Orthotic Modification for Ankle Instability

1
2014 Fall ABPM In-training Exam

Orthotics and Prosthedics
E
A 34 year-old male has a permanent injury to the common peroneal nerve as a result of an improper cast application
as a child.
In treating the pedal sequelae, which of the following is most useful?
A. Functional orthotic with extrinsic forefoot and rearfoot posting

B. UCBL orthosis
C. Metatarsal bar on extra depth orthopedic shoe
D. Patellar tendon weight bearing brace
E. MAFO
2
Orthotics and Prosthetics

C
A 27 year-old patient has been diagnosed with functional hallux limitus.
Which of the following orthotic modifications is most appropriate?
A. Lateral heel post flare

B. Mortons extension
C. First ray cut-out
D. Lateral clip
3
Orthotics and Prosthetics

A
A 27 year-old male presents with lateral ankle instability. Examination reveals a rigid pes cavus with limited
subtalar joint range of motion. His resting calcaneal stance position is shown.
Which of the following orthotic modifications is most appropriate?
A. Add lateral flare to heel post

B. Extend the medial heel post
C. Incorporate medial heel skive
D. Post the rearfoot in varus
4
Orthotics & Prosthetics

B
A 12 year-old male presents as shown, complaining of pain along the inside and outside of both ankles, worse on the
right. Prior surgeries were performed in Poland for which no records are available. His parents refuse any further
surgical correction. Examination demonstrates marked equinus and varus.
Which of the following is the most appropriate orthotic prescription for this patient?
A. Functional orthotic
B. AFO
C. CROW
D. Shaffer plate
5

C
A 35 year-old male, who is otherwise asymptomatic, is noted on radiograph to have the findings shown. He was
involved in a motorcycle collision 2 years ago.
Which of the following should be prescribed to prevent further subtalar deterioration?
B. Shaffer plate
C. UCBL
D. Whitman-Roberts
6

A
A 39 year-old male complains of forefoot pain, making him unable to function at his current job as a maintenance
worker at a local hospital. Radiograph is shown. Examination demonstrates first MTP joint crepitus with limited
passive range of motion.
Which of the following is the most appropriate orthotic accommodation for this patient?
A. Morton's extension
B. Varus forefoot post
C. Metatarsal pad
D. Second metatarsal cut-out
7

B
A 67 year-old female with Type 2 DM presents with a massively swollen ankle for 2 months and mild pain. She is in
renal failure and is not a candidate for surgical reconstruction. Examination demonstrates complete absence of pedal
sensation. Radiograph is shown.
Which of the following is the most appropriate brace to accommodate her deformity?
B. CROW
C. AFO
D. UCBL
8

C
A 35 year-old female runner has pain at the plantar first metatarsal head. Radiographs are shown.
Which of the following is the best accommodation to a functional orthotic for this patient?
A. One-fourth inch heel lift

B. Lateral extrinsic heel wedge
C. First MTP joint cut-out
D. Morton's extension; plantar heel aperture
9

C
Assuming the negative casts shown, taken via the suspension method, were done properly, which of the following
correctly describes the forefoot to rearfoot relationship?
A. Left - 1 forefoot valgus

B. Right - 20 forefoot varus
C. Left - 8 forefoot varus
D. Right - 4 forefoot valgus
10

D
A 50 year-old male relates progressive flattening of his left foot and complains of pain in the arch and posterior
ankle. Subtalar joint range of motion is painless and demonstrates 15 of inversion and 10 of eversion bilaterally.
His relaxed calcaneal stance position is 3 everted.
Which of the following is NOT an appropriate treatment option for this patient?
A. Hinged AFO
B. Semi-rigid orthotic plate
C. Medial skive modification
D. First ray cut-out
11
Pathomechanics
C
A 37 year-old female presents with pain and swelling of her left ankle. Examination reveals instability on single
heel raise and marked abduction of the forefoot in stance ("too many toes" sign). Radiographs reveal pes planus
bilateral, worse on the left.
Which of the following imaging studies is most likely to confirm the diagnosis?
A. Axial CT
B. Ultrasonography
C. MRI scan
D. Harris-Beath plain film radiograph views
12
Pathomechanics
D
A 24 year-old rugby player presents with pain in the right first MTP joint, sustained when he caught his big toe on
the turf while playing a match over the weekend. Examination reveals edema dorsal to the first MTP joint, with
moderate pain upon flexion and mild pain with extension.
Which of the following is the most likely diagnosis?
A. Sesamoiditis
B. Extensor tendonitis
C. Joplins neuroma
D. First MTP joint sprain
13
Pathomechanics
A
Which of the following gait findings is most likely observed in runners who wear minimalist shoes?
A. Forefoot striker
B. Excessively dorsiflexed ankle joint
C. Foot slap at heel strike
D. Late midstance pronation
14
Pathomechanics
C
A 27 year-old male presents with sesamoiditis determined to be biomechanical in origin.
Based on the radiographic findings, which of the following is the most probable cause of the sesamoiditis?
A. Excessive supination
B. Ankle block
C. Anterior cavus
D. Excessive pronation
15
Pathomechanics
C
A 37 year-old male is evaluated for a left osseous ankle equinus (shown) with secondary arthritis subsequent to a
motorcycle collision sustained several years earlier. Examination reveals fixed ankle equinus in 20 of
plantarflexion. Treatment has consisted of a custom shoe with heel lift for the functional leg length inequality. The
opposite ankle has been adjusted with shoe therapy to level the patient's hips.
Which of the following additional shoe modifications should be prescribed on the left?
A. Metatarsal bar
B. Thomas heel
C. Rocker bottom
D. Morton's extension
16
Pathomechanics
A
A 42 year-old obese male presents with pain in the front of his foot for 3 months, worsening within the past 3 weeks.
Radiographs are indeterminate and show no evidence of osseous pathology. In the MRI shown the arrow is pointing
to the second metatarsal.
Which of the following is the most likely cause of this problem?
A. First ray hypermobility

B. Osteoporosis
C. Brachymetatarsia 4th
D. Clinodactyly
17
Pathomechanics
B
A 32 year-old mail carrier presents with pain on the lateral side of his right ankle. Examination demonstrates
pinpoint pain 2cm proximal to the tip of the fibular malleolus. Radiograph is shown.
Which of the following most likely contributes to the development of this stress fracture?
A. Flexible pes plano valgus deformity

B. Rigid pes cavus deformity
C. First ray hypermobility
D. Plantarflexed first ray
18
Pathomechanics
B
A 39 year-old female presents with a callus beneath the second metatarsal head as shown. She trims this herself
regularly. Despite numerous professional treatments including excision by a dermatologist, acid treatments and laser
treatments, her problem remains. When professionally removed by a podiatrist, she is pain free for only a week.
She has numerous medical problems and is not a surgical candidate.
Which of the following is the most appropriate care for this patient?
B. Accommodative orthotic
C. Shaffer plate
D. UCBL
19
Pathomechanics
A
A 50 year-old male complains of increasing pain with flattening of his left foot, as shown, of 4 months duration. He
denies trauma. The pain has increased in the past month.
Which of the following events most likely led to this pathology?
A. Shifting of STJ axis medially and increased ground reactive pronatory moment arm
B. Decreased strength of peroneus brevis, leading to flattening of rearfoot and midfoot
C. The moment arm of the tibialis posterior for supination is stronger than peroneus brevis for pronation
D. Weakening of posterior tibialis muscle leading to decreased pronatory strength
20
Pathomechanics
D
The 52 year-old male shown presents with burning pain along his left medial ankle and plantar/medial heel. He
denies trauma and states the burning pain has been getting worse over the past 3-4 years. He runs 10-12 miles per
week and has worn the same pair of running shoes for the past 2 years.
Which of the following is LEAST likely to be contributing to this patient's complaints?
A. Limited ankle joint and first MTP joint dorsiflexion

B. A high degree of tibial varum and supinatus
C. Compression of the flexor retinaculum on the medial plantar nerve
D. Charcot-Marie-Tooth disease
21
Pedorthics
D
A new patient presents with shoes that he's had previously modified with a carbon fiber plate from heel to toe.
Which of the following conditions is likely to have been addressed with this shoe modification?
A. Dorsal metatarsal cuneiform exostosis

B. Claw toes
C. Osseous ankle equinus
D. Structural hallux limitus
22
Pedorthics
A
Which of the following shoe modifications are most appropriate for augmentation of other therapies for countering
excessive subtalar pronation.
A. Thomas heel with medial stabilizer

B. Heel to toe lateral sole wedge
C. Reverse Thomas heel and lateral stabilizer
D. Solid ankle cushion heel (SACH heel)
23
Pedorthics
B
Based on the radiograph, which of the following is the most appropriate pedorthic management for this patient?
A. Inlay depth shoes with accommodative insoles

B. Rocker sole shoes
C. Custom molded shoes
D. Arizona brace
24
Pedorthics
B
A 41 year-old female complains of great toe pain in shoe gear. She underwent bunion surgery 3 years ago. Her
pain began soon after surgery and has worsened. Current radiographs are shown.
Which of the following is the most appropriate shoe gear?
A. Straight lasted
B. Custom molded
C. Semi curve lasted
D. Extra depth
25
Pedorthics
A
A 30 year-old male is seen in the ED for evaluation of a left toe injury that occurred within the last 2 hours. He was
kicked from behind while playing soccer.
What is the best shoe modification for this patient to prevent redislocation?
A. Medial carbon shank

B. One quarter inch heel lift
C. Lateral sole wedge
D. Metatarsal bar
26
Pedorthics
C
Select the condition shown that is most appropriate to the shoe or shoe modification listed.
Which foot would benefit most from a shoe with a reverse last?
A. Item A
B. Item B
C. Item C
D. Item D
27
Pedorthics
D
A 56 year-old male complains of long-term pain in his first MTP joint. Examination reveals moderately severe pain
and crepitation with dorsiflexion. He is undomiciled and uninsured. Radiographs are shown.
Which of the following shoe recommendations/modifications are most appropriate for this patient?
A. Heel lift
B. Negative heel
C. Less rigid-sole
D. Metatarsal rocker bar
28
Pedorthics
D
A 70 year-old male with Type 1 DM exhibits a rocker bottom deformity, as shown on the accompanying radiograph.
He recently underwent extensive wound care to heal a plantar ulcer. Surgical correction to prevent recurrance is not
an option at this time.
Which of the following foot wear is best prescribed for this patient?
A. Plastizote healing sandal

B. Rocker sole shoes with leather orthoses
C. Depth inlay shoes with metatarsal rocker bars
D. Custom molded shoes with multi-density insoles
29
Pedorthics
D
A 67 year-old male complains of chronic ankle pain and swelling with daily activity. Radiograph is shown.
Which of the following is the most appropriate accommodation for this patient?
A. SACH heel
B. Functional orthosis
C. Thomas heel
D. Rocker sole
30
Pedorthics
A
A 73 year-old female presents with pain and swelling in the left foot and ankle for the past 6 months. Her pain is
reproduced when attempting to perform a heel raise. The MRI and her clinical presentation are shown.
Which of the following shoe modifications is most appropriate for this patient?
A. Medial heel and sole wedge

B. Lateral heel wedge
C. 3/8 inch heel raise bilateral
D. Rocker bottom sole
31
Podopediatrics
C
A 10 year-old child has bilateral symptomatic pes planus and genu recurvatum.
How might you modify a pair of orthoses to best suit this child's needs?
A. Construct a deep heel cup.

B. Create a plantar fascial groove.
C. Apply a heel lift into the rearfoot post.
D. Apply a 5 varus forefoot post.
E. Apply a medial flare to the rearfoot post.
32
Podopediatrics
B
A 1 year-old child presents with an adducted left foot during gait. The left patella faces straight ahead. Examination
reveals a rectus foot and 2 of external malleolar position.
Which of the following is the most likely etiology for the left foot position?
A. Tight adductor muscles

B. Tibial antetorsion
C. Tight iliotibial band
D. Genu varum
E. Metatarsus adductus
33
82
Biomechanics
Podopediatrics
A
A 2 year-old child presents with intoeing.
Biomechanical examination:
Measurement Right Left

Hip rotation: 35 external 60 internal 35 external 60 internal
Knee rotation @ 45 flexion: 20 external 20 internal 20 external 20 internal
Malleolar position: 8 external 8 external
Foot: C-shaped lateral border reducible to rectus
Which of the following is the most likely etiology for the intoeing?
A. Flexible metatarsus adductus with internal femoral position

B. Rigid metatarsus adductus with internal femoral torsion
C. Flexible metatarsus adductus with internal tibial torsion
D. Rigid metatarsus adductus with internal tibial torsion
E. Flexible metatarsus adductus with lax knee ligaments
34
Podopediatrics
D
A 2 year-old is presented for evaluation of in-toeing on the left. Orthometric and radiographic findings on the left
demonstrate:
Hip rotation (flexed): 47 internal 45 external

Hip rotation (extended): 47 internal 45 external
Malleolar position: 15 external
Metatarsus adductus angle: 31
Which of the following is the most likely cause for the childs in-toeing?
A. Femoral antetorsion
B. Tight hip capsular ligaments
C. Insufficient tibial torsion
D. Metatarsus adductus
35
Podopediatrics
B
A 9 year-old is evaluated for in-toeing on the right. Orthometric findings on the right demonstrate:
Hip rotation (flexed): 42 internal 40 external

Hip rotation (extended): 42 internal 28 external
Malleolar position: 19 external
Metatarsus adductus angle: 10
Which of the following is the most likely cause for the childs in-toeing?
A. Femoral antetorsion
B. Tight hip capsular ligaments
C. Insufficient tibial torsion
D. Metatarsus adductus
36
Podopediatrics
C
You are consulted for evaluation of a 6 month-old with the left foot deformity shown, present since birth. Clinically
the condition is flexible. No other abnormalities are noted.
Which of the following is the most appropriate initial treatment for this deformity?
A. Counter Rotation Splint

B. AFO
C. Serial casting
D. Surgical correction
37
Podopediatrics
C
After appropriate closed reduction, immobilization, and healing in good position which of the following fractures
has the poorest prognosis?
A. Salter 2 of tibia
B. Salter 3 of tibia
C. Salter 4 of tibia
D. Torus fracture of tibia
38
Podopediatrics
B
A 13 year-old male is presented by his mother for evaluation of bilateral heel pain, accentuated after basketball and
when he rises from a recumbent position. Examination reveals pain elicited with side-to-side compression to the
calcaneus bilaterally. There is pain with palpation to the inferior Achilles bilaterally. Patellar and Achilles DTRs
are normal and no clonus is observed. Radiograph is shown.
Orthometric findings reveal:
Right Left
Ankle dorsiflexion, knee extended 12 12
Subtalar inversion 30 25
Subtalar eversion 5 5
A. Tarsal tunnel syndrome

B. Calcaneal apophysitis
C. Tarsal coalition
D. Os trigonum fracture
39
Podopediatrics
C
A 3 year-old male is presented by his mother who is concerned that he is becoming "knock-kneed".
Which of the following is the appropriate course of action?
A. Whitman-Roberts orthotic to shift the pressure in the opposite direction

B. Type D heel stabilizers to stabilize the heel
C. Do nothing and re-evaluate in 1 year
D. Add Thomas heel to all shoes
40
Podopediatrics
D
An 8 year-old female was dispensed functional foot orthoses for postural fatigue. Within 1 year she developed an
unilateral hallux abducto valgus deformity. Examination revealed no limb length discrepancy or other
biomechanical abnormality.
Which of the following problems with the orthotic prescription would most likely have contributed to this
development?
A. Device was too short

B. Device maximally pronated midtarsal joint
C. Caused excessive first ray plantarflexion
D. Allowed excessive abnormal subtalar joint pronation
41
Cardiology & Pulmonology

C
A 79 year-old male patient appears short of breath and is using his accessory muscles for respiration but does not
appear to be in acute distress. Examination demonstrates a normal respiratory rate and normal sinus rhythm. There is
decreased tactile fremitus, increased resonance to percussion and decreased breath sounds bilaterally.
A. Adult respiratory distress syndrome

B. Chronic bronchitis
C. Emphysema
D. Pneumothorax
42

A
A 57 year-old male complains of incurvated toenails that he cannot care for himself. He states that his nails had
started to change a few years ago. Examination reveals a similar appearance of his fingernails (shown).
Which of the following should be ruled out?
A. Bronchogenic carcinoma
B. Hyperparathyroidism
C. Myeloma
D. Graves disease
43

C
A 48 year-old male presents to the ED after a motorcycle collision with difficulty breathing and an ankle fracture.
Radiograph is shown.
Which of the following is the correct radiographic impression?
A. COPD
B. Pneumonia
C. Pneumothorax
D. Rib fractures
44

B
A 78 year-old male retired fire fighter presents with painful chronic Achilles tendonitis. Examination reveals
moderately severe lower limb swelling bilaterally and a painful left Achilles tendon insertion. Past medical history
includes prostatic hypertrophy. Chest radiograph is shown.
Which of the following is the most likely cause of the bilateral limb swelling?
A. Deep venous thrombophlebitis

B. COPD
C. Chronic renal failure
D. Lymphedema praecox
45

D
A 68 year-old female presents 10 days S/P digital arthroplasty of the right fifth toe with a painful leg cramp of 3
days duration. Medications include Tamoxifen and pioglitazone. Review of systems reveals breathlessness when
walking but the patient denies claudication symptoms. The surgical site is healing well and the sutures are removed.
Which of the following is the best course of action?
A. Order chest radiographs

B. Obtain ankle brachial index
C. Recommend a course of stretching
D. Order D-dimer study
46

B
A 67 year-old female with Type 2 DM presents for foot care. She provides a list of medications and a log of recent
blood pressures recorded by the nursing staff.
Blood Pressure Classification

Systolic Blood Pressure (mmHg) Diastolic Blood Pressure (mmHg)
Normal <120 <80
Prehypertension 120139 8089
Stage 1 Hypertension 140159 9099
Stage 2 Hypertension 160 100
Observation Systolic Diastolic

Monday 152 90
Thursday 156 95
Saturday 159 96
Tuesday 150 95
Which of the following best characterizes the stage of hypertension?
A. Pre-hypertension
B. Stage 1(mild-moderate)
C. Stage 2 (severe)
D. Insufficient data to stage
47

A
An 81 year-old female is seen with darkening of the toes as shown, which began 1 week ago. She has Type 2 DM,
loss of protective threshold and an ABI of 0.8. She was recently diagnosed with atrial fibrillation.
A. Shower emboli
B. Ischemic changes
C. Raynaud's phenomenon
D. Perfringens infection
48
Dermatology
B
A 6 year-old male is presented with multiple bruises on his arms and legs which are mostly brown and yellow. The
parents claim to have hired a new nanny 3 days ago.
Based on the appearance of the observed bruising, when did the episode most likely occur?
A. 3 - 4 weeks ago
B. 8 14 days ago
C. 4 7 days ago
D. 1 3 days ago
49
Dermatology
B
A 58 year-old female is seen for several painful 1 cm blisters both palms and soles. Past history includes uterine
cancer which has responded to surgery and oral 5-fluorouracil. She admits numbness and tingling of the palms and
soles.
A. Vesicular tinea pedis

B. Hand-foot syndrome
C. Dyshidrotic eczema
D. Peripheral neuropathy
50
Dermatology
D
A 55 year-old hypertensive diabetic male presents with lesion shown on his lower leg. He denies trauma or other
cutaneous lesions.
A. Kaposi's sarcoma
B. Majocchis granuloma of tinea corporis
C. Cutaneous lupus erythematosis
D. Necrobiosis lipoidica diabeticorum
51
Dermatology
D
A 56 year-old male with Type 2 DM presents with a pruritic rash on the legs, arms and trunk of 48 hours duration.
The face, palms and soles are spared. Past medical history includes controlled schizophrenia. BP is WNL. He
denies difficulty breathing and any history of genital ulceration. Medications are metformin and amlodipine
(Norvasc) which were initiated 10 days earlier.
A. Tinea corpus
B. Neurodermatitis
C. Psoriasis
D. Drug reaction
52
Dermatology
B
The photomicrograph depicted shows "papillomatous proliferation of the epidermis with hyperkeratosis" from a
lesion excised from the dorsum of the foot.
Which of the following is most likely?
A. Squamous cell carcinoma

B. Verrucae plantaris
C Superficial spreading malignant melanoma
D Actinic keratosis
53
Dermatology
C
A 58 year-old female presents for evaluation of excessively dry feet, arms and legs of many years duration. A
recent forearm cutaneous biopsy demonstrates hyperkeratosis and a lack of a granular cell layer.
Which of the following is the best diagnosis?
A. Verrucae plantaris
B. Tinea pedis and corporis
C. Icthyosis vulgaris
D. Generalized psoriasis
54
Dermatology
C
This 41 year-old male has noticed progressive depigmentation of his left foot over the past year. He reports no
pain, and no other body parts are affected. He has been under the care of a prolotherapist for his hypothyroidism,
who has radically changed his diet and increased his thyroxine.
A. Pituitary tumor
B. Amelanotic melanoma
C. Vitiligo
D. T. mentagrophytes infection
55
Emergency Medicine
D
A 46 year-old female who underwent bunionectomy under local anesthesia with IV sedation complains of chest pain
while in post anesthesia recovery. Past medical history is not significant.
Which of the following is the most appropriate course of action for this patient?
A. 4L oxygen; monitor blood gases

B. Chest x-rays; initiate basic life support
C. Sublingual nitroglycerin
D. EKG; serum troponin levels
56
Emergency Medicine
A
A 58 year-old female with Type 2 DM complains of swelling, pain and discoloration of her left leg and foot over the
past 4 days. She recently returned from an interstate road trip. Past medical history is significant for CHF.
Which of the following is LEAST effective in diagnosing this condition?
A. Homans sign
B. Duplex Doppler ultrasound
C. D-dimer
D. Contrast venography
57
Emergency Medicine
D
A 54 year-old female with Type 1 DM is seen in the ED with the following abnormal laboratory values.
Result Normal
Blood sugar (mg/dL) 450 60-120
Arterial bicarbonate (mEq/L) 10 19 25
Arterial pH 7.25 7.35 - 7.45
Which of the following is the most likely explanation?
A. Underlying renal disease, stress

B. Overdosage of oral hypoglycemic agent, depression
C. Electrolyte imbalance, proteinuria
D. Omission of insulin injection, infection
58
Emergency Medicine
A
A 45 year-old male presents with sudden difficulty breathing with hoarseness, itching and nausea, immediately after
taking his new prescription anti-inflammatory medication.
In addition to activating the EMS, injection of which of the following is the most appropriate?
A. Epinephrine (Adrenalin)
B. Dexamethasone (Decadron)
C. Etidocaine (Duranest)
D. Diphenhydramine (Benadryl)
59
Emergency Medicine
C
On presentation for a matrixectomy a 35 year-old female with Type 2 DM and hypertension becomes diaphoretic
and confused. A glucometer is unavailable.
Which of the following is the most appropriate intervention?
A. Administer metformin 250 mg

B. Infuse dextrose 5% in water
C. Give 20 Grams instant glucose tablets
D. Inject 15 units of regular insulin
60
Emergency Medicine
A
A 42 year-old male who fell asleep on the beach while inebriated was evaluated several hours later for the lesion
shown.
A. Second degree burn

B. Allergic reaction
C. Pemphigus
D. Jelly fish sting
61
Emergency Medicine
D
A 72 year-old Type 2 DM has had neuropathic and vascular changes for the past several years. He now presents to
the ED with chills and fever. Medical history includes a Penicillin allergy. Radiograph is shown.
Which of the following is the most appropriate course of action at this time?
A. Pantalar arthrodesis
B. IV Vancomycin
C. Charcot foot reconstruction
D. Emergent BKA
62
Endocrinology
A
A 60 year-old frail female presents with a concern about developing osteoporosis.
Which of the following measures is preventative regarding this condition?
A. Walking
B. Swimming
C. Long term steroid use
D. Surgical menopause
63
Endocrinology
A
A 67 year-old male with Type 2 DM presents for a pre-scheduled pre-op discussion. The following is reported or
noted on examination:
Headache
Confusion
Fruity breath
Tachypnea
Tachycardia
The patient remains conscious throughout the visit.
Which of the following should be administered at this time?
A. 25 units of regular insulin

B. 1 baby aspirin (81 mg.)
C. 8 oz. of a glucose beverage
D. Sublingual nitroglycerin
64
Endocrinology
C
An 70 year-old male with poorly controlled Type 2 DM presents with a red, hot, painful right first MTP joint.
Laboratory findings demonstrate:
Test Result Normal Range
Hemoglobin (g/dl) 13 12-15

Hematocrit (%) 38 38-44
WBC (/l) 6,800 4,500-11,000
BUN (mg/dl) 47 8-45
Uric acid (mg/dl) 10.3 2.0 - 8.0
Creatinine (mg/dl) 1.0 0.6-1.5
Random glucose (mg/dl) 150 60-110
HgbA1c (%) 10 >5
Ankle Brachial Index 0.85 1.0 -1.4
Which of the following medications will most likely to worsen his diabetic control?
A. Colchicine
B. Indomethacin (Indocin)
C. Prednisone dose pack (Medrol)
D. Allopurinol (Zyloprim)
65
Endocrinology
D
A 40 year-old female presents with non-pitting, brawny edema in both lower extremities which has an "orange rind"
appearance. Vascular studies are normal. Laboratory studies show an elevated TSH (thyrotropin).
A. Thyrotoxicosis
B. Contac dermatitis
C. Erythema chronicum migrans
D. Myxedema
66
Endocrinology
D
A 62 year-old male is evaluated for ongoing Type 2 DM. Routine laboratory findings reveal an HgbA1c of 7.0%.
HbA1c eAG (estimated Average Glucose)

(%) (mmol/L) (mg/dL)
5 5.4 (4.26.7) 97 (76120)
6 7.0 (5.58.5) 126 (100152)
7 8.6 (6.810.3) 154 (123185)
8 10.2 (8.112.1) 183 (147217)
9 11.8 (9.413.9) 212 (170249)
10 13.4 (10.715.7) 240 (193282)
11 14.9 (12.017.5) 269 (217314)
12 16.5 (13.319.3) 298 (240347)
Which of the following is the most appropriate course of action for this patient?
A. Increase oral hypoglycemics

B. Institute insulin therapy
C. Alter diet
D. Council and repeat test in 3 months
67
Endocrinology
D
An 82 year-old female with RA is scheduled to undergo panmetatarsal head resection with first MTP joint
arthrodesis. DEXA scan densitometry testing confirms severe osteoporosis.
Which of the following complications is of greatest concern due to osteoporosis?
A. Infection
B. Delayed bone healing
C. Hematoma
D Failure of fixation
68
Endocrinology
C
A 53 year-old male with Type 2 DM and peripheral neuropathy presents for treatment of ulceration on the right third
toe which he states has changed in appearance over the past year. He has been using Silvadene cream and Band-
aids, but reports worsening of the wound.
Which of the following is the most appropriate work-up?
A. Triphasic bone scan

B. Non-invasive arterial testing
C. Biopsy
D. Wound fungal culture
69
Gastroenterology & Nephrology

B
During the H & P on a 39 year-old male, the patient describes recent onset of pain in the perineal region as well as
having dysuria and urinary frequency. He denies having gross hematuria or any urethral discharge. The patient
relates to having recurrent "bladder infections". Examination elicits pain associated with palpation of the prostate.
Urine culture and sensitivity demonstrate an absence of bacterial growth.
Based on the above findings, which of the following is the most likely diagnosis?
A. Benign prostatic hypertrophy

B. Prostatitis
C. Cystitis
D. Bacturia
E. Prostate cancer
70

D
An 80 year-old female with chronic lymphedema has developed severely debilitating muscle weakness in both legs.
Current treatment consists of long-term diuretics and sequential compression lower extremity boots. Examination
reveals +1/4 deep tendon reflexes but no pathologic reflexes. Electrocardiogram reveals a flattened and inverted T-
wave, a U-wave and depressed S-T segment. All laboratory findings are within normal limits except for
electrolytes, which are as follows:
Patient Normal
Na (mEq/L): 144 135-145
K (mEq/L): 2.4 3.5-5.0
Cl (mEq/L): 95 100-106
Mg (mEq/L): 2 1.5-2.1
pH: 7.5 7.35-7.45
Which of the following is the most likely etiology of this patient's condition?
A. Malabsorption syndrome
B. Coronary insufficiency
C. Abnormal renal excretion of bicarbonate due to tubular disease
D. Diuretic therapy
71

D
A 72 year-old male, accompanied by his son, complains of acute burning pain in the soles of both feet. He appears
disheveled and unkept, smells of urine and is disoriented to time and place. Physical exam reveals poor pedal
hygiene, bounding pedal pulses bilateral and a marked loss of sensation from mid-calf distally. His muscle strength
is good. Past medical history is unclear as he is a poor historian. Recent HgbA1c, serum glucose and thyroid
function tests are normal. His thermoregulatory sweat test with sodium alizarin sulfate indicator is seen below.
Which of the following is the most likely etiology for this patient's symptoms?
A. Diabetic peripheral neuropathy

B. Multiple sclerosis
C. Guillian-Barre syndrome
D. Alcoholic peripheral neuropathy
72

C
A 41 year-old male complains of itching, malaise and nausea, along with the eye changes shown, which developed 1
month after starting oral terbinafine.
A. Reiters syndrome
B. Iron deficiency anemia
C. Hepatocellular disease
D. Neutropenia
73

C
A 68 year-old female with Type 2 DM develops uncontrollable hypertension with pulmonary and peripheral edema.
After starting an ACE inhibitor she developed acute renal failure.
A. CHF
B. Myxedema
C. Renal artery stenosis
D. COPD
74

A
A 70 year-old female with uncontrolled Type 2 DM is seen post-op with an acute foot infection. She complains of
excessive thirst and dizziness when arising and relates decreased urinary output. Laboratory findings include a high
BUN/CR ratio, hyaline casts in her urine, elevated serum potassium and generalized acidosis.
A. Pre-renal failure
B. Nephrolithiasis
C. Hyperglycemia
D. Hyperkalemia
75

B
A 22 year-old male is scheduled for excision of the soft tissue lesion shown. His medical history is significant for
frequent and easy bruising. Pre-op laboratory findings reveal a PTT of 40 sec. (n=15-28 sec.).
Which of the following is the most likely cause of this finding?
A. Sexually transmitted disease resulting in hemolytic disorder

B. Occult hepatic dysfunction
C. ASA intake
D. NSAID intake
76
General Medicine
A
A 75 year-old female with Type 2 DM is hospitalized for treatment of a foot infection. Three days post admission
she exhibits bilateral pitting edema, paroxysmal nocturnal dyspnea, and jugular venous distension.
A. CHF
B. DVT
C. Aortic stenosis
D. Acute myocardial infarction
77
General Medicine
D
A 47 year-old female presents to the ED with a grade 3A open fracture dislocation of the ankle. The wound is
bleeding and is contaminated with grass and dirt. Past medical history is significant for mitral valve repair and
recurrent DVTs with PE; she does not have an IVC filter.
Which of the following laboratory tests will NOT need to be completed prior to surgery?
A. Hemoglobin and hematocrit

B. APTT, PT/INR
C. BMP (basic metabolic panel)
D. CK, total and ionized calcium
78
General Medicine
D
A 78 year-old male is evaluated pre-op for hammertoe surgery. Past medical history is unremarkable. The patient
takes no medications. Pre-op laboratory findings reveal the following:
Test Result Normal Range

Hemoglobin (g/dl) 13 12-15
Hematocrit (%) 40 38-44
MCV (m3) 81 80-94
MCH (pg) 28 27-31
MCHC (%) 31 32-36
RBC (x10/l) 4 4.6-6.2
WBC (/l) 6,800 4,500-11,000
BUN (mg/dl) 21 8-45
Creatinine (mg/dl) 1.0 0.6-1.5
Na+ (mEq/L ) 140 135-145
K+ (mEq/L) 4.5 3.5-5.0
Albumin( g/dl) 3.5 3.5-5.0
Cl- (mEq/L) 104 100-106
Random glucose (mg/dl) 150 60-110
HgbA1c (%) 10 <5
Ankle Brachial Index 0.85 1.0 or greater
Based on the findings noted, which of the following is the most appropriate course of action?
A. Findings are normal for age - proceed with surgery

B. Occlusive vascular disease present - refer for vascular consult
C. Anemia present - refer for medical workup and clearance
D. Hyperglycemia present - refer to endocrinologist for workup
79
General Medicine
B
A 27 year-old female with protein C deficiency is evaluated for the ulceration shown. She has lost the right fourth
and fifth toes due to gangrene. She wishes to understand the cause and effect of her condition.
Which of the following is the most appropriate explanation for the patient?
A. Protein C causes the body to form clots

B. Her body is lacking a mechanism to prevent or limit clot formation
C. Homocysteine builds up in her blood making her more prone to form blood clots
D. She has antibodies to antithrombin III, which causes her blood to be thicker and clot
80
General Medicine
A
A 47 year-old female is evaluated for the heel ulceration shown. She was initially treated as an inpatient with
surgical debridement, biopsy, negative pressure wound therapy, then full thickness skin graft. She has an estimated
50% graft take. Laboratory results reveal:
Biopsy left heel: chronic and acute inflammatory cells, no malignancy or signs of PVD infiltrates
CBC with diff Patient Normal

RBC (x10 6 /mcL) 3.8 4.2-5.4
WBC (/CMM) 9.0 4.8-10.8
Hgb (gm/dL) 6.4 14.0-18.0
Hct (%) 19.2 42.0-52.0
Plt (/CMM) 300 140-440
MCV (fL) 95 80.0-99.0
BMP Patient Normal

Na (mmol/L) 135 132-146
K (mmol/L) 4.0 3.5-5.1
Cl (mmol/L) 100 99-109
CO2 (mmol/L) 24 20-31
BUN (mg/dL) 18 9-23
Creatinine (mg/dL) 0.9 0.70-1.30
Glucose (mg/dL) 87 <200
Which of the following is the most likely cause of this patient's inability to heal?
A. Anemia
B. Diabetes
C. Renal failure
D. Vasculitis
81
General Medicine
B
A 72 year-old female with Type 2 DM has discoloration of the left fourth toe, as shown. Medications include regular
insulin, Metformin, HCTZ and Prozac.
Which of the following is the most appropriate management on the morning of surgery
A. Hold Metformin; double the insulin dose

B. Hold Metformin; half the insulin dose
C. Continue Metformin; double the insulin dose
D. Continue Metformin; half the insulin dose
82
General Medicine
C
A 68 year-old male with Type 2 DM presents with a recurrent ingrown toenail. Examination reveals palpable pulses
and ankle brachial indices of 1.4 bilaterally.
Which of the following pre-op studies is most appropriate?
A. CT Arteriogram
B. Creatinine
C. Toe brachial index
D. Serum calcium
83
Hematology & Oncology

B
A 14 year-old basketball player presents with pain in his right ankle, described as a low grade aching sensation that
has been constant over the past 3 months. Constitutional symptoms include loss of appetite and a low grade fever.
Examination reveals diffuse, mild pain at the distal third of the tibia. Radiographic findings include a radiolucent
area at the distal tibia with cortical destruction and a lamellar, periosteal reaction.
In addition to an MRI, which of the following studies should be included in the initial work-up?
A. Sed rate, bone scan, right ankle

B. Chemistry panel, chest radiographs, whole body bone scan
C. Sed rate, chemistry panel, bone culture
D. Chemistry panel, urinalysis, CT scan right ankle, blood cultures
84

D
A 20 year-old female, recently arrived from Nicaragua, is presented by her mother for a large, painless bump on the
bottom of the right foot, present since birth. It has not grown. She is concerned that this might be something that
needs to be removed. MRI confirms hemangioma.
Which of the following is the most appropriate treatment for this lesion?
A. Excision and biopsy

B. Amputation of foot
C. Sclerotherapy
D. Observation
85

B
A 68 year-old male with Type 2 DM and peripheral neuropathy presents with a darkened hyperkeratotic lesion sub
fourth metatarsal head, as shown. His second toe was previously amputated due to osteomyelitis. Despite regular
debridement and off-loading the lesion has worsened. Biopsy of the lesion reveals pleomorphic cells with abundant
pigment with H&E stain at 400x.
Which of the following is the likely diagnosis?
A. Transfer lesion with hemosiderin stained callus

B. Melanoma
C. Basal cell carcinoma
D. Fungal abscess
86

C
A 68 year-old female with painful bunions returns to your practice after a 2 year hiatus. Up until now she has been
in good health and was planning on the foot surgery. Pre-op imaging indicates a 1cm right upper lobe mass.
Which of the following is the most likely recommendation for the patient?
A. Proceed with foot surgery and evaluate mass in post-op period

B. Admit; General Surgery consult
C. Defer foot surgery and refer to Oncology
D. Proceed with foot surgery under local anesthesia only
87

D
A 40 year-old female scheduled for bunionectomy is discovered to have been taking the herbal preparations
Echinacea and Gingko Biloba 1 week pre-op.
Which of the following is the most appropriate recommendation for this patient?
A. The herbal preparations pose little to no surgical risk

B. Reduce the amount she is taking by half pre-op
C. Prescribe ASA therapy prior to surgery
D. DC the herbal preparations 5-7 days pre-op
88

A
A 60 year-old male presents with a 2 year history pain and swelling of the left ankle. The patient cannot recall any
injury. Examination reveals pain on ankle dorsiflexion. The skin is intact. Lateral radiograph and MRI are shown.
Based on the findings, which of the following is the best course of action?
A. Guided needle core biopsy

B. Bone biopsy of talus
C. Three phase bone scan
D. Diagnostic ultrasonography
89

C
A 27 year-old female presents with the nail finding shown. It is asymptomatic and appeared insidiously a year
earlier. She is in good health and there are no other such lesions elsewhere. She runs 12 miles per week over 3
days.
Which of the following is the description of the lesion shown?
A. Beau's line
B. Splinter hemorrhage
C. Melonychia striata
D. Cutis marmorata
90
Neurology
B
Three months post a left ankle inversion sprain, a 67 year-old non insulin dependent diabetic male presents with
constant severe pain regardless of weight bearing status and mild swelling of the left ankle. Physical examination
reveals a decreased range of motion of the left ankle with pain on active and passive motion.
A. Charcot disease
B. Chronic regional pain syndrome
C. Disuse atrophy
D. Slow healing ankle sprain
91
Neurology
A
A 17 year-old female complains of difficulty finding shoes that fit properly and of changes in the shape of her feet.
Examination reveals a high medial arch and severe hammertoes 1-5, bilateral. Muscle testing reveals anterior and
lateral leg groups are +3/5, bilateral.
Which of the following would best confirm the suspected diagnosis?
A. Nerve biopsy
B. Spinal tap
C. Arthritis profile
D. Drug testing
92
Neurology
C
A 34 year-old construction worker fell from a ladder at work. Muscle testing on the right reveals +2/5 strength of the
peroneals, extensor hallucis longus, extensor digitorum longus, and posterior tibial muscles. His MRI is shown.
Which of the following is most consistent with these findings?
A. Low back strain

B. Spinal stenosis
C. Disk herniation
D. Tumor
93
Neurology
B
A 35 year-old male complains of frequent ankle sprains and leg cramps occurring over the last several years.
Examination reveals a steppage gait. Neurologic findings include decreased DTRs, proprioception and vibratory
sensation bilaterally.
A. Cerebral palsy
B. Charcot-Marie-Tooth disease
C. Poliomyelitis
D. Duchennes Muscular Dystrophy
94
Neurology
C
A 40 year-old female with spastic cerebral palsy complains of brace irritation on the right.
Which of the following clinical findings would be expected on physical examination?
A. Tremors, hypotonia, weakness, uncoordinated movements

B. Ankle clonus, athetosis, irregular and involuntary movements of muscles
C. Clasp knife hypertonia, ankle clonus, extensor plantar response
D. Weakness, cerebral motor cortex damage, hypotonia
95
Neurology
D
A 72 year-old female presents for evaluation of a painless ulcer of several months duration. She has a long history
of upper extremity atrophy and areflexia, with loss of pain and temperature in the shoulders and upper arms. Pain,
temperature and DTRs are absent in both legs and feet. A cervical spine MRI reveals spinal cord cavitations with
accumulation of fluid. Thoracic kyphoscoliosis is seen.
A. Severe diabetic neuropathy

B. Tertiary syphilis
C. Post polio syndrome
D. Syringomyelia
96
Neurology
B
A 67 year-old male complains of "crawling" sensations in both feet that disturb his sleep several nights a week and
are relieved by pacing. Examination reveals barely palpable pedal pulses, DTRs are normal, and decreased
vibratory sensation bilaterally. Laboratory findings reveal the CBC, serum iron and serum glucose to be WNL.
Which of the following is most useful for the patent at this time?
A. Night splints
B. Requip (ropinirole)
C. Pletal (cilostazol)
D. Daily walking program
97
Psychosocial, Community Medicine & Public Health, Biostatistics

D
The following chart compares the number of lower limb amputations due to diabetes distributed by race and sex for
town "X" in 1991:
Race Male Female Total

White 12,500 14,500 27,000
Non-white 2,500 3,500 6,000
Total 15,000 18,000 33,000
There were 6.6 million people in town X in 1991.
Which of the following was the amputation rate due to diabetes?
A. 15,000/18,000
B. 18,000/33,000
C. 27,000/33,000
D. 33,000/6,600,000
98
Community Medicine & Public Health, Biostatistics

A
In evaluating a large, double blinded, randomized control study assessing the effectiveness of a newly released
topical antifungal agent, this study would provide which of the following levels of evidence?
A. Level one
B. Level two
C. Level three
D. Level four
99
Psychosocial, Community Medicine, Public Health, Biostatistics

C
The table of data below reports on the association between ulceration and neurologic status gathered on 425 patients.
Sensation Intact Peripheral Neuropathy

Ulceration Absent 200 50
Ulceration Present 25 150
Utilizing the above information table, what is the probability of ulceration in patients with neuropathy?
A. 100%
B. 89%
C. 75%
D. 41%
100

A
A 76 year-old female presents for foot care. The patient is recently widowed and has stopped taking trips with her
seniors group. She admits a loss of appetite and appears to have difficulty following the conversation.
Which of the following is the most appropriate action?
A. Referral to a mental health professional

B. No action necessary, these are normal grief behaviors
C. Counsel on assisted living options
D. Call adult protective services
101

C
A 42 year-old female with Type 2 DM, who is HIV positive, is referred for evaluation of painful feet. Current
medications include furosemide and protease inhibitors. Radiographs are shown.
Which of the following is the most likely cause of the osteopenia?
A. Diabetes
B. Menopause
C. Protease inhibitors
D. Furosemide
102

C
A 72 year-old female, who is an avid walker, complains of a lack of energy in her legs and no longer wishes to walk.
One year ago her husband died. She has lost 10% of her body weight over the last year. Examination reveals
decrease in muscle strength in both legs compared to her initial examination 1 year ago.
Significant laboratory results:

Serum albumin decreased
Hemoglobin decreased
Total cholesterol decreased
A. Manic depression
B. Normal age related laboratory findings
C. Failure to thrive
D. Multi infarct dementia
103

A
A 61 year-old presents with painful burning blisters limited to the right buttock down to his foot of 1 week duration.
Past medical history is significant for Type 2 DM, metastatic colon cancer and hypogammaglobulinemia.
Based on the suspected diagnosis which of the following vaccines may have prevented the condition?
A. Varicella zoster
B. Diptheria, Pertussis, Tetanus
C. Measles, Mumps, Rubella
D. Human papilloma virus
104
Rheumatology
B
A 9 year-old female presents with a painful, swollen left ankle. There is no history of trauma. Past medical history
reveals mouth dryness and a lack of tearing.
Based on the suspected diagnosis which of the following is the most appropriate treatment?
A. Prescribe NSAIDs and RICE

B. Prescribe oral steroids, order a CBC and rheumatology consult
C. Obtain patients sexual history, obtain a joint aspirate, prescribe antibiotics
D. Prescribe NSAIDs, order a CBC and serum uric acid
105
Rheumatology
C
A 39 year-old hospitalized male patient complains of numbness and tingling in his feet. He has multiple arthralgias
and vasculitis. Physical examination reveals the presence of bilateral parotid enlargement, keratoconjunctivitis and
xerostomia. Laboratory studies reveal an ESR (Westergren) of 55 mm/hr (10-20 mm/hr), WBC of 7,000/l (4000-
9000/l) with eosinophilia, and a positive rheumatoid factor.
A. Felty's syndrome
B. Reiter's syndrome
C. Sjogren's syndrome
D. Takayashu's disease
106
Rheumatology
D
A 58 year-old female presents with a painful right first MTP joint of 3 days duration. Past medical history includes
arthritis and hypertension controlled with aspirin and HCTZ. Examination reveals a red, warm, swollen first MTP
joint. Joint aspiration reveals straw colored, highly viscous fluid with weakly positive birefringent crystals seen
below.
A. Septic arthritis
B. Gout
C. RA
D. Pseudogout
107
Rheumatology
A
A 50 year-old presents with recurrent painful inflammation of the first MTP joint of the left foot.
Based on the clinical information and radiograph shown, which of the following is the most likely diagnosis?
A. Chronic gout
B. RA
C. Pseudogout
D. Osteoarthritis
108
Rheumatology
D
A 45 year-old male presents with a red, hot, swollen right first MTP joint. The patient denies trauma. No open
wounds are present. Oral temperature is 37.3C (99.2 F). Laboratory findings reveal: uric acid 8.5 mg/dl (4.0-8.5
mg/dl), and WBCs 9,800/ul (4000-9000/ul). Synovial fluid analysis is shown.
Which of the following is the most appropriate intervention?
A. Pneumatic immobilizer
B. Methotrexate
C. Amoxicillin/Clavulanate
D. Ibuprofen
109
Rheumatology
B
A 38 year-old male runner presents with bilateral heel pain of 6 months duration. He has been unresponsive to rest
and orthoses. Past medical history reveals back stiffness every morning that lasts about 90 minutes. Examination
reveals palpable tenderness at the tibial tuberosities, iliac crests and posterior heels. Laboratory findings reveal mild
anemia, elevated ESR and CRP, however RA factor, anti-CCP, and ANA are absent.
Based on the clinical presentation, which of the following is the most likely diagnosis?
A. Achilles tendonosis
B. Ankylosing spondylitis
C. RA
D. Haglunds deformities
110
Rheumatology
C
A 23 year-old male complains of long-standing heel pain combined with a history of intermittent low back and hip
pain. Radiograph is shown. Laboratory findings reveal a positive HLA-B27.
A. Rheumatoid arthritis
B. Systemic lupus erythematosus
C. Ankylosing spondylitis
D. Gouty arthritis
111
Wound Care
D
An 83 year-old non-ambulatory female presents with a non-healing ulcer on the posterior heel. Examination reveals
a non-draining, malodorous, 4 cm ulcer with a dry eschar and surrounding erythema. Pedal pulses are palpable and
her ABI is .9. Laboratory findings include a serum albumin level of 3.7 mg/dL (normal 3.5 to 5 mg/dL).
Which of the following is the most appropriate initial treatment?
A. Unna boot, enzymatic debridement

B. Enzymatic debridement, protein supplementation
C. Total contact cast, antibiotics, anti-coagulant therapy
D. Heel protector, antibiotics, debridement
112
Wound Care
D
A patient with a history of recurrent DVT states that her "blood thinner" is monitored monthly.
Which of the following is most reliable for evaluating her coagulation status?
A. Activated PTT
B. Prothrombin time
C. Bleeding time
D. International Normalized Ratio (INR)
113
Wound Care
B
This 62 year-old male with right hemiparesis S/P CVA is seen in the ED for treatment of the ulceration shown. The
wound has been present for 2 months, but discoloration and swelling developed 2 weeks ago. Three days ago he
developed purulence, fever, chills, sweats, and malaise. Medications include Coumadin, Lasix, and Norvasc. He
has no known drug allergies.
Which of the following are the most appropriate tests to order prior to proceeding with emergency I&D?
A. TCPO2, CBC with differential, MRI

B. Radiograph, Basic Metabolic Panel, INR
C. Swab culture, venous Duplex, serum K+
D. Bone scan, EKG, Hgb A1C
114
Wound Care
B
A 47 year-old female with RA is referred for evaluation and treatment of painful wounds on the lateral right foot.
The wounds began as small discolored spots that opened and drained clear watery fluid and have progressively
enlarged over the past month. Treatment has consisted of oral antibiotics and Silvadene cream.
Which of the following is the most appropriate treatment plan at this time?
A. Swab culture, bone scan, arterial Doppler

B. Radiograph, tissue culture, biopsy
C. Debridement, MRI, venous Duplex
D. Hospital admission, culture, IV antibiotics
115
Wound Care
D
A 67 year-old male presents with non-healing ulcerations, as shown, on both legs and feet. His medical history is
significant for CAD, multiple MIs and CHF. His lower extremity edema has been present for at least 10 years with
copiously draining ulcerations for 3 years. Cardiology reports abnormal ejection fraction of 18%.
Which of the following is the most appropriate method of compression for this patient?
A. Lymphedema pumps
B. Unna boot
C. Elastic compression garments
D. Rest and slight elevation
116
General Orthopedics
B
All of the following may relieve painful subluxation of the MTP joints (as in RA) EXCEPT:
A. Polyurethane inserts in a flat shoe

B. Rigid foot orthosis in a 5/8" heeled Oxford shoe
C. Metatarsal bar to the outer sole of the shoe
D. Soft moldable sandals
117
General Orthopedics
D
A 49 year-old female who is 3 months S/P ORIF of an ankle fracture has had difficulty walking since cast removal.
She feels off balance despite use of the ankle brace shown.
Which of the following is the most stable gait assistive device for training this patient?
A. Single cane
B. Knee walker
C. Double cane
D. Walker
118
General Orthopedics
D
A 14 year-old male presents with right knee pain. He recently started Little League but denies injury. His parents
relate that he recently has grown 3 inches over the last 6 months.
A. Blounts disease
B. Chondromalacia patella
C. Slipped capital tibial epiphysis
D. Osgood-Schlatter syndrome
119
General Orthopedics
B
A 28 year-old male complains of dull aching pain to the right heel. He denies injury or change in activity. The
discomfort is present when non-weight bearing and is exacerbated by activity.
Based on the images shown, which of the following is the most likely diagnosis?
A. Osteoid osteoma
B. Unicameral bone cyst
C. Fibrous dysplasia
D. Osteosarcoma
120
General Orthopedics
D
A 3 week old female is presented for evaluation of her right foot. Examination demonstrates forefoot adductus,
hindfoot varus, and ankle equinus. The deformity is non-reducible.
Based on the exam and accompanying radiograph, what is the most likely diagnosis?
A. Metatarsus adductus
B. Vertical talus
C. Skewfoot
D. Talipes equinovarus
121
General Orthopedics
D
A 63 year-old female tripped over a parking curb yesterday and experienced sudden right foot pain. She has had
difficulty walking on the right foot since that time. Examination reveals diffuse edema and ecchymosis to the
medial heel and foot but no erythema. Skin integument and neurovascular structures are intact on the right foot.
Radiographs are shown.
Which of the following is the most likely etiology of the patients pain?
A. Acute gouty arthropathy

B. Fractured posterior talar process
C. Sinus tarsi syndrome
D. Navicular fracture
122
General Orthopedics
A
A 4 year-old male is referred for evaluation of pain on the inner aspect of the left foot and abnormal gait for the past
month, when his sister accidentally landed on his foot while playing. The condition is worsening. Musculoskeletal
examination reveals smooth, unrestricted range of motion at the ankle, STJ and MTJ bilaterally. Gait is antalgic on
the left with persistent supination of the left foot. Radiographs are shown.
Based on the suspected diagnosis, which of the following is the most appropriate treatment at this time?
A. Cast immobilization
B. NSAID therapy; PTB brace
C. AFO
D. UCBL with valgus rearfoot post
123
General Orthopedics
B
A 45 year-old male presents 14 days following a spider bite, as shown, and reports progressive swelling and redness.
I&D was performed in the OR, and an extensive amount of necrotic tissue was removed.
Which of the following is the most likely resultant initial gait abnormality?
A. Spastic
B. Steppage
C. Equinus
D. Circumducted
124
General Orthopedics
D
In which of the conditions shown is a total ankle joint replacement procedure most indicated?
A. Condition A
B. Condition B
C. Condition C
D. Condition D
125
General Orthopedics
B
A 27 year-old male is undergoing left ankle ligament surgery.
The structure depicted by the arrow is a branch of what nerve?
A. Saphenous
B. Superficial peroneal
C. Deep peroneal
D. Anterior tibial
126
Medical Imaging
A
A 47 year-old male presents with a painful big toe joint. Radiograph is shown.
In which of the following locations will excessive shoe wear most likely be observed?
A. Hallux IP joint
B. Medial heel
C. Central forefoot
D. First MTP joint
127
Medical Imaging
C
A 62 year-old with Type 2 DM presents with the inability to put weight on his right foot. He sustained an injury 8
months earlier for which he was cast-immobilized and maintained non-weight-bearing for 2 months. His recent
HgbA1c is 5.5. The patient is insensate distal to the knee. MRI is shown.
A. Pagets disease
B. Charcot
C. Sudecks atrophy
D. Stress fracture of tibia
128
Medical Imaging
D
A 27 year-old male with Type 1 DM presents 2 weeks after stepping on a nail. Radiograph is shown.
Which of the following is most consistent with the radiographic findings?
A. Avascular necrosis
B. Hematogenous contamination
C. Contiguous spread of infection
D. Direct inoculation
129
Medical Imaging
B
A 24 year-old male presents with right foot and ankle pain with ambulation 18 months following a MVA where he
was a passenger. He complained of foot pain at the time but this was not addressed as they were secondary to other,
more life threatening injuries. Examination reveals minimal ankle edema; the ankle dorsiflexes to neutral; he has full
ankle joint plantar flexion but limited, painful eversion and inversion of the hindfoot. Radiographs are shown.
Which of the following is the most likely diagnosis for this patient?
A. AVN of the talar body and osteoarthritis of the talonavicular joint

B. AVN of the talar body and non-union of the talar neck
C. Non-union of the talar neck and osteoarthritis of the talonavicular joint
D. Chronic osteomyelitis to the talus and osteoarthritis to the talonavicular joint
130
Medical Imaging
D
A 47 year-old male presents with acute ankle pain and swelling that occurred while golfing.
The MRI findings are shown.
Which of the following tendons is most likely ruptured?
A. Achilles
B. Tibialis anterior
C. Peroneus longus
D. Tibialis posterior
131
Medical Imaging
D
An 18 year-old male college student complains of left ankle pain for the past 4 months after prolonged activity. He
reports no swelling or bruising and denies injury. Past medical history includes allergies to shrimp and sulfa drugs.
Examination reveals pain with ankle dorsiflexion and palpation of the anterior medial ankle. Radiographs are
shown.
Which of the following is the most appropriate additional imaging study for this patient?
A. Triphasic bone scan

B. CT
C. Double contrast arthrogram
D. MRI
132
Medical Imaging
C
A. B.
C. D.
Which of the conditions shown is best treated by fine needle aspiration/biopsy?
A. Condition A
B. Condition B
C. Condition C
D. Condition D
133
Medical Imaging
D
A. B.
C. D.
Which of the conditions shown is best treated by tibial-calcaneal arthrodesis?
A. Condition A
B. Condition B
C. Condition C
D. Condition D
134
Medical Imaging
D
A 26 year-old male basketball player has had chronic lateral ankle pain for the past 6 months. He has a history of
multiple ankle injuries during the course of his career, none of which have been professionally treated. His MRI is
shown. He wishes to complete his basketball season.
Which of the following is the most appropriate conservative care for this patient?
A. Casting
B. NSAID therapy
C. Aspiration
D. Bracing
135
Medical Imaging
D
A 62 year-old male with Type 2 DM presents with mummified, gangrenous changes to the first 3 toes on the right.
TCPO2 findings are 15mm hg. at the dorsal right foot, 27mm hg. at the ankle and 35mm hg. above the ankle. The
right ABI is 1.1. Arteriogram of the right lower extremity is shown.
Based on the vascular findings, which of the following is the most appropriate amputation level?
A. Chopart
B. Symes
C. Tranmetatarsal
D. Transtibial
136
Rehabilitation & Physical Therapy

B
For which of the following conditions would contrast bath therapy be LEAST appropriate?
A. RA
B. Scleroderma
C. Ankylosing spondylitis
D. Osteoarthritis
E. Reiter's syndrome
137

D
You wish to control a drop foot with an ankle foot orthosis. Of the following contact points the LEAST necessary
for adequate functional control is the:
A. Posterior calf
B. Anterior leg
C. Sole of foot
D. Dorsum of foot
138

A
A patient presents 3 months post pantalar arthrodesis for muscle rehabilitation.
Which of the following muscle contractions can be used to rehabilitate the tibialis posterior?
A. Isometric
B. Eccentric
C. Concentric
D. Isotonic
139

B
A 28 year-old male requires marked limited weight bearing of both lower extremities due to bilateral calcaneal
fractures. Axillary crutches are to be dispensed.
Which of the following is the best setup for achieving a swing-through gait with these crutches?
A. Crutches secured to axilla and when supine crutch extends anterior to the foot
B. Elbows flexed 30 and when supine crutch extends lateral to the calcaneus
C. Crutches 2 fingers inferior to axilla and with elbows extended
D. Elbows extended and when supine crutch extends anterior to the foot
140

C
A 43 year-old female with sickle cell disease complains of pain and swelling of her hip and ankle following an
inversion injury and fall.
Which of the following is contraindicated for this patient?
A. NSAIDs
B. Opioids
C. Ice
D. Iontophoresis
141

B
For which of the following conditions is the use of ice for pain control best indicated?
A. CRPS
B. Acute gout
C. Raynaud's phenomenon
D. Sickle cell disease
142

D
The patient shown suffered a 2 burn 6 months ago.
Which of the following modalities is most effective for managing scar contracture in this patient?
A. Contrast bath
B. Electrical stimulation
C. Iontophoresis
D. Therapeutic touch
143

A
The device shown is best utilized to rehabilitate from which of the following pathological conditions?
A. Ankle sprain
B. Achilles tendonitis
C. PTTD
D. OCD of talus
144

D
A patient presents with retrocalcaneal bursitis.
Which of the following modalities are the most suitable to provide deep heat?
A. Diathermy, TENS
B. Diathermy, electrical stimulation
C. Hot packs, whirlpool
D. Hot packs, ultrasound
145

D
A 27 year-old male, who had a severe anterior compartment injury, now has permanent damage to the deep peroneal
nerve.
Which of the following is the most appropriate treatment?
A. Custom orthotic with forefoot and rearfoot posting

B. PTB brace
C. Extra depth orthopedic shoe with inlay
D. Polypropylene ankle-foot orthosis
146
Trauma & Sports Medicine

D
A 29 year-old female step aerobic instructor with a moderate bunion deformity complains of pain around the first
MTP joint of about 2 months duration. The pain is worse when walking barefoot. She does not recall any specific
trauma to the area.
Based upon this information, which of the following is the most likely diagnosis?
A. Subluxation of the first MTP joint

B. Fibular sesamoid fracture
C. Flexor hallucis brevis rupture
D. Tibial sesamoid fracture
147

D
A 20 year-old male complains of ankle pain. Standard lateral ankle radiograph reveals an incomplete fracture
through the talar neck with marked osteosclerosis of the talar body.
A. Bone island
B. Normal fracture healing with callus impingement
C. Osteoblastic metastasis
D. Avascular necrosis
148

D
A patient presents following a forced dorsiflexion injury of his right foot. He can't bear weight on that foot.
Which of the following would be the most likely site for a fracture?
A. Calcaneal beak
B. Navicular tuberosity
C. Posterior process of talus
D. Talar neck
149

D
A 70 year-old male enters the ED 1 hour after stepping on broken glass, as shown. He has a history of liver failure.
Irrigation of the wound with primary repair is planned.
Which of the following injectables is the most appropriate to achieve anesthesia?
A. Bupivicaine
B. Lidocaine
C. Diphenhydramine
D. Procaine
150

D
A 32 year-old female tennis player presents for recent acute pain in the posterior right ankle during a match. MRI is
shown.
A. Inflamed retrocalcaneal bursa

B. Tumor or mass within the Achilles tendon
C. Avulsion fracture of the calcaneus at the Achilles tendon insertion
D. Partial rupture of the Achilles tendon
151

B
A 32 year-old male presents to the ED following a fall and unable to bear weight on the right lower extremity.
Radiographs are shown.
Which of the following clinical findings are most significant in determining the timing for surgical intervention?
A. Exquisite pain with light touch to the anterior and medial ankle
B. Non-palpable DP and PT pulses
C. Superficial disruption of skin integrity
D. Fracture blisters
152

C
A 52 year-old female with Type 2 DM presents to the ED with sudden swelling and dislocation of the left second
toe. She denies trauma but has loss of protective sensation.
Which of the following structures is most likely to have been damaged in contributing to the deformity shown?
A. First plantar interosseous

B. First lumbricale
C. Second plantar plate rupture
D. Second dorsal interosseous
153

B
A 49 year-old female complains of constant heel pain of 11 day duration. She denies trauma or injury. She is
currently training for a marathon, and her longest mileage to date is 12 miles. Imaging studies are shown.
Which of the following is the most likely etiology of her pain?
A. Tarsal tunnel syndrome

B. Calcaneal stress fracture
C. Achilles insertion tendinopathy
D. Os trigonum syndrome
154

C
A 40 year-old male sustained an ankle laceration from a "weed whacker" 2 days ago, as shown. He complains of
continued oozing of blood from the laceration.
Which of the following is the most appropriate treatment to obtain hemostasis?
A. Application and inflation of ankle tourniquet

B. Cauterization with silver nitrate
C. Insertion of thrombin impregnated gel foam
D. Ligature of the vessels with primary skin closure
155

B
A 54 year-old male presents to the ED 2 hours after twisting his ankle.
Which of the following findings would lead to consideration of compartment syndrome?
A. Absent DP pulse
B. Extreme pain
C. Hyperhydrosis
D. Ecchymosis
156
Surgical Criteria
B
A patient presents with an infected, draining laceration of the plantar heel. The area is very painful and requires
debridement.
Which of the following would be the most important factor influencing the adequacy of local anesthesia?
A. Extent of arterial circulation

B. Extent of infection
C. Type of local anesthetic agent
D. Amount of local anesthetic agent
157
Surgical Criteria
C
A 45 year-old male presents with peroneal spasm and painful, decreased subtalar and midtarsal joint ranges of
motion. Radiographs reveal a calcaneonavicular synchondrosis, narrowing of the subtalar joint and severe talar
beaking. CT scan confirms the diagnosis of calcaneonavicular bar and degenerative arthritis of the subtalar joint.
Non surgical management failed to bring relief.
Which of the following is the treatment of choice?
A. Midtarsal joint arthrodesis

B. Resection of coalition
C. Triple arthrodesis
D. Pantalar arthrodesis
158
Surgical Criteria
C
A 20 year-old carpenter presents with a clean 3 mm puncture wound 2 hours after stepping on a nail at work. The
nail penetrated to an unknown depth through his shoe and sock, near the region of the third metatarsal head. His last
tetanus immunization was 6 months ago. Following local treatment, the patient returns 48 hours later with pain,
purulent drainage and erythema at the wound site. Radiographs taken at this time are negative.
Which of the following would provide the most definitive information?
A. CT
B. Sonography
C. MRI
D. Triphasic bone scan
159
Surgical Criteria
D
Following a Keller arthroplasty a 72 year-old female complains of pain on top of her great toe while wearing shoes.
A. Metatarsus primus elevatus

B. Hallux varus
C. Hypermobile first ray
D. Hallux malleus
160
Surgical Criteria
B
A college scholarship basketball player presents with a transverse metaphyseal diaphyseal fracture of the base of the
fifth metatarsal (Jones fracture).
Which of the following treatments is most appropriate?
A. Short-leg non-weight bearing cast

B. Internal compressive fixation and immobilization
C. Soft cast with surgical shoe
D. Bone stimulator
161
Surgical Criteria
B
A 32 year-old female with a history of Wolfe-Parkinson-White Syndrome will be undergoing elective surgery for a
painful bunion that has not responded to conservative care.
Based on her history, which of the following should be included in her pre-op evaluation?
A. Comprehensive metabolic panel

B. Cardiology consult and clearance
C. PET scan
D. MRI
162
Surgical Criteria
B
A full thickness skin graft is chosen to cover a 3 cm by 2 cm lateral maleollar clean traumatic defect.
Which of the following is the most appropriate concerning donor graft size?
A. Graft should be 30% larger

B. Graft should be 3% to 5% larger
C. Harvest the exact size of the defect
D. Skive edges to avoid raised periphery
163
Surgical Criteria
B
This 48 year-old patient presents for evaluation of a non-painful discolored nail on the right third toe of 6 months
duration. Histopathological examination of a 3.0 mm punch biopsy revealed melanoma in situ.
Which of the following is the most appropriate treatment?
A. Wide excision
B. MTP joint disarticulation
C. Distal Symes amputation
D. Transmetatarsal amputation
164
Surgical Criteria
C
A 54 year-old male presents with a painful HAV. Examination reveals limited first MTP joint dorsiflexion and
dorsal pain with passive range of motion. Radiographs reveal a dorsal first MTP joint exostosis and metatarsus
primus elevatus.
Which of the following procedures is most appropariate for this patient?
A. Total joint implant

B. Keller bunionectomy
C. Cheilectomy with first MTP joint plantarflexory osteotomy
D. First MTP joint arthrodesis
165
Surgical Criteria
C
A 72 year-old female has been experiencing pain in the right first MTP joint for over 5 years. Past medical history
is unremarkable and non-contributory. Radiographs are shown. Examination reveals painful first MTP joint range
of motion, with 5 of dorsiflexion and 5 of plantarflexion. She has a functional dorsiflexed first ray.
Based on the radiographic and clinical findings, which of the following is most appropriate for this patient?
A. Joint replacement with Silastic hemi implant

B. McBride and plantarflexion osteotomy of the first metatarsal
C. First MTP joint arthrodesis
D. Cheilectomy and Lapidus procedure
166
Surgical Criteria
A
This is a lateral radiograph of a 14 year-old female being worked up for surgical correction of a flexible flat foot
deformity.
Which of the following represents the radiographic apex of the deformity?
A. Talonavicular joint
B. Naviculocuneiform joint
C. Cuneiform first MTP joint
D. Calcaneocuboid joint
E. Ankle joint
167
Surgical Criteria
C
This is the radiograph of a 53 year-old female complaining of a painful, stiff, first MTP joint that has been
developing over the past 3 to 5 years. Ten years previously she underwent "some type of surgery for arthritis" in her
great toe.
Which of the following best describes the cause of silicone hemi-implant failure in this patient?
A. Silicone leakage into subcutaneous tissue

B. Joint alignment abnormality
C. Implant failure
D. Infection
E. Surgical technique
168
Surgical Criteria
D
A neuropathic diabetic presents for care of the condition shown. Ascending cellulitis is present and the head of the
proximal phalanx of the digit is clearly visible protruding through the wound. MRI findings are negative for
osteomyelitis. The patient has an ABI of 0.75.
Following resolution of the ascending cellulitis with the use of IV antibiotics, which of the following should be
scheduled for this patient?
A. Primary closure
B. Interphalangeal fusion
C. Transmetatarsal amputation
D. Digital amputation
E. Open reduction and repair
169
Surgical Criteria
E
A 27 year-old male presents with first MTP joint pain recalcitrant to conservative care.
Based on the radiograph shown, which of the following procedures is the most appropriate to alleviate the patients
condition?
A. Cheilectomy
B. Joint resection
D. Joint replacement
E. First metatarsal osteotomy
170
Surgical Criteria
B
A 29 year-old active male presents with a rigid hammertoe as shown, determined to have been caused by a history of
flexor substitution.
Which of the following is the most appropriate procedure for correcting the deformity?
A. Extensor tenotomy only

B. Proximal IP joint fusion
C. Middle phalanx resection
D. PIP joint arthroplasty
E. Flexor tendon transfer
171
Surgical Criteria
D
A 52 year-old male has had unilateral subtalar joint pain since childhood but no ankle pain or pain in the other pedal
joints. Standard radiographs identified sclerotic changes along the subtalar joint as well as mild osteophytic lipping
along the dorsal talonavicular and navicular-cuneiform joints on the affected side. A CT scan revealed the findings
shown.
Which of the following procedures is most indicated?
A. Resection of calcaneo-navicular bar

B. Resection of tarsal coalition
C. Calcaneal osteotomy
D. Subtalar fusion
E. Triple arthrodesis
172
Surgical Criteria
D
A 7 year-old male who is 3 days S/P injury is presented to the ED with the abscess shown. He was playing
barefooted in the park and stepped on a shard of glass.
Which of the following is the most appropriate treatment at the present time?
A. Order appropriate systemic antibiotic therapy

B. Order appropriate topical antibiotic therapy
C. Apply rest, ice, compression and elevation
D. Perform I & D
E. Order a CBC and sedimentation rate
173
Surgical Criteria
B
A 32 year-old female presents with hallux limitus secondary to dropping a bowling ball on her foot several years
ago. Examination reveals no evidence of metatarsus primus elevatus. There is first MTP joint pain on the end range
of dorsiflexion but no radiographic evidence of articular disease.
If surgery is elected, which of the following procedures is most appropriate for the clinical presentation?
A. Implant arthroplasty
B. Cheilectomy
D. Arthrosurface cap procedure
E. OAT cartilage replacement
174
Surgical Criteria
D
A 35 year-old male presents with a painful, recurrent osteochondroma as show in the radiograph. He underwent
surgery for the condition 6 months earlier with a nail-sparing fishmouth incision.
Which of the following is most appropriate at this time?
A. Distal amputation of digit

B. Repeat fishmouth incision
C. Total nail plate matrixectomy
D. Nail avulsion and lift nail bed for exposure
E. Laser ablatement of bone
175
Surgical Criteria
C
A patient is scheduled for a flatfoot correction incorporating an opening calcaneal osteotomy with allograft.
Which of the following is an advantage of an allograft over an autograft?
A. More effective incorporation

B. Larger size of available bone
C. Easier accessibility
D. Decreased possibility of rejection
E. Greater assurance of being disease free
176
Surgical Criteria
C
A 27 year-old female presents with a congenitally overlapping fifth toe, as shown, complaining of pain in all shoes.
Past surgical history includes prior arthroplasty at the PIP joint through a "V" to "Y" skin incision, which offered no
relief.
Which of the following surgical procedures would best address the current deformity?
A. Amputation of the digit

B. MTP joint and PIP joint arthrodesis
C. Extensor tenotomy and transposition skin "Z-plasty"
D. Flexor brevis transfer
177
Surgical Criteria
D
You consult on a 39 year-old female with pain sub right first metatarsal head of 6 weeks duration. The referring
podiatrist is considering dorsiflexory osteotomy of the first metatarsal to correct the problem. Radiographs and
clinical photo are shown.
Which of the following is the appropriate recommendation for this patient?
A. Proceed with surgery as planned

B. Perform sesamoidectomy rather than osteotomy
C. Address metatarsus adductus to correct the problem
D. Alter shoe gear and re-evaluate in 6 weeks
178
Surgical Criteria
C
A transpositional Z-plasty is scheduled to redirect a scar and add length.
Based on the illustration, which of the following is correct regarding the greatest gain in length?
A. 30 angle provides the greatest gain in length

B. 45 angle provides the greatest gain in length
C. 60 angle provides the greatest gain in length
D. All three provide the same gain
179
Surgical Criteria
B
A 19 year-old female long distance runner experiences lateral foot and ankle pain secondary to a dislocating
peroneal tendon. Shoe modification and in-shoe orthotic therapy has not alleviated her condition. Her MRI and a
clinical photo are shown.
Which of the following is the most appropriate course of treatment?
A. Cast immobilization
B. Surgical repair
C. Steroid injection
D. AFO
180
Surgical Criteria
C
A 37 year-old male is evaluated 4 hours after sustaining direct trauma to his left foot. Examination reveals dorsal
midfoot pain, swelling and ecchymosis. The toes are warm and the patient can demonstrate active but painful
dorsiflexion at the ankle and MTP joints. Radiograph is shown.
Based on the information given which of the following is the most appropriate course of action?
A. Immediate fasciotomy for compartment syndrome

B. ORIF of intraarticular navicular fracture
C. Compression dressing and non-weight bearing
D. Excision of fracture fragment
181
Surgical Criteria
B
A 32 year-old male complains of pain, swelling and ecchymosis of the left hallux 3 days after a fire escape ladder
dropped on his foot. Radiographs are shown.
Which of the following is the most appropriate treatment at this time?
A. Splint immobilization; crutches; Non-weight bearing for 8 weeks

B. ORIF
C. Arthrodesis of the hallux IP joint
D. Evaluate for compartment syndrome
182
Surgical Criteria
C
A 28 year-old male presents as shown. He underwent "toenail surgery" 4 years earlier, but was so traumatized by
the experience that he never returned for followup. Medical history is unremarkable. He is afebrile.
Which of the following is the most appropriate course of action?
A. Perform immediate phenol matrixectomies

B. Begin antibiotics and Epsom salt soaks
C. Work up for chronic osteomyelitis
D. Symes amputation of hallux and second toe
183
Surgical Criteria
D
A 42 year-old female who underwent elective surgery for a Tailor's bunion 12 years earlier now complains of a
painful flail toe.
Which of the following procedures should be recommended?
A. Fifth MTP joint arthrodesis

B. Bone graft lengthening of fifth metatarsal
C. Extensor tenotomy of fifth toe
D. Syndactylization of fourth and fifth toes
184
Surgical Criteria
D
This 42 year-old male who underwent a bunionectomy 4 years ago complains of pain in the hallux and first MTP
joint, as well as a frequent recurrent ingrown right hallux toenail.
Which of the following procedures is most appropriate at this time?
A. Phenol matrixectomies
B. Keller bunionectomy
C. Arthrosurface of metatarsal head
D. Arthrodesis of first MTP joint
185
Infectious Disease
D
A healthy 40 year-old male presents with an acute paronychia of 5 days duration. The patient is allergic to penicillin
and sulfa drugs. Examination reveals green, purulent drainage with erythema to the MTP joint.
Which of the following is the most appropriate empiric antibiotic?
A. Vancomycin
B. Clindamycin
C. Ampicillin
D. Levofloxacin
186
Infectious Disease
D
An 8 year-old male demonstrates pain with ankle joint motion and on palpation of the distal tibia. Past medical
history is remarkable for a prior upper respiratory infection. Examination reveals a temperature of 38.3 C (101F).
Gait is antalgic. CBC demonstrates WBCs 15,000 (n = 3,000-10,000) with a left shift.
Which of the following studies would be the most sensitive and specific for making the diagnosis?
A. Technetium 99 MDP bone scan

B. Enzyme-linked immuno-sorbent assay (ELISA)
C. Rheumatology profile
D. Subperiosteal needle aspiration
187
Infectious Disease
A
Three weeks following surgical debridement of calcaneal osteomyelitis a patient presents with malaise, anorexia,
and diarrhea. He has been on an IV second generation cephalosporin.
Which of the following is the most appropriate course of action?
A. Discontinue antibiotic, obtain stool cultures

B. C&S of the surgical site, empiric triple antibiotic regimen
C. Blood cultures, vancomycin (Vancocin)
D. Triphasic bone scan, compete blood count (CBC)
E. Amantadine (Symmetrel), atropine/diphenoxylate (Lomotil)
188
Infectious Disease
D
The patient pictured is scheduled for pinch graft coverage of this wound which was the result of an I&D performed
21 days prior. The patient has Type 2 DM without peripheral neuropathy and has been treated on Vancomycin for
MRSA x 14 days total.
If pinch graft is not elected, which of the following modalities would result in the LEAST amount of contraction for
the wound shown?
A. Graftjacket (human dermal allograft)

B. Oasis (porcine intestinal submucosa)
C. Apligraf (living bilayered cell therapy)
D. Full thickness autograft
189
Infectious Disease
A
A 57 year-old healthy female presents to the ED with discoloration of the right great toe after having dropped a large
can of vegetables on the toe four hours prior. Neurovascular status is intact. Following nail plate avulsion
laceration of the nail bed is noted. Radiograph reveals a non-displaced, transverse fracture of the distal phalanx.
Which of the following is the most appropriate antibiotic regimen for this patient?
A. First generation Cephalosporin

B. PCN and aminoglycocide
C. Piperacillin/Tazobactam
D. Vancomycin
190
Infectious Disease
C
A 54 year-old patient with Type 2 DM presents for evaluation of calcaneal osteomyelitis. Gram stain demonstrates
many gram positive cocci in chains and clusters and gram negative rods.
Which of the following is the most appropriate empiric antibiotic treatment to begin before open biopsy can be
obtained?
A. Penicillin G (Bicillin)
B. Cephalexin (Keftab) + metronidazole (Flagyl)
C. Ciprofloxacin (Cipro) + clindamycin (Cleocin)
D. Vancomycin (Vancocin)
191
Infectious Disease
D
A 40 year-old man complains of fever, chills, nausea, vomiting, and severe myalgia 5 days after undergoing an
uneventful subtalar arthrodesis. The patient has a temperature of 39.6 C (103.3 F), a systolic blood pressure of
90mm Hg, a heart rate of 110 beats/min, and respirations of 20/min. Examination reveals a diffuse, erythematous,
blanching rash over the entire body, an enlarged, tender liver, and inflamed oral pharynx. The surgical wound is
pictured below. A scant amount of clear exudate covered the incision.
A. Anaerobic cellulitis
B. Necrotizing fascitis
C. Clostridial myonecrosis
D. Toxic shock syndrome
192
Peripheral Vascular Disease

C
Which of the following disease processes is found to be most aggravated by the use of cigarettes?
A. Atherosclerosis
B. Medial arterial sclerosis
C. Thromboangitis obliterans
D. Venous thrombosis
193

A
A 65 year-old female presents with discomfort and swelling of the left leg for the last 5 days. She is undergoing
chemotherapy for breast cancer. She denies any falls or trauma.
Which of the following is the best management plan?
A. Order venous ultrasound

B. Apply loose Unnas boot
C. Prescribe topical steroid
D. Dispense CAM walker
194

B
A 67 year-old male with Type 2 DM and coronary artery disease, who is post quadruple coronary artery bypass
graft, is referred for evaluation of discoloration of his left great toe. The problem began 2 months ago as a small
scab that progressively enlarged.
In addition to standard radiographs which of the following should be ordered?
A. MRI and CBC with differential

B. Basic metabolic panel and CTA
C. ABI, EKG, Chest x-ray
D. CRP, tissue and blood cultures
195

B
A 54 year-old female presents with a non-healing foot ulcer. Examination reveals an ankle brachial index of 1.2
(>1) and a TCpO2 of 45 mmHg (>55 mm Hg).
A. Poor arterial collateralization

B. Medial calcific sclerosis affected the study results
C. Vasospastic disease
D. Venous congestion
196

D
A 49 year-old male is referred for ulceration at the medial left ankle as shown. The patient describes acute swelling
and redness in the left leg of 1 months duration, after driving non-stop from Tennessee to Arizona. The area of
ulceration began as a vesicle that opened and left the wound pictured.
Which of the following studies are most appropriate at this time?
A. VQ scan, ankle-brachial index, and CRP

B. MRI, arterial Doppler, and blood culture
C. CTA and comprehensive metabolic panel
D. Radiograph, venous Duplex, D-dimer
197

C
A 52 year-old male presents with a severely painful ulcer on the lateral aspect of the left ankle that began as a
painful small lump that "broke down". He denies any trauma to the area. Past medical history is remarkable for well
controlled hypertension, and ulcerative colitis. Medications include verapamil (Covera HS) and sulfasalazine
(Azulfidine). Arterial and venous studies are normal.
Which of the following is the most likely underlying diagnosis?
A. Venous stasis
B. Arterial ischemia
C. Pyoderma gangrenosum
D. Squamous cell carcinoma
198

A
An 83 year-old female is referred for evaluation of the left heel wound shown 12 weeks post pinning of the left hip.
She was hospitalized after femoral fracture with prolonged bed rest. Examination reveals redness, swelling, necrotic
soft tissue in the base and foul odor. Test results reveal:
Venous Duplex
Negative for DVT, no assessment of perforators or reflux performed
Arterial Doppler
ABI left 1.4, monophasic posterior tibial and DP signals
Radiographs left foot

Soft tissue defect with associated edema, osseous cortical defect in the posterior calcaneus
In addition to off-loading the heel which of the following is the most appropriate treatment?
A. Admit; order MR angiography; begin IV antibiotics

B. Debride; obtain soft tissue culture; order oral antibiotics
C. Order negative pressure wound therapy
D. Order hyperbaric oxygen therapy
199
Wound Care
C
Based on the photograph:
What is the most likely etiology for the ulcer?
A. Neuropathy
B. Pressure
C. Venous
D. Trauma
200
Wound Care
D
A 76 year-old male with Type 2 DM complains of a non-painful ulcer on the medial aspect of his right ankle.
Examination reveals an arthritically enlarged medial malleolus and an irritating medial shoe counter.
Which of the following is the best treatment?
A. Oral cephalexin
B. Add mid-sole rocker to shoe
C. Desoximetasone
D. Trim shoe counter

Orthotic Modification for Ankle Instability

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Orthotic Modification for Ankle Instability

Diunggah oleh

Hak Cipta:

Format Tersedia

1

2014 Fall ABPM In-training Exam

In treating the pedal sequelae, which of the following is most useful?

A. Functional orthotic with extrinsic forefoot and rearfoot posting

Orthotics and Prosthetics

A 27 year-old patient has been diagnosed with functional hallux limitus.

Which of the following orthotic modifications is most appropriate?

A. Lateral heel post flare

Orthotics and Prosthetics

Which of the following orthotic modifications is most appropriate?

A. Add lateral flare to heel post

Orthotics & Prosthetics

Orthotics & Prosthetics

Which of the following should be prescribed to prevent further subtalar deterioration?

Orthotics & Prosthetics

Orthotics & Prosthetics

Orthotics & Prosthetics

A. One-fourth inch heel lift

Orthotics & Prosthetics

A. Left - 1 forefoot valgus

Orthotics & Prosthetics

Which of the following is the most likely diagnosis?

A 27 year-old male presents with sesamoiditis determined to be biomechanical in origin.

Which of the following is the most likely cause of this problem?

A. First ray hypermobility

A. Flexible pes plano valgus deformity

Which of the following events most likely led to this pathology?

Which of the following is LEAST likely to be contributing to this patient's complaints?

A. Limited ankle joint and first MTP joint dorsiflexion

A. Dorsal metatarsal cuneiform exostosis

A. Thomas heel with medial stabilizer

A. Inlay depth shoes with accommodative insoles

Which of the following is the most appropriate shoe gear?

A. Medial carbon shank

A. Plastizote healing sandal

A. Medial heel and sole wedge

A. Construct a deep heel cup.

A. Tight adductor muscles

A 2 year-old child presents with intoeing.

Measurement Right Left

A. Flexible metatarsus adductus with internal femoral position

Hip rotation (flexed): 47 internal 45 external

Hip rotation (flexed): 42 internal 40 external

A. Counter Rotation Splint

Orthometric findings reveal:

Which of the following is the most likely diagnosis?

A. Tarsal tunnel syndrome

Which of the following is the appropriate course of action?

A. Whitman-Roberts orthotic to shift the pressure in the opposite direction

A. Device was too short

Cardiology & Pulmonology

Which of the following is the most likely diagnosis?

A. Adult respiratory distress syndrome

Cardiology & Pulmonology

Which of the following should be ruled out?

Cardiology & Pulmonology

Which of the following is the correct radiographic impression?

Cardiology & Pulmonology

A. Deep venous thrombophlebitis

Cardiology & Pulmonology

Which of the following is the best course of action?

A. Order chest radiographs