to fifty that we know of, but the main ones
that you need to know are prokanamide and hydrolyzine. Those two alone cause around
thirty percent of all of the cases of drug induced lupus. Then there's a
few other high old ones that often get tested on that I would remember.
I used to remember thenemonic chips, c hipps because the letters in drug induced
lupus are d I L as in dill, and then it makes me think
of those Dill potato chips or Dill pickle chips. However you want to remember
it. When you see drug induced lupus d I L dill, think of
Dill chips, chipps, and you'll know the high old meads that are always
tested on. SO chips stands for carbon, magic, hydralazine, isoniazid,
prokanamide, penicillamine, and sulfacealazine. Know those and you'll very likely get the
question right. That's literally all I remembered for the exam, and I got
both questions right that I was asked in school. Question seventeen. Thirty two
year old male with a seizure disorder complains of acute left shoulder pain after sustaining
a seizure earlier this morning. On a physical exam, the patient holds the
arm in adduction and internal rotation and is unable to externally rotate the affected arm.
Radiographs are obtained, which reveal a circular appearance of the humoral head with
a light bulb appearance, what type of shoulder dislocation did this patient likely sustain?
So that is going to be a posterior shoulder dislocation. So if the
posterior shoulders dislocation, you're looking for a few things in the question. One,
the mechanism of injury. Generally, any kind of trauma or blow to
the anterior portion of the shoulder with the arm adducted and internally rotated can cause
a posterior dislocation. But what's unique and very high yield about this kind of
dislocation is that they are common after a sisure or electrocution due to the violent
muscle contractions that take place during these type of injuries. So know that seizure,
electric shock super high y'eld for the exam, and then a physical exam.
The patient with a posterior dislocation will usually hold the arm in adduction and
internal rotation, generally unable to externally rotate. And then finally on X ray,
be familiar with the light bulb sign for posterie dislocations. Because of the
internal rotation of the arm, the tuberosities no longer project laterally, which result
in a circular appearance of the humoral head. And supposedly it looks like a
light bulb. So adduction and internal rotation. Know the mechanism of injury,
shock or seizure, and know the light bulb sign on X ray, So
remember those high yield things. I want you to visualize a warning on a
poster board. On the posterboard, there's a picture of a broken light bulb,
a finger, and a guy being shocked, and it says if you
add your finger into a broken light bulb, you'll get shocked. So add
and into helps. Remember adducted in internal rotation is the common presentation broken light
bulb because remember the light bulb sign on X ray and shocked because remember the
unique mechanism of injury, electric shock, or seizure. And all this is
on a posterboard because the poster board helps you remember Posterior dislocation question eighteen sixty
seven year old female presents the office complaining of persistent hand persistent pain in her
hands and knees for several months. She describes the pain as being worse in
the evening, with stiffness in the morning that only lasts for a few minutes.
On physical exam, there is a bony deformity and enlargement noted on the
distal interflangeal joints. The joints are hard and enlarged, but not warm to
the touch. Given the patient's likely diagnosis, what is the name for the
enlargement of the distal interflangel joints seen in this patient? So that is going
to be Heberden nodes. So this patient likely has osteo authritis, persistent pain
in the hands and knees, pain that's worse in the evening, and stiffness
in the morning that only lasts for a few minutes. Remember, inflammatory authritis,
like rheumatoid arthritis, is morning stiffness for sustained periods of time, generally
over sixty minutes osteo authors. If morning stiffness is present, it's usually only
for a few minutes at most. We also see the joints are hard and
enlarged, unlike rheumatoid authritis, which usually has warm and boggy joints. So
this is a classic presentation for osteo authritis and the bony enlargement of the distal
interphalangeal joints we see in this patient is known as Heberden nodes and these are
considered a clinical marker for generalized osteo authritis. Question nineteen fifty three year old
woman with the history of diabetes and hypothyroidism presents the office complaining of shoulder pain
and stiffness over the span of the past few months. She denies trauma to
the shoulder and states the symptoms have increased in severity over the past few weeks.
Physical exam reveals significant limitation in both active and passive range of motion in
all planes of the affected shoulder. Rotator cuff strength is normal, and radiographs
of the shoulder display no Apuormladies, what is the likely diagnosis in this patient?
So that's going to be adhesive capsulitis aka frozen shoulder. So why is
this adhesive capsulitis and not some sort of sub a chromeo pathology like rotator cuff
tendinopathy, like impingement syndrome, etc. Well, there's a few reasons.
One, when you have a rotator cuff tendinopathy and impingement syndrome, usually they're
going to mention the vignette a history of heavy lifting or repetitive movements related to
occupation or sports, which is not included in this patient's history. I also
mentioned the vignette the patient has normal rotator cuff strength, which is another clue
there. And then finally, which is really important, this patient has weakness
in both active and passive range of motion. Painful sub chromeial conditions will generally
demonstrate weakness with active range of motion, but will have normal passive range of
motion. And then, of course, this patient fits the classic description,
which is a female in the fifth or sixth decade of life with a history
of diabetes and or thyroid disorder. Patient checks all of those boxes and that
is why this is adhesive capsulitis question. Twenty forty nine year old female with
a recent diagnosis of rheumatoid arthritis presents to the office today. She stays she
was started on the prox in two months ago after being diagnosed, but the
pain is becoming more severe and the medication is no longer working as well,
which additional medication will be the best option to add to a regiment to slow
progression and prevent further erosion of the joints. So again, remember she was
diagnosed authritis shes given the proxiin. Symptoms are progressing. What other medications should
you add to this patient's regimen? A diclofenac, B, prednisone, C,
zolodronic acid, D and fliximab or E methotrexate. So the answer is
going to be E methotrexate. So let's talk first why it's not the other
options. First, diclofenac. It's just another end set like the proxin that
she's already taking, so no value there. Plus end sets have no impact
on disease progression. Next prednisone. Prednisone can be used for symptomatic relief,
even has some disease modifying effect, but it is not the best option on
this list by a long shot. Next soldronic acid. That's an easy one
because we know this is bisphosphonate not used for treatment of rheumatoiathritis. Next in
fleiximab. So this is a TNF inhibitor and it is used in the tree
an of rhumatoidauthritis, but it's not first line. It's generally used as an
adjunct agent and patients not getting the therapeuticals with the first line met and that
first line med is methotrex sate. Methotrex said is a dMar disease modifying anti
raumatic drug, and while there are other drugs in this class hydroxy chloroquin sulfa
salazine, methotrexate is the most commonly used d MART and first line for ra
because compared to the other meds, it has a faster on set of action,
greater efficacy, better long term tolerance. So if there's one drug you
absolutely have to know for rheumatoid athritis, that's definitely going to be methotrexate.
Question twenty one. An injury to which nerve common and humoral shaft fractures can
lead to weakness and extension of the wrist i e. Wrist drop and fingers,
that is going to be the radial nerve. Because the way the radial
nerves wraps around the humorist and travels down the arm, the radial nerve is
susceptible to injury when a patient suffers a humoral shaft fracture, and the most
common neurological complication of humoral shaft fractures is a radial nerve injury. So classically
you'll hear being described as wrist drop, but when this nerve is injured.
The patient can have parastheses of the dorsal hand or weakness of the wrist and
finger extension, and this injury actual occurs in around eleven percent of mid shaft
humoral fractures. So when you hear wrist drop, be thinking of a radial
nerve injury. Question twenty two, fifty eight year old Mail presents at the
office to seek treatment for his recurrent episodes of gout. He's not currently taking
any urate lowering medications and he has treated previous acute attacks with new proxy and
he has at home. Labs are drawn which reveal an elevation and serum urate
levels in a twenty four hour urinary uric acid secretion of two hundred and thirty
milligrams. The normal range is two hundred and fifty to seven hundred and fifty
milligrams per twenty four hours. Remember his was two hundred and thirty. Which
of the following medications would increase the excretion of uric acid in the urine for
this patient A indomethicin B, hydroxy chloroquin C, probenecid D Fubus's stat or
elipurinol. So that is going to be c robenesid. So there's a lot
of words in this vignette, but all it's asking you is which one of
these meds make you pee out more uric acid? And the medication is probenicid.
So that's a uricosuric drug, and it can be used in patients with
renal under excretion of uric acid, as we see in this patient. The
other meds starting with endomethicin, which is just an end said used for a
qute attacks, hydroxychloroquin which is not used in the treatment of gallons, primarily
used for lupus, and then finally we have for bucks a statin al pureanol.
Those are both xanthine oxidase inhibitors which work by decreasing uric acid production.
So the only medication on the list that increases urinary uric acid secretion is going
to be probenicid. Question twenty three, twenty two year old Mail presents to
the office complaining of chronic right sided hip and thigh pain for the past six
months. He reports the pain is worse at night, and he does not
recall any injuries to the leg. He states that when he takes ibprofen,
the pain is almost completely eliminated for a short period of time. X rays
reveal a small round lucency with a sclerotic margin on the proximal femur that is
later diagnosed as an osteoid osteoma. What is likely being secreted from this benign
tumor that is leading to the pain the boy is experiencing be a second to
thing about that, So that is prostaglandins, so osteoid osteoma. There's really
two high old things that you need to know about this benign bone tumor.
One, this tumor produces high levels of prostaglandins. And the second thing is
that this type of tumor responds extremely well to END sets. Within a matter
of minutes, the pain will be relieved, which will will be mentioned in
the vignette. And this will help you differentiate from other types of bone tumors
like osteoblastoma, which has minimal pain relief with ND sets. That's what will
differentiate these two on a vignettes. So we need to remember that osteoid osteoma
dramatic pain relief with ND sets. Osteoblastoma minimal pain relief. So why do
ND sets work so dramatically at reducing the pain. Well, if you remember
back to pharmacology, you remember N sets block the production of prostaglandins through the
inhibition of cyclooxygenase. So for osteoid osteoma again, remember two things. One
they crank out a bunch of prostic landings and two for this reason, the
pain experience responds extremely well to end SAIDs. And I hate to even mention
this. The way that I used to remember this osteoid osteoma the letters OOM
whenever i'd see those two o's and osteoid osteoma. I used to remember that
song that said, oh, oh, it's magic, you know. And
I used to remember, oh, it's magic, and SAIDs. I hate
that at the fact that I had to sing there, but to help you
remember that, hopefully you'll remember me singing it's completely ridiculous, ridiculous, but
it helped. It helped stick for me. So we see osteoid osteoma,
think ooh it's magic. End sets because of how well d sets work,
and improving the pain from the increase in prostic gland is. All right,
now they've heard me sing, Let's quickly move on to the next question.
Question twenty four. Scoliosis is defined as an abnormal lateral curvature of the spine
with a cob angle of greater than blank degrees, So that is going to
be greater than ten degrees. So cob angle is the most widely used measurement
for quantifying final curvature and scoliosis, which is calculated using plane radiographs. You
should definitely know that lateral spinal curvature with a cob angle of over ten degrees
defined scoliosis. And then the only other number you might want to have in
the back of your head is a cob angle of anywhere from forty to fifty
degrees or greater as usually where surgical intervention is indicated. Question twenty five.
Fifty nine year old female presents at the office today complaining of right shoulder pain
after a fall from her bike earlier in the day. Shoulder radiographs are performed
which reveal an anterior dislocation of the right shoulder. She also complains of numbness
and tingling in the lateral part of the shoulder. Physical exam reveals deltoid muscle
weakness, which nerve was likely injured in this patient, so that is going
to be the axillary nerve. So the axillary nerve is the nerve most often
injured with shoulder dislocations, and approximately forty two percent patients with anterior shoulder dislocations
will have some degree of axillary nerve dysfunction. The nerve runs around the surgical
necked of the humorous and this is important. It innervates the deltoid muscle and
the skin overlying the lateral shoulder, and that's why this patient is complaining of
numbness and tingling in the lateral part of the shoulder, also known as the
shoulder badge distribution. And this is also why she's presenting with deltoid muscle weakness
as the axillary nerve innervates These areas so very typical presentation for someone who sustained
an anterior shoulder dislocation. So remember, axillary nerve injury is very common in
shoulder dislocations, especially anterior shoulder dislocations. So with anterior shoulder dislocations, there's
a bunch of high old associations, there's bank art lesions, axillary nerve dysfunction,
So how do you remember all of them for the exam? So you
remember it all by remembering a guy named Antonio. And Antonio is this guy
who's holding a picture in one hand and an axe in the other hand.
The picture that he's holding is of a bank on top of a hill,
and he's holding both the picture and the axe up and out by his side,
so his arms are abducted and externally rotated. So Antonio helps you remember
this is an anterior dislocation. The picture he's holding with a bank on top
of a hill helps you remember bank art lesions and hill sack lesions are often
caused by anterior dislocations. And then the axe he's holding in his other hand
helps you remember axillary nerve actually a nerve injury is most common in anterior dislocations.
And then finally, the position of his arms holding these things abducted and
externally rotated, helps you remember both the way the arm is usually positioned during
physical exam and during the injury too. So remember a guy named Antonio holding
a picture of a bank on top of a hill in one hand, holding
an axe in the other hand. Both arms are abducted and externally rotated.
It's all you need to know for anterior dislocations. Question twenty six, thirty
two year old mother of a six week old newborn complains of recurrent radial sided
wrist pain that is exacerbated by thumb and wrist movement. She Denai's trauma to
the area. On physical exam, tenderness is noted over the radial styloid at
the first dorsal compartment and flection of the thumb across the palm with ulnar deviation
of the wrist results in pain over the radial styloid area. What is the
most likely diagnosis in this patient? So that is going to be decare vein
tendinopathy. So why decoarevein tendinopathy. First we have a thirty two year old
postpartum female. This fits the most common demographic perfectly as this is most common
in women thirty to fifty years old, especially four to six weeks after delivery
in the postpartum period. Next, we have pain in the radial side of
the wrist exascerbated by thumb and wrist movement. This makes sense as the tendons
evolved in decour vein are the EPB and APL tendons, which are responsible for
movement of the thumb. And most importantly, she has a positive Finkel steam
test, which is pain over the radio styloid with lar deviation of the wrist
with the thumb flexed across the palm. That's classic decore vein tendinopathy. In
case you need a way to remember the tendons involved in decour veins, because
I did get this on an exam question. The tendons involved are the abductor
policis longest and the extensor policis brevist the APL and EPB tendons. Remembering the
abbreviations will be enough to get it right on a multiple choice question. So
I used to remember apples as an APL with extra peanut butter as an EPB
tendon are delicious as in decuare vein, So apples with extra peanut butter are
delicious. Apples APL tendon extra peanut butter, EPB tendant are delicious. Decoare
vein tendant apathy, And that was enough for me to get the question right.
On an exam question, sixty two year old mail presents the office complaining
of severe pain. In his first tone, he denize trauma to the area.
Arthocentesis reveals negatively bier for engine needle shaped crystals and then the diagnosis of
gout is established. Pasthematical history includes type two diabetes, osteoarthritis, and end
stage renal disease. Which class of medication would be most appropriate to treat this
patient's acute gaut flares? To remembery as a pathematical history type two diabetes,
osteoarthritis, and end stage renal disease. Which class of medication are you going
to treat as acute gautflare with? So that's going to be glucal cortaquois.
So you have to think about what are the first line meds to treat acute
gaut flare. So really there's only three ND sets, steroids and culture scene.
We know ND sets are out of the question because this patient has end
stage renal disease. Culture scene can be used in mild kidney disease when GFR
is about thirty, but end stage renal disease other agents are preferred. So
in this patient, the most appropriate effective class of medication is your glucal corticoids,
your steroids, as they are safe and mild all the way to severe
renal disease and extremely effective in treating acute gaut flares. Question twenty eight.
A distal radius fracture that involves dorsal displacement of the distal radius fragment is known
as what type of fracture? Again, a distal radius fracture that involves dorsal
displacement of the distal radius fragment is known as what type of fracture that is
going to be a Collie's fracture. So there's two different types of distal radius
fractures you should be familiar with. That's Collies and Smith. Collies involves dorsal
displacement of the distal radius. Smith involves palmer or volar displacement of the distal
radius. The way that I remember Collie's associated with dorsal displacement is by remembering
Collie is a breed of dog, the type of dog that last he was
a Collie dog. So when you think of Collie's fracture, I want you
to think of a Collie dog. And the first two letters in dog are
the first two letters in dorsal doo And this helps you remember Collie fractures are
dorsally angulated radius fractures and by method of exclusion, Smith is the opposite,
which is a volar angulated distal radius fracture. So when you see collie fracture,
think of a Collie dog. Question twenty nine, forty seven year old
mail with history of intravenous drug use presents the emergency department complaining of progressive lower
back pain and worsening gait and stability over the last two weeks. On physical
exam, he has point tenderness in the lumbar region, weakness in bilateral low
extremities, diminished sensation to light touch, and a temperature of one oh three
point to fahrenheit thirty nine point five degrees celsius. Laboratory studies reveal leucocytosis as
well as in elevation and an orthrocyte sedimentation rate and see reactive protein radiographs of
the lumbar spine are remarkable. MRI reveals a ring enhancing lesion at L two
to L four, which bacterial pathogen would likely be isolated in this patient.
So one's a little bit triggy. That's going to be staff oreus. So
first, what does this patient likely have likely has a spinal epidural abscess?
Well, why first do you have an IVY drug user with a triad of
fever, back pain, and neurologic deficits. Right away, spinal abcess should
be high on your list of differentials. Next, we have an elevation of
white blood cells as well as elevated ESR and CRPEP. Around sixty percent of
patients with a spinal abcess will have lucocytosis. In almost all cases of spinal
epidural abscess will have an elevation of ESR and CRPEP. Usually, radiographs are
going to be normal and MRI, which is key, which will reveal an
enhancing epidural mass often described as a ring enhancing lesion. Definitely know that term,
and that's the confirmation right there, we have a spinal epidural abscess,
and the leading bacterial pathogen causing a spinal epidural abcess is staff orea and around
sixty three percent of cases. Question thirty fifty seven year old Mail reports right
shoulder pain after sustaining a fall at work two weeks ago. He states he
is unable to lift his arm above his head without significant pain and finds he
is unable to sleep on the affected side at night. On physical exam,
with the patient's affected arm completely internally rotated, thumb pointing down elbow extended at
ninety degrees of an abduction pain and weakness is experience when the clinician attempts to
adduct the arm while the patient resists. Go to repeat that again. Physical
exam patient's arm affected arm completely internally rotated thumb pointing down elbow extended ninety degrees
of abduction. Pain and weakness is experience when the clinician attempts to adduct the
arm while the patient resists. MRI confirms a full thickness tear of a tendon
in the rotator cuff. Which tendon of the rotator cuff is likely affected in
this patient, So that is going to be the superspinades So why well to
start? Majority of rotator cuff lesions begin as partial tears of the superspin natas
tending, so it's sorry the most common tended to be affected. So we
have that working for us. But then the physical exam findings are what's sealed
the deal. We have a patient performing the empty contest, also known as
the job test. This is generally considered the gold standard for evaluating superspinatis function
because the position of the arm isolates the superspinatus, making it the primary muscle
opposing that downward motion of the arm. So the arm completely internally rotated,
thumb pointing down, elbow extended. Clinician depresses the arm while the patient resists
and pain and weakness is indicative of a partial or complete superspinadis tend in tears.
Remember if you see the empty contests or the job test being performed,
this is to assess the superspinatus question. Thirty one forty one year old female
has symptoms consistent with rheumatoid athritis and labs are drawn to assist in making the
diagnosis. The decision assistant informs the patient that a rheumatoid factor as well as
a very specific antibody for rheumatoid arthritis are both elevated. Which antibiotics, which
antibody specific to rheumatoid arthritis is likely elevated in this patient. So again,
which antibody specific to rheumatoid athritis is likely elevated in this patient? So that
is going to be your anti cyclic cutrilinated peptide aka your anti CCP. So
your anti CCP antibodies are very specific for rheumatoid arthritis. Usually over ninety percent
specific for the disease, So if they ask for the most specific test for
RA, generally this will be your anti CCP. And compared to this rheumatoid
factor, which has a relatively poor specificity since they're found in healthy individuals and
up to thirty percent of patients with lupus. So your most specific test again
for rumatoiouthritis is your anti CCP. And if you can't remember which specific which
is the specific antibody for RA specific is spelled with two c's, look for
the antibody with two cs in it, and that's going to be your anti
CCP question. Thirty two sixty three year old Mail presents at the office today
complaining of diarrhea and abdominal cramping for the past few days. Denies any recent
dietary changes, no recent travel, and states the only change in his life
was that he was recently diagnosed with gout and started on a new medication.
Which medication did this patient likely start on for the treatment of gout? So
that is culture scene. So culture scene is notorious for causing GI problems,
especially diarrhea, so much so that on Appocrates it actually says in the comments
diarrhea will likely proceed pain relief, which I thought. It's very funny,
so definitely know this for adverse drug reactions. For culture scene, It's an
exam favorite for some reason, and I definitely remember getting a question about it
in school. Question thirty three. Fourteen year old boy presents to the office
complaining of anterior knee pain. He states the pain is most severe when he
plays basketball or squats down. On exam, you note a pronounced tender tibule
tubercle. What is the mainstay of treatment for the likely diagnosis in this patient?
So that is going to be conservative, and says I set her up.
So this is osgod Schlauter disease. We have a fourteen year old boy
fits the demographic already, as osgod Schlatter is most common in males nine to
fourteen years of age, especially in those who have undergone a rapid growth spurt.
Pain is usually exacerbated when squatting, jumping, running, etc. Which
is common during sports like basketball, as we see in this patient. And
then an exam the pronounced tender tibial tubercle seals the deal. As we know
this is an injury caused by repetitive strain and chronic evulsion of the a hypothesis
of the tibial tubercle. A lot of hard words for me to say right
now. So the mainstafe treatment Frosgat schlaughter disease is conservative and says etc.
Surgical repair is rare and you can remember instead of osgod schlaughter disease, remember
Osgod's squatter denase SULPs. Remember it's exacerbated by activity like squatting, and then
Denise helps you remember this is an issue with the knees. Question thirty four,
a forty three year old female presents to the office complaining of numbness and
tingling in her hands, mostly affecting the thumb, index and middle finger and
part of the ring finger. She states it is worse at night, sometimes
waking her from sleep. Both a tunnel and phalin test are positive. On
physical exam, patient is likely experiencing compression of which nerve, so is the
median nerve sus. Patient is experiencing carpal tunnel syndrome, which is a compression
of the median nerve. We know this because we have a patient with parastheses
and the median nerve territory, which would be the first three fingers and radio
half of the fourth. In addition, she states it's worse at night,
which is very common for carporal tunnel. Finally, have a positive Tannell and
Phalin test which seals the deal. So we know this is carpal tunnel,
which is median nerve compression. And just a quick tip the two maneuvers that
were listening to this vignette for carpal tunnel, the Tannelle tests and Phalin test
they're often tested on, so it's good to know what they involved. So
the Tannell tests is just percussing or tapping over the median nerve to see if
pain or parastheses is reproduced in the median nerve innervated fingers. So you used
to remember the t and Tennelle stood for tapping. And then the Phalin test
you basically just flop your hands over and put the dorsal surfaces or the back
of the hands together for a minute. Positive tests pain or parasteses and the
media nerve innervated fingers. And I used to remember the word phalin sounds like
fallen, so I used to remember this is the test for your hand have
fallen or flopped over because that's what it looks like men perform the test.
You can look at a picture of it and then so you just remember that
the hands have fallen or falin over because that's how the test is performed.
Question thirty five. A sixty seven year old Mail presents to the office today
complaining of persistent elbow pain. He does not recall any trauma to the elbow,
but the pain he is experiencing in his elbow is affecting his golf game.
As he is an avid golfer. An exam pain is elicited by performing
wrist flexion against resistance. Tenderness would likely be felt over which part of the
elbow in this patient. Give you a second to think about that, So
that is the medial epicondyle. So we have a classic case of medial epicondolitis
aka golfer's elbow. We have a sixty seven year old Mail, avid golfer
with elbow pain, no preceding trauma, and the key is that the pain
is reproduced on exam with the risk being flex against resistance. So in this
case, the patient would likely have pain in the medial epicondyle. As the
medial epicondol is the bony origin for the wrist flexors which is affected in this
condition. The way that I remember the high oldt about medial epicondo lightis aka
golfer's elbow was by remembering the sentence mini golf is fun. So the M
and mini helps remember this is the medial epicondol involved in golfer's elbow golf obviously
because this is also known as golfer's elbow. And then the F and fun
helps you remember this involves flexion. So whether it's pain with wrist flexion against
resistance on exam, the fact that it involves the flex or carpi radialis or
that it's caused from repetitive flection. Mini golf is fund M for medial epicondol
golfer golf, golfer's elbow, and then F for flection flex or. Question
thirty six, which test is performed as part of the physical exam in a
suspected Achilles tend in rupture, then involves squeezing the gas strucnemius muscle and watching
for plant our flection of the foot. So that's the Thompson test. So
Thompson tests nice and simple is squeeze the calf and look to see if the
foot planter flexes. If not, this is a positive test indicating a likely
Achilles tend in rupture. Question thirty seven. Thirty one year old male was
playing football with his friends when one of his friends landed on the lateral aspect
of his right knee in an attempt to tackle him. He immediately felt a
tearing cessation, which was followed by severe pain. A Valgus stress test is
performed, which displays pain and laxity at approximately thirty degrees of flexion. What
structure of the knee did this patient likely injure? So that's the medial collateral
ligment. So we have a patient with lateral trauma to the knee and a
positive Valgus stress test. The MCEL will be the most common structure to be
injured in this setting. So the medial collateral ligament injuries have a positive Valgus
stress test. Lateral collateral ligament injuries have a positive v rust stress test.
It's easy to get those mixed up. So this is how I used to
remember them. So first, how do you associate MCL injuries with Valgus stress
So Valgus has the word gus in it. So whenever I see Valgus,
I think of Mucco Gusto, the m and mucho Gusto helps me remember this
is a test of the MCL ligament. And then VA Russ test for LCO
injuries has the word rusts in it, and that makes me think of rust
as in the sentence leaky pipes rust and the L and leaky helps you remember
the VA rust stress involves the LCIL. So remember mucho gusto for Valgus test
to help your remembrances soociated with injuries, and then leaky pipes rust for vera
rust test to help your remembrance associated with LCIL injuries. Question thirty eight fifty
sixty year old female presents to the office complaining of persistent heal pain that is
worse when first getting out of bed in the morning. She states, and
improves as the day goes on and stretching in the morning seems to help.
She denies trauma to the area. Radiographs are negative and on physical exam point
tenderness is noted over the medial tubercle of the calcaneus. What is a likely
diagnosis in this patient? So that is going to be plantar fasciitis. It's
a pretty easy one. Anytime you have a patient complaining of heal pain that's
worse in the morning when they first get out of bed, or worse after
periods of inactivity, especially with point tenderness right at the insertion side of the
plant or fascia, which is the medial tubercle of the calcaneus. Obviously,
plant or fasciators should be high the listed differentials. Treatment is generally going to
be conservative for these patients. Rest and said it's better shoes, etc.
Question thirty nine sixty seven year old female presents to the office four months after
fracturing her left hand. The hand was properly splinted at the time of injury
and recent radiographs reveal a well healed fracture without any indication of malunion. She
presents to the office due to new symptoms in the left hand. She notes
the hand appears to perspire profusely compared to the right side, along with noting
severe pain to even the slightest touch. Physical exam demonstrates hyperaesthesia and weakness in
the affected hand. Increased hair growth and brittle nails are also noted compared to
the unaffected side. What is the most likely diagnosis in this patient? So
I'm gonna give you a second thing about that is a little complicated. So
that is complex regional pain syndrome. Anytime you see a patient that had an
injury in the vignette, they go out of their way to say it healed
properly, it was treated properly, etc. And yet the patient is still
in excruciating pain months later. Always have complex regional pain syndrome at the top
of your list of differentials. So if complex regional pain syndrome, the treatment
and diagnostic tests are pretty low yield, the highest yield thing to know about
it is its bizarre combination of clinical manifestations. So the way that I remember
the common clinical manifestations that you will see in a vignette for complex regional pain
syndrome is by instead of remembering complex regional pain syndrome, I remembered complex regional
paint syndrome. And what does paint stand for? So PA I NT so
the P stands for perspiration. This is due to the autonomic dysfunction. Forty
percent of patients will experience increased sweating the A and paint stands for after injury
because remember this will most commonly take place after some sort of bone or soft
tissue injury, so look for some sort of injury mentioned in the vignette weeks
or months prior. The I stands for inappropriate pain because it's out of proportion
to the initial injury. Pain is typically the most prominent in debilitating symptom of
CRPS. So remember I stands or inappropriate pain. It's not appropriate to have
ten out of ten pain in your hand from a fracture you had four months
ago that has healed so high for inappropriate pain. N stands for nail changes.
Remember your trophic changes, so these patients can have both increased or decreased
nail growth brittle nails. Also look for changes in hair growth as well.
And then the TEA stands for temperature changes, so relating back to the autonomic
change these patients can have, and some patients, you'll notice a difference difference
in skin temperature on the effective versus the unaffected size of a side of one
or more degree celsius. Question forty. A fourteen year old mail presents to
the office complaining of right thigh pain and swelling that has persisted for several weeks
after he bumped his leg at school. He also reveals he has had trouble
sleeping at night because he often feels hot and sweaty. On exam, tenderness
and warmth is felt on the lateral aspect of his right thigh. Radiographs are
negative for fracture, but reveal a permeative or moth eaten appearance of the approximal
femur, as well as a periosteal reaction with layers of reactive bone that resemble
layers of an onion. Skin. Biopsy is obtained which displays sheets of uniform
small round blue cells, and cytogenetic testing reveals a chromosomal translocation of eleven and
twenty two. What is the most likely diagnosis in this patient? So that
is going to be using sarcoma. So you have a young male, minor
trauma to the leg leading to localized pain and swelling that is not improving.
He has constitutional symptoms fever and night sweats, all very typical of ewing sarcoma.
But then we have our keywords or numbers, moth, onion, blue,
eleven and twenty two. Out of all the words that vignette, those
are the key to choosing the right answer. So the X ray findings that
moth eat and appearance and the onion skin appearance, while they can be seen
in other conditions, for the sake of a vignette, it will very likely
be Ewing sarcoma as this is a common finding on X ray. And then
we have the translocation between chromosome eleven and twenty two and the small round blue
cells on histology. That just solidifies the diagnosis. And here's how I used
to remember most of the keywords. So when I would see Euing sarcoma Ewing
sarcoma, I would think of another famous person with that name, Patrick Ewing.
So Patrick Ewing was a famous basketball player. He wore the number thirty
three, played for the New York Knicks. So how does that help.
Well, First, Patrick Ewing's number was thirty three and eleven plus twenty two
equals thirty three, so that helps remember the eleven twenty two translocation. Second,
the famous New York Knicks basketball jersey was almost all blue with a little
touch of orange, and the blue jersey helped me remember the blue cells on
histology. And then finally, I just used to remember Patrick Ewing like Steed
onion rings and just visualized him showing down on some onion rings, which helped
me remember the onion skin appearance on X ray. So whenever I see Ewing
sarcoma, I visualized Patrick Ewing wearing his blue jersey with the number thirty three
on it, eating some onion rings, and I remembered all the things that
I needed to know for Ewing sarcoma. Question forty one. Forty six year
old male who suffered a fall from his roof earlier in the day has just
completed a series of X rays. The X ray revealed a number of fractures
as as well as a dislocation of the right tibio for moral joint aka the
knee joint. What is the most dangerous potential complication that can arise following a
tibio FORMORL dislocation that needs to be considered in this patient, So that is
going to be a pop lteal artery injury. This is the most dangerous complication
following a tibio FORMORL dislocation aka a knee dislocation, and delay in diagnosis or
impair can lead to amputation. So you need to make sure after you reduce
the dislocation. You assess the distal and poploteal pulses, measure, ankle brachial
index, et cetera to ensure there's no signs of vascular compromise. Question forty
two, what is the most common ligament to injure in an ankle sprain?
So that is going to be the anterior tilo fibular ligament aka the atf ligament.
I used to remember that by remembering the letters in atf ligament. Standford
always tears first because this is the ligament in the ankle most likely to tear
in an ankle sprain. Question forty three. Seventeen year old Mail presents to
the ear after sustaining an injury to his right arm. After X rays are
complete, the attending physician informs him the ray reveal a proximal ulnar fracture accompanied
by a radial head dislocation. I'll repeat that the X rays reveal a proximal
ulnar fracture accompanied by a radial head dislocation. This type of injury is also
known as what type of fracture? So that is a montegia fracture. So
there's two types of fractures. Slash dislocations you need to know for the forearm.
First one, as we saw in this vignette, is a Montegia fracture,
which is a proximal ulnar fracture accompanied by a radial head dislocation. And
then the second type is known as a Galiazzi fracture, which is a radial
midshaft fracture with dislocation of the distal radial owner joint. And while it's a
dislocation or instability of the radio owner joint, it's most common that the ulna
gets dorsally displaced. So how can you remember which is which? You remember
something known as gruesome murder. Gruesome murder helps you remember which bone is fractured
and then secondly which is dislocated. So the first three letters of gruesome gru
The G stands for Galiazzi, the R stands for radius fracture, and then
the U stands for ulnar dislocation. And then murder. First three letters are
Mu, R M stands for Montezia, U stands for ulnar fracture, and
then the R stands for radiohead dislocation. So again, remember gruesome murder.
First three letters of gruesome help you remember a Galiazzi fracture. It's a radius
fracture and a ulnar dislocation aka the radio owner a joint to be specific,
and then the first three letters of murder mure help you remember Montezia ulnar fracture
and radiohead dislocation. Question forty four. Twenty six year old female presents at
the office complaining of fatigue, joint pain, and a low grade fever for
the past few weeks. She also reports that she develops a painful burn after
being in the sun for just a short period of time. On physical exam,
you note a rash that is distributed over the cheeks and nose, sparing
the nasal labial folds, as well as diffuse discoid lesions. What would be
the best initial test to order in this patient? So that is your anti
nuclear antibody IKA, your ANA test. So in this patient, systemic lupus
erthematosis should be at the top of your list of differentials. Anytime you have
a young female of childbearing age with a joint with joint pain, rash,
and fever, always consider lupus. On exam, she has the classic mail
or butterfly rash that spares the nasal labial folds as well as the discoid lesions,
and then she describes a photosensitive rash that burn after a short period of
time in the sun. So the best initial or screening test and a patient
you suspect may have lupus is your ANA, your anti nuclear antibodies. It's
not a specific test, but it's very sensitive, and this is where you'll
always start when screen for lupus, and then after you proceed to your more
specific antibodies, your anti double stranded DNA in your anti Smith question forty five,
twenty seven year old Mail presents to the ear after a bicycle accident he
had earlier on in the day. He states his bike hit a pothole which
sent him flying off his bike, landing on his outstretched hands. He is
now complaining of pain along the radial side of the right wrist and is tender
just proximal to the base of the thumb at the anatomic snuff box. A
fracture of bone should be suspected in this patient until proven otherwise. So that's
the scaffoid. This is a very simple one scaffoid or an avicular fracture.
You have a patient who had to fall into an outstretched hand, which is
most often the mechanism of injury for a scafoid fracture. He has pain on
the radial side of the wrist. Snuffbox tenderness. You're done. This is
a scaffoid fracture until proven Otherwise, as soon as you hear snuffbox tenderness,
always be thinking of a scaffoid fracture. Question forty six forty seven year old.
Forty seven year old female presents to the office complaining of dry mouth and
dry eyes for several months. She has used over the counter eye drops with
minimal improvement. Physical exam reveals dry mucus membranes and swollen parodied glands. Explain
to the patient who will be performing a test to assess for tear production.
What is the name of the test that will be performed. So that is
going to be the Schermer test. So this patient very likely has Scholgrin syndrome.
Of course we would need to perform some labs your anti row anti law
ana, but she has all of the classic clinical manifestations dry eyes, dry
mouth, product gland enlargement. And then the test we performed to assess for
tear production is called the Schermer test. Now with Shogrin syndrome. In addition
to your Schermer test, there's two really high y old things that you need
to know, and that's your anti row and anti law antibodies that are used
in diagnosing this condition. And the way that I used to remember these three
high old tests is by instead of remembering Shogrin syndrome, I would remember slow
green syndrome slow green instead of showgreen. And what's slow in green? A
frog? That helps remember a slow green, slow green frog landed in my
cup of Sherbert. So create that visual in your head if a cup of
sherbet, that little frozen fruit treat, and then a frog landed right in
it, So showgreen is now slow green. A slow green frog landed in
your cup of Sherbert. Frog. The second two letters are our, O
that helps you remember anti row landed. First two letters are LA that helps
you remember anti law and Sherbert helps you remember Schermer test. So that worked
for me. Just remember slow green instead of showgreen. Remember that slow green
frog landing in your cup of Sherbert. Question forty seven, twenty seven year
old mail presents to the office with right knee pain after a sports related injury.
A few days prior, he was running and felt a sudden pop in
his knee, and the past few days he has found the knee is often
locking up, making it difficult to fully extend. And physical exam you note
joint line tenderness in the right knee as well as a palpable click and pain
when performing the McMurray test. What type of injury to this patient likely sustain?
So that's going to be a meniscal tear, all right, So what
are the keys here to tell us this is a meniscal injury and not some
other type. First the pop and lock of the knee. It's common for
a patient with a miniscal injury to complain of a pop, lock and drop,
so the knee popping, locking where they can't fully extend the knee,
and then sometimes the knee even giving out where they drop because the knee just
gave way. And then finally the physical exam findings which are key. First
the joint tenderness, which is a very sensitive physical exam finding, but it's
non specific. But then we have our McMurray test, which seals the deal,
which is a pain will pop or click in the knee with repetitive passive
flection and extension. If you ever forget that, the McMurray test is associated
with meniscal injuries. So Murray is obviously a man's name, and meniscal when
broken down, has the words men is call, So men is call?
Remember men is called? And what are men called? Murray as in the
McMurray test. So if you see an exam question or the answers with the
name Murray in it, remember that's a man's name, and it's what men
are called, as in menace called. And then I'll help you. Remember
the McMurray test is used in miniscal tears. Question forty eight. Twenty two
year old Mail presents the office today complaining of swelling in his right upper arm
that has increased in size over the past year. State's theoria is not painful.
Radiographs are obtained which reveal a large pedunculated lesion that is pointing away from
the joint space. A biopsy is obtained in the physician informs the patient that
the swelling they have in their arm is caused from the most common type of
benign bone tumor. What type of benign bone tumor? Does this patient likely
have, so that is an osteochondroma. So osteochondromas are the most common benign
bony tumor, counting for thirty percent of all benign bone tumors. Usually,
these types of tumors are seen in the second decade of life, more common
in males than females, and often, although not always, the mass will
be described as pain less and then on radiograph look for them to describe as
the mass as pointing away from the joint space. And then sometimes the lesion
can be described as being pedunculated, which we see in this patient, which
just means the cap is larger than the base. Think of a mushroom,
so narrow stock, big cap be aware. Also, sometimes the legions can
be described as sessile, which means the base is larger than the cap,
but often you'll see them being described as pedunculated. Question. Twenty nine year
old female presents the the office complaining of anterior knee pain. She denies history
of trauma to the knee. She is an avid runner and has a marathon
coming up in the next few weeks and is hoping for some improvement before the
event. And physical exam lateral movement of the patella results in discomfort and apprehension
from the patient. What common disorder of the knee is this patient likely suffering
from. So that is patelo femorl syndrome. So when you get this question
on an exam, it's always going to look the same. It's going to
be a female runner or cyclist with knee pain, no trauma. You really
just need to decide on one thing. Is this patelo flemorl syndrome or is
this iliotibial band syndrome? Very simple. If it's anterior knee pain, it's
patelo flemorl syndrome. If it's lateral pain, it's iliotibial band syndrome. Easiest
way to remember this is just to think of the anatomy involved. Maybe you
can't remember where your iliotibial band is, but I'm sure all of us know
where our patella is, our kneecap, anterior side of the knee. So
if it's a female runner with anterior knee pain, it's patelo flemorl syndrome.
As in the case of our patient in this vignette, she also has a
positive apprehension sign, which is where you have the patient flex the knee slightly,
apply some lateral pressure to the patella, and if they squirm around or
attempt to straighten the knee, that's a positive test. If you can't remember
that Patelo fmorl syndrome is the most is most common among female runners, just
remember it like I did, instead of remembering Patelo femoral syndrome. Instead of
remember it as Patelo female run syndrome. So instead of Patelo femoral syndrome,
Patelo female run syndrome. As those are the key things to remember about this
condition. Question fifty blank fractures are the most common carbal bone fracture. Blank
fractures are the most common carpal bone fracture. So that's scafoid fractures. So
I figured i'd end this on an easy one. Scafoid fractures are the most
common carbal bone to fracture. As we just went over a few minutes ago
in question forty five, make sure to look out for snuffbox tenderists in these
types of fractures. All right, those fifty high old MSK questions. Hopefully
that will help you for your exam. Thank you as always for listening to
the podcast. Good Luck on your exams, good luck in PA school,
your pants, your pantry and your rs.