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13. A 35 year old man presents with a swelling in the right knee joint.

The patient says

that the pain is severe and he also complains of sweating and evening rise of temperature.
On physical examination, the knee is found to be swollen and shows effusion. The joint
mobility is restricted and painful. The joint is tender. A synovial biopsy was obtained and
it shows epithelioid cell granuloma, with Langerhans giant cells. Ziehl Nielsen stain on
the drained effusion shows red ,beaded bacilli. The most likely diagnosis in this case is
A. Brodies absecess
B. Myositis ossificans
C. Ewings sarcoma
D. Chondrosarcoma
E. Giant cell tumor
F. Pyogenic osteomyelitis
G. Tuberculous osteomyelitis
14. A 7 year old male child presents with painful swelling in the right leg for the past 2
The mother says the male had a fall. Following which he developed pain at that site that
subsided with treatment. On examination, the patient is febrile. There is localized
tenderness in the right leg over the metaphyseal region with a discharging sinus and
the movements of leg are restricted. The blood examination shows Hb 10.g/dL. Total
WBC count is 22,000 cell/cumm, differential count of 90 neutrophils, 12 lymphocytes 1
monocyte and 1 eosinophil. The ESR is 55mm at the end of first hour. The radiological
examination shows a cavity in the bone containing a piece of dead bone. The most
likely diagnosis in this case is
A. Pyogenic osteomyelitis
B. Myosotis ossificans
C. Ewings sarcoma
D. Tuberculous osteomyelitis
E. Lyme arthritis
F. Disseminated gonococcemia
15. A 15 year old boy is brought to the hospital with complains of pain and swelling
the right knee. X rays of the right knee revealed a mass arising from the lower end of
femur and a sunburst appearance in tissue surrounding the bone mass. You anticipate
the sections of the mass revealed.
A. Malignant chondroblasts
B. Malignant osteoblasts
C. Malignant osteoclasts
D. Malignant small round blue cells that are S100 antigen positive
E. Malignant small round blue cells that were PAS positive
16. A 35 year old woman is discovered to have mass in her uterus that may be a sarcoma.
She is advised hysterectomy and warned that if the growth does indeed seem to be a
sarcoma when opened, she will have to undergo bilateral salpingo-oophorectomy also.
This will lead to development of menopausal symptoms in the days to come. She is

very concerned about these side effects because her mother fractured her hip in a
minor fall due to osteoporosis. Which of the following is the best option for prevention of
bone loss?
A. Regular exercise
B. Calcium supplementation
C. Progesterone therapy
D. Vitamin D supplementation
E. Estrogen therapy
F. Prednisone
G. Calcium and phosphate supplementation
H. Increased protein intake
17. For the past 15 years, a 72 year old female has experienced a loss in height and has
had a chronic back ache, resulting in a forward curvature of the spine. Radiographs of
the vertebral column show decreased bone density and wedge shaped flattening of the
vertebral bodies in the mid thoracic region. Which of the following is the most likely
pathogenesis of this clinical condition?
A. Decreased estrogen
B. Genetic defect in osteoclast
C. Hypovitaminosis D
D. Metastasis to bone
18. An 11-year-old boy complains of pain in his left leg with no history of prior trauma.
pain is not relieved by acetaminophen and slowly progresses. Radiographic
examination shows a femoral tumor with an "onion-skin" pattern of circumferential
reactive periosteal bone. Examination of biopsy material stained with hematoxylin and
eosin reveals small uniform blue round cells. On the basis of this information, which of
the following is the most likely genetic mutation?
A. del 1p
B. t(2,13)
C. t(11,22)
D. t(12,22)
E. t(X,18)
19. Radiographic studies of a 2-year-old child brought to an emergency room reveal a
fracture of the humerus and evidence of multiple old fractures in ribs and long bones of
the extremities. A social worker wants to initiate prosecution of the parents for child
abuse, but an alert emergency room physician notices that, despite the broken arm, the
toddler shows minimal bruising. A very careful, directed, physical examination reveals
that the toddler has "peculiar teeth," a blue tinge to the sclera, and unusually mobile
joints. The disease that the physician suspects the child has is characterized by an
abnormality of which of the following biochemical functions?
A. Collagen type I synthesis
B. Collagen type II synthesis
C. Collagen type III synthesis
D. Collagen type IV synthesis

E. Collagen type V synthesis

20. Which of the following is the most common bony location for a metastatic
A. Distal femoral metaphysis
B. Proximal tibial metaphysis
C. Distal humeral epiphysis
D. Thoracic vertebral bodies
E. Carpal navicular bone
21. A 7 year old boy is brought to the hospital with history of numerous fractures in the
These fractures resulted from minimal trauma to the bones. Physical examination
reveals evidence of fresh and healing fractures. Examination of his peripheral blood
shows leukoerythroblastosis. Which of the following abnormalities is most characteristic
of this boys disease process?
A. Abnormal osteoclasts
B. Defective synthesis of type I collagen
C. Decreased calcification of osteoid matrix
D. Decreased proliferation of cartilage cells at epiphyseal plates of long bones
E. Abnormal osteoblasts
22. This bone tumor is more common in patients over 40 years of age, more commonly
occurs in the axial skeleton (pelvis) , usually not sensitive to chemotherapy , has a blue
glistening gross appearance and the behavior of this tumor depends on histologic grade
A. Chondrosarcoma
B. Ewings sarcoma
C. Giant cell tumor
D. Osteogenic sarcoma
23. A 18 year old boy presents to the orthopedic outpatient department with complains of
pain in the bone of his right leg. On further questioning he states that the pain is usually
nocturnal and when he pops up aspirin it usually is relieved. The doctor orders a X ray
of the right leg which reveals a radiolucent, small central rounded area which is
surrounded by thick sclerotic bone. The lesion measures approximately 1.5 cm in
diameter. The most likely diagnosis for this lesion would be?
A. Osteogenic sarcoma
B. Ewings sarcoma
C. Chondrosarcoma
D. Chondroma
E. Liposarcoma
F. Embryonal rhabdomyosarcoma
G. Osteoblastoma
H. Osteoma
I. Osteoid Osteoma

24. A 79 year old man has had progressively worsening lower back, bilateral hip and right
shoulder pain for the past 6 years. He reports that he has had to buy larger hats. On
Physical examination there is no joint swelling, erythema, warmth or tenderness, but the
range of motion is reduced. Radiographs of the affected joint shows narrowing of joint
spaces, with adjacent bony sclerosis. A skull radiograph shows thickening of the skull
bone. . Laboratory studies show a serum alkaline phosphatase level of 173 U/L,
calcium 9.5 mg/dL and phosphorus3.4 mg /dL. A bone biopsy is performed and has the
appearance as shown below. Which of the following complications is the patient most
likely to suffer as a result of this condition?

A. Ankylosing spondylitis
B. Osteoid Osteoma
C. Osteoblastoma
D. Osteosarcoma
E. Enchondroma
25. A 30-year-old man with dwarfism is admitted to the hospital for hip replacement due
severe osteoarthritis. He has short arms and legs and a relatively large head. His
parents do not show signs of this congenital disease. This patient most likely has a
spontaneous mutation in the gene encoding which of the following proteins?
A. Collagen type I
B. Dystrophin
C. Fibroblast growth factor receptor
D. Growth hormone receptor
E. Insulin-like growth factor

26. A 17-year-old girl suffers a spiral fracture of her right tibia, and the leg is casted.
Unfortunately, the fracture does not heal correctly due to excessive motion and
interposition of soft tissue at the fracture site. Which of the following represents the
most likely complication of nonunion in this patient?
A. Codman triangle formation
B. Cup-shaped epiphysis
C. Involucrum formation
D. Osteomyelitis
E. Pseudoarthrosis
27. While playing in a softball game, a 35-year-old man was hit by a baseball bat on the
side of the head. He was unconscious for several minutes and later regained
consciousness when in transit to the hospital. He progressively lost consciousness and
died. The photograph shows the gross appearance of the brain at autopsy. Which of the
following underlying conditions best explains the cause of the lesion?

A. Contusion with bleeding into the subarachnoid space

B. Disruption of bridging veins emptying into the superior sagittal sinus
C. Rupture of the middle meningeal artery due to a skull fracture
D. Hemorrhagic infarction involving the cerebral cortex
E. Rupture of a berry aneurysm into the subarachnoid space
28. A 65-year-old man with an expressionless face and stooped posture shuffles when
walking. He has constant tremor of the thumbs and index fingers of both hands at rest.
Physical examination shows increased rigidity of the arm muscles when resisting
extension of the arm. All deep tendon reflexes are normal. The first photograph shows a
midbrain from a patient with similar signs and symptoms. The second photograph
shows a normal midbrain for comparison. Which of the following best explains the
pathogenesis of this disorder?

A. Amyotrophic lateral sclerosis (ALS)

B. Degeneration of dopaminergic substantia nigra neurons

C. Loss of striatal neurons in the caudate nucleus

D. Presence of hyperphosphorylated tau protein
E. Motor neuron lesion
29. The photograph shows the posterior view of a stillbirth. The mother has an increased
serum a-fetoprotein level. Which of the following supplement regimes could have
prevented this malformation?

A. Vitamin C throughout pregnancy

B. Vitamin B12 throughout pregnancy
C. Vitamin B6 prior to birth
D. Prenatal vitamins throughout pregnancy
E. Folic acid prior to pregnancy
30. A 62-year-old man awakes one morning with a frontal headache. He experiences
dizziness, suddenly loses consciousness, and dies. The photograph shows the gross
appearance of the brain at autopsy. Which of the following underlying conditions best
explains the pathogenesis of this lesion?

A. Cerebral atherosclerosis
B. Embolism from the heart
C. Metastatic carcinoma
D. Systemic hypertension
E. Ruptured berry aneurysm
31. A 55-year-old woman with a history of chronic rheumatic heart disease suddenly
developed weakness and sensory changes in the right side of the face and right upper
extremity. On auscultation, an opening snap and mid-diastolic rumble located at the
apex of the chest was heard. Pulse was irregular, and there was a loss of a wave in the
jugular venous pulse. On day 3 of hospitalization, the patient had cardiorespiratory
arrest and died. The photograph shows the gross appearance of the brain at autopsy.
Which of the following underlying conditions best explains the cause of the lesion?

A. Cerebral atherosclerosis
B. Embolism from the heart
C. Metastatic carcinoma

D. Systemic hypertension
E. Ruptured berry aneurysm
32. For the past 4 months, a 59-year-old man with a 30-year history of smoking cigarettes
complained of persistent headaches. For several days, he had projectile vomiting and
bilateral blurry vision. Physical examination showed bilateral papilledema. An MRI
revealed a mass lesion involving the corpus callosum with spread to both cerebral
hemispheres. The patient died a few days later of a transtentorial herniation. The
photograph shows the gross appearance of the brain at autopsy. Which of the following
underlying conditions is the most likely cause of the lesion?

A. Cerebral infarction
B. Glioblastoma multiforme (GBM)
C. Intracerebral hemorrhage
D. Medulloblastom
E. Metastaatic lung carcinoma
33. A 72-year-old man was out walking when he suddenly felt a loss of sensation and
function in his right arm and in the right side of his face. He was hospitalized and died 2
weeks later. The photograph shows the gross appearance of the brain at autopsy.
Which of the following underlying conditions best explains the cause of the lesion?

A. Cerebral atherosclerosis
B. Embolism from the heart
C. Metastatic carcinoma
D. Systemic hypertension
E. Ruptured berry aneurysm
34. An 18-year-old girl comes to the emergency department because of a severe headache
and a stiff neck. Her temperature is 39.4C (103F). Physical examination shows nuchal
(neck) rigidity. A lumbar puncture is performed.
Analysis of cerebrospinal fluid shows reveals low glucose and increased protein level
with markedly increased neutrophils count. Which of the following is the most likely
A. Acute purulent meningitis
B. Cryptococcal meningitis
C. Rabies encephalitis
D. Enterovirus meningitis
E. Mycobacterial meningoencephalitis
35. A 54-year-old man with polycystic kidney disease comes to the emergency
because of the most excruciating headache. He says that all he remembers is that he
was at work, yelling at a bratty teenager while serving food in the local high school
cafeteria, and then he woke up on the floor of the cafeteria kitchen. He says that he
must have passed out because he would never lie down on that dirty floor by choice.
Physical examination shows nuchal rigidity. A lumbar puncture is performed and shows
xanthochromasia. Which of the following is the most likely diagnosis?

A. Acute purulent meningitis

B. Concussion
C. Intracerebral hemorrhage
D. Subarachnoid hemorrhage
E. Transient ischemic attack
36. A 75-year-old woman appears well after slipping on wet pavement and striking the
side of her head. When questioned, she says that she does not remember the fall.
Subsequently she complains of persistent headache and confusion. Magnetic imaging
studies reveal a subdural hematoma over the lateral aspect of the right cerebral
hemisphere. Which of the following is a well-known association or characteristic of this
A. Bleeding from arteries of the circle of Willis
B. Rapidly progressive cerebral compression
C. Characteristically caused by venous hemorrhage
D. Laceration of branches of middle meningeal artery
E. Causally associated with hypertension
37. A newborn girl is found to have herniation of both the Spinal cord and meninges
through a defect in the vertebral arch of the spinal column. Her mother had not had
prenatal care and had not taken nutritional supplements during pregnancy. Which of the
following best describes this defect?
A. Spina bifida occulta
B. Meningocele
C. Meningomyelocele
D. Anencephaly
E. Microcephaly
38. Following a bar fight, a 22-year-old man is brought unconscious to the emergency
department. Several minutes earlier, he had been hit on the head with a heavy iron club
and had been briefly unconscious, but had then apparently recovered. One or two
minutes later, he had again lost consciousness. Which of the following is the most likely
A. Epidural hematoma
B. Subarachnoid hemorrhage
C. Subdural hematoma
D. Transient ischemic attack
E. Stroke
39. A 60-year-old man, a suicide victim, has been brought to autopsy. Before dying, he
been despondent after being informed that he had an extremely aggressive brain
tumor. There had been a recent onset of headache, seizures, and mental status
changes, and MRI had demonstrated an infiltrating neoplasm invading the cerebral
hemispheres and crossing the midline, with areas of necrosis and abnormal blood
vessels. The autopsy confirms the MRI findings and also demonstrates hemorrhage

and a pseudopalisade arrangement of tumor cells. The tumor is most likely one of the
A. Ependymoma
B. Glioblastoma multiforme
C. Meningioma
D. Neurilemmoma (schwannoma)
E. Oligodendroglioma
40. A 70-year-old man presents with loss of memory for recent events. He has forgotten
grandchildrens names, and he has been unable to manage his personal finances. Also,
he has lost his way while driving to familiar locations. Which of the following is the most
likely diagnosis?
A. Alzheimer disease
B. Amyotrophic lateral sclerosis
C. Creutzfeldt-Jakob disease
D. Huntington disease
E. Parkinson disease
41. Several years ago, a 60-year-old woman had presented with bradykinesia, rigidity, a
resting pill-rolling tremor in her right hand, and mask-like, expressionless facies. She
currently presents with gait problems, taking short, shuffling steps and losing her
balance easily. Which of the following is the most likely diagnosis?
A. Alzheimer disease
B. Amyotrophic lateral sclerosis
C. Creutzfeldt-Jakob disease
D. Huntington disease
E. Parkinson disease
10. The picture shown below is of a smear of synovial fluid obtained from the right,
swollen and painful knee joint of a 65 year old man by arthrocentesis. An X- ray of the
involved knee joint reveals linear and punctuate densities in and around the articular
cartilage. The patient is a nonalcoholic. His serum uric acid is within normal range. The
pathogenesis of this disease most closely relates to

A. Deposition of monosodium urate crystals in the articular cartilage

B. Deposition of positively birefringent crystals in the articular cartilage

C. Diffuse proliferative synovitis leading to formation of pannus and destruction of

articular cartilage
D. Infectious arthritis secondary to transmission of Borrelia burgdorferi by tick bite
E. Destruction of articular cartilage due to age dependent phenomenon
F. Disseminated gonococcemia with septic arthritis
G. Osteomyelitis secondary to hematogenous spread of Staphylococcus aureus
11. A 29 year old man sees his physician because of burning pain on urination that has
persisted for 3 days. There is a urethral discharge. A sample of the exudate is positive
by ELISA for Chlamydia trachomatis. Three weeks later, the man has increasing
stiffness of the knees and ankles and lower back pain. A radiograph of the lumbar spine
shows narrowing with sclerosis of the sacroiliac joints. One month later he develops
ulcers over the penile glans and the conjunctiva are red. A follow up examination shows
a slightly irregular heart rate and a murmur suggestive of aortic regurgitation. The back
pain continues on and off for 5 more months. Which of the following test results is most
likely to be positive?
B. HLA-B27 antigen
C. Lyme disease
D. Purified protein derivative
E. RPR (rapid plasma reagin)
F. Rheumatoid factor
G. Monosodium urate crystals
H. CPPD crystals
12. A 54 year old woman states that for the past 12 years the pain in her hands has
progressively worsened to the point where she cannot effectively use both hands (see
figure). Which of the following laboratory findings is most likely to be reported?

A. Antibodies against Borrelia Burgdorferi

B. Antibodies against double stranded DNA
C. HLA- B27 genotype
D. Hyperuricemia
E. Rheumatoid factor
13. A 30 year old woman presents to your office with a chief complaint of morning
of approximately 1 years duration along with a subjective feeling of fatigue. On further
questioning she relates problems with dry eyes and mouth. Her parotid glands are
enlarged bilaterally. Her hands show fusiform swellings around the
metacarpophalangeal joints and bilateral knee effusions are present. No skin or
genitourinary abnormalities are noted. A serum rheumatoid factor is positive and ESR is
elevated. A serum test for antibody against SS-B antigen is also positive. All other
routine hematology and chemistry determinations are normal. The patient undoubtedly
has the early signs of:
A. Charcots arthorpathy
B. Reiters syndrome
C. Feltys syndrome
D. Sjogrens syndrome
E. Marie Strumpell disease (Ankylosing spondylitis)
14. A 30 year old man sees his physician because he has had abdominal pain and bloody
diarrhea for the past four days. On physical examination, there is diffuse tenderness on
palpation of the abdomen. Bowel sounds are present. There are no masses and no
organomegaly. A stool culture is positive for Shigella flexneri. The episode resolves

spontaneously within one week after onset. Six weeks later the patient sees his
physician because of increasingly severe lower back pain. Physical examination now
shows stiffness of the lumbar joints and tenderness affecting the sacroiliac joints. He is
treated with ibuprofen. Several months later the back pain recurs, and complains of
redness of the right eye and blurred vision. Serologic testing for which of the following is
most likely to be positive in this patient?
A. Rheumatoid factor
B. Chalmydia trachomatis
D. HLA-B27
E. Borrelia burgdorferi
15. An 85-year-old man presents with a 3-week history of painful swelling of his right
Aspiration of joint fluid returns numerous neutrophils and crystals, which are described
as rhomboid and coffin-like. Chemical analysis shows that these crystals are composed
of calcium pyrophosphate. Which of the following is the most likely diagnosis?
A. Ankylosing spondylitis
B. Gout
C. Infectious arthritis
D. Pseudogout
E. Rheumatoid arthritis