1. A 50-year-old man with a history of urinary tract calculi has firm, palpable 1 cm nodules of the helix of the right ear and over the olecranon bursa. These nodules have been present for months:
ANSWER: T - Chronic gout can lead to deposition of urates to form tophi in a variety of soft tissue locations.
2. A 30-year-old office worker notes pain and tingling of her right hand in the thumb and first two fingers:
ANSWER: C - Repetitive motion, such as with typing, may result in a carpal tunnel syndrome. Pressure on the median nerve as it traverses beneath the flexor retinaculum results in numbness and tingling in the distribution of this nerve to the hand.
3. A 40-year-old man has muscle aches and pains, along with chronic pain in both small and large joints, but without deformity or swelling. Radiographs of the hand and feet reveal no abnormal findings. Serologic tests, including antinuclear antibody, rheumatoid factor, and serologic test for syphilis (VDRL), are negative:
ANSWER: Q - Fibromyalgia is an ill-defined entity because there is no specific pathologic finding in the soft tissues and joints, but the pain can be disabling.
4. A 25-year-old man has pain, tenderness, and limitation of motion of his left knee. Arthroscopy reveals exuberant brownish nodular synovial proliferation:
ANSWER: E - Pigmented villonodular synovitis is not common, but the nodular proliferation of synovium with chronic inflammation, giant cells, and hemosiderin deposition can be dramatic.
5. A 52-year-old man is found to be HLA-B27 positive. He has lower back pain. A radiograph of the pelvis reveals narrowing with sclerosis of the sacroliac joints bilaterally:
ANSWER: G or R - Almost all patients with ankylosing spondylitis of the vertebral column are HLA-B27 positive. There is also an association of this HLA marker with Reiter's syndrome (arthritis, uveitis, urethritis, and sometimes aortitis).