Bone, Joint & Soft Tissue (1-60)Question 1

Excluding multiple myeloma, each of the following statements regarding primary boneneoplasms is correct EXCEPT:

A Less than half are malignant. B Most occur about the knee. *C Most occur in older persons. D Osteosarcomas are more frequent than chondrosarcomas. E Males are more frequently affected than females.

Question 2

An 80-year-old woman falls out of bed and breaks her hip. Radiographs show not only afracture of the left femoral head, but also a compressed fracture of T10. She probablyhas:

A Vitamin D deficiency B A pyogenic infection C Osteogenesis imperfecta *D Decreased bone mass/osteoporosis

E Polyostotic fibrous dysplasia

Question 3

Chondrosarcoma is:

This is a chondrosarcoma, which has a predilection for involvement of metaphysis or diaphysis.

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This high power microscopic appearance of a chondrosarcoma demonstrates ** pleomorphic chondrocytes that are piled together in a haphazard arrangement. In general, **chondrosarcomas occur over a wider age range than osteosarcomas, including older adults

A The most frequent primary tumor of bone B Usually seen in distal skeletal bones C More common in females *D Sometimes seen to arise in benign cartilagenous tumors E Associated with Paget's disease of bone

Question 4

You perform a sternal bone marrow aspirate on a 62 year old male and get a dark redjelly-like material in the syringe. The patient's total protein is 8.5 gm/dl with an albumin of4.1 gm/dl. The smear of the aspirate will show which of the following as a prominentfeature:

A Giant cells B Fibroblasts C Osteoblasts D Metastatic renal cell carcinoma *E Plasma cells

Question 5

A 66-year-old female with increasing difficulty in performing activities of daily livingbecause of osteoarthritis is LEAST likely to have:

A Monoarticular involvement an oesteophytes OA is more felt than an outward deformity. Mornining stiffness in hands that gets better with use

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B Knee involvement xxC Bony ankylosis / xtic of Rh Arthritis

The prominent ulnar deviation of the hands and "swan neck" deformity of the fingers is due to rheumatoid arthritis (RA). This autoimmune disease leads to synovial proliferation with inflammation and joint destruction, typically in a symmetrical pattern involving small joints of hands and feet, followed by wrists, ankles, elbows, and knees. Rheumatoid factor can be identified serologically in most 80%, but not all, RA patients.

Sometimes persons with rheumatoid arthritis (RA) have rheumatoid nodules form in subcutaneous locations at pressure points, such as the elbow shown here. Rheumatoid nodules may also appear viscerally, such as on the pleura of the lung.

This is the synovium in rheumatoid arthritis. There is chronic inflammation with lymphocytes and plasma cells that produce the blue areas beneath the nodular proliferations. This "pannus" is destructive and produces erosion of the articular cartilage, eventually destroying the joint.

D Morning stiffness and gets worse with useE Heberden's nodes and crepitus and wt bearing jts

Question 6

A 13-year-old boy with pain in his left leg is found to have a neoplasm of the femur ( + Pelvis) thatradiologically is diaphyseal in location and on biopsy is seen microscopically to becomposed of numerous small round blue cells. He also has fever. The probable diagnosisis:

zzA Ewing's sarcoma ( Homer Wright rosette)

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Ewing's sarcoma. This primary bone tumor mainly occurs in the ***diaphysis of long bones of children and young adults. There is a slight male predominance. As seen here, the irregular tan to red to brown tumor mass is breaking through the cortex. More normal fatty marrow is seen at the far right.

Ewing's sarcoma is one of the "small round blue cell" tumors histologically.classic t( 11:22) , onion skinning on X-ray

Ewing's sarcoma contains abundant glycogen, as seen by the reddish granular cytoplasmic staining by PAS stain here

B Medulloblastoma C Neuroblastoma D Chondroblastoma E Osteoblastoma

Question 7

A 14 year old African male with sickle cell anemia (Hgb SS) is most prone to developosteomyelitis with:

A Staphylococcus aureus B Pseudomonas aeruginosa

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xxC Salmonella //An infection that becomes established in bone is difficult to treat, since bone is relatively avascular. The result is an osteomyelitis. If this process occurs over years, the bone becomes markedly remodelled. At the site of involvement, there is a central area of pale necrotic "sequestrum" that is surrounded by irregular remodelled "involucrum" that produces marked distortion. The weakened bone is prone to fracture. In this case, the irregular involucrum is seen above in the upper femur. D E. coli E Candida

Question 8 A 70 year old male has noted increasing back and leg pain for years. Radiographs revealbony ** sclerosis of the sacroiliac, lower vertebral, and upper tibial regions with ***corticalthickening, but without mass effect or bony destruction. If that weren't enough trouble, hesays his hats don't even fit anymore. The major laboratory finding is an ***elevated serumalkaline phosphatase. The best diagnosis is:

A Adenocarcinoma of prostate with metastases xxB Paget's disease of bone

This is P aget's disease of bone in which the mixed ** osteoclastic and ** osteoblastic stage is present. A line of osteoblasts is present forming new bone, but lacunae containing multinucleate osteoclasts are at the same time destroying bone. The result is a patchwork mosaic of bone without an evenly formed lamellar structure. This stage of Paget's disease is preceded by a mainly lytic phase and is followed by a "burnt out" sclerotic phase.Paget's disease is seen in elderly Caucasians of European ancestry. The serum alkaline phosphatase is increased, but the serum calcium and parathormone are not. Under ** polarized light, the irregularities of the bony lamellae are apparent, with a "tile-like" or "mosaic" patternC Renal failure with renal osteodystrophy D Osteoporosis E Osteomalacia

Question 9 An expansile, eccentric lesion that radiographically is seen to be surrounded by a rim ofreactive bone in the metaphysis of the distal femur in an 18-year-old female is mostconsistent with:

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A Fibrous dysplasia B Ewing's sarcoma C Chondrosarcoma D Osteosarcoma zzE Aneurysmal bone cyst

aneurysmal bone cyst .The radiographic appearance is typically that of ballooning, or aneurysmal dilation, of the affected bone--usually the metaphysis of a long bone or dorsal vertebral body. Grossly, there are fleshy aggregates of tumor surrounding cystic spaces filled with blood. The breakdown of the blood into hemosiderin has led to brownish staining of some of the cysts seen here.

This is an aneurysmal bone cyst at high power magnification. Note the ** prominent multinucleated cells and ***the plump spindle cells of the stroma.

Question 10 The finding of osteoblastic metastases of the vertebral column is most consistent withwhich of the following primary neoplasms:

A Infiltrating ductal carcinoma of breast B Endometrial adenocarcinoma zzC Adenocarcinoma of prostate

This radiograph demonstrates bright osteoblastic metastases in the vertebral column in a patient with metastatic adenocarcinoma of prostate. Almost all others are osteolytic.

Almost all others are osteolytic D Mucinous cystadenocarcinoma of ovary

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E Renal cell carcinoma

Question 11

Which statement regarding osteosarcoma of bone is INCORRECT:

A There is a male predominance. 15- 20yoxxB Bone trauma is a predisposing factor. No apparent bone pathologyC Some cases are associated with radiation exposure. D Femur and tibia adjacent to the knee are common sites. E Metastases are usually hematogenous. To the lung

Question 12

True statements concerning gouty arthritis include all of the following EXCEPT:

zzA Most patients with hyperuricemia will develop it. MOST with Hyperuricimia do not get gout. But almost qbody who gets it has hyperuricimiaB The first metatarsal-phalangeal joint is usually involved. C Sodium urate crystals can be seen in synovial fluid. D Tophi can erode bone and cartilage. E Males are affected more than females.

Question 13

A 5 year old boy has very short arms and legs, such that his height is less than the 5thpercentile for age. However, his trunk and head appear normally proportioned for age.The most likely diagnosis is:

A Fibrous dysplasia B Osteogenesis imperfecta C Ollier's disease D Alport's syndrome

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zzE Ach ondroplasia(AD),mutation of FGFR3, that inhibit cartilage formation

Question 14

A 38 year old female has been on long-term corticosteroid therapy for treatment ofsystemic lupus erythematosus. The bone disease most commonly complicating thistherapy is:

A Paget's disease of bone B Rickets C Osteochondritis zzD Osteoporosis // secondary osteoporosis/ immobilization, endocrinopaties( thyrotixicosis) steroids.Primary causes include 1]estrogen deficiency, 2] lack of activity and 3] genetic factors. E Osteomala

Question 15 A 15-year-old girl is noted to have an abnormal lateral curvature of the spine. This isprobably due to:

zzA Asymmetric cartilage growth of vertebral body end plates B Multiple osteochondromas of the vertebral bodies C Vitamin D deficiency with rickets D A disorder of procollagen synthesis with multiple compressed fractures E Trauma

Question 16

A lateral projection from the metaphysis of the lower femur that is composed of a 3 cmstalk of bony cortex capped by cartilage is probably a(an):

zzA Osteochondroma

an osteochondroma of bone. This is a bony projection (exostosis). Most are solitary, incidental lesions that may be excised if they cause local pain. There is a rare condition of multiple osteochondromatosis marked by bone deformity and by a greater propensity for development of chondrosarcoma.

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osteochondroma cut into three sections. A bluish-white cartilagenous cap overlies the bony cortex. These are probably not true neoplasms, but they are a mass lesion that extends outward from the metaphyseal region of a long bone.B Giant cell tumor C Aneurysmal bone cyst D Osteoid osteoma E Enchondroma

Question 17 All of the following statements regarding Paget's disease of bone are true **EXCEPT: A There is an increased risk for osteosarcoma. B Most cases have polyostotic (multiple bone) involvement. C Patients may develop congestive heart failure. D Paramyxovirus infection has been implicated as an etiology. zzE It is usually seen in young males. Men > 40yo

Question 18 An elderly woman who has fractured her hip most likely has: A A dietary lack of vitamin D xxB Osteoclastic resorbtion coupled with some slowing of bone formation C An abnormality of type 1 collagen synthesis D A decrease in the osteoid matrix of bone E Primary hyperparathyroidism from a parathyroid adenoma

Question 19 Of the following bone lesions, the one that is most frequently associated withhyperparathyroidism is:

A Osteochondroma B Giant cell tumor C Paget's disease of bone zzD Osteitis fibrosa cystica

Primary hyperparathyroidism. The increased parathormone levels lead to bone resorbtion, seen best in subperiosteal regions of the phalanges.E Fibrous dysplasia

Question 20 A man in his 20's begins to note persistent lower back pain and stiffness that diminisheswith activity. In his 30's he also develops hip and shoulder arthritis, and in his 40's he isbothered by decreased lumbar spine mobility. These findings are most typical for:

A Rheumatoid arthritis zzB Ankylosing spondylitis

spondyloarthropathies are a diverse group conditions characterized by an inflammatory arthritis that involves the spine and/or peripheral joints, along with additional organ system involvement. Most of them are marked

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serologically by the presence of the tissue antigen known as HLA-B27. These conditions can be 1] chronic and progressive (ankylosing spondylitis), 2]relapsing or recurrent (Reiter syndrome), or 3]variable (psoriatic and enteropathic arthritis). C Osteoarthritis D Lyme disease E Calcium pyrophosphate dihydrate deposition disease

Question 21

Of the following bone diseases, which has a female predominance:

zzA Aneurysmal bone cyst B Osteosarcoma C Chondrosarcoma D Ewing's sarcoma E Osteochondroma

Question 22 A 21-year-old male college student has noted increasing pain and soreness in his leftshoulder after a summer working on the ranch and bucking bales of hay while at a ranchup in the Cache Valley. He can hardly raise his left arm. Clear fluid is aspirated from thesubacromial region. He probably has:

A Tenosynovitis B Costochondritis zzC Bursitis

Tendinitis or injury of the rotator cuff is often the cause for shoulder pain. The supraspinatus tendon is most often affected. There can be inflammation, fibrosis and adjacent bursitis. The supraspinatus tendon can be torn by falling on an outstretched arm or lifting a heavy object. Seen here is an MRI scan of the left shoulder demonstrating a full thickness tear of the supraspinatus tendon.D Ganglion cyst E Pseudogout

Question 23

An acute pyogenic arthritis is LEAST likely to:

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A Complicate gonorrheal infection B Complicate septicemia C Involve large joints D Lead to ankylosis with chronicity zzE Occur with Lyme disease

Question 24 A social worker refers a 2-year-old child to you because of suspected child abuse. Youfind multiple recent and healing ** long bone fractures, ** blue sclerae, **hearing loss, and**misshapen teeth. Your diagnosis is:

A Extensive trauma ("shaken baby syndrome") zzB Osteogenesis imperfecta /brittle bone dz

Essential defect ion the formation of collagen type 1 that form bone matrix. Multiple modes of inheritance, generalized osteopenia, jt laxity.C Achondroplasia D Rickets E Osteopetrosis

Question 25 Which of the following statements regarding the development of an osteosarcoma ofbone is TRUE: mc malignant bone tumor.in males < 25

A The majority of cases arise in Paget's disease of bone. B About 10% arise from osteoid osteomas. C Most arise in the bones of the arm. D Most occur following radiation therapy. zzE Patients with retinoblastoma are at risk.

Stained + for vimentin suggest it s a sarcoma. Ostoid production is x’tic of osteosarcoma.

Question 26 A 41-year-old male has had ** backache with muscle spasms,** weakness, and ** pain in theright hip all the way to his toes for months. Physical exam reveals that the circumferenceof this leg is smaller than the left, and he has ** paresthesias in an L5 distribution. Thesefindings are most likely due to:

A Spondylolisthesis B Spina bifida zzC Herniated nucleus pulposus / sciatica/L5-S1

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herniation of the nucleus pulposis of the intervertebral disc between L5 and S1. In the transverse view shown here, the herniation is seen to compress the nerve roots on the left.D Osteoporosis E Paget's disease of bone

Question 27 A solitary destructive bony lesion of the skull that is composed histologically ofhistiocytes, eosinophils, plasma cells, and lymphocytes in a 5-year-old male is most likely:

A Osteoid osteoma B Letterer-Siwe syndrome zzC Eosinophilic granuloma

D Osteitis fibrosa cystica E Tuberculosis

Question 28 Which of the following statements regarding rheumatoid arthritis (RA) is INCORRECT: A Pannus in joints contains numerous lymphocytes and plasma cells. B Small joints are affected more than large joints. C Joint involvement is typically symmetric. zzD Males are affected more than females.it is AI dz, means women affected more than men.E Joint ankylosis is a long-term complication.

Question 29 A young girl has pain in the region of the right upper thigh, which is relieved by aspirin. Aradiograph reveals a small lucent area in the femur surrounded by sclerotic bone.[ pathogneumonic] Themost likely diagnosis is:

A Enchondroma B Multiple myeloma C Eosinophilic granuloma zzD Osteoid osteoma // pain is worse at night and and is relieved by ASA

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E Osteochondroma

Question 30 All of the following are likely sources for metastatic lesions to bone EXCEPT: zzA Adenocarcinoma of colon B Oat cell carcinoma of lung /LUNGC Infiltrating ductal carcinoma of breast /BREASTD Renal cell carcinoma KIDNEYE Adenocarcinoma of prostate PROSTATEF It could have come from the thyroid gland

Question 31 A 49-year-old female has noted that she cannot completely extend the middle finger ofher left hand. In the palm of her hand at the base of this finger there is an ill-defined massthat is very firm to palpation. What histologic appearance will this mass most likelydemonstrate:

zzA Fibromatosis B Rhabdomyosarcoma C Granulomatous inflammation D Dystrophic calcification E Giant cell tumor of tendon sheath

Question 32 A 45-year-old female notices that she develops tingling and numbness over the palmarsurface of her thumb, index, and middle fingers after several hours at her computerworkstation doing word processing. Pain in the same area often occurs at night as well.Which of the following pathologic findings accounts for her symptoms:

A Toxic peripheral neuropathy B Rheumatoid arthritis C Gout D Hypertrophic osteoarthropathy zzE Localized tenosynovitis

Question 33 A 55-year-old patient with chronic renal failure and renal osteodystrophy may have all ofthe following findings EXCEPT:

A Enlarged parathyroid glands zzB Hyperostosis C Aluminum toxicity D Hyperphosphatemia E Hypocalcemia

Question 34

A 45-year-old male has pain in his right knee. As he moves about during the day, the

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pain decreases. The underlying disease process is probably:

A Osteoporosis B Osteochondroma C Osteomalacia zzD Osteoarthritis / I would expect the pain to increase but it is unilateral knee jt so it makes senseE Osteopetrosis

Question 35 As he continues to age, decreasing mobility of his bothers a 50-year-old malespine at the hips,[ bomboo spine] and he has a "hunched over" appearance of the upper back. Theseproblems have been slowly progressive. This man is LEAST likely to have: This is ANKLYLOSIS SPONDYLITIS ,and 2] Reiter’s triad conjunctivitis, uretritis and arthritis.

A A similarly affected relative zzB Involvement of the peripheral joints C Sacroiliac ankylosis D Onset of his disease in the 20's E HLA-B27

Spondyloarthropathies

Radiograph Disease HLA-B27

Sacroiliitis Arthritis Other Tissues

Ankylosing Spondylitis

++++ ++++ ++ Uveitis, Aortitis

Reiter Syndrome Triad

+++ +++ ++ 1]Uveitis, 2Conjunctivitis, 3Urethritis

Psoriatic Arthritis

+ ++ +++ Psoriasis, Conjunctivitis, Iritis

  Enteropathic Arthritis

+++ + ++ Inflammatory bowel disease

Question 36

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A form of arthritis that affects young persons, often has a febrile onset, involves only afew joints (usually knees or ankles), and is accompanied by generalizedlymphadenopathy is:

A Gonococcal arthritis B Ankylosing spondylitis zzC Juvenile rheumatoid arthritis D Tuberculous arthritis E Gout

Question 37

The majority of cases of arthritis have clinical symptoms that are a result of:

zzA Loss of articular hyaline cartilage // mc form of arthritis and increases with ageB Synovitis C Underlying osteomyelitis of bone D Bone marrow fibrosis E Crystal deposition

Question 38 Of the following mass lesions of bone, the one that is most likely to be present in an olderadult, rather than in a child or young adult, is:

A Osteosarcoma zzB Chondrosarcoma (n their 40+) C Ewing's sarcoma D Giant cell tumor E Osteoid osteoma

Question 39 Multiple firm white irregular mass lesions are scattered throughout the vertebrae in a 71year old male. He was known to have a markedly elevated serum alkaline phosphatasealong with hypercalcemia. Which of the following explanations is most likely for thesefindings:

zzA Metastatic carcinoma of prostate

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note the multiple hot spots of metastatic lesions.B Osteochondromatosis C Ewing's sarcoma D Fibrous dysplasia of bone E Osteomalacia

Question 40

A 30 year old male has pain about his left knee that he has noted worsening "for weeks".A radiograph reveals a 6 cm lytic lesion involving the epiphyseal region of the distal femurwith a "soap bubble" appearance. The lesion is curretted, and histologically there arenumerous giant cells in a stroma with plump to spindle shaped mononuclear cells. Themost probable diagnosis is:

A Osteosarcoma B Chondrosarcoma C Malignant fibrous histiocytoma zzD Giant cell tumor of bone

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giant cell tumors of bone are composed of osteoclast-like multinucleated giant cells in a sea of round to oval mononuclear stromal cells. There may also be foamy macrophages and hemosiderin deposition in the stroma. Though these tumors are biologically benign, they can expand and cause pain, deformity, or fracture. They are treated by curettage or resection, but not radiation.E Tuberculosis

Question 41

Following a humeral fracture in a 16 year old boy suffered while he was going down aseries of steps on in-line skates, the fracture is set. The fracture callus the forms duringthe first month while the arm is in the cast is not as strong as the surrounding bonebecause callus:

A Is mainly formed from type IV collagen zzB Contains woven, rather than lamellar, bone

This is ***irregular new bone, or woven bone, which is forming in the region of a fracture. ** Osteoblasts are seen lining the irregular trabeculae, and there is an ** osteoclast near the center.

C Consists mostly of acute inflammatory cells D Lacks osteoblasts E Is formed primarily of bone marrow

Question 42

The appearance of irregularly thickened bone showing a mosaic of both ** osteolysis and** osteogenesis in ** multiple sites in vertebrae, pelvis, and humerus is most often seen as acondition involving bone in a patient with which of the following histories:

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zzA 76 year old male with congestive heart failure Pagets’s dx/ polyostotic formB 11 year old female with precocious puberty C 5 year old girl with multiple long bone fractures and blue sclerae D 85 year old female with fracture of femoral neck E Stillborn with multiple long bone fractures

Question 43 A 61 year old male is found to have a mass in the proximal humerus. This mass isslow-growing. Metastases are not present. After resection, the mass is found to be firmand have a bluish-white appearance on sectioning. The histologic feature that is mostlikely to be characteristic of this mass is:

A Small round blue cells B Osteoid zzC Atypical chondrocytes D Giant cells E Plasma cells

Question 44 A former center for the Oakland Raiders football team retired in his 30's after a career ofmore than a decade. He now finds that he has a lot of stiffness in his right knee in themorning which soon abates, but by the end of the day he is taking non-steroidalanti-inflammatory medications for pain. These findings are most typical for:

A Rheumatoid arthritis B Ankylosing spondylitis zzC Osteoarthritis *** D Lyme disease E Osteomyelitis

Question 45 Along the extensor surface of the forearm of a 42 year old woman can be felt a firm, nontender, 1 cm rounded subcutaneous mass. Microscopically, the ***nodule shows an area ofcentral necrosis surrounded by ** palisading epithelioid cells. Which of the followinglaboratory findings is most likely to accompany this lesion:

zzA Positive rheumatoid factor

Rheumatoid nodule. Seen in patients with severe rheumatoid arthritis and appear beneath the skin over bony prominences such as the elbow. They can occasionally appear in visceral organs. There is a central area of fibrinoid necrosis surrounded by pallisading epithelioid macrophages and other mononuclear cells.B Elevated antinuclear antibody

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C Monoclonal gammopathy D Anti-Jo-1 (anti-histidyl-tRNA synthetase) // inflammatory myopathiesE Acetylcholine receptor antibody

Question 46 Slow, progressive erosion of articular cartilage, followed by subchondral sclerosis andformation of osteophytes, has occurred in the joints of the hands as well as the vertebraeof a 69 year old male. There is pain, but no swelling. Ankylosis of the joints has notoccurred. The most likely explanation for this is:

A Lyme disease zzB Osteoarthritis C Rheumatoid arthritis D Remote fractures E Osteoporosis

Question 47 A stillborn male is 37 weeks gestation at birth. Skeletal abnormalities had been seen onultrasonography at 20 weeks gestation and consisted of long bone shortening. At birth,the extremities are malformed and shortened and a postmortem radiograph reveals** multiple long bone fractures. The underlying disorder is most likely to be:

A Achondroplasia B Fibrous dysplasia C Rickets D Congenital syphilis zzE Osteogenesis imperfecta

Question 48 An elderly Caucasian male is at risk for all of the following complications of polyostoticPaget's disease of bone EXCEPT: these are the complication of Paget’s dz

A Sarcoma of bone B Fractures zzC Osteomyelitis D Congestive heart failure E Facial droop from nerve palsy

Question 49 Multiple "hot spots" with increased uptake appear on bone scan of a 56-year-old male.He has had pain in the ** right arm, **left leg, and **back, and there has been a **fracture of theright humerus. The most likely explanation for these findings is:

zzA Metastatic carcinoma B Aneurysmal bone cysts C Osteomalacia D Osteoid osteomas E Osteomyelitis

Questions 50 and 51: Click on the checkbox first, then the lettered item:

B(50) A soft tissue mass is present in an older male in association with bonydestruction of the knee joint, along with local pain and swelling. This has progressivelyworsened for several years.

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A (51) A ring-like rash is noted on the skin of the left lower thigh by a 35 year oldwoman. This is followed a couple of months later by an arthritis that involves severaljoints in succession, including right hip, left knee, and left elbow. She is otherwise healthy.

A Borrelia burgdorferi ( erythema migrans) Lyme dzB Neisseria gonorrheae// why not C for 50C Staphylococcus aureus D Treponema pallidum E No infectious etiology

Questions 52 and 53: Click on the checkbox first, then the lettered item:

E (52) A 45 year old female has ** deformities of her hands, **with ulnar deviation, as aconsequence of*** pannus in proximal interphalangeal joints.

D (53) Acute inflammation of first metatarsal-phalangeal joint is noted in a 45 year oldmale.

A Systemic lupus erythematosus B Lyme disease C Osteoarthritis D Gouty arthritis E Rheumatoid arthritis // affects small bone of the hand and feet

Questions 54 and 55: Click on the checkbox first, then the lettered item:

E (54) Hypermobility of joints, and skin that is hyperextensible and easily torn, arefindings in a young girl.

Ehlers-Danlos syndrome (EDS), a connective tissue disease in which there is a disorder of collagen synthesis. There are several types with various inheritance patterns. Pictured here is a hyper-extensible, hypermobile joint typical of EDS.

B (55) A long-limbed 22 year old female is developing aortic valvular insufficiency.

A Osteogenesis imperfecta, type I B Marfan's syndrome C Osteogenesis imperfecta, type II D Achondroplasia E Ehlers-Danlos syndrome

Questions 56 and 57: Click on the checkbox first, then the lettered item:

D (56) Pseudogout involves the knees of a 55-year-old male. This is always in the differential for OA and RA . it is made of calcium pyrophosphate crystals that are positive rhomboid birefrigent crystal.

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E (57) Synovium in a patient with rheumatoid arthritis.

A Monosodium urate crystals/this is true gout/needle shaped ,negative birefringent crysrtalsB Cholesterol crystals C Plasma cells and lymphocytes D Calcium pyrophosphate crystals// positive birefringment rhomboid shaped crystals E White blood cells

Questions 58 and 59: Click on the checkbox first, then the lettered item:

D (58) Malignant spindle cells making *** osteoid are observed in a lesion of the tibialmetaphysis in a 15 year old male.

B (59) A firm 7 cm mass with a bluish-white cut surface is removed from the left iliacwing of a 60-year-old male.

A Fibrous dysplasia B Chondrosarcoma ****C Osteoid osteoma D Osteosarcoma ***.// stained with viamentin/ E Ewing's sarcoma

Question 60

Ultrasound at 20 weeks gestation reveals that the male fetus has long bones measuring atless than the 5th percentile for age, but there are no fractures. Normal numbers of fingersand toes are present. The internal organs including the heart, lungs, liver, kidneys, andbrain appear to be normal in size. The most likey explanation among the following is:

A Maternal vitamin D deficiency zzB Achondroplasia ***C Fibrous dysplasia D Paget's disease of bone E Congenital cytomegalovirus infection

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