Primary Care Review: Musculoskeletal and Rheum

Which of the following statements concerning OA is true?

*All of the above:* Cartilaginous fraying is common 1/3 of adults age 25 to 75 years have radiographic evidence of OA The most common sites for the disease are in small joints of the hand, the foot, and the knees and/or hips Mild synovitis may develop in response to crystals or cartilaginous debris

A 32-year-old female gives a history of chronic aching pain especially of the neck, shoulders, back and hips. She complains of fatigue and frequent headaches. Examination reveals several trigger points of pain on palpation. What is the most appropriate clinical intervention?

Active exercise therapy and Amytryptaline

A 35-year-old female comes to your office with a 1-year history of "aching and hurting all over". In addition, she complains of a chronic headache, difficulty sleeping, and generalized fatigue. When questioned carefully, she describes "muscle areas tender to touch." Although the pain is "worse in the back," there is really is no place where it doesn't exist. She also describes headaches, generalized abdominal pains, and some constipation On examination, the most striking finding is the presence of 13 discrete "trigger points" (tender muscle areas when palpated) These include the treapezius muscle, the sternomastoid, the masseter muscle, the levator scapulae, the muscles inserting into the area of the greater trochanter, the muscles inserting into the upper border of the patellae, and six areas on the back that together cover almost the entire back areas The rest of the physical examination is normal. Her BP is 120/70 mm Hg, and her cardiovascular, respiratory, and abdominal examinations are normal What is the most appropriate treatment for this patient?

Active exercise therapy and Amytryptaline

A 45-year-old obese male comes to the ED in the middle of the night screaming and holding his left toe. He tell you that he thinks he has an acute blood vessel blockage in his left toe. He wakes up the entire ED observation unit with his screams.His history is significant for essential HTN, for which he has been treated with a thiazide diuretic for the past 5 years. He categorically relates to you that he has never had the symptoms that he is experiencing now.On examination the patient s temperature is 38 C and his BP is 170/110. he has an inflamed, tender, swollen left great toe. There is extensive swelling and erythema of the left foot.No other joints are swollen. No other abnormalities are found on physical exam. What is the most likely diagnosis?

Acute gouty arthritis

A 67-year-old man with chronic arthritis is found to have passed a uric acid stone after an episode of renal colic. On workup he is found to have multiple radiolucent stones in the left renal pelvis, uric acid excretion of 900 mg/d, a serum uric acid concentration 9.8 mg/dL, a serum creatinine concentration of 1.8 mg/dL, and monosodium urate crystals in an effusion in the left knee. The drug of choice for long-term therapy in this patient is

Allopurinol

Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase?

Allopurinol (Zyloprim)

Four patients present with progressive right hip pain that is most bothersome when active. In which patient would a slipped capital femoral epiphysis be suspected as the cause of the hip pain?

An 11-year-old boy who is obese with a history of bouts of right hip pain and knee pain for < 6 months

A 53 year-old male is seen in the emergency department following a motor vehicle collision in which his knee impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced in the emergency department. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?

Angiography

A 35 year-old man complains of the gradual onset of low back pain and stiffness. Physical examination reveals sacroiliac tenderness and a grade 2/6 murmur of aortic insufficiency. X-ray studies of the pelvis show erosion of the sacroiliac joints. The most likely diagnosis is:

Ankylosing spondylitis

A 23-year-old female presents with complaints of a sudden onset of severe pain and swelling of the right knee. While playing basketball 2 hours ago, she was running when an opponent stepped in front of her, causing her to stop short and her knee gave way. PE reveals tenderness to palpation with moderate swelling and decreased extension. Lachman's test is positive. Varus and valgus stress in full and 30 degree extensions are negative. Which of the following is the most likely diagnosis?

Anterior cruciate ligament(ACL) tear

A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. The most useful test to make a definitive diagnosis is

Antinucleolar antibody

An elderly patient presents to the ED complaining of right shoulder pain occurring after falling on his right outstretched hand with the elbow extended. On physical examination the arm is pale and pulseless and there is tenderness of the upper arm. Which of the following structures is most likely injured?

Axillary artery

Which of the following is the most common serious consequence of untreated giant cell arteritis?

Blindness

A 23 y/o woman with a history of Raynaud's phenomena since her teens comes to with complaints of difficulty swallowing. On exam you find taut skin over her fingers with tapering digits. There is evidence of chondrocalcinosis on X-ray and a modified Barium swallow reveals esophageal dysmotility. The most likely diagnosis is:

C.R.E.S.T. syndrome

RA may affect what part of the vertebral spine

C1-C2

A 40 year old female is brought into the emergency department status post fall. She is C-spine immobilized complaining of low back pain with shooting pains down the right leg. She apparently has lost function of her bowels and bladder. Your physical exam reveals signifcantly decreased motor function in the lower extremeties and complete loss of sensation in both feet. During rectal exam, you note loss of sphincter tone and the patient states that she feels "numb" in the perineum. Based on these findings, you suspect

Cauda equina syndrome

A 70-year-old man with renal insufficiency and recurrent attacks of proven gouty arthritis has elevated serum and urine uric acid levels. He is now asymptomatic. The most appropriate approach is

Chronic allopurinol

The wife of a 52 year old steelworker, who is a regular patient with chronic low back pain, calls the office in a panic. The patient has suddenly developed "saddle" distribution numbness, and urinary bladder incontinence after bending over to pick up a bundle of branches from the yard. You instruct her to call an ambulance or have him transported to the local emergency room immediately. You next step would be which of the following?

Contact the on-call neurosurgeon or orthopedic spine surgeon to arrange for immediate surgery.

A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice?

Continuous extension of the DIP with splinting

A 19-year-old patient presents after a skiing accident, complaining of knee pain. Exam reveals laxity and anterior movement of the tibia with the knee flexed at 45 degrees. Which structure was injured?

Cruciate ligament

A 50-year-old white female presents with aching and stiffness in the trunk, hip, and shoulders. There is widespread muscle pain after mild exertion. Symptoms are worse in the morning and improve during the day. They are also worsened by stress. The patient is always tired and exhausted. She has trouble sleeping at night. A definitive diagnosis is best made by

Demonstration of 11 tender points

A 18-year-old previously healthy female student develops a lilac-colored rash in a butterfly distribution about the eyes, on the bridge of the nose, and on the cheeks.(see below)She has a similar rash on her knuckles. She has had an associated muscle weakness manifested by difficulty arising from a chair and climbing stairs. She takes no medicines. Other than the rash and proximal muscle weakness, the woman's examination is unremarkable. The most likely diagnosis is

Dermatomyositis

A 45 y/o man comes to you for evaluation of progressive muscle weakness. On physical exam note a rash on the upper eyelids and a scaly eruption on his knuckles. On laboratory analysis you find elevated muscle enzymes. The most likely diagnosis is:

Dermatomyositis

A 6 year-old female presents to the clinic with her parents because of lower back pain and difficulty walking for one week. The pain is described as a dull ache that is constant in the midlumbar region with radiation into the abdomen. She has a low grade fever of 100 degrees F which the parents note has been persistent for several days. Upon exam it is noted that the child has restricted forward flexion and extension secondary to pain. She has tenderness over the L3 vertebrae. An area of cellulitis from an insect bite is discovered over her left scapula. Which of the following is the most likely diagnosis?

Discitis

Why are fractures of the scaphoid bone prone to aseptic necrosis?

Disrupted arterial supply

Which of the following tests are useful for diagnosing a torn anterior cruciate ligament of the knee?

Drawer sign and Lachman test

Which of the following findings on joint aspiration is most likely to be associated with gout?

Fluid, *cloudy and watery*; white blood cell count, *12,000*/ L; crystals, needle-like and *strongly negatively* birefringent

A 51- year-old man recently underwent a physical examination during which you obtained a routine chemistry profile. All values were normal except for a serum uric acid of 7.5 mg /dL. He has no history of gouty arthritis, renal disease, or urolithiasis. The most appropriate management of this problem would be to:

Follow the patient expectantly without pharmacologic intervention

In which of the following clinical situations would a diagnosis of ankylosing spondylitis most likely be correct?

For the past 10 years, a 28-year-old man has had low back pain and stiffness, worse at night and relieved with activity

A 75 year-old female presents with complaints of stiffness, aching, and pain in the muscles of her neck, shoulders, lower back, hips, and thighs. There is no associated weakness associated with the stiffness and achiness. Laboratory evaluation shows an elevated C reactive protein and erythrocyte sedimentation rate. Which of the following medications is used to treat this condition immediately and will also serve to prevent a known complication from this disorder?

Glucocorticoids

A 24-year-old woman for the past 2 days has had fever and pain in the left wrist, right ankle, and left knee. Nine painful skin lesions are present on the distal extremities, predominantly about the joints (pic not shown) The most likely diagnosis is

Gonococcemia

A 65-year-old woman who has a 12-year history of symmetrical polyarthritis is admitted to the hospital. Physical examination reveals splenomegaly, ulcerations over the lateral malleoli, and synovitis of the wrists, shoulders, and knees. There is no hepatomegaly. Laboratory values demonstrate a WBC count of 2500/mL and a rheumatoid factor titer of 1:4096. The patient s WBC is likely to reveal

Granulocytopenia

You are asked to see Mr. Bob Smith, a 65 y/o retired plumber with hip and knee pain. PMH is negative. After a thorough musculoskeletal examination, your correct diagnosis is osteoarthritis. You have likely also detected that Mr. Smith has:

Heberden's nodes

A 64-year-old patient presents to a clinic with a 1 week history of lower back and left leg pain. The pain is worsened by sitting and limits the patient's activities. PE reveals paravertrebal muscle spasm, diminished sensation along the medial aspect of the left foot and a diminished left patellar reflex. What is the most likely diagnosis?

Herniated lumbar disk

A 52 year-old male presents with a severely painful, swollen right great toe. He denies recent trauma, but reports several similar episodes of toe pain and swelling over the past two to three years. He has a history of alcohol abuse and hypertension, for which he "takes medication" of unknown type. Examination reveals bright erythema and edema associated with the right first MCP joint. Which of the patient's antihypertensive medications may be contributing to this condition?

Hydrochlorothiazide (HCTZ)

A 20-year-old woman has developed low-grade fever, a malar rash, and arthralgias of the hands over several months. High titers of anti-DNA antibodies are noted, and complement levels are low. The patient s white blood cell count is 3000/mL, and platelet count is 90,000/mL. The patient is on no medications and has no signs of active infection. Which of the following statements is correct?

If glomerulonephritis, severe thrombocytopenia, or hemolytic anemia develops, high-dose glucocorticoids therapy would be indicated

A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be encountered?

Inability to extend the wrist against resistance

A 23-year-old male presents with acute onset of non-traumatic left knee pain with fever and chills. The joint is swollen and warm to touch with a limited ROM. What is the most likely diagnosis?

Infectious arthritis

A 16-year-old male complains of bilateral knee pain. There is no history of trauma. Examination reveals patellar bursa tenderness. X-ray show bilateral fragmentation of the tibial tubercle apophysis. Which of the following is most likely on history and physical examination?

Knee pain that is exacerbated by descending stairs

A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected?

L5-S1

A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 20 degrees of flexion and the tibia is forced forward while the femur is stabilized. Which of the following knee maneuvers does this represent?

Lachman test

A 65-year-old obese man complains of progressive pain in both knees, exacerbated by walking. Past medical history is unremarkable.PE discloses normal pulses and circulation and no joint effusions. Bony crepitus is evident upon movement of either knee joint. Routine laboratory studies, including an ESR, are normal. Radiographs of the knees reveal joint space narrowing. What is the most important pathophysiologic feature in this situation?

Loss of articular cartilage

Arthritis is a common complication of which of the following diseases?

Lyme disease

A 74-year-old patient presents to the office with a 1-week history of pain in the lower back, buttocks, and thighs. The patient states that the pain is moderate to severe, worsened by ambulation and standing, but relieved by sitting. Which diagnostic test would best assess the spinal canal?

MRI

Which of the following medications is the initial treatment of choice for suppressing the progression of rheumatoid arthritis (RA)?

Methotrexate (Rheumatrex)

Long term treatment and follow-up of patients with osteoarthritis should include

Muscle strengthening exercises

Disease-modifying antirheumatic drugs(DMARDS) include all of the following EXCEPT?

NSAIDs

What is the first DOC for the suppression of inflammation in a patient with RA?

NSAIDs

A 65-year-old man with a history of chronic hypertension, diabetes mellitus, and degenerative joint disease presents with acute onset of severe pain of the MTP joint and swelling of the left first toe. Physical examination shows exquiste tenderness of the joint with swelling, warmth, and erythema. There is no history of trauma or other significant medical problems. Synovial fluid analysis and aspiration is most likley to show:

Needle-shaped, negatively birefrigent crystals

A 25 y/o male presents with complaints of a swollen and painful left knee. The fluid is aspirated and two days later, the cultures are growing a gram-negative organism. The most likely organism is:

Neisseria gonorrhea

All of the following are characteristic patterns of joint involvement in rheumatoid arthritis EXCEPT:

Oligoarticular involvement

A 53 year-old patient presents with severe pain at the base of the thumb and no other finger involvement. The pain is worse with activity and lasts a short period of time following rest. There is no specific history of trauma to the thumb but the patient admits working with her hands as a typist. Which of the following is the most likely diagnosis?

Osteoarthritis

A 55-year-old executive assistant presents to your office for evaluation of pain in her wrists. She states that the pain has been present intermittently for several months, but over the last 2 weeks, it has been present daily. She has taken over-the-counter analgesics for the pain, which seems to help. She denies fever, chills, or rashes. On physical examination, she has pain and tenderness over the right wrist but not he left. She has a hard dorsolateral nodule over the DIP joint of her right middle finger. The MCP joints are normal. What is your most likely diagnosis?

Osteoarthritis

Intraarticular injection of hyaluronic acid has been approved for treatment of patients with which of the following conditions?

Osteoarthritis of the knee

A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibial plateau. Which of the following is the most likely diagnosis?

Pes anserine bursitis

A 23-year-old fast food worker presents to your office for evaluation of pain in his feet, especially the heels. He notes that the pain is most intense when he first awakens, then eases up somewhat after walking or a few minutes. By the end of the day, the pain has returned again to its full intensity. He has tried over-the-counter analgesics without success. He denies fever, chills, trauma, or injury to his feet. On physical examination, he has tenderness upon palpation of the plantar fascia. There are no deformities or joint swelling. What is your most likely diagnosis?

Plantar fasciitis

A 47-year-old man has had fever, weight loss, arthralgias, pleuritic chest pain, and midabdominal pain for the past 2 months. One week ago he noticed difficulty dorsiflexing his right great toe. BP is 150/95 mmHg (he has always been normotensive), and laboratory studies reveal anemia of chronic disease, high erythrocyte sedimentation rate, and polymorphonuclear leukocytosis. CXR is clear. The most likely diagnosis is

Polyarteritis nodosa

A 45-year-old woman presents to her physician with an 8-month history of gradually increasing limb weakness. She first noticed difficulty climbing stairs, then problems rising from chairs, walking more than half a block, and, finally, lifting her arms above shoulder level. Aside from some difficulty swallowing, she has no ocular, bulbar, or sphincter problems and no sensory complaints. Family history is negative for neurological disease. Examination reveals significant proximal limb and neck muscle weakness with minimal atrophy, normal sensory findings, and intact deep tendon reflexes. The most likely diagnosis in this patient is

Polymyositis

A 55-y/o female presents with c/o bilateral wrist and hand pain. States it awakens her from sleep at night, and that sometimes she will be awake for an hour or more, "shaking and flapping" her hands. States, "it doesn't happen every night, but has been happening more and more frequently lately". Also has experienced numbness and tingling in wrists and fingers. You expect to find:

Positive Tinel's sign

A 72-year-old man develops severe pain and swelling in both knees, shortly after undegoing abdominal hernia repair surgery. Physical examination shows warmth and swelling of both knees with large effusions. Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly positive birefrigent crystals int he synovial fluid. Gram stain is negative. the most likley diagnosis is:

Pseudogout

A 55-year-old woman with a history of severe mutilating arthritis.Hand X-Rays on seen below. She also has a scaling plaque-like rash. This patient most likely has

Psoriatic arthritis

A 39-year-old female comes to your office with a 6-month history of malaise, paresthesias in both hands, and vague pain in both hands & wrists. She has also felt extremely fatigued. She tells you that the pains in her joints are much worse in the morning. She is also beginning to notice pain & swelling in both knees. The patient has a normal family history with no significant diseases noted. The patient is taking no drugs and has no allergies. On examination, there is a sense of bogginess & slight swelling in both hands, in both wrists, and in the small bones of the hands. Both knees also feel somewhat swollen & boggy. There are no other joint abnormalities, and the rest of the physical exam is normal. What is the most likely diagnosis in this patient?

RA

A 42-year old woman presents with an eight week history of morning stiffness, pain, swelling in her third through fifth proximal interphalangeal joints, and fatigue. On examination, she has clinical evidence of bilateral arthritis in the affected joints. On laboratory examination, her erythrocyte sedimentation rate [ESR] is elevated at 59; her rheumatoid factor is negative. Based on this information, which of the following is her most likely diagnosis?

RA

Endotracheal intubation should be performed with caution in patients with which of the following underlying conditions due to the propensity to cause subluxation of C1 on C2?

RA

The above hand radiograph is most consistent with which of the following entities? (image not shown here - ulnar deviation and subluxation of thumb joints)

RA

A 22 year-old male was playing soccer when he fell onto his outstretched arm He now presents with pain at the right elbow and an inability to fully extend it. The neurovascular status is normal, distal to the elbow. The x-ray reveals no obvious fracture but there is a posterior fat-pad sign. What is the most likely diagnosis?

Radial head fracture

A 10-year-old child presents with acute onset of right knee pain, inflamed conjunctiva, mild burning with urination, and a history of fever and diarrhea one week prior. The most likely diagnosis is

Reactive arthritis(Reiter's syndrome)

A 3-year-old boy complains of elbow pain after wrestling with his brother. The father states his son cried initially and is currently reluctant to use his right elbow. On exam tenderness of the radial head increased with supination is noted. His neurovascular status is normal. Radiographs show subluxation of the radial head. The standard treatment of choice is:

Reduction by flexion and supination of the forearm

An otherwise healthy 12-year-old patient presents for a preparticipation sports PE. On PE, the patient has a spinal curve abnormality with marked elevation of the right scapula and a right thoracic hump. Results of spinal films indicate a 25 degree curvature. Which is the most important plan for treatment?

Refer the patient for evaluation by an orthopedic surgeon

A 26 year-old man has had swelling in his right ankle with tenderness of his Achilles tendon for several days. He also has had a mild burning sensation in both eyes. A month earlier he had a urethra discharge that disappeared spontaneously after one week. This patient most likely has:

Reiter s syndrome (Reactive arthritis)

A 35 y/o women presents to you complaining of abdominal pain and a malar rash that began shortly after the initiation birth control pills. She also complains of diffuse arthralgias of wrists and ankles. On laboratory evaluation she has a positive ANA in high titer, a positive ds DNA antibody, and an elevated ESR with a low compliment level. Based on the above the most likely diagnosis is:

SLE

A 60-year-old female complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On exam, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. The next step in evaluation is

Schirmer test and measurement of autoantibodies

A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis?

Septic arthrtitis

A 40-year-old woman presents with purulent nasal discharge, cough, hemoptysis, and dyspnea. CXR reveals bilateral nodules; creatinine and ESR are elevated; urinalysis reveals hematuria and proteinuria. Accurate statements regarding this woman's condition include

She probably has circulating antineutrophil antibodies

A 13 year old male complains of intermittent right hip pain radiating to the groin and thigh. The pain most often occurs after playing soccer and will vary in intensity. He does not recall any specific trauma and has had this intermittent pain for approximately 8 months to a year. Today however, the patient states that the pain is more severe and is having difficulty bearing weight on the right leg. You note that the patient hold his leg in external rotation. During hip flexion, the thigh laterally rotates. Hip X rays do not reveal any joint-space norrowing or widening. CBC, sed rate and rhematoid factor are normal. Your most likely diagnosis is

Slipped capital femoral epiphysis

A 62 year old male presents to clinic for "weakness." He looks "depressed." He complains of fatigue and difficulty lifting his arms and some leg weakness when he tries to go up to his upstairs bedroom at night. If he sits for long periods of time, he arises stiff. He states that he has felt feverish over the past few weeks, between 100-102 deg F orally when he has taken his temperature and admits to some "night sweats" when prompted. He has lost about 10 pounds over the past month and his pants are looking "big" for him. He's just not hungry. He continues to work as a lumber yard manager. Physical exam reveals no discernable weakness on objective neurological exam and an otherwise normal exam except his slow, paced movements indicating fatigue. Lab studies show an elevated erythrocyte sedimentation rate, mild anemia, and an increased alkaline phosphatase. In consideration of the diagnosis, you order a muscle biopsy to be performed by the end of the week and immediately begin a course of which of the following?

Small dose prednisone, by mouth

A 33-year-old computer operator complains of burning and tingling pain in the wrist and hand. The pain occurs with use and never at rest. Range of motion is full, there is no muscle atrophy. Pulses are brisk. What is the initial treatment?

Splinting of the hand and forearm

Plain films are ordered for a patient with ankylosing spondylitis. What diagnostic findings would be expected?

Squaring of the vertebrae & ossification of annulus fibrosis and anterior longitudinal

The most common cause of septic arthritis in adults over 35 is:

Staphylococcus aureus

A 34 year-old female, with a past medical history of irritable bowel syndrome and migraines, presents with fatigue, generalized aching and stiffness of the trunk, hip, and shoulder girdles. She complains of pain and tightness in the neck and across the upper posterior shoulders. She complains of poor sleep, but denies depression. Physical examination is unremarkable except for numerous tender points on palpation. Laboratory evaluation was unremarkable. Which of the following is the best intervention for this patient?

Supervised exercise program

A patient presents with hand pain and swelling of about 3 months duration. Which one of the following findings would be the most suggestive of rheumatoid arthritis?

Swelling and tenderness of the metacarpal phalangeal joints

Which of the following laboratory tests would be helpful in the diagnostic evaluation of infectious arthritis?

Synovial fluid analysis

A pediatrician colleague asks you to examine her wrist. She has been having pain over the radial aspect. There is no history of trauma. On exam, there is no focal bony tenderness. The Finkelstein test is positive. You tell the Doctor she has:

Tenosynovitis of the extensor pollicis and brevis and abductor pollicis tendons (in the groove of the radial styloid).

The orthopedist tells you that his patient has an open intra-articular comminuted fracture. This means all of the following EXCEPT:

The fracture runs across the bone horizontally.

Which of the following statement regarding the use of NSAID's in OA and as given to an elderly patient is true?

The most common NSAID toxicity in elderly patients is GI

A 22-year-old male develops the insidious onset of low back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, eye problems, or nail changes. On exam the patient has loss of mobility with respect to lumbar flexion and extension.He has a kyphotic posture. A plain film of the spine shows widening and sclerosis of the sacroiliac joints. Some calcification is noted in the anterior spinal ligament. Which of the following best characterizes this patient s disease process?

The patient has a spondyloarthropathy, most likely ankylosing spondylitis

A 18 year-old male presents with pain in his wrist after he fell off of a moving motor cycle. Physical examination reveals tenderness in the anatomic snuffbox. No fracture is noted on plain radiography of the wrist. Which of the following is the recommended treatment for this patient?

Thumb spica cast application

A 20 year old female fell off of her mountain bike at Markham Park and presents to your urgent care center for evaluation later that day. She notes that she fell "over the handlebars" and tried to "catch" herself with outstretched arms. She has terrible pain in the left wrist and is in obvious distress. There is swelling and she doesn't let you move it without a fight. Pain is primarily on the radial aspect of the wrist and she has exquisite snuff box tenderness on deep palpation. There are no fractures on the A/P and oblique x-rays of her wrist (and you remember to get comparison of the good right wrist also). The next step in treatment would be which of the following?

Thumb spica slint of left wrist & referral to orthopedist

A 45 year-old patient presents with pain in the left wrist after a FOOSH (fall on outstretched hand) injury. On examination he has snuff box tenderness with limited range of motion. Which of the following immobilization devices is the most appropriate intervention?

Thumb spica splint

A tingling sensation radiating from the wrist to the hand upon striking the median nerve is a positive:

Tinel sign

An elderly woman slipped in her driveway, injuring her right wrist. Radiographs show a Colles fracture. Before sending the patient to orthopedics, intervention should include immobilization with which splint

Volar

A 56 year-old white post-menopausal female had a recent surveillance DEXA bone densitometry. The T-score is -2.7 for her right hip. In counseling this patient, in addition to medications, which of the following would you recommend?

Weight bearing exercises

A 70-year-old female with mild dementia complains of hip pain. There is some limitation of motion in the right hip. The first step in evaluation is

Xray of right hip

A 58 year-old male presents complaining of anterior right shoulder pain the day after performing extensive yard work. The pain is localized over the anterior proximal humerus with distinct point tenderness. There are no visible abnormalities. The patient has full range of motion and strength with all shoulder movements. The pain is reproduced by asking the patient to resist the examiner during supination of the right elbow. Which of the following is the most likely diagnosis?

bicipital tendonitis

A 36 year-old male has a history of recurrent low back pain. When lifting a stack of books yesterday, he experienced sudden, severe pain in the lumbar area. He denies radicular pain. His lower extremity examination is unremarkable, and his back examination is remarkable for paraspinal muscle tenderness and increased pain with flexion at the waist. Which of the following management options should be instituted at this time?

continue ordinary activities as tolerated

A patient with long-standing RA develops a left septic knee. The infection most likely was spread via

hematogenous transmission

When instructing a patient on the correct way to use crutches, the patient should be advised to

report paresthesias of either upper extremity

A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is most consistent with which of the following?

scoliosis

A 13-year-old junior high school student is brought into your office by her mother for evaluation of unequal shoulder height. Her mother first noticed this 2 weeks ago. There is no history of birth trauma or recent injury. On physical examination, there is a lateral curvature of the spine. The curvature is more pronounced with forward flexion. Based on this information, what is your most likely diagnosis?

scoliosis

A 60-year-old male complains of pain in both knees coming on gradually over the past 2 years. The pain is relieved by rest and worsened by the movement. There is bony enlargement of the knees with mild inflammation. Crepitation is noted on motion of the knee joint. There are no other findings except for bony enlargement at the distal interphalangeal joint. The patient is 5 feet 7 in. tall and weighs 210 lb. The best way to prevent disease progression is

weight reduction