First Aid Express 2018 workbook: MUSCULOSKELETAL page 1

Musculoskeletal, Skin, and

Connective Tissue
Questions

ANATOMY AND PHYSIOLOGY

1. A 36-year-old man presents with difficulty abducting his left arm above 15 degrees. His left shoulder

appears flattened and asymmetric to his right arm. What sensory deficit is most likely? Which nerve

is likely involved? (p 437) ___________________________________________________________

______________________________________________________________________________

2. A 24-year-old woman was in a car accident and suffered a fracture of the midshaft of her humerus.
When asked to hold up her arm, her wrist could not be extended and appeared floppy. What sensory
deficits is she likely experiencing? Which nerve is most likely affected? (p 437) _______________

______________________________________________________________________________

3. A 20-year-old man presents with a fracture of his medial epicondyle. When asked to flex his wrist,
his hand is radially deviated. Why is this deviation happening? (p 437) ______________________

______________________________________________________________________________

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4. In the chart below, describe the characteristics of brachial plexus lesions. (pp 436-439)

Lesion Injured Nerve(s) Presentation Affected Muscle(s)

Ape hand

Erb palsy

Klumpke palsy

Median claw

Ulnar claw

5. In a case of possible knee injury, abnormal passive abduction indicates a torn _________________
(ACL/MCL), and a positive anterior drawer sign indicates a torn ___________ (ACL/MCL) (p 440)

6. What ligaments are torn in the unhappy triad? (p 441) ___________________________________

7. An injury to which ligament represents the most common type of ankle sprain? (p 441) ___________
______________________________________________________________________________

8. A 30-year-old man comes to the physician after being tackled below the knee in a football game with
his friends. The patient is using a steppage gait. What is the most likely diagnosis, and what sensory
deficits are likely? (p 442) _________________________________________________________

______________________________________________________________________________

9. A 42-year-old man presents to the clinic with difficulty adducting his thigh. He had been skiing the
previous week. He mentions that his thigh is hurting and that he’s not sure what he did to it. What
type of injury is most likely? (p 442) _________________________________________________

______________________________________________________________________________

10. A 22-year-old woman has difficulty climbing stairs. What type of mechanical injury would pre-dispose
her to this problem? (p 443) _______________________________________________________

______________________________________________________________________________

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11. A 22-year-old man is brought to the emergency department after a motor vehicle accident. His blood
alcohol level is 0.20. He had not been wearing a seatbelt. Physical examination reveals he has
difficulty flexing his thigh and substantial difficulty extending his leg. What injury is most likely?

(p 442) _________________________________________________________________________

12. A 23-year-old woman who was a passenger in a motor vehicle accident is brought to the emergency

department. She had been wearing a seat belt. Physical examination reveals trauma to the lateral

aspect of the knee. What motor deficit is most likely? (p 442) _____________________________

______________________________________________________________________________

13. What causes medial tibial stress syndrome (shin splints)? (p 444) __________________________

______________________________________________________________________________

14. How is developmental dysplasia of the hip diagnosed in newborns? (p 444) __________________

______________________________________________________________________________

15. What artery is paired with the long thoracic nerve? (p 445) _______________________________

16. What nerve and artery are located in the popliteal fossa? (p 445) __________________________

17. __________ (Type 1/Type 2) muscle is associated with increased oxidative phosphorylation,
whereas ___________ (type 1/type 2) muscle is associated with increased anaerobic glycolysis.
(p 447)

18. How do osteoblasts build bone? How do osteoclasts dissolve bone? (p 448) ___________________

______________________________________________________________________________

19. What are the effects of PTH on bone? (p 448) _________________________________________

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PATHOLOGY
20. Indicate whether the lab findings in the chart below are elevated, decreased, or normal. (p 451)

Alkaline
Condition Phosphate PTH Serum Ca2+
Phosphatase
Osteitis fibrosa
cystica, primary
hyperparathyroidism
Osteitis fibrosa
cystica, secondary
hyperparathyroidism
Osteomalacia
Osteopetrosis
Osteoporosis
Paget disease

21. What disease is associated with increased risk of osteosarcoma? (p 452) ____________________

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22. In the image below, identify the type of tumor according to its location in the bone. (p 453)

23. A 64-year-old man with no significant medical history has had increasing back pain and right hip pain
for the past decade. The pain is worse at the end of the day. Physical examination shows
enlargement of the distal interphalangeal joints. What is the most likely diagnosis? (p 454) ______

______________________________________________________________________________

24. A 36-year old woman presents to the clinic with a new complaint of fatigue of several months’
duration. She also reports stiffness in both hands in the morning, which decreases after showering.
Physical examination reveals a low-grade fever, and subcutaneous nodules are palpated along her
forearms bilaterally. What type of hypersensitivity reaction is occurring? (p 454) _______________

______________________________________________________________________________

______________________________________________________________________________

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25. A 50-year-old obese man comes to the emergency room at 3 a.m. because of a painful great toe.
The pain began 5 hours earlier, after he walked home from a bar where he had steak and beer. He
is allergic to NSAIDs. What is the most appropriate treatment? (p 455) ______________________

______________________________________________________________________________

26. In the chart below, compare and contrast gout and calcium pyrophosphate deposition disease
(previously called pseudogout). (p 455)

Gout Pseudogout
Sexual predilection
Joint most often affected
Crystal composition
Crystal shape
Birefringence
Treatment

27. An 11-year-old boy presents with pain in his knees and ankles, along with daily spiking fevers, a
salmon-pink macular rash on his trunk, and uveitis. What is a likely diagnosis? (p 456) ____________

______________________________________________________________________________

28. What are the four symptoms of Sjögren syndrome? What are the two common autoantibodies found
in these patients? (p 456) _________________________________________________________

______________________________________________________________________________

29. List three causes of septic arthritis. (p 456) _____________________________________________

______________________________________________________________________________

30. A 27-year-old man presents with a 6-month history of low back pain and stiffness that awakens him
during the night and is worse in the morning. He has tenderness over his sacroiliac joints bilaterally
and decreased motion of his lumbar spine. What is the most likely diagnosis? (p 457) __________

______________________________________________________________________________

31. A 31-year-old man comes to the emergency room because his eyes have been red and itchy for the
past 8 hours. For the past month, he has experienced pain during urination and diffuse joint pain;
however, 3 weeks earlier he tested negatively for gonorrhea and chlamydia. Tests are also negative
for rheumatoid factor. What is the most likely diagnosis? (p 457) _____________________________

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32. A 17-year-old girl complains of fever and a painful swollen left elbow. In addition, she has had pain
in her right knee for the past several days. Her cheeks are slightly red but not tender. Her VDRL test
result is positive. She is shocked to learn that she has syphilis because she has no sexual history.
What is the most likely explanation for this finding? (p 458) _______________________________

______________________________________________________________________________

33. In Lambert-Eaton myasthenic syndrome, symptoms __________ (improve/worsen) with muscle use.
In myasthenia gravis, symptoms ______________ (improve/worsen) with muscle use. (p 459)

34. Acetylcholinesterase inhibition __________ (does/does not) reverse symptoms in Lambert-Eaton

myasthenic syndrome and __________ (does/does not) reverse symptoms in myasthenia gravis
(p 459)

35. What does CREST stand for, and with what antibody is it associated? (p 460) ________________

______________________________________________________________________________

______________________________________________________________________________

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DERMATOLOGY
36. Identify the structures on the image below. (p 461)

37. Match the dermatologic term with its definition. (pp 462, 464)
_____ A. Blister containing pus 1. Acantholysis
_____ B. Dried exudates from vesicle, bulla, or pustule 2. Acanthosis
_____ C. Elevated skin lesion <1 cm 3. Bulla
_____ D. Epidermal hyperplasia 4. Crust
_____ E. Flat discoloration <1 cm 5. Dermatitis
_____ F. Inflammation of skin 6. Macule
_____ G. Large, fluid-filled blister 7. Papule
_____ H. Macule >1 cm 8. Patch
_____ I. Papule >1 cm 9. Plaque
_____ J. Separation of epidermal cells 10. Pustule
_____ K. Small, fluid-filled blister 11. Vesicle
_____ L. Transient smooth papule or plaque 12. Wheal

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 First Aid Express 2018 workbook: MUSCULOSKELETAL page 9

38. With what disease is seborrheic dermatitis associated? (p 463) _____________________________

39. Match the skin disorder with its defining characteristic(s). (pp 463-468)
_____ A. Areas of complete depigmentation 1. Acanthosis nigricans
_____ B. Associated with insulin resistance 2. Actinic keratosis
_____ C. Auspitz sign 3. Albinism
_____ D. Genital warts 4. Bullous pemphigoid
_____ E. Honey-colored crusts 5. Cellulitis
_____ F. Horn cysts 6. Condyloma acuminatum
_____ G. Infection of dermis and subcutaneous tissues 7. Eczema
_____ H. Infection of stratum granulosum 8. Erythema multiforme
_____ I. Intensely pruritic wheals 9. Hives
_____ J. Nikolsky sign negative 10. Impetigo
_____ K. Normal melanocyte number, ↓ melanin 11. Pemphigus vulgaris
_____ L. Potentially fatal 12. Psoriasis
_____ M. Premalignant lesion 13. Seborrheic keratosis
_____ N. Target lesion 14. Staphylococcal scalded skin
_____ O. Pruritic eruptions in antecubital fossa 15. Vitiligo

40. With which GI disease is dermatitis herpetiformis associated? (p 467) _______________________

41. In the chart below, compare and contrast the characteristics of bullous pemphigoid and pemphigus
vulgaris. (p 467)

Characteristic Bullous Pemphigoid Pemphigus Vulgaris

Pattern of immunofluorescence
Location of blisters
Oral involvement
Nikolsky sign

42. Second-degree burns occur ___________ (with/without) pain and heal _________ (with/without)
scarring, while third-degree burns occur ___________ (with/without) pain and heal _________
(with/without) scarring. (p 468)

43. Actinic keratosis is a precursor to _________________ (melanoma/squamous cell carcinoma), while

dysplastic nevus is a precursor to ___________________ (melanoma/squamous cell carcinoma).
(p 469)

44. What is the most common type of skin cancer? (p 469) __________________________________

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45. Name a tumor marker of melanoma. (p 469) __________________________________________

46. What type of skin cancer may benefit from vemurafenib? (p 469) __________________________

PHARMACOLOGY
47. In the arachidonic acid pathway (p 470):

A. Phospholipase A2 facilitates the conversion of _____________ into ____________________

______________________________________________________________________________

B. Lipoxygenase facilitates the conversion of _____________ into _______________________

______________________________________________________________________________

C. Cyclooxygenase facilitates the conversion of _____________ into _____________________

______________________________________________________________________________

48. What is the mechanism of action of acetaminophen? (p 470) _____________________________

49. What is the mechanism of action of aspirin? (p 471) ____________________________________

50. What is the mechanism of action of NSAIDs? (p 471) ___________________________________

51. Why should a person who takes NSAIDs consider switching to a COX-2 inhibitor? What is the risk of
COX-2 inhibitors? (p 471) _________________________________________________________

______________________________________________________________________________

52. What is the mechanism of action of bisphosphonates? (p 471) ____________________________

______________________________________________________________________________

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 First Aid Express 2018 workbook: MUSCULOSKELETAL page 11

Answers

ANATOMY AND PHYSIOLOGY

1. Axillary nerve damage leads to loss of sensation over the shoulder.

2. Radial nerve damage leads to loss of sensation over the posterior arm, dorsal hand, and thumb.

3. This patient likely injured his ulnar nerve. Therefore, he has lost function of the flexors on the ulnar
portion of his wrist, but has retained the flexors innervated by the median nerve, which are on the
radial aspect of the hand. Hence, when these flexors flex, they cause radial deviation.

4.

Lesion Injured Nerve(s) Presentation Affected Muscle(s)

Recurrent branch,
Ape hand Unopposable thumb Opponens pollicis
median nerve
Limb hangs at side, Abductors, lateral
Upper trunk, C5-
Erb palsy medially rotated; rotators, and biceps
C6 nerve roots
forearm pronated are paralyzed

Lower trunk; C8- MCP extended;

Klumpke palsy All lumbricals
T1 nerve roots DIP/PIP flexed

Distal median Second/third fingers

Median claw Lateral lumbricals
nerve clawed

“Pope’s blessing”
Ulnar claw Distal ulnar nerve when asked to Medial lumbricals
extend fingers

5. MCL; ACL.

6. Medial meniscus, ACL, MCL.

7. Anterior talofibular ligament.

8. With injury to the common peroneal nerve, sensory deficit would occur at the anterolateral leg and
dorsal aspect of the foot.

9. Anterior hip dislocation, causing damage to the obturator nerve.

10. Posterior hip dislocation, causing injury to the inferior gluteal nerve.

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11. Pelvic fracture, causing damage to the femoral nerve.

12. Difficulty with foot inversion and plantar/toe flexion due to damage to the tibial nerve.

13. Bone resorption that outpaces bone formation in tibial cortex.

14. Developmental dysplasia of the hip is tested with Ortolani and Barlow maneuvers, as the
manipulation of newborn hip reveals a “clunk.” Diagnosis is confirmed via an ultrasound. An X-ray
would not be used, as cartilage is not ossiffed before the newborn is 4-6 months old.

15. Lateral thoracic artery.

16. The tibial nerve and popliteal artery.

17. Type 1; type 2.

18. They catalyze mineralization by secreting collagen; they dissolve bone by secreting acid and
collagenases.

19. Catabolic effects, including osteitis fibrosa cystica.

PATHOLOGY
20.
Alkaline
Condition Phosphate PTH Serum Ca2+
Phosphatase
Osteitis fibrosa
cystica, primary ↑ ↓ ↑ ↑
hyperparathyroidism
Osteitis fibrosa
cystica, secondary ↑ ↑ ↑ ↓
hyperparathyroidism
Osteomalacia ↑ ↓ ↑ ↓
Osteopetrosis Normal Normal Normal Normal/↓
Osteoporosis Normal Normal Normal Normal
Paget disease ↑ Normal Normal Normal

21. Paget disease.

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 First Aid Express 2018 workbook: MUSCULOSKELETAL page 13

22.

23. Osteoarthritis.

24. The patient has rheumatoid arthritis, which is associated with a type III hypersensitivity (immune
complex) reaction.

25. This patient has gout; treat with colchicine if NSAIDs are contraindicated.

26.
Gout Pseudogout
Sexual predilection Men None
Joint most often affected MTP joint of big toe Knee
Crystal composition Monosodium urate Calcium pyrophosphate
Crystal shape Needle Rhomboid
Birefringence Negative Weakly positive
Treatment NSAIDs; if NSAIDs NSAIDs, colchicine,
contraindicated, glucocorticoids
colchicine

27. Systemic juvenile idiopathic arthritis.

28. Inflammatory joint pain, keratoconjunctivitis sicca, xerostomia, and bilateral parotid enlargement.
SS-A (Ro) and SS-B (La).

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29. Staphylococcus aureus, Streptococcus, and Neisseria gonorrhoeae.

30. Ankylosing spondylitis.

31. Reactive arthritis (Reiter syndrome).

32. She has lupus, the great imitator! VDRL results are false-positive due to cross-reaction between
antiphospholipid antibodies and the cardiolipin used in the VDRL.

33. Improve; worsen.

34. Does not; does.

35. Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and

Telangiectasia. Associated with anticentromere antibody.

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 First Aid Express 2018 workbook: MUSCULOSKELETAL page 15

DERMATOLOGY
36.

37. A-10, B-4, C-7, D-2, E-6, F-5, G-3, H-8, I-9, J-1, K-11, L-12.

38. Parkinson disease.

39. A-15, B-1, C-12, D-6, E-10, F-13, G-5, H-14, I-9, J-4, K-3, L-11, M-2, N-8, O-7.

40. Celiac disease.

41.
Characteristic Bullous Pemphigoid Pemphigus Vulgaris
Pattern of immunofluorescence Linear Reticular or lacelike
Location of blisters Subepidermal Intraepidermal
Oral involvement No Yes
Nikolsky sign Negative Positive

42. With, without; without, with.

43. Squamous cell carcinoma; melanoma.

44. Basal cell carcinoma.

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45. S-100 tumor marker.

46. Melanoma patients with unresectable or metastatic disease with BRAF V600E mutation.

PHARMACOLOGY
47. A = Phospholipase A2 facilitates the conversion of membrane lipids into arachidonic acid. B =
Lipoxygenase facilitates the conversion of arachidonic acid into hydroperoxides (which then get
converted into leukotrienes). C = Cyclooxygenase facilitates the conversion of arachidonic acid into
endoperoxides (which then get converted into prostacyclin, prostaglandins, and thromboxane).

48. Acetaminophen causes reversible inhibition of cyclooxygenase.

49. Aspirin causes irreversible inhibition of cyclooxygenase.

50. NSAIDs cause reversible inhibition of cyclooxygenase.

51. Many people who take NSAIDs suffer from gastrointestinal distress and ulcer formation, which can
be avoided by using COX-2 inhibitors. COX-2 inhibitors do, however, increase the risk of thrombosis.

52. Bind hydroxyapatite in bone to inhibit osteoclast activity.

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