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Find a mistake? Email dlynch@creighton.edu -Musculoskeletal and Integument Questions-
Questions by Lecture: L01-Yee-Questions 1, 4, 5 L02-03-McGuire-Questions 25-27 L04-Burd-Questions 2, 3, 13 L05-07-Kenik-Questions 6-9, 14, 32 L08-Scofield-Question 10, 40, 41 L09-11-Hurley-Questions 11,12, 15-17 L12-Gale-Questions 28, 29 L13-14-Hunter-Questions 20-24 L15-Hunter-Questions 33-35 L16-Brumback-Questions 36-39 L17-Yee-Questions 30, 31, 69 L18-Hunter-Questions 33-35 MDC-Questions 18,19 L19-Hunter-Questions 42, 43 L20-Hunter-Questions 44, 45, 72 Histopathology Lab-Hunter-Questions 46-49 L21-22-Huerter-Questions 50, 51, 65, 67, 70 L23-24-Shehan-Questions 52-54, 71 L25-Hansen-Questions 55, 59, 60 L26-27-Dowd-Questions 61-64 L28-Scofield-Questions 56-58 Overview Questions - 66, 68
Questions 1-5 1. In formation of the long bones, the primary ossification center can best be described as: A. osteoblasts which deposit bone near the epiphyseal capillaries B. osteoclasts which remove bone near the epiphyseal capillaries C. osteoclasts which remove bone near the medullary cavity in the middle third of the bone D. osteoblasts which deposit bone near the periosteum in the middle third of the bone
2. Which of the following is not an absolute indication for surgery for a patient with a herniated lumbar disc? A. patient rates pain as a 10 out of 10 refractory to physical therapy B. sciatica which has intensified over the last 2 months C. patient can not walk because of left leg weakness D. bilateral leg weakness, bilateral absence of ankle reflex, decreased rectal tone
3. Your 55 year old patient has had chronic back pain for many years, and you suspect a herniated lumbar disc. He is not a candidate for surgery. He works at the bank as a teller sitting down most of the day. What is the best advice to reduce intradiscal pressure while he works? A. remain sitting, but sit up as straight as possible B. remain sitting, but lean forward 10 degrees C. avoid sitting, stand up straight instead D. avoid sitting, stand up while leaning forward 10 degrees
4. Endochondral ossification is best described by which of the following? A. mesenchymal cells differentiate into osteoblasts which make bone B. mesenchymal cells differentiate into chondrocytic cells to make hyaline cartilage, which is calcified C. mesenchymal cells differentiate into chondrocytic cells to make hyaline cartilage, which is replaced by bone D. mesenchymal cells differentiate into osteoblasts to make hyaline cartilage which is calcified
5. The production of cartilage matrix would most likely be happening in which zone of the epiphyseal growth plate? A. resting zone B. proliferative zone C. hypertrophic cartilage zone D. calcified cartilage zone E. ossification zone
Answers 1-5 1. Answer D The primary ossification center arises around 8 weeks when osteoblasts deposit bone beginning at the outside of the bone (periosteum).
2. Answer C The three absolute indication that Dr. Burd gave are Cauda Equina Syndrome (answer D), progressive neurological deficit (answer B), and intractable pain (answer A). Profound weakness, the need to return to work, and persistent pain are all relative indications for surgery.
3. Answer C Dr. Burd's slide shows that the worst position to be in is sitting down while leaning forward. In order of increasing pressure: lying down<standing<sitting. Leaning forward only increases pressure.
4. Answer C Endrochondral ossification involves replacing hyaline cartilage with type I cartilage that is then calcified. Answers B and D would simply result in "calcified cartilage, not bone", to quote Dr. Yee. Intramembranous ossification is involved in making facial bones, and that process is described in answer A.
5. Answer A The resting zone is involved in production of cartilage. The proliferative zone has increasing number of cells, easily identified by the stacks of thin cells. The hypertrophic cartilage zone is where the cells from the proliferative zone stop replicating and grow. Together, these three zones are responsible for the growth of the epiphyseal growth plate.
Questions 6-10 6. A 60 year old patient is being treated for diabetes and hypertension. Recently he has had trouble getting out of his chair, and claims that he feels 'weak'. His CPK is elevated. Which of the following medications could cause this? A. lispro B. nystatin C. metoprolol D. metformin E. simvastatin
7. Mixed connective tissue disease, or MCTD, can mimic scleroderma. What serologic criteria is found in MCTD but not in systemic sclerosis? A. anti-double stranded DNA antibodies B. anti-ribonucleoprotein (RNP) antibodies C. anti-centromere antibodies D. ANA
9. The fundamental lesion(s) in progressive systemic sclerosis (scleroderma) can best be described as an autoimmune process that results in: A. endothelial injury and excessive collagen synthesis B. endothelial injury C. excessive collagen synthesis D. T-cell mediated injury to myofibers
9. Which of the following is not responsive to steroid treatment? A. rheumatoid arthritis B. eosinophilic fasciitis C. systemic sclerosis D. carpal tunnel syndrome
10. When treating gout, which NSAID should be avoided? A. indomethacin B. acetylsalicylic acid C. sulindac D. celecoxib
Answers 6-10 6. Answer E Statins (HMG-CoA reductase inhibitors) can cause myopathy. Don't confuse these with nystatin (used to treat candidiasis). Other drugs which can cause myopathies are alcohol, corticosteroids, colchicine, zidovudine, and hydroxychloroquine.
7. Answer B Almost all cases of MCTD have anti-RNP antibodies. MCTD will have features of systemic sclerosis, Raynaud's phenomenon, and inflammatory myositis. ANA is a feature of systemic sclerosis (and also SLE, Sjogren syndrome, inflammatory myopathy, et al.). Anti-centromere antibodies is more likely found in limited sclerosis, or CREST syndrome. Anti-dsDNA is specific for SLE.
8. Answer A In scleroderma, two things are happening. First, small vessel endothelial cells are damaged. Secondary to this damage, excessive collagen is produced that manifests as tightening of the skin. In addition to the superficial damage, there is fibrosis in the kidneys (causing hypertension), lungs (difficulty breathing), and GI tract (malabsorption et al). Answer D describes polymyositis and dermatomyositis.
9. Answer C Systemic sclerosis is only treated for its complications, such as hypertension.
10. Answer B Aspirin is contraindicated in gout since it lowers secretion of uric acid in the proximal tubule. As an aside: remember what a proximal tubule looks like? There are no clear boundaries between the cells.
Questions 11-15 11. Which of the following is not a feature of ankylosing spondylitis? A. results in new bone formation B. pain improves with activity C. preferential targeting of spine D. women are more affected than men
12. Which of the following does not correctly state a difference between gout and calcium pyrophosphate deposition disease (CPPD)? A. Gout crystals are strongly birefringent, unlike CPPD crystals which are weakly birefringent. B. Gout crystals are needle shaped, whereas CPPD crystals are rhomboid shaped. C. Blood tests are not diagnostic in gout, but are diagnostic in CPPD. D. X-rays are useful in diagnosing CPPD, but are not useful in diagnosing gout.
13. A patient complains of pain radiating from the deltoid and across his upper chest. Which dermatome is this? A. C4 B. C5 C. C6 D. C7 E. C8
14. A patient complains of difficulty moving his foot following a cycling accident. You find that on his right side, the patient has difficulty everting his foot and decreased ankle jerk. The left ankle jerk is normal. The knee jerk is present bilaterally, and his strength is otherwise normal. Which of the following injury best explains his condition? A. far lateral herniation of L3-4 disc B. far lateral herniation of L4-5 disc C. far lateral herniation of L5-S1 disc D. posterio-lateral herniation of L4-5 disc E. posterio-lateral herniation of L5-S1 disc
15. Which patient can be diagnosed with fibromyalgia following standards of the American College of Rheumatology? A. 17 year old female with 3 months of neck and shoulder pain and 14 tender points B. 58 year old man with 4 months of widespread pain and 11 tender points C. 40 year old female with 8 weeks of widespread pain and 12 tender points
Answers 11-15 11. Answer D Unlike rheumatoid arthritis, ankylosing spondylitis (AS) is more likely to affect men. AS affects ligaments and tendons, particularly where they attach to bone. This results in fusion of the spine, seen as 'bamboo spine' on an X ray.
12. Answer C Blood tests are not diagnostic in either disease. In gout, hyperuricemia may not be present even during an acute attack. Blood tests are not helpful in diagnosing CPPD, although low serum calcium levels would likely rule it out.
13. Answer B
14. Answer E The injured nerve rook is S1. This could be caused by postero-lateral herniation of the L5-S1 disc. If the herniation were far lateral in this disc space, then L5 would be most likely be affected. If the L5 nerve root were affected, then there would be a decreased knee jerk and weakness in the extensor digitorum. If the L4 nerve root were affected, there would be a decreased knee jerk and weakness in the tibialis anterior (weak foot inversion).
15. Answer B The criteria are 3 months of chronic widespread pain with 11 tender points. Fibromyalgia tend to occur more often in women, and may be associated with increased levels of substance P.
Questions 16-20 16. Which of the following is the most likely location to be affected in both chronic degenerative joint disease and rheumatoid arthritis? A. PIP B. DIP C. MCP D. wrist
17. For treating fibromyalgia, which pharmacologic therapy has not been shown to result in significant improvement? A. tricyclic antidepressants (amitriptyline) B. serotonin norepinephrine reuptake inhibitors (dulonetine) C. analgesics (tramadol) D. dopamine agonists (bromocriptine) E. anticonvulsants (gabapentin)
18. Which type of melanoma is highly invasive because it lacks the radial growth phase? A. superficial spreading melanoma B. nodular melanoma C. lentigo maligna melanoma D. acral lentiginous melanoma
19. Which of the following skin cancers is least likely to metastasize? A. basal cell carcinoma B. squamous cell carcinoma C. malignant melanoma
20. The genetic defect that results in the complete loss of hypoxanthine guanine phosphoribosyl-transferase (HGPRT) is: A. the most common cause of gout B. a condition that leads to hypouricemia C. the most common cause of pseudogout D. a condition that leads to mental retardation, self-mutilation, and hyperuricemia
Answers 16-20 16. Answer A Rheumatoid arthritis preferentially affects the wrist, MCP, and PIP. Chronic degenerative joint disease preferentially affects the PIP, DIP and base of the thumb. The rheumatoid lesion will feel softer than the bony change in chronic degenerative disease. Listen to L10-Hurley from Spring 2008 at 7 minutes to review.
17. Answer D
18. Answer B Nodular melanoma is highly invasive and has a poor prognosis because it lacks the radial growth phase. Think NOdular as in NO radial growth phase. Remember that the radial growth phase is when the melanoma does not penetrate the basement membrane. The vertical growth phase is worrisome because it penetrates through the skin.
19. Answer B Basal cell carcinoma has a rare incidence of metastasis. Out of these three, melanoma is the most likely to metastasize, up to 20% of cases.
20. Answer D Lesch-Nyhan syndrome is an X-linked genetic disorder that results in complete loss of HGPRT. An obvious manifestation is hyperuricemia, which may lead to gout. (Remember that hyperuricemia does not automatically result in gout!) Lesch-Nyhan syndrome is rare, and accounts for a small percent of gout cases. More importantly, this syndrome results in severe neurological defects, including mental retardation and self-mutilation. Gout most often occurs as a primary condition when the enzyme defect is not known.
Questions 21-25 21. Which of the following bone disorders could present as either decreased or increased bone formation? A. osteogenesis imperfecta B. osteoporosis C. osteopetrosis D. osteitis deformans (Paget disease) E. none of the above
22. Which of the following statements best describes the most common benign bone tumor, an osteochondroma? A. Usually in the metaphysis of the distal femur, it is composed of cartilage and bone B. Usually in the metaphysis of the distal femur, it is composed of marrow, cartilage, and bone C. Usually in the epiphysis of the distal femur, it is composed of cartilage and bone D. Usually in the epiphysis of the distal femur, it is composed of marrow, cartilage, and bone
23. A 20 year old man presents with a 3 month history of pain around his left knee. An X-ray reveals lifting of the periosteum at the distal femur surrounded by a radio-opaque area with a spiked appearance. His family history is significant for retinoblastoma. What is the most likely diagnosis? A. osteoblastoma B. Paget disease C. osteosarcoma D. Ewing's sarcoma E. chondrosarcoma
24. An otherwise healthy and normal appearing 1 year old boy presents to the Dallas, TX emergency room after a mild fall with a broken tibia and humerus. His parents say he just started taking his first steps a few days ago. They report a history of many broken bones in the family. What is the most likely fundamental problem in this family? A. defective type I collagen production B. defective type IV collagen production C. mutation in FGFR3 D. vitamin D deficiency
25. A cartilage tumor is more likely to be benign if: A. it is large B. it is peripheral C. there are multiple masses D. it is painful
Answers 21-25 21. Answer D Paget's disease has an early phase of bone resorption and a late phase of bone formation. The end result is that there is a large amount of weak bone produced. Paget's may be triggered by a viral infection. Osteogenesis imperfecta is caused by defecteve type I collagen (decreased bone). Osteopetrosis is the result of decreased bone resorption by osteoclasts (increased bone).
22. Answer B Dr. Hunter said that its important to know where these tumors are found. Knowing where the most common tumors are should equal easy points on the quiz. Osteochondromas occur most often in young adult males.
23. Answer C If the bone pathology is at the knee, it's most likely osteochondroma or osteosarcoma. The radiographic findings in this case are indicative of osteosarcoma, which is the most common primary malignant tumor of the bone. (In other words, Dr. Hunter will ask a question about it). It is found around the knee most often, in the metaphysis of either the femur or tibia. Many texts describe the X ray as spiculated (spiky) or sunburst in appearance. Also, Codman's triangle is present, described as lifting of the periosteum. Here's where the other tumors are found: Osteoblastoma = vertebra Ewing = proximal femur / pelvis chondrosarcoma = proximal femur / pelvis
24. Answer A Osteogensis imperfecta is the result of deficient type I collagen production. There are many variants of the disease. Another reasonable answer is vitamin D deficiency. However, rickets does not generally present with broken bones upon minor trauma. Moreover, vitamin D supplementation in milk and cereal largely avoids this condition. It is much more likely to believe a genetic inheritance pattern than a long history of avoiding all foods which contain vitamin D (cereal, milk, beef, eggs, fish).
25. Answer B Dr. McGuire sad that benign cartilage tumors tend to be small, peripheral, solitary, and painless.
Questions 26-29 26. An 60 year old man complains of 6 months of upper thigh pain. He denies any trauma. X ray of his hip shows a large radiolucent lesion around the proximal third of the femur with speckled calcification. What is the most likely diagnosis? A. chondroma B. chondrosarcoma C. osteosarcoma D. avascular necrosis of bone
27. When is the earliest you would expect a broken bone to have a hard callus? A. 2 days B. 2 weeks C. 6 weeks D. 10 weeks
28. The first motor units recruited in any given movement is likely to be: A. large oxidative motor units B. small oxidative motor units C. large glycolytic motor units D. small glycolytic motor units
29. Which of the following is not a feature of 'fast twitch' muscle fibers, as compared to 'slow twitch' muscle fibers? A. low oxidative capacity B. high excitability C. large diameter D. high sarcoplasmic reticular Ca++ pumping capcity
30. Which of the following cell types is normally not found in the epidermis? A. keratinocyte B. melanocyte C. Langerhans cell D. Merkel cell E. dendrocyte
Answers 26-29 26. Answer B The location and radiograph findings are typical of chondrosarcoma, a malignant cartilage producing tumor. Chondroma is less likely since the lesion is large, central, and painful (key differences that indicate malignancy). Osteosarcoma is usually found in a younger population at the knee, and has a spiculated appearance on X ray. Avascular necrosis of bone may be idiopathic or follow trauma. It would not result in a large lesion on the femur.
27. Answer D In the reparative phase of fracture repair, a soft callus is formed from 4-8 weeks followed by a hard callus from 8-12 weeks. The soft callus is composed of hyaline cartilage whereas hard callus is composed of bone. Here's the article I found that said a bony callus should be evident by 4 weeks at the latest (which made me rewrite the question). Normally there is radiographic evidence of healing by 2 weeks.
28. Answer B The slow (oxidative) motor units are recruited first. The smallest motor units are recruited first.
29. Answer B Slow (oxidative) muscle fibers are much more excitable that fast muscle fibers, and are therefore the first fibers recruited for movement.
30. Answer E Dendrocytes are found in the dermis
Questions 31-35 31. Bullus pemphigoid is an autoimmune disorder that attacks the basement membrane between the epidermis and the dermis via IgG antibodies. Between what two layers would the IgG be deposited? A. stratum basale and reticular dermis B. stratum basale and papillary dermis C. stratum spinosum and reticular dermis D. stratum spinosum and papillary dermis E. stratum spinosum and stratum basale
32. A patient presents with a 3 month history of progressive weakness. On physical examination, you find bilateral decreases in strength in the legs and back. In addition, she has a rash surrounding both eyes. Laboratory values are significant for elevated LDH and CPK, and a positive ANA. What is the diagnosis? A. SLE B. myasthenia gravis C. Lambert-Eaton syndrome D. scleroderma E. dermatomyositis
33. A 70 year old man presents with discomfort in his thigh for 2 months. X ray revealed a radiolucent mass without any calcification. Biopsy of the tissue showed a pinwheel pattern of fibroblasts. Which soft tissue tumor does he most likely have? A. liposarcoma B. fibrosarcoma C. malignant fibrous histiocytoma D. lipoma
34. Rhabdomyosarcoma is the most common soft tissue tumor of which age group? A. 0-15 B. 15-30 C. 30-50 D. 50-70 E. 70+
35. A 50 year old man has had a painless, slowly enlarging mass in his arm for the past 2 years. A biopsy reveals a herringbone pattern. What is the most likely diagnosis? A. liposarcoma B. fibrosarcoma C. malignant fibrous histiocytoma D. lipoma
Answers 31-35 31. Answer B
32. Answer E These are typical findings for the CD8+ T cell mediated injury to myofibers in dermatomyositis. If there were no rash, polymyositis would be likely. Additional tests to diagnose include EMG of the muscles, and biopsy.
33. Answer C The real tipoff here is that the biopsy has a pinwheel patten. Dr. Hunter describes it as 'storiform'. Malignant fibrous hisiocytoma is the most common sarcoma of the elderly (60s & 70s). Not only is it common, but it's deadly since it metastasizes up to 50% of the time.
34. Answer A Rhabdomyosarcoma (malignant skeletal muscle tumor) is a small blue cell tumor and is the most common soft tissue sarcoma in children. It comes in three types, perhaps the most important is embryonal. It may present as a grape-like mass protruding from the vagina. Knowing this rather distinct presentation should be easy points on a test.
35. Answer B Like question 33, the real tipoff is knowing that cellular pattern on the biopsy. Fibrosarcoma looks like a herrigbone patten. This tumor commonly presents as a slow growing painless mass in the upper extremity. Here's what the biopsy would look like. Below it is what a herringbone pattern looks like.
Questions 36-40 36. Which stain(s) could you use to visually differentiate Type I and Type II muscle fibers? A. lipid stain (Oil Red O) B. oxidative stain (NADH) C. glycogen stain (PAS) D. ATPase stain E. all of the above
37. Small vessel vasculitic myopathy best describes which of the following? A. Kearns-Sayre syndrome B. Becker muscular dystrophy C. polymyositis D. dermatomyositis E. nemaline myopathy
38. Which two of the following mitochondrial myopathies can present with neurologic pathology? Which two present with ocular pathology? A. Kearn's Sayre syndrome B. MERRF C. Leber's syndrome D. MELAS
39. Which is not a characteristic of neurogenic muscle disease? A. two sizes of muscle fibers are evident B. loss of mosaic appearance (ie group typing) C. extensive fibrosis D. muscle fibers become thin and pointed
40. Of the following patients with gout, who should not be treated with oral colchicine? A. A 50 year old with longstanding hypertension B. A 45 year old with Chron's disease C. A 25 year old with diabetes D. A 70 year old with dementia
Answers 36-40 36. Answer E Remembering the properties of Type I and Type II fibers should make A, B, and C obvious choices. Therefore, all of the above must be the right answer. The ATPase stain may be a less obvious choice, but it is used commonly because it gives the clearest results. The other stains can be somewhat ambiguous.
37. Answer E Dermatomyositis is a complement mediated, small vessel vasculitic myopathy that results in perifascicular atrophy. Dr. Brumback made a point to repeat that statement. Polymyositis differs grossly in that it does not involve a rash and microscopically in that lymphocytes invade the muscle fibers. Both polymyositis and dermatomyositis result in proximal muscle weakness (ie trouble getting out of a chair) and elevated plasma muscle enzymes (CKP, myoglobin). Kearns-Sayre syndome is one of many mitochondrial myopathies. This presents as eye muscle paralysis. Leber's optic atrophy results in blindness.
38. Neurologic: B and D; Ocular A and C Dr. Brumback went quickly through these, but here's the key points: Leber's = progressive blindness Kearns-Sayre=can't move eye muscles MERRF=seizures MELAS=seizures and stroke episodes
39. Answer C Fibrosis tends to occur is the problem is myopathic. Neurogenic disease results in a group of muscle fibers first becoming smaller (answer A) and angulated (answer). When these fibers are reinnervated, they tend to become the same as neighboring muscle fibers (answer B).
40. Answer B Colchicine (especialy orally) can cause GI effects including diarrhea, nausea, and vomiting. An individual with an inflammatory disease of the GI tract would be a poor candidate for colchicine.
Questions 41-45 41. Which is the best explanation for why allopurinol is beneficial in treating gout? A. Allopurinol prevents the formation of uric acid, causing the buildup of more soluble molecules. B. Allopurinol prevents the formation of uric acid as a non-purine analog xanthine oxidase inhibitor. C. Allopurinol competitively inhibits HGPRT D. Allopurinol acts of the proximal tubule to prevent reabsorption of uric acid
42. You are looking at a biopsy specimen from a suspicious skin lesion. The tissue consists mainly of spindle cells in a storiform pattern, and it stains with CD34. What is the most appropriate statement to tell the patient? A. This is characteristic of basal cell carcinoma, which rarely metastasizes. B. This is characteristic of dermatofibrosarcoma, a rare but treatable skin cancer. C. This is characteristic of actinic keratosis, a precursor to squamous cell carcinoma D. This is characteristic of keratoacanthoma, a neoplasm that heals spontaneously
43. A 45 year old patient presents to you with dozens of velvety pigmented papules on his trunk and extremities that appear stuck on. He is concerned since he had very few nevi before 3 months ago. Which of the following aspects of his history is most relevant to his current lesions: A. He works as a charter fishing guide in Florida B. He has a 40 pack/year history of smoking C. He has had 20 lifetime male sexual partners D. He has controlled diabetes
44. After walking in the woods while wearing sandals, a 20 year old man develops a weeping erythematous rash with vesicles. Which type of cell is least likely to be involved in this reaction? A. neutrophil B. Langerhans cell C. CD4+ T cell D. CD8+ T cell
45. Erythema multiforme is a hypersensitivity reaction in the skin characterized by targetoid vesicles. It can be triggered by infection, drugs, and malignancy, among others. How is Stevens-Johnson syndrome different from erythema multiforme? A. Stevens-Johnson syndrome involves mucosal membranes B. Stevens-Johnson syndrome is only involved on the the extremities C. Stevens-Johnson syndrome is a type IV hypersensitivity reaction, not a type II like erythema multiforme D. Stevens-Johnson syndrome is not triggered by drugs
Answers 41-45 41. Answer A Allopurinol is a purine analog xanthine oxidase inhibitor. Its actions result in the buildup of hypoxanthine and xanthine which are more soluble than uric acid. Answer B describes febuxostat. Answer C would make gout worse. Answer D describes both probenacid and sulfinpyrazone, two uricosuric agents.
42. Answer B The storiform patten of spindle cells is most characteristic of dermatofibrosarcoma. The other lesions tend to involve keratinocytes. Another reasonable answer for this biopsy would be Kaposi sarcoma, especially if we knew that the patient was immunosuppressed.
43. Answer B He most likely has many seborrhei keratoses. These can develop as an explosion of growth, which is associated with paraneoplastic syndrome. This is called the Leser-Trelat sign. His age and smoking history put him at high risk for lung cancer.
44. Answer D The delayed type IV hypersensitivity reaction begins when Langerhans cells are exposed to an antigen (such as poison ivy). The antigen is then presented to CD4+ T cells. These T cells are responsible for producing the eczema upon re-exposure. They produce cytokines which attract inflammatory cells such as neutrophils.
45. Answer A Stevens-Johnson syndrome is a more extensive form of erythema multiform that involves both the skin and the mucosal membranes. Both are type II hypersensitivity reactions.
Questions 46-50 46. The H&E of a skin biopsy seen below was most likely taken from a patient with:
A. superficial spreading melanoma B. squamous cell carcinoma C. basal cell carcinoma D. bullus pemphigoid E. seborrheic keratosis
47. How would you treat a patient with the lesion seen in this skin biopsy?
A. antibiotics B. antivirals C. resection of lesions D. steroids E. allopurinol
48. This tissue section came from a skin lesion that is best described as:
A. common, malignant B. rare, malignant C. common, benign D. rare, benign E. common, precursor of malignancy
49. A 20 year old male had noticed increasing pain around the knee over the last 3 months. A biopsy of the proximal tibia was taken and results are shown below. What would you most expect from an X ray of his knee?
A. These cells are producing cartilage, so the X ray would be radiolucent B. These cells are producing osteoid, so the X ray would show new bone growth C. These cells are destroying his tibia, so the X ray would be radiolucent D. These cells are essentially normal, so the X ray would reveal no pathology
50. Your patient has an erythematous, weeping lesion on her face. If you treat this lesion with steroids, which of the following preparations is most appropriate? A. non-fluorinated ointment B. non-fluorinated cream C. non-fluorinated lotion D. fluorinated ointment E. fluorinated cream F. fluorinated lotion
Answers 46-50 46. Answer C This is an example of palasading cells. They form a ring around the tumor islands. This is evident in cancers resulting from the basal cell layer in the epidermis.
47. Answer D This is bullous pemphigoid, a disease caused by IgG antibodies against the basement membrane between the epidermis and dermis. In the picture, the epidermis and dermis have separated. In pemphigus vulgaris, the antibodies are directed against desmosomes within the epidermis. In either case, immunosuppression by steroids is the most effective treatment.
48. Answer C This is seborrheic keratosis. It is a common, benign lesion which exhibits epidermal hyperplasia and horn cysts.
49. Answer B This patient falls in a likely group for osteosarcoma. The biopsy shows new osteoid being produced (the pink stuff), and this would appear as a sunburt or spiculated pattern on an Xray. Dr. Hunter said in the histopath lab to compare the following three bone cancers:
50. Answer C Don't use a potent steroid on warm, wet areas such as the face, axilla, and groin. Potent steroids tend to be fluorinated. Since the lesion is 'wet' (weeping), it would be better to use a lotion. Lotions, powders, and wet dressing are better for acute inflammation which tends to be wet. Chronic inflammation should be treated with an ointment. For example, an area of severe scaling lichenification would be treated with a fluorinated ointment.
Questions 51-55 51. A KOH (potassium hyroxide) solution is least helpful in the diagnosis of which of the following? A. yeast infection B. fungal infection C. bacterial infection D. mites E. scabies
52. A 16 year old patient presents complaining of a rash. On examination, he has numerous red papules on his trunk and extremities, parts of which appear dry and silver in color. Which of the following most likely caused his rash? A. Recent withdrawal from systemic steroids B. Recent treatment with nystatin C. Recent streptococcal infection D. Frequent bathing
53. Hemangioma of infancy is characterized by all of the following except: A. it often shrinks after the first year B. it is far more likely to affect females C. it is the most common tumor of infancy D. it is made of benign proliferation of blood vessels E. it is premalignant
54. Which of the following is not associated with an increased risk of skin cancer? A. organ transpantation B. chronic, non-healing wounds C. AIDS D. tattoos E. Xenoderma pigmentosum F. tanning beds G. sunlight H. HPV
55. Which correctly pairs the cancer with an appropriate underlying mutation: A. Merkel cell carcinoma, ICAM-1 B. squamous cell carcinoma, p53 C. basal cell carcinoma, BRAF D. melanoma, ras
Answers 51-55 51. Answer C A 10% KOH solution is used to dissolve keratin. This allows for easy identification of yeast and hyphae, fungus, and parasites such as mites or scabies. A Gram stain is most appropriate for bacteria.
52. Answer C This pattern is Guttate psoriasis. It commonly occurs after a strep infection. Withdrawal of systemic steroids may induce pustular psoriasis. Nystatin can cause a delayed type IV hypersensitivity reaction, but the rash would appear as erythematous, weeping skin with vesicles. Frequent bathing may cause eczema.
53. Answer E Hemangiomas are common, benign tumors that tend to affect females. They tend to regress after the first year. They require close monitoring, although they do not become malignant.
54. Answer D Tattoos have no association with skin cancer. Tanning beds have been conclusively shown to increase risk for melanoma.
55. Answer B SCC is better associated with p53 mutations. BRAF mutations are more characteristic of melanoma (in addition to CDKN2A).
Questions 56-60 56. Excessive topical use of which of the following drugs is most likely to result in toxicity characterized by vomiting, blurry vision, and tinnitus? A. salicylic acid B. azelaic acid C. adapalene D. calcipotriene E. PABA
57. Which sunscreen is best at blocking UVA1, UVA2, and UVB? A. PABA B. cinoxate (a type of cinnamate) C. titanium dioxide D. oxybenzone (a type of benzophenone)
58. When treating a severe case of psoriasis in a patient with decreased kidney function, which of the following should be avoided? A. acitretin B. cyclosporine C. methotrexate D. alefacept
59. Which wavelength of UV radiation is most likely to pass through the atmosphere to reach the surface of the earth? A. 350 nm B. 300 nm C. 250 nm D. all of the above are equally likely to pass through the atmosphere
60. After DNA damage, which proteins are involved in stopping the cell cycle to facilitate repair? A. p53 B. ATR C. p16 (ink4a) D. all of the above E. Both A and B F. Both A and C
56. Answer A The toxicity described in the question is salicylism which can also occur from the acne medication salicylic acid. More often, salicylism is from aspirin overdose.
57. Answer C The physical sunscreens such as titanium dioxide and zinc oxide are those that reflect light across the spectrum. Cinnnamtes and PABA are for UVB. Benzophenones are for UVB and UVA2.
58. Answer B Renal toxicity is associated with cyclosporine. Acitretin, as with most retinoids, should be avoided in pregnant women. Methotrexate is a folic acid analog that causes antimitotic effects. Alefacept blocks T cells via the CD2 receptor.
59. Answer A UVA light has the longest wavelength, the lowest energy, and the best chance to penetrate the atmosphere. Answer B is UVB light, which is partially blocked. Answer C is UVC light which is almost entirely blocked.
60. Answer D
Questions 61-65 61. Thromboxane A2 is formed in __________ and acts as a __________. A. platelets, vasoconstrictor B. platelets, vasodilator C. RBCs, vasoconstrictor D. RBCs, vasodilator E. WBCs, vasoconstrictor F. WBCs, vasodilator
62. What is the primary advantage of a selective COX2 inhibitor versus a non-selective COX inhibitor? A. COX2 inhibitors are less expensive B. COX2 inhibitors have less GI effects C. COX2 inhibitors cause vasodilation D. COX2 inhibitors are not converted in toxic metabolites in heavy alcohol users
63. Which of the following is not a feature of acetaminophen? A. may cause hemolytic anemia in rare cases B. may cause kidney toxicity C. may cause methemoglobinemia D. may cause hepatic necrosis in alcoholics E. may cause Reye's syndrome in children
64. Which of the following patients should be given acetaminophen (instead of aspirin) for fever and pain reduction? A. 50 year old man with chronic gouty arthritis B. 30 year old man with ulcerative colitis C. 15 year old with well controlled asthma D. 5 year old recovering from strep throat E. all of the above should be given acetaminophen
65. An elevated skin lesion that measures 7mm in size is best described as a : A. macule B. papule C. patch D. plaque E. vesicle
Answers 61-65 61. Answer A Thromboxane A2 also causes platelet aggregation. It is derived from prostaglandins in the COX1, or constitutive, pathway.
62. Answer B Since the COX1 pathway is still intact, there are less likely to be GI effects. Selective COX2 inhibitors are expensive and may cause vasoconstriction (CV risk). Acetaminophen (not nonselective COX inhibitors) is converted into toxic metabolites when taken by alcoholics.
63. Answer E Reye's syndrome a feature of aspirin when used in children often following viral infection. It causes neurologic symptoms (from encephalopathy) and liver damage and is often fatal. Acetaminophen can cause liver and kidney toxicity, and may cause methemoglobinemia (Fe+3 in hemoglobin that can't carry oxygen). Rarely, it causes hemolytic anemia.
64. Answer E Acetaminophen is preferred over aspirin in a variety of cases including: gout, asthma, GI irritation, and young patients.
65. Answer B Macule (<1cm) and patches (>1cm) are flat. Papules (<1cm) and plaques (>1cm) are raised (ie palpable). Vesicles (<0.5cm) and bulla (>0.5cm) are fluid-filled blisters.
Questions 66-70 66. Rheumatoid arthritis is the same type of hypersensitivity reaction as A. contact dermatitis to nickel earrings B. SLE C. uticaria in response peanuts D. bullous pemphigoid E. erythema multiforme
67. Which of the following is a feature of lichen planus not found in psoriasis? A. appears as white over a pink papule B. arthritis C. often affects both the skin and mucosae D. more commonly found on elbows and knees
68. Which of the following does not produce a rash on the palms and/or soles? A. syphilis B. Rocky Mountain spotted fever C. erythema multiforme D. Reiter's arthritis E. all produce rashes on the palms and/or soles
69. Which of the following correctly orders the layers of skin from the outside inward? A. s. corneum, s. granulosum, s. spinosum, s. basale, papillary dermis, reticular dermis B. s. corneum, s. spinosum, s. granulosum, s. basale, papillary dermis, reticular dermis C. s. corneum, s. granulosum, s. spinosum, s. basale, reticular dermis, papillary dermis D. s. corneum, s. granulosum, s. spinosum, s. basale, reticular dermis, papillary dermis
70. Which of the following best describes an ointment? A. powder in water B. water in oil C. oil in water emulsion
Answers 66-70 66. Answer B Both rheumatoid arthritis and SLE are type III hypersensitivity reactions (immune complex). Answer A is type IV, C is type I, D and E are type II.
67. Answer C Psoriasis does not affect the mucosae, but up to 70% of patients with lichen planus are affected on the mucosae. Answer A is a feature of both diseases, and B and D are characteristic of psoriasis alone. Dr. Shehan describes lichen planus as "pruitic, purple, polygonal papules".
68. Answer E Not an all-inclusive list, but these are some key ones we've covered.
69. Answer A
70. Answer B Lotion is answer A. Cream is answer C. Ointments are mostly oil, which makes them best for dry skin.
Questions 71-73 71. In the treatment of moderate to severe psoriasis, which is least appropriate? A. retinoids B. systemic corticosteroids C. anti-mitotic agents D. vitamin D3 analogs
72. In which of the following diseases are you most likely to see granular deposits of IgA at the tips of dermal papillae? A. bullus pemphigoid B. pemphigus vulgaris C. dermatitis hermetiformis D. acanthosis nigricans E. none of the above
73. In skeletal muscle contraction, where does calcium bind? A. troponin C B. tropomyosin C. myosin binding groove D. actin filament
71. Answer B Dr. Shehan was very clear in his lecture to not give systemic steroids because upon withdrawal the psoriasis may get worse.
72. Answer C Both answers A and B are from IgG antibodies. Acanthosis nigricans is hyperpigmentation, often in the axilla, and may be associated with visceral malignancy.
73. Answer A Calcium binds to troponin C cause a conformational change in tropomyosin, thereby exposing actin.
Fact Recall: Most common location for cervical disc disease? C5-6 (~50% of cervical radiculopathy) Most common lumbar sites for herniation? L4-5 and L5-S1 (90% of lumbosacral radiculopathy) Genes involved in osteoblast differentiation? osterix and Runx2 Transcription factor involved in the differentiation of mesenchymal cells into chondrocytic cells? Sox9 Adult lack of Vitamin D causes what? osteomalacia Best test to rule in rheumatoid arthritis? cyclic citrullinated peptide (CCP) Most specific test for SLE? anti-double stranded DNA antibody Clearest difference between inflammatory and non-inflammatory synovial fluid? WBCs (<2000=non- inflammatory) How do we differentiate between polymyositis and dermatomyositis? dermatomyositis has a rash Difference between metastatic cancer and vertebral osteomyelitis? cancer spares the disc Joint most often affected in gout? first MTP (ie: big toe) HLA that confers predilection for seronegative spondyloarthrophathy? HLA-B27 The body's response to loss of cartilage in joints? osteophyte, or pathologic bony outgrowth Most common malignant melanoma? superficial spreading melanoma Most common pathogen in osteomyelitis? S aureus Oncogene involved in Ewing sarcoma and Primitive Neuroectodermal Tumor? c-myc What is rheumatoid factor? IgM autoantibodies to Fc portion of IgG Most common soft tumor of adulthood? lipoma (no clinical significance) Most common primary bone tumor? osteosarcoma What stain is used to identify melanocytes? S100 What stain is used to identify Langerhans cells? CD1 Children are most likely to get which soft tissue tumor? rhabdomyosarcoma Precursor to squamous cell carcinoma? actinic keratosis Most common epithelial tumor? seborrheic keratosis Uticaria is most often which type of hypersensitivity reaction? Type I (IgE dependent) Erythema multiforme is which type of hypersensitivity reaction? Type II (antibody dependent) SLE is which type of hypersensitivity reaction? Type III (deposition of immune complex) Contact dermatitis is which type of hypersensitivity reaction? Type IV (T-cell mediated) Articular cartilage is mostly composed of what? type II collagen Genotype associated with psoriasis? HLA-Cw6 Most common tumor of infancy? hemangioma Antidote for hepatic necrosis from acetaminophen OD? N-acetyl cysteine Why does sun exposed skin get wrinkled over time? breakdown of collagen and elastin Predominant cell in a xanthoma? histiocyte Impetigo is an infection of S aureus or streptococci of what layer? stratum corneum What cell regenerates new muscle fiber after injury? satellite cell Type of muscular dystrophy that affects type I fibers? myotonic muscular dystrophy Embyologic origin of keratinocytes? embryonic ectoderm Origin of melanocytes? neural crest For melanoma, what is the Clark level that fills the papillary dermis? III Treatment for excess sweating? botox injection Most hair follicles are in what phase? anagen (growth) How can you make a definitive diagnosis of allergic (type IV) contact dermatitis? patch testing Uticaria is mediated by what action of what cell? mast cell degranulation Primary pathogenic factor in acne? comedone formation (plugging of a pore) Type of psoriasis if it affects nearly the entire body? erythrodermic Eczema is a group of inflammatory skin disorders characterized by what? itching What NSAIDS to avoid in high CV risk? selective COX-2 inhibitors (like celecoxib) Temporal arteritis associated with what musculoskeletal disorder? polymyalgia rheumatica Which band of skeletal muscle doesn't change length upon contraction? A band
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