Orthopedics
The average age of pubertal growth spurt in North American boys is: 9.5 - 11.5 years. 10 - 12 years. 12 - 14 years. 14 - 16 years.
12 - 14 years. Explanation: Growth spurt in girls takes place earlier than boys. In girls of North American origin, the growth spurt occurs between 10 - 12.5 years. Completion of the growth spurt occurs later in boys but not usually before 16 years of age. In girls, completion of the growth spurt can occur as early as 14.5 years.
The age at which a child can first walk backwards is: 12 months. 15 months. 18 months. 24 months.
18 months. Explanation: Common developmental tasks for an 18 month old include: walking backwards, throwing a ball, saying 15-20 words, pointing to multiple body parts, pointing and naming objects in a book, and stacking 3-4 blocks.
Which patient below should be screened for osteoporosis? 60 year-old male with rheumatoid arthritis 50 year-old Caucasian female A 65 year-old male who is otherwise healthy A 62 year-old post menopausal female
60 year-old male with rheumatoid arthritis Explanation: Routine screening for osteoporosis is not recommended in males unless risk factors are present, like rheumatoid arthritis. Screening in women is recommended starting at age 65. If risk factors are present in a female, screening is recommended at an earlier age. Screening is usually performed by bone mineral density using a dual energy x-ray absorptiometry (DXA) scan.
A patient has cut himself on a fence post while working outside. He has not had a tetanus shot in more than 10 years. How long can he wait before getting the immunization and still prevent tetanus? 24 hours 48 hours 72 hours 5 days
72 hours Explanation: A patient has 72 hours after an injury to receive the tetanus immunization and be protected from tetanus. In an elderly adult who has completed the initial tetanus series, a Tdap is recommended. This will provide immunization against both tetanus, diphtheria, and acellular pertussis. He should receive another immunization in 10 years if he has not had another "dirty" injury. In the case of a "dirty" injury, immunization is recommended after 5 years.
What medication is recommended by American College of Rheumatology as a first line agent for a patient who has been unsuccessful with non-pharmacologic interventions for osteoarthritis pain? Naproxen Acetaminophen Ibuprofen Tramadol
Acetaminophen Explanation: Osteoarthritis is a chronic condition and non-pharmacologic interventions should be tried initially. When these do not bring about relief of pain, or bring incomplete relief of pain, medications should be considered. Initially, acetaminophen up to 650 mg four times daily can be tried. Hepatotoxicity must be monitored, but is not common using this dose. Unfortunately, acetaminophen is less effective at pain relief than NSAIDs like ibuprofen or naproxen. However, these are associated with greater risk and so should not be used if a medication associated with less risk brings relief. This is especially true in an elderly patient.
A 49 year-old patient has osteoarthritis in the lumbar spine and hip. His hip x-ray demonstrates bone on bone. What can be done to resolve his complaints of pain in his hip? Acetaminophen onlyAn NSAID onlyAcetaminophen and physical therapy IncorrectAcetaminophen and a referral to orthopedics
Acetaminophen and a referral to orthopedics Explanation: This patient has severe osteoarthritis if the x-ray reveals "bone on bone". He should be given something to help manage his pain (acetaminophen initially). He needs referral to an orthopedic doctor for evaluation if this is consistent with his desire. Medications alone will likely not resolve his pain. Additionally, he is 49 years old with no mention of other diseases and would likely be a good candidate because of his young age.
A 6 year-old complains that his legs hurt. His mother states that he has complained for the past 2 weeks, and she thought it was from "playing outside too much". When asked to identify the painful areas, the child points to the midshaft of the femurs. He grimaces slightly when asked to walk. What should be part of the differential diagnosis? Osgood-Schlatter disease Growing pains Acute lymphocytic leukemia (ALL) Psychogenic pain
Acute lymphocytic leukemia (ALL) Explanation: Bone pain is common in children, especially adolescents. However, a six year-old with complaints of mid-bone pain should be evaluated for ALL. Osgood-Schlatter produces pain in the knees. Growing pain usually occurs at nighttime. There is no information from history to suggest psychogenic pain, but ALL must always be considered since it is the most common malignancy in children. The child should be assessed for lymphadenopathy since this accompanies bone pain in ALL at least 50% of the time.
A male patient takes HCTZ daily for hypertension. He developed severe pain in his great toe yesterday. He was diagnosed with gout today and started on a medication. Which medication listed below would be contraindicated at this time? Allopurinol Prednisone Colchicine Indomethacin
Allopurinol Explanation: Allopurinol has no role in treatment of acute gout because it plays no role in inflammation. Therefore, it should not be initiated during an acute attack for relief of symptoms. Most learned authorities agree that if a patient takes an antihyperuricemic agent like allopurinol, and has an attack, the therapy should be continued.
A 70 year old patient has had intermittent back pain for more than 3 years. In the last year, it is constant (pain scale is 2-3/10) and at times is sharp. She is not a surgical candidate. What class of medication would be a good choice for improvement of chronic pain in this patient? Naproxen Codeine Amitriptyline Sertraline
Amitriptyline Explanation: This patient's pain sounds neuropathic. It is typical of pain experienced by people who have radiculopathy or neuropathy. It may be treated with tricyclic antidepressants or topical anesthetics. Opioids will produce relief and so can physical therapies. Pain management is specific to the type pain a patient experiences.
Which of the following tests, if positive, is part of the criteria for systemic lupus erythematosus (SLE)? Antinuclear antibody (ANA) Rheumatoid factor Elevated liver function studies Erythrocyte sedimentation rate (ESR)
Antinuclear antibody (ANA) Explanation: The criteria for diagnosis of lupus have been established by the American College of Rheumatology. It includes 11 criteria: malar rash, discoid rash, sun-related rash, painless oral ulcerations, joint pain or swelling involving two or more joints, inflammation involving the heart or lungs, renal disorder, a non-specified neurological disorder (seizures or psychosis), CBC abnormalities such as anemia, leukopenia, or thrombocytopenia, immunologic disorders (another positive autoimmune test such as an anti-phospholipid antibody test), or positive ANA. Having 4 or more of these criteria either at one time or over time can constitute a diagnosis of SLE. An elevated sedimentation rate is a very non-specific measure of inflammation.
A 50 year-old patient reports acute pain in his lower back that started 2 weeks ago after working in his yard. The pain radiates into his right leg intermittently. He has been managing his pain with over the counter NSAIDs. There are no red flags in his history or exam. When should consideration be given to imaging studies? Now At 4 weeks At 8 weeks There is no need
At 4 weeks Explanation: Imaging studies are usually not indicated for uncomplicated acute low back pain. The probable precipitant, working in his yard, is a common cause of low back pain. As long as pain is of less than 4 weeks duration and there are no red flags in history or exam, radiologic tests can be delayed. Radiologic studies should be considered initially in selected patients with history of cancer, age greater than 50 years, significant trauma or neurologic deficits, or pain inconsistent with history.
75 year-old patient has osteoarthritis and pain. Which of the following medications increases the risk of a GI related ulceration? Celecoxib Warfarin Tramadol Amitriptyline
Celecoxib Explanation: Celecoxib is an NSAID. All NSAIDs increase the risk of upper and lower GI ulcerations. Other lower GI complications include perforation, stricture, anemia, and hypoalbuminemia. Warfarin does not increase the risk of ulceration, but if ulceration occurs, the risk of bleeding is greatly increased. Neither tramadol nor amitriptyline is considered ulcerogenic.
A nurse practitioner has successfully reduced a nursemaid's elbow. How can the NP know that it was successful? X-rays Child moves the affected arm at the elbow A click is heard The deformity has resolved
Child moves the affected arm at the elbow Explanation: Successful reduction occurs when the child moves the affected arm at the elbow. Normal range of motion is established immediately if done correctly. X-rays are not needed. There is no visible deformity when subluxation occurs. The examiner's clue is clinical history and position in which the child holds his arm. When the examiner performs the reduction, the examiner may feel a click over the radial head when the arm is hyperpronated.
A nurse practitioner has successfully reduced a nursemaid's elbow. How can the NP know that it was successful? X-rays Child moves the affected arm at the elbow A click is heard The deformity has resolved Explanation: Successful reduction occurs when the child moves the affected arm at the elbow. Normal range of motion is established immediately if done correctly. X-rays are not needed. There is no visible deformity when subluxation occurs. The examiner's clue is clinical history and position in which the child holds his arm. When the examiner performs the reduction, the examiner may feel a click over the radial head when the arm is hyperpronated.
Child moves the affected arm at the elbow Explanation: Successful reduction occurs when the child moves the affected arm at the elbow. Normal range of motion is established immediately if done correctly. X-rays are not needed. There is no visible deformity when subluxation occurs. The examiner's clue is clinical history and position in which the child holds his arm. When the examiner performs the reduction, the examiner may feel a click over the radial head when the arm is hyperpronated.
A 75 year-old female who is otherwise healthy has osteoarthritis in her right knee. She complains of pain not relieved by acetaminophen 2000 mg daily. What should be done? Increase her acetaminophen to 4 grams daily Consider an NSAID Continue acetaminophen and order physical therapy Continue acetaminophen and refer to orthopedics
Continue acetaminophen and order physical therapy Explanation: Acetaminophen should be restricted to 3,250 mg acetaminophen daily. Daily doses of 4 grams daily are more likely to result in hepatotoxicity. Because osteoarthritis is a chronic disease, medications will be taken daily and NSAIDs would be better avoided if possible. NSAID use can be tried if acetaminophen does not provide relief. Consider physical therapy (PT) for pain relief. Strengthening of muscles may result in some relief. If cost is an issue, low does NSAID could be tried, but is a riskier option than PT.
A male patient who injured his back lifting a heavy object reports that he has low back pain. He is diagnosed with a lumbar strain. He is afraid to continue activities of daily living and especially walking because he has pain with these activities. What statement below is true? Stop doing any activities that produce pain in your lower back. Continue your activities of daily living, but stop walking, except to go to the bathroom. Bedrest will help your back pain. Continue your activities of daily living and walking.
Continue your activities of daily living and walking. Explanation: Pain associated with a lumbar strain does produce pain with activity and walking. This patient should be educated that pain is some pain is expected and that it will not produce permanent injury. He should be encouraged to engage in activities of daily living and normal walking. Generally, this will speed his return to normal activities. Bedrest is no longer recommended. Patients feel better sooner and have fewer complications if bed rest is avoided.
A 75 year-old female, who knits daily, has a positive Finkelstein test. What is her likely diagnosis? Gamekeeper's thumb De Quervain's tenosynovitis Osteoarthritis of the thumb Trigger thumb
De Quervain's tenosynovitis Explanation: De Quervain's tenosynovitis represents inflammation of the extensor and flexor tendons in the thumb. It is 8x more common in women than men and may accompany pregnancy, trauma, or some systemic diseases like rheumatoid arthritis. The classic finding in de Quervain's tenosynovitis is a positive Finkelstein test. Pain can radiate up the forearm. The probable precipitant is this patient's daily knitting.
A 75 year-old has pain from osteoarthritis in her right knee. What intervention is considered first line to treat her pain? Exercise Acetaminophen Ibuprofen Tramadol
Exercise Explanation: American College of Rheumatology recommends exercise as first line treatment for osteoarthritis. Since osteoarthritis is a chronic condition, medications are not the initial intervention for pain relief. Non-pharmacologic interventions like heat and exercise are always attempted initially. When initial interventions are unsuccessful, they are continued and medications are added. Relief of pain is the primary indication for use of medications.
A 55 year-old male patient describes severe pain at the base of his left first toe. He is limping and says he can't remember hurting his toe. Which symptom below suggests something other than gout? Pain Elevated sedimentation rate Erythema Fever
Fever Explanation: This presentation is classic for gout except that gout is not associated with fever. This presentation coupled with fever should prompt the examiner to suspect septic arthritis. If this is the presentation, this patient should have a joint tap (or refer to an orthopedic surgeon). Synovial fluid will be aspirated and sent to the laboratory for evaluation. The fluid will contain white cells and bacteria if infection is present.
Which diagnosis is the least likely cause of extrinsic shoulder pain? Angina Hepatobiliary disease Pneumonia Gout
Gout Explanation: The origin of shoulder pain can be intrinsic or extrinsic. In evaluation of a patient with shoulder pain, this is the initial determination. The shoulder is a common joint where pain is extrinsic. In the cardiovascular system, pain can be due to myocardial ischemia or thoracic outlet syndrome. In the abdomen, hepatobiliary disease, ectopic pregnancy or splenic injury can produce shoulder pain. Infectious organisms in the joint (intrinsic pain) or pneumonia can produce shoulder pain. Gout has a propensity for distal joints, not the shoulder.
An adolescent athlete has injured his ankle playing basketball. He has right ankle pain, ecchymosis, significant edema, and he is unable to bear weight at the time of the clinical exam. Which diagnosis is least likely? An avulsion fractureGrade I sprain CorrectGrade II sprainGrade III sprain
Grade I sprain Correct Explanation: Ankle sprains are generally graded based on clinical signs. A grade I sprain results from minimal stretching or small tears in the ligament. There is mild tenderness and edema, and the patient is able to bear weight. A grade II sprain is more significant. The clinical signs are more severe stretching and tearing of ligament(s) with moderate pain, edema, tenderness, and ecchymosis. Weight bearing is painful, but the patient can walk. A grade III sprain is the most severe. It involves complete tear of a ligament. There is joint instability, severe pain, edema, tenderness, and ecchymosis. Patients usually are unable to bear weight due to pain. An avulsion fracture could produce the same symptoms described above. This patient needs an x-ray to rule out fracture.
A 79 year-old frail adult reports that she had a fall last week. She had no broken bones but is very sore. In evaluating this adult, what question is most important to ask? Do you have gait problems? Have you had other falls this year? Are you on any new medications? Does your family know that you fell?
Have you had other falls this year?Explanation: The assessment of falls in older adults is important. Providers should ask older patients about falls. If a single fall is reported, gait and balance should be evaluated. If there is no observable difficulty, continue to monitor. If the fall is NOT a single event, a fall assessment should be done. This would involve fall history, gait and balance, home hazards, physical factors like joint pain or neurologic disease, vision, a medication evaluation, and others depending on patient's history.
A 60 year-old has been on NSAIDs for the past week for shoulder pain. He has complaints of blood on toilet tissue when wiping after a bowel movement. What should be suspected? He has a GI bleed from NSAIDs. He could have hemorrhoids. He does not have a GI bleed. The bleeding is from tissue friability from NSAIDs. This is unrelated to the NSAIDs.
He could have hemorrhoids Explanation: He could have hemorrhoids. It is unusual for a patient to have lower GI bleeding from one week's use of an NSAID. He is more likely to have upper GI symptoms (or bleeding) because of prostaglandin synthesis inhibition. This patient needs a colonoscopy to determine the etiology of the bleeding. The NSAID should be stopped.
A young athlete is found to have a depression of the longitudinal arch of both feet. He complains of heel pain bilaterally. The rest of his foot is normal and he has continued with his activities. What could be recommended for his heel pain? An x-ray of the foot is needed first. He needs some heel support in his shoes. NSAIDs should be used initially. Rigid orthotics could be ordered for his shoes.
He needs some heel support in his shoes. Explanation: A description of functional flat foot is described in this question. It is common among athletes. Although pain is not always present with this finding, it may accompany the finding but is usually not severe enough to inhibit activity. The treatment deemed to be best is a well-supported heel counter. The heel counter is the rigid part of the shoe that supports the heel. A radiograph is not needed unless the patient presents with other symptoms or fails to derive relief from the heel counter. NSAIDs may help symptoms of pain, but they will not correct the underlying problem. Orthotics may increase his pain. These are more helpful in patients with more severe pes planus.
An adolescent athlete has sprained his ankle. What instruction should be given to him regarding activity? He can resume regular activities in about one week. He should be able to walk pain-free before he starts to run. His ankle should be taped prior to competition. He can resume activity when the edema has resolved.
He should be able to walk pain-free before he starts to run. Explanation: A sprained ankle is a common orthopedic injury in athletes. Resumption of regular activities can take place when he is able to walk pain-free. His ankle does not necessarily need taping prior to competition but it may need support with an orthotic device. The edema may take weeks to completely resolve. In fact, edema after resumption of athletic activities is common.
An elderly patient had a total knee replacement (TKR) 10 months ago. He is doing well. What information should he be given regarding the knee replacement? He should take an aspirin daily for the first year. He should receive an antibiotic prior to dental procedures. He should take the flu shot annually. There are no recommendations 6 months after his surgery.
He should receive an antibiotic prior to dental Explanation: American Dental Association and American Academy of Orthopedic Surgeons recommend dental prophylaxis for 2 years after any joint replacement. Up to two years after replacement, prophylaxis should be given about one hour before any dental procedures. Two grams of amoxicillin can be given. In penicillin allergic patients, clindamycin can be given.
A 4 year-old was brought into the clinic by her mother who reports that she pulled her arms upward to pick her up and now the child won't use her right arm. A nursemaid's elbow is suspected. Which statement below is correct? The child is crying because her arm hurts. She will need to be admitted to the hospital for fracture reduction. Her arm is slightly flexed and held close to her body. Her elbow is held straight at her side and her fingers are in a fist.
Her arm is slightly flexed and held close to her body Explanation: Nursemaid's elbow is a subluxation of the radial head. The typical position of the affected arm is as described in the answer above. The patient is usually not in pain unless someone attempts to move the elbow. Reduction of the elbow can be done in an ER with the child seated in the caregiver's lap by hyper pronation of the forearm. It is painful but very brief. No treatment is necessary after reduction.
A 66 year-old African American female has multiple risk factors for osteoporosis. Which choice listed below is NOT a risk factor for osteoporosis? Her age Her race Glucocorticoid intake Excessive alcohol intake
Her race Explanation: Risk factors for osteoporosis (in addition to those listed) include low body weight, cigarette smoking, rheumatoid arthritis, previous fracture, and parental history of hip fracture. African American race is not a risk factor but Caucasian and Asian races are.
Besides inadequate intake of Vitamin D in elder adults, what other factor contributes to deficiencies? Impaired synthesis of previtamin D Decreased physical activity Diminished hepatic function Decreased body mass
Impaired synthesis of previtamin D Explanation: Elderly adults are at increased risk of Vitamin D deficiency related to several factors. In addition to those mentioned, lack of sun exposure decreases synthesis of Vitamin D. As renal status declines in older patients, hydroxylation diminishes which diminishes available Vitamin D. Patient with dark skin are also at increased risk of Vitamin D deficiencies.
A patient is at increased risk of osteopenia if she uses which form of birth control? Injectable progestin Intrauterine device Oral contraceptives Natural family planning
Injectable progestin Explanation: An injectable form of progestin, medroxyprogesterone acetate administered every 3 months by injection increases the risk of osteopenia and osteoporosis. Most learned authorities recommend calcium supplementation 500 mg T.I.D. while using this product.
What does a positive anterior drawer test demonstrate with an injured knee? Injury to the lateral meniscus Instability of the anterior cruciate ligament Stability of the posterior cruciate ligament Stability of the lateral knee
Instability of the anterior cruciate ligament Explanation: The anterior cruciate ligament (ACL) is often injured in athletes. The typical injury occurs when the foot is planted and the knee is extended; or in collision injuries such as in football, basketball, or soccer. Pain is reported by the athlete immediately after the injury. To perform the anterior drawer test, the patient lies down on his back and his knee is flexed to 90 degrees. Once the foot is stabilized, the tibia is grasped and forcibly pulled toward the examiner. Abnormal movement (or laxity) is assessed by comparing the injured knee to the opposite kne
Which of the following is NOT true regarding cervical whiplash injury? This occurs after a traumatic event. It may be accompanied by severe pain, spasm. Is identifiable on MRI or CT, but not x-ray. Occipital pain and headache can occur.
Is identifiable on MRI or CT, but not x-ray. Explanation: Whiplash injury commonly follows a car accident when a rear collision is involved. Loss of range of motion is common as is delayed pain sensation. Pain may not be perceived until the next day. There is usually no identifiable abnormality on x-ray, CT scan, or MRI. Sometimes muscle spasm can be identified with an imaging study, but, there is usually no abnormality found despite a complaint of pain by the patient.
What is the value of Vitamin D supplementation in the diet of older adults? It decreases the risk of falls. It decreases the severity of hip fractures. There is no clear value unless a Vitamin D deficiency is identified. It helps to prevent fractures.
It decreases the risk of falls. Explanation: Vitamin D reduces the relative risk of falls by 22%. In older patients, daily intake of Vitamin D should be 800 IU. In addition to Vitamin D, 1200 mg of calcium is also recommended.
Which factor listed below is NOT considered a risk factor for development of osteoporosis? Asian race Infrequent physical activity Alcoholism Late menopause
Late menopause Explanation: Late menopause increases the patient's exposure to estrogen. Estrogen plays a role in development of hard, dense bones. Early menopause is a risk factor. Other risk factors include cigarette smoking, low body weight, female gender, low calcium and vitamin D intake.
An x-ray report of a patient's painful right knee indicates "joint space narrowing". What does this mean? The patient is agingGout is presentThis is a normal findingLoss of cartilage has occurred
Loss of cartilage has occurred Explanation: In the knee, joint space narrowing indicates a loss of articular cartilage and usually worsening osteoarthritis. As cartilage wears away, the meniscus becomes displaced and the space normally found in the joint becomes narrowed. This is referred to as "joint space narrowing". This can occur as a result of osteoarthritis but is seen in rheumatoid arthritis, ankylosing spondylitis, and in some connective tissue disorders.
What should the nurse practitioner assess in a patient who reports a fall but does not have serious physical injury? Blood pressure while the patient is seated Medications taken a few hours before the fall Visual acuity and ability to distinguish colors The ability to get out of a chair easily
Medications taken a few hours before the fall Explanation: There are many things to assess when a patient reports a fall. The blood pressure should be compared in various positions: sitting to standing, lying to sitting, to assess for orthostatic hypotension. Assessing blood pressure only in a sitting position will not help identify orthostatic hypotension. Medication history in the last 72 hours would be important. Sometimes medications taken the night before will leave a patient with decreased alertness the following day. The circumstances surrounding the fall should be discussed. Visual assessment should be assessed, but color differentiation is not specific to the assessment. Gait and balance assessment as well as assessment of cognitive changes should be done.
Which of the following is true regarding metatarsus adductus? This is another term for clubfoot Mild flexible metatarsus usually spontaneously corrects X-rays are usually necessary to diagnose this Infants frequently require casting to correct
Mild flexible metatarsus usually spontaneously corrects Explanation: Metatarsus adductus (MA) is the most common congenital foot deformity. It is not related to clubfoot. In MA, the forefoot deviates medially, the hindfoot remains in a neutral position. This is a common cause of in-toeing gait and usually spontaneously corrects. This can be diagnosed on clinical presentation. An x-ray is not necessary. Casting is usually reserved for severe MA characterized by a rigid forefoot.
Which symptoms are most commonly found in a patient with rheumatoid arthritis? Morning stiffness, positive rheumatoid antigen and antinuclear antibody Fever, symmetrical joint involvement, normal sedimentation rate Asymmetrical joint involvement, male gender, pain Nodular lesion on the elbow, negative sedimentation rate, positive antinuclear antibody
Morning stiffness, positive rheumatoid antigen and antinuclear antibody Explanation: Rheumatoid arthritis is a difficult diagnosis to make because there are many factors to evaluate and none are consistently positive in all patients. Clinical clues that should cause the examiner to suspect rheumatoid arthritis are symmetrical peripheral polyarthritis, morning stiffness lasting greater than one hour, the presence of rheumatoid nodules, bone erosions on x-ray, positive sedimentation rate as an early phase reactant, positive rheumatoid antigen, and positive antinuclear antibody. None of these characteristics are positive in all patients and other autoimmune rheumatic diseases can be part of the differential.
Which symptom can be used to rule out a fracture? Degree of pain Extent of mobility Degree of swelling No symptom can rule out a fracture
No symptom can rule out a fracture Explanation: A fracture of a bone generally results in swelling, pain, and decreased mobility due to swelling and/or pain. Fractures are not asymptomatic events, but no single symptom can rule a fracture out. Fractures are usually the result of trauma, but tumor, osteoporosis, and cancer should be considered if history suggests this.
A college age basketball player landed awkwardly on his foot and ankle after jumping during a game yesterday. He states that he sprained his ankle. He complains of ankle pain and foot pain but is able to limp into the exam room. How should he be managed? Rest, ice, compression, elevation Non-weight bearing until fracture is ruled out C Short leg splint NSAIDs and rest with partial non-weight bearing
Non-weight bearing until fracture is ruled out Explanation: The mechanism of injury suggests a possible ankle sprain or fracture. However, the foot pain is suspicious of a possible 5th metatarsal fracture, the most common fracture occurring with an ankle sprain. He should receive an x-ray of the foot and ankle and should be kept non-weight bearing until the fracture is ruled out.
A patient presents with right shoulder pain (7/10 on the pain scale) after an acute shoulder injury yesterday. He fell against a brick wall while working at his home. He reports pain that radiates into his upper arm. How should this be managed? Immobilize the right shoulder for 3 days Rest, ice, and naproxen for one week Order an x-ray of the right shoulder Prescribe physical therapy for the patient
Order an x-ray of the right shoulder Explanation: An x-ray is generally the initial test used to evaluate trauma that results in acute pain. An x-ray could demonstrate fracture of the clavicle or humerus, or dislocation. It would not be helpful for evaluation of most soft tissue injuries. No other interventions are appropriate until fracture and dislocation have been ruled out.
A 14 year-old male client reports dull anterior knee pain, exacerbated by kneeling. What is the likely etiology? Patellar fasciitis Osgood-Schlatter disease Osteosarcoma of the tibia Over developed quadriceps
Osgood-Schlatter disease Explanation: Osgood-Schlatter disease is an overuse syndrome that produces pain and tenderness at the tibial tuberosity. It is also called tibial tuberosity apophysitis. Although Osgood-Schlatter disease sounds ominous, it is very common during adolescence. It occurs generally in males ages 13-14, and ages 11-12 in females.
A 16 year-old complains that his knees hurt. His mother states that he has complained of knee pain for the past 2 weeks. He has a prominent tibial tubercle. What should be part of the differential diagnosis? Osgood-Schlatter disease Growing pains Acute lymphocytic leukemia (ALL) Psychogenic pain
Osgood-Schlatter disease Explanation: Osgood-Schlatter is an osteochondritis of the tibial tubercle that can produce pain in the knees of adolescents. Pain gradually increases over time and can become extremely painful, especially if the knee sustains a direct hit or when the patient kneels. The diagnosis can be made on clinical presentation without the need for imaging studies. This is usually treated by rest, ice/heat, NSAIDs, and strengthening of the quadriceps muscle. Activity should not be stopped, but instead slowed down if symptoms become too painful.
An 80 year-old patient is very active but presents today with posterior hip pain for the past week. Which of the following is least likely part of the differential diagnosis? Osteoarthritis Sacroiliac joint disease Lumbar radiculopathy Herpes zoster
Osteoarthritis Explanation: The most common presentation of osteoarthritis of the hip involves anterior hip pain, not posterior hip pain. Posterior hip pain is the least common pain pattern associated with the hip. This should raise suspicion of pain referred from another area, such as the SI joint, the lumbar area, or herpes zoster. Anterior hip pain, typical of osteoarthritis, radiates into the groin.
What is the most prevalent skeletal problem in the United States? Osteoarthritis Correct Stress fractures Osteoporosis Gouty arthritis
Osteoarthritis Correct Explanation: Osteoarthritis (OA) is the most common form of arthritis and the most common skeletal abnormality listed above. Risk factors for OA are known to be advancing age, female gender, obesity, and joint injuries. Joint injuries or fractures from earlier decades will increase the likelihood of OA in the affected joint.
An adolescent complains of knee pain. He is diagnosed with Osgood-Schlatter disease. What assessment finding is typical? The pain is always bilateral. Pain worsens with quadriceps contraction. There will be an avulsion of the quadriceps tendon. Assessments vary. An x-ray can be used for diagnosis.
Pain worsens with quadriceps contraction Explanation: In patients with Osgood-Schlatter disease, pain can be unilateral or bilateral. What is obvious on assessment is a swelling of the tibial tubercle. X-rays are not needed for diagnosis. Pain worsens with squatting or crouching and with contraction of the quadriceps muscle against resistance. An avulsion of the quadriceps tendon should be part of the differential for patients who exhibit severe pain.
A 12 year-old male with hip pain presents to the NP clinic. Hip pain has occurred with activity for the past 4-6 weeks but his pain is worse and now involves the knee. There is no history of trauma. How should the work-up be initiated? Order a hip and knee x-ray Order a hip x-ray and a sed rate Perform Trendelenburg's test in the office Have the child squat in the office to assess the hips
Perform Trendelenburg's test in the office Explanation: There are several diagnoses in the differential. The assessment of this child should begin in the office. Asking the child to stand on the affected leg performs the Trendelenburg's test. If there are weak adductor muscles in the affected hip, a pelvic tilt will be visible in the unaffected hip. This can be found in children with a slipped capital femoral epiphysis, Legg-Calve-Perthes disease, or developmental dysplasia of the hip. After assessment of the hip, knee, and gait in the office, a hip x-ray to include AP and lateral should be ordered. The advantage of a sedimentation rate or C-reactive protein is that it will be elevated in patients with the aforementioned hip problems. It will be elevated in septic arthritis and other inflammatory causes of hip pain.
A patient complains of "first step in the morning" pain in his heel. He states that it has progressed to "end of the day" heel pain. What probably has contributed to this most? Driving a vehicle long distances Walking in new tennis shoes Riding a bicycle Pes planus
Pes planus Explanation: This patient's symptoms are descriptive of plantar fasciitis. Pain usually begins as only pain in the morning with resolution after several steps and the passage of time. As plantar fasciitis worsens, patients complain of heel pain during the day, after sitting for a while, and at the end of the day. The most important contributor to this is pes planus, "flat feet". Approximately 70% of patients with plantar fasciitis have pes planus.
A positive Tinel's test can be used to assess carpal tunnel syndrome. What other test can be used to assess for this? Patrick's test Finkelstein's test Phalen's test Allen's test
Phalen's test Explanation: The other test commonly used to assess a patient with suspected carpal tunnel syndrome is Phalen's test. This test is also called the "backward praying test". It asks the patient to put the back of his hands together with flexion of the wrists. This narrows the carpal tunnel and may reproduce symptoms in a patient with carpal tunnel syndrome. The symptoms likely to be reproduced are paresthesias in the affected hand.
A 45 year-old male who is in good health presents with complaints of pain in his left heel. He states that the first few steps out of bed in the morning are extremely painful. He has no history of trauma. What is the likely etiology of his pain? Achilles tendinitis Plantar fasciitis Calcaneal spur Arthritis of the foot
Plantar fasciitis Explanation: Plantar fasciitis is an inflammation of the ligaments in the plantar fascia. The fascia is a thick white tissue that begins at the heel and extends under the foot to the toes. It supports the foot during walking. Patients who are at increased risk are long-distance runners, dancers, people who are on their feet for long periods of time. This can be treated with rest, ice, NSAIDs short-term, stretching exercises, orthotics, and steroid injections.
A 60 year-old female presents with history of low back pain of recent origin. Her gait is antalgic and she reports loss of bladder function since the onset of back pain this morning. What should be done? Order physical therapy Refer to the emergency department Refer to a neurologist Keep non-weight bearing until x-rays are completed
Refer to the emergency department Explanation: This patient has symptoms of cauda equina syndrome. This is a medical emergency. Urinary retention with overflow incontinence is typical. Other symptoms that can accompany this are saddle anesthesia, sciatica down both legs, and leg weakness, evidenced by the inability to support one's own weight on the affected side.
A long distance runner is diagnosed with a tibial stress fracture. Which statement is true about the injury? The pain worsens with rest. The patient should be casted for 6 weeks. Plain x-rays will confirm the diagnosis. Rest and an alternative activity are recommended.
Rest and an alternative activity are recommended. Explanation: Stress fractures are an example of an overuse injury. These occur in patients who are engaged in repetitive physical activities. These commonly occur in the feet and shins, though it is usually unilateral. X-rays usually do not demonstrate stress fractures, so history and exam are important. Treatment involves resting the injured joint. Engaging in an alternative exercise (termed, cross-training) that does not stress the fractured area, is recommended. One example of cross training is swimming. Casting and crutches are reserved for use when conservative treatments are not effective.
A patient who frequently has episodes of gout should avoid which groups of food? Beans, rice, and tea Scrambled eggs, milk, and toast Roast beef with gravy, rice Fish and steamed vegetables
Roast beef with gravy, rice Explanation: Patients who have gout exacerbations should avoid foods high in purines. A low purine diet can significantly reduce risk of gout. Uric acid is a byproduct of purine metabolism. Purines can be found in high concentrations in beef, pork, bacon, lamb, seafood, beer, bread, gravy, and most alcoholic beverages. Foods considered low in purines are fruits and fruit juices, green veggies, nuts, dairy products, chocolate.
A 16 year-old male plays trumpet in the school marching band. He has had marching practice every day for the last week. Today he complains of pain in his left midfoot. The foot is neither swollen nor red. What is the most likely diagnosis in the differential? Strain Bursitis Stress fracture Tendonitis
Stress fracture Explanation: This is a stress fracture and commonly occurs with an abrupt increase in activity, especially marching. A stress fracture of the metatarsals is commonly called a "march" fracture because it is frequently seen in soldiers who march. This occurs because of an increase in weight-bearing loads on the metatarsals. Stress fractures occur more commonly in patients with flat feet. Stress fractures of the 2nd, 3rd, and 4th metatarsals account for 90% of metatarsal stress fractures.
A 60 year-old patient who is otherwise healthy, presents with acute onset of right knee pain. She denies injury but reports that she walked up a lot of steps yesterday. She is diagnosed with prepatellar bursitis. What is a common finding? Limping and erythema about the anterior knee Swelling and pain to touch of the anterior knee Posterior knee pain, anterior knee edema, and redness Tenderness to touch of the tibial tubercle
Swelling and pain to touch of the anterior knee Explanation: Prepatellar bursitis is often precipitated by an increase in activity involving the knee, such as was given in history by this patient. If it was infectious in origin, erythema would be present, but based on this patient's history and absence of risk factors, that is less likely. Prepatellar bursitis is characterized by swelling and inflammatory changes anterior to the patella, no symptoms posteriorly. The patient probably will limp due to pain. Tenderness to touch of the tibial tubercle is characteristic of Osgood Schlatter disease, but, is common in an under 19 years age group.
An 8 year-old has a painful limp. He reports that his knee hurts medially. On exam he has pain with internal rotation of the hip. How should the NP manage this situation? He should be immediately referred to orthopedics. The NP should order a hip x-ray, CBC and ESR. The NP should order a hip and knee x-ray. He should be referred for synovial fluid aspiration.
The NP should order a hip x-ray, CBC and ESR. Explanation: In an 8 year-old, there are several diagnoses in the differential. One must consider Legg-Calve Perthes, transient synovitis of the hip, a slipped capital femoral epiphysis (SCFE), and a septic hip. This could be as benign as transient synovitis that does not require referral. All of the others mentioned would need urgent orthopedic referral. Once the diagnostics were completed, the NP would have a better idea about whether orthopedic referral was essential.
When should functional rehabilitation occur once a patient has had an ankle or knee sprain? The day of the injury About 5 days post-injury 2-3 weeks after injury When the patient's pain level allows
The day of the injury Explanation: Early functional rehab (beginning the day of the injury) speeds time of recovery and allows resumption of activities much earlier than not. Early rehab includes range of motion exercises initially, with progression to muscle strengthening, proprioception, and activity-specific training (walking, speed walking, running).
Which statement below best characterizes scoliosis in an adolescent? It is more common in males and is idiopathic. There can be unequal rib prominences or shoulder heights. The diagnosis can be made when the curvature is 8? or more. There is a strong familial component to this condition.
There can be unequal rib prominences or shoulder heights. xplanation: Scoliosis is diagnosed when the degree of curvature is 10? or more. It is more common in girls because they have more rapid vertical growth than boys. There is not a strong familial component to this disease. Rather, it is idiopathic. It is assessed using the Adams Forward Bend test. There can be unequal scapula prominences and heights, waist angles, and chest asymmetry.
Which statement below is true regarding NSAIDs for low back pain? They are as equally efficacious as acetaminophen for pain. They are associated with more side effects than acetaminophen. They provide superior relief of symptoms at one week post injury. They should not be used to treat acute low back pain.
They are associated with more side effects than acetaminophen. Explanation: NSAIDs are associated with side effects such as renal impairment, acute renal failure, and gastritis in patients who use these for pain and inflammation relief. Anecdotally, patients report greater relief of pain with NSAID use compared to acetaminophen, but research does not support this. Research studies support the use of NSAIDs for acute low back pain. The 2007 Joint Practice Guidelines of the American College of Physicians and the American Pain Society advise the use of acetaminophen or NSAIDs as first line therapy for acute pain.
Women are commonly screened for osteoporosis at age 65 years. How should screening for osteoporosis be managed in a male this age? They should be screened starting at age 65 if they have risk factors. They should be screened routinely at age 65. They do not need screening since this is not prevalent in males. They should be screened if they have prostate disease.
They should be screened starting at age 65 if they have risk factors. Explanation: Men develop osteoporosis less frequently than women do. However, low bone density in the elderly is a common finding. If males have risk factors and are 65 years or older, most learned authorities agree with screening using DEXA scan. Common risk factors in men are systemic steroid use, low body mass index, hypogonadism, or primary hyperparathyroidism. They are treated with bisphosphonates and other interventions (calcium and Vitamin D supplementation, weight bearing exercises, etc.) just as females are.
A 60 year-old adult with an antalgic gait and complaints of hip pain is examined. He has trochanteric tenderness. What is the most common cause of this? Bone cancer Trochanteric strain Trochanteric bursitis Osteoarthritis
Trochanteric bursitis Explanation: Tenderness over the trochanter is common in trochanteric bursitis. There are superficial and deep bursa that can be assessed. Other causes of trochanteric tenderness are fractures, stress fractures, and diseases where metastases have occurred, like prostate cancer
Which beverage below does not increase the risk of gout in a male who is prone to this condition? Vodka Beer Wine Bourbon
Wine Explanation: Alcohol is known to be a contributing factor in development of gouty arthritis. Males are more prone to gout than females, and alcohol consumption increases the likelihood of gout development. Of all alcohols, wine contributes least to the development of gout. Consumption of meat and fish increase the concentration of uric acid and thus, the risk of developing gout.
What joints are least commonly involved in osteoarthritis? Fingers Wrists Hips Knees
Wrists Explanation: Osteoarthritis (OA) is characterized by destruction of the articular cartilage. The fingers, knees, hips, and spine are most commonly affected. OA is more common in men before age 45 years, but is more common in females after age 55 years. Often osteophytes form in the diseased joints. The most commonly involved joints are found in the fingers.
A man fell off a 3-foot stepladder while working at home. He presents to your office with complaints of foot pain. He has point tenderness over the lateral malleolus, swelling, but he is able to ambulate. How should this be managed? ACE wrap and rest Rest, ice, compression, and elevation X-ray of the foot and ankle Non-weight bearing for 3-7 days
X-ray of the foot and ankle Explanation: This patient suffered trauma to his foot and/or ankle after a fall. A sprain is in the differential, but a fracture must be ruled out before this patient is allowed to continue to ambulate. An x-ray is needed now and he must be kept non-weight bearing until this is ruled out. A fracture should be suspected since the stem of the question indicates "point tenderness".
Clubfoot: always requires an urgent neurosurgical referral. involves the foot and lower extremity. involves the foot only. can be corrected with casting and exercises.
involves the foot and lower extremity. Explanation: Clubfoot is also known as talipes equinovarus. The foot is plantar flexed and the forefoot and sole are thrust medially. This involves the foot and lower extremity. It is an urgent orthopedic referral, not neurosurgical referral. Casting and splinting usually takes place initially with surgical treatment delayed if needed until 3-6 months if necessary. However, the majority of patients will be successfully corrected with taping, splinting, and/or casting when early intervention occurs.
Ankle inversion is a common complaint from a patient with a: medial ankle sprain. lateral ankle sprain. severely torn ligament. fracture of the medial malleolus.
lateral ankle sprain Explanation: An ankle inversion causes the sole of the foot to roll into the body. This produces stretching of the lateral malleolar ligaments of the ankle and a lateral ankle sprain. Injury to the medial ligaments is a more serious injury and can produce a medial ankle sprain or an avulsion fracture. No information in the stem of the question suggests a fracture or tear of the ligament, though all sprains produce varying degrees of ligament tears.
A 70 year-old African American male complains of pain in his back and trunk. Cardiovascular disease is ruled out. He has a normocytic normochromic anemia with hypercalcemia. A likely diagnosis is: multiple myeloma. lymphoma. leukemia. prostate cancer.
multiple myeloma. Explanation: Multiple myeloma is a neoplastic proliferation in the bone marrow which results in skeletal destruction. It is more common in older patients; the average age of diagnosis is 66 years. Common clinical findings are pain in the long bones, especially those of the trunk and back. Accompanying findings are anemia, usually normocytic/ normochromic, hypercalcemia, and renal insufficiency.
Management of a sprained ankle includes: x-rays. rest, ice, compression, elevation. anti-inflammatory medications. activity as tolerated.
rest, ice, compression, elevation Explanation: X-rays are not needed for a sprain. This question stem states the patient's injury. RICE is the acronym for rest, ice, compression, and elevation. Anti-inflammatory medications are recommended, but one NSAID has not been shown to be superior to another.
The "get up and go" test in an elderly patient is used to evaluate: risk for falls. lower extremity strength. mental acuity. driving safety.
risk for falls. Explanation: The "get up and go" test is used to evaluate musculoskeletal function. The patient is asked to rise from a seated position in an armchair, walk across the room, turn around, and return to the chair. This test evaluates the patient's gait, balance, leg strength, and vestibular function. It should be assessed in patients who report a fall or who present after a fall but who appear without injury.
The drop arm test is used to assess patients with suspected: cervical injury. rotator cuff injury. impingement syndrome. malingering.
rotator cuff injury Explanation: Rotator cuff injury is one of the most common causes of shoulder pain. The rotator cuff is composed of 4 muscles. The one most susceptible to injury is the supraspinatus. Consequently, this is the one most commonly torn. To assess whether the supraspinatus muscle is intact, the drop arm test is performed. The patient is asked to abduct his affected arm laterally to 90 degrees. He is then asked to slowly lower it to his side. A positive test is noted when the arm "drops". This usually indicates that the supraspinatus is injured.
Bone mineral density screening in women over age 65 years is an example of: primary prevention. secondary prevention. tertiary prevention. quaternary prevention.
secondary prevention. Explanation: Secondary prevention is evidenced by early detection of disease in a patient. Bone mineral density screening is intended to identify women (or men) who may have decreased bone density but who are asymptomatic. Primary prevention is an example of an action intended to prevent a disease or condition before it starts. Tertiary prevention is an example of preventing worsening of a disease after it has already been discovered.
A patient with sciatica is most likely to describe relief of symptoms with: sitting. standing. side lying or standing. walking.
side lying or standing. Explanation: Sciatica is caused by nerve root irritation. This produces a burning pain that usually radiates down the posterior aspect of the leg. The pain is often associated with numbness and tingling. Pain usually increases with coughing, sneezing, or straining. Relief of pain usually occurs in positions where nerve root irritation is minimized. These are commonly standing or side lying. It is usually worsened by sitting.
A positive Trendelenburg's test could be used to identify a child with: scoliosis. Osgood-Schlatter disease. nursemaid's elbow. slipped capital femoral epiphysis.
slipped capital femoral epiphysis. Explanation: Asking a child with a complaint of hip pain to stand on the affected side is how the Trendelenburg test is assessed. A positive Trendelenburg test occurs when standing on the affected leg causes a pelvic tilt, such that the unaffected hip is lower. This can be assessed and observed in children with slipped capital femoral epiphysis, Legg-Calve-Perthes disease, or developmental dysplasia of the hip. Nursemaid's elbow is a common ligamentous injury in young children. The radial head becomes subluxed. Displacement is usually easy to reduce.
A characteristic of rheumatoid arthritis not typical in osteoarthritis is: weight loss. morning stiffness. symmetrical joint involvement. the presence of Bouchard's nodes.
symmetrical joint involvement. Explanation: Rheumatoid arthritis is characterized by pain, symmetrical involvement of multiple joints, morning stiffness lasting longer than one hour. Patients with osteoarthritis have morning stiffness lasting less than one hour, usually less than 30 minutes. Weight loss is not typical in either of these diseases. Bouchard's nodes are typical in osteoarthritis and represent enlargement of the proximal interphalangeal joint.
A patient has suspected plantar fasciitis. The plantar fascia is best examined: with the great toe dorsiflexed. with the foot in neutral position. while the patient stands. with the ankle at a 90 degree angle.
with the great toe dorsiflexed. Explanation: When the great toe is dorsiflexed, the plantar fascia is easy to palpate because it tightens and can be easily palpated on the sole of the foot. Anterior heel pain is usually easily appreciated when the patient has plantar fasciitis.
The Ottawa ankle rules help the examiner determine when: an inversion ankle injury has occurred. an anterior talofibular fracture has occurred. x-rays are needed with a suspected ankle sprain. referral to orthopedics should occur.
x-rays are needed with a suspected ankle sprain. Explanation: The Ottawa ankle rules have been extensively tested on adults and pediatric patients who present with acute ankle pain. They direct the examiner to order ankle or foot x-rays when certain criteria are met. When the rules are followed, unnecessary x-rays are significantly reduced. The examiner should order x-rays when the patient has ankle or midfoot pain/bone tenderness, has bone tenderness at the base of the 5th metatarsal, or is unable to bear weight for four steps when examined.
