a = new Array(207);
var f = "<FONT FACE=ARIAL SIZE=2>"
a[0] = ""
a[1] = f + "(A) Incorrect. A gouty arthritis is more likely to be accompanied by swelling, and deformity with joint destruction. The pain is not related to usage."
a[2] = f + "(B) Incorrect. Rheumatoid arthritis typically involves small joints of the hands and feet most severely, and there is a destructive pannus that leads to marked joint deformity."
a[3] = f + "(C) CORRECT. Degenerative osteoarthritis is a common and progressive condition that becomes more frequent and symptomatic with aging. There is erosion and loss of articular cartilage with joint space narrowing. There is minimal inflammation."
a[4] = f + "(D) Incorrect. Osteomyelitis represents an ongoing infection that produces marked bone deformity, not just joint narrowing."
a[5] = f + "(E) Incorrect. Lyme disease produces a chronic arthritis, but it is typically preceded by a deer tick bite with a skin lesion. It is much less common than osteoarthritis."
a[5.1] = f + "(F) Incorrect. Pseudogout, or calcium pyrophosphate dihydrate deposition disease, is more often a disease of the elderly, accompanied by meniscal calcification and joint space narrowing. There can be acute attacks with marked pain. The knees are most often involved."
a[6] = f + "(A) Incorrect. A poor diet could be lacking in vitamin D, though endogenous vitamin D production occurs with sunlight exposure. The findings are those of osteomalacia and are similar clinically to osteoporosis."
a[7] = f + "(B) Incorrect. An osteomyelitis is not typical at this age and does not usually present as fractures in multiple locations."
a[8] = f + "(C) Incorrect. This inherited disorder of collagen synthesis is initially diagnosed in fetuses and young children."
a[9] = f + "(D) CORRECT. She most likely has osteoporosis of bone with accelerated bone loss leading to the propensity for fractures. Physical inactivity further accelerates bone loss and decreases muscle mass and agility that contribute to falls."
a[10] = f + "(E) Incorrect. This is a rare disorder with that can be seen with McCune-Albright syndrome."
a[10.1] = f + "(F) Incorrect. So-called 'pathologic fracture' from weakening of bone by metastases can occur, but such patients are often very ill, with a history of weight loss, and prior bone pain."
a[11] = f + "(A) Incorrect. Osteosarcoma is the most frequent primary malignancy of bone, not chondrosarcoma."
a[12] = f + "(B) Incorrect. Distal cartilagenous tumors are more likely to be benign, whereas those in a central location are virtually always malignant."
a[13] = f + "(C) Incorrect. Primary malignancies of bone, including chondrosarcoma, are more common in males."
a[14] = f + "(D) CORRECT. Though probably a sporadic occurrence in the case desccribed here, chondrosarcomas can occur in association with enchondromatosis and with osteochondromatosis."
a[15] = f + "(E) Incorrect. The term 'Paget sarcoma' may be used to describe the bone malignancies arising in the setting of long-standing Paget disease of bone. Most often these have the histologic pattern of osteosarcoma. A few cases are fibrosarcoma, chondrosarcoma, or other sarcomas."
a[16] = f + "(A) Incorrect. Giant cells may be seen in a variety of benign and malignant lesions of bone, but this does not explain the hypergammaglobulinemia."
a[17] = f + "(B) Incorrect. Fibroblasts produce collagen and are more numerous with the gross appearance of firm, white scar tissue."
a[18] = f + "(C) Incorrect. Osteoblasts are most numerous in repair of bone, a benign process, and the woven bone of callus, though not as strong as lamellar bone, is still very firm."
a[19] = f + "(D) Incorrect. Osteolytic metastases of renal cell carcinoma could have the gross appearance described here, but would not account for hypergammaglobulinemia."
a[20] = f + "(E) CORRECT. The patient has multiple myeloma. The bone marrow needle was in a lytic lesion filled with plasma cells. His serum globulin is high as a result of his monoclonal gammopathy."
a[21] = f + "(A) Incorrect. Hyperglycemia is a feature of diabetes mellitus, which is associated with peripheral vascular disease that increases the risk for foot ulcerations and osteomyelitis."
a[22] = f + "(B) Incorrect. The arthralgias common to many autoimmune diseases with a positive ANA, such as systemic lupus erythematosus, are not usually associated with joint swelling, redness, or deformity."
a[23] = f + "(C) CORRECT. Gouty arthritis can be associated with hyperuricemia, but not all cases of gout have hyperuricemia. The big toe is the most common joint involved with gout. Acute gouty attacks are associated with intense pain from acute inflammation."
a[24] = f + "(D) Incorrect. There can be bone luceny from osteitis fibrosa cystica with hyperparathyroidism, but the joints are not greatly affected, nor is there swelling or redness."
a[25] = f + "(E) Incorrect. Rheumatoid arthritis leads to marked joint deformity, typically of small joints in hands and feet. The pain usually persists for weeks to months."
a[26] = f + "(A) CORRECT. A 'small round blue cell' tumor involving bone is Ewing sarcoma, a form of primitive neuroectodermal tumor (PNET), commonly seen at this age and in the diaphyseal region of bone."
a[27] = f + "(B) Incorrect. Medulloblastoma, though composed of small blue cells, arises in the central nervous system (posterior fossa) in children."
a[28] = f + "(C) Incorrect. Though neuroblastoma is composed of small blue cells, it typically arises in the adrenal in children."
a[29] = f + "(D) Incorrect. A chondroblastoma arises in the epiphysis of bone."
a[30] = f + "(E) Incorrect. An osteoblastoma is essentially just a large osteoid osteoma, often in vertebra."
a[31] = f + "(A) Incorrect. This organism is associated with plague, in septicemia, pneumonic, and bubonic (lymphadenitis) forms."
a[32] = f + "(B) Incorrect. This organism is associated with gas gangrene. In soft tissues, it can be introduced in association with trauma."
a[33] = f + "(C) CORRECT. Salmonella osteomyelitis is a feature seen in patients with sickle cell anemia. Other organisms that are frequent causes for osteomyelitis with sickle cell anemia include <I>Staphylococcus aureus</I> and gram negative organisms such as <I>Klebsiella</I>."
a[34] = f + "(D) Incorrect. This is not a common organism with osteomyelitis, except perhaps in the neonatal period."
a[35] = f + "(E) Incorrect. This would be a very rare finding with osteomyelitis."
a[36] = f + "(A) Incorrect. Metastatic disease to bone produces focal lesions, not more diffuse enlargement."
a[37] = f + "(B) CORRECT. There is both proliferation and destruction of bone that leads to an increase in size of the affected bone and increased blood flow that predisposes to congestive heart failure to account for these findings. Narrowing of bony canals traversed by peripheral or cranial nerves can lead to nerve palsies."
a[38] = f + "(C) Incorrect. Renal osteodystrophy leads to lesions of osteitis fibrosa cystica admixed with osteomalacia, which are focal in nature."
a[39] = f + "(D) Incorrect. Osteoporosis leads to decreased bone mass, not an increase in bone size or bony sclerosis."
a[40] = f + "(E) Incorrect. Osteomalacia from vitamin D deficiency has an appearance with osteopenia similar to osteoporosis in adults."
a[41] = f + "(A) Incorrect. Fibrous dysplasia is a localized, abnormal proliferation of fibrous tissue in bone arranged with haphazard trabeculae of woven bone. A polyostotic form of this disease associated with endocrinopathies is called McCune-Albright syndrome."
a[42] = f + "(B) Incorrect. Ewing sarcoma lesions are usually diaphyseal in location and can extend into soft tissues."
a[43] = f + "(C) Incorrect. Chondrosarcomas are more typical of the metaphyseal region of older adults, though there is a wide age range. They are usually not lytic lesions."
a[44] = f + "(D) Incorrect. Osteosarcomas occur in the metaphyseal region and are not typically lytic."
a[45] = f + "(E) CORRECT. The major differential diagnosis for aneurysmal bone cyst is giant cell tumor of bone. Though benign, it can weaken the bone and cause fracture."
a[46] = f + "(A) Incorrect. The bright areas are osteoblastic metastases, not lytic areas of osteomyelitis."
a[47] = f + "(B) Incorrect. Hyperparathyroidism should be accompanied by increased bone lucency from osteitis fibrosa cystica."
a[48] = f + "(C) CORRECT. A prostatic adenocarcinoma should be the first guess (particularly in an older male!) with osteoblastic (bone-forming) tumor metastases. Extensive metastases can act as a myelophthisic process that leads to peripheral blood leukoerythroblastosis. His cancer may be causing urinary tract obstruction with renal failure."
a[49] = f + "(D) Incorrect. Hypocalcemia is not typically related to bone disease."
a[50] = f + "(E) Incorrect. Lyme disease can be associated with an arthritis, but not bone lesions."
a[51] = f + "(A) Incorrect. Ewing sarcoma has a peak incidence at a younger age. It most often involves the diaphyseal region. It does not produce osteoid."
a[52] = f + "(B) CORRECT. Osteoid production is characteristic for osteosarcoma. The location about the knee is common. Most arise in the metaphyseal region. Overall, malignancies are uncommon in children, but bone tumors are one of the most common malignancies at this age."
a[53] = f + "(C) Incorrect. Chondrosarcomas do not make osteoid. They can occur overa wide age range."
a[54] = f + "(D) Incorrect. Myelomas are seen in older adults and produce lytic bone lesions filled with plasma cells."
a[55] = f + "(E) Incorrect. Metastases are unlikely to occur at this age. Overall, metastases are the most common malignancy involving bone. Primary bone tumors are not common."
a[56] = f + "(A) CORRECT. Gouty tophi can develop with gouty arthritis. He has increased deposition of sodium urate crystals in the soft tissue around a joint. Most patients with an increased serum uric acid do not have a gouty arthritis, though some do. Most cases of gout (90% or more) have an elevated serum uric acid and are 'primary gout' from overproduction or underexcretion of uric acid, but usually without an identifiable cause."
a[57] = f + "(B) Incorrect. Gout is not directly related to diabetes mellitus. Diabetic nephropathy could lead to chronic renal failure and secondary gout from diminished uric acid excretion, but that is far less common than primary gout."
a[58] = f + "(C) Incorrect. Persons with rheumatoid arthritis may have rheumatoid nodules in a similar location, and they are a form of granuloma, but there is no deposition of sodium urate crystals with rheumatoid arthritis."
a[59] = f + "(D) Incorrect. Gouty tophi are not related to cholesterol metabolism. Cholesterol crystals may follow a traumatic arthritis."
a[60] = f + "(E) Incorrect. An increased serum creatinine may occur with renal failure, and gout may cause renal failure, but the presence of gouty tophi is more likely related to deranged uric acid metabolism."
a[60.1] = f + "(F) Incorrect. An increased serum calcium could rarely lead to metastatic calcification, which may occur in lung, stomach, and kidney, but not as large deposits."
a[61] = f + "(A) Incorrect. Fibrous dysplasia that is polyostotic can be seen with McCune-Albright syndrome, but that does not account for symmetrical long bone shortening."
a[62] = f + "(B) Incorrect. Osteogenesis imperfecta (OI) leads to multiple fractures and bone shortening, but not exclusively the lower legs. There are several forms of OI."
a[63] = f + "(C) Incorrect. Ollier disease is associated with enchondromatosis."
a[64] = f + "(D) Incorrect. Alport syndrome is associated with renal failure and deafness."
a[65] = f + "(E) CORRECT. This is the most common form of short-limbed dwarfism. Though it has an autosomal dominant inheritance pattern, about half of cases represent spontaneous new mutations, and there is no family history. Heterozygotes have normal longevity, while homozygotes usually die soon after birth."
a[65.1] = f + "(F) Incorrect. Thanatophoric dysplasia is a form of short-limbed dwarfism that is lethal in utero or shortly after birth."
a[66] = f + "(A) Incorrect. Paget disease of bone is not related to corticosteroid therapy."
a[67] = f + "(B) Incorrect. Rickets is due to a deficiency of vitamin D in children with growing bones."
a[68] = f + "(C) Incorrect. Osteochondritis is an inflammatory process. Corticosteroids reduce inflammation."
a[69] = f + "(D) CORRECT. Osteoporosis is one of the complications of long-term therapy with corticosteroids. Corticosteroids decrease osteoblast mRNA production, reducing the proteins synthesized. Corticosteroids decrease intestinal calcium absorption. Corticosteroids increase renal phosphate excretion to promote secondary hyperparathyroidism and bone resorption."
a[70] = f + "(E) Incorrect. This is due to vitamin D deficiency in adults."
a[71] = f + "(A) CORRECT. She has scoliosis, which is an idiopathic, but common, condition that has a female predominance."
a[72] = f + "(B) Incorrect. Osteochondromatosis is rare and is seen mostly in males. The extremities are affected most, and dwarfism results in severe cases."
a[73] = f + "(C) Incorrect. The bony deformities of rickets would not likely be asymmetric."
a[74] = f + "(D) Incorrect. She does not have osteogenesis imperfecta, which is associated with multiple fractures, particularly of long bones."
a[75] = f + "(E) Incorrect. Trauma may lead to bone deformities, but not typically of the spine with lateral curvature."
a[76] = f + "(A) CORRECT. Osteochcondromas are not true neoplasms but an exaggeration of the growth plate. They are benign and slow-growing. They may cause discomfort because they project outward from the bone."
a[77] = f + "(B) Incorrect. These tumors expand the bone outward."
a[78] = f + "(C) Incorrect. These are located in the metaphysis and are expansile lesions."
a[79] = f + "(D) Incorrect. Osteoid osteomas can be painful lesions, but they are located within the bone cortex. A small nidus is surrounded by sclerotic bone."
a[80] = f + "(E) Incorrect. Enchondromas are benign cartilagenous tumors that are located within bone."
a[81] = f + "(A) Incorrect. Bone diseases are not associated with dementias."
a[82] = f + "(B) Incorrect. The involvement of Paget disease of bone, even if polyostotic, is not extensive enough to affect hematopoiesis."
a[83] = f + "(C) Incorrect. Paget disease of bone does not affect the liver."
a[84] = f + "(D) Incorrect. The biochemical abnormalities of Paget disease of bone are subtle and not likely to affect renal function."
a[85] = f + "(E) CORRECT. He has Paget disease of bone, and he has the classic phase of mixed osteolysis and osteogenesis. The increased blood flow into the involved areas of bone can lead to high output congestive heart failure in older persons with minimal cardiac reserve. Paget disease of bone is most often seen in older Caucasians."
a[86] = f + "(A) Incorrect. Hypoparathyroidism is not going to accelerate bone loss. The bone resorption that accompanies hyperparathyroidism can cause osteoporosis. Over 95% of cases of osteoporosis are 'primary' with unknown cause."
a[87] = f + "(B) CORRECT. She has osteoporosis with decreased bone mass. Most cases do not have a specific etiology, but Cushing syndrome with hypercortisolism can promote osteoporosis. Her age should make you suspicious, since she is not likely to be postmenopausal."
a[88] = f + "(C) Incorrect. This elevation in serum globulin should make you suspect a monoclonal gammopathy, but myeloma leads to focal bone lytic lesions."
a[89] = f + "(D) Incorrect. Hyperuricemia can be associated with gout that can cause focal bone destrution near affected joints, the bone mass overall is not decreased."
a[90] = f + "(E) Incorrect. Hypercholesterolemia is associated with accelerated atherosclerosis which does not affect bone mass."
a[90.1] = f + "(F) Incorrect. She is not likely to have an increased alkaline phosphatase, even though her bone loss is accelerated."
a[91] = f + "(A) Incorrect. This lateral projection of growth plate from the bone cortex is not associated with disorders of calcium metabolism."
a[92] = f + "(B) Incorrect. The appearance of giant cell tumor is not related to hyperparathyroidism. The so-called 'brown tumor' of hyperparathyroidism, though it contains numerous osteoclast-like cells resembling giant cells, is not a true neoplasm."
a[93] = f + "(C) Incorrect. Paget disease of bone is not related to calcium metabolism or parathyroid function."
a[94] = f + "(D) CORRECT. Osteitis fibrosa cystica lesions are filled with osteoclasts and can have a cystic appearance on radiography. In some cases the osteoclast proliferation is so florid that a 'brown tumor' is formed. There is an association with hyperparathyroidism. Persons with hyperparathyroidism may feel well, but may also have headaches, bone pain, or abdominal pain."
a[95] = f + "(E) Incorrect. Fibrous dysplasia does not result from hyperparathyroidism."
a[96] = f + "(A) Incorrect. RA typically involves small joints symmetrically."
a[97] = f + "(B) CORRECT. He probably is also HLA B27 positive. The earlier in life ankyloising spondylitis begins, the worse the prognosis. There is a progressive bony ankylosis, especially of sacroiliac joints and spine."
a[98] = f + "(C) Incorrect. Osteoarthritis typically involves a single large joint."
a[99] = f + "(D) Incorrect. However, the third stage of Lyme disease can have intermittent attacks of arthritis involving large joints, particularly knee, with swelling."
a[100] = f + "(E) Incorrect. 'Pseudogout' is more typical of the elderly and occurs in acute attacks."
a[101] = f + "(A) CORRECT. Most bone lesions (and the worst ones) have a male predominance."
a[102] = f + "(B) Incorrect. Primary malignant tumors of bone have a male predominance."
a[103] = f + "(C) Incorrect. Primary malignant tumors of bone have a male predominance."
a[104] = f + "(D) Incorrect. Primary malignant tumors of bone have a male predominance."
a[105] = f + "(E) Incorrect. This benign tumor of bone has a male predominance."
a[106] = f + "(A) Incorrect. Inflammation of the tendon sheath (tenosynovitis) is more common in the wrists and hands."
a[107] = f + "(B) Incorrect. Costochondral junctions of ribs are present in the anterior chest."
a[108] = f + "(C) CORRECT. Synovial-lined bursal sacs that are adjacent to joints can become inflamed and distended with watery fluid, more often in males engaging in excessive manual labor or exercise."
a[109] = f + "(D) Incorrect. Ganglion cysts develop in the connective tissue of a tendon sheath or joint capsule and are usually seen in the wrist."
a[110] = f + "(E) Incorrect. Deposition of calcium pyrophosphate crystals in pseudogout is more typical of persons over age 50 and usually involves the knee."
a[111] = f + "(A) CORRECT. <I>Neisseria gonorrheae</I> infection can produce an acute arthritis. A gram stain of a joint aspirate may show many neutrophils with intracellular gram-negative diplococci."
a[112] = f + "(B) Incorrect. Sickle cell anemia may be associated with osteomyelitis due to <I>Salmonella</I> organisms, but arthritis is rare."
a[113] = f + "(C) Incorrect. Small joints (such as the hand) are more likely to be involved than large joints (such as the hip) with rheumatoid arthritis. There is proliferative synovitis with lymphocytes and plasma cells, not neutrophils."
a[114] = f + "(D) Incorrect. Autoimmune diseases such as systemic lupus erythematosus are often associated with arthralgias, but there is minimal actual joint inflammation and typically no deformity."
a[115] = f + "(E) Incorrect. The arthritis of Lyme disease from <I>Borrelia burgdorferi</I> infection is often seen in stages II or III of the disease and is not typically purulent."
a[116] = f + "(A) Incorrect. Don't make the mistake of assuming all fractures are due to trauma. This child has additional findings not explained by trauma."
a[117] = f + "(B) CORRECT. This is a disorder of type 1 collagen synthesis, with subsequent risk for fractures of bone. The blue sclerae, hearing loss, and dental abnormalities are characteristic for OI."
a[118] = f + "(C) Incorrect. Achondroplasia is a form of dwarfism, but it is not characterized by fractures."
a[119] = f + "(D) Incorrect. The bones in a growing child with rickets will be deformed, but extensive fractures are not common."
a[120] = f + "(E) Incorrect. This rare condition (Albers-Schonberg disease) is a hereditary defect in osteoclast function with markedly thickened, sclerotic bone that fractures readily."
a[121] = f + "(A) Incorrect. Mutations of the fibrillin gene are present with Marfan syndrome, which affects the connective tissue of the cardiovascular system most severely."
a[122] = f + "(B) Incorrect. The FGFR gene mutations are associated with skeletal dysplasias, such as achondroplasia, that are not usually accompanied by fractures."
a[123] = f + "(C) Incorrect. The Rb gene is a tumor suppressor gene. If both copies of the gene are mutated, then the risk for malignancy is increased. One of the malignancies that can occur is osteosarcoma."
a[124] = f + "(D) Incorrect. NF1 can be associated with bone deformities beginning in childhood as a consequence of growth of neurofibromas."
a[125] = f + "(E) CORRECT. Osteogenesis imperfecta is an inherited disorder of type I collagen synthesis, leading to 'brittle bones' with high risk for factures. This is OI type II, the perinatal lethal form, which has both autosomal recessive and autosomal dominant inheritance patterns."
a[126] = f + "(A) Incorrect. In the disorder spondylolisthesis, the vertebral body, pedicles, and facets 'slips' forward to produce back pain, and limited motion. Symptoms are often bilateral."
a[127] = f + "(B) Incorrect. Spina bifida is a failure of fusion of the laminae of the neural arch and is usually occult until an injury or radiograph reveals it. It is the least severe form of neural tube defect."
a[128] = f + "(C) CORRECT. He has a herniated intervertebral disk in which impingement of the herniated disk on spinal nerve roots (most often L5 or S1 in the lumbar region) produces sensory and motor disturbances."
a[129] = f + "(D) Incorrect. Osteoporosis at his age and in a male is unlikely. Compressed vertebral fractures may involve nerve roots, but are not as likely as a herniated disk."
a[130] = f + "(E) Incorrect. This is unlikely at his age. Paget is often painless, but if advanced, a nerve root may become entrapped."
a[131] = f + "(A) Incorrect. This lesion has a central nidus surrounded by sclerotic bone."
a[132] = f + "(B) Incorrect. Letterer-Siwe disease is the disseminated form of Langerhans cell histiocytosis and most often occurs in children under 3."
a[133] = f + "(C) CORRECT. Eosinophilic granulomas are a localized form of Langerhans cell histiocytosis that can be found in skull or long bones and can mimic osteomyelitis. The mixed inflammatory cell infiltrated can have histiocytes, plasma cells, lymphocytes, and even eosinophils."
a[134] = f + "(D) Incorrect. This localized bone lesion occurs most often in patients with hyperparathyroidism."
a[135] = f + "(E) Incorrect. Epithelioid macrophages and Langhans giant cells should be present in a granuloma with M. tuberculosis."
a[136] = f + "(A) Incorrect. The RPR is a screening test for syphilis. Gummatous necrosis in tertiary syphilis may involve large joints such as the knees.."
a[137] = f + "(B) Incorrect. HLA-B27 is often positive in ankylosing spondylitis which involves the spine."
a[138] = f + "(C) Incorrect. The anti-double stranded DNA positivity is most specific for systemic lupus erythematosus, which is unlikely to be complicated by joint deformity."
a[139] = f + "(D) CORRECT. Joint deformity frequently occurs with chronic rheumatoid arthritis. Females are affected more than males, and pregnancy may lessen the severity of the disease. However, men can get RA, too. Disease modifying anti-rheumatic drugs (DMARDS) often include methotrexate alone or in combination with leflunomide, sulfasalazine, hydroxychloroquine, or biologicals such as anti-TNFa agents."
a[140] = f + "(E) Incorrect. Ankylosis can and does occur often with severe rheumatoid arthritis."
a[141] = f + "(A) Incorrect. Though an enchondroma occurs within bone, there is not a radiolucent nidus."
a[142] = f + "(B) Incorrect. This is a lesion filled with plasma cells and seen in older adults."
a[143] = f + "(C) Incorrect. This lesion has a variety of inflammatory cells, including eosinophils and usually does not have surrounding sclerotic bone."
a[144] = f + "(D) CORRECT. An osteoid osteoma has a central nidus with surrounding sclerotic bone. This lesion can be very painful from release of prostaglandins. Prostaglandin production is blocked by the aspirin."
a[145] = f + "(E) Incorrect. This lesion usually produces a lateral projection from the bony cortex."
a[145.1] = f + "(F) Incorrect. A Ewing sarcoma is unlikely to be so localized as this, and pain from a malignancy is unlikely to be relieved by aspirin."
a[146] = f + "(A) Incorrect. The presence of multiple lesions suggests metastases. Chondrosarcomas can arise over a wide age range. They tend to produce a single large mass that can have focal calcifcations."
a[147] = f + "(B) Incorrect. Oat cell (small cell anaplastic) carcinomas of lung often metastasize widely, particularly to bone, but are almost exclusive to smokers."
a[148] = f + "(C) Incorrect. Breast cancers are known for their propensity to bone metastasis. Breast cancers are rare in men."
a[149] = f + "(D) Incorrect. Renal cell carcinomas can produce osteolytic metastases. In the absence of hematuria, a large renal cell carcinoma capable of metastases is unlikely."
a[150] = f + "(E) CORRECT. Prostate adenocarcinomas often produce osteoblastic metastases. They are one of the most common malignancies in older men."
a[151] = f + "(A) CORRECT. This is a so-called Dupuytren contracture due to a palmar fibromatosis. The etiology is obscure."
a[152] = f + "(B) Incorrect. In adults, these tumors are uncommon and appear as large masses in deep soft tissues."
a[153] = f + "(C) Incorrect. A foreign body granuloma could occur at this site, but would not likely lead to a contracture of one finger."
a[154] = f + "(D) Incorrect. This would not lead to a marked contracture."
a[155] = f + "(E) Incorrect. This appears as a more well-circumscribed mass without contracture."
a[156] = f + "(A) Incorrect. The neuropathy she has is too localized to suggest a toxic etiology."
a[157] = f + "(B) Incorrect. Rheumatoid arthritis leads to pain, but not in a localized area in median nerve distribution."
a[158] = f + "(C) Incorrect. Gout may lead to tophaceous deposits, but over bony prominences, not median nerve."
a[159] = f + "(D) Incorrect. Hypertrophic osteoarthropathy is characterized by clubbing of the digits as well as arthritis. It is most often associated with cardiorespiratory diseases such as chronic obstructive pulmonary disease."
a[160] = f + "(E) Incorrect. Though diabetes mellitus may result in peripheral neuropathy, such a diabetic neuropathy is unlikely to be so localized as in this case, and unlikely to be related to repetitive motion."
a[160.1] = f + "(F) CORRECT. She has carpal tunnel syndrome, an entrapment neuropathy of the median nerve. In middle-aged women, tenosynovitis is often present, worsened by repetitive motion. Prolonged flexion while sleeping may exacerbate carpal tunnel syndrome."
a[161] = f + "(A) Incorrect. Chondrocalcinosis affecting joints is not related to diabetes mellitus or renal failure."
a[162] = f + "(B) CORRECT. In secondary hyperparathyroidism, the parathyroid glands are hyperplastic. The renal failure impairs renal phosphate excretion, leading to hyperphosphatemia, which depresses the serum calcium and turns on parathyroid hormone production, leading to renal osteodystrophy."
a[163] = f + "(C) Incorrect. Multiple myeloma may produce renal failure (myeloma kidney) from excessive light chain excretion, but myeloma is not related to diabetes mellitus. The bone lesions of multiple myeloma containing plasma cells are characteristically lytic."
a[164] = f + "(D) Incorrect. Osteochondromatosis leads to multiple bony exostoses; it is unrelated to diabetes mellitus or renal failure."
a[165] = f + "(E) Incorrect. Osteopetrosis is rare and unlikely to occur with chronic renal failure or diabetes mellitus."
a[166] = f + "(A) Incorrect. Osteoporosis would be uncommon in a 45-year-old man. Back pain is a more typical symptom for osteoporosis."
a[167] = f + "(B) Incorrect. This mass lesion could be located about the knee, but the pain would probably be exacerbated by movement or local trauma."
a[168] = f + "(C) Incorrect. The findings with osteomalacia would be similar to osteoporosis, and back pain would be more typical."
a[169] = f + "(D) CORRECT. Osteoarthritis often involves a larger, weight-bearing joint. The pain usually diminishes initially with movement, but recurs with reuse or prolonged use of the affected joint."
a[170] = f + "(E) Incorrect. This uncommon inherited metabolic disorder leads to 'brittle bones' that predispose to fractures."
a[171] = f + "(A) CORRECT. The hereditary nature of ankylosing spondylitis means that about one-fourth of close relatives have the disease. Bony ankylosis of the sacroiliac joint from sacroiliitis is a common outcome in a patient who has had ankylosing spondylitis for years."
a[172] = f + "(B) Incorrect. Gummatous necrosis is a feature of tertiary syphilitic involvement of bone, which most often involves the knees."
a[173] = f + "(C) Incorrect. A mosaic pattern of osteolysis and osteosclerosis is characteristic for Paget disease of bone, which is more common in older persons and does not have a hereditary pattern. The bone deformity may involve any adjacent joint. Paget disease typically has an onset in older persons."
a[174] = f + "(D) Incorrect. Osteonecrosis can be seen with ischemia and infection."
a[175] = f + "(E) Incorrect. Pannus formation is characteristic for rheumatoid arthritis, which most often affects the small joints of hands and feet first."
a[176] = f + "(A) Incorrect. Gonococcal arthritis is a suppurative arthritis, and it is seen most often in young persons as a complication of gonorrheal infection."
a[177] = f + "(B) Incorrect. Ankylosing spondylitis typically involves the spine. It is slowly progressive, beginning in the 3rd decade, and does not have a febrile component or lymphadenopathy."
a[178] = f + "(C) CORRECT. Also known as Still disease, juvenile idiopathic arthritis (JIA), also called juvenile rheumatoid arthritis (JRA) is not frequent. About 5% of rheumatoid arthritis cases occur in persons <16 years of age."
a[179] = f + "(D) Incorrect. Tuberculous arthritis is a complication of adjacent osteomyelitis or dissemination. It is destructive and monoarticular, usually involving the spine."
a[180] = f + "(E) Incorrect. Gouty arthritis usually involves the big toe of males with hyperuricemia who are past the third decade."
a[181] = f + "(A) CORRECT. Osteoarthritis is very common. The articular surface becomes worn or damaged with time, leading to pain and loss of mobility."
a[182] = f + "(B) Incorrect. Chronic inflammation with synovial proliferation (pannus) is more a feature of rheumatoid arthritis, which is overall much less common than osteoarthritis."
a[183] = f + "(C) Incorrect. Osteomyelitis is not frequent and arthritis is not a common association."
a[184] = f + "(D) Incorrect. Although fibrosis of adjacent marrow beneath the articular cartilage affected by arthritis may occur, it is of no major importance -- most hematopoiesis is in vertebra, ribs and sternum."
a[185] = f + "(E) Incorrect. Gouty arthritis with sodium urate deposition and 'pseudogout' with calcium pyrophosphate deposition are not nearly as common as osteoarthritis and do not involve the hips as often."
a[186] = f + "(A) Incorrect. Osteosarcomas are more likely to appear in the first to third decades of life. Some, however, are 'secondary' and appear in older persons with Paget disease of bone."
a[187] = f + "(B) CORRECT. Chondrosarcomas occur over a wide age range. Many arise in older adults. The 'secondary' forms that follow enchondromatosis appear later in life."
a[188] = f + "(C) Incorrect. Ewing sarcomas usually occur in the first two decades of life."
a[189] = f + "(D) Incorrect. Most giant cell tumors occur in women between the ages of 20 and 40."
a[190] = f + "(E) Incorrect. This painful lesion appears in the first three decades of life, more often in males."
a[191] = f + "(A) CORRECT. An elevated serum alkaline phosphatase in an older adult is a red flag for metastatic carcinoma to bone. The mnemonic 'lead kettle' or 'PbKTL' suggests common primary sites: prostate, breast, kidney, thyroid, lung."
a[192] = f + "(B) Incorrect. Osteochondromatosis is rare. Osteochondromas are exostoses of bone."
a[193] = f + "(C) Incorrect. Ewing sarcoma is seen in children and young adults, typically in the diaphyseal region of long bones."
a[194] = f + "(D) Incorrect. Fibrous dysplasia is uncommon disorder of bone maturation that leads to bone deformity with fracture."
a[195] = f + "(E) Incorrect. Vitamin D deficiency in adults can lead to decreased bone mineralization with an appearance similar to osteoporosis."
a[196] = f + "(A) Incorrect. Osteosarcoma is usually seen in the metaphyseal region and destroys cortex of bone. Very atypical cells with osteoid production are seen microscopically."
a[197] = f + "(B) Incorrect. Chondrosarcomas have atypical chondrocytes with cartilagenous matrix. They often form a bulky mass without distinct borders."
a[198] = f + "(C) Incorrect. An MFH is a sarcoma that may arise in bone and lead to destruction with erosion of bone."
a[199] = f + "(D) CORRECT. A giant cell tumor of bone typically arises in the epiphysis in an adult, usually about the knee."
a[200] = f + "(E) Incorrect. Tuberculosis leads to a chronic osteomyelitis with bone destruction and remodelling."