Musculoskeletal FNP review Fitzgerald info

Cox-2

-inflammatory response. - pain transmission. -Maintenance of gastric protective mucosal layer. - Renal arteriole constriction.

Initial diagnostic tests for RA

ANA, ESR, CRP Anti-citrullinated protein antibody (ACPA) Rheumatoid factor (RF) Radiographs,

A 72-year-old man presents at an early stage of osteoarthritis in his left knee. He mentions that he heard about the benefits of using glucosamine and chondroitin for treating joint problems. In consulting the patient, you mention all of the following except: A. any benefit can take at least 3 months of consistent use before observed. B. glucosamine is not associated with any drug interactions. C. clinical studies have consistently shown benefit of long-term use of glucosamine and chondroitin for treating OA of the knee. D. chondroitin should be used with caution because of its anti-platelet effect.

C

As part of the evaluation of patients with OA, the NP anticipates finding: A. anemia of chronic disease. B. elevated CRP level. C. no disease-specific laboratory abnormalities. D. elevated antinuclear antibody (ANA) titer.

C

Clinical findings of the knee in a patient with OA include all of the following except: A. coarse crepitus. B. joint effusion. C. warm joint. D. knee often locks or a pop is heard.

C

Pseudogout has been linked with abnormal activity of the: A. liver. B. kidneys. C. parathyroid. D. adrenal gland.

C

Secondary gout can be caused by all of the following conditions except: A. psoriasis. B. hemolytic anemia. C. bacterial cellulitis. D. renal failure.

C

The most helpful diagnostic test to perform during acute gouty arthritis is: A. measurement of erythrocyte sedimentation rate (ESR). B. measurement of serum uric acid. C. analysis of aspirate from the affected joint. D. joint radiography.

C

Treatment of pseudogout can include all of the following except: A. NSAIDs. B. colchicine. C. allopurinol. D. oral corticosteroids.

C

Which of the following dietary supplements is associated with increased risk for gout? A. vitamin A B. gingko biloba C. brewer's yeast D. glucosamine

C

Cytoplasmic pattern ANA is associated with

Biliary Cirrhosis

Deformity of the proximal interphalangeal (PIP) joints found in an elderly patient with OA is known as:

Bouchard nodes

52-year-old woman has RA. She now presents with decreased tearing, "gritty"-feeling eyes, and a dry mouth. You consider a diagnosis of: A. systemic lupus erythematosus. B. vasculitis. C. Sjögren syndrome. D. scleroderma.

C

51. Which of the following is not characteristic of rheumatoid arthritis (RA)? A. It is more common in women at a 3:1 ratio. B. Family history of autoimmune conditions often is reported. C. Peak age for disease onset in individuals is age 50 to 70 years. D. Wrists, ankles, and toes often are involved.

C. Because Peak age is 20-40 not 50 - 70

Osteoporosis prevention measures include all of the following except: A. calcium supplementation. B. selective estrogen receptor modulator use. C. vitamin B6 supplementation. D. weight-bearing and muscle-strengthening exercises.

CLong-term bisphosphonate treatment (i.e., >5 years) has been associated with: A. atypical fractures. B. hyperprolactinemia. C. osteoarthritis. D. bone marrow suppression.

Celebrex spares COX1 or COX2

COX1 (more COX2 selective)

This acutely painful condition typically affects the metacarpophalangeal joint of the great toe. The onset is sudden and is accompanied by significant distress.

Gout

According to the latest recommendations from the National Osteoporosis Foundation (NOF), the calcium intake goal should be the equivalent of __________ mg/d for men between 50 to 70 years of age, and the dose should be _________ mg/day for women 51 years and older and men older than age 70 years.

1000; 1200

How much daily calcium is recommended for women older than 50 years of age?

1200mg

clinical presentation in patients with OA includes an insidious onset of symptoms, including use-related joint pain that is relieved by rest and joint stiffness that occurs with rest but resolves with less than ______ minutes of activity.

15

Osteoporosis is also defined as bone density more than _______ standard deviations below the average bone mass for women who are younger than 35 years old.

2.5

After the acute flare of gout has subsided, a ________ hour urine collection for uric acid helps assess whether the patient overproduces or undersecretes uric acid.

24

RA involves at least _______ joint groups, and can recur after a period of inactivity

3

What disease is also called calcium pyrophosphate deposition (CPPD) disease, presents similarly to gout but is caused by the presence of calcium pyrophosphate dehydrate crystals in the joint.

Pseudogout

For long-term prevention, patients should be given _________ IU of vitamin D3 once or twice per month plus 1000 to 2000 IU of vitamin D3 daily.

50,000

For treatment of vitamin D deficiency in adults, a dose of 50,000 IU of vitamin D3 by mouth once per week for at least ____ weeks is advised, with extension of this course to ____ weeks if the initial 25(OH)D level was below 30 ng/mL.

8, 16

Knee and hip joint replacement should be considered when pain cannot be adequately controlled, when function is severely compromised, or when more than _____% of the articular cartilage is worn away.

80

153. In counseling a postmenopausal woman, you advise her that systemic estrogen therapy users can possibly experience: A. an increase in breast cancer rates with long-term use. B. reduction in high-density lipoprotein cholesterol. C. a 10% increase in bone mass. D. no change in the occurrence of osteoporosis.

A

Long-term bisphosphonate treatment (i.e., >5 years) has been associated with: A. atypical fractures. B. hyperprolactinemia. C. osteoarthritis. D. bone marrow suppression.

A

Is there minimal or a lot of morning stiffness in OA?

A lot

Rheumatoid factor

An IgM antibody present in approximately 50 - 90% of patients with RA

____________ use can precipitate gout, its use in the presence of the condition is contraindicated.

Aspirin

128. A Still murmur: A. is an indication to restrict sports participation selectively. B. has a buzzing quality. C. is usually heard in patients who experience dizziness when exercising. D. is a sign of cardiac structural abnormality.

B

130. Risk factors for mitral regurgitation include a prior diagnosis of all of the following except: A. rheumatic heart disease. B. scarlet fever. C. endocarditis. D. calcific annulus.

B

152. The bisphosphonate therapy given as an annual infusion is: A. risedronate. B. zoledronic acid. C. ibandronate. D. denosumab.

B

A significant adverse effect of biologic therapy for treating RA is: A. myopathy. B. infections. C. renal impairment. D. elevated liver enzymes.

B

An adverse effect associated with the use of glucosamine is: A. elevated ALT and AST. B. bronchospasm. C. increased bleeding risk. D. QT prolongation.

B

First-line treatment of SLE in a patient with mild symptoms is: A. systemic corticosteroids. B. hydroxychloroquine plus NSAIDs. C. anakinra. D. methotrexate.

B

The clinical presentation of acute gouty arthritis affecting the base of the great toe includes: A. slow onset of discomfort over many days. B. greatest swelling and pain along the median aspect of the joint. C. improvement of symptoms with joint rest. D. fever.

B

Which of the following patients would be an appropriate candidate for treatment with teriparatide (Forteo)? A. a 54-year-old woman with osteopenia B. a 64-year-old woman with BMD T-score of -2.5 and prior hip fracture C. a 67-year-old man with a BMD T-score of -1 D. a 72-year-old woman who has a stable BMD T-score of -1.5 with bisphosphonate treatment for the past 3 years

B

You hear a fixed split second heart sound (S 2 ) in a 28-year-old woman who wants to start an exercise program and consider that it is: A. a normal finding in a younger adult. B. occasionally found in uncorrected atrial septal defect. C. the result of valvular sclerosis. D. often found in patients with right bundle branch block.

B

gouty crystals that fill tophi precipitate more easily in _____ areas of the body.

Cooler

In ___________ syndrome there is compression that can lead to rectal or perineal pain and disturbance in bowel and bladder function. Signs of lumbosacral strain are present, and the straight-leg-raising maneuver reproduces pain.

Cuada equina

154. When counseling a patient taking a bisphosphonate such as alendronate (Fosamax), you advise that the medication should be taken with: A. a bedtime snack. B. a meal. C. other medications. D. a large glass of water.

D

Pseudogout is caused by the formation of what type of crystals in joints? A. uric acid B. calcium oxalate C. struvite D. calcium pyrophosphate dihydrate

D

The most common locations for tophi include all of the following except: A. the auricles. B. the elbows. C. the extensor surfaces of the hands. D. the shoulders.

D

Which of the following joints is most likely to be affected by osteoarthritis (OA)? A. wrists B. elbows C. metacarpophalangeal joint D. distal interphalangeal joint

D

What drugs are started as soon as the diagnosis of RA is made?

DMARDS. i.e. methotrexate

Gout risk factors

Diabetes Family history Obesity

______________(hormone) deficiency is a potent risk factor, and osteoporosis is most common in postmenopausal women;

Estrogen

Tophi often develop in the __________ _____; less common locations include nasal cartilage, extensor surfaces of the hands and feet, and over the elbows.

External ear

About 90% of patients presenting with primary gout are ________[men or women]; the condition is rarely seen in women before menopause.

Men

the preferred method of preventing NSAID-induced gastric ulcer?

Misoprostol (cytotec)

ANA

Most sensitive marker for lupus (95%) RA (only 30-50%)

Tylenol or NSAIDS for RA

NSAIDS

First-line therapy for treating patients with acute gouty arthritis usually includes:

Naproxen sodium

With the first episode of gout an initial uric acid level is usually ________.

Normal

What anemia would you see in RA?

Normocytic Normochromic

________ appears to minimize osteoporosis risk, in part because of high endogenous estrogen production by fatty tissue and increased bone weight-bearing.

Obesity

Radiographic findings of osteoarthritis of the knee often reveal:

Osteophytes

What is a disorder of bone thinning in which bone absorption exceeds bone formation to the degree that bone density is insufficient to meet skeletal needs.

Osteoporosis

Nucleolar pattern ANA is associated with:

Scleroderma or Crest

How Dp you minimize the risk of drug-induced esophagitis, with biphosphonates?

Take the medication in the morning with a full glass of water. 30 minutes before food, other liquids, or medications. Remain upright for at least 1 hour.

What joints are effected in pseudo gout

The knees (most commonly) wrists and ankles also can be involved, with symptoms of swollen, warm, and severely painful joints.

Non-tender, firm nodules located in soft tissue.

Tophi

T/F: A systolic cardiac murmur is often benign.

True

T/F: AAOS strongly recommends all of the following therapeutic agents for the management of symptomatic OA of the knee oral NSAIDs, topical NSAIDs & tramadol.

True

T/F: In particular, the presence of sinus arrhythmia in a younger adult is a normal finding and is not an indication for curtailing activity.

True

T/F: Knee OA straight-leg raises without weights, quadriceps sets, limited weight-bearing aerobic exercises. Not squats with weights

True

T/F: Taking a high dose of aspirin or ibuprofen causes an increase in the drug's half-life.

True

T/F: Thiazides can precipitate gout in someone with a gout genetic predisposition.

True

T/F: with gout you should reduce inflammation first and then treat hyperuricemia, trying to avoid a rapid reduction in serum uric acid, which can make the episode worse.

True

RECOMMENDATIONS FOR OSTEOPOROSIS SCREENING

Women age 65 and older and men age 70 and older, regardless of risk factors • Younger postmenopausal women, women in the menopausal transition, and men age 50 to 69 with clinical risk factors for fracture • A woman or man after age 50 who has broken a bone • Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., long-term glucocorticoid) associated with low bone mass or bone loss

Does the RF titer level correspond to the severity of the disease (RA)?

Yes it does

In RA The stiffness is ________________ (symmetrical or asymmetrical) , is typically worst on arising, lasts about __________hour

symmetrical, 1 hour

The parathyroid hormone _______________is an anabolic agent that can reduce the risk of vertebral fractures by 65% in patients with osteoporosis.

teriparatide (Forteo)

Biological response modifiers— Non-TNF:

abatacept, rituximab, anakinra, tocilizumab, others

Names of biphosphonates

alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and zoledronic acid (Reclast)

Xanthin oxidase inhibitors (XOIs),

allopurinol (Aloprim, Lopurin, Zyloprim) or febuxostat (Uloric)

chondroitin is generally well tolerated, it should be used with caution because of a potential __________ effect.

anticoagulant

Side effects of febuxostat

associated with rash, nausea, and reduced liver function.

This treatment is typically reserved for women with very low bone density or who have had a prior fracture. Treatment with this medication should be limited to a 2-year duration because of a potentially increased risk of osteosarcoma.

teriparatide (Forteo)

Examples of high-purine foods

certain seafood (scallops, mussels) organ and game meats beans spinach asparagus oatmeal baker's & brewer's yeasts when taken as dietary supplements.

What special examinations should be periodically obtained during hydroxychloroquine sulfate use?

dilated eye retinal examination

The hands (with sparing of the ___________ joints), wrists, ankles, and toes are most often involved.

distal interphalangeal

the ______________joint is the most common OA site, the most problematic joint involvement is in the hip and knee.

distal interphalangeal

In rare cases, low trauma atypical ________ fractures have been associated with long-term use of bisphosphonates (i.e., >5 years).

femoral

What other medications have been studied and found to be helpful with urate excretion

fenofibrate and losartan

In osteoporosis, For every reduction of bone mass by 1 standard deviation, the relative risk of ___________ rises by 1.5-fold to 3-fold.

fracture

Where is the COX-1 enzyme found in the body

gastric mucosa large intestine mucosa kidneys platelets vascular epithelium

What do DMARDS do?

help minimize the risk of joint damage and disease progression

Probenecid side effects

higher concentrations of uric acid in the urine = risk of kidney stones - rash - abdominal pain.

________ fracture is often the first clinicalmanifestation of osteoporosis, it usually indicates advanced disease, as does loss of terminal adult height.

hip

Probenecid (Probalan) mechanism of action

improves the kidney's ability to remove uric acid from the body.

Causes of secondary gout

increased catabolism and purine turnover: -psoriasis -myeloproliferative and lymphoproliferative diseases -chronic hemolytic anemia conditions with decreased renal uric acid clearance - intrinsic kidney disease and renal failure.

*Major adverse effects of biologics?

increased risk for infection with some dormant infections (i.e. tuberculosis) consider vaccination

Biological response modifiers— Anti-TNF:

infliximab, adalimumab, , etanercept, certolizumab, golimumab, others

What if DMARDS and NSAIDS fail in RA?

intra-articular corticosteroid injection -(not more than two to three injections per joint per year to minimize risk of joint deterioration) -systemic corticosteroids (not more than 2 - 8 weeks)

What best describes the presentation of a patient with OA: worst symptoms in weight-bearing joints ______ in the day

later

How do Xanthin oxidase inhibitors (XOIs) like allopurinol work?

limit the amount of uric acid the body produces.

name 2 functions of COX1 in relation to the stomach and Kidneys

maintains gastric mucosal layer and proper perfusion to the kidneys

Cox-1

maintenance of gastric protective mucosal layer.

The FDA advises that the risks associated with calcitonin use outweigh the benefits in treating osteoporosis, largely based on two large studies indicating slightly higher rates of _________ among patients taking this agent.

malignancy

In gout The entire great toe is usually reddened and enlarged, with the greatest amount of swelling noted along the __________ border of the joint; this usually is also the point of greatest discomfort.

medial

What are traditional DMARDs

methotrexate leflunomide sulfasalazine hydroxychloroquine, minocycline

Cultures of joint aspirates in reactive arthritis typically have (positive or negative) results.

negative

Risk factors for pseudogout include

older age, joint trauma, family history of the condition, and mineral imbalances (e.g., hemochromatosis, hypercalcemia, or hypomagnesemia). hypothyroidism or hyperparathyroidism.

A short course of a systemic corticosteroid, such as _______ (0.5 mg/kg/day for 5-10 days, or 0.5 mg/kg/day for 2-5 days, then taper for 7-10 days), is a helpful alternative to colchicine.

prednisone

In gout undersecretors of Uric acid benefit from ___________, and overproducers benefit from ____________ or febuxostat.

probenecid, probenecid

What does COX2 do

produces prostaglandins

_________-strengthening exercises should be performed in OA of the knee

quadriceps

A selective estrogen receptor modulator such as _______________helps preserve bone density. Because it does not attach to estrogen receptor sites in the breast or uterus, a selective estrogen receptor modulator is often considered an alternative to hormone therapy.

raloxifene (Evista)

Side effects of allopurinol

rash and low blood counts

Physical examination in OA

smooth, cool joints and coarse crepitus.

Drugs that cause gout

thiazide niacin aspirin cyclosporine Alcohol can precipitate gout by causing hyperuricemia

In OA, the articular cartilage becomes rough and wears away. Bone spurs often form, and the synovial membrane ___________(thins or thickens) . Consequently the joint space narrows.

thickens

Biological response modifiers— Oral JAK inhibitors:

tofacitinib

Calcitonin (Miacalcin or Fortical) is another antiresorptive medication that is most helpful in building ________ bone.

vertebral