Lange Q&A book

Question 1

A 53 y/o obese man presents with a third attack of gout within 1 year. Following the tx of this acute attack, further lab testing is performed and the pt is found to have an elevated serum uric acid level and a 24hr uric acid secretion of 950mg. Which of the following meds would be most appropriate to initiate for prevention of further gouty attacks?

a: colchicine
b: probenecid
c: prednisone
d: allopurinol
e: indomethacin

Answer 1

d: medications used to prevent gout exacerbation include allopurinol and uricosuric drugs, s/a probenecid. Allopurinol inhibits the production of uric acid and is indicated for patients who overproduce uric acid, and uricosuric drugs are used in pts who undersecrete uric acid. Criterion to classify a pt as an overproducer of uric acid is a 24hr uric acid excretion test. The result showing uric acid excretion of 800mg or greater indicates that the pt is an overproducer. In this pt scenario, there is an overproduction of uric acid, making the case for the use of allopurinol. If this pts 24hr uric acid secretion was less than 800mg, the use of a uricosuric drug would then be appropriate. Prednisone, colchicine, and indomethacin are alternative txs for acute attacks of gout and are not used for preventive measures.

Question 2

A 32 y/o woman with hx of anxiety presents with worsening fatigue and sleep disturbance associated with unbearable “pain all over the body” for the past several months. The PE is essentially unremarkable except for localized painful tenderness to palpation over the trapezius, upper back, and buttocks. Which of the following is the most likely dx?

a: fibromyalgia
b: polymyositis
c: Paget disease
d: polymyalgia rheumatica
e: SLE

Answer 2

a: fibromyalgia. It is most frequently seen in women between ages 20-50. Pts complain of chronic msk pain commonly associated with fatigue and sleep disturbances as well as HA and numbness. PE is normal except for the presence of multiple “trigger points.”

Question 3

The dx of SLE is supported by a positive initial antibody screen; however, this test is not specific. Which of the following tests is most specific in the diagnostic evaluation of SLE?

a: gliadin antibody
b: antibody to double-stranded DNA (anti-dsDNA)
c: antinuclear antibody (ANA)
d: anticentromere antibody
e: antiribosomal P antibody

Answer 3

b: autoantibody production is the primary immunological abnormality seen in pts with SLE; the ANA is most characteristic of SLE and seen in 95% of pts with SLE but is not specific for dx of SLE. A positive ANA can also be found in pts with scleroderma, rheumatoid arthritis, Sjogren’s, dermatomyositis, and polyarteritis. ANA testing should be employed as the initial screening test in a pt suspected of having SLE. A negative total ANA test is strong evidence against the dx of SLE, whereas a positive test is not confirmatory of the dx.

Question 4

Skin thickening that begins as swelling of the fingers and hands associated with telangiectasia, dysphagia, and hypomotility of the GI tract is most likely seen with which of the following?

a: sarcoidosis
b: scleroderma
c: dermatomyositis
d: eosinophilic fasciitis
e: eosinophilia-myalgia syndrome

Answer 4

b: scleroderma is characterized by diffuse thickening of the skin and is associated with areas of telangiectasia and changes in skin pigmentation. Most pts with scleroderma also have an associated polyarthralgia, Raynaud phenomena, and GI involvement.

Question 5

Which of the following conditions is strongly associated with systemic scleroderma (SS)?

a: polymyositis
b: reactive arthritis
c: dermatomyositis
d: Sjogren disease
e: Raynaud phenomenon

Answer 5

e: Most pts with SS will also have vascular dysfunction, most commonly Raynaud phenomenon. There is no increased association of scleroderma with polymyositis, reactive arthritis, dermatomyositis, or Sjogren ds.

Question 6

A 65 y/o man presents with complaints of acute onset of pain/swelling of the R. great toe. He denies any recent alcohol ingestion or trauma to the area. On PE, the pt is afebrile, and the first metatarsophalangeal joint is erythematous, swollen, and warm to the touch. Lab evaluation reveals a WBC count of 12,000 and a normal differential. Serum uric acid level is found to be 5 mg/dL. Synovial fluid analysis reveals the presence of rhomboid-shaped crystals. Which of the following is the most likely dx?

a: acute gout
b: pseudogout
c: psoriatic arthritis
d: infectious arthritis
e: rheumatoid arthritis

Answer 6

b: Pseudogout presents similarly to acute gout and is best dx by finding of the rhomboid-shaped crystals of calcium pyrophosphate in joint aspirates. Joints commonly involved in pseudogout are the knees and wrists and other joints such as the metacarpophalangeals, hips, shoulders, ankles, and elbows. The dx of pseudogout is further supported by the finding of a normal serum uric acid level. Acute gout would more likely be associated with an elevated serum uric acid level. Psoriatic arthritis commonly presents with asymmetrical oligoarticular involvement of two to four joints, and in a higher % of pts, there is known presence of the dermatological expression of psoriasis. In infectious (septic) arthritis, the WBC count would be between 50,000-200,000. Rheumatoid arthritis usually presents with symmetrical polyarticular involvement of 3 or more joints.

Question 7

Which of the following patterns of stiffness is most characteristic of pts with rheumatoid arthritis?

a: morning stiffness lasting at least 1 hour
b: exacerbation of joint stiffness with walking
c: frequent, brief episodes of stiffness after inactivity
d: stiffness reflected by a major delay in muscle relaxation
e: stiffness evidenced by increased resistance to passive movement

Answer 7

a: morning stiffness lasting at least 1 hour is characteristic of rheumatoid arthritis (RA). Exacerbation of joint stiffness with weight bearing (s/a walking) and frequent, brief episodes of stiffness (lasting

Question 8

Related infections that have been identified as triggers of reactive arthritis include sexually transmitted infections and which of the following other types of infections?

a: ear infections
b: eye infections
c: enteric infections
d: musculoskeletal infections
e: CNS infections

Answer 8

c: Reactive arthritis, previously known as Reiter syndrome, typically presents with the clinical triad of urethritis, conjunctivitis, and arthritis. Most cases of reactive arthritis are associated with either a sexually transmitted infection or an enteric infection. Common STI etiological triggers are Chlamydia trachomatis or Ureaplasma urealyticum. Enterically Shigella, Salmonella, Yersinia, or Campylobacter are organisms associated with reactive arthritis.

Question 9

A 45 y/o woman with recent dx of rheumatoid arthritis (RA) has begun tx with celecoxib. She has been on this medication for 3 months and notes that her pain continues. Early signs of joint involvement are present in the patient’s hands. Which of the following medications is the most appropriate to add to her tx?

a: aspirin
b: rituximab
c: etanercept
d: leflunomide
e: methotrexate

Answer 9

e: The tx of RA is aimed at reduction of pain, preservation of function, and prevention of deformity. Although NSAIDs provide symptomatic relief, they do not alter progression or prevent erosion of the joint. In addition to NSAID therapy, DMARDs should also be initiated as soon as the dx is confirmed. The most common initial DMARD used as tx of RA is methotrexate. Aspirin should not be added because of the increased risk of GI side effects as well as having no effect on altering RA disease progression. Rituximab is a bDMARD and is indicated to be added in pts with RA refractive to tx with combination therapy of methotrexate and a TNF inhibitor. Etanercept is a TNF inhibitor. This class of meds is often added in pts with PA who are not responding to methotrexate alone. Leflunomid is a pyrimidine synthesis inhibitor that is approved for the tx of RA; however, it is contraindicated for use in premenopausal women secondary to its carcinogenic and teratogenic potential

Question 10

A 48 y/o woman presents with a cc of gradually progressing difficulty in climbing the stairs over the past 3 months. The PE shows there is notable proximal muscle weakness of the upper and lower extremities. The remainder of the examination is unremarkable. The lab evaluation shows an elevated serum creatinine phosphokinase level, and a muscle bx reveals lymphoid inflammatory infiltrates. Which of the following is the appropriate initial tx of choice for this pt?

a: prednisone
b: azathioprine
c: methotrexate
d: immunoglobulin
e: hydrochloroquine

Answer 10

a: The most likely dx is this patient is polymyositis. This is supported by the finding of gradual progressive proximal muscle weakness and elevation of creatinine phosphokinase level. The finding of the lymphoid inflammatory infiltrates on muscle bx confirms the dx. Initial tx of choice in this condition is the use of a corticosteroid (prednisone). Pts who do not respond to prednisone may then benefit from use of methotrexate or azathioprine. Both IV immune globulin and hydroxychloroquine are effective for the tx of pts with dermatomyositis that is resistant to prednisone therapy.

Question 11

Which of the following is the correct term to describe the abrupt onset of swelling and extreme tenderness to palpation involving the metatarsophalangeal joint of the great toe?

a: crepitus
b: podagra
c: xerostima
d: trigger point
e: chondrocalcinosis

Answer 11

b: Podagra is the term utilized to denote the involvement of the great toe in cases of gout. Crepitus refers to sound or feeling associated with movement of joints due to joint irregularities. Xerostima is the term applied to symptoms of dryness of the mouth, which may be seen in Sjogren’s. Trigger points typically describe areas of pain revealed by palpation of involved muscle areas in pts with fibromyalgia. Chondrocalcinosis refers to presence of calcium-containing salts in articular cartilage associated with metabolic diseases, s/a pseudogout.

Question 12

Which of the following is an established risk factor for osteoporosis and is also an indication for measuring bone density?

a: obesity
b: alcoholism
c: hypercalcemia
d: history of scoliosis
e: short-term corticosteroid therapy

Answer 12

b: Risk factors for osteoporosis and indications for measuring bone density include alcoholism. Low BMI (6mg or prednisone for more than 1month), not short term corticosteroid therapy are also indications for measuring bone density.

Question 13

A 22 y/o man presents with an insidious onset of low back pain over the last 6 months. He describes the pain as dull and has difficulty localizing the pain. The pain radiates to his thighs. The pain is worse in the morning and associated with stiffening that lessens during the day. The pt notes that there is no hx of trauma. The initial lab evaluation shows an elevated EST, positive HLA-B27, and a negative RF. Plain films of the lumbar spine reveal bilateral blurring of the sacroiliac joints. Which of the following is the most likely dx?

a: SLE
b: lumbar disc disease
c: RA
d: anklyosing spondylitis
e: polymyalgia rheumatica

Answer 13

d: Ankylosing spondylosis is the most likely dx in this pt. This condition is a chronic inflammatory disorder of the joints of the axial skeleton and commonly presents in the late teens or twenties. Male pts have a higher incidence than do female pts. A common presentation is pain in the lower back with radiation to the thighs and associated limitation of movement that may lessen during the day. Lab findings include elevated ESR and a positive HLA-B27. The HLA-B27 is not a specific test for ankylosing spondylitis; a small % of the normal population has a positive finding of this antigen. The earliest radiographic findings occur in the sacroiliac joints, with detection of erosion and blurring of the joint space “bamboo spine”

Question 14

Which of the following clinical manifestations is associated with systemic disorders that are HLA-B27 related, including anklyosing spondylitis, reactive arthritis, psoriasis, and Behcet syndrome?

a: uveitis
b: dysentary
c: vasculitis
d: hyperuricemia
e: thoracic involvement

Answer 14

a: Uveitis is an associated finding. These disorders can cause a nongranulomatous anterior uveitis that usually presents unilaterally with pain, redness, photophobia, and visual loss. Dysentary is more likely to be associated with reactive arthritis. Vasculitis is seen with Behcet disease. Hyperuricemia may be found with psoriasis. Thoracic involvement is often found in ankylosing spondylitis.

Question 15

A 67 year old man presents with pain and stiffness in his shoulders and hips lasting for several weeks with no hx of trauma. He also has complaints of HA, throat pain, and jaw claudication. It is imperative to dx this pt promptly in order to prevent which of the following conditions?

a: anemia
b: cerebral aneurysms
c: mononeuritis multiplex
d: ischemic optic neuropathy
e: respiratory tract complicatoins

Answer 15

d: The most urgent need for dx of a pt with symptoms of polymyalgia rheumatica (PMR) and giant cell arteritis is to prevent blindness caused by ischemic optic neuropathy as a result of occlusive arteritis of the ophthalmic artery. Early dx is imperative as the neurological damage to the optic nerve is not reversible.

Question 16

Which of the following is a cause of inflammatory polyarthritis?

a: gout
b: osteoarthritis
c: reactive arthritis
d: psoriatic arthritis
e: SLE

Answer 16

e: Inflammatory causes of polyarthritis include SLE and RA. Gout, although inflammatory, is most commonly nonarticular. Osteoarthritis is a noninflammatory process that is also usually monarticular. Both reactive arthritis and psoriatic arthritis involve two to four joints and therefore classified as oligoarticular.

Question 17

Reactive arthritis most commonly presents with a tetrad of urethritis, conjunctivitis, mucocutaneous lesions, and oligoarthritis (2-4 joints involved). Which of the following joints are most commonly involved in this condition?

a: sacroiliac joints
b: metatarsophalangeal joints
c: large weight-bearing joints
d: metacarpophalangeal joints
e: distal interphalangeal joints

Answer 17

c: The most common joints involved in reactive arthritis are the large weight-bearing joints of the knees and ankles. Small joints of the feet, such as the MTP joints, and not likely involved in reactive arthritis. MCP joints are primarily involved in RA or SLE. DIP joints are commonly involved in osteoarthritis and psoriatic arthritis

Question 18

Patients dx with Sjogren’s should be counseled to avoid which of the following class of medications?

a: penicillins
b: decongestants
c: antihistamines
d: corticosteroids
e: fluoroquinolones

Answer 18

b: Sjogren syndrome is an autoimmune disorder that commonly presents with dryness of the eyes, mouth, and other areas of the body covered by mucous membranes. Because of this chronic dysfunction of the exocrine glands and chronicity of dryness of the eyes and mouth, pts should be counseled to avoid decongestants and atropinic drugs. The use of this medication further exacerbates their symptoms.

Question 19

Approximately 90% of ankle injuries result from which MOI?

a: eversion
b: inversion
c: plantar flexion
d: eversion and plantar flexion
e: inversion and plantar flexion

Answer 19

e: Approximately 90% of ankle injuries result from forced inversion with the ankle in plantar flexion. The anterior talofibular ligament is the most commonly injured ligament

Question 20

A 62 y/o man presents complaining of progressively worse R. shoulder pain for 5 weeks. The pain is located anterolaterally and is aggrevated by overhead activities. The pt notes significant pain when trying to sleep with his arm in a forward-flexed position and his hand behind his head. The pt notes weakness of the right arm and states that he has noticed that he uses the arm less because of the pain. On PE, you elevate the pts arms to 90 degrees, abduct to 30 degrees, and internally rotate the arms with the thumbs pointing downward. You note weakness and drooping of the right arm with this maneuver that is exacerbated when you apply downward pressure to the right arm. On the basis of this presentation, what is the most likely injured structure?

a: infraspinatus tendon
b: supraspinatus tendon
c: teres minor tendon
d: subscapularis tendon
e: bicipital tendon

Answer 20

b: The maneuver described is the supraspinatus strength test of the “empty can test.” Weakness in this maneuver is suggestive of injury to supraspinatus tendon. The teres minor and infraspinatus tendons are external rotators.

Question 21

A 22 y/o female was playing basketball when she tripped and landed on the pavement with her hands outstretched. She presents complaining of abrasions on the right thenar eminance and “wrist pain.” PE reveals tenderness to palpation between the the extensor pollicus longus and extensor pollicus brevis. Assessment of the median, ulnar, and radial nerves reveals no sensor or motor changes when compared to the left hand. Radial and ulnar pulses are 2+ bilaterally with capillary refill less than 2 sec on all 5 fingers of right hand. Posterior-anterior wrist x-rays with the wrist in ulnar deviation reveal no fx or dislocations. What is the appropriate management for this pt at this time?

a: immediate ortho referral
b: cock-up splint until symptoms resolve
c: PT referral for assessment and tx
d: thumb spica splint and repeat x-ray in 3 weeks
e: no further tx necessary because the x-ray was negative and no vascular or neurological abnormalities were noted on examination

Answer 21

d: The scaphoid bone is based in the proximal row of carpal bones but extends into the distal row, making it more vulnerable to injury when a pt falls on an outstretched hand. The scaphoid bone is the most frequently injured carpal bone, accounting for 60-70% of all carpal fx. At the time of initial injury, 10-15% of scaphoid fx may not be visible on plain x-rays. Pts with pain in the anatomical snuffbox to palpation or axial loading, even with normal x-rays, should be tx as though they have a scaphoid fx and placed in a thumb spica splint. Repeat x-ray should be taken after 2-3 weeks. If x-rays still normal but tenderness over scaphoid bone persists, a bone CT scan or MRI can be ordered. Fx of the scaphoid have high incidence of nonunion and osteonecrosis because the major blood supply enters in the distal segment of the bone and can be disrupted with injury/fx.

Question 22

A 53 y/o woman presents with pain in her R wrist. The pain is aggravated by movement of the thumb and when she makes a fist. She also notes that when she moves her thumb, there is an occasional locking sensation in the radial aspect of the wrist. PE of the wrist reveals swelling and tenderness over the distal radius, and full flexion of the thumb into the palm, with ulnar deviation of the wrist, produces pain. X-ray evaluation of the wrist shows no bone abnormalities. Which of the following would be the tx of choice in this pts presentation?

a: immobilization of the wrist with a thumb spica splint
b: tendon sheath corticosteroid injection
c: operative tx to restore functionality
d: prompt neurological evaluation
e: proceed to bone scant to evaluate area of pain

Answer 22

a: This pt presentation is most consistent with DeQuervain tendonitis (tenosynovitis), inflammation of the abductor pollicis longus and extensor pollicis brevis, which results from thickening of the tendon sheath results in pain, swelling, and a triggering phenomenon of locking or sticking. This disorder is more common in middle-aged women and in repetitive motion injuries. On PE, the finding of a +Finkelstein test, which is pain with full flexion of the thumb into the palm, with ulnar deviation of the wrist is diagnostic of DeQuervain’s. Initial tx is aimed at immobilization of the wrist to allow for pain and inflammatory relief. A course of NSAIDs is helpful for pain relief as well. Corticosteroid injection is reserved for pts who fail with immobilization and NSAID use. Operative tx should be considered only if injections are not helpful. X-rays not helpful

Question 23

Which of the following most accurately describes the PE findings suggestive of a boutonniere deformity?

a: hyperextension of the PIP joint with fixed flexion of the DIP joint
b: persistent extension of the PIP joint with hyperflexion of the DIP joint
c: hyperextension of the DIP joint with flexion of the PIP joint
d: persistent flexion of the PIP joint with hyperextension of the DIP joint
e: hyperextension of the DIP joint with extension of the PIP joint

Answer 23

d: A Boutonniere deformity classically presents as persistent flexion of the PIP joint with hyperextension of the DIP joint. A swan neck deformity is also commonly found with patients who have RA. A swan neck deformity classically manifests as hyperextension of PIP joint with fixed flexion of the DIP joint

Question 24

A 62 y/o man is postop day 2 from a R THR. He has been ambulating with PT, and his diet has been advanced to full w/o restrictions. On morning rounds, the pt admits to an acute onset of pain in left first MTP joint. The joint is erythematous to inspection. Pain is elicited with ROM, and the pt is unable to bear weight on his foot secondary to pain. Aspiration of the joint reveals calcium pyrophosphate crystals. What is the most likely dx?

a: gout
b: pseudogout
c: septic joint
c: bunion

Answer 24

b: Pseudogout, like gout, frequently develops 24-48 hrs after major surgery. Pseudogout involves the knee most frequently but can affect the ankle, wrist, and MTP joints. identification of calcium pyrophosphate crystals in the join aspirates is dx of pseudogout.

Question 25

A 25 y/o man was involved in a motor vehicle accident (MVA) and complains of right leg pain. The car was traveling approx 50 mph when the driver lost control of the car, causing it to leave the road and run head-on into a tree. At the time of the accident, he was sitting in the passenger side of the front seat. The force of the collision caused the dashboard to be driven violently back against the pts knees. On the basis of this MOI, what would you expect to find when you inspect the right leg?

a: flexed, abducted, and externally rotated
b: shortened, abducted, and externally rotated
c: shortened, abducted, and internally rotated
d: shortened and externally rotated
e: shortened, adducted, and internally rotated

Answer 25

e: The MOI suggests a posterior hip dislocation. In a posterior hip dislocation, the femur is dislocated posterior to the acetabulum when the thigh is flexed, as may occur in a head-on MVA when the pts knee is violently impacted by the dashboard. The significant clinical findings of a posterior hip dislocation are an extremity that is shortened, adducted, and internally rotated. An anterior hip dislocation classically presents as a flexed, abducted, and externally rotated leg. A fx femoral neck is classically externally rotated and shortened

Question 26

NSAIDs are frequently utilized in treating pts with osteoarthritis. In addition for the potential for bleeding and GI effects, the primary concern, especially in elderly pts, is irreversible damage to which of the following?

a: eyes
b: heart
c: kidneys
d: peripheral vascular system
e: CNS

Answer 26

c: NSAIDs are metabolized in the liver and excreted by the kidneys. Elderly pts are more at risk of developing irreversible damage to the renal system. Renal function physiologically decreases with advancing age. With decreased clearance of the medication, renal damage ensues and leads to accumulation of the drug and further renal damage. Renal function should be monitored in the elderly pt receiving HD of NSAIDS. Hepatic failure is also a concern with the use of NSAIDs.

Question 27

A 7 y/o boy is brought to the ED after sustaining a fall onto his outstretched hand. He complains of pain involving the entire arm and refuses to move his arm, which is held at 90 degrees. On PE, there is notable tenderness over the elbow with associated swelling and pain on attempted rotation. There is no apparent tenderness to palpation involving the wrist or shoulder. The child refuses to participate with ROM evaluation. X-ray evaluation of the elbow shows the presence of a positive posterior ‘fat pad sign’. What is the most likely dx with this pts presentation?

a: nursemaid elbow
b: lateral epicondylitis
c: medial epicondylitis
d: radial head dislocation
e: occult fracture of the radial head

Answer 27

e: The most likely dx in this pt presentation is an occult fx of the radial head. This is supported by the MOI, PE, and x-ray findings. On PE, tenderness over the radial head with local swelling and pain with rotation and flexion of the forearm is usually present. Fx of the radial head may be subtle on initial x-rays. The finding of anterior fat pad may be a normal finding, but the finding of a posterior fat is pathological and usually indicates and occult fx of the radial head. Nursemaid elbow is more commonly seen in children 1-3 and is associated with injury that is pulling in nature on the hand with the elbow in full extension. Later and medial epicondylitis are typically overuse injuries that occur in pts 35-50. Radial head dislocation may be associated with fx of the radial head; the supporting evidence in this case does not support dislocation. Radial head dislocation is typically posteriorly and evident on x-rays.

Question 28

A 35 y/o man presents with complaints of swelling and pain in L knee. The pt states he sustained a twisting injury in a basketball game 3 days ago. The injury did not take him out of the game; he was able to participate with minimal difficulty. Over the last 2 days, the pain has progressed. He notes a catching sensation and pain that is more medially located. On PE, the pt is found to have tenderness over the medial joint line and limited ROM. Forced flexion and circumduction of the joint causes a painful click. What is most likely the dx?

a: ACL tear
b: medial meniscus tear
c: pes anserine bursitis
d: tibial plateau fx
e: MCL tear

Answer 28

b: Pt presentation is most consistent with medial meniscus tear. Medial meniscus tears are more likely to present with a twisting injury to the knee. Pts usually are ambulatory after the injury, with pain and swelling progressing 2-3days after the injury. The pain is usually located in the medial or lateral side of the knee and is associated with a catching or locking sensation caused by swelling or mechanical blockage from torn meniscus. On PE, there is tenderness over medial or lateral joint line. The McMurray test is positive when forced flexion and circumduction of the joint causes a painful click

Question 29

A 15 y/o boy was playing football and was hit during a play, causing an abduction injury of his left lower leg. He locates the pain along the medial aspect of the knee, and there is a minimal level of joint effusion. Which of the following tests would assess for stability of the MCL?

a: valgus stress test
b: varus stress test
c: apprehension sign
d: Lachman test
e: anterior drawer sign

Answer 29

a: Evaluating the MCL is best completed by applying a valgus stress to the knee extended and then fully flexed at 25 degrees and then evaluating the stability. If the knee shows exaggerated laxity, there is more likelihood that the MCL is torn.

Question 30

Which of the following is most diagnostic of a septic joint?

a: synovial fluid analysis
b: plain radiograph
c: ultrasound of joint
d: CT scan of joint
e: MRI of joint

Answer 30

a: The evaluation of septic arthritis is best accomplished with synovial fluid analysis and culture. Radiograph can be normal. Ultrasound evaluation can demonstrate fluid in joint but is not specific of dx. CT scan and MRI of the join are not specific to dx.

Question 31

A 39 y/o woman presents with complaints of pain in her left foot of 4 weeks duration. The pt works as a cashier, which requires her to be on her feet for long hours. She notes that the pain is more severe on the bottom of her foot and is worse upon arising in the morning and then subsides with ambulation. The pt has a benign medical hx and no other complaints. Which of the following is the most likely dx?

a: heel spur
b: Achilles tendonitis
c: tarsal tunnel syndrome
d: plantar fasciitis
e: posterior tibial nerve entrapment

Answer 31

d: Pt presentation of pain is typical of plantar fasciitis, where pain is located on the bottom of the foot and is more commonly severe on initially getting up in the morning and lessens with ambulation. In most cases of plantar fasciitis, there is maximal pain along the plantar medial aspect of the heel, corresponding to the origin of the plantar fascia at the medial calcaneal tuberosity. Heel spurs are more likely associated with continued pain. Achilles tendonitis is more likely to occur over the bony prominence of the calcaneus

Question 32

Which of the following best describes the deformity that causes a “mallet finger” ?

a: rupture or avulsion of the insertion of the extensor tendon at the base of the distal phalanx
b: rupture or avulsion of the insertion of the flexor tendon at the base of the distal phalanx
c: fx of the distal phalanx
d: dislocation of the DIP joint
e: fx of the proximal phalanx

Answer 32

a: Mallet finger is caused by rupture or avulsion of the insertion of the extensor tendon. It is also known as a baseball finger due to the cause of injury commonly associated with a ball striking the finger, causing sudden passive flexion of the actively extended DIP joint. The presentation is a DIP joint that is unable to extend at the joint

Question 33

Which of the following clinical manifestations is most characteristic of polymyalgia rheumatica (PMR)?

a: subcutaneous inflammatory lesions
b: pain and stiffness in proximal muscle groups
c: insidious onset of symmetrical joint involvement
d: widespread musculoskeletal pain and tender points
e: symmetrical weakness initially in the legs that progresses caudally

Answer 33

b: An abrupt onset of proximal muscle pain and stiffness in the shoulder and pelvic girdle areas, usually associated with fever, malaise, and weight loss, is characteristic of PMR