Musculoskeletal Chapter 15
What are bursae?
Bursae are pouches of synovial fluid that reduce friction between bones muscles, or tendons
Where is bursitis most common?
Bursitis commonly develops in the subdeltoid and subacromial bursa in the shoulder. The Olecranon Bursa of the elbow The greater trochanteric bursa lateral to the hip The isheal bursa The prepatellar bursa
What is bursitis?
Inflammation of the bursa The bursa provide lubrication for movement of tendons over bones and can be affected by trauma - overuse - infection, inflammation, and neoplasms
What is spondylolisthesis?
Spondylolisthesis is the forward displacement of a vertebra, especially the fifth lumbar vertebra, most commonly occurring after a fracture. Backward displacement is referred to as retrolisthesis.
What is Ankylosing spondylitis?
a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae and sacroiliac joints, there is reduced chest wall expansion and excessive thoracic kyphosis is also present
Jeff, age 16, was involved in a MVA, he walks into the office with an obvious facial fracture, then collapses. What should your first action be? - call his parents for permission to treat - assess for an adequate airway - obtain head and maxillofacial CT - assess for septal hematoma
- assess for an adequate airway
Management of fibromyalgia would include: - giving psychotropic drugs such as amitriptyline in a low dose at bed time - instructing clients to keep as busy as possible to keep their minds off their symptoms - using high doses of NSAID's - avoiding exercise
- giving psychotropic drugs such as amitriptyline in a low dose at bed time NSAID's have not proven helpful in fibromyalgia
What pathophysiology associated with transient pain after exercising usually begins hours after exercise with soreness that can last up to a week? - Increased lactic acid production, muscle breakdown and inflammation - Mild muscleotendinous inflammation - Major musclulotendinous inflammation periostitis and bone microtrauma - breakdown in soft tissue and stress fx
Increased lactic acid production, muscle breakdown and inflammation
What is Peyronies disease?
Peyronies disease is a connective tissue disorder that results in painful curvature of the penis
Osteoarthritis is primarily a noninflammatory condition. T or F
T
What is the most consistent finding with a meniscal tear?
Tenderness to palpation along the joint line
How do you assess for hip, knee and ankle symmetry?
The duck walk with buttocks on heels is used to assess for hip, knee and ankle symmetry
What is the recommended daily calcium intake for adults over the age of 50 with low bone mass? - 1200 mg/day - 1000 mg/day - 1300 mg/day - 1500 mg/day
- 1500 mg/day
You are performing muscle strength testing on a patient presenting with musculoskeletal pain and find that the patient has complete range of motion with gravity eliminated. Which numeric grade of muscle strength would you give this patient? - 1 - 2 - 3 - 4 - 5
- 2 5 - Normal - Complete ROM against gravity with full or normal resistance 4 - Good - Complete ROM against gravity with some resistance 3 - Fair - Complete ROM against gravity 2 - Poor - Complete ROM with gravity eliminated 1 - Trace - Muscle contraction but no or very limited joint movement 0 - Zero - No evidence of muscle function
In a client with osteomalacia, you would expect levels of - serum calcium to be elevated - alk phos to be elevated - creatinine excretion to be elevated - serum phosphorous to be elevated
- Alkaline Phosphatase levels are moderately elevated in osteomalacia Serum Ca+, creatinine levels are all low in osteomalacia
The clinician is caring for Diane, a 22-year-old woman who presents with an injured ankle. Diane asks the clinician if she will need an x-ray. The clinician explains to Diane that an x-ray is not always necessary for an injured ankle, and that the decision to obtain radiographs is dependent on the exam and Diane's description of her injury. Which of the following clues in Diane's exam or history would alert the clinician to the need for obtaining radiographs? - If she was not able to bear weight immediately after the injury - If the ankle developed marked swelling and discoloration after the injury - If crepitation occurs with palpation or movement of the ankle - All of the above
- All of the above
To aid in the dx of meniscus damage, which test should you perform? - Bulge test - Lachman test - Drawer test - Apley's compression test
- Apley's compression test Bulge test - assesses for effusion Lachman test - ACL Drawer test - stability of the ACL and PCL
Alexander age 18 sprained his ankle playing ice hockey. He is confused as to whether to apply heat or cold. What do you tell him? - Use continuous heat for 12 hours then use heat or cold to your own preference - Use continuous cold for 12 hours then use heat or cold to your own preference - Apply cold for 20 minutes then take it off for 30 - 45 minutes / repeat the first 24 - 48 hours while awake - Alternate between cold and heat for 20 minutes each for the first 24 hours.
- Apply cold for 20 minutes then take it off for 30 - 45 minutes / repeat the first 24 - 48 hours while awake Cold will cause vaso constriction and decrease edema, preventing further bleeding into the tissue. Ice has been proven to speed recovery in ankle sprains, however ice should not be applied continuously because it can hamper circulation and cause frostbite. Always recommend padding between the skin and ice. Heat causes vasodilation which can make swelling worse...
The clinician suspects that a client has patellar instability. In order to test for this, the client is seated with the quadriceps relaxed, and the knee is placed in extension. Next the patella is displaced laterally and the knee flexed to 30°. If instability is present, this maneuver displaces the patella to an abnormal position on the lateral femoral condyle, and the client will perceive pain. Testing for patellar instability in this way is known as: - Apprehension sign. - Bulge sign. - Thumb sign. - None of the above
- Apprehension sign.
You have detected the presence of crepitus on examination of a patient with a musculoskeletal complaint. Additionally, there is limited range of motion with both active and passive movement. These findings suggest that the origin of the musculoskeletal complaint is: - Articular - Inflammatory - Nonarticular - A and B
- Articular
Steve, age 15 has only one testicle, when he asks you if he can play on the soccer team at school, how do you respond? - No, you would be taking too much of a risk injuring your remaining testicle - you can play non-contact sports, soccer is too strenuous - As long as you protect your remaining testicle, go for it - It should have no bearing on activity
- As long as you protect your remaining testicle, go for it
Jim age 22, a stock boy has an acute episode of LBP. You order an NSAID and tell him which of the following: - Maintain moderate bedrest for 3 to 4 days - call the office for narcotic meds if there is no relief with the NSAID after 24-48 hours - Begin lower back strengthening exercises depending upon pain tolerance - Wear a Boston Brace
- Begin lower back strengthening exercises depending upon pain tolerance The expression is - let pain be your guide / exercise asap and as tolerated
Which of the following tests is considered the "gold standard" for definitively diagnosing osteoporosis? - Bone alkaline phosphatase levels - Urinary N-telopeptide assay - Bone mass density measurement by densitometry - Magnetic resonance imaging (MRI)
- Bone mass density measurement by densitometry
Mr. McKinsey was recently given a dx of degenerative joint disease. Which assessment test would you use to check for effusion on his knee? - thomas test - Tinel's sign - Bulge test - Phalens test
- Bulge test If an effusion is present, a bulge will appear to the sides or below the patella when the practitioner compresses the area above the patella
The most widely accepted screening for psoriatic arthritis is the: - ACR (American College of Rheumatology) - CASPAR (Classification of Psoriatic Arthritis Criteria) - Psoriasis Area and Severity Index - Rome Criteria
- CASPAR (Classification of Psoriatic Arthritis Criteria)
Which muscle enzyme is elevate in polymyositis? - Aldolase A - AST (aspartate aminotransferase) - CK (creatine kinase) - LDH (Lactate dehydrogenase)
- CK (creatine kinase) Elevated levels are found in polymyositis, traumatic injuries, and progressive muscular dystrophy Aldolase A is elevated in muscular dystrophy and dermatomyositis Asparate aminotransferase is found in skeletal muscles but mainly in the heart and renal cells LDH levels are elevated in skeletal muscle necrosis and progressive muscular dystrophy
Mrs. Anderson is a 35-year-old woman who has been recently diagnosed with carpal tunnel syndrome. She has two young children and asks the clinician what the chances are that they will also develop carpal tunnel syndrome. Which of the following responses would be correct regarding the risk of developing carpal tunnel syndrome? - Carpal tunnel syndrome commonly occurs in families. Genetic factors are thought to account for about half the risk of developing carpal tunnel. - Only people with occupations that require repeated flexion extension of the wrist, use of hand tools that require forceful gripping, or hand tools that vibrate are at risk for developing carpal tunnel. - An underlying musculoskeletal disorder must be present for a person to develop carpal tunnel. - Carpal tunnel syndrome only occurs in the presence of a hormonal imbalance.
- Carpal tunnel syndrome commonly occurs in families. Genetic factors are thought to account for about half the risk of developing carpal tunnel. CTS is well known to occur in families CTS is the most common entrapment neuropathy
Joyce age 87 broke her wrist after falling off a curb, She just had a plaster cast applied to her wrist. In instructing her family on allowing the cast to dry properly you tell them to: - continuously elevate Joyce's arm on a pillow - Change the position of Joyce's arm every hour - Position a fan near Joyce during the night to ensure even drying of the cast - put a blanket over the cast to absorb moisture
- Change the position of Joyce's arm every hour Re-position her arm to prevent indentations Elevating will prevent edema but is not necessary all the time A fan will dry only the outside of the cast A blanket will keep the cast from drying
Sean age 48 has asymptomatic hyperuricemia, what is your initial therapy? - NSAID's - Dietary counseling - Colchicine - Allopurinol
- Dietary counseling Diet plays a minor role but avoiding or limiting foods high in purine and alcohol can help prevent attacks An acute attack is treated with NSAID's and Colchicine Zyloprim is not used in acute attacks
Which of the following statements is true regarding vertebrae? - All people have only 24 vertebrae (cervical, thoracic, lumbar) - Due to differences in race or gender, select groups may have 23 to 25 vertabrae - It is common to have fewer than 23 vertebrae - It is common to have more than 23 vertebrae
- Due to differences in race or gender, select groups may have 23 to 25 vertabrae 7 - cervical 12 - vertabrae 5 - lumbar 5 - sacral 3-4 - occcygeal
Daniel who is 45 and of northern european descent, has a dysfunctional and disfiguring condition affecting the palmar tissue between the skin and the distal palm and fourth and fifth fingers, What do you suspect? - Hallux valgus - DeQuervain's tenosynovitis - Dupuytrens contracture - Hallux rigidus
- Dupuytrens contracture This is progressive and results in flexor contracture Usually not painful, but tender Occurs in males 40 to 60 Occurs in those of European descent Surgery is recommended when the client is unable to straighten their fingers
Which of the following is true regarding scoliosis? - Functional scoliosis is flexible, it is apparent with standing and disappears with forward bending - Functional scoliosis is fixed, the curvature shows both on standing and bending forward - Structural scoliosis is fixed, the curvature shows both on standing and on bending forward - Functional scoliosis is permanent, whereas structural scoliosis can result from outside influences such as leg length discrepancy or muscle spasms.
- Functional scoliosis is flexible, it is apparent with standing and disappears with forward bending It is due to a problem that does not involve the spine such as leg length discrepancy or muscle spasm.
Steve age 32 fell off a roof while shingling it. He is complaining of pain in his left hip and leg area. Other than an xray what would make you suspect a fractured hip? - clicking sensation when moving the hips - a positive pelvic tilt test - Hematuria - absence of distal reflexes
- Hematuria Pelvic fx's commonly injure the urinary bladder and urethra
Mrs. Gray is a 55-year-old woman who presents with tightness, pain, and limited movement in her right shoulder. She denies any history of trauma. Her exam reveals a 75% reduction in both active and passive range of motion of the right shoulder. Mrs. Gray is also experiencing tenderness with motion and pain at the deltoid insertion. Her medical history is significant for type 1 diabetes mellitus and hypertension. Her social history reveals that she is a secretary and that she is right-handed. Based on her exam and medical history, you suspect adhesive capulitis or "frozen shoulder." Which clue in Mrs. Gray's history supports this diagnosis? - Hx of HTN - Her affected shoulder is also her dominant arm - Her hx of DM - Her work as a secretary predisposes her to repetitive motions
- Her hx of DM Adhesive Capsulitis - idiopathic loss of passive and active ROM of the shoulder. NOT related to hand dominance, gender or occupation Patients are usually 40 to 60 years of age DM type 1 is the most common risk factor
Bet, age 49, come in with low back pain. An xray of the lumbar/sacral spine is within normal limits. Which of the following dx do you explore further? - Scoliosis - Osteoarthritis - Spinal Stenosis - Herniated nucleus pulposus
- Herniated nucleus pulposus An xray will show scoliosis, osteoarthritis and spinal stenosis, but not a herniated nucleus pulposus Xrays are usually not indicated for LBP unless it is thought to be bony, traumatic or to r/o systemic dz
There are many precursors of DVT, such as decreased blood flow, injury to the blood vessel wall and altered blood coagulation. Which clinical risk factor for DVT is the result of hypercoagulability? - High estrogen states, such as with oral contraceptives - Trauma that results in orthopedic injury - An indwelling IV catheter of a lower extremity - Prolonged sedentary position related to immobility
- High estrogen states, such as with oral contraceptives High estrogen states is a clinical risk factor for DVT Venous status can be r/t to prolonged sedentary positions and is common in clients who are immoble
Which of the following would be considered a common cause of sudden death in athletes younger than age 30? - Bronchospasm from exercise induced asthma - Hypertrophic CM - Compartment syndrome - Meningitis
- Hypertrophic CM Three types: Hypertrophic CM, idiopathic LV hypertrophy, coronary artery anomalies
Greg, age 26 runs marathons and frequently complains of painful contractions of his calf muscles after running. You attribute this to: - Hypercalemia - Hyponatremia - Heat exhaustion - dehydration
- Hyponatremia Painful contractions of muscles with exertion is usually due to an electrolyte imbalance. Usually the gastrocnemius and hamstring muscles are involved, treatment of heat cramps include passive stretching, cessation of activity and cool environment.
For your client with a knee injury, you order an NSAID to be taken on a daily basis for the next 2 weeks. Your teaching should include which of the following? - You may take this medication on an empty stomach as long as you eat within 2-3 hours of taking it - If one pill does not seem to help, you can double the dose for subsequent doses - If you notice nausea/vomiting or black or bloody stools, take the next dose with a glass of milk or a full meal - If you have additional pain, an occasional acetaminophen is permitted in between the usual doses of the NSAID
- If you have additional pain, an occasional acetaminophen is permitted in between the usual doses of the NSAID When teaching about NSAID's tell them not to take them on an empty stomach but take them with food or milk and stop the medication immediately if they notice any nause/vomiting, coffee ground emesis or bloody or tarry stools. An occasional acetaminophen is alright in between doses
Dan developed osteomylitis after a MCA, which of the following statements about the clinical manifestations of osteomylitis is correct? - Integumentary includes swelling erythema and warmth at the site - there is a low grade fever with intermittent chills - musculoskeletal effects include tenderness of the entire leg - cardiovascular effects include bradycardia
- Integumentary includes swelling erythema and warmth at the site as well as drainage and ulceration through the skin with lymph node involvement / pt would more than likely be tachycardic, with high fever and chills
Which of the following statements is true concerning the management of the client with a herniated disc? - Muscle relaxants and narcotics can be used to control moderate pain but should be discontinued after 3 weeks of use. - An epidural injection is helpful in reducing leg pain that has persisted for at least 3 weeks after the herniation occurred. - Intolerable pain for more than a 3-month period is an indication for surgical intervention. - All of the above
- Intolerable pain for more than a 3-month period is an indication for surgical intervention.
Manny age 52 is a postal worker who drives all day. He presents with LBP and has decreased sensation to pinprick in the lateral leg and web of the great toe. This indicates discogenic disease in the dermatomal pattern of which area? - L3/L4 (L4 root involvement) - L4/L5 (L5 root involvement) - L5/S2 (S1 root involvement) - None of the above
- L4/L5 (L5 root involvement)
Paul has malignant fibrosarcoma of the femur. He recently had surgery and is now on radiation therapy. You want to order a test to determine the extent of tumor invasion of the surrounding tissues and the response of bone tumor to the radiation. Which of the following tests would you order? - an xray - MRI - CT - needle biopsy
- MRI MRI will be more detailed and show response of the bone tumor to the radiation Needle bx determines stage of cancer CT evaluates extent of tumor into the bone, soft tissue and neurovascular structures
Marsha, age 34, presents with symptoms resembling both fibromyalgia and chronic fatigue syndrome, which have many similarities. Which of the following is more characteristic of fibromyalgia than of chronic fatigue syndrome? - MS pain - Difficulty sleeping - Depression - Fatigue
- MS pain - related more to fibromyalgia MS pain is NOT characteristic of chronic fatigue syndrome Fatigue is related more to chronic fatigue syndrome Depression and Difficulty sleeping are both related to Fibromyalgia and CFS
John is a 16-year-old boy who presents to the emergency room after hurting his knee in a football game. He described twisting his knee and then being unable to extend it completely. John tells the clinician that he heard a pop when the injury occurred and has been experiencing localized pain. The clinician suspects a meniscal tear. Which test would be most appropriate to assess for the presence of a meniscal tear? - Valgus stress test - McMurray circumduction test - Lachman test - Varus stress test
- McMurray circumduction test
You are caring for a patient that has a hx of psoriasis and now is showing signs of musculoskeletal signs and symptoms with joint involvement. Seropositivity provides a definitive diagnosis of psoriatic arthristis. Your initial tx choice for mgmt is: - disease modifying antirheumatic drugs (DMARD's) - NSAID's - tumor necrosis factor alpha inhibitors - uricosuric
- NSAID's are the first line tx DMARD's such as methotrexate are used for early stage tx of active dz with structural damage and inflammation Biological agents or TNF-alpha are considered for patients with active dz and inadequate response to one or more systemic DMARD's
In assessing an infant for developmental dysplasia of the hip, the practitioner places the infant supine, flexes the knees by holding the thumbs on the inner midthighs, with fingers outside on the hips, touching the greater trochanters, stabilizes one hip and abducts and gently pulls anteriorly on the other thigh. If this external rotation feels smooth with no sound present there is no hip dislocation. This is: - The Allis test - Lasegue's sign - McMurray test - Ortolani maneuver
- Ortolani maneuver
Your patient has just been told that he has a primary bone tumor. He was so upset when he heard that he focused only on the word tumor and not on the prognosis. Which of the following tumors is malignant? - Osteochondroma - Chondroma - Osteosarcoma - Giant cell tumor
- Osteosarcoma Is the most common malignant tumor that occurs in the long bones and knees Osteochondroma is the most common benign tumor and usually occurs in the pelvis, scapula, and ribs Chondroma occurs in the hands feet, ribs, spine, sternum or long bones Giant cell tumor is a tumor of the bone marrow cells in the shaft of long bones such as the femur, tibia, radius, and humerous
Janet is a 30-year-old woman who has been recently diagnosed with a herniated disc at the level of L5-S1. She is currently in the emergency room with suspicion of cauda equina compression. Which of the following is a sign or symptom of cauda equina compression? - Gastrocnemius weakness - A reduced or absent ankle reflex - Numbness in the lateral foot - Paresthesia of the perineum and buttocks
- Paresthesia of the perineum and buttocks Cauda equina is a continuation of the spinal cord below the first lumbar level in the adult. These nerves are responsible for specific sensory and motor functions. In some instances of herniation, there may be bilateral lower extremity weakness, anesthesia or paresthesia of the perineum and buttocks (saddle anesthesia) with bowel and bladder retention or incontinence This is a medical / surgical emergency
What disorder affects older individuals particularly women, and is characterized by pain and stiffness in the cervical spine and shoulder and hip girdles with signs of systemic infection such as malaise, wt loss, sweats and low grade fever - fibromyalgia syndrome - Myofasical somatic syndrome - Polymyalgia rheumatica - Reiter's syndrome
- Polymyalgia rheumatica Myalgias in the cervical spine, shoulder and hip with PMR can be profound and are commonly accompanied by systemic symptoms.
In analyzing synovial fluid, a yellow green color may indicate which of the following? - trauma - gout - bacterial infection - RA
- RA Synovial fluid that is yellow green in color indicates inflammation as in RA Normal synovial fluid is clear and light yellow or straw colored Osteoarthritis synovial fluid is clear and light yellow or straw colored Gout the synovial fluid is turbid and yellow/milky white in color Bacterial infection the fluid is turbid, gray-green or green/yellow
Joan has been diagnosed with osteoporosis confirmed by DEXA scan. You have educated her on the importance of increasing calcium and vit d, and starting a low impact exercise program. She asks you about a drug called a SERM, which of the pharmacological therapies for osteoporosis is classified as a selective estrogen receptor modulator (SERM)? - Alendronate - Risedronate - Salmon calcitonin - Raloxifene
- Raloxifene Alendronate and Risedronate are both biphosphonates and can be used in the prevention and treatment of osteoporosis
Sandy, age 49 presents with loss of anal sphincter tone, impaired micturition, incontinence, and progressive loss of strenght in the legs. you suspect cauda equina syndrome, What is your next action? - Order PT - Order lumbar/sacral x-ray - Order extensive lab work - Refer to a neurosurgeon
- Refer to a neurosurgeon Cauda equina syndrome is a disorder where there is loss of anal sphincter tone, impaired micturition and incontinence, saddle anesthesia at the anus, perineum or genitals and weakness in both legs x-ray is not helpful MRI is useful Neuro consult is essential
Which test assesses for thoracic outlet syndrome by having the client abduct his or her arms 90 degrees externally rotated with elbows flexed 90 degrees and then have the client open and close his or her hands for 3 minutes? - Neer test - Speeds test - Hawkins test - Roos test
- Roos test The Roos test suggests thoracic outlet syndrome when the client positions his or her shoulders in abduction and external rotation of 90 degrees with the elbow flexed to 90 degrees. The client then opens and closes his/her hand for 3 minutes.
Ethan, a 10 year old boy jumps off a 2 foot wall, twisting his foot and ankle upon landing. His ankle xray shows a fx of the distal tivia over the articular surface into the epiphysis and physis. Based on the Salter-Harris classification for growth plate injuries you this is a : - Salter-Harris II - Salter-Harris III - Salter-Harris IV - Salter-Harris V
- Salter-Harris III Salter-Harris I is through the physis (growth plate) Salter-Harris II is through the metaphysis and the physis Salter-Harris III is through the epiphysis and physis Salter-Harris IV is through the metaphysis, epiphysis and physis Salter-Harris V is a compression injury of the physis
Hilda age 73 presents with a complaint of low back pain. Red flags in her history of a minor fall, osteopenia, prolonged steroid use for SLE. These suggest the following possiblities for which of the following serious underlying conditions as the cause of her low back pain: - Cancer - Cauda equina syndrome - Neurological compromise - Spinal fx
- Spinal fx
You suspect a herniated disc on Sarah, age 72. You elevate her affected leg when she is in the supine position and it elicits back pain and sciatic nerve pain, which indicates a positive test. This is known as which test or sign? - Femoral stretch test - Cross straight leg raising test - Doorbell sign - Straight leg raising test
- Straight leg raising test All the tests listed may be used to assess for herniated disc In the cross-straight leg raising test - elevation of the uninvolved leg produces sciatic pain down the contralateral leg The Doorbell sign is the development of sciatic pain with the spinous process over the protruded disk is deeply palpated The Femoral Stretch test is done with the client prone and the leg extended and the knee flexed. Pain radiating to the anterior thigh indicates an L4 radiculopathy. Suspect a herniated disk
In assessing the skeletal muscles you turn the forearm so that the palm is up. This is called? - Supination - Pronation - Abduction - Eversion
- Supination Turning the forearm up is supination. Pronation - turning palm down Abduction - moving limb away from midline Eversion - moving the sole of the foot outward at the ankle
One of the initial steps in assessing patients with musculoskeletal complaints is to determine whether the complaint is articular or nonarticular in origin. Which of the following is an example of an articular structure? - Bone - Synovium - Tendons - Fascia
- Synovium
Which of the following statements is true concerning the musculoskeletal exam? - The uninvolved side should be examined initially and compared to the involved side. - The part of the body that is causing the patient pain should be examined first - The patient should not be asked to perform ROM exercises whenever possible to avoid causing pain - Radiographs should always be obtained prior to exam so as not to cause further injury to the patient
- The uninvolved side should be examined initially and compared to the involved side
Jennifer is an 18-year-old girl who comes to the emergency room after a fall during a soccer game. Jennifer explains that she fell on her left side and kept her arm out straight to break her fall. She has been experiencing severe pain and limited range of motion in her left shoulder. The clinician has diagnosed Jennifer with a dislocated shoulder. Which of the following statements are true concerning shoulder dislocation? - Posterior dislocations are more common than anterior dislocations. - There is a risk of neurovascular and neurosensory trauma, so the clinician should check for distal pulses. - Recurrent dislocations are uncommon and would require a greater force to result in injury. - Surgery is most commonly the treatment of choice.
- There is a risk of neurovascular and neurosensory trauma, so the clinician should check for distal pulses. Posterior dislocations are LESS common than Anterior
Mrs. Allen is a 60-year-old woman who has been diagnosed with osteoporosis. She is very concerned about the risk of breast cancer associated with hormone replacement therapy and is wondering what else is available to her. The clinician explains that biphosphonates are another class of drugs used in the prevention and treatment of osteoporosis. What teaching should the clinician give Mrs. Allen in regard to taking biphosphonates? - Taking biphosphonates can result in hypercalcemia, so calcium intake should be decreased while taking this class of drugs. - There is potential for upper gastrointestinal (GI) irritation, so these medications are contraindicated in people with abnormalities of the esophagus or delayed esophageal emptying. -This class of drugs can be taken at any time of the day without regard to meals. - None of the above
- There is potential for upper gastrointestinal (GI) irritation, so these medications are contraindicated in people with abnormalities of the esophagus or delayed esophageal emptying.
Which test is used to diagnose an Achilles tendon rupture? - Boutonniere test - Lachman test - Thompson test - Drawer test
- Thompson test Is used to dx an achilles rupture Lachman test assesses for ACL tear Anterior drawer test also assesses for an ACL tear and is more reliable than the Lachman
Jim, age 64 has RA, Which of the following drugs would be of least benefit for him?> - Disease modifying antirheumatic drugs - Tylenol - NSAID's - Glucocorticoids
- Tylenol Tylenol has no anti-inflammatory properties DMARD's, NSAID's and steriods all reduce inflammation and can help reduce pain
Sam is a 25-year-old man who has been diagnosed with low back strain based on his history of localized low back pain and muscle spasm along with a normal neurological examination. As the clinician, you explain to Sam that low back pain is a diagnosis of exclusion. Which of the following symptoms would alert the clinician to the more serious finding of a herniated nucleus pulposus or ruptured disc? - Morning stiffness and limited mobility of the lumbar spine - Unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain - Fever, chills, and elevated erythrocyte sedimentation rate - Pathologic fractures, severe night pain, weight loss, and fatigue
- Unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain The most common cause of radicular pain to the lower extremities is a herniated lumbar intervertrebral disc.
Karen is postmenopausal, is taking 1500 mg of calcium but does not understand why she also needs to take vitamin D. You tell her that: - A deficiency of vitamin D results in an inadequate mineralization of bone matrix - All vitamins need to be supplemented - Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone - Vitamin D binds with calcium to allow active transport into cells
- Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone Vitamin D deficiency causes inadequate mineralization of bone matrix (rickets)
The American College of Obstetricians and Gynecologists guidelines for exercise during pregnancy and after delivery include which of the following? - Women should try to exercise moderately for at least 30 minutes on most if not all days of the week - Exercise in the supine position is the position of choice - Anaerobic exercise during pregnancy is preferred over aerobic exercise - Exercise should be discontinued upon discovery of pregnancy and resumed after delivery
- Women should try to exercise moderately for at least 30 minutes on most if not all days of the week Exercising in the supine position should be avoided after the first trimester because it is assoc with decreased cardiac output
The clinician has instructed Sam, a 25-year-old patient with low back strain, to use NSAIDs to manage his symptoms of pain and discomfort. Which of the following statements would be most appropriate when teaching Sam about the use of NSAIDs to manage his pain? - You should start with the lowest dose that is effective in managing your pain, because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such as ulcers and hemorrhage. - You should start with the lowest dose that is effective in managing your pain in order to avoid developing tolerance to the medication. - You should take the maximum recommended dose of NSAIDs so that you will not need to take narcotics to control your pain. - It is important to take NSAIDs on an empty stomach in order to increase absorption.
- You should start with the lowest dose that is effective in managing your pain, because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such as ulcers and hemorrhage.
A Baker's cyst is: - inflammation of the bursa - a form of tendonitis - a buildup of synovial fluid behind the knee - the result of a swollen ligament
- a buildup of synovial fluid behind the knee also called a popliteal cyst. It is usually the result of inflammation from knee arthritis, or cartilage (usually meniscal) tear Symptoms consist of pain, inability to extend the knee and may mimic symptoms of a DVT
Jennifer says that she has heard that caffeine can cause osteoporosis and asks why, how do you respond? - Caffeine has no effect on osteoporosis - a high caffeine intake has a diuretic effect that may cause calcium to be excreted more rapidly - caffeine affects bone metabolism by altering intestinal absorption of calcium and assimilation of calcium into the bone matrix - caffeine increases bone resorption
- a high caffeine intake has a diuretic effect that may cause calcium to be excreted more rapidly The effect of caffeine on osteoporosis is controversial, but its diuretic effect may cause calcium to be excreted more rapidly
During your assessment of your clients foot, you note that the foot is in alignment with the long axis of the lower leg and that weight bearing falls on the middle of the foot, from the heel along the mid foot to between the second and third toes. What do you diagnose? - a normal foot - hallux valgus - talipes equinovaris - hammertoes
- a normal foot
You are assessing Maya, a 69 year old Asian woman for the first time. you are trying to differentiate between scoliosis and kyphosis. Kyphosis involves: - asymmetry of the shoulders, scapulae and waist creases - a lateral curvature and vertebral rotation on PA xrays - one leg appearing shorter than the other - a posterior rounding at the thoracic level
- a posterior rounding at the thoracic level Scoliosis involve all the others
Janine age 69 has a class III case of RA, according to the American Rheumatism Association her function would be - adequate for normal activities despite a handicap of discomfort or limited motion of one or more joints - largely or wholly incapacitated, bedridden or confined to a wheelchair permitting little or no self care - completely able to carry on all usual duties without handicaps - adequate to perform only a few or none of the duties of usual occupation or self care
- adequate to perform only a few or none of the duties of usual occupation or self care Class I - refers to the client who can carry on all usual duties w/o handicap Class II - refers to the client whose function is adequate for normal activities despite a handicap of discomfort or limited motion at one or more joints Class III - refers to Janine - adequate to perform only a few or none of the duties of usual occupation or self care Class IV - largely or wholly incapacitated, bedridden or confined to a wheelchair permitting little or no self care
When teaching Alice age 67 to use a cane because of osteoarthritis of her left knee and important point to stress is to tell her to: - carry the cane in the ipsilateral hand - advance the cane with the ipsilateral leg - make sure that the cane length equals the height of the iliac crest - use the cane to aid in joint protection and safety
- advance the cane with the ipsilateral leg The cane should be carried in the contralateral hand and the cane length should equal the height of the greater trochanter.
Jesse, age 49, thinks she has RA. Before any diagnostic tests are performed, you complete a physical exam and make a tentative dx of osteoarthritis rather than RA. Which clinical manifestation ruled out RA? - fatigue - affected joints are swollen cool and bony hard - decreased ROM - stiffness
- affected joints are swollen cool and bony hard In osteoarthritis the affected joints are swollen, cool and bony hard. In RA the affected joints appear red, hot and swollen and are boggy both RA and OA have decreased ROM and stiffness
A coccygeal fx is tx with: - traction - surgical repair - analgesia and by use of a donut cushion when sitting - prolonged bedrest for 6 weeks
- analgesia and by use of a donut cushion when sitting
You correctly perform the obturator test when you raise the clients leg with knee flexed and internally rotate the leg. A positive obturator test is indicative of: - avascular necrosis of the femoral head - cholecystitis - hip bursitis - appendicitis
- appendicitis A positive obturator test, especially with a positive McBurney's point and positive Psoas sign is indicative of appendicitis Although internal rotation of the hip can cause hip discomfort in a client with hip bursitis and AVN, the obturator test elicits RLQ abdominal pain indicative of appendicitis https://www.youtube.com/watch?v=6LrL4ysi_A
Lois, age 52 who has been given a dx of sarcoidosis, has joint symptoms including arthralgias and arthritis, your next plan of action would be to: - order a bone scan - obtain a tissue bx - begin a course of glucocorticoids - obtain and EKG
- begin a course of glucocorticoids Sarcoidosis is an exaggerated immune response to a class of antigens or self antigens. 50% of patients have joint symptoms, myopathy, polyarthritis and glucocorticoids are prescribed to suppress the immune response
Mike a golf pro, has had chronic back pain for many years. His workup reveals that it is not the result of a degenerative disk problem. His back goes out about twice and year and he is out of work for about a week each time. Which of the following would you suggest he do? - consider changing careers to a less physical job - begin a planned exercise program to strengthen back muscles - make an appointment with a neurosurgeon for a surgical consult - start on dialy low dose narcotic to take away the pain
- begin a planned exercise program to strengthen back muscles In this instance Mike may benefit from regular planned exercise program to strengthen his back.
John age 17 is a stock boy at a local supermarket. He is in the office for a routine visit. You notice that he had an episode of LBP 6 months ago from improperly lifting boxes. In discussing proper body mechanics with him to prevent further injury to tell him: - bend at your knees and face the object straight on - Hold the boxes away from your body at arm's length - Bend and twist simultaneously as you lift - Keep your feet firmly together
- bend at your knees and face the object straight on
Sam age 50 presents with Paget's disease, that has been stable for several years. Recently his serum alkaline phosphatase level has been steadily rising. You determine that it is time to start him on: - NSAID's - corticosteriods - bisphosphonates - calcitonin
- bisphosphonates NSAID's are helpful in patients with Paget's dz, however when Alk phos levels begin to rise, this indicates that the disease is progressing. Bisphosphinates decrease bone resorption by inhibiting osteoclast activity. Calcitonin also inhibits osteoclast bone resorption but is not as powerful as bisphosphinates
Jane age 64 comes in for a visit. She has a cast on her right arm and tells you that she has a comminuted fx of her radius. When she asks what that means, you tell her that in a comminuted fx the: - bony fragments are in many pieces - broken ends of the bone protrude through the soft tissue and skin - bone breaks cleanly but does not penetrate the skin - bone is crushed
- bony fragments are in many pieces A compression fx is when the bone is crushed
Carol age 62 has swollen bony proximal interphalangeal joints, you describe these as: - heberden's nodes - bouchard's nodes - osler's nodes - murphys nodes
- bouchard's nodes - bony enlargements of the PIP - heberden's nodes are bony enlargements of the DIP bouchard's and heberden's nodes suggest OA Osler's nodes are painful raised lesions of the fingers toes or feet that occur with bacterial endocarditis
Shane age 28 has a cast on his right arm because of an inline skating accident. Twelve hour after the cast is applied, he complains of severe pain. His fingers are pink, yet he states that they are tingling and numb, what do you suspect? - compartment syndrome - phlebitis - osteomyelitis - muscle contracture
- compartment syndrome usually develops within the first 48 hours When assessing for compartment syndrome - 5 P's P - Pain P- pulselessness P- pallor P- parathesia P- paralysis
To plan a community education program, the NP needs to know that persons at highest risk for developing TOS are: - bicycle riders - dancers - computer programmers - swimming instructors
- computer programmers TOS results from compression of nerves, blood vessels, or both in the upper extremity arising from the head, neck, shoulders, upper extremities and chest. Predisposing factors are head and neck trauma, poor posture, and certain occupations such as piano players and computer programmers.
You are assessing Mike, age 16, after a football injury to his right knee, You elicit a positive anterior/posterior drawer sign. This test indicates an injury to the: - lateral meniscus - cruciate ligament - medial meniscus - collateral ligament
- cruciate ligament A positive anterior/posterior drawer sign or lachman test are both utilized to assess for cruciate ligament injury.
When you elicit a painful Finkelsteins sign you are testing for: - CTS - bursitis of the shoulder - deQuervain's tenosynovitis - tennis elbow
- de quervain's tenosynovitis The test is positive if pain is elicited in the area of the lateral epicondyle
Lillian age 70 was told that she has osteoporosis, when she asks you what that is you respond that osteoporosis is: - develops when loss of bone matrix (resorption) occurs more rapidly than new bone growth (deposition) - is a degenerative joint disease characterized by degeneration and loss of articular cartilage in synovial joints - is a chronic systemic inflammatory disorder characterized by persistent synovitis of multiple joints - is a metabolic bone disorder characterized by inadequate mineralization of bone matrix
- develops when loss of bone matrix (resorption) occurs more rapidly than new bone growth (deposition) Osteoarthritis is a degenerative bone disease RA is a chronic systemic inflammatory disorder characterized by persistent synovitis of multiple joints Osteomalacia is a metabolic bone disorder charcterized by inadequate mineralization of bone matrix often characterized by Vit D deficiency
What is the type of joint that is freely movable, such as the shoulder joint called? - synarthrosis joint - amphiarthrosis joint - diarthrosis joint - juxtarthrosis joint
- diarthrosis joint (aka synovial joints) This is a freely movable joint - the shoulder, joints in the limbs, and hips
Sam age 34 fx his femur when his horse tripped over a jump. With this type of injury, you know that Stan is at risk for fat emboli. Early assessment findings for this would include: - fever, tachycardia, rapid respiration's, and neurological manifestations - neurological manifestations, temperature elevation, bradycardia and pallor - hostility, combativeness, substernal pain and weak thready pulse. - lethargy hypothermia, paresthesia and absent peripheral pulses.
- fever, tachycardia, rapid respiration's, and neurological manifestations Fat emboli usually occur within 72 hours after the injury
When grading muscle strengh on a scale of 1 - 5 a grade of 4 indicates: - full rom against gravity with full resistence - full rom against gravity with some resistance - full rom with gravity - full rom with gravity eliminated (passive motion)
- full rom against gravity with some resistance Grade 5 = full ROM against gravity with full resistence Grade 4 = Full ROM against gravity with some resistence Grade 3 = Full ROM with gravity Grade 2 = Full ROM with gravity eliminated (passive motion) Grade 1 = slight muscle contraction Grade 0 = no muscle contraction
Ginny, age 48, has RA and gets achy and stiff after sitting through a long movie. This is referred to as: - longevity stiffness - gelling - intermittent arthritis - molding
- gelling Refers to the achiness and stiffness that occur in clients with rheumatoid arthritis after a period of inactivity
Cass, age 67, tell you that she has been diagnosed with a condition that causes sudden flares of pain, swelling and redness of the joints of her toes. She cannot remember the name of the dx but she knows that it is caused by urate crystals that get stuck in the join and cause pain. Joan is on HCTZ for management of her HTN. You suspect: - septic arthritis - gout - RA - Charcot neuro- osteoarthropathy
- gout Gout involves the abnormal metabolism of uric acid that results in hyperuricemia. High concentrations of urate precipitate into crystals that collect in tissue and joint spaces and can cause pain and inflammation. Septic Arthritis presents with a sudden onset of pain swelling, and heat in the joint, however is more likely to occur in the knee, followed by the hip, shoulder, wrist and ankle. RA typically affects multiple joints simultaneously and is a slow and progressive disease. Charcot neuro-osteoarthropathy occurs in DM patients presents as a hot swollen red joint. These patients usually report a hx of trauma, surgery or prior infection.
Alan age 46 presents with a tender red swollen knee. You rule out septic arthritis and dx gout by confirming: - an elevated WBC - hyperuricemia - a significant response to a dose of ceftriazone - a positive ANA
- hyperuricemia A septic joint would more than likely cause an elevated WBC and a positive culture Ceftriazone is an abx used in teh tx of septic arthritis A + ANA may indicate SLE or scleroderma
Jill age 49 has recently begun a rigorous weight lifting program. She presents to the office today with a shoulder dislocation. Which of the following clinical manifestations make you suspect an anterior shoulder dislocation over a posterior dislocation? - inability to shrug the shoulders - absence of pain - inability to rotate the shoulder externally - Shortening of the arm
- inability to shrug the shoulders Anterior dislocations are far more common. Symptoms of an anterior dislocation include the inability to shrug the shoulder, pain, and lengthening of the arm Inability to rotate the shoulder externally is a clinical manifestation of a posterior should dislocation along with the inability to elevate the arm.
A common cause of in-toeing in childhood is: - internal tibial torsion - femoral retroversion - external tibial torsion - flat feet
- internal tibial torsion Is the most common cause of in-toeing in children External tibial torsion is the most common cause of out-toeing Femoral retroversion is the second most common cause of out-toeing
Colchicine may be used to terminate an acute attack of gouty arthritis, as well as to prevent recurrent episodes. The mechanism of action is to: - interrupt the cycle of urate crystal deposition and inflammatory response - increase serum uric acid levels - potentiate the excretion of uric acid - inhibit the tubular reabsorption of urate, promoting the excretion of uric acid
- interrupt the cycle of urate crystal deposition and inflammatory response Used to treat an acute attack of gout, colchicine does not alter serum uric acid levels. Colchicine is generally used as a second line drug when NSAIDS or corticosteroids are contraindicated or not effective
When Maxwell, age 12 slid into homeplate while playing baseball he injured his ankle, you are trying to differentiate between a sprain and a strain. You know that a sprain: - is an injury to the ligaments that attach to bone in a joint - is an injury to the tendons that attach to the muscles in a joint - is an injury resulting in tears of the muscles - does not result in joint instability
- is an injury to the ligaments that attach to bone in a joint A sprain is defined as an injury to the ligaments that connect bone to bone in a joint that results from a twisting motion and may cause joint instability. A strain is defined as an injury to the muscles and or tendons that attach muscles to bones
Heidi, age 29, is a nurse who has an acute episode of back pain. You have determined that it is a simple mechanical backache and order: - bedrest for 2 days - muscle relaxants - let pain be your guide and continue activities - back strengthening exercises
- let pain be your guide and continue activities Faster symptomatic recovery is seen in patients with mechanical back injury who return to normal activity Back strengthening exercises should be started within 6 weeks of injury
Treatment of choice for polymyalgia rheumatica (PMR) is - acetaminophen or NSAID's - low dose steroids - tricyclic antidepressants - abx
- low dose steroids Tx of choice for PMR consist of low dose steroids starting at 10 to 15 mg and tapering to 5 - 7.5 mg daily for several weeks or months
The most common cause of cauda equina syndrome is: - fracture - hematoma - lumbar intervertebral disk herniation - space occupying lesion
- lumbar intervertebral disk herniation is the most common cause of CES. Other causes include trauma, fx, hematoma , abscesses, lymphoma and other space occupying lesions
Mrs. Matthews has RA. On reviewing an xray of hip you notice that there is marked absence of articular cartilage. What mechanism is responsible for this? - Antigen-antibody formation - lymphocyte response - Immune complex formation - lysosomal degradation
- lysosomal degradation this occurs when leukocytes produce lysosomal enzymes that destroy articular cartilage. The collagen fibers and the protein polysaccharides of articular cartilage are broken down by the enzymes
June, a 59 year old cashier, presents with back pain with no precipitating factors. The pain is located over her lower back and muscles without sciatica, and is aggravated by sitting and certain movements. It is alleviated with rest. Palpation localizes the pain and muscles spasms are felt. There was an insidious onset with progressive improvement. What is your initial diagnosis? - ankylosing spondylitis - musculoskeletal strain - spondylolisthesis - herniated disc
- musculoskeletal strain Musculoskeletal strain is aggravated by sitting, standing and certain movements. Palpation localizes the pain and spasms may be felt
The straight leg raising maneuver can be used to diagnose: - nerve root compression - a fractured hip - anterior cruciate ligament tear - tendinitis
- nerve root compression
Harry age 59 has Paget's disease of the bone. It was diagnosed as a result of routine blood work during his annual physical, which showed an increase in serum alkaline phosphate levels. You know that the most common complication of Paget's disease is: - osteosarcoma - nerve compression - fractures - bone pain
- osteosarcoma The development of osteosarcoma in Paget's lesions is the most serious complication of Paget's disease The instance is almost 1000-fold greater than age matched patients without Paget's
A clinical manifestation of symmetric neurogenic pain may indicate: - radiculopathy - reflex sympathetic dystrophy - entrapment neuropathy - peripheral neuropathy
- peripheral neuropathy Asymmetric neuropathy will include radiculopathy, reflex sympathetic dystrophy and entrapment neuropathy A claudication pain pattern will be present in PVD, giant cell arteritis with jaw pain and lumbar stenosis
You have completed a work up on Michael age 13, and confirmed Osgood - Schlatter dz. You should - refer to ortho for early surgical correction - recommend pt for quadriceps strength training - advise him to temporarily discontinue all sports until his growth plates have completely fused - tell Michael that he can resume his usual activities immediately without concern and should begin aggressive exercises to increase muscle bulk and strength
- recommend pt for quadriceps strength training Osgood - Schlatter dz is a benign self limited knee condition in young boys and girls. Tx consists of ice, analgesics, NSAID's and temporary avoidance of pain producing activities. Conservative management consists of - quadriceps strength training exercises to decrease tension on the tibial tubercle. Surgical correction is not recommended until all other options have been tried
James age 17 has been complaining of a painful knob below his right knee that has prevented him from actively participating in sports. He has recently been given the dx of Osgood-Schlatter dz and asks you about his tx options. You tell him that the initial tx is: - relative rest; he could benefit from hamstring stretching, heel cord stretching and quadriceps stretching exercises - immobilization; a long leg knee immobilizer is recommended - surgical intervention; removal of the bony fragments is necessary - bedrest for 1 week
- relative rest; he could benefit from hamstring stretching, heel cord stretching and quadriceps stretching exercises Initial tx starts with relative rest with stretching If the problem persists - long knee immobilizer Surgery is rarely needed Osgood-Schlatter dz is an overuse injury that results from excessive tension and pull of the patellar tendon on the tibial tuberosity. Conservative tx while an adolescent will avoid potential problems as an active adult
Margaret age 55, presents to you for evaluation of left hand and wrist pain with swelling after a slip and fall on the ice yesterday. On exam, you note tenderness to her anatomical snuffbox, you know this probably indicates: - ulnar styloid fx - scaphoid fx - hamate fx - radial head fx
- scaphoid fx tenderness over the anatomical snuffbox usually indicates a scaphoid (navicular) fracture. the most common injury of the carpal bones. Poor blood supply puts the scaphoid bone at risk for avascular necrosis; therefore any tenderness over this region warrants an xray
The C5 myotome innervates: - wrist extension - elbow extension - shoulder abduction and elbow flexion - ulnar deviation at the wrist along with finger flexion and abduction
- shoulder abduction and elbow flexion C5 innervates should abduction and elbow flexion C6 innervates wrist extension C7 innervates elbow extension C8 Finger flexion and abduction
Which are the modifiable risk factors for osteoporosis? - low etoh intake - low caffeine intake - smoking - excessive exercise
- smoking Risk factors include: - high etoh intake - high caffeine intake - sedentary lifestyle - calcium deficiency - estrogen deficiency
You are considering a dx of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease or Pseudogout in a 72 year old man with complaints of pain and stiffness in his wrists and knees. The most useful diagnostic test to assist you in making this dx would be: - synovial fluid analysis and xray - bacterial culture - bone scan and MRI - anticitrullinated protein antibody (ACPA) test and RA factor
- synovial fluid analysis and xray CPPD disease or Pseudo gout may appear clinically similar to gouty arthritis, however in CPPD crystals form in the cartilage and lead to inflammation Dx is made through synovial fluid aspirate
When wrist and finger extension causes pain over the extensor carpi radialis longus tendon and the extensor digitorum communis, you would suspect: - tennis elbow - golfers elbow - deQuervains dz - intersection syndrome
- tennis elbow With tennis elbow, wrist and finger extension causes pain over the extensor carpi radialis longus tendon and the extensor digitorum communis - golfers elbow pain is experienced on wrist flexion over the flexor carpi radialis, the flexor carpi ulnaris and the pronator teres tendons
Christian is a 22 year old carpenter who is right hand dominant, comes to you for follow up from the ED where he was seen for right forearm pain. He states he was diagnosed with right forearm tendonitis and wants you to explain this diagnosis to him. You explain to him that he has inflammation of one or more tendons which are: - ropelike bundles of collagen fibrils that connect bone to bone - the collagen fibers that connect muscle to bone - the pouches of synovial fluid that cushion bone and other joint structures - the fibrocartilaginous disks that seperate bony surfaces
- the collagen fibers that connect muscle to bone
Which part of the body is affected by Dupuytrens contracture? - the fourth and fifth fingers - the great toe - the tibia - the penis
- the fourth and fifth fingers Dupuytrens contracture manifests itself by nodular thickening of the connective tissue of one or both hands, usually affecting the fourth and fifth fingers. There is usually inability to extend the fingers
To diagnose fibromyalgia, there must be tenderness on digital palpation in at least 11 of 18 (nine pairs) tender point sites, which would include: - the occiput, low cervical, trapezius, and supraspinatus - the PIP, MCP joints of the hands and the MTP and PIP joints of the foot - the facet joints of the cervical, thoracic, and lumbar spine, - the radial and ulnar styloids and medial and lateral malleoli
- the occiput, low cervical, trapezius, and supraspinatus Facet joints of the spine are often tender in facet arthritis PIP, MCP and MTP joint tenderness often occurs primarily in RA
Anne, a 67 year old female sustained a fall on an outstretched hand, presents holding her arm against her chest with her elbow flexed. Based on the specific location of the pain you suspect a radial head fracture, your best initial assessment strategy to assess for radial head fracture would be - to palpate for tenderness, swelling, and crepitus just distal to the lateral epicondyle - to palpate for tenderness, swelling and crepitus along the radial wrist - to palpate for tenderness in the anatomical snuffbox - to order an xray of the wrist
- to palpate for tenderness, swelling, and crepitus just distal to the lateral epicondyle the radial head is the proximal aspect of the radius located in the elbow joint. Falling on an outstretched hand transfers a great deal of force to the radial head.
Sandra, a computer programmer has just been given a new diagnosis of carpel tunnel syndrome, your next step is to - refer her to a hand surgeon - take a complete hx - try neutral position wrist splinting and order an oral NSAID - order an EMG
- try a neutral position hand splint and order oral NSAID's For symptoms of less than 10 months duration, conservative tx is tried first. EMG only confirms CTS and is not necessary
What is a herniated disc?
A herniated disk is often preceded by years of recurrent episodes of localized back pain and there is usually leg pain that overshadows the back pain
What is De Quervain's tenosynovitis?
De Quervain's tenosynovitis occurs when the synovial lining of the tunnel becomes inflamed narrowing the opening of the tunnel.
How do you perform the McMurray test?
Done to assess the meniscal ligament. Fully flex the knee with the leg externally rotated for a medial meniscal tear If internally rotated assesses for lateral meniscal tear A painful cartilage click is considered a positive sign
Mickey is on a chemotherapeutic antibiotic for musculoskeletal neoplasm. Which drug do you think he is taking? Cyclophosphamide (Cytoxan) Doxorubicin (Adrianmycin) Methotrexate (Rheumatrex) Cisplatin (Platinol)
Doxorubicin (Adrianmycin) is the only antineoplastic antibody listed Cyclophosphamide is an alkylating agent Methotrexate is an antimetabolite Cisplatin is an inorganic platinum agent
The presence of a positive rheumatoid factor is always indicative of rheumatoid arthritis. T or F
F
If any limitation or any increase in range of motion occurs when assessing the musculoskeletal system, the angles of the bones should be measured by using: - Phalens test - skeletometry - the Thomas test - goniometer
Goniometer If any limitation or increase in ROM occurs when assessing the MS system, the angles of the bones should be measured using a goniometer, which gives precise measurements of ROM Phalens test is used to dx CTS Skeletometry does not exist Thomas test is for hip ROM
How do you assess for scoliosis, hip motion and hamstring tightness?
Have the participant standing with knees straight and then touch the toes to check for scoliosis, hip motion and hamstring tightness
What are ligaments?
Ligaments connect bone to bone in the joints
First line drug therapy for acute low back pain includes the use of: NSAID's muscle relaxants opioids antidepressants
NSAID's as well as asa and tylenol
What is Reiter's syndrome?
Reiters syndrome or reactive arthritis is a classic triad of non-gonococcal urethritis, conjunctivitis and arthritis that follows certain infections of the GI or GU tract
What is the largest joint in the body? - hip - shoulder - knee - elbow
The knee
What are synarthrosis or fibrous joints?
These are immovable joints such as skull sutures, epiphyseal plates, ribs, and manubrium of the sternum
Normal estrogen function is important for preventing osteoporosis in both men and women. Estrogen works to prevent osteoporosis in which of the following ways? - By decreasing the erosive activity of osteoclasts - By promoting osteoclastogenesis - By inhibiting osteoclast apoptosis - All of the above
- By decreasing the erosive activity of osteoclasts
During a sports preparticipation physical exam, when you ask the client to rise up on his toes and raise his heels you are observing for - calf symmetry and leg strength - hip, knee and ankle symmetry - hip, knee and ankle motion - scoliosis, hip motion and hamstring tightness
- calf symmetry and leg strength
Which of the following can assist in diagnosis of myasthenia gravis? - repetitive nerve stimulation - cogwheel rigidigy - chvosteks sign - trousseau's sign
- repetitive nerve stimulation RNS is the the most frequently used electrodiagnostic test for MG. Serological testing includes: serum anti-AChR antibodies Cogwheel rigidity is seen in Parkinsons Dz Chvostek's and Trousseaus signs are signs of tetany
Mr. Miller a 72 year old African American with type 1 DM. He has been a chronic smoker for 50 years. He has been told recently that he must have an above the knee amputation because of a gangrenous foot. He has lost his will to live, and states "they shoot horses, don't they" How do you respond? - You should be thankful they can saver you life if not your leg - your wife needs you, you must think of her at this time - How do you feel surgery will affect you? - I will stay with you before, during and after surgery because I know this is a hard time for you.
I will stay with you before, during and after surgery Explore his feelings...
Which of the following tests assesses the patency of the radial and ulnar arteries? - Allen test - Finkelstein's test - Phalen's test - Tinel's sign
- Allen test Finkelsteins test assesses for de Quervain's tenosynovitis Phalens and Tinels are for CTS
Which of the following statements is true concerning the treatment of fibromyalgia syndrome? - There is currently no cure for the disorder; however, patients should be made aware that symptom relief is possible. - Treatment is directed toward controlling discomfort, improving sleep, and maintaining function. - Fibromyalgia syndrome can be difficult to manage, requiring a variety of approaches and multiple medications. - All of the above
- All of the above
Which of the following statements is true regarding the treatment of carpal tunnel syndrome? - The goal of treatment is to prevent flexion and extension movements of the wrist. - Splints are used in carpal tunnel syndrome because they allow for free movement of the fingers and thumb while maintaining the wrist in a neutral position. - Corticosteroid injections are discouraged in the treatment of carpal tunnel syndrome because of the risks for median nerve damage, scarring, and infection. - All of the above
- All of the above
Which stage of Paget's disease is characterized by elevated numbers of osteoblasts resulting in abnormal increases in bone remodeling, leading to an irregular deposition of collagen fibers? - Lytic - Mixed - Sclerotic - All of the above
- Mixed Lytic stage - osteolytic lesion may be observed in the skull or long bone Mixed stage - x-ray reveals both osteolytic and sclerotic changes in the same bone Sclerotic stage - sclerotic lesion dominates the bone and there may be an increase in the bone itself
Which of the following signs or symptoms indicate an inflammatory etiology to musculoskeletal pain? - Decreased CRP - Hyperalbuminemia - Morning stiffness - Weight gain
- Morning stiffness
Martin age 58 presents with urethritis, conjunctivitis, asymmetric joint stiffness, primarily in the knees, ankles and feet. Which condition do you suspect? - Syphilis - Gonorrrhea - HIV - Reactive arthritis
- Reactive arthritis or Reiters syndrome Associated symptoms include the classic triad of conjunctivitis, nongonococcal urethritis and arthritis. A common pneumonic is the client who - can't see can't pee and can't climb a tree
BMD testing is recommended by the National Osteoporosis Foundation for which of the following client populations to assess whether they are at risk for osteoporosis? - All women age 65 and older regardless of risk factors - All men age 65 and older regardless of risk factors - All women in the 30's for baseline - All women of menopausal age
- All women age 65 and older regardless of risk factors AND on post menopausal women under the age of 65 with risk factors AND on women of menopausal age who present with fractures after the age of 50 AND on men age 70 and older OR between the ages of 50 and 69 with risk factors
Mr. Jackson is a 65-year-old man recently diagnosed with osteoarthritis. The clinician has explained to Mr. Jackson that the goals for managing osteoarthritis include controlling pain, maximizing functional independence and mobility, minimizing disability, and preserving quality of life. Mr. Jackson explains to the clinician that his first choice would be to use complementary therapies to control his condition and asks what therapies are most effective in treating osteoarthritis. What would be the most appropriate response of the clinician? - "Complementary therapies should only be considered if surgical interventions are not successful." - "I am unfamiliar with the available complementary therapies for osteoarthritis and prefer to discuss more mainstream treatments such as NSAIDs and physical therapy to manage your condition." - "I would be happy to discuss all the treatment options available to you. Complementary therapies such as acupuncture, acupressure, and tai-chi are being studied for use in the treatment of osteoarthritis and have shown promise when used with standard medical therapy." - "It would be crazy to use complementary therapies to treat such a serious condition."
- "I would be happy to discuss all the treatment options available to you. Complementary therapies such as acupuncture, acupressure, and tai-chi are being studied for use in the treatment of osteoarthritis and have shown promise when used with standard medical therapy."
Anne Marie states that she has a maternal hx of rheumatoid dz but that she has never been affected. Today she presents with complaints of dryness of the eyes and mouth, what do you suspect? - RA - SLE - Sjogrens syndrome - Rosacea
- Sjogrens syndrome Sjogrens syndrome affects the salivary and lacrimal glands causing dry eyes and mouths. it is an inflammatory disease of the exocrine glands and may be isolated or associated with rheumatic disease, RA or SLE
The knee is an example of a: - spheroidal joint - hinge joint - condylar joint - fibrous joint
- condylar joint A condylar joint such as the knee and TMJ has articulating surfaces that are convex and concave and are termed condyles. Spheroidal joints have a ball and socket configuration Hinge joints are flat and uniplanar allowing only gliding motion in a single plane such as flexion and extension
A 13 year old obese boy reports low grade left knee pain for the past 2 months. He denies antecedent trauma but admits to frequent horseplay with his friends. The pain has progressively worsened and he is now unable to bear weight at all on his left leg. His current complaints include left groin, thigh and medial knee tenderness. His exam demonstrates a negative drawer, Lachman and McMurray tests; left hip with decreased internal rotation and abduction; and knee flexion causing external hip rotation. Based upon the above scenerio you suspect: - left menicus tear - left anterior cruciate ligament tear - slipped capital femoral ephipysis - Osgood-Schlatter disease
- slipped capital femoral ephipysis Slipped capital femoral ephipysis is a displacement of the femoral head relative to the femoral neck that occurs thru the physis (growth plate) of the femur. The vast majority of clients are obese, as the added weight increases sheer stress through the physis. The mean age is 12 years for female and 13 years for males. Surgery is often required to stabilize the growth plate to prevent further slippage and to avoid complications
Jake, age 16, comes into the office with a human bite on his fist. What is the first course of action? - De-bride and irrigate the wound thoroughly. - Initiate broad-spectrum antibiotics. - Leave the wound open for drainage. - Administer a tetanus injection.
De-bride and irrigate the wound immediately X-ray to rule out osteomylitis, fractures, or retained teeth from the offender Wound culture of an older wound PO Augmentin - leave wound open for drainage Possible need for tetanus injection
