B Rheumatoid Arthritis

(כל התשובות לשאלות וההסברים לתשובות בלינק, אין קובץ תשובות נפרד)

Question 1

An otherwise healthy 44-year-old man with no prior medical history has had increasing back pain and right hip pain for the past decade. The pain is worse at the end of the day. On physical examination he has bony enlargement of the distal interphalangeal joints. A radiograph of the spine reveals the presence of prominent osteophytes involving the vertebral bodies. There is sclerosis with narrowing of the joint space at the right acetabulum seen on a radiograph of the pelvis. Which of the following diseases is he most likely to have?

A Gout

B Rheumatoid arthritis

C Osteoarthritis

D Osteomyelitis

E Lyme disease

F Pseudogout

Question 2

An 80-year-old woman has had no major medical problems, but she has never been physically active for most of her life. One day she falls out of bed and immediately notes a sharp pain in her left hip. She is subsequently unable to ambulate without severe pain. Radiographs show not only a fracture of the left femoral head, but also a compressed fracture of T10. Which of the following conditions is she most likely to have?

A Vitamin D deficiency

B Acute osteomyelitis

C Osteogenesis imperfecta

D Osteoporosis

E Polyostotic fibrous dysplasia

F Metastatic breast carcinoma

Question 3

A 51-year-old man has noted right hip pain for the past 3 months. On physical examination he has diminished range of motion of the right hip. A radiograph reveals a 10 x 13 cm mass involving the right ischium of the pelvis. The mass has irregular borders and there are extensive areas of bony destruction along with some scattered calcifications. The lesion is resected, and grossly the mass has a bluish-white cut surface. Which of the following attributes is most likely to describe this mass?

A The most frequent primary tumor of bone

B Usually seen in distal skeletal bones

C More common in females

D Sometimes seen to arise in benign cartilagenous tumors

E Associated with Paget disease of bone

Question 4

A 62-year-old man has had back pain for 4 months. No abnormal findings are noted on physical examination. A CBC shows a WBC count of 3700/microliter, hemoglobin 10.3 g/dL, hematocrit 31.1%, MCV 85 fL, and platelet count 110,000/microliter. His total serum protein is 8.5 gm/dl with an albumin of 4.1 gm/dl. A chest radiograph shows no abnormalities of heart or lung fields, but there are several lucencies noted in the vertebral bodies. A sternal bone marrow aspirate is performed and yields a dark red jelly-like material in the syringe. Which of the following cell types is most likely to be numerous on microscopic examination of this aspirate?

A Giant cells

B Fibroblasts

C Osteoblasts

D Metastatic renal carcinoma cells

E Plasma cells

Question 5

A 58-year-old man has the sudden onset late one evening of severe pain in his left great toe. There is no history of trauma. On examination there is edema with erythema and pain on movement of the left 1st metatarsophalangeal joint, but there is no overlying skin ulceration. A joint aspirate is performed and on microscopic examination reveals numerous neutrophils. Over the next 3 weeks, he has two more similar episodes. On physical examination between these attacks, there is minimal loss of joint mobility. Which of the following laboratory test findings is most characteristic for his underlying disease process?

A Hyperglycemia

B Positive antinuclear antibody

C Hyperuricemia

D Hypercalcemia

E High rheumatoid factor titer

Question 6

A 13-year-old boy complains of pain persisting in his left leg for 3 weeks. On physical examination his temperature is 37.9 C. A radiograph of the leg reveals a mass in the diaphyseal region of the left femur with overlying cortical erosion and soft tissue extension. A bone biopsy is performed and the lesion on microscopic examination shows numerous small round blue cells. Which of the following neoplasms is he most likely to have?

A Ewing sarcoma

B Medulloblastoma

C Neuroblastoma

D Chondroblastoma

E Osteoblastoma

Question 7

A 14-year-old African man has a history of multiple episodes of sudden onset of severe abdominal pain and back pain lasting for hours. Each time this happens, his peripheral blood smear demonstrates numerous sickled erythrocytes. A hemoglobin electrophoresis shows 94% Hgb S, 5% Hgb F, and 1% Hgb A2. He now has a painful right hip that is tender to palpation. A radiograph reveals irregular bony destruction of the femoral head. Which of the following infectious agents is most likely responsible for his findings?

A Yersinia pestis

B Clostridium perfringens

C Salmonella, not typhi

D Group B Streptococcus

E Candida albicans

Question 8

A 70-year-old man has noted increasing back and leg pain for 3 years. He has greater difficulty hearing on the left. On physical examination he has decreased range of motion at the hips. Radiographs reveal bony sclerosis of the sacroiliac, lower vertebral, and upper tibial regions with cortical thickening, but without mass effect or significant bony destruction. If that weren't enough trouble, he says his hats don't even fit him anymore. He now has orthopnea and pedal edema. Laboratory studies show a serum alkaline phosphatase of 264 U/L. Which of the following conditions is he most likely to have?

A Metastatic adenocarcinoma

B Paget disease of bone

C Renal failure with renal osteodystrophy

D Decreased bone mass

E Vitamin D deficiency

Question 9

An 18-year-old woman has noted pain and swelling of her right distal thigh associated with activity for the past year. She has no history of any trauma. On examination after performing physical exercise, there is tenderness on palpation above the right knee. Radiographs show an expansile, eccentric, lytic lesion located in the metaphysis of the distal femur that is surrounded by a rim of reactive new bone as a host response. Which of the following diseases is she most likely to have?

A Fibrous dysplasia

B Ewing sarcoma

C Chondrosarcoma

D Osteosarcoma

E Aneurysmal bone cyst

Question 10

A 77-year-old man has experienced persistent dull back pain for 4 months, unrelated to physical activity. He has noted a 6 kg weight loss during this time. On physical examination there are no remarkable findings. A CT scan of the spine reveals scattered 0.4 to 1.2 cm bright lesions in the vertebral bodies. Laboratory findings include a WBC count of 6700/microliter with differential of 70 segs, 8 bands, 2 metamyelocytes, 15 lymphs, 5 monos, and 2 nucleated RBCs/100 WBCs, Hgb 11.2 g/dL, Hct 33.3%, MCV 88 fL, and platelet count 89,000/microliter. Serum chemistries include sodium 144 mmol/L, potassium 4.5 mmol/L, chloride 100 mmol/L, CO2 26 mmol/L, urea nitrogen 35 mg/dL, creatinine 3.8 mg/dL, and glucose 78 mg/dL. Which of the following additional laboratory test findings is he most likely to have:

A Blood culture positive for Neisseria gonorrheae

B Parathyroid hormone, intact, of 100 pg/mL

C Serum prostate specific antigen of 35 ng/mL

D Serum calcium of 5.5 mg/dL

E Positive serology for Borrelia burgdorferi

Question 11

A 16-year-old boy has noted pain in his left knee after each hockey practice session for the past month. On examination there is tenderness to palpation of his left knee, with reduced range of motion. A plain film radiograph of the left leg reveals a mass of the proximal tibial metaphysis that erodes the bone cortex, lifting up the periosteum where reactive new bone is apparent. The mass does not extend into the epiphyseal region. A bone biopsy is performed and microscopic examination shows atypical, elongated cells with hyperchromatic nuclei in an osteoid stroma. Which of the following neoplasms is he most likely to have?

A Ewing sarcoma

B Osteosarcoma

C Chondrosarcoma

D Multiple myeloma

E Metastatic seminoma

Question 12

A 53-year-old man has noted a slowly enlarging "bump" on his left elbow for the past 2 years. On physical examination there is a 2 cm firm, non-tender mass over the left olecranon process. The mass is excised and on sectioning has a chalky white consistency. Microscopically, the mass is composed of elongated, needle-shaped crystals that under polarized light are negatively birefringent. Surrounding the crystals is a granulomatous inflammatory infiltrate. Which of the following laboratory test findings is he most likely to have?

A Hyperuricemia

B Hyperglycemia

C Elevated rheumatoid factor

D Hypercholesterolemia

E Increased serum creatinine

F Hypercalcemia

Question 13

A 5-year-old boy measures than the 5th percentile in height for age. On physical examination most of his decreased height is due to very short legs. However, his trunk and head appear normally proportioned for age. He is of above average intelligence and becomes an orthopedic surgeon. His parents and relatives are not affected by this disorder. Which of the following is the most likely diagnosis?

A Fibrous dysplasia

B Osteogenesis imperfecta

C Ollier disease

D Alport syndrome

E Achondroplasia

F Thanatophoric dysplasia

Question 14

A 38-year-old woman has severe systemic lupus erythematosus with renal complications. She is treated with long-term corticosteroid therapy. Which of the following bone diseases is she most likely to develop?

A Paget disease of bone

B Rickets

C Osteochondritis

D Osteoporosis

E Osteomalacia

Question 15

A 15-year-old girl is noted to have an odd, twisted appearance to her back while she is out swimming with her friends. She is tall and thin. A radiograph reveals an abnormal lateral bowing of the spine, with 20 degrees of lateral curvature in the mid-thoracic region. Which of the following is most likely to produce these findings?

A Asymmetric cartilage growth of vertebral body end plates

B Multiple osteochondromas of the vertebral bodies

C Vitamin D deficiency with rickets

D A disorder of procollagen synthesis with multiple compressed fractures

E Trauma

Question 16

A 23-year-old man notes some minor discomfort over the lateral aspect of his right knee after a day working in a cramped cubicle (because IT put the 'desktop' workstation on the floor). On physical examination he has a palpable "bump" in this region. A radiograph of the knee reveals a lateral bony projection from the lower femoral metaphysis. There is no adjacent soft tissue swelling. The lesion is excised and is composed of a 3 cm stalk of bony cortex capped by cartilage. Which of the following is the most likely diagnosis?

A Osteochondroma

B Giant cell tumor

C Aneurysmal bone cyst

D Osteoid osteoma

E Enchondroma

Question 17

A 75-year-old man has complained of lower back pain for 8 years. As part of a workup for a persistently elevated lymphocytosis, he has a right posterior iliac crest marrow biopsy performed. On microscopic examination hematopoiesis is normal, but the bone spicules are thickened with irregular cement lines forming a mosaic appearance with both increased osteoblastic and osteoclastic activity. Which of the following conditions is most likely to occur in conjunction with his underlying disease process?

A Dementia

B Myelofibrosis

C Hepatic cirrhosis

D Chronic renal failure

E Congestive heart failure

Question 18

Bone densitometry performed on a 42-year-old woman shows her bone mass decreased more than 2 standard deviations below the mean for age in her left femoral head, wrist, and lumbar vertebral region. Six months later, the amount of bone loss is seen to be increased by repeat densitometry examination. These findings are most likely to be associated with which of the following serum laboratory test abnormalities:

A Parathormone of 5 pg/mL

B Cortisol of 75 microgm/dL

C Total immunoglobulin of 3.5 g/dL

D Uric acid of 15.7 mg/dL

E Total cholesterol of 514 mg/dL

F Alkaline phosphatase of 238 U/L

Question 19

A 30-year-old healthy man has experienced headaches for the past month. On physical examination there are no abnormal findings. Laboratory studies show a serum calcium of 12.2 mg/dL with phosphorus of 2.5 mg/dL and albumin of 4.3 g/dL. Which of the following bone lesions is most frequently associated with these findings?

A Osteochondroma

B Giant cell tumor

C Paget disease of bone

D Osteitis fibrosa cystica

E Fibrous dysplasia

Question 20

During the past year a 22-year-old man begins to note persistent lower back pain and stiffness that diminishes with activity. Within the next 10 years he develops hip and shoulder pain with decreased range of motion. On physical examination at age 42 he has diminished lumbar lordosis with decreased lumbar spine mobility. He has no other major medical problems. Which of the following is the most likely diagnosis?

A Rheumatoid arthritis

B Ankylosing spondylitis

C Osteoarthritis

D Lyme disease

E Calcium pyrophosphate dihydrate deposition disease

Question 21

A clinical study is performed with subjects who have been diagnosed with a primary bone lesion. The demographic data for these subjects is analyzed. Which of the following bone diseases is most likely to be found to have a female predominance?

A Aneurysmal bone cyst

B Osteosarcoma

C Chondrosarcoma

D Ewing sarcoma

E Osteochondroma

Question 22

A 21-year-old college student has noted increasing pain and soreness in his left shoulder after a summer working on the ranch and bucking bales of hay (heavy lifting and turning motions) while at a ranch up in the CacheValley. On physical examination he can hardly adduct his left arm to the level of his shoulder. An aspiration of the subacromial region is performed and clear fluid is obtained. Which of the following is the most likely diagnosis?

A Tenosynovitis

B Costochondritis

C Bursitis

D Ganglion cyst

E Pseudogout

Question 23

Over the past 4 days, an 18-year-old man has developed marked pain and swelling in his right hip that makes movement difficult. He has no history of major medical problems. On physical examination there is pain on movement with diminished range of motion of the hip. A joint aspirate from the hip reveals cloudy fluid that on microscopic examination shows numerous neutrophils but no crystals. Which of the following conditions is most likely to have preceded development of his hip problem?

A Gonococcal urethritis

B Sickle cell anemia

C Rheumatoid arthritis

D Systemic lupus erythematosus

E Erythema chronicum migrans

Question 24

A social worker refers a 2-year-old child to the physician because of suspected child abuse. On physical examination, the child has blue sclerae, diminished hearing in both ears, and misshapen teeth. There are no external contusions or lacerations of the skin. Radiographs of the child's extremities show recent and healing long bone fractures. Which of the following is the most likely diagnosis?

A Extensive trauma ("shaken child syndrome")

B Osteogenesis imperfecta

C Achondroplasia

D Rickets

E Osteopetrosis

Question 25

A 23-year-old G2 P1 woman has noted minimal fetal movement at 18 weeks gestation. An ultrasound scan shows that the fetal limbs are shortened. At 30 weeks gestation a stillborn fetus is delivered. A postmortem radiograph reveals extensive long bone, rib, and pelvic fractures. Autopsy reveals a normal appearance to internal organs. A mutation involving a gene encoding for which of the following proteins is most likely to produce these findings?

A Fibrillin

B Fibroblast growth factor receptor 3

C Retinoblastoma

D Neurofibromin

E Type I collagen

Question 26

A 41-year-old previously healthy man has had backache with muscle spasms, weakness, and pain felt in the right hip radiating all the way to his toes for the past 8 months. He does not have headaches or other neurologic problems. Physical examination reveals that the circumference of his right leg is smaller than the left, and he has paresthesias in an L5 distribution in the right leg. Which of the following conditions is he most likely to have?

A Spondylolisthesis

B Spina bifida

C Herniated nucleus pulposus

D Osteoporosis

E Paget disease of bone

Question 27

A 5-year-old child has complained of pain on the left side of his head for 3 weeks. There are no abnormal findings on physical examination. A skull radiograph reveals a solitary destructive bony lesion of the left mastoid region. A biopsy is performed and microscopic examination shows that this lesion is composed histologically of a mixed inflammatory cell infiltrate. Which of the following is the most likely diagnosis?

A Osteoid osteoma

B Letterer-Siwe syndrome

C Eosinophilic granuloma

D Osteitis fibrosa cystica

E Tuberculosis

Question 28

A 49-year-old man has complained of episodes of joint pain for over 10 years. This pain has occurred in a remitting and relapsing pattern. On physical examination there are deformities of his hands involving the fingers, with swan-neck deformities and ulnar deviation. His condition improves following corticosteroid and gold therapy. Which of the following serologic tests is most likely to be positive in this man?

A Rapid plasma reagin

B HLA-B27

C Anti-double stranded DNA

D Rheumatoid factor

E Borrelia burgdorferi

Question 29

An 11-year-old boy has complained of pain in the region of the right upper thigh for 2 weeks. This pain is worse at night and is relieved by aspirin. On physical examination no abnormal findings are noted. A radiograph of his right leg reveals a small lucent area in the proximal femoral cortex surrounded by sclerotic bone. Which of the following is the most likely diagnosis?

A Enchondroma

B Multiple myeloma

C Eosinophilic granuloma

D Osteoid osteoma

E Osteochondroma

F Ewing sarcoma

Question 30

A 69-year-old man has experienced a 5 kg weight loss in the past two months without dieting. He is a non-smoker. During the past 3 weeks he has had extensive bone pain in his back and extremities. On physical examination the range of motion of his extremities is normal. His stool is negative for occult blood. A radiograph of the spine shows focal vertebral masses with increased brightness. A nuclear medicine scan reveals focal areas of increased uptake ("hot spots") in the pelvis, vertebrae, and ribs. Laboratory studies show a serum alkaline phosphatase of 281 U/L. A urinalysis is normal. Which of the following neoplasms is he most likely to have?

A Adenocarcinoma of colon

B Oat cell carcinoma of lung

C Infiltrating ductal carcinoma of breast

D Renal cell carcinoma

E Adenocarcinoma of prostate

Question 31

A 49-year-old woman has noted increasing difficulty with movement of her left hand for the past 2 years. On examination she cannot completely extend the left middle finger. In the palm of her hand at the base of this finger there is an ill-defined mass that is very firm to palpation. What will microscopic examination of this excised mass most likely show?

A Fibromatosis

B Rhabdomyosarcoma

C Granulomatous inflammation

D Dystrophic calcification

E Giant cell tumor of tendon sheath

Question 32

A 45-year-old woman notices that she develops tingling and numbness over the palmar surface of her thumb, index, and middle fingers after several hours at her computer workstation doing word processing. Pain in the same area often occurs at night as well. On physical examination she has minimal atrophy of thenar muscles of both hands. Which of the following conditions is most likely to account for her symptoms?