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USMLE Step 1 High‐Yield Musculoskeletal Topics
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Musculoskeletal
High Yield USMLE Step 1 Notes
Welcome to the Musculoskeletal High-Yield Notes for Step 1.
These are the most commonly tested topics on the exam—ideal for quick review in your last 2 weeks before the exam, when you’re short on time, or when you’re just starting out and want to focus on what is high yield. Created and peer-reviewed by physicians who scored 260+ on Step 1 in a Q&A style to reinforce active learning.
How to use this file
- Read the question ➔ cover the answer ➔ self-quiz before revealing.
- Review the NOTES ➔ they include high-yield details you don’t want to miss.
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- Don’t forget to watch the video lessons that go with this file. Learn more here.
Table of Contents
Upper Limb
1. A 28-year-old man presents with wrist drop after fracturing the mid-shaft of his humerus. What nerve is most likely injured?
➔ Radial nerve (C5 to T1)
- Note: Causes:Midshaft humerus fracture and Compression in axilla : “Saturday night palsy,” crutches
- Injury Site: Mid-shaft humerus (radial groove)
- Motor: Wrist, finger, elbow extension → wrist drop
- Sensory: Posterior arm + forearm, dorsal hand
2. A 19-year-old wrestler sustained a shoulder injury during a match and now has a flattened deltoid and can’t abduct his arm beyond 15°. What nerve is likely damaged?
➔ Axillary nerve(C5–C6)
- Note: Injured in surgical neck fractures or anterior shoulder dislocation.
- Motor: Deltoid (abduction 15–90°), Teres minor (external rotation)
- Sensory: Lateral shoulder
- Keyword: “Flat shoulder” appearance
3. A 40-year-old cyclist presents with numbness and tingling in the 4th and 5th fingers of his right hand. He reports that symptoms worsen after long bike rides. On exam, there is weakness in finger abduction and atrophy of the hypothenar eminence. What is the most likely site of nerve compression?
➔ Ulnar nerve in guyon canal (C8-T1)
- Note: Injured at elbow (medial epicondyle) or wrist (hook of hamate, Guyon canal).
- Affects intrinsic hand muscles(palmar and dorsal interossei and the medial 2 lumbricals) →weak finger abduction/adduction.
- Sensory loss: medial 1.5 fingers and hypothenar eminence
- Froment sign positive(losing adductor pollicis “pinching” muscle): Inability to hold paper between thumb and index finger *
4. A 49-year-old woman falls while skating and sustains a forearm injury. She has reduced sensation over the lateral forearm and weakened elbow flexion. Which nerve is injured?
➔ Musculocutaneous nerve(C5-C7)
- Note: Injury Site: trauma to upper arm, Normally travels in the space between the biceps brachii muscle (above) and the brachialis muscle (below) in the upper arm
- Motor: Biceps, brachialis → elbow flexion, forearm supination
- Sensory: Lateral forearm
- Maintains the biceps reflex (C5,C6)
5. A 45-year-old woman undergoes a mastectomy for breast cancer. On follow-up, she has difficulty abducting her arm above 90° and shows prominence of the scapula when pushing against a wall. Which nerve was most likely injured during the procedure?
➔ Long thoracic nerve(C5-C7)
- Note: Innervates serratus anterior → anchors scapula.
- Causes: Mastectomy, stab wound, lateral thoracic trauma
- Injury causes winging, impaired overhead abduction (>90°)
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6. A 34-year-old woman who works long hours at a computer presents with numbness and tingling in the thumb, index, and middle fingers. Symptoms worsen at night. Physical exam reveals a positive Tinel sign. What is the most likely diagnosis?
➔ Carpal tunnel syndrome
- Note: Causes: Repetitive use (typing), pregnancy, hypothyroidism, acromegaly and dialysis-related amyloidosis.
- Median nerve entrapment under transverse carpal ligament (along with the Flexor digitorum superficialis and profundus tendons)
- Symptoms: paresthesia (lateral 3.5 digits), thenar atrophy, weak thumb opposition. Positive Phalen/Tinel.
Created with BioRender.com
7. A 34-year-old man presents with neck pain radiating to his right shoulder and lateral forearm after lifting a heavy box. He reports weakness when trying to flex his elbow. On examination, he has decreased sensation over the deltoid region. Reflex testing reveals reduced biceps. Which nerve roots are most likely affected?
➔ C5–C6
- Note: Motor: Deltoid, biceps
- Reflex: ↓ Biceps
- Sensory: Lateral upper arm(deltoid region)
- Note: A nerve root comes directly off the spinal cord; a nerve forms after roots join and carries both motor and sensory signals in the periphery.
| Level | Disc Involved | Sensory Loss | Motor Weakness | Reflexes Affected |
|---|---|---|---|---|
| C5 | C4–C5 | Anterior shoulder | Biceps and deltoid | ↓ Biceps |
| C6 | C5–C6 | Radial forearm to thumb and index finger | Biceps and wrist extensors | ↓ Biceps, ↓ Brachioradialis |
| C7 | C6–C7 | Palmar/dorsal fingers II–IV | Triceps, wrist and finger extensors | ↓ Triceps |
| C8 | C7–T1 | Fingers IV–V, hypothenar, medial forearm | Finger flexors | None |
8. A 5-year-old child falls from a tree and grabs a branch, now presents with a claw hand and difficulty with fine finger movement. What nerve roots are affected?
➔ C8–T1
- Note: Klumpke’s palsy (C8–T1): Lower trunk injury → intrinsic hand muscle paralysis + claw hand, often with sensory loss in the medial hand and forearm.
- Erb’s palsy (C5–C6): Upper trunk injury → “waiter’s tip” posture with arm adducted, internally rotated, extended, and pronated.
- Seen in trauma or birth injury.
9. A thirty-year-old woman presents with occasional numbness, tingling and swelling of the arm.. Physical examination reveals decreased radial pulse on the right with arm abduction and external rotation. Chest X-ray reveals a bony outgrowth extending from the C7 vertebra. What is the most likely cause of her symptoms?
➔ Compression by a cervical rib
- Note: Cervical rib (from C7) can compress neurovascular structures in the thoracic outlet (brachial plexus, subclavian artery/vein) → leads to arm paresthesia, weakness, swelling, and vascular congestion.
James Heilman, MD (https://commons.wikimedia.org/wiki/File:C7ribMark.png), https://creativecommons.org/licenses/by-sa/4.0/legalcode
| Muscle | Innervation | Main Action | Injury Clues |
|---|---|---|---|
| Supraspinatus | Suprascapular nerve | Initiates abduction (0–15°) | Most commonly torn; positive drop arm test |
| Infraspinatus | Suprascapular nerve | External rotation | Pitching injury (overhead throwing); posterior shoulder pain |
| Teres minor | Axillary nerve | External rotation & adduction | Rarely isolated injury; involved in posterior cuff injuries |
| Subscapularis | Upper/lower subscapular nerves | Internal rotation | Seen in anterior dislocations or subscapularis tears |
10. A 45-year-old man presents with shoulder pain after attempting to lift a heavy object above his head. On physical exam, there is weakness during the initial 15° of arm abduction, but strength improves as abduction continues. The drop arm test is positive. Which muscle is most likely injured?
➔ Supraspinatus
- Note: Shoulder abduction is initiated (0–15°) by the supraspinatus muscle via the suprascapular nerve, and continued (15–90°) by the deltoid muscle via the axillary nerve.
11. A 22 year-old man presents to the emergency department after falling on an outstretched hand during a football game. He complains of pain and swelling in the right wrist. On examination, there is point tenderness in the anatomical snuffbox. What is most likely to happen if the diagnosis is missed?
➔ Avascular necrosis Scaphoid Fracture
- Note: Results from Fall on outstretched hand (FOOSH) and Presents as Anatomical snuffbox tenderness (A triangular depression on the lateral (radial) dorsal wrist)
- Normal Blood supply goes retrograde Distal-to-proximal → proximal pole at risk of avascular necrosis
- Hamate hook fracture:may injure ulnar nerve, causing hypothenar pain and grip weakness.
- Lunate dislocation: Typically from a fall on an outstretched hand; can compress the median nerve, leading to acute carpal tunnel syndrome.
Mohamed Jarraya, Daichi Hayashi, Frank W. Roemer, Michel D. Crema, Luis Diaz, Jane Conlin, Monica D. Marra, Nabil Jomaah, and Ali Guermazi (https://commons.wikimedia.org/wiki/File:Scaphoid_fracture_with_a_radiolucent_line_after_12_days.jpg), „Scaphoid fracture with a radiolucent line after 12 days“, https://creativecommons.org/licenses/by/3.0/legalcode
12. A 12-year-old boy falls off a bicycle. X-ray shows a supracondylar fracture of the humerus with anterior displacement of the distal fragment. On examination, he has absent radial pulse and cold pale hand. Which vascular structure is most likely injured?
➔ Brachial artery
- Note: Structures in cubital fossa (lateral → medial): Radial nerve → Biceps tendon → Brachial artery → Median nerve
- Supracondylar fracture can cause 2 common injuries:
– Brachial artery injury → ↓ distal pulses, cold hand median nerve injury → sensory loss over lateral palm, motor loss (can also be injured in misplaced needles)
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Lower Limb
13. A 45-year-old woman has difficulty walking. On exam, she exhibits a Trendelenburg gait, and her left hip drops when standing on her right leg. Which nerve is most likely injured?
➔ Right superior gluteal nerve
- Note: The superior gluteal nerve innervates the gluteus medius, gluteus minimus, These muscles abduct the thigh and stabilize the pelvis.
- Injury(as in superomedial injection in the gluteal region) → pelvic drop on the contralateral side when standing on the affected leg (positive Trendelenburg sign).
- So a left hip drop = Right superior gluteal nerve injury
- Inferior gluteal (L5-S2) supplies the gluteus maximus which is the main hip extensor (injury causes difficulty getting up from a seated position)
14. A 70-year-old woman has difficulty walking and frequent falls. On exam, she cannot adduct her right thigh and has sensory loss over the medial thigh. Which nerve is most likely injured?
➔ Obturator nerve
- Note: Injured in: Pelvic surgery, tumors, hip dislocation
- Motor: Thigh adductors (adductor longus, brevis, magnus, gracilis)
- Sensory: Medial thigh
15. 60 year old woman presents with severe pain in her left hip and is unable to walk. On exam, her left lower limb is shortened and externally rotated. X-ray confirms a femoral neck fracture. Which muscle is responsible for the external rotation observed in this patient?
➔ Piriformis
- Note: Piriformis is one of the main External (lateral) rotators of the hip: Rotates thigh/foot away from midline.
- Piriformis muscle can compress the sciatic nerve as it exits the pelvis, causing piriformis syndrome (a non-disc cause of sciatica).
16. A patient presents with severe buttock and posterior thigh pain radiating down the leg after lifting heavy boxes. Straight leg raise reproduces the pain. What nerve is affected?
➔ Sciatic nerve (L4-S3)
- Note: Often compressed by disc herniation or Posterior hip dislocation or piriformis syndrome
- Injury → radiating posterior leg pain, positive straight leg raise and common peroneal / tibial neuropathy.
Splits into common peroneal and tibial nerves and supplies all muscles below the knee!
17. A man develops foot drop and numbness over the dorsum of his foot after fracturing the fibular neck. What nerve is most likely injured?
➔ Common peroneal nerve
- Note: The common peroneal nerve wraps around the fibular neck superficially → vulnerable to injury.
Divides into: - Superficial peroneal: sensory to dorsum of foot, motor to peroneus longus and brevis responsible of foot eversion
- Deep peroneal: sensory to webspace between hallux and 2nd digit, motor to dorsiflexors → injury → foot drop, steppage gait.
(PED = Peroneal Everts and Dorsiflexes)
18. A 33-year-old man presents with difficulty walking after a motor accident. On exam, he is unable to plantarflex or invert his foot, and he has lost sensation on the sole of the foot. Which nerve is most likely injured?
➔ Tibial nerve
- Note: Tibial nerve is a Branch of the sciatic nerve, Gives sensory branches to the sole of the foot
- Gives motor branches to Gastrocnemius, soleus → plantarflexion, Tibialis posterior → inversion
- Inability to do plantar and toe flexion → inability to walk on toes
(TIP = Tibial Inverts and Plantarflexes)
19. A 30-year-old woman presenting after delivery with numbness over the lateral thigh, worsened by tight clothing. There is no motor weakness. What nerve is affected?
➔ Lateral femoral cutaneous nerve
- Note: Lateral femoral cutaneous nerve is a purely sensory nerve supplying the lateral thigh.
- Caused by tight belts or clothing, obesity, pregnancy, prolonged hip flexion (in delivery) causing nerve compression under inguinal ligament → meralgia paresthetica (burning pain or numbness in the lateral thigh).
20. A 36-year-old man from a TB-endemic region presents with 3 weeks of low back pain, fever, and weight loss. On exam, his hip is flexed, and passive extension elicits significant pain. Spinal tenderness is noted over the lumbar vertebrae. CT imaging shows a fluid collection in the muscle on the image. What is the action of this muscle?
➔ Flexion of the hip joint
- Note: TB can infect vertebrae (Pott disease) → spreads to psoas muscle causing → psoas abscess
- Psoas muscle is the major flexor of the hi and the patient Presents with:
- Fever, back/groin pain, Pain on passive hip extension (psoas sign)
- Hip flexion posture
- CT/MRI: Retroperitoneal fluid collection along psoas sheath
- “Fluid collection on imaging = abscess”
James Heilman, MD (https://commons.wikimedia.org/wiki/File:ParaspinalabscessMark.png), https://creativecommons.org/licenses/by-sa/4.0/legalcode
21. A 32-year-old man has urinary and fecal incontinence following pelvic trauma. Physical exam shows loss of the anal wink reflex and decreased sensation in the perineal region. Which nerve is most likely affected?
➔ Pudendal nerve (S2–S4)
- Note: Motor: External urethral & anal sphincters, pelvic floor muscles
- Sensory: Perineum, external genitalia, Anal wink reflex (S2–S4)
22. A 25-year-old male presents after a sports injury. On examination, stroking the inner thigh does not produce testicular elevation on the same side. A nerve that lies on the external surface of the spermatic cord is suspected to be injured. Which nerve is most likely damaged?
➔ Genitofemoral nerve (L1-L2)
- Note: Divides into: 1- Genital branch (on spermatic cord, motor to cremaster muscle, sensory to scrotum/labia)
2- femoral branch (sensory to upper thigh) - Injury → absent cremasteric reflex, at risk during hernia repair.
23. A 67-year-old man undergoes femoral artery catheterization. Hours later, he develops difficulty climbing stairs. On exam, he has decreased patellar reflex and sensory loss over the anterior thigh and medial leg. Which nerve and nerve roots are most likely affected?
➔ Femoral nerve; L2–L4
- Note: Motor:
- Gives Motor supply to:
Quadriceps femoris → knee extension
Sensory:Anterior thigh and Medial leg via saphenous nerve - Reflex: Patellar (L2–L4)
24. A 54-year-old man presents with lower back pain radiating down the posterior aspect of his right leg into the lateral foot. He reports difficulty standing on his toes. On neurologic exam, there is weakness with plantarflexion, diminished Achilles tendon reflex, and decreased sensation over the lateral foot and sole. Which nerve root is the most likely site of nerve root compression?
➔ L5–S1
- Note: Common cause: Herniated disc compressing S1 root (posterolateral herniation at L5–S1)
- Motor: Weak plantarflexion (gastrocnemius, soleus),toe-walking difficulty
- Sensory: Loss over posterior calf, lateral foot, sole, ↓ Achilles tendon reflex
| Level | Disc Involved | Sensory Loss | Motor Weakness | Reflexes Affected |
|---|---|---|---|---|
| L3 | L2–L3 | Anterior thigh | Hip flexion, knee extension, hip adduction | ↓ Patellar, ↓ Adductor |
| L4 | L3–L4 | Anterior thigh, medial leg | Knee extension, hip adduction | ↓ Patellar |
| L5 | L4–L5 | Lateral thigh/leg, dorsum of foot, big toe | Foot dorsiflexion (drop), big toe extension | ↓ Posterior tibial (hamstring) |
| S1 | L5–S1 | Posterior leg, lateral foot | Foot plantarflexion, eversion (toe walking difficulty) | ↓ Achilles, ↓ Lateral hamstring |
| S2–S4 | S1–S4 | Posterior thigh, perineum (S3–S4) | None | ↓ Bulbocavernosus, ↓ Perineal |
CYP3A42D6,N. Mosteghanemi & O. Imauven, Dermatomes radiculaires humains, CC BY-SA 4.0
https://commons.wikimedia.org/wiki/File:Dermatomes_radiculaires_humains.png
25. A soccer player presents with knee pain after a tackle. Lachman test shows increased anterior translation of the tibia. Which ligament is most likely torn?
➔ Anterior cruciate ligament (ACL)
- Note: Prevents anterior tibial translation; injured by pivoting, deceleration.
- PCL: Prevents posterior displacement of tibia; tested with posterior drawer test.
- McMurray test: Flex and rotate the knee → pain/click = meniscus tear
- LIME mnemonic: Lateral meniscus → Internal rotation; Medial meniscus → External rotation (during McMurray test).
26. A researcher is studying skeletal muscle contraction, she observes changes in the sarcomere structure. Which of the following components remains the same length during contraction?
➔ A band
- Note: Sarcomere = Z line to Z line (entire unit that shortens)
- A band: Contains entire length of thick (myosin) filaments; does not shorten during contraction.
- H zone: Central part of A band with only thick filaments; shortens during contraction.
- I band: Contains only thin (actin) filaments; shortens during muscle contraction.
- M line (band): Midline of the sarcomere where thick filaments are linked; serves as attachment point for myosin.
Richfield, David (2014). “Medical gallery of David Richfield“. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.009. ISSN 2002-4436 https://commons.wikimedia.org/wiki/File:Sarcomere.svg
27. A researcher is studying skeletal muscle contraction. He finds that disruption of the T-tubule system leads to impaired muscle contraction. What is the role of T-tubules in skeletal muscle?
➔ Transmit depolarization signals to the sarcoplasmic reticulum
- Note: T-tubules are invaginations of the sarcolemma that carry action potentials deep into the muscle fiber, triggering a synchronized calcium release from the sarcoplasmic reticulum (via ryanodine receptors) → coordinated contraction.
28. A 22-year-old man falls onto his left shoulder. He presents with pain and deformity over the midclavicular region. On exam, the affected shoulder is drooping and medially rotated. X-ray confirms a midshaft clavicle fracture. What explains the displacement of the bone fragments?
➔ Upward pull by sternocleidomastoid; downward pull by arm weight and pectoralis major
- Note: Clavicle fracture Presents with Swelling, bony irregularities and deformity at the fracture site
- Sternocleidomastoid pulls medial fragment upward
- Arm weight + pectoralis major pull lateral fragment downward and medially
Majorkev at English Wikipedia (https://commons.wikimedia.org/wiki/File:Clavicle_Fracture_Left.jpg), „Clavicle Fracture Left“, https://creativecommons.org/licenses/by/3.0/legalcode
29. A 65-year-old man has progressive lower back pain, numbness, and leg weakness that worsen with walking and improve when leaning forward. MRI shows narrowing of the lumbar spinal canal. Which ligament is most likely hypertrophied?
➔ Ligamentum flavum
- Note: Spinal stenosis: Narrowing of spinal canal, usually due to degenerative changes (osteophytes, disc bulging, ligamentum flavum hypertrophy) → compresses spinal cord/nerve roots, in older patients (>60 years)
- The patient present with Lower back pain with neurogenic claudication (leg pain, numbness, weakness) that worsens with walking/extension (upright posture) and Improves with flexion (leaning forward, sitting, shopping cart sign)
Note: Normal leg pulses (vs. vascular claudication → Peripheral arterial disease with weak pulses)
InjuryMap (https://commons.wikimedia.org/wiki/File:Spinal_stenosis.svg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
Bone pathology
30. A 66-year-old man with multiple myeloma. X-ray of the spine shows multiple punched-out lytic lesions. What is the cause of the bone destruction seen in this condition?
➔ Activation of osteoclasts by RANKL
- Note: Osteoclast activation is promoted by:
- RANKL (binds RANK on osteoclast precursors), IL-1, TNF-α, and IL-6 (supportive roles, enhance RANKL effects), Parathyroid hormone (PTH) indirectly activates osteoclasts by stimulating osteoblasts to release RANKL
- OPG (osteoprotegerin, a RANKL decoy receptor) prevents RANK-RANKL interaction → less osteoclast activity.
- Osteoblastic activity measured by bone Alkaline Phosphatase (HY in paget’s disease)
31. An anesthetized patient develops hyperthermia, muscle rigidity, and increased CO₂ after receiving succinylcholine and halothane. What is the underlying pathophysiology?
➔ Excessive calcium release
- Note: The sarcoplasmic reticulum (SR) stores calcium in skeletal muscle for contraction and Ryanodine receptors (RYR1) on the SR release Ca²⁺ into the cytoplasm → triggers muscle contraction.
- Mutations in Ryanodine receptors after exposure to inhalant anesthetics → uncontrolled Ca²⁺ release and sustained muscle contraction, heat production, acidosis, and rhabdomyolysis (Malignant hyperthermia)
- Treatment: Dantrolene → inhibits ryanodine receptors
32. A 46-year-old construction worker presents with a swollen, tender area over the anterior aspect of his right knee. He reports that the swelling started gradually after kneeling for long periods. On exam, there is localized erythema and fluctuant swelling over the patella. Knee range of motion is full but painful. Which of the following is the most likely diagnosis?
➔ Prepatellar bursitis
- Note: Bursitis is caused by repetitive trauma or prolonged kneeling (e.g., “housemaid’s knee”)
- Presents with Localized swelling, erythema, tenderness, pain with active movement(no pain with passive movement) and No weakness → helps exclude joint pathology like arthritis or ligament tears.
33. A 30-year-old woman presents with pain near the base of her right thumb. She works as a nanny and frequently lifts a 6-month-old infant. Examination shows tenderness over the radial side of the wrist and pain when the thumb is grasped and the wrist is ulnarly deviated. Which of the following is the most likely diagnosis?
➔ De Quervain tenosynovitis
- Note: Results from Overuse of thumb tendons (e.g. lifting infants) → presents with Pain localized to the tendon sheath with preserved joint movement due to inflammation of abductor pollicis longus & extensor pollicis brevis tendons “Pollicis”
- Key test: Finkelstein test – thumb in fist + ulnar deviation → pain at radial wrist
34. A 25-year-old woman presents with a painless, smooth, round swelling on the dorsal aspect of her right wrist that has gradually increased in size and transilluminates on examination. What is the most likely diagnosis?
➔ Ganglion cyst
- Note: Benign, fluid-filled swelling over a joint capsule or tendon sheath, Most common on dorsum of wrist
- Transilluminates on exam = means fluid filled
35. A 19-year-old man is brought to the ER after being trapped under debris for 2 hours. His left leg is swollen, tense, and extremely painful, especially with passive toe movement. Pulses are palpable. What is the next best step?
➔ Perform emergent fasciotomy
- Note: Crush injury → bleeding + edema in closed fascial space → ↑ Intracompartmental pressure → ↓ Venous outflow → ↓ Capillary perfusion → Muscle & nerve ischemia and tissue necrosis
- 6 Ps: Pain (out of proportion), Paresthesia, Pallor, Paralysis, Pulselessness, Poikilothermia, Pain with passive stretch and neuropathy are early findings
- TTT→ emergency fasciotomy to Avoid necrosis
36. A healthy 13-year-old boy has short stature and delayed puberty (Tanner stage 1). His father had similar “late bloomer” growth. Bone age = 10 years; parents are average height. What is the most likely diagnosis?
➔ Constitutional growth delay
- Note: Constitutional Growth Delay (CGD):
- Normal parental height with Delayed bone age < chronological age and Normal pubertal development (just delayed)
- Will reach normal adult height after delayed puberty
Familial Short Stature: - Short parents with Bone age matches chronological age and Remains short in adulthood
GH Deficiency: - Slowed linear growth, bone age < chronological, often with central symptoms (hypoglycemia, fatigue, delayed puberty)
37. A 3-year-old girl refuses to move her left arm after being pulled up by the hand. She holds the arm slightly flexed and pronated; no swelling or bruising is seen. What is the most likely diagnosis?
➔ Radial head subluxation
- Note: Caused by traction injury to an extended arm with Annular ligament slipping over radial head
- Common in toddlers (1–4 years) presenting with arm held in pronated and slightly flexed position
- Tx: Supination + flexion or hyperpronation technique
38. A 13-year-old boy presents with anterior knee pain that worsens after running and jumping during basketball practice. Exam shows tenderness over the tibial tubercle and mild swelling. No joint effusion or instability is noted. What is the most likely diagnosis?
➔ Osgood-Schlatter disease
- Note: The tibial tubercle serves as a secondary ossification center (apophysis), playing a key role in knee extension and growth during adolescence
- Results from Repetitive strain on the tibial tubercle apophysis during growth in adolescent athletes (running, jumping). Patient presents with Pain with knee extension; relieved by rest
Lucien Monfils (https://commons.wikimedia.org/wiki/File:Osgood.jpg), „Osgood“, https://creativecommons.org/licenses/by-sa/3.0/legalcode
39. An obese 12-year-old boy presents with groin and thigh pain for 2 weeks and a new limp. He keeps his leg externally rotated. X-ray shows posterior displacement of the femoral head relative to the neck. What is the diagnosis?
➔ Slipped Capital Femoral Epiphysis (SCFE)
- Note: Displacement of femoral epiphysis in obese adolescents, Present with hip/groin/knee pain + limp with the Leg held in external rotation
- X-ray shows slipping of the femoral head (like a scoop of ice cream). Tx: Urgent surgical fixation
- DD Legg-Calvé-Perthes disease: idiopathic avascular necrosis in young children with crescent sign on xray
Public domain found here: https://commons.wikimedia.org/wiki/File:Slipped_capital_femoral_epiphysis.jpg
40. A 6-year-old boy was brought to the clinic for a limp over the past month. He has no history of trauma. Exam shows decreased internal rotation and abduction of the left hip. X-ray shows a flattened and fragmented femoral head. What is the most likely diagnosis?
➔ Legg-Calvé-Perthes disease
- Note: Idiopathic avascular necrosis of femoral head in Boys 4–10 years, painless limp ± hip/knee pain with ↓ Abduction & internal rotation
- X-ray: flattened or fragmented femoral head
41. A 42-year-old man on high-dose prednisone daily. He denies recent trauma or fever. On exam, there is pain with internal rotation of the hip. X-ray is unremarkable, but MRI reveals a crescent sign and segmental flattening of the femoral head. What is the most likely diagnosis?
➔ Avascular necrosis of the femoral head
- Note: Chronic corticosteroid use impairs blood flow to the femoral head leading to bone ischemia and collapse. The Patient presents with Gradual groin/hip pain with weight-bearing.
- MRI is most sensitive showing flattening of the femoral head and crescent sign
- Causes include: steroid, chronic Alcohol use, Sickle cell disease, SLE, decompression disease, legg Calvé-Perthes disease, Gaucher Disease and Slipped capital femoral epiphysis
Public domain found here: https://commons.wikimedia.org/wiki/File:X-ray_of_idiopathic_avascular_necrosis_of_the_femoral_head_-_Anteroposterior.jpg
42. A 75-year-old woman has a trauma to the left hip. She cannot bear weight and her leg appears shortened. X-ray shows a femoral neck fracture. Which complication is common if the blood supply is compromised?
➔ Avascular necrosis of the femoral head
- Note: Normally the Medial femoral circumflex artery (provide retrograde blood supply to femoral head) runs at the femoral neck and injured in femoral neck injuries → ischemia of the femoral head → Avascular necrosis (osteonecrosis) of femoral head → collapse, joint dysfunction
(note: similar to avascular necrosis after scaphoid fracture)
43. A 65-year-old postmenopausal woman presents with a left hip fracture. A DEXA scan confirms decreased bone mineral density. Laboratory tests show normal calcium, phosphate, ALP, and PTH. What is the most likely underlying pathophysiology?
➔ Trabecular bone thinning
- Note: Osteoporosis is Characterized by decreased bone mass, especially trabecular (spongy) bone
- Labs are normal (Ca²⁺, phosphate, PTH, ALP)
- Risk factors include: Age, postmenopausal estrogen loss, Inactivity, corticosteroid use, smoking, alcohol, low calcium/vitamin D intake
- Commonly causes: Vertebral compression, hip (femoral neck) fracture, Colles fracture (distal radius)
- Diagnosis: DEXA scan T-score ≤ –2.5
44. A 78-year-old woman with a history of osteoporosis presents with acute mid-back pain after bending to lift a light object. Exam shows focal tenderness over the thoracic spine. X-ray reveals a vertebral compression fracture. What is the most likely cause?
➔ Osteoporosis
- Note: Osteoporosis reduces bone mass and weakens trabecular bone, making bones fragile and prone to fractures under minimal stress. the patient presents in elderly with Sudden-onset back pain, focal vertebral tenderness, and height loss.
- Back Pain DD :
Focal tenderness: – Vertebral osteomyelitis (fever + high ESR in IV drug users),compression fracture
– Radicular pain: Disc herniation, spinal stenosis
– Neoplastic pain (night pain, weight loss, past history of cancer): Metastases, multiple myeloma
45. A 68-year-old woman with a DEXA T-score of –2.8 (lumbar spine) has osteoporosis presents after a hip fracture and wants to prevent future fractures. Which drug should be indicated?
➔ Bisphosphonates
- Note: Osteoporosis management:
- Bisphosphonates is the First-line drug for osteoporosis prevention & treatment, it Inhibits osteoclast-mediated bone resorption
Side effects: esophagitis, jaw osteonecrosis
- Prevention lines:
Start with Weight-bearing exercises
Avoid smoking, limit alcohol, reduce fall risk
Ensure calcium + vitamin D intake for bone health
46. A 34-year-old woman is evaluated for fatigue and diffuse arthralgia. Physical exam shows no abnormalities. Chest X-ray reveals bilateral hilar lymphadenopathy. Labs are as follows: Calcium: ↑, Phosphate: ↑, PTH: ↓
What explains this patient’s lab findings?
➔ Increased calcitriol production by activated macrophages
- Note: Sarcoidosis:
- Granulomatous disease → macrophages express 1α-hydroxylase which Converts 25-OH vitamin D to calcitriol independently of PTH
- Activated Vitamin D normally: ↑ Calcium and phosphate absorption from the gut, Promotes bone mineralization and Inhibits PTH via negative feedback
47. A 2-year-old boy presents with developmental delay, frontal bossing, bowed legs, and costochondral swelling. Labs show ↓calcium, ↓phosphate, ↑ALP, and ↑PTH. What is the most likely diagnosis?
➔ Rickets
- Note: Vit D deficiency → poor mineralization and less absorption of calcium and phosphorus from the intestine
- X-rays show widened epiphysis with cupping and fraying of the metaphyses due to defective mineralization.
- Affected children present with genu varum (bowed legs), prominent costochondral junctions (known as the rachitic rosary), and a soft, pliable skull (craniotabes).
- Labs: ↓Ca, ↓Phos, ↑ALP, ↑PTH.
48. A 72-year-old man presents with worsening headaches, hearing loss, and an enlarged skull. Physical exam shows frontal bossing. Lab studies reveal normal Calcium and phosphorus levels but high Alkaline phosphatase (ALP)
What is the most likely diagnosis?
➔ Paget disease of bone
- Note: Paget disease of bone (osteitis deformans) is a disease causing Disorganized bone remodeling → ↑ osteoclasts, then chaotic osteoblast activity(marked by high ALP levels)
- The classic presentation is in Older adults (>60) with Bone pain, enlarged skull, cranial nerve compression (hearing loss), Fractures and can cause High-output heart failure (↑ AV shunts)
- Labs: ↑ ALP and Normal calcium, phosphate, and PTH
Imaging:Mixed lytic and sclerotic lesions or Thickened, deformed bone
| Disorder | Serum Ca²⁺ | PO₄³⁻ | ALP | PTH |
|---|---|---|---|---|
| Osteoporosis | Normal | Normal | Normal | Normal |
| Paget disease of bone | Normal | Normal | ↑ | Normal |
| Secondary hyperparathyroidism | ↓ | ↑ | ↑ | ↑ |
| Osteomalacia / Rickets | ↓ | ↓ | ↑ | ↑ |
| Hypervitaminosis D (sarcoidosis) | ↑ | ↑ | Normal | ↓ |
49. A 15-year-old boy presents with bone pain and a mass in his femur. X-ray shows a sunburst pattern and Codman triangle. What is the most likely diagnosis?
➔ Osteosarcoma
- Note: Malignant metaphyseal tumor; commonly affects Metaphysis of long bones (often around knee region).
- Risk factors: RB mutation, radiation, Paget and Li-Fraumeni syndrome.
X-ray: sunburst, Codman triangle( elevation of periosteum). - Chondrosarcoma is a malignant cartilage-producing tumor of the Medulla(often pelvis, ribs, long bones), showing atypical chondrocytes in cartilage matrix on biopsy and glistening masses on imaging.
50. A 13-year-old boy with a mass in his diaphysis has a biopsy showing small, round blue cells. Translocation t(11;22) is present. Diagnosis?
➔ Ewing sarcoma
- Note: Most often arises in the diaphysis of long bones, pelvis, ribs presents with Local pain, swelling, fever may mimic infection
- Associated with t(11;22) translocation → EWS-FLI1 fusion gene with Biopsy showing : Small round blue cells (primitive neuroectodermal origin)
- Xray: “Onion-skin” periosteal reaction (layered appearance)
51. A 72-year-old woman presents with knee pain that worsens at the end of the day. X-ray shows joint space narrowing, osteophytes, and subchondral sclerosis. What is the most likely diagnosis?
➔ Osteoarthritis
- Note: Degenerative disease of weight-bearing joints.(wear and tear) more common with aging, obesity, joint overuse, female sex and prior joint trauma.
- Pain worsens with use, improves with rest with no extended morning stiffness and X-ray showing : osteophytes, joint space narrowing
- Managed with activity modification and analgesics (chronic NSAIDs usually used look for their complications like peptic ulcers)
Inflammatory Conditions
52. A 47-year-old woman has morning stiffness and swollen PIP, MCP, and wrist joints. X-ray shows joint erosions. Which antibody is most specific for her condition?
➔ Anti-cyclic citrullinated peptide (anti-CCP)
- Note: Rheumatoid arthritis is an autoimmune inflammation affecting females more commonly with Patients presenting with symmetric arthritis, morning stiffness >1 hr that improves with use, pannus and systemic inflammatory symptoms (fever, weight loss)
- Labs: show positive rheumatoid factor (IgM antibody against IgG Fc region) which is sensitive and anti-cyclic citrullinated peptide antibody (more specific).
53. Middle aged female with morning stiffness and joint pain in her hands. Exam shows symmetric swelling of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, with no distal interphalangeal (DIP) involvement. What is the most likely diagnosis?
➔ Rheumatoid arthritis
- Note: Rheumatoid arthritis affects MCP, PIP joints (not DIP), with symmetric inflammation and can cause deformities as swan neck boutonniere and ulnar finger deviation
- Osteoarthritis affects DIP and PIP (Heberden’s and Bouchard’s nodes)
54. A 58-year-old woman with rheumatoid arthritis presents with painful mouth ulcers. She has been on rheumatoid arthritis medications for 6 months.Labs show neutropenia and anemia. What is the cause of her symptoms?
➔ Methotrexate toxicity
- Note: Methotrexate (1st-line DMARD for RA): Inhibits dihydrofolate reductase → ↓ DNA synthesis in fast-dividing cells.
- → Side effects: oral ulcers, bone marrow suppression (↓ WBC, anemia, ↓ platelets), hepatotoxicity, pulmonary fibrosis. Prevented by folinic acid (leucovorin); monitor CBC, LFTs, PFTs.
- TNF-α Inhibitors (2nd-line DMARDs): infliximab,adalimumab. they increase the risk of latent TB reactivation (need TNF-α to maintain granulomas)..
55. 60-year-old woman with long-standing rheumatoid arthritis is scheduled for surgery with intubation. What is the most important pre-intubation step??
➔ Perform lateral cervical spine X-ray
- Note: RA → risk of atlantoaxial subluxation (C1–C2 instability) → spinal cord compression during neck extension/intubation → check cervical spine X-ray first.
- RA can also cause Felty syndrome (RA + neutropenia + splenomegaly) and anemia of chronic disease
56. A 56-year-old man has sudden overnight pain, redness, and swelling in his right big toe. He drinks alcohol regularly. Joint aspiration shows needle-shaped, negatively birefringent crystals. What is the most likely diagnosis?
➔ Gout
- Note: Caused by monosodium urate crystal deposition with triggers: alcohol, red meat, thiazides, CKD and Overproduction of uric acid (as in Lesch-Nyhan syndrome and tumor lysis syndrome)
- Most commonly Affects 1st MTP joint (podagra) with asymmetric red swollen painful joints and tophi (often on external ear, olecranon bursa, Achilles tendon)
- Aspiration: needle-shaped, negatively birefringent crystals
57. A 50-year-old man with recurrent gout has an acute ankle attack. Joint fluid confirms gout. What is the treatment for this acute episode?
➔ NSAIDs
- Note: In acute gout: NSAIDs, Colchicine ( inhibits microtubule polymerization ) and steroid
- Chronic management: Allopurinol or febuxostat (xanthine oxidase inhibitors)(can’t be used in acute attack as it may exacerbate the condition)
Probenecid (Inhibits reabsorption of uric acid)
Pegloticase – recombinant uricase → converts uric acid to allantoin (soluble)
58. A 65-year-old man with hemochromatosis presents with a swollen right knee. X-ray shows chondrocalcinosis. Aspirate reveals rhomboid crystals with positive birefringence. Diagnosis?
➔ Pseudogout
- Note: Calcium pyrophosphate crystals deposition (CPPD), usually in knees with rhomboid, positively birefringent crystals.
- More common in hemochromatosis, hyperparathyroidism patients with X-ray showing chondrocalcinosis (cartilage calcification).
- Acute treatment: NSAIDs, glucocorticoids and colchicine
Prophylaxis: colchicine.
59. A 72-year-old man has acute right knee pain, swelling, redness, and fever. Synovial fluid shows cloudy, purulent fluid with WBC >50,000/mm³ (neutrophil-predominant). What is the most appropriate next step?
➔ Joint aspiration and IV antibiotics
- Note: Septic arthritis usually present with Acute monoarthritis + systemic signs (fever, leukocytosis)
- Synovial fluid: purulent, WBC >50,000, neutrophil predominant (Common organisms: S. aureus, N. gonorrhoeae)
- TTT: Prompt joint drainage + IV antibiotics
- Disseminated gonococcal infection can present with purulent monoarthritis or a triad of: pustular skin lesions, polyarthritis and tenosynovitis
60. A 48-year-old woman has dry eyes, dry mouth, difficulty swallowing dry foods, and bilateral parotid swelling. Schirmer test is positive. What is the most likely mechanism?
➔ Lymphocytic infiltration of exocrine glands
- Note: Sjögren Syndrome is an Autoimmune destruction (lymphocytic infiltration) of exocrine glands, especially lacrimal and salivary glands patient present with Classic triad: Xerophthalmia (dry eyes), Xerostomia (dry mouth), Parotid gland enlargement
- Positive Schirmer test (measures tear production) and Positive Anti-SSA (Ro), Anti-SSB (La) antibodies
- Associated with: Other autoimmune diseases (e.g., RA, SLE) and ↑ Risk of non-Hodgkin lymphoma
61. A 35-year-old man has chronic low back pain worse in the morning, improving with activity. He has occasional red, painful eyes. Exam shows limited spinal flexion; X-ray shows sacroiliac fusion. What is most likely associated?
➔ HLA-B27 positivity
- Note: Ankylosing spondylitis present with: Chronic inflammatory back pain, Morning stiffness >30 min, improves with exercise
- Extra-articular features: Uveitis (painful red eye), Aortic regurgitation, Restrictive lung disease (from costovertebral joint involvement)
- X-ray: sacroiliitis,bamboo spine (vertebral fusion), Labs: ↑ ESR/CRP, HLA-B27+
62. A man presents with arthritis, conjunctivitis, and dysuria 2 weeks after a bout of bloody diarrhea from camping. What is the diagnosis?
➔ Reactive arthritis
- Note: Typically follows GI or GU infection (e.g., Chlamydia, Salmonella, Shigella, Yersinia, Campylobacter Classic triad:
- Arthritis (asymmetric, often lower limbs), Urethritis, Conjunctivitis
Mnemonic: “Can’t see, can’t pee, can’t climb a tree”
63. A 27-year-old woman presents with a malar rash, photosensitivity, oral ulcers, and RBC casts in urine. On physical exam a malar rash sparing the nasolabial folds is found. What is the diagnosis?
➔ Systemic Lupus Erythematosus (SLE)
- Note: Autoimmune, type III hypersensitivity (immune complex deposition) → inflammation and tissue damage, Presents with Malar rash, photosensitivity, oral ulcers, Arthritis, Serositis (pleuritis, pericarditis)
Renal involvement(glomerulonephritis)
Hematologic: anemia, leukopenia, thrombocytopenia - Labs: +ve ANA (sensitive), +ve Anti-dsDNA, anti-Smith (specific) anti-SSA/Ro in pregnant patient → neonatal lupus with heart block.
Doktorinternet (https://commons.wikimedia.org/wiki/File:Lupusfoto.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
64. A patient with recurrent thrombosis and miscarriages tests positive for anticardiolipin antibodies. PTT is prolonged but not corrected by mixing. What is the diagnosis?
➔ Antiphospholipid syndrome
- Note: Autoimmune hypercoagulable state, often linked to SLE with thrombosis and miscarriage.
- Labs: anticardiolipin, anti-β2 glycoprotein, lupus anticoagulant (↑ PTT, not corrected by mixing). Important: despite ↑ PTT, not a bleeding disorder!
65. A 30-year-old woman has episodes where her fingers turn white, then blue, then red and painful after cold exposure. She has no other symptoms; exam is normal. What is the diagnosis?
➔ Raynaud Phenomenon
- Note: Caused by exaggerated vasospasm of digital arteries in response to cold leading to transient ischemia and color change
- Primary Raynaud: is idiopathic more common in young women,
Secondary Raynaud: associated with autoimmune diseases (e.g., SLE, scleroderma) - Managed by Avoiding triggers (cold, stress) and CCBs for vasodilation
Profpedia at English Wikipedia (https://commons.wikimedia.org/wiki/File:Raynaud_syndrome_on_female_airman’s_hand.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
66. A 34-year-old woman has widespread pain, fatigue, and cognitive fog. She has multiple tender points. on exam. ESR and CRP are normal. Diagnosis?
➔ Fibromyalgia
- Note: Chronic widespread pain with fatigue and tender points.
Labs are normal ESR and CRP. - Treat with exercise, TCAs, SNRIs. No inflammation.
67. 45-year-old woman has progressive difficulty climbing stairs and lifting her arms. She also has a reddish-purple rash on her eyelids and knuckles. Labs show ↑ CK and positive anti-Mi-2 antibodies. What is the most likely diagnosis?
➔ Dermatomyositis
- Note: Autoimmune, T cell–mediated proximal muscle weakness (not pain) mainly affects Proximal muscles → difficulty lifting her arms, difficulty climbing stairs (weakness not tenderness!) and Heliotrope rash(rash on the eyelids), Gottron’s papules(rash on the knuckles) and “shawl and face” rash
- Associated with occult malignancy and Labs show= +ve ANA, elevated CK and specific antibodies like anti-Jo-1, anti-SRP and anti-Mi-2
- Polymyositis has a similar presentation without the rash!
Elizabeth M. Dugan, Adam M. Huber, Frederick W. Miller, Lisa G. Rider (https://commons.wikimedia.org/wiki/File:Dermatomyositis9.jpg), „Dermatomyositis9“, https://creativecommons.org/licenses/by-sa/3.0/legalcode
68. A 62-year-old man on simvastatin recently started having fibrates. He now has new muscle aches and proximal weakness. Labs show elevated CK. What is the most likely cause?
➔ Statin-induced myopathy
- Note: Mechanism: Inhibition of HMG-CoA reductase →leading to mitochondrial dysfunction and muscle pain (myopathy) and Symmetric proximal weakness and the Risk ↑ with fibrates or CYP inhibitors
- Labs: ↑ CK, normal ESR.
- Steroid myopathy = Painless proximal weakness Normal CK with Gradual onset, often due to long-term corticosteroid use
69. A 55-year-old woman has proximal muscle pain and stiffness in the morning. She has no weakness, but ESR is elevated and CK is normal. Likely diagnosis?
➔ Polymyalgia rheumatica
- Note: Proximal muscle stiffness in shoulders/hips with normal strength.
- More common in females > 50 and associated with giant cell arteritis
- ↑ ESR/CRP (unlike fibromyalgia which has normal inflammatory markers) normal CK.
- Responds to low-dose steroids.
| Condition | Weakness | Pain & Tenderness | ESR | Creatine Kinase | Other Features |
|---|---|---|---|---|---|
| Glucocorticoid-induced myopathy | Yes | No | Normal | Normal | Prominent atrophy |
| Polymyalgia rheumatica | No | Yes | ↑ (elevated) | Normal | Stiffness of shoulders & hips and associated with GCA |
| Polymyositis & dermatomyositis | Yes | Uncommon | Normal or ↑ | ↑ (elevated) | Increased malignancy risk |
| Statin-induced myopathy | Variable | Yes | Normal | Normal or ↑ | More risk when fibrate is added |
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70. A 60-year-old woman has a new-onset unilateral headache, jaw pain when chewing, and proximal muscle stiffness. ESR is 110. Why should glucocorticoids be started before biopsy?
➔ Prevent blindness
- Note: Giant cell (temporal) arteritis: granulomatous inflammation of large arteries (temporal artery), women >50.and associated with polymyalgia rheumatica(proximal muscle stiffness)
- The patient presents with unilateral headache, jaw tenderness and temporal artery tenderness and elevated ESR, IL-6 levels
- Can also cause ischemic optic neuropathy → irreversible blindness so give high dose steroids immediately before biopsy results to prevent blindness!
71. A 38 year old Japanese woman presents with upper limb claudication, asymmetric BP, and neck bruit. Biopsy shows granulomatous thickening of the aortic arch. What is the diagnosis?
➔ Takayasu arteritis
- Note: Large vessel vasculitis with granulomatous inflammation of the aortic artery and its branches, more common in young Asian females.
- Presents with fever, arthritis, myalgia and weak upper limb pulses, ESR elevated.
- Treatment is glucocorticoid
72. A 35-year-old male smoker has painful foot ulcers, gangrene, and Raynaud phenomenon. What behavioral change is most essential?
➔ Smoking cessation
- Note: Buerger disease (thromboangiitis obliterans): medium vessel vasculitis in smokers causing thrombosis, gangrene, autoamputation of the fingers and Raynaud’s phenomenon.
- Strongest risk factor is tobacco use.
73. A 3-year-old child has fever for 6 days, bilateral conjunctivitis, strawberry tongue, and swollen hands and feet. What life-threatening complication may develop?
➔ Coronary artery aneurysm
- Note: Kawasaki disease: medium-vessel vasculitis in asian children.
- Present with CRASH: Conjunctivitis, Rash, Adenopathy
Strawberry tongue/mucositis, Hands/feet edema + Fever >5 days - Risk of coronary aneurysm or rupture
- Treat with IVIG + aspirin (only condition where aspirin is given to children despite the risk of reye syndrome)
Kawasaki_symptoms.jpg: Dong Soo Kim derivative work: Natr (talk) (https://commons.wikimedia.org/wiki/File:Kawasaki_symptoms_B.jpg), „Kawasaki symptoms B“, https://creativecommons.org/licenses/by/2.0/legalcode
74. A middle-aged patient has weight loss, fatigue, abdominal pain, melena, hypertension, livedo reticularis, and hematuria. Labs: ↑ ESR, ↑ creatinine, negative ANCA. Biopsy: transmural inflammation with fibrinoid necrosis. What infection is associated with this condition?
➔ Hepatitis B
- Note: Polyarteritis nodosa: medium-vessel vasculitis with Segmental necrotizing inflammation and fibrinoid necrosis and Associated with HBV and HCV.
- Presents with fever, weight loss, fatigue and multi system involvement: GI (abdominal pain),
Renal (nephropathy and renal microaneurysms appear as “string of pearls” on imaging )
Skin lesions (livedo reticularis and palpable purpura)
Neuropathy but spares the lung.
75. A patient has oral ulcers, genital ulcers, erythema nodosum, and a history of DVT. Likely diagnosis?
➔ Behçet syndrome
- Note: Small vessel vasculitis with recurrent oral/genital ulcers.
- Associated with HLA-B51. Often post-viral trigger.
76. A child presents 2 days after an upper respiratory infection. with palpable purpura on the legs, abdominal pain, and joint swelling. UA shows hematuria and RBC casts. Diagnosis?
➔ Henoch-Schönlein purpura(HSP)
- Note: IgA vasculitis is the most common vasculitis in children and present as IgA nephropathy (Berger’s) with hematuria days after upper respiratory infection (hematuria weeks after is PSGN)
- HSP is another association with IgA vasculitis + Triad of: palpable purpura on extensor surfaces(buttocks), arthralgia, abdominal pain(intussusception).
77. A man with asthma develops sinusitis, peripheral neuropathy, and palpable purpura. Labs show eosinophilia and p-ANCA. What is the diagnosis?
➔ Eosinophilic granulomatosis with polyangiitis
- Note: Small-vessel necrotizing vasculitis with granulomas patients present with asthma, eosinophilia, neuropathy palpable purpura.
- Can also cause nephritic syndrome as RPGN (rapidly progressive glomerulonephritis) with crescent formation on biopsy.
- MPO-ANCA/ p-ANCA positive and elevated IgE level and eosinophilia.
78. A patient presents with chronic sinusitis, nasal ulceration, hematuria, and hemoptysis. Labs reveal elevated creatinine, hematuria with RBC casts, and positive c-ANCA.. Diagnosis?
➔ Granulomatosis with polyangiitis (Wegener)
- Note: Necrotizing granulomatous vasculitis of small vessels patient present with Triad of: upper airway (sinusitis, nasal ulcerations)
Lungs and small airways (hemoptysis and cavitary lesions),
Kidney (rapidly progressive glomerulonephritis (hematuria, red cell casts). - Labs: PR3-ANCA/c-ANCA positive
79. A 41-year-old woman presents with fatigue, double vision,difficulty chewing and ptosis by the end of the day. Which medication improves symptoms?
➔ Cholinesterase inhibitor
- Note: Myasthenia gravis: is an autoimmune disease with autoantibodies (type 2 HSN) against post-synaptic AChR → fatigable weakness.
- Presents with Fluctuating muscle weakness (worse with use (fatigability) and at the end of the day), ptosis, diplopia, and bulbar symptoms
- Associated with thymoma and Improves with AChE inhibitors as pyridostigmine and removal of thymoma if associated.
80. A 60-year-old man with a heavy smoking history has difficulty rising from chairs and climbing stairs. Exam shows decreased reflexes and proximal muscle weakness that improves with use. Chest CT shows a hilar mass. What’s the most likely cause?
➔ Autoantibodies against presynaptic calcium channels
- Note: Lambert-Eaton Syndrome is an autoimmune disease with Autoantibodies against presynaptic Ca²⁺ channels → ↓ ACh release.
- Strength improves with use also Hyporeflexia and autonomic symptoms (dry mouth, impotence) are common
- Associated with small cell lung cancer.
81. A 45-year-old woman has tight skin on her hands and face, difficulty swallowing, and cold-induced finger color changes. Exam shows sclerodactyly and facial telangiectasias. Labs: positive ANA, anti-centromere antibodies. What’s the diagnosis?
➔ Scleroderma (Systemic sclerosis)
- Note: Autoimmune fibroblast activation → fibrosis and collagen deposition in various organs:-Renal(scleroderma renal crisis with severe HTN and treated with ACE inhibitors)
– Lung(interstitial fibrosis or pulmonary HTN) - Usually affect females with limited scleroderma CREST syndrome: Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasia. Anti-centromere Ab.
- Diffuse scleroderma: Widespread skin + early organ involvement and Anti-Scl-70 (anti-topoisomerase I).
Frank Breuckmann, Thilo Gambichler, Peter Altmeyer and Alexander Kreuter (https://commons.wikimedia.org/wiki/File:Systemic_sclerosis_finger.jpg), „Systemic sclerosis finger“, https://creativecommons.org/licenses/by/2.0/legalcode
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MSK Pharmacology
82. A 3-year-old child presents with vomiting, diarrhea, and altered consciousness after being treated for viral illness with aspirin. Diagnosis?
➔ Reye syndrome
- Note: Reye syndrome = aspirin + viral illness in children
- Causes hepatic dysfunction + cerebral edema (astrocyte swelling)
- Avoid aspirin in kids unless Kawasaki disease
83. A 35-year-old woman takes ibuprofen for menstrual cramps. Which of the following best describes the primary mechanism by which NSAIDs alleviate her symptoms?
➔ Decreases prostaglandin formation
- Note: NSAIDs reversibly inhibit COX-1 and COX-2 enzymes → ↓ prostaglandins while aspirin is an irreversible inhibitor
- ↓PGs = ↓ platelet function (COX-1) necessary in atherosclerosis patients
- ↓ PGE2 → ↓ pain, fever, inflammation
- Celecoxib is a selective COX-2 inhibitor that reduces inflammation and pain with less GI toxicity
84. A 62-year-old woman with chronic osteoarthritis has been taking ibuprofen daily for over a year. She now presents with epigastric pain and black stools. Labs show mild anemia. What is the most likely cause of her symptoms?
➔ NSAID-induced gastric ulcer
- Note: NSAIDs: inhibit COX-1 and COX-2 enzymes → ↓ prostaglandins which normally: 1- improve renal perfusion: ↓ PGs →vasoconstriction of afferent arteriole → ↓ GFR → CKD (can also cause Interstitial nephritis(WBC casts, eosinophils, sterile pyuria) and renal papillary necrosis)
- 2-protects the GI mucosa, ↓ PGs → gastric ulcers
85. A 28 year old female patient overdoses on acetaminophen.Labs show elevated AST and ALT. She is a chronic alcohol user. What is the mechanism of liver injury?
➔ Glutathione depletion by NAPQI
- Note: Acetaminophen is a reversible COX inhibitor specifically works in the CNS and metabolized by CYP450 enzymes → forms NAPQI, which depletes glutathione to clear it
So Acetaminophen overdose → leads to NAPQI accumulation and hepatotoxicity - Alcohol induces CYP2E1, increasing NAPQI formation → greater risk of toxicity
- Treat with N-acetylcysteine (replenishes glutathione)
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Dermatology
86. A man has red plaques with silvery scales on his elbows and knees. He also has nail pitting and a sausage-like toe. What is the diagnosis?
➔ Psoriasis
- Note: Well-demarcated erythematous plaques with silvery scale on extensor surfaces, Associated with nail pitting, psoriatic arthritis (DIP involved)
- Histology: Munro microabscesses, Auspitz sign(small bleeding spots when scraped)
- TTT: topical steroids, vitamin D.
Haley Otman (https://commons.wikimedia.org/wiki/File:Psoriasis_on_elbow.jpg), „Psoriasis on elbow“, https://creativecommons.org/licenses/by/3.0/legalcode
87. A patient presents with itchy, purple, polygonal, flat-topped papules on wrists. Oral mucosa shows white lacy lines. What is the likely diagnosis?
➔ Lichen planus
- Note: “6 Ps”: Pruritic, Purple, Polygonal, Planar, Papules, and Plaques
- Wickham striae = lacy white pattern on mucosa
- Histology: sawtooth lymphocytic infiltration and Associated with HepatitisC.
Warfieldian (https://commons.wikimedia.org/wiki/File:Lichen_planus_on_leg.JPG), „Lichen planus on leg“, https://creativecommons.org/licenses/by-sa/3.0/legalcode
88. A 22-year-old woman first noticed a single oval lesion on her trunk. A few days later, she developed multiple smaller lesions giving a “Christmas tree” pattern on her back. What’s the diagnosis?
➔ Pityriasis rosea
- Note: Etiology linked to viral infection (HHV-7/6), Starts with herald patch (single large lesion) → followed by multiple smaller lesions in a “Christmas tree” distribution.
- Usually self-limited
Public domain found here: https://commons.wikimedia.org/wiki/File:Pityriasis_rosea-4.jpg
89. A woman has itchy red rash in flexural areas like the antecubital fossa. She also has asthma. Diagnosis?
➔ Atopic dermatitis
- Note: Type I hypersensitivity reaction
- Common in children and young adults
- Flexural involvement; history of allergies/asthma
- Risk for secondary infection (S. aureus, eczema herpeticum)
Authors of the article with the image: Elaine C. Siegfried, Adelaide A. Hebert. (https://commons.wikimedia.org/wiki/File:Clinical_features_of_atopic_dermatitis_in_English.png), https://creativecommons.org/licenses/by/4.0/legalcode
90. A hiker develops vesicular rash along the waistband after contact with poison ivy. What is the mechanism?
➔ Type IV hypersensitivity
- Note: Allergic contact dermatitis from poison ivy, nickel, latex on the exposed area (linear pattern)
- T-cell mediated (delayed) reaction Type IV hypersensitivity (NOT Type 1 allergy)
61cygni (https://commons.wikimedia.org/wiki/File:Shiitake_mushroom_dermatitis.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
91. A 17-year-old boy comes to the clinic with worsening facial acne over the past year. He has multiple comedones and pustules on his face and upper back.What explains the pathophysiology of this condition?
➔ Increased sebaceous gland activity under androgen influence
- Note: Cutibacterium acnes colonizes sebaceous follicles → inflammation, keratin plug formation, comedone development.
- Androgens (puberty, PCOS) → ↑ sebum production → worsens acne; risk factors include oily skin, friction, occlusive products, stress.
92. A 19-year-old woman presents with moderate to severe inflammatory acne that has not improved with topical treatments. She has numerous inflamed papules, pustules, and nodules on her face and back. What is the next best step in management?
➔ Oral tetracyclines
- Note: Mild acne: topical retinoids, benzoyl peroxide.
- Moderate acne: add topical antibiotics (clindamycin) or oral antibiotics (tetracyclines).
- Severe/refractory acne: oral isotretinoin (vitamin A derivative) → requires pregnancy testing due to teratogenicity.
93. 28-year-old African American man presents with multiple papules and pustules on his cheeks and neck that worsen after shaving. What is the diagnosis?
➔ Pseudofolliculitis barbae
- Note: Razor bumps, Not infectious happens in tightly curled hair → hair reenters skin after shaving → foreign body reaction → papules, pustules, hyperpigmentation
Public domain found here: https://commons.wikimedia.org/wiki/File:Pseudofolliculitis_Barbae.jpg
94. A 32-year-old man with celiac disease presents with chronic diarrhea, weight loss and intensely itchy, grouped vesicles on his elbows and knees. What is the most likely diagnosis?
➔ Dermatitis herpetiformis
- Note: Autoimmune skin disorder linked to celiac disease present with pruritic, grouped vesicles on extensor surfaces (elbows, knees, buttocks).
- Pathology shows IgA deposits at dermal papillae, Improves with gluten-free diet.
BallenaBlanca (https://commons.wikimedia.org/wiki/File:Diapositiva_1.jpg), „Diapositiva 1“, https://creativecommons.org/licenses/by-sa/3.0/legalcode
95. A 22-year-old man presents with hypopigmented and hyperpigmented patches on his chest and back that do not tan. KOH prep reveals spaghetti-and-meatball appearance of yeast and hyphae. What is the most likely diagnosis?
➔ Pityriasis versicolor
- Note: Caused by Malassezia species present with Hypo/hyperpigmented scaling macules, worse with sun.
- KOH prep: spaghetti-and-meatballs (hyphae + spores).
- Treatment: topical or oral antifungals.
Mohammad2018 (https://commons.wikimedia.org/wiki/File:Pytriasis_versicolor.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
96. A 7-year-old boy is brought to the clinic with a patchy area of hair loss on his scalp that has been growing and the area is itchy. KOH preparation of skin scrapings reveals segmented hyphae. What is the diagnosis?
➔ Tinea capitis
- Note: Dermatophyte infection of scalp → scaly, erythematous plaques, hair loss, black dots
- KOH prep: branching, septate hyphae
- Treatment: oral antifungals (griseofulvin, terbinafine)
Gzzz (https://commons.wikimedia.org/wiki/File:Teigne_tondante_enfant.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
97. A 14-year-old anxious girl is brought to the clinic for evaluation of patchy hair loss. Exam shows irregular patches of hair loss with hairs of varying lengths, but no signs of inflammation, scaling. What is the diagnosis?
➔ Trichotillomania
- Note: Hair-pulling disorder → Recurrent pulling of hair → irregular patches of hair loss, hairs of varying length, no inflammation or scarring
- Treatment: cognitive-behavioral therapy, SSRI
Public domain found here: https://commons.wikimedia.org/wiki/File:Trichotillomania_1.jpg
98. A 32-year-old man is concerned about gradual hair loss over the vertix and frontal scalp over the past few years. His father and older brother both have similar patterns of hair loss. What explains the underlying mechanism of this condition?
➔ Excess local conversion of testosterone to dihydrotestosterone (DHT)
- Note: Androgenic alopecia (male pattern baldness): has Polygenic inheritance, associated with ↑ local 5α-reductase activity → converts testosterone to DHT → hair loss
- TTT: Topical minoxidil (vasodilator), Oral finasteride (5α-reductase inhibitor)
Tembrizi (https://commons.wikimedia.org/wiki/File:Calvicie-Drive-Thru.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
99. A 28-year-old woman presents with severe nighttime itching and small, erythematous papules and excoriations on her wrists, fingers, and waistline. Her partner has similar symptoms. What is the most likely cause?
➔ Scabies
- Note: Intense pruritus (especially at night), burrows, papules, excoriations that develops more commonly in web spaces, wrists, waistline.
- Spread by close contact; treat with topical permethrin or oral ivermectin.
Gzzz (https://commons.wikimedia.org/wiki/File:Scabies_hand_and_fingers_2.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
100. A child develops skin detachment, fever, and mucosal erosions after taking lamotrigine. What is the likely diagnosis?
➔ Toxic epidermal necrolysis
- Note: Severe CD8+ cytotoxic T-cell–mediated mucocutaneous reaction with widespread epidermal necrosis and sloughing often due to anticonvulsants (lamotrigine, phenytoin), sulfa drugs
- Nikolsky sign positive
- SJS <10% Body Surface Area, TEN >30%
Dr. Thomas Habif (https://commons.wikimedia.org/wiki/File:Stevens-johnson-syndrome.jpg), „Stevens-johnson-syndrome“, https://creativecommons.org/licenses/by-sa/3.0/legalcode
101. A newborn has widespread skin peeling but no mucosal involvement. Cultures grow S. aureus. What is the diagnosis?
➔ Staphylococcal scalded skin syndrome
- Note: Exfoliative toxin from Staph aureus, Affects neonates and children
- Positive Nikolsky sign, mucosa spared (unlike TEN)
- More widespread (not localized as in impetigo)
CNX OpenStax (https://commons.wikimedia.org/wiki/File:OSC_Microbio_21_02_SSSS.jpg), https://creativecommons.org/licenses/by/4.0/legalcode
102. A 45-year-old woman develops painful oral ulcers and flaccid skin blisters that rupture easily. Biopsy shows intraepidermal acantholysis and antibodies against desmoglein. What is the most likely diagnosis?
➔ Pemphigus vulgaris
- Note: Type II hypersensitivity IgG antibodies against desmoglein (desmosomes) that normally connects keratinocytes in the epidermis, Damage → loss of keratinocyte adhesion and bullae formation.
- Presentation: oral mucosa involvement, flaccid bullae, positive Nikolsky sign with reticular pattern on the immunofluorescence
Emmanuelm at English Wikipedia (https://commons.wikimedia.org/wiki/File:Pemphigus_immunofluorescence.jpg), „Pemphigus immunofluorescence“, https://creativecommons.org/licenses/by/3.0/legalcode
103. An 80-year-old man develops itchy, tense blisters on his trunk. Oral mucosa is spared. Skin biopsy shows subepidermal blistering with linear IgG and C3 deposition along the basement membrane. What is the most likely diagnosis?
➔ Bullous pemphigoid
- Note: Bullous pemphigoid = Type II hypersensitivity IgG antibodies against hemidesmosomes (basement membrane) that normally anchor basal keratinocytes in epidermis to the underlying basement membrane.
- Patient presents with Tense blisters, no mucosal involvement, negative Nikolsky sign. Immunofluorescence shows linear pattern
Mohammad2018 (https://commons.wikimedia.org/wiki/File:Bullous_pemphigoid_new_image.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
104. A woman presents with depigmented macules on her hands and face. Wood lamp accentuates the patches. Likely diagnosis?
➔ Vitiligo
- Note: Autoimmune destruction of melanocytes leading to Complete Irregular depigmentation.
- Associated with autoimmune diseases (e.g., thyroid, T1DM)
- DD Waardenburg syndrome: A genetic neural crest cell migration disorder causing defective melanocyte development → patchy/asymmetric depigmentation of skin, hair (white forelock), and irises, often with sensorineural hearing loss.
Grook Da Oger (https://commons.wikimedia.org/wiki/File:Vitiligo.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
105. A patient has hypopigmented skin but normal number of melanocytes. He reports frequent sunburns. What enzyme is deficient?
➔ Tyrosinase
- Note: Albinism = defect in melanin synthesis, not melanocyte number
- Commonly due to tyrosinase deficiency
- Risk: skin cancer.
Vasok5566 (https://commons.wikimedia.org/wiki/File:Альбинос.jpg), https://creativecommons.org/licenses/by-sa/4.0/legalcode
106. An elderly man presents with rapidly growing dark brown lesion on his back. It has a rough, greasy texture and appears to be “stuck on” the skin surface. Diagnosis?
➔ Seborrheic keratosis
- Note: Benign lesion with “stuck-on” appearance
- Keratin pseudocysts on histology
- Sudden multiple lesions = Leser-Trélat sign → consider GI malignancy
James Heilman, MD (https://commons.wikimedia.org/wiki/File:Seborrheic_keratosis_on_human_back.jpg), „Seborrheic keratosis on human back“, https://creativecommons.org/licenses/by-sa/3.0/legalcode
107. A 70-year-old man presents with multiple greasy, yellow, scaly patches on his scalp and nasolabial folds. Diagnosis?
➔ Seborrheic dermatitis
- Note: Inflammatory skin condition affecting sebaceous gland–rich areas (scalp, face, eyebrows) → greasy, yellow scales and erythematous plaques.
- Associated Parkinson’s disease in adults and can present in infants in the scalp as cradle cap.
- Treated with antifungals and mild corticosteroids
LepoRello (https://commons.wikimedia.org/wiki/File:Cradle_cap_Infant_2_months_old.jpg), „Cradle cap Infant 2 months old“, https://creativecommons.org/licenses/by-sa/3.0/legalcode
108. A patient presents with a pigmented skin lesion that is >6 mm, has asymmetric shape, irregular borders, multiple colors, and has recently changed in size.What is the diagnosis?
➔ Melanoma
- Note: Melanoma = malignancy of neural crest–derived melanocytes(can be related to BRAF mutation treated with vemurafenib)
- ABCDE: Asymmetry, Border, Color, Diameter (>6mm), Evolution over time
- Subtypes: acral lentiginous (palms/soles, in darker skin), lentigo maligna
Public domain found here: https://commons.wikimedia.org/wiki/File:Melanoma.jpg
109. A 50-year-old Black man presents with a dark, irregularly pigmented lesion on the sole of his foot. He reports it has slowly enlarged over the past few months. Biopsy confirms melanoma. What is the most likely subtype?
➔ Acral lentiginous melanoma
- Note: Acral lentiginous = melanoma on palms, soles, or under nails. More common in darker-skinned patients.
- Lentigo maligna = melanoma in situ, slow-growing, sun-damaged skin (face, elderly).
Xavier-Júnior, José & Munhoz, Tania & Souza, Vinicius & Campos, Eloísa & Stolf, Hamilton & Marques, Mariângela. (https://commons.wikimedia.org/wiki/File:Photography_of_a_large_acral_lentiginous_melanoma.jpg), https://creativecommons.org/licenses/by/4.0/legalcode
110. A 68-year-old man presents with several rough, scaly, erythematous papules on his forehead and scalp. He has a history of chronic sun exposure. What is the most likely diagnosis?
➔ Actinic keratosis
- Note: Actinic keratosis = premalignant skin lesion from sun exposure.
- Scaly, rough, erythematous plaques or papules (sandpaper-like) and can progress into squamous cell carcinoma.
Future FamDoc (https://commons.wikimedia.org/wiki/File:Actinic_keratoses_on_forehead.JPG), https://creativecommons.org/licenses/by-sa/4.0/legalcode
111. A 65-year-old man has a chronic non-healing ulcer on his lower lip. Biopsy shows keratin pearls. Diagnosis?
➔ Squamous cell carcinoma
- Note: SCC = malignant keratinocytes more common below lower lip
- Risk factors: sun exposure, chronic wounds, arsenic, tobacco (oral SCC)
- Keratin pearls seen on histology
Jayabal Pandiaraja1 and A. Shalini (https://commons.wikimedia.org/wiki/File:Micrograph_of_squamous_cell_carcinoma_metastasis_to_the_skin.jpg), https://creativecommons.org/licenses/by/4.0/legalcode
112. A gardener develops a pearly papule with rolled edges and telangiectasias near his eye. Biopsy shows peripheral palisading cells. What is the diagnosis?
➔ Basal cell carcinoma
- Note: Basal cell carcinoma = most common skin cancer presents with rolled borders Waxy, pearly papules, central ulceration, telangiectasia
- More common above the upper lip, Histology shows basal cells with peripheral palisading nuclei
Public domain found here: https://commons.wikimedia.org/wiki/File:Basal_cell_carcinoma.jpg
113. A patient presents with a painful ulcer over the distal toe with punched-out edges and decreased pulses. What type of ulcer is this?
➔ Arterial ulcer
- Note: Arterial ulcers = distal toes/pressure points, punched-out, painful, associated with arterial insufficiency, weak/absent pulses
- Risk factors: atherosclerosis, diabetes
- Contrast with venous ulcers: mid-calf, irregular border, edema
- Neuropathic ulcers: painless, over pressure points, with claw toes and absent reflexes
| Feature | Venous Ulcer | Arterial Ulcer | Neuropathic Ulcer | Pressure Injury |
|---|---|---|---|---|
| Cause | Chronic venous stasis (most common ulcer type) | Peripheral arterial disease (e.g., atherosclerotic narrowing) | Peripheral neuropathy (e.g., diabetic foot ulcers) | Extended pressure without relief (e.g., in immobile patients) |
| Location | Lower leg (gaiter zone, ankle to mid-calf), often near the malleoli | Tips of toes, front of shin, pressure-exposed points | Over bony prominences (e.g., metatarsal heads, heel) | Weight-bearing areas (e.g., sacrum, ischium, heel) |
| Appearance | Irregular edges, shallow, often with exudate | Symmetrical with sharply demarcated, punched-out borders | Thickened (hyperkeratotic) edges, undermined wound borders | Ranges from redness (non-blanchable) to deep skin and tissue loss depending on stage |
| Pain | Mild to moderate discomfort | Severe pain | Typically painless | Painful |
| Associated Features | Varicose veins, skin telangiectasia, leg swelling, stasis dermatitis (red, eczematous patches) | Cool, pale, thin (atrophic) skin; hair loss; absent distal pulses | Claw toe deformities, Charcot joints, loss of reflexes | Commonly complicated by infections or bone involvement (osteomyelitis) |
🏁 Final Thoughts
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Disclaimer
Version 1.0 May 2025. No part of this document may be reproduced or distributed without written permission. For personal study only. Medical information herein is for educational purposes and does not constitute clinical advice. Always confirm with current guidelines and your institution’s policies.
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