Cram The Pance - S1E48 50 High Yield MSK Questions

Episode Date: November 5, 2022

50 High Yield Musculoskeletal/Rheumatology Questions. Review for your PANCE, PANRE, Eor's and other Physician Assistant exams. Merchandise Link: https://cram-the-pance.creator-spring.com/►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)Included in this review: Polymyositis & Dermatomyositis, Reactive Arthritis, Rheumatoid Arthritis, Sjogren Syndrome, Systemic Sclerosis (Scleroderma), Systemic Lupus Erythematosus, Fibromyalgia, Gout, Calcium Pyrophosphate Crystal Deposition Disease (Pseudogout), Juvenile rheumatoid arthritis, Osteoporosis, Polyarteritis nodosa, Polymyalgia rheumatica, Anterior Glenohumeral Dislocation, Posterior Glenohumeral Dislocation, Rotator Cuff Injuries, Rotator Cuff Tear, Adhesive Capsulitis/ Frozen Shoulder, Supracondylar Humerus Fractures, Radial Head Fractures, Ulnar Shaft (Nightstick) Fracture, Monteggia & Galeazzi Fractures, Radial Head Subluxation / Nursemaid Elbow, Medial Epicondylitis, Lateral Epicondylitis, Cubital Tunnel Syndrome / Ulnar Neuropathy, Carpal Tunnel Syndrome, Scaphoid (Navicular) Fracture, Distal Radius Fractures (Colles vs. Smith Fracture), Lunate Fractures, de Quervain Tendinopathy, Mallet Finger, Ulnar collateral ligament injury (Gamekeeper's or Skier's thumb), Boxers Fracture, Complex Regional Pain Syndrome, Hip Fracture, Hip Dislocations, Slipped Capital Femoral Epiphysis, Legg-Calve-Perthes Disease, Osgood-Schlatter Disease, Anterior Cruciate Ligament Injury, Posterior Cruciate Ligament Injury, Medial Collateral Ligament Injury, Lateral Collateral Ligament Injury, Meniscal Injury, Tibiofemoral Dislocations, Patellofemoral Syndrome, Iliotibial Band Syndrome, Ankle Sprain, Achilles Tendon Rupture, Plantar Fasciitis, Interdigital (Morton’s) Neuroma, Jones Fracture, Lisfranc (Tarsometatarsal) InjuryBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so 50 high yield MSK questions, a bunch of mnemonics 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 1. A 42-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 intermeditarsal space. What is the most likely diagnosis in this patient? So that is going to be a Morton neuroma. So Mortonaroma, 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, etc. that these patients feel is going to be most common in the third intermeditarsal 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 to 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. At least 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 for more neuroma, third intermeditarsal 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 63-year-old female presents to 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 2.8. The treating physician decides to start the patient on raloxifen. What is likely positive in this patient's past medical history that would influence the decision

to start her on raloxifen rather than alternative osteoporosis agents? So that is going to be breast cancer. So raloxifen or eloxifine 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 that you probably have heard of in the same class, and that's tamoxifen. Tomoxifen, tamoxifen, so it sounds very similar. So remember, reloxifen is in the same class as tamoxifen. And in addition to training osteoporosis, it can also be used for breast cancer prophylaxis. Question three, a 42-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.

hands that makes it difficult to make a fist. On physical exam, you note telangiactasia's on the palms and face. Labs are positive for both anti-nuclear antibodies as well as antisensromere 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 Crest syndrome. Remember, Crest stands for calcinosis cutus, radonodininin. phenomenon, esophageal dysmotility, sclerodactylidylidactylidia. So we see the calcinosis cutest. Those are those small white calcium deposits in her hands.

She has heartburn, which is from the esophageal dysmotility disorder, telangiotasias, as well as the tightening of the skin of the hands, which can progress to sclerotally, 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 antithromere antibody test, which I used to remember as antichristomere instead to help me remember this antibody is positive in Crest syndrome. So if you see a positive antiscentromere, instead think of antichristomere and think of Crest syndrome, which is associated with limited systemic sclerosis.

Question four, a 63-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 reduced range of motion. Labs reveal elevated erythrocyte sedimentation rate and Cereactive protein. Serum rheumatoid factor as well as creatine kinase are normal. The patient is diagnosed with polymyalgia rheumatica and started on corticosteroids. 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 arthritis. So remember, giant cell arthritis is associated with polymyalgia rheumatica. You have to know that anywhere from 5 to 30% of patients with PMR will have giant cell arthritis. This always shows up on exam questions 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 in a patient, make sure you're asking the patient about headaches, jaw clotication, transient vision loss to make sure they don't need a workup for giant cell. So the way that I used to remember that Paul E. myelagia rheumatica is associated with giant cell arthritis is by instead of remembering it as Paul E. myalgia rheumatica, instead remember it. as Paul B. Myelioromatica. Paul B, as in Paul Bunyan, the giant from those kids' books,

and then you'll always remember this is associated with giant cell arthritis. 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 asymptomatic. So remember to assess for loss of height or kifosis, as these are sometimes the only indicator of a vertebral compression fracture in an osteoporotic patient. Question six, 62 year old male presents to the emergency department after being involved in a motor vehicle accident. He's complaining of severe pain in his right hip.

On physical exam, you note 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 90% 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 abducted, which is the classic presentation for posterior dislocations where anterior are classically externally rotated and abducted. Question seven, 46-year-old male 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 paristhesia, 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 caught Aquinas syndrome. They have the classic clinical manifestations, lower back pain radiating into the legs, saddle parishthesia, urinary, and kidney. continence, loss of rectal tone, all of these areas are affected because Cata Aquinas syndrome is severe compression of multiple lumbosacral nerve roots that innervate these regions. So when Cotacquina 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. MRI is going to be your test of choice.

All right. Question eight. Interior dislocation, aka forward slippage of one vertebral body. with respect to the one beneath it is known as, so that is going to be spondylolisthesis. So forward slipping of a vertebral body relative to an adjacent inferior vertebral body, that's spondylolisthesis. 30 to 50% of the time, this is a consequence of spondylolisthesis. Anyways, how do you remember spondylolis 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 spondolo list thesis, at the end of the word, it has list thesis in it. like list your thesis statement. So when I see spondolo list 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 your thesis statement forward. So when you see spondolo list thesis, right away think list thesis and then what are you going to do with your thesis? You're going to 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 spondolo list thesis. A little weird, but it definitely worked for me. Question nine. 32-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 erythema over the cheeks and nose, sparing the nasal labial folds. You suspect lupus in order an 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, antacentromere antibody. answer B, anti-tissue Transglutaminesase antibody, C, anti-Smith antibody, D, anti-sichlic, sotrillinated peptide antibody. Again, A, antacentromere, B, anti-tissue Trininase, C, anti-Syclutrillinase, Peptide. So the answer is going to be C, C, anti-Smith antibody. All right, so let's talk about why it's not the other ones. First, A, antacentromerea antibodies, as we discussed before. This is most commonly used in the diagnosis of limited systemic sclerosis, subtlitis. type, aka Crest Syndrome, B, antitissue Transglutamines body that's used for the diagnosis

of celiac disease. And finally, anticyclics, citrillinated peptide antibody or anti-CC. It's most commonly used for diagnosis of rheumatoid arthritis. And while it can be elevated in lupus, it is in no way the best lab test listed here. The best lab to order out of these four is by far the anti-Smith antibodies. Antismith 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-barrow shotgun. Anytime I saw the word lupus, I just created this very weird visual of Lou taking a piss on his Smith and Weston double-barrel shotgun. You won't forget it. It's such a weird visual.

So Smith and Wesson helped me to remember the anti-Smith antibodies, and double-barrow shotgun helped me remember the anti-Smith. double-stranded DNA antibodies. So remember when you see lupus, I want you to think of Lou taking a piss on his Smith-and-Wesson double-barrow shotgun. Create that visual in your head and remember the two main specific labs you need to know for lupus, anti-smith and anti-double stranded DNA. Question 10. A three-year-old boy presents at the office accompanied by his mother 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. On 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 subluxation, 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 radial 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's no signs of fracture. They shouldn't have any focal bony tenderness, bruising deformity. And while in 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 radial head subluxation, x-rays are generally not indicated. Question 11. A 51-year-old female presents to the office today complaining of muscle weakness. She describes difficulty combing her hair and rising from a chair. On physical exam, you note a rash around the eyes, violaceous papules over the dorsal aspect of both hands, as well as erythema across the

shoulder's upper back and upper chest. Labs are drawn, which reveal an elevated creatine kinase level, as well as positive anti-me-2 antibodies. What treatment should be initiated in this patient for the suspected diagnosis? That is going to be glucocorticoids. So this patient has dermatomyocytis. She has the Gotron Papules, heliotrope rash, decreased muscle strength, the shawl sign, plus elevated CK, and anti-meat two antibodies. That's about as clear cut as you can get. And then we know for dermatomyocytics, glucocorticoids are the cornerstone of your initial therapy. This is usually prednisone at a dose of one milligram per kilogram per day. Now, dermatomyocitis has a few very high yield findings. And the way that I used to remember all the high yield stuff for dermatomyocitis

was instead of remembering dermatomyocitis. I used to remember it as permato myocitis. So all you do is replace the D-U with a P. And now you have perm, P-E-R-M, perm, perm, so why perm? Because whenever you think of this disease, I want you 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 caper shawl over her shoulders, as you normally wear in a salon or a barbershop. She's just relaxing and having some me time. Me time spelled with an M.I. This is 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 visual 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 wear in the salon, having some me time. Now, 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 that helps to remember the Gautron Papuels that are the most common on the top of the fingers. And she's wearing the cape or shawl, which helps to remember the shaw sign or photo distributed poikiloderma, 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 MI, that helps to remember the anti-me-2 antibodies, which are her. highly specific for dermatomyocitis. So remember, change the D to a P and you have perm matomyocitis, lady getting a perm, having some me time, eyebrows waxed, getting her nails done, and wearing a cape. Question 12. A 52-year-old male presents to the emergency department complaining of severe pain in its first metatarsopal angio joint. He denies trauma to the area and states it started suddenly. Arthrocentesis is performed, which displays negatively biopharynge, needle-shaped crystals. Patient has a history of hypertension, type 2 diabetes, hypersticis, Hyperlipidemia and current medications include hydrochlorothyside, metformin, glypizide, and resubastatin.

Which medication that the patient is currently taking is the most likely culprit leading to his current clinical manifestations? Again, those meds are hydrochlorothyside, metformin, glypid, and resubicatin. The med is going to be hydrochlorathyzide. All right, so this is about as clear cut in case of gout as you can get, severe pain first tone, negatively biopharynge-need needle-shaped crystals on arthrocentesis. So all you have to remember is which meds can cause gout flares. And in this case, it's hydrochlorothyside.

So remember, thyside diuretics like hydrochlorothyside, increase urate reabsorption at the proximal renal tubule, which can elevate uric acid levels and precipitate gout flares. So are one of the many meds that can cause gout flores. So how do remember the main meds that can cause gout? So I used to remember, if you put too much seafood on your plate, you'll get gout. Plate stands for pyrozytide, loop diuretics, aspirin, thysides like hydrochlorothiazide, and then ethambutal. So again, plate, P-L-A-T-E, Pyrazinamide, loop diuretics, aspirin, thiazhyazides, ethambutal. That helps you remember the main meds that you need to know that can lead to gout flares. Question 13, 72-year-old female presents to the office today for routine checkup.

Past medical history includes hypertension, hyperlipidemia. She states she has concerns about osteoporosis as her mother was diagnosed within her 60s and wound up with a hip fracture. Dexter's scan is ordered, which reveals a T-score of negative 2.6. 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 30 minutes and take with 6 to 8 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 30 minutes after taking the medication and taking it with at least 6 to 8 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 30 minutes. It's also important for them to remain NPO 30 minutes after the dose. So no other food or med for 30 minutes.

But by far, the most important thing to know that they will test you on is avoiding recumbrance for at least 30 minutes. All right, question 14. A 27-year-old male 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, a pop in the knee followed by immediate swelling. That swelling, that hemarthrosis, is a very common presentation for an ACL tear. Up to 77% of patients with acute hemarthosis after injury of the knee have an ACL tear. And then you have the positive test, which we know is the most sensitive test for an ACL tear. And you can remember that the Lockman test 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 15.

14-year-old boy presents to the office company by his mother, complaining of right knee and thigh pain. He denies trauma to the area. He describes the pain as severe and deep in his leg, and he often finds the pain keeps him up at night. His mother 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 an 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, 32% of all patients.

And then finally, the sunburst 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 mothy in appearance on x-ray. And then ewing sarcoma often will also have systemic symptoms. 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 16, which of the following drugs have been associated with a high risk of causing drug-induced

lupus? A, prokhanemide, B, metformin, C, azithromycin, D, gabapentin, E, Alprazanlam. So I'll give you a second to think about that. That is going to be A. Procanamide. So there's a bunch of drugs that can cause lupus close to 50 that would. we know of, but the main ones that you need to know are prokynomide and hydrolyzine. Those two alone cause around 30% of all of the cases of drug-induced lupus. Then there's a few other high-yield ones that often get tested on that I would remember. I used to remember the mnemonic chips,

C-H-I-P-P-S, because the letters in drug-induced lupus are D-I-L as in Dill, and that 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-D-L-Dil. Think of Dill Chips, C-H-I-P-PS, and you'll know the high-yield meds that are always tested on. So, Chips stands for carbamazepine, hydrolyazine, isin, prokynomide, penicillamine, and sulfosin. 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 17, 32-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 humeral 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 with the posterior shoulder 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 seizure or electrocution due to the violent muscle contractions that take place during these type of injuries.

So know that seizure, electric shock, super high yield 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 posterior dislocations because of the internal rotation of the arm, the tuberosities no longer project laterally, which result in a circular appearance of the humeral head. And supposedly, it looks like a light bulb. So no 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 poster board, 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 and internal rotation as 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 poster board because the poster board helps remember posterior dislocation.

Question 18, 67-year-old female presents to the office complaining of persistent pain in her hands and knees. 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 interphalangeal 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 interphalangeal joints seen in this patient? So that is going to be Hebriden nodes. So this patient likely has osteoarthritis, persistent pain in the hands and knees, pain that's in the evening and stiffness in the morning that only lasts for a few minutes.

Remember, inflammatory arthritis like rheumatoid arthritis is morning stiffness for sustained periods of time, generally over 60 minutes. Osteoarthritis, 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 arthritis, which usually has warm and boggy joints. So this is a classic presentation for osteoarthritis, and the bony enlargement of the distal interphalangial joints we see in this patient is known. as Hebriden nodes, and these are considered a clinical marker for generalized osteoarthritis.

Question 19. A 53-year-old woman with the history of diabetes and hypothyroidism presents to 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 abnormalities.

What is the likely diagnosis in this patient? So that is going to be adhesive capsulitis, aka frozen shoulder. So why is this adhesive capsulitis and not some sort of subachromial pathology like rotator cuff tendonopathy, like impingement syndrome, etc. Well, there's a few reasons. One, when you have rotator cuff tendonopathy and impingement syndrome, usually they're going to mention the vignette history of heavy lifting or repetitive movements related to occupation or sports, which is not included in this patient's history. I also mentioned in 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 subachromial 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. This patient checks all of those boxes, and that is why this is adhesive capsulitis. Question 20, 49-year-old female with a recent diagnosis of rheumatoid arthritis presents to the office today. She states she was started on Naproxin 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 would be the best option to add to her regimen to slow progression and prevent further erosion of the joints? So again, remember she was diagnosed with rheumatoid arthritis, She was given neproxin, symptoms are progressing. What other medications should you add to this patient's regimen? A, dichlofenac, B, prednisone, C, zoologronic 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, dichlofenac, it's just another insid like neproxin that she's artery taking, so no value there. Plus, enseds have no impact on disease progression. Next, prednisone. Prednisone can be used for symptomatic relief. It even has some disease. disease-modifying effect, but it is not the best option on this list by a long shot. Next, Sodrogenic acid. That's an easy one because we know this is bisphosphonate, not used for treatment of rheumatoid arthritis.

Next, in Flixamab. So this is a TNF inhibitor, and it is used in the treatment of rheumatoid arthritis, but it's not first-line. It's generally used as an adjunct agent and patients not getting the therapeuticals with the first-line med. And that first-line med is methotrexate. Methotrexate is a demar disease-modifying antarmatic drug. And while there are other drugs in this class, hydroxychloroquine, sulfosalazine, methotrexate is the most commonly used demard in first line for RA because compared to the other meds, it has a faster onset of action, greater efficacy, better long-term tolerance. So if there's one drug you absolutely have to know for rheumatoid arthritis, that's definitely going to be methotrexate. Question 21. An injury to which nerve common inhumeral shaft fractures can lead to weakness in 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 humorous 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 paristhesies of the dorsal hand or weakness of the wrist and finger extension. And this injury actually occurs in around 11% of mid-shaft humoral fractures. So when you hear wrist drop, be thinking of a radial nerve injury.

Question 22, 58-year-old male 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 the neproxin he has at home. Labs are drawn, which reveal an elevation and serum urate levels, and a 24-hour urinary uric acid secretion of 230 milligrams. The normal range is 250 to 750 milligrams per 24 hours. remember his was 230.

Which of the following medications would increase the excretion of uric acid in the urine for this patient? A, endomethysin, B, hydroxychloroquine, C, probenicid, D, phobuxostat, or E, alipurinol. So that is going to be C, probenicid. 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 probenic. So that's a uricuric 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 endomethicine, which is just an insid used for acute attacks,

hydroxychloroquine, which is not used in the treatment of goutes, primarily used for lupus. And then finally, we have phoboxycinet and alpurnal. 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 23, a 22-year-old male 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 ibuprofen, 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? Give you a second to think about that. So, that is prostate glandins. So osteoid, osteoma, there's really two high-yield things that you need to know about this benign bone tumor. One, this tumor produces high levels of prostate glandins. And the second thing is that this type of tumor responds extremely well to ensigns. Within a matter of minutes, the pain will be relieved, which 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 inseds. That's what we'll differentiate these two in a vignette. So you need to remember that. osteoid, osteoma, dramatic pain relief with ensets, osteoblastoma, minimal pain relief. So why do inseds work so dramatically at reducing the pain? Well, if you remember, back to pharmacology, you remember, inseds blocked the production of prostate glandids through the inhibition of cycloxygenase.

So for osteoid, osteoma, again, remember two things. One, they crank out a bunch of prostate glandins. And two, for this reason, the pain experience responds extremely well to inseds. And I hate to even mention this, but the way that I used to remember this, osteoid osteoiaoma the letters O O O O. Whenever I'd see those two O's in osteoid osteoma, I used to remember that song that said, O, oh, oh, it's magic, you know, and I used to remember OO, it's magic, Nseds. I hate that the fact that I had to sing there, but to help you remember that, hopefully you'll

remember me singing. It's completely ridiculous, but it helped it stick for me. So we see osteoid osteoamah, think O, O, O, it's magic, Nseds, because of how well Ns work at improving the pain from the increase in prostate gland is. All right. Now, they've heard me sing. Let's quickly move on to the next question. Question 24, 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 10 degrees. So cob angle is the most widely used measurement for quantifying spinal curvature in scoliosis, which is calculated using plane radiographs. You should definitely

know that lateral spinal curvature with a cob angle of over 10 degrees defined scoliosis, then the only other number you might want to have in the back of your head is a cob angle of anywhere from 40 to 50 degrees or greater is usually where surgical intervention is indicated. Question 25, 59-year-old female presents to 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 42% of patients with anterior shoulder dislocations will have some degree of axillary nerve dysfunction. The nerve runs around the surgical neck of the humorous, and this is important. It innervates the deltoid muscle and the skin overlying the lateral shoulder. And that's why 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 a 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 remember axillary nerve injury is most common in anterior dislocations and then finally the position of his arms holding these things abducted and externally rotated helps 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 26. 32-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 denies trauma to the area. On physical exam, tenderness is noted over the radial styloid at the first dorsal compartment, and flexion 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 de-quarevane tendonopathy. So why de-quare-veined tendonopathy? First, we have a 32-year-old postpartum female. This fits the most common demographic perfectly, as this is most common in women, 30 to 50 years old, especially four to six weeks after delivery in the postpartum period. Next, we have pain in the radial side of the wrist, exacerbated by thumb and wrist movement. This makes sense, as the tendons involved in de-quare-vein are the

EPB and APL tendons, which are responsible for movement of the thumb. And most importantly, she has a positive Finkelstein test, which is pain over the radial styloid with ulnar deviation of the wrist with the thumb flexed across the palm. That's classic decorvean tendinopathy. In case you need a way to remember the tendons involved in decoir veins, because I did get this on an exam question. The tendons involved are the abductor polysis longest and the extensor polysis brevis, the APL and EPB tendons.

Remembering the abbreviations will be enough to get a 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 de quervane. So apples with extra peanut butter are delicious. Apples APL tendon tendon, extra peanut butter, EPB tendon are delicious, decoir vein tendonopathy. And that was enough for me to get the question right on an exam question. Sixty-year-old male presents to the office complaining of severe pain in his first toe. He denies trauma to the area. Arthrosynthesis revealed negatively birefringen needle-shaped crystals, and the diagnosis of gout is established. Past medical history includes type 2 diabetes, osteoarthritis, and end-stage renal disease.

Which class of medication would be most appropriate to treat this patient's acute gout flares? So remember, he has a past medical history, type 2 diabetes, osteoarthritis, and end-stage renal disease, which class of medication are you going to treat as acute gout flare with? So that's going to be glucocorticoids. So you have to think about what are the first-line meds to treat acute? gut out flare. So really there's only three. Enseds, steroids, and colchocene. We know ensigns are out of the question because this patient has end stage renal disease. Colchocene can be used in mild kidney disease when GFR is above 30, but end stage renal disease, other agents are preferred. So in this

patient, the most appropriate effective class of medication is your glucocorticoids, your steroids as they are safe and mild all the way to severe renal disease and extremely effective in treating acute gout Flares. Question 28. 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 collies 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 palmar or volor displacement of the distal radius. The way that I used to remember collies

is associated with dorsal displacement is by remembering collie is a breed of dog, the type of dog that lassie 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 d'o. 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 coli fracture, think of a collie dog. Question 29. 47-year-old male 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 103.2 Fahrenheit, 39.5 degrees Celsius. Laboratory studies reveal leukocytosis, as well as an elevation and in orthodox. Thracite sedimentation rate and C-reactive protein. Radiographs of the lumbar spine are unremarkable.

MRI reveals a ring-enhancing lesion at L2 to L4. Which bacterial pathogen would likely be isolated in this patient? This one's a little bit tricky. That's going to be staph aureus. So first, what does this patient likely have? It likely has a spinal epidural abscess. Well, why? First, you have an IV drug user with a triad of fever, back pain, and neurologic deficits.

right away spinal abscesses would be high on your list of differentials. Next, we have an elevation of white blood cells as well as elevated ESR and CRP. Around 60% of patients with a spinal abscess will have leukocytosis. In almost all cases of spinal epidural abscess, will have an elevation of ESR and CRP. Usually radiographs are going to be normal, an MRI, which is key, which will reveal an enhancing epidural mass, often described as a ring enhancing lesion. Definitely know that term. that's the confirmation right there. We have a spinal epidural abscess and the leading bacterial

pathogen causing a spinal epidural abscess is staph aureus in around 63% of cases. Question 30, 57-year-old male 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 90 degrees of abduction, pain and weakness is experienced when the clinician attempts to adduct the arm while the patient resists. I'm going to repeat that again. Physical exam, patient's arm affected arm, completely internally rotated, thumb pointing

down, elbow extended, 90 degrees of abduction, pain and weakness is experienced 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 super spinaidus. So why? Well, to start, majority of rotator cuff lesions begin as partial tears of the super spenadus tendon. So it's already the most common tendon to be affected.

So we have that working for us. But then the physical exam findings are what sealed the deal. We have a patient performing the empty can test, also known as the Job test. This is generally considered the gold standard for evaluating super spinaidus function because the position of the arm isolates the super spinautus. 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 resist,

and pain and weakness is indicative of a partial or complete super spenatus tendon tear. So remember, if you see the empty can test or the Job test being performed, this is to assess the super spinaidus. Question 31. 41-year-old female has symptoms consistent with rheumatoid arthritis, and labs are drawn to assist in making the diagnosis. The physician assistant informs the patient that a rheumatoid factor as well as a very specific antibody for rheumatoid arthritis are both elevated.

Which antibody specific to rheumatoid arthritis is likely elevated in this patient? So again, which antibody specific to rheumatoid arthritis is likely elevated in this patient? So that is going to be your anticyclic citrillinated peptide, aka your anti-CCP. So your anti-CCP antibodies are very specific for rheumatoid arthritis. usually over 90% 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 the serumatoid factor,

which has a relatively poor specificity, since they're found in healthy individuals and up to 30% of patients with lupus. So your most specific test, again, for rheumatoid arthritis, is your anti-CC. 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 C's in it, and that's going to be your anti-CCP. Question 32. 63-year-old male 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 colchicine. So Colchocene is notorious for causing GI problems, especially diarrhea. So much so that on Apocrydes, it actually says in the comments, diarrhea will likely precede pain relief, which I thought is very funny. So definitely know this for adverse drug reactions for Colchocene. It's an exam favorite for some reason, and I definitely remember getting a question about it in school. Question 33.

The 14-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 tibial tubercle. What is the mainstay of treatment for the likely diagnosis in this patient? So that is going to be conservative, Nsides, ice, etc. So this is Osgood Schlaher disease. We have a 14 year old boy fits the demographic already as Osgood Schlaher is most common in males 9 to 14 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 on exam, the pronounced tender tibule tubercle seals the deal. As we know, this is an injury caused by repetitive strain and chronic evulsion of the apophysis of the tibial tubercle. A lot of hard words for me to say right now. So the mainstay of treatment for Osgood Schlauter disease is conservative, neds, etc. Surgical repair is rare, and you can remember instead of Osgood Schlaugher disease, remember Osgood's squatter denise. This helps you remember it's exacerbated by activity like squatting, and then Denise

helps you remember this is an issue with the knees. Question 34. A 43-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 tennel and phelan test are positive on physical exam. The patient is likely experiencing compression of which nerve. So that is the median nerve.

So this patient is experiencing carpal tunnel syndrome, which is a compression of the median nerve. We know this because we have a patient with paristhesias in the median nerve territory, which would be the first three fingers and radial half of the fourth. In addition, she states it's worse at night, which is very common for carpal tunnel. Finally, we have a positive tinell and phalan test, which seals the deal, so we know this is carpal tunnel, which is medium nerve compression. And just a quick tip, the two maneuvers that were listed in this vignette for carpal tunnel, the tine test and phalan test, they're often tested on, so it's good to know what they involve. So the tinell test is just percussing or tapping over the median nerve to see if pain or paris seizures is reproduced in the median nerve innervated fingers.

So you used to remember the T and Tenel stood for tapping. And then the Phelan 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 is pain or parisages and the median nerve innervated fingers. And I used to remember the word phelan sounds like fallen. So I used to remember this is the test where your hands have fallen or flopped over because that's what it looks like when you perform the test. You can look at a picture of it.

And then so you just remember that the hands have fallen or phelan over. That's how the test is performed. Question 35. A 67-year-old male 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. On 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 epicondylitis, aka golfer's elbow. a 67-year-old male, avid golfer with elbow pain, no preceding trauma. And the key is that the pain is reproduced on exam with the wrist being flexed against resistance. So in this case, the patient would likely have pain in the medial epicondyle, as the medial epicondal is the bony origin for the wrist flexors, which is affected in this condition. The way that I used remember the high-yield stuff about medial epicondylitis, aka golfer's elbow, was by remembering the sentence mini-golf is fun. So the M and Mini helps you remember this is the medial epicondial, involved in golfer's elbow. Golf, obviously, because this is also known as golfer's elbow,

and then the FF in 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 flexor carpi radiolus, or that it's caused from repetitive flexion. Mini-golf is fun, M for Mediol Epi-Condial, golf for golfer's elbow, and then FFlection flexor. Question 36, which test is performed as part of the physical exam in a suspected Achilles tendon rupture that involves squeezing the gastroachnumous muscle and watching for plantar flexion of the foot. So that's the Thompson test. So Thompson test, nice and simple. You squeeze the calf and look to see if the foot planter flexes. If not, this is a positive test indicating a likely Achilles tendon rupture. Question 37. 31 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. immediately felt a tearing sensation, which was followed by severe pain. A val-gust stress test is performed, which displays pain and laxity at approximately 30 degrees of flexion. What structure of the knee did this patient likely injure? So that's the medial collateral ligament. So we have a patient with lateral trauma to the knee and a positive valgus stress test. The MCL 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 varus 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 Mucho gusto. The M in Mucho, gusto helps me remember.

This is a test of the MCL ligament. And then Verus test for LCL injuries has the word rust in it. And that makes me think of rust, as in the sentence, leaky pipes rust. And the L and Leakey helps remember the Verruz stress involves the LCL. So remember Mucho Gusto for Val Gus test to help you remember it's associated with MCList injuries. And then Leaky Pipes Rust for Verruz test to help you remember it's associated with LCL injuries. Question 38, a 56-year-old female presents to the office complaining of persistent heel pain. That is worse when first getting out of bed in the morning.

She states it 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 the 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 heel 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 planter fascia, which is the medial tubercle of the calcaneus.

Obviously, plantar fasciitis should be high in the list of differentials. Treatment is generally going to be conservative for these patients. rest, neds, better shoes, etc. Question 39. 67-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-heeled 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 hyperesthesia 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 going to give you a second to think about that one, because it's 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, et cetera, 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 with complex regional pain syndrome, the treatment and diagnostic tests are pretty low yield. The highest you'll think 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 P-A-I-N-T. So the P-S-Sans for perspiration. This is due to the autonomic dysfunction. 40% of patients will experience increased sweating. The A in pain 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 eye stands for inappropriate pain because it's out of proportion to the initial injury. Pain is typically the most prominent and debilitating symptom of CRPS. So remember, eye stands for inappropriate pain. it's not appropriate to have 10 out of 10 pain in your hand from a fracture you had four months ago that is healed. So I 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 T stands for temperature changes. So relating back to the autonomic change, these patients can have. And some patients, you'll notice a difference in skin temperature on the effective versus the unaffected size of one or more degrees. Celsius. Question 40. A 14-year-old male 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 proximal 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 11 and 22. What is the most likely diagnosis in this patient? So that is going to be ewing 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, night sweats, all very typical of ewing sarcoma, but then we have our key words or numbers. Moth, onion, blue, 11, and 22. Out of all the words in that vignette, those are the key to choosing the right answer. So the x-ray findings, that moth-eaten 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 11 and 22, and the small round blue cells on histology. that just solidifies the diagnosis.

And here's how I used to remember most of those key words. So when I would see Ewing's 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 33, played for the New York Knicks. So how does that help? Well, first, Patrick Ewing's number was 33, and 11 plus 22 equals 33.

So that helps remember the 1122 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 likes to eat onion rings and just visualized him chowing down on some onion rings, which helps me remember the onion skin appearance on X-ray. So whenever I see Ewing's sarcoma, I visualize Patrick Ewing,

wearing his blue jersey with the number 33 on it, eating some onion rings, and I remembered all the things that I needed to know for Ewing's sarcoma. Question 41, a 46-year-old male who suffered a fall from his roof early, on the day has just completed a series of x-rays. The x-ray revealed a number of fractures as well as a dislocation of the right tibial femoral joint, aka the knee joint. What is the most dangerous potential complication that can arise following a tibule formal dislocation that needs to be considered in this patient?

So that is going to be a popliteal artery injury. This is the most dangerous complication following a tibial formal dislocation, aka a knee dislocation, and delay in diagnosis and repair can lead to amputation. So you need to make sure after you reduce the dislocation, you assess the distal and popliteal pulses, measure ankle breakule index, et cetera, to ensure there's no signs of vascular compromise. Question 42. What is the most common ligament to injure in an ankle sprain? So that is going to be the anterior talofibular ligament, aka the ATF ligament. I used to remember that by remembering the letters in ATF ligament, Stanford always tears first, because this is the ligament in the ankle most likely to tear in an ankle sprain.

Question 43. 17-year-old male presents to the ER after sustaining an injury to his right arm. After x-rays are complete, the attending physician informs him, the x-rays will 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 montesia fracture. So there's two types of fractures slash dislocation.

locations you need to know for the forearm. First one, as we saw in this vignette, is a Montesia fracture, which is a proximal ulnar fracture, accompanied by a radial head dislocation. And then the second type is known as a Galeazi 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 radial 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. Grusome murder helps you remember which bone is fractured, and then secondly, which is dislocated. So the first three letters of gruesome, G-R-U, the G stands for G-R-A-R-R-B-R-R-B

the G stands for radius fracture, and then the U stands for ulnar dislocation, and then murder, first three letters are M-U-R, M stands for Montesia, U stands for ulnar fracture, and then the R-Stands for radial head dislocation. So again, remember gruesome murder. First three letters of gruesome help you remember a Gali-Azy fracture, say radius fracture, and a ulnar dislocation, aka the radial owner joint, to be specific, and then the first three letters of murder, M-U-R, help you remember, mitesia, ulnar fracture, and radial head dislocation.

Question 44. 26-year-old female presents to 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 dischoid lesions.

What would be the best initial test to order in this patient? So that is your anti-nuclear antibody, i.k.a. your A.NA test. So in this patient, systemic lupus eryematosis 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 malar butterfly rash that spares the nasal labial folds, as well as the disoidsions. And then she describes a photo. sensitive rash that burn after a short period of time in the sun. So the best initial or screening tests in 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 screening for lupus, and then after you proceed to your more specific antibodies, your anti-double-stranded

DNA, and your anti-Smith. Question 45, 27-year-old male presents to the ER 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 tendered just proximal to the base of the thumb at the anatomic snuff box, a fracture of which bone should be suspected in this patient until proven otherwise. So that's the scaphoid. This is a very simple one, scaphoid or navicular fracture. You have a patient who had to fall onto an outstretched hand, which is most often the mechanism of injury for a scaphoid fracture. He has pain on the radial side of the wrist. Snuffbox tenderness, you're done. This is a

scaphoid fracture until proven otherwise. As soon as you hear snuffbox tenderness, always be thinking of a scaphoid fracture. Question 46, 47-year-old male, uh, 47-year-old female presents at 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 parodid glands. Explain to the patient, it 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 Shermer test. So this patient, likely has Shogran syndrome. Of course, we would need to perform some labs, your anti-row, anti-law, A-Na, but she has all of the classic clinical manifestations, dry eyes, dry mouth,

prodigal an enlargement. And then the test we perform to assess for tier production is the is called the Shurmer test. Now with Shogren syndrome, in addition to your Shurmer test, there's two really high-yield things that you need to know, and that's your anti-Roe and anti-law antibodies that are used in diagnosing this condition. And the way that I used to remember these three high-yield tests is by instead of remembering showgren syndrome i would remember slow green syndrome slow green instead of show green and what's slow and green a frog that helps remember a slow green frog landed in my cup of sherbert so create that visual in your head you have a cup of sherbert that little frozen fruit uh treat and then a frog landed right in it so show green is now slow green

a slow green frog landed in your cup of sherbert frog the second two left two letters are O that helps you remember anti-Roe. Landed, first two letters are LA that helps you remember anti-law. And Sherbert helps you remember Shermer test. So that worked for me. Just remember Slow Green instead of Shogreen. Remember that slow-green frog landing in your cup of Sherbert. Question 47.

27-year-old male 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. In the past few days, he has found the knee is often locking up, making it difficult to fully extend. On 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 did this patient likely sustain? So that's going to be a menisical tear. All right, so what are the keys here to tell us this is a menisical injury and not some other type? First, the pop and lock of the knee. It's common for a

patient with a menisical 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 line 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 painful pop or click in the knee with repetitive passive flexion and extension. If you ever forget that the McMurray test is associated with menisical injuries. So Murray is obviously a man's name and menisical 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 minusical tears. Question 48. 22-year-old male presents to the office today complaining of swelling in his right upper arm that has increased in size over the past year. He states the area is not painful. Radiographs are obtained which reveal a large pedunculated lesion that is pointing away from the joint space. A biopsy is obtained and 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 osteocondroma. So osteocondromas are the most common benign boney tumor, accounting for 30% 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 painless. And then on a radiograph, look for them to describe as the mass as pointing away from the joint space.

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 lesions 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 49 20 29 year old female presents to 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 on 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 patello femoral 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 patello femoral syndrome or is this iliotibial band syndrome?

Very simple. If it's anterior knee pain, it's pettelofamoral 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, interior side of the knee. So if it's a female runner with anterior knee pain, it's patello femoral 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 patello fomoral syndrome is the most common among female runners, just remember it like I did instead of remembering Patelofamoral syndrome instead remember it as Patelow Female Run Syndrome. So instead of Patelofamoral syndrome, Patelow Female Run Syndrome, as those are the key things to remember about this condition. Question 50. Blank fractures are the most common carpal bone fracture.

Blank fractures are the most common carpal bone fracture. So that's scaphoid fractures. So I figured I'd end this on an easy one. Scaffoid fractures are the most common carpal bone to fracture. as we just went over a few minutes ago in question 45. Make sure to look out for snuffbox tenderness in these types of fractures. All right, those 50 high-yield 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 panery, and your EORs.