S1E48 50 High Yield MSK Questions

Alright, so 50 high yield MSK questions, bunch of them onics 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, it's cram the pants on YouTube. Alright, let's go ahead and get started question one. 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 intermittent hospital space. What is the most likely diagnosis in this patient? So that is going to be a mornin neuroma. So a mornin neuroma, which is a compressive neuropathy. When it comes to mornin 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 over pronation of the foot can cause this condition. And the parasthesia, the numbness burning, etc. that these patients feel is going to be most common in the third intermittent hospital space. The way that I remember these three key things for the vignette is by focusing on the m and more neuroma. If you turn an m on its side, it's a three that helps you remember the third intermittent hospital space is the most common area you'll 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. In 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 over pronation of the foot. So remember for more neuroma, third intermittent hospital 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 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 relax if in. What is the what is likely positive in this patient's past medical history that would influence the decision to start her on relax if in rather than alternative osteoporosis agents. So that is going to be breast cancer. So relax if in or a lot of in is a selective estrogen receptor modulator. And while it does not work as well as bisfosfinates, 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/treatment. They probably have heard of in the same class and that's tomoxifen. Tomoxifen, relax if in. So it sounds very similar. So remember, relax if in is in the same class as tomoxifen and it is shouldn't train osteoporosis. It can also be used for breast cancer prophylaxis. In 3, 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 that makes it difficult to make a fist. On physical exam, you know it to land geectages on the palms and face. Labs are positive for both anti-nuclear antibodies as well as anti-centramar 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 calcino-suscutus, radoninaminone, soft geodesmotility, sclerodactyl and telangiectasia. So we see the calcino-suscutus. Those are those small white calcium deposits in her hands. She has heartburn, which is from the esophageal dysmotility disorder, telangiectasia as well as the tightening of the skin of the hands, which can progress to sclerodactyl where we have this claw like appearance of the hands. So this is classic limited systemic sclerosis aka crest syndrome, which we know will generally have a positive ANA and most importantly a positive anti-centramar antibody test, which I used to remember as anti-crestomir instead to help me remember this antibody as positive in crest syndrome. So if you see a positive anti-centramar instead think of anti-crestomir and think of crest syndrome, which is associated with limited systemic sclerosis. In 4, 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 C-reactive protein. C-rm rheumatoid factor as well as creatine kinase are normal. Patient is diagnosed with polymylgearumatica 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 arteritis. So remember, giant cell arteritis is associated with polymylgearumatica. You have to know that anywhere from 5 to 30% of patients with PMR will have giant cell arteritis. 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 to work up for giant cell. So the way that he's to remember that polymylgearumatica is associated with giant cell arteritis, is by instead of remembering it as polymylgearumatica, instead remember it as poly B myelgearumatica, poly B as in poly bunny in the giant from those kids books, and then you'll always remember this is associated with giant cell arteritis. In 5, 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 chifosis as these are sometimes the only indicator of a vertebral compression fracture in an osteoporotic patient. Question 6, 62 year old male presents the emergency department after being involved in a motor vehicle accident, is complaining of severe pain in his right hip. On physical exam, you 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 adducted, which is the classic presentation for posterior dislocations, where anterior are classically externally rotated and adducted. Question 7, 46 year old male presents 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, parasthesia 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 a quina syndrome. They have the classic clinical manifestations, lower back pain radiating to the legs, saddle, parasthesia, urinary incontinence, loss of rectal tone. All of these areas are affected because caught a quina syndrome is severe compression of multiple lumbar sacral nerve roots that innervate these regions. So when caught a quina 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 court, MRI is going to be your test of choice. All right. Question 8, anterior dislocation, aka forward slippage of one vertebral body with respect to the one beneath it is known as so that is going to be 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 spondylolisis. Anyways, how do you remember? Spondylolisthesis 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 spondylolisthesis, at the end of the word, it has list thesis in it. List your thesis statement. So when I see spondylolisthesis, 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 asked you to pass the your thesis statement forward. So when you see spondylolisthesis, 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 spondylolisthesis. Little weird, but it definitely worked for me. Question 9, 32-year-old female presents 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 tests listed below would be most appropriate to order next to assist in making the diagnosis. Answer A, anti-centramarine antibody, answer B, anti-tissue transglutaminase antibody, C, anti-smith antibody, D, anti-cyclic, sutrylineated peptide antibody. Again, A, anti-centramarine, B, anti-tissue transglutaminase, C, anti-smith, D, anti-cyclic, sutrylineated peptide. So the answer is going to be C, anti-smith antibody. All right, so let's talk about why it's not the other ones. First, A, anti-centramarine antibodies, as we discussed before. This is most commonly used in the diagnosis of limited systemic sclerosis, subtype, aka crest syndrome, B, anti-tissue transglutaminase body that's used for the diagnosis of celiac disease, and finally, anti-cyclic, sutrylineated peptide antibody or anti-ccp. It's most commonly used for diagnosis of rheumatoid arthritis. and while it can be elevated and loop is, 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. Anti-smith antibodies as well as anti-double stranded DNA are the most specific lab tests you can use for loop is. So those are really the two that you need to know for loop is. I used to remember the word loop is, sounds like "loo" like the name "loo" and "piss" like taking a piss. So "loo" piss. And I used to remember a guy named "loo" taking a piss on a Smith and Wesson double barrel shotgun. Anytime I saw the word "loop is" I just created this very weird visual of "loo" taking a piss on a Smith and Wesson double barrel shotgun. You won't forget it, it's such a weird visual. So "smith and Wesson" helped me remember the anti-smith antibodies and double barrel shotgun helped me remember the anti-double stranded DNA antibodies. So remember when you see loop is, I want you to think of "loo" taking a piss on a Smith and Wesson double barrel shotgun. Create that visual in your head and remember the two main specific labs you need to know for loop is, anti-smith and anti-double stranded DNA. Question 10, a three year old boy presents to 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. Radio graphs are negative for fracture. So that is going to be a radial head subluxation, a KAA nurse made elbow. So this one's pretty straightforward, we have a young child under five. 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 humoral joint. And it gets stuck there until it's reduced. You always want to make sure you do a really good physical exam in these children and make sure there is no signs of fracture. They shouldn't have any focal bony tenderness, 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 in 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 coming her hair and rising from a chair. In physical exam, you note a rash around the eyes, vialicious papules over the dorsal aspect of both hands, as well as earthema across the shoulders, upper back and upper chest. Labs are drawn, which reveal an elevated creatine kinase level, as well as positive anti-Me2 antibodies. What treatments should be initiated in this patient for the suspected diagnosis? That is going to be glucocorticoids. So this patient has Dermatomyocytus. She has the Giotron papules, Heliatroprache, Decrease Muscle Strength, the Shal sign plus elevated CK, and anti-Me2 antibodies. That is about as clear cut as you can get. And then we know for Dermatomyocytus, glucocorticoids are the cornerstone of your initial therapy. This is usually prednisone at a dose of 1 milligram per kilogram per day. Now Dermatomyocytus has a few very high yield findings. And the way that I used to remember all the high yield stuff for Dermatomyocytus was instead of remembering Dermatomyocytus. I used to remember it as per-Matomyocytus. So all you do is replace the D with a P. And now you have Perm, P-E-R-M, per-Matomyocytus. So why per-M? Because whenever you think of this disease, when you 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 within 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 the visual you need to create. Lady in a chair getting her hair perm, getting her nails done, eyebrows wax with the caper 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 then helps you remember the Heliotropa rash that's coming around the eyes, upper eyelids especially. She's getting her fingernails done, then helps you remember the go-tron papules that are the most common on the top of the fingers. And she's wearing the caper shawl, which helps you remember the shawl sign, or photo-distributed poikylo derma, which is most common in the upper back neck and upper chest. Exactly where the cap is distributed when you wear it anytime you get your hair done. And then remember she's having some Me time. Me time spelled M-I, then helps you remember the anti-Me to antibodies, which are highly specific for a Germatomyocytus. So remember, change the D to a P and you have perm, M-Iocytus. Lady getting a perm, having some Me time, eyebrows waxed, getting her nails done, and wearing a cap. Question 12, 52-year-old male presenting the emergency department complaining of severe pain in this first meditarso-fulangial joint. The denies trauma to the area and states it started suddenly. Arthrocentesis is performed, which displays negatively by her foringent needle-shaped crystals. Patient has a history of hypertension, type 2 diabetes, hyperlipidemia, and current medications include hydrochlorothyazide, metformin, glipazide, and resuvastatin. Which medication that the patient is currently taking is the most likely culprit leading to his current clinical manifestations. Again, those meds are hydrochlorothyazide, metformin, glipazide, and resuvastatin. The med is going to be hydrochlorothyazide. Alright, so this is about as clear cut a case of gout as you can get, severe pain for a stone, negatively by her foringent needle-shaped crystals on her for a synthesis. So all you have to remember is which meds can cause gout flares. And in this case, it's hydrochlorothyazide. So remember thyazide diuretics, like hydrochlorothyazide, increase urate reabsorption at the proximal renal tubule, which can elevate uric acid levels and precipitate gout flares. So they're one of the many meds that can cause gout flares. So how do you 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 pure zinomide, loop diuretics, aspirin, thyazides, like hydrochlorothyazide, and then a thambutal. So again, plate PLATE, pure zinomide, loop diuretics, aspirin, thyazides, ethanbutal. And helps you remember the main meds that you need to know that can lead to gout flares. Question 13, 72-year-old female presents the office today for routine checkup. Pass medical history includes hypertension, hyperlipidemia. She states she has concerns about osteoporosis as her mother was diagnosed with it in her 60s and wound up with a hip fracture. Dexascan is ordered, which reveals a T-score of negative 2.6. It 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 recombinancy for at least 30 minutes and take with 6-8 ounces of water. So first you need to know the first line medication for osteoporosis. That of course is bisfosfinates. And one of the most important adverse drug reactions from bisfosfinates 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 6-8 ounces of water. It is actually a contraindication listed on all the bisfosfinates to give these to a patient who cannot remain upright for at least 30 minutes. It is also important for them to remain in P.O. 30 minutes after the dose. So know their food are met for 30 minutes. But by far the most important thing to know that they will test you on is avoiding recombinancy for at least 30 minutes. Alright, question 14. 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 anterior 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 hematrosis is a very common presentation for an ACL tear. Up to 77% of patients with acute hematrosis after injury of the knee have an ACL tear. And then you have the positive lockman test which we know is the most sensitive test for an ACL tear. And you can remember that the lockman 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 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 and 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 lew- uing sarcoma, it's most common in osteosarcoma. And then also uing sarcoma will most often be described as having an onion, skin or mothi in appearance on x-ray. And then uing sarcoma often will also have systemic symptoms, fever, 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 eye problem. osteosarcoma. Question 16, which of the following drugs have been associated with a high risk of causing drug-induced lupus? A, procanomide, B, metformin, C, azithromycin, D, gabapentin, E, alprasilam. So I'll give you a second to think about that. That's going to be A procanomide. So there's a bunch of drugs that can cause lupus close to 50 that we know of, but the main ones that you need to know are procanomide and hydrozene. 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 namanic chips, CHI, PPS, because the letters in drug-induced lupus are DIL as in DIL. That makes me think of those DIL potato chips or DIL pickle chips. However you want to remember it, when you see drug-induced lupus, DIL, think of DIL chips, CHI, PPS. And you'll know the high-yield meds that are always tested on. So chips stands for carbamazepine, hydrozene, isonizid, procanomide, penicillamine, and sulfosalazine. 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. When physical exam, the patient holds the arm in adduction and internal rotation and is unable to externally rotate the affected arm. Radiographs are obtained, which reveal a circular appearance of the humoral head with a light bulb appearance. What type of shoulder dislocation did this patient likely sustain? So that is going to be a posterior shoulder dislocation. So if the posterior 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 humoral head. And supposedly it looks like a light bulb. So now 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 an 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 you remember posterior dislocation. Question 18, 67 year old female presents the office complaining of persistent pain, inner hands, and knees for several months. She describes the pain as being worse in the evening, with stiffness in the morning that only lasts for a few minutes. On physical exam there is a bony deformity and enlargement noted on the distal interflangial 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 interflangial joints seen in this patient? So that is going to be heberdened nose. So this patient likely has osteoarthritis, persistent pain in the hands and knees, pain that's worse in the evening, and stiffness in the morning that only lasts for a few minutes. Remember inflammatory 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 hardened 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 interflangial joints we see in this patient is known as heberdened nose and these are considered a clinical marker for generalized osteoarthritis. Question 19, 53 year old woman with a 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. Herocardial 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 adhesiv capsulitis, aka frozen shoulder. So why is this adhesiv capsulitis and not some sort of subacromal pathology like rotator cuff tendonopathy, like impingement syndrome, etc. There are a few reasons. Usually they are 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 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 subacromal 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 adhesiv 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 the prox in two months ago after being diagnosed but the pain is becoming more severe and the medication is no longer working as well. Which additional medication 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 which was given to prox and symptoms are progressing. What other medications should you add to this patient's regimen? A) Diclophinec, B) prednisone, C) Zolodronic Acid, D) and Fliximab or E) Methotrexate. So the answer is going to be E) Methotrexate. So let's talk first why it's not the other options. First that Clophinec is just another onset like the prox and that she's already taking so no value there. Plus NSAIDs have no impact on disease progression. Next prednisone, prednisone can be used for symptomatic relief. It even has some disease modifying effect but it is not the best option on this list by a long shot. Next, Zolodronic Acid. That's an easy one because we know this is a Bisfosphenate not used for treatment of rheumatoid arthritis. Next, infliximab. 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 therapeutic goals with the first line med and that first line med is Methotrexate. Methotrexate is a demarc disease modifying anti-romatic drug and while there are other drugs in this class, hydroxychloroquine, sulfosalzine. Methotrexate is the most commonly used demarc and first line for R.A. because compared to the other meds it has a faster onset of action. The rare 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 in humoral shaft fractures, can lead to weakness and extension of the wrist, I.e. wrist drop and fingers. That is going to be the radial nerve. Because the way the radial nerve wraps around the humerus 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 it being described as wrist drop but when this nerve is injured the patient can have paresthesia of the dorsal hand or weakness of the wrist and finger extension. 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 gut. He's not currently taking any uric/lowering medications and he has treated previous acute attacks with an approximate he has at home. Labs are drawn which reveal an elevation in serum uric levels and a 24-hour urinary uric acid secretion of 230 mg. The normal range is 250 to 750 mg/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. Indomethicin, B. Hydroxychloroquine, C. Probenicid, D. Fabucsis stat, or E. Allopyrinol. So that is going to be C. Probenicid. So there's a lot of words in this fin yet but all it's asking you is which one of these meds make you pee out more uric acid? And the medication is probenicid. So that's a uricosteric 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 Indomethicin which is just an end-side used for acute attacks. Hydroxychloroquine which is not used in the treatment of gouts, primarily used for lupus. And that finally we have a Bucsis stat and allopyrinol. Those are both Zanthian 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, 22 year old male presents the office complaining of chronic, right-sided hip and thigh pain for the past six months. 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. Extraries reveal a small round loosensy with a sclerotic margin on the proximal feed. 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 prostaglandins. 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 prostaglandins. And the second thing is that this type of tumor responds extremely well to NSAIDs. 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 NSAIDs. That's what will differentiate these two out of vignettes. We need to remember that. Osteoid osteoma, dramatic pain relief with NSAIDs, osteoblastoma, minimal pain relief. So why do NSAIDs work so dramatically at reducing the pain? Well, if you remember back to pharmacology, you remember NSAIDs blocked the production of prostaglandins through the inhibition of cyclooxygenase. So for osteoid osteoma, again, remember two things. One, they crank out a bunch of prostaglandins. And two, for this reason, the pain experience responds extremely well to NSAIDs. And I hate to even mention this the way that I used to remember this. Osteoid osteoma, the letters OO. Whenever I'd see those two O's in osteoid osteoma, I remember that song that said OO, it's magic. You know, and I used to remember OO, it's magic. NSAIDs. 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 to stick for me. So we see osteoid osteoma think OO, its magic NSAIDs, because of how well NSAIDs work and improving the pain from the increase in prostaglandins. 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 define 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, as usually where a 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 shoulders dislocations will have some degree of axillary nerve dysfunction. The nerve runs around the surgical neck of the humerus, and this is important. It innervates the deltoid muscle and the skin overlying the lateral shoulder. And that's why this patient is complaining of numbness and tingling in the lateral part of the shoulder, also known as this 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 ax 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 ax up and out by his side. So his arms are abducted and externally rotated. So Antonio helps you remember this as 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 ax he's holding, in his other hand, helps you 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 ax in the other hand. Both arms are abducted and externally rotated. So 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. So that is going to be dequevere vein tendonopathy. So why dequevere vein 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. Exasperated by thumb and wrist movement. This makes sense as the tendons involved in dequevere vein are the epb and apial tendons, which are responsible for movement of the thumb. And most importantly, she has a positive finkel seam test, which is pain over the radial styloid with ulnar deviation on the wrist with the thumb flexed across the palm. That's classic dequevere vein tendonopathy. In case you need a way to remember the tendons involved in dequevere veins, because I did get this on an exam question, the tendons involved are the abductor polisus longus, and the extensor polisus briefus, the apel 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 apel with extra peanut butter as an epb tendon are delicious as in dequevere vein. So apples with extra peanut butter are delicious. Apples, apial tendons, extra peanut butter, epb tendon, are delicious, dequevere vein tendonopathy. That was enough for me to get the question right on an exam question. 62-year-old male presents the office complaining of severe pain in his first toe. Arthrosynthesis reveals negatively by a fringe and needle shaped crystals that diagnosis of gout is established. Pass 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 a acute gout flair with? So that's going to be glucocorticoids. So you have to think about what are the first line meds to treat acute gout flair. So really there's only three. Endsets, steroids, and colchocene. We know endsets are out of the question because this patient has end stage renal disease. Colchocene can be used in mild kidney disease when GFR is about 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 collys fracture. So there's two different types of distal radius fractures you should be familiar with. That's collys and smith. Collys involves dorsal displacement of the distal radius. Smith involves Palmar or a volar displacement of the distal radius. The way that I remember collys is associated with dorsal displacement is by remembering collys is a breed of dog, the type of dog that last he was, a colliedog. So when you think of collys fracture, I want you to think of a colliedog. And the first two letters in dog are the first two letters in dorsal DO. This helps you remember collys 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 collys fracture, think of a colliedog. Question 29, 47-year-old male with history of intravenous drug use presents in 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 in an ortho-site sedimentation rate and see 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 staff-oreous. 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, a fever, back pain, and neurologic deficits. Right away, spinal abscesses should 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, and almost all cases of spinal epidural abscess will have an elevation of ESR and CRP. Usually, radiographs are going to be normal in 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, staff or ears and 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 an 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 spinatus. So why? Well to start, majority of rotator cuff lesions begin as partial tears of the spine and the spine. So the most important thing is to have a lower back of the spine. So the main state of treatment for oscotch-flotter disease is a lower back of the spine. So the main state of treatment for oscotch-flotter disease is conservative and says, etc. So the main state of treatment for oscotch-flotter disease is procussing or tapping over the median nerve to see if pain or paresthesia is reproduced in the median nerve innervated fingers. So you just remember the T and T-nell stood for tapping. And then the failin test, you basically just flop your hands over and put the dorsal surfaces or the back of the hands together for a minute. Positive test is pain or paresthesia in the median nerve innervated fingers. And I just remember the word failin sounds like fallen. So I just 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. So you just look at a picture of it. And then so you just remember that the hands have fallen or failin over because 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. An exam pain is elicited by performing wrist flexion against resistance. Tenderness would likely be felt over which part of the elbow in this patient. So that is the medial epicondyle. So we have a classic case of medial epicondylitis, aka golfer's elbow. We have a 67 year old male avid golfer with elbow pain, no proceeding 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 epicondyle is the bony origin for the wrist flexors which is affected in this condition. The way that I remember the high-yield stuff about medial epicondylitis, aka golfer's elbow, was by remembering the sentence, mini golf is fun. So the M in mini helps you remember this is the medial epicondyle involved in golfer's elbow. Golf obviously because this is also known as golfer's elbow. And then the F 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 carpeureadialis, or that it's caused from repetitive flexion. Mini golf is fun, M for medial epicondyle. Golf for golfer's elbow. And then F for flexion flexor. Question 36, which test is performed as part of the physical exam in a suspected Achilles tendon rupture that involves squeezing the gastrocnemius 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 plantar 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. He immediately felt a tearing sensation which was followed by severe pain. A valgus 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. They 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 their rust stress test. It's easy to get those mixed up. So this is how I used to remember them. So first, how do you associate MCL injuries with valgus stress? So valgus has the word gusts in it. So whenever I see valgus, I think of mocho gusto. The M in mocho 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 in leaky helps you remember the verus stress involves the LCL. So remember mocho gusto for valgus test to help you remember it's associated with MCL injuries. And then leaky pipes rust for verus test to help you remember it's associated with the LCL injuries. Question 38, 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 the morning seems to help. Radiographs are negative and on physical exam point tenerness is noted over the medial tubercle of the calcaneus. So that is going to be plantar fasciitis. So pretty easy one. Anytime you have a patient complaining of heel pain, that is worse in the morning when they first get out of bed or worse after periods of inactivity. Especially with point tenerness right at the insertion side of the plantar fascia, which is the medial tubercle of the calcaneus. Obviously, plenetrop胎. plantar fasciitis should be high in the list of differentials. Treatment is generally going to be conservative for these patients, rest, and said, better shoes, etc. Question 39. Sixty-seven-year-old female presents to the office four months after fracturing her left hand. The hand was properly splintered 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. I'm going to give you a second to think about that one. Complex regional pain syndrome. Anytime you see a patient that had an injury in the vignette, they go out of their way to say it healed properly, it was treated properly, etc. And yet the patient is still in excruciating pain months later, always have complex regional pain syndrome at the top of your list of differentials. So with complex regional pain syndrome, the treatment and diagnostic tests are pretty low yield. The highest yield thing to know about it is its bizarre combination of clinical manifestations. So the way that I remember the common clinical manifestations that you will see in a vignette for complex regional pain syndrome is by, instead of remembering complex regional pain syndrome, I remembered complex regional pain syndrome. And what does pain stand for? So PA, INT. So the P stands 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 A stands for inappropriate pain because it's out of proportion to the initial injury. Pain is typically the most prominent in debilitating symptom of CRPS. So remember A 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 and 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 difference in skin temperature on the effect of the unaffected size of side 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. An exam tenernis 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 periostial reaction with layers of reactive bone that resemble layers of an onion skin. Biopsy is obtained which display sheets of uniform small round blue cells and cytogenetic testing reveals a chromosomal translocation of 11 and 22. So it's going to be eulingsarcoma. So you have a young male minor trauma to the leg leading to localized pain and swelling that is not improving. He has constitutional symptoms fever and night sweats all very typical of eulingsarcoma but then we have our keywords or numbers. Moth onion blue 11 and 22 out of all the words and that vignette those are the key to choosing the right answer. So the x-ray findings that moth eat an appearance in the onion skin appearance. While they can be seen in other conditions for the sake of a vignette, it will very likely be eulingsarcoma 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 keywords. So when I would see eulingsarcoma, eulingsarcoma, 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 11 22 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 the onion rings and just visualized him, chowing down on some onion rings which helped me remember the onion skin appearance on x-ray. So whenever I see ewing 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 sarcoma. Question 41. 46 year old male who suffered a fall from his roof earlier in the day has just completed a series of x-rays. The x-ray reveal a number of fractures as well as a dislocation of the right tibial for moral joint, aka the knee joint. What is the most dangerous potential complication that can arise following a tibial for moral 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 for moral dislocation aka knee dislocation and delay and diagnosis are apparently to amputation. So you need to make sure after you reduce the dislocation you assess the distal and popliteal poses, measure ankle, brachial index, etc. up 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 talo-fibular ligament aka the ATF ligament. I used to remember that by remembering the letters in ATF ligament, stand for 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-ray reveal a proximal ulnar fracture accompanied by a radial head dislocation. I'll repeat that. The x-ray 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 montigia fracture. So there's two types of fractures/dislocations you need to know for the forearm. First one as we saw in this vignette is a montigia fracture which is a proximal ulnar fracture accompanied by a radial head dislocation. And then the second type is known as a galliazifracture which is a radial mid shaft fracture with dislocation of the distal radial ulnar joint. And while it's a dislocation or instability of the radial ulnar joint, it's most common that the ulnar 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, GRU, the G stands for galliazee, the R stands for radius fracture and then the U stands for ulnar dislocation and then murder. First three letters are MUR, M stands for montigia, 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 galliazifracture, radius fracture and a ulnar dislocation, aka the radial ulnar joint to be specific. And then the first three letters of murder, MUR, help you remember a montigia, ulnar fracture and radial head dislocation. Question 44, 26 year old female presents at the office complaining of fatigue, joint pain and a low grade fever for the past few weeks. She also reports that she develops a painful burn after being in the sun for just a short period of time. On physical exam you know a rash that is distributed over the cheeks and nose, sparing the nasolabial folds as well as diffuse discoyleations. So what would be the best initial test to order in this patient? So that is your anti-nuclear antibody, aka your ANA test. So in this patient systemic lupus erythematosis should be at the top of your list of differentials. Anytime you have a young female of child bearing 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 nasolabial folds as well as the discoyleations and then she describes a photosensitive rash that burn after a short period of time in the sun. So the best initial or screening test in a patient you suspect may have lupus is your ANA, your anti-nuclear antibodies. It is not a specific test but it is a very sensitive and this is where you will 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 the ER after a bicycle accident he had earlier on in the day. He states his bike had a pothole which sent him flying off his bike, landing on his outstretched hands. He is not complaining of pain along the radial side of the right wrist and is tender just proximal to the base of the thumb at the anatomic snuff box. A fracture of which bone should be suspected in this patient until proven otherwise. So that is the scaphoid. This is a very simple one, scaphoid or nevicular fracture. You have a patient who had a fall on to 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. Snuff box tenderness you are done. This is a scaphoid fracture until proven otherwise. As soon as you hear snuff box tenderness, always be thinking of a scaphoid fracture. Question 46, 47 year old female presents the office complaining of dry mouth and dry eyes for several months. She has used over the counter eye drops with minimal improvement. Physical exam reveals dry mucus membranes and swollen parodied glands. Explain to the patient you 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 Schirmer test. This patient very likely has showgren syndrome. Of course we would need to perform some labs, your anti-row, anti-law, ANA. But she has all of the classic clinical manifestations, dry eyes, dry mouth, prodiglaine enlargement. And then the test we. performed to assess for tear production is called the Schirmer test. Now with Schoengrin syndrome in addition to your Schirmer test, there's two really high yield things that you need to know and that's your anti-row and anti-law antibodies that are used in diagnosing this condition. The way that I just remember these three high yield tests is by instead of remembering Schoengrin syndrome, I would remember slow green syndrome. Slow green instead of Schoengrin and what's slow in green, a frog that helps remember a slow green frog landed in my cup of Sherbert. So create that visual in your head if a cup of Sherbert, that little frozen fruit treat and then a frog landed right in it. So Schoengrin is now slow green, a slow green frog landed in your cup of Sherbert. Frog, the second two letters are RO, that helps remember anti-row. Landed first two letters are LA, that helps remember anti-law and Sherbert helps remember Schirmer test. So that worked for me just remember slow green instead of Schoengrin, remember that slow green frog landing in your cup of Sherbert. Question 47, 27 year old male presents to the office of the right knee pain after a sports related injury a few days prior. He was running and felt a sudden pop in his knee and the past few days he has found the knee is often locking up, making it difficult to fully extend. And physical exam, you know, joint line tenderness in the right knee, as well as a poppable click and pain when performing the McMurray test. So that's going to be a meniscal tear. All right, so what are the keys here to tell us this is a meniscal injury and not some other type. First the pop and lock of the knee, it's common for a patient with a meniscal 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 not 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 meniscal injuries, so Murray is obviously a man's name and meniscal when broken down has the words men is call. So men is call. Remember men is called and what are men called Murray as in the McMurray test. So if you see an exam question or the answer is what the name Murray in it. Remember that's a man's name and it's what men are called as in meniscal and then I'll help you remember the McMurray test is used in meniscal tears. Question 48, 22 year old male presents to the office today complaining of swelling and his right upper arm that has increased in size over the past year. States the area is not painful. Redugraphs are obtained which reveal a large, pedunculated lesion that is pointing away from the joint space. Biapsy is obtained in the physician informs the patient that the swelling they have in their arm is caused from the most common type of benign bone tumor. What type of benign bone tumor does this patient likely have? So that is an osteocondroma. So osteocondromas are the most common benign bone tumor counting 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 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 at Biaware 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, 29 year old female presents at the office complaining of anterior knee pain. She unites 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. A physical exam lateral movement of the battella results in discomfort and apprehension from the patient. What common disorder of the knee is this patient likely suffering from. So that is battelo 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. Really just need to decide on one thing. Is this battelo femoral syndrome or is this Iliotibio band syndrome? Very simple if it's anterior knee pain, it's battelo femoral syndrome, if it's lateral pain, it's Iliotibio band syndrome. Easiest way to remember this is just to think of the anatomy involved. Maybe you can't remember where your Iliotibio band is but I'm sure all of us know where our battella is or kneecap anterior side of the knee. So if it's a female runner with anterior knee pain, it's battelo femoral syndrome as in the case of our patient in this fin yet. She also has a positive apprehension sign which is where you have the patient flex the knee slightly, apply some lateral pressure to the battella and if they squirm around or attempt to straighten the knee that's a positive test. If you can't remember that battelo femoral syndrome is the most common among female runners, just remember it like I did instead of remembering battelo femoral syndrome instead of battelo femoral syndrome, battelo femoral syndrome as those are the key things to remember about this condition. Question 50, blank fractures are the most common carbobone fracture, blank fractures are the most common carbobone fracture. So that's scaffoid fractures. So I figured I'd end this on an easy one, scaffoid fractures are the most common carbobone to fracture. As we just went over a few minutes ago on question 45, make sure to look out for snuff mocks, tenderness in these types of fractures. Alright, those 50 high old MSK questions, hopefully that will help you for your exam. Thank you as always for listening to the podcast. Good luck on your exams, good luck in PA school, your parents, your panoray and your URs.