11. Elderly female with knee pain

Question 1

Differential Diagnosis for Knee Pain

Extreme pain with any movement; also painful to touch

Answer 1

Gout / Pseudogout

Question 2

Differential Diagnosis for Knee Pain

Posterior popliteal area

Answer 2

Popliteal (Baker’s) Cyst

Question 3

Differential Diagnosis for Knee Pain

Generalized or joint line tenderness; pain aggrevated by weight-bearing activities, relieved by rest

Answer 3

Osteoarthritis

crepitus on phys. exam

Question 4

Differential Diagnosis for Knee Pain

Lateral knee pain

Answer 4

Iliotibial Band Tendonitis

Question 5

Differential Diagnosis for Knee Pain

Medial joint line pain

Answer 5

Medial Collateral Ligament Sprain

Question 6

Differential Diagnosis for Knee Pain

Lateral joint line pain

Answer 6

Lateral Collateral Ligament Sprain

Question 7

Nonsteroidal anti-inflammatory medications, like ibuprofen (Advil, Motrin), can worsen the symptoms of GERD, especially if taken on an empty stomach.

Answer 7

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Question 8

Assesses the stability of the anterior cruciate ligament (and not the posterior cruciate ligament)

Answer 8

Lachman’s test

Question 9

Assess the anterior cruciate and posterior cruciate ligaments, respectively

Answer 9

Anterior and posterior drawer signs

Question 10

Assess functioning of the medial and lateral collateral ligaments

Answer 10

Valgus and varus stress tests

Question 11

Can assess the medial and lateral menisci, though it has low sensitivity and specificity for diagnosing meniscal tears

Answer 11

McMurray test

Question 12

Imaging to Evaluate Osteoarthritis

Imaging for knee pain in a patient with no preceding trauma may not be necessary when the history and physical exam are consistent with osteoarthritis

Answer 12

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An x-ray would also be warranted if there is no improvement with initial conservative treatment.

Question 13

Imaging to Evaluate Osteoarthritis

MRI would be preferred if locking, popping, or joint instability were of concern, to detect meniscal or ligament damage

Answer 13

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Question 14

Major radiographic features of OA

Answer 14

Joint space narrowing
    Subchondral sclerosis  (Hardening of tissue beneath the cartilage. In osteoarthritis, there is increased periarticular bone density.)
    Osteophytes (Also known as bone spurs; bony projections arising from the joint.)
    Subchondral cysts (Fluid-filled sacs in the bone marrow.)

Question 15

Paracetamol, or acetaminophen, is effective and safe, and should be the first choice for short-term, mild to moderate pain related to osteoarthritis

Answer 15

First choice analgesic for both short and long-term treatment of mild to moderate pain related to osteoarthritis because of its tolerability and low side-effect profile.

Question 16

Management of Pain Related to Osteoarthritis

NSAIDS

Answer 16

Second choice to acetiminophen because of their association with gastrointestinal side-effects, including gastritis.

Question 17

Management of Pain Related to Osteoarthritis

Intra-articular corticosteroid
injections

Answer 17

Should be considered if the knee joint is inflamed, as evidenced by swelling and pain.
No more than three injections per year, and no more frequent than one injection per month.

Question 18

Carpal Tunnel Exam

Answer 18

Tinel’s sign: Tap over the median nerve at the wrist to reproduce symptoms

Phalen’s test: Flex wrist by having patient place dorsal surfaces of hands together in front of her for 30 to 60 seconds to reproduce symptoms

Question 19

The most common side effect of long-acting opioids is constipation

Answer 19

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Question 20

Annual Visit Preventive Medicine

Answer 20

1. Screening tests
2. Update adult immunizationsTetanus - Sustitute one-time dose of Tdap for Td booster, then boost with Td every 10 years
   Pneumococcal Polysaccharide - If > 65 years, one dose
   Flu - One dose annually
   Zoster - If > 60 years, one dose