Muscukoskeletal

Pt is a 25 year old male that presents to the clinic a day after sustaining an injury after playing soccer. Patient reports he was playing soccer and did a quick change in direction, he suddenly heard a "pop" and felt like he was kicked in the calf by someone. He describes the pain as burning, and decided to apply ice and see if it would improve but it did not. What is patient's most likely diagnosis. A. Calcaneal Bursitis B. Torn ACL C. Achilles Tendon Rupture D. Claudication

. Achilles Tendon Rupture

68 year old female present to the clinic with complains of right hip pain. The pain started suddenly 4 days ago while she was going for a run. Patient states she normally walks about 3 miles per day but that specific day she tried running for the first time in years. Patient denies any trauma to the affected hip. On exam patient had localized lateral hip and buttock but more over the greater trochanter, pain gets worse with rotation. Which diagnosis is the most appropriate for this patient? Hip fracture Hip bursitis Soft tissue injury Arthritis

1) Hip Bursitis This condition is very common and can result from trauma or the overuse of muscle and tendons. Degenerative changes, biochemical abnormalities, or systemic diseases also play a role in the development of this condition. The major affected groups include the trochanteric, iliopsoas, and ischiogluteal. Out of all types trochanteric is the most common and it affects women more that men (Buttaro et al., 2021).

16 year old patient presents with right knee swelling and pain. She states she noticed a "pop" sound during basketball practice when she was jumping up to catch a rebound. Within the first two hours, the patient noticed evident swelling. Patient is unable to fully flex or extend the knee. Her condition is most likely: Posterior cruciate ligament (PCL) tear Meniscus injury Anterior cruciate ligament (ACL) tear Patellar tendonitis

3. Anterior cruciate ligament (ACL) tear A "pop" sound and symptoms of dizziness, fainting or sweating is associated with an acute anterior cruciate ligament (ACL) tear. Within the first two hours of injury, swelling also occurs which differentiates ACL from a posterior cruciate ligament (PCL) injury (Buttaro et al., 2020).

With what medication do we need to educate our patients on the risk of Achilles tendon rupture? Levofloxacin Doxycycline Metronidazole Azithromycin

A, Levofloxacin. Levofloxacin is a fluoroquinolone antibiotic. There are six fluoroquinolones currently approve by the FDA including ciprofloxacin, ofloxacin, gemifloxacin, levofloxacin, moxifloxacin and delafloxacin. A Black Box warning has been placed on fluoroquinolone antibiotics after an FDA safety review revealed that fluoroquinolones, when used systemically, are associated with disabling and potentially permanent side effects. These side effects can involve the tendons, muscles, joints, nerves, and central nervous system. Therefore the U.S. Food and Drug Administration has advised that the serious side effects associated with fluoroquinolone antibiotics generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections who have other treatment options. Fluoroquinolones should be reserved for those patients who do not have alternative treatment options.

First-line therapy for a Grade I ankle sprain should include all of the following except: A. Immobilization B. Non-weight bearing activity C. Active ROM exercises D. Rest, ice, compression with TED stockings, elevation (RICE)

A. Immobilization

You are seeing a 47 year old male patient in clinic today for right shoulder pain ongoing about 5 weeks. He works on a construction crew and is frequently doing overhead movements. Pain is over the lateral deltoid, does not radiate, and is worse with overhead movements. You perform three specialty tests that yield positive results: the drop arm test, active painful arc, and weakness with external rotation. What shoulder injury is at the top of your differential list? A. Rotator cuff tear B. Biceps tendonitis C. SLAP lesion D. Chronic shoulder instability

A. Rotator cuff tear

Patients with fibromyalgia should be encouraged to do all the following except: A. consider adopting a high-intensity aerobic activity such as jogging B. limit caffeine use C. utilize stress management techniques D. participate in a program of exercise focused on maintaining flexibility

A. consider adopting a high-intensity aerobic activity such as jogging

A 12 year old female is at the primary care clinic for her annual wellness exam. She reports intermittent back pain with activity but denies it affects her daily activities. During her physical assessment, the nurse practitioner notices a lateral curvature of the spine in the frontal plate. What is the most likely diagnosis? Kyphosis Juvenile scoliosis Adolescent scoliosis Lordosis

Adolescent Scoliosis Idiopathic scoliosis is further classified by age, infantile being 0-3 years of age, juvenile being 3-10 years of age, and adolescent being 11 and older (Garzon Maaks et al., 2020). Kyphosis, often called round back, is an exaggerated normal posterior curvature of the thoracic spine (Garzon Maaks et al., 2020). Lordosis is an AP curvature of the lumbar spine

A 28 year old male patient presents to the clinic complaining of back pain that occurred while lifting weights at the gym yesterday. He states it is difficult to stand straight up, and at times the pain radiates down one leg. What is the likely location of the spine you would suspect he may have sustained an injury to based off of this information? T12 L5-S1 C7 L1

Answer: 2 L5-21. Due to the patient's reported history of how the injury occcurred, a lumbar herniated disc would be suspected. This injury typically occurs at L4-L5 or L5-S1. Symptoms include acute onset of back pain, unilateral radicular pain typically down the buttock and back of the leg, or pain exacerbated by sitting/walking/standing/coughing/sneezing.

Your 46 year old female patient presents for a follow up of her new diagnosis of fibromyalgia. At the previous visit she was not ready to discuss treatment options, she is ready now. All of the following are recommended treatment options, except which one. A) Medications that are started on the highest dose to help keep symptoms under control, then gradually taper to a lower dose. B) Aerobic exercise that should be consistent, this can help reduce pain, improve sleep and function. C) Trigger point injections as an adjunct to treatment regimen. D) Cognitive Behavioral Therapy

Answer: A Low dose of medications should be started to prevent unwanted side effects and if increasing is needed, should start off slowly. All other options are treatment managements for fibromyalgia.

A 29 y/o female patient presents to her family provider for complaints of severe fatigue. She states that she isn't sleeping well at night because she has all over muscle aches. Even if she is able to sleep all night, she wakes up feeling like she hasn't slept. She is waking up stiff and has trouble walking first thing in the morning. She is constantly forgetting things and feels like she is in a fog during the day. She states this started about 3 months and has consistently worsened. Her WPI score is 9 and her SSS score is 6. What would be your primary differential diagnosis for this patient? a) Rheumatoid arthritis b) Fibromyalgia c) Insomnia d) Osteoporosis

B. Fibromyalgia Widespread Pain Index (WPI) score ≥7 and symptom Severity Scale (SSS) score ≥5 Symptoms need to have been present for at least 3 months Generalized pain in at least four of five regions: left upper region, right upper region, axial region, left lower region, and right lower region. (Buttaro et al., 2021)

56 year old female presents to the clinic with chief complaint of foot pain. She describes the pain as a "burning pain" on the bottom (plantar) aspect of her right foot. She can feel a palpable ball where the pain is located. It radiates between two of her toes and leads to numbness in her toes. Occasionally she has a sharp pain or "shock" sensation. She said the pain gets worse when she has to wear shoes with a heal or tight fitting shoes. What is the best diagnosis for this patient? Plantar fasciitis Morton's Neuroma Freiburg's Infarction Plantar plate rupture

B. Morton's Neuroma

A 56yo male comes to the clinic with the chief complaint of right knee pain. He works as a contractor and has been laying flooring in a new apartment complex recently. He reports 5/10 pain when kneeling to lay flooring but denies pain with weight bearing or range of motion. On exam, there is localized edema over the lower portion of the patella and the along the patellar tendon. Pain is reproducible with palpation over the patella. The examiner diagnoses the patient with the following condition: A. Osteoarthritis B. Prepatellar bursitis C. Gout D. Infrapatellar bursitis

B. Prepatellar bursitis

A 30-yo female sees you, her primary care provider, with complaint of swelling and stiffness surrounding the joints of the bilateral hands. She notes that she first started to feel discomfort and stiffness over 1-year ago, but the condition has worsened over that past 2-months. You order several lab tests including ANA, ESR, CRP, RF, and anti-CCP. Based on the lab findings you suspect rheumatoid arthritis and refer her to a rheumatology provider. What information is not accurate when teaching this patient about rheumatoid arthritis? A. Hands, wrists, ankles, and toes are most often affected. B. This condition is more common in men than in women. C. This condition is autoimmune and often is found in families. D. Peak onset of this condition is between the ages of 20-40-years. F. This condition presents as symmetrical early-morning synovial joint pain and stiffness.

B. This condition is more common in men than in women. All of the rest of the answers are accurate information. However, rheumatoid arthritis is more common in women than men by a 3:1 ratio.

All of the following are true about gout except: A) Gout is the most common inflammatory arthritis in humans B) The prevalence of gout increases with age C) Left untreated, gout symptoms of pain and swelling will gradually go away without any damaging effects D) Local trauma, binge drinking alcohol, overeating, fasting, diuretics, and initiation of urate lowering therapies can all precipitate an acute gout attack

C) Left untreated, gout symptoms of pain and swelling will gradually go away without any damaging effects. Buttaro (2021) states that gout is a chronic disease that can affect anyone and is the most common inflammatory arthritis in humans. Other risk factors for gout (besides those listed in letter D above) are low dose aspirin use and comorbidities such as obesity, chronic kidney disease, and metabolic syndrome. IF "left untreated, the frequency and the severity of attacks may increase, with additional joints affected and the development of tophi (chalk stones) which leads to structural joint damage

1. Patients with osteoporosis fractures usually have a prodromal period of ______. Patients with pathologic fractures usually have a prodromal period of _____. A _______ may be needed to differentiate the two. a. weeks to months, 1-4 weeks, biopsy b. 1-4 weeks, weeks to Months, DEXA scan c. 1-4 weeks, weeks to months, biopsy d. weeks to months, 1-4 weeks, DEXA scan

C. 1-4 weeks, weeks to months, biopsy

28-year-old pregnant female presents to the office with complaints of pain, numbness and tingling to her right thumb, index, and long fingers. She states the symptoms are intermittent, seem worse at night, and have been waking her up from a sound sleep. She works at her sister's bakery as a cake decorator and she states the pain/numbness can become so severe she needs to stop decorating and "shake" her hand to get relief. At times she drops objects and cannot open jars because of her symptoms. Further physical examination should be focused on the diagnosis of: A) Ganglion Cyst B) Palmer Fibrosis C) Carpal Tunnel Syndrome D) Stenosing Tenosynovitis (Trigger Finger)

C. Carpal Tunnel Syndrome

A 35-year-old female patient presents to your office complaining of right wrist pain that started two days ago and has progressively worsened. Pt states she has noticed that the pain is much worse when she picks up an item, such as her baby's bottle. Pt denies any trauma, previous injuries, surgeries, or repetitive movements of her wrist. Upon examining the patient, pain upon palpation is noted to the proximal aspect of the thumb and radius. The patient has a positive Finkelstein test. Her condition is most likely:A. Ganglia B. Scaphoid Stress Fracture C. De Quervain Tenosynovitis D. Fibromyalgia

C. De Quervain Tenosynovitis De Quervain tenosynovitis involves painful inflammation of the extensor pollicis brevis and abductor pollicis longus tendon on the dorsal aspect of the wrist. It is common in women ages 30-40, especially postpartum women, because of the specific hand and wrist positions involved in infant care. Motions that require repeated thumb extension and abduction with wrist radial and ulnar deviation can exacerbate their symptoms. Examples of these motions are grasping, pinching, wringing, and lifting.

You are seeing a 72-year-old male patient for an acute visit for left great toe pain. He has a known history of gout which typically affects the left great toe and currently takes allopurinol 300mg daily for urate-lowering therapy. He reports sudden onset of symptoms 3 days ago with swelling, redness, heat, and severe pain in the toe. Rates pain 7/10 at rest and 8/10 with any movement or pressure on the toe. Denies fevers or any other systemic symptoms. Your assessment is consistent with an acute gout flare. The patient's comorbidities include HTN and stage 3 chronic kidney disease. What do you recommend for pharmacologic treatment of this flare? Meloxicam 15mg PO daily x7 days Increase allopurinol to 400mg PO daily Colchicine PO 1.2mg now, followed by 0.6mg after 1 hour Prednisone PO 40mg daily x3 days, then 20mg daily x3 days, then 10mg daily x3 days, then 5mg daily x3 days.

Colchicine - he has at more risk of GI side effects (diarrhea, nausea, vomiting) due to his kidney disease

All of the following are red flags for a patient presenting with low back pain except: A.) New lower extremity weakness B.) Bowel/bladder dysfunction C.) Weight loss D.) Failure to improve after 2 weeks of conservative treatment

Correct answer: D - Failure to improve after 2 weeks of conservative treatment. A red flag for a patient with low back pain would be failure to improve after 1 month of conservative treatment.

What is the most common bacteria that causes septic arthritis? A. Escherichia coli B. Pseudomonas aeruginosa C. Staphylococcus epidermis D. Staphylococcus aureus

D. Staphylococcus aureus

A 62-year-old patient has complaints of neck pain that radiates to the arms, subtle gait disturbances, paresthesia in the arms, and bladder dysfunction. You suspected they may have cervical myelopathy. With cervical myelopathy, a patient must have 3/5 clinical prediction rules. All are prediction rules except: A.) Inverted supinator sign B.) Age>45 C.) +Hoffman sign D.) -Babinski sign

D.) -Babinski sign Patient's with cervical myelopathy, will have a + Babinski sign along with an inverted supinator sign, age>45, and a +Hoffman sign

You suspect an ankle sprain when the patient states: a. Being hit by another soccer player during the game b. Having an ankle pain after sprinting around the track c. Dropping a 10 pound weight on his lower leg d. Twisting his ankle while running bases during a baseball game

D: Twisting his ankle while running bases during a baseball game.

Part one: True or False- Low back pain is the second most common musculoskeletal problem worldwide. Part two: During your discharge instructions, the patient asks for nonpharmacological recommendations you have about lower back pain. Please list three recommendations you would give the patient to help assist with their discomfort.

False: "Low back pain is the most common musculoskeletal problem worldwide and is estimated to affect up to 85% of the population at some time in a person's life" (Buttaro et al., 2021). During your discharge instructions, the patient asks for nonpharmacological recommendations you have about lower back pain. Please list three recommendations you would give the patient to help assist with their discomfort. Range of motion exercises Stretching exercises Core stabilization and motor control exercises Strengthening exercises Conditioning or cardiovascular fitness exercises Spinal manipulative therapy Ice Superficial heat Ultrasound to treat tendon, ligament, and joint injuries Transcutaneous electrical nerve stimulation (TENS) for analgesia Traction Education of body mechanics and positioning

A 30 year old female presents to clinic today with a chief complaint of right wrist pain. She is 2 months postpartum and has been noticing the pain is worse when she is picking up and handling her newborn baby. You ask her to flex her thumb across the palmar surface of her hand and wrap her fingers around her thumb. You then take her hand and manually deviate it towards the ulnar aspect of her arm which reproduces the pain she has been experiencing. This special maneuver you just performed is known as _____________ and it is indicative of ______________.

Finkelstein Test If positive indicative of: De Quervain Tenosynovitis (Tenosynovitis= inflammation of the tendon AKA tendonitis of the radial side of the wrist)

A 38 year old make presents to the the ED for severe left toe pain that began 3 hours ago. The pain is very sharp, intense, and painful to the touch. He is currently rating the pain 8/10. This did occur once last month, but went away after a few hours. Patient has not noticed any pattern to the the pain episodes thusfar. He has tried ibuprofen 400 mg which helped for a little, but the pain returned. Ice and heat provided no relief. He denies any known trauma to the foot, he also denies any numbness or tingling. What would be your gold standard diagnostic for this patient? A: Uric acid B: Xray (left foot) C: Joint aspiration D: ESR

Joint Aspiration is the gold standard Demonstration of MSU crystals in the joint fluid or tophus is still the gold standard for the diagnosis of gout; however, joint aspiration is invasive and not always possible in the primary care setting. A gout diagnosis may made clinically. Supportive data necessary for the diagnosis of gout include a typical clinical history of a sudden (reaching its pain peak within 2 to 4 hours) and severe, exquisitely painful joint, most classically the first MTP joint (toe), that may wake the patient from sleep

A patient was recently diagnosed with tennis elbow. They came in complaining of pain localized on or around the _________ epicondyle that is reproduced by ____________. What is the management for this diagnosis?

Lateral; resistive wrist extension; Management: Oral or topical NSAIDs such as Diclofenac, splinting, toning exercises, physical therapy, if conservative treatment fails then can try steroid injection or eventual referral to orthopedic surgeon

A 42 year old male walks into to the clinic with a complaint of pain in his left knee. He said he was playing pick-up basketball 2 weeks ago and when he went to pivot to shoot the basketball, he felt a pop in his knee. He was able to walk so he decided to continue playing the game. Over the next 24 hours he started to have more pain and swelling. He has since felt his left knee has locked a couple of times and states the pain increases when twisting. His condition is most likely: a) ACL tear b) Patellar tendonitis (Jumpers knee) c) Bursitis d) Meniscus tear

Meniscus tear

Adolescent female accompanied by mother in office for c/o localized right knee pain x 1 month. Also noticed that she started having right upper hamstring pain shortly after the knee pain started. Reports pain is worse when climbing the stairs, jumping, and when kneeling on the floor with her dog. Rates pain at its worse 10/10 and with rest 5/10. Describes pain as a constant ache. The mother reports patient has been limping for the past few days. They have tried ice once which did not relieve the pain. The patient is a long-time soccer player and has practice 6 days a week for 2 hours each day year-round. The patient does not remember doing anything different to cause pain. The positive exam finding is tibial tubercle tenderness. The patient most likely has: Patellofemoral pain syndrome Growing pains Jumpers knee Osgood-Schlatter disease

Osgood-Schlatter is a disease that growing adolescents may experience during growth spurts ( 9 -16 y/o) due to rapid changes in the musculoskeletal system. The disease causes pain and inflammation at the patellar tendon's insertion site (growth plate) and the tibial tubercle from the pulling of the quadriceps. Over time the pulling can cause the tubercle to become more prominent. Those engaged in sports that require running and jumping (basketball, volleyball, sprinters, gymnastics, football, soccer) are at high risk, but that does not exclude others that are not. Most grow out of the disease when they have completed their growth spurt. However, the bony prominence is permanent. Subjective c/o- limping, knee pain, tenderness and swelling of the tubercle, and or anterior and posterior muscle tightness of the upper leg. Objective- pain/tenderness with palpation to the tibial tubercle. Witness the patient experience pain with jumping, walking, and kneeling movements. May use an x-ray to confirm or r/o. Plan- reduce pain and inflammation by R.I.C.E. and stretching exercises targeting the quadriceps and hamstrings. May use NSAIDs if not contraindicated.

Of the following, which is NOT a symptom of ulnar tunnel syndrome (also known as: ulnar nerve entrapment or cubital tunnel syndrome)? Numbness and tingling down medial aspect of forearm, pinky finger, and medial half of ring finger Symptoms come on or are worsened by bending elbows Positive Phalen's maneuver Decreased grip strength and finger coordination on affected side

Phalen's maneuver. This is not the correct test since it is used for assessment of carpal tunnel syndrome, which is compression of the median nerve and not the ulnar nerve.

Your 56-year-old male patient presents with a history of back pain for the past two weeks. During your assessment, you have the patient lay back, extend his knee, and lift his right leg to a 60-degree angle. The patient reports shooting pain down the back of his right leg while leg is elevated. This is an example of: Negative straight leg test Positive straight leg test Negative femoral stretch test Positive femoral stretch test

Positive straight leg test. I found this interesting because the result isn't considered positive if the patient experiences pain only in the low back with the straight leg raise. It is considered positive if nerve pain/ radiculopathy is felt down the leg with the straight leg raise.

45 yo male presents for locking or catching of his ring finger during work at his factory job while doing flexion-extension activities. He also reports stiffness in his finger and palm in the morning. Upon exam, you note a pop felt as the ring finger is extended. Which differential diagnosis would be most appropriate for this patient? a. Carpal tunnel b. Stenosing tenosynovitis ("trigger finger") c. Dupuytren contracture d. Ganglion cyst

The correct answer is B. Stenosing tenosynovitis ("trigger finger"). This is a disorder of the flexor tendons of the fingers or thumb. It most commonly involves the middle or ring finger and is more prevalent in patients with diabetes, gout, or rheumatoid arthritis. There is a narrowing of the fibrous canal which impedes tendon movement causing a painful locking or triggering of the affected finger. The provider should place their finger on the MCP joint and as the patient extends their finger a "pop" is felt.

A 70 y.o. male presents to clinic with complaint of increased pain, swelling and erythema to right knee that has been worsening for the last 4 days. He denies any injury or recent surgeries to the area, but endorses difficulty weight bearing on the right extremity. He has tried taking 1000mg of Tylenol TID without relief. Vitals are WNL, except for a low-grade temp of 100.2F. Right knee exam is significant for joint swelling, erythema, pain with movement and rest, weight bearing difficulties and limited ROM. Which component of the PE makes the diagnosis more likely to be septic arthritis and not a gout flare?

The main difference between the diagnosis being septic arthritis versus a gout flare is pain with movement AND rest. With a gout flare patients typically present with pain during movement and find relief while resting.

Henry a 18-month-old male came up to his father and wanted to picked up after dinner time as he was tired and fussy. He picked him up while on phone by both arms, Henry instantly wanted to be put down. Mother noticed that when he walked away in the living room, he had right arm flexed while left arm was swinging at side. During trying to take off his shirt at bedtime, he started to cry when mother attempted to straighten out his right arm. What is likely going on with 18-month-old Henry? a) right ulna fracture b) right shoulder dislocation c) subluxation of right radial head d) right clavicle fracture

c) subluxation of right radial head. According to Garzon Maaks et al. (2020), typical injury is caregiver stating patient complains of arm pain after being pulled up by arms. Usually, the child will then not use the affected arm. Pain is present with movement but not simply with palpation. Radiographs in these elbow injuries will be normal. Reduction is of radial head is recommended by supination and flexion technique

A 45-year-old patient presents to the office with a complaint of pain in her right foot and heel area that is the worst when she gets up in the morning or when she gets up after she has been sitting down for a while. She exercises regularly but has not been running lately due to the pain in her right foot. She states that it is most comfortable when she has shoes on and is moving around. Walking barefoot or standing "really make the pain worse". Her condition is most likely: a. Achilles Tendinopathy b. Morton Neuroma c. Plantar fascitis d. Achilles tendon rupture

c. Plantar fascitis