Mod 4: Buttaro Ch 154-170, 195-170 Flashcards
A patient injures an ankle while playing soccer and reports rolling the foot inward while falling with immediate pain and swelling of the lateral part of the joint. The patient is able to bear weight and denies hearing an audible sound at the time of injury. What does this history indicate?
a. Likely ankle sprain with a possible fracture
b. Mild ankle injury without fracture
c. Mild soft tissue injury only
d. Serious ankle injury with certain fracture
a. Likely ankle sprain with a possible fracture
inversion- rollin sole inward toward midline
at risk for lateral ligaments injury
eversion-rolling sole outwards away from
midline
-at risk for deltoid ligament injury
**Immediate swelling, bruising of the joint raises the index of suspicion for a fracture or a substantial amount of joint involvement. will need xrays to confirm
***any pop sounds indicate a more serious injury
A patient who is a distance runner reports pain in one heel that is worse in the morning and
seems to improve with exercise. The provider notes localized swelling and a bony prominence
at the heel. What is the initial treatment for this condition?
a. Cessation of all sports activities and exercise
b. Crutches and partial weight bearing
c. Physical therapy for ultrasound therapy
d. Referral to an orthopedist for MRI and evaluation
a. Cessation of all sports activities and exercise
This patient has symptoms consistent with Achilles tendonitis.
Immediate cessation of sports and exercise is the first step in management.
**if tear= emergency, classic sign = I thought i got shot in my calf, refer to ortho
Crutches and partial weight bearing may be indicated if symptoms do not improve with rest and NSAIDs.
Physical therapy is used as adjunctive therapy. Symptoms that do not improve require referral.
Stretching and using heal lift inserts
A patient has pain on the plantar aspect of the heel with weight bearing after rest. The pain is worsened with dorsiflexion of the foot. What is the initial treatment for this patient?
a. A series of steroid injections
b. Avoiding all high-impact activities
c. Night splints
d. Wearing flat shoes only
b. Avoiding all high-impact activities
The fascia supports the arch with movement like jumping and running
sx: pain with weight bearing the 1st thing in am
The initial treatment includes avoiding all high-impact activities. A single steroid injection may be given with subsequent injections if no improvement.
Night splints are part of second-tier treatment.
Flat shoes should be avoided.
A provider discovers a bone tumor as an incidental finding on a radiograph in a patient who has sustained an injury to a ligament. The patient has not had pain prior to the injury. What will the provider do next?
a. Consult with an orthopedic specialist
b. Order a chest CT and full body scan
c. Refer the patient to for a bone biopsy
d. Repeat the radiograph in 3 to 6 months
d. Repeat the radiograph in 3 to 6 months
Latent bone tumors are usually discovered as incidental findings during evaluation for musculoskeletal injury. OFTEN BENIGN If the injury is the source of pain, the radiograph may be repeated in 6 to 12 months to determine whether it is increasing in size. WHICH IS A CONCERN FOR MALIGNANCY
Consultation with an orthopedic specialist, referral for a biopsy, and further testing with chest CT or full body scanning are done if there is suspicion of an active tumor.
A patient reports persistent lower back pain and constipation. A digital rectal examination
reveals a mass at the sacrum. What will the primary care provider do to manage this patient?
a. Order spinal radiographs in 3 months
b. Perform an MRI of the sacrum
c. Refer the patient to an oncologist
d. Schedule the patient for a biopsy
GRADESMORE.COM
c. Refer the patient to an oncologist
This patient has a chordoma based on symptoms (low back pain, constipation) and a palpable mass coming out of the sacrum. A referral to an oncologist is necessary. These tumors have a significant risk for malignancy, so waiting 3 months is not an option.
bone is common sites for mets especially cancer of breast, prostate, kidney thyroid and lung
sx of bone pain that are concerning:
- bone pain worse at night
- pain longer than 6 months
- progressing in severity
- and/or swelling
3 most common bone lesions:
- osteosarcoma (cancer that begin in bone cell often in long bones of arms/legs)
- Chordoma: which is a type of sarcoma with a predilection for the sacrum,
- Multiple myeloma- cancer of the plasma cell (WBC in bone marrow)
Which treatments may be used to manage bone pain in patients with bone tumors? (Select all that apply.)
a. Bisphosphonates
b. Exercise
c. External beam radiation
d. Massage
e. Vertebroplasty
a. Bisphosphonates
b. Exercise
c. External beam radiation
e. Vertebroplasty
Bisphosphonates can decrease pain by preventing growth and development of existing and new bone lesions.
Exercise is useful to maintain function and reduce pain.
External beam radiation is useful in most patients.
Vertebroplasty involves injecting bone cement to stabilize bone.
Massage is not recommended.
A patient experiencing shoulder pain is seen by an orthopedic specialist who notes erythema, warmth, and fluctuance of the shoulder joint. What is the next step in treatment for this patient?
a. Admit to the hospital for intravenous antibiotics.
b. Inject lidocaine into the joint and reassess in 5 to 10 minutes.
c. Order a plain radiograph of the shoulder to identify possible fracture.
d. Perform a shoulder ultrasound to further evaluate the cause.
a. Admit to the hospital for intravenous antibiotics.
Bursa = sac lined with a membrane that produces and contains synovial fluid that provides lubrication and facilitates smooth movements b/w tissue of extremities
MOST COMMON: SHOULDER, HIP, KNEE, HEEL
can become septic (red, hot swollen = Immediate referral is indicated for patients who present with symptoms consistent with septic bursitis, such as with the symptoms above.
-can do synovial aspiration to dx
Lidocaine is injected into a painful joint to evaluate for improvement to determine whether bursitis or tendonitis is present as a result of impingement.
This exam is not consistent with fracture. An ultrasound is not indicated.
A patient with elbow pain without localized erythema or warmth is diagnosed with bursitis of the elbow and serum laboratory results are pending. What is the initial treatment while waiting for these results?
a. Aspiration of the bursal sac for culture
b. Corticosteroid injection into the bursal sac
c. Elbow pads, NSAIDs, rest, and ice
d. Physical and occupational therapy
c. Elbow pads, NSAIDs, rest, and ice
bursitis without signs of septic treated with
Initial therapy includes conservative measures for comfort. but must draw CBC, ESR, CRP
Until infection is suspected, based on the white blood count and inflammatory markers, and without localized signs of infection, aspiration of the bursal sac is not indicated.
Corticosteroids should not be injected into the bursal sac until infection has been excluded. Physical and occupational therapy should not precede comfort measures.
What are included in the initial management of bursitis of the heel? (Select all that apply.)
a. Activity modification and bracing
b. Closed heel shoes to prevent further injury
c. Corticosteroid injections
d. Nonsteroidal anti-inflammatory medications
e. Rest, ice, compression, and elevation
a. Activity modification and bracing
d. Nonsteroidal anti-inflammatory medications
e. Rest, ice, compression, and elevation
Activity modification and bracing, NSAIDs, and RICE are all used initially to treat heel bursitis. Patients should wear open-heeled shoes. Corticosteroid injections should be used cautiously to prevent rupture of the Achilles tendon.
Which cause is implicated in patients with fibromyalgia syndrome (FMS)?
a. Autoimmune disease
b. Central nervous system dysfunction
c. Muscle dysfunction
d. Viral disease
b. Central nervous system dysfunction
fibromyalgia-wide spread muscle skeletal pain, fatigue, non restorative sleep, DEPRESSION, ha, gi problems
-considered a rheumatologic
condition
-unclear cause
DX: wide spread pain > 7/10
generalized pain in at least 4-5 regions
pain present for at least 3 months
Although the cause of FMS is unclear, current research suggests a CNS cause and not muscle, autoimmune, or viral causes.
tx with low dose TCA= amytriptaline 10mg taken 2-3 hours before bedtime
or SNRIs= fluoxetine, duloxetine
When counseling a patient about the long-term effects of fibromyalgia syndrome, what is important to include in teaching?
a. A multidisciplinary approach to treatment is most effective.
b. Eventual damage to muscles and joints will occur.
c. Exercise may cause discomfort and damage to muscles.
d. Medications are useful for controlling and preventing symptoms.
a. A multidisciplinary approach to treatment is most effective.
A multidisciplinary approach to FMS management can help with pain management, stress,
and exercise. Although patients experience pain, damage to tissues does not occur. Exercise
may be painful but does not cause damage. Medications help alleviate some, but not all symptoms.
Which are symptoms associated with fibromyalgia? (Select all that apply.)
a. Gastrointestinal complaints
b. Hepatosplenomegaly
c. Musculoskeletal pain
d. Nonrestorative sleep
e. Renal complications
a. Gastrointestinal complaints
c. Musculoskeletal pain
d. Nonrestorative sleep
Fibromyalgia may cause GI complaints, musculoskeletal pain, and nonrestorative sleep. Hepatosplenomegaly and renal complications are not associated with fibromyalgia.
A postmenopausal female patient has a blood test that reveals hyperuricemia, although the patient has no symptoms of gout. What will the provider do initially?
a. Ask the patient about medications and medical history
b. Begin therapy with colchicine and an NSAID
c. Recommend a low-purine, alcohol-restricted diet
d. Treat for gout prophylactically to prevent a flare
a. Ask the patient about medications and medical history
Patients without symptoms of gout but with hyperuricemia do not need treatment, since most of these patients will never have a gout flare. It is important, however, to determine the cause of this finding and correct it if possible, since it is a risk factor for gout. Certain medications and medical conditions can predispose patients to gout.
Colchicine and NSAIDs are used to treat symptoms of gout.
Dietary changes are not necessary and are difficult to follow.
Prophylaxis for prevention of flares is for patients who have gout and who are between flares.
A patient with gout and impaired renal function who uses urate-lowering therapy (ULT) is experiencing an acute gout flare involving one joint. What is the recommended treatment?
a. Administration of intraarticular corticosteroid
b. Discontinuing ULT while treating the flare
c. Oral colchicine for 5 days
d. Therapy with NSAIDs begun within 24 hour
a. Administration of intraarticular corticosteroid
Intraarticular steroids are practical and beneficial when only one or two joints are involved
Gout- chronic disease caused by a built of urate in the blodd= hyperurecemia
urate= product of purine metabolism, insoluable to humans, typically gets excreted in urine
-excess urate can deposit in joints and lead to pain.
SX: rapid onset, red, hot, swollen joint, that increases in pain, pain often begins at night
typically occurs 1st in metatarsal joint (toe)
more common in diet consisting of Alcohol, overeating, fasting diuretics
MEN typically have one joint effected episodes
POSTMENAPAUSAL WOMEN- it will affect less than 4 joints
TX: Focused on treating acute attack with oral corticosteroids or NSAIDS with in 24-48 of attack or chochicine
Long-term= use of urate lowering agents- daily use of Allupurinol not to be used during an attack because it will prolong it. SART 5-6 weeks AFTER attack Must have urate level less than 6
NSIADs are contraindicated in patients with renal disease and colchicine should not be used in those with low glomerular filtration rates.*
A patient experiences a second gouty flare and the provider decides to begin urate-lowering therapy (ULT). How should this be prescribed?
a. Begin with a high-loading dose and gradually decrease.
b. Start ULT during the current flare for best results.
c. Start ULT in 5 weeks along with an anti-inflammatory drug.
d. ULT should be suspended during future gouty flares.
c. Start ULT in 5 weeks along with an anti-inflammatory drug.
Beginning therapy with a urate-lowering drug during an acute flare will prolong the flare.
Typically, ULT is begun 5 to 6 weeks AFTER A FLARE a flare and should be given with an anti-inflammatory drug, since the initial period of ULT administration is associated with flares.
ULT dosing should start low and gradually increase.
It is not recommended to stop ULT during future flares, but to treat those flares while continuing the ULT.
A patient reports the sudden onset of pain, redness, and swelling in one knee joint but denies a fever. The provider elicits exquisite pain with manipulation of the joint and notes no decrease in pain when the joint is at rest. Which is the likely cause of this arthritis?
a. Bacterial infection
b. Gout
c. Lyme disease
d. Rheumatoid arthritis
a. Bacterial infection
Biggest symptom = pain at rest and pain relieved by medicine
fever is not always present
septic arthritis = emergency
casued by autoimmune, gout, infection
**if pain is continued despite therapy =sign of infection
synovial sites = most common due to more likely to experience trauma that can damage joint and lead to increase risk of organisms affecting area
***STAPH= MOST COMMON
However can have STD organism cause septic arthritis
Will need synovial fluid analysis to confirm BACTERIAL cause
blood cultures will not show anything
Septic arthritis is usually painful both with movement and at rest and is accompanied by swelling and erythema. Fever is not always present. The other causes of arthritis are not painful at rest.
An adolescent patient reports intermitted pain and swelling in various joints on the right side including the knee, elbow, wrist, and ankle. A physical examination reveals tenosynovitis and a maculopapular rash. Which diagnostic tests will be most helpful in determining a diagnosis in this patient?
a. Blood cultures and a complete blood count
b. Cultures of the urethra, pharynx, cervix, and rectum
c. Skin lesion scrapings and cultures
d. Urine cultures and renal function studies
b. Cultures of the urethra, pharynx, cervix, and rectum
most common cause of from bacteria, fungi, virus, and STD
This patient has signs of gonococcal arthritis. Cultures of the urethra, pharynx, cervix, and rectum will be positive in 80% of patients with this infection.
Blood cultures are likely to be negative. Culturing skin lesions is not helpful. Renal involvement is not part of this infection.
A patient has marked swelling of a shoulder joint with erythema and severe pain. The provider suspects a bacterial cause. Which culture will be most helpful to determine the cause of these symptoms?
a. Blood culture
b. Synovial fluid culture
c. Urethral culture
d. Urine culture
Synovial fluid culture is the most important exam for diagnosis of septic arthritis.
Blood culture may be positive in only 10% of cases.
Urethral culture is performed if gonococcal arthritis is suspected. Urine culture is not helpful.
A patient reports severe back pain located in the lumbar spine. To evaluate whether the patient has axial pain or radicular pain, which assessment is necessary?
a. Asking the patient to perform the Valsalva maneuver
b. Assessing reflexes and asking about tingling or numbness
c. Determining whether the pain is present with prolonged sitting
d. Noting whether pain is mitigated with frequent position shifts
a. Asking the patient to perform the Valsalva maneuver
axial pain = dull and acing
ridicular pain caused by things that can cause the spinal nerve root to be pinched which causes searing pain down the nerve roots
Valsava maneuver determine if pain is caused by radicular or axial
Associated neurological signs are present with radicular pain and include numbness, tingling, weakness, and reflex changes.
The other symptoms occur with both axial and radicular pain.
A patient has an acute onset of lower back pain associated with lifting heavy objects at work. A physical examination reveals no loss of lower extremity function or neurological symptoms. What is the initial intervention for this patient?
a. Magnetic resonance imaging (MRI) to evaluate soft tissue involvement
b. Plain radiographs to evaluate the extent of the injury
c. Traction therapy to minimize complications
d. Treatment with a nonsteroidal anti-inflammatory drug (NSAID)
d. Treatment with a nonsteroidal anti-inflammatory drug (NSAID)
NSAIDs are appropriate as first-line treatment in patients without potential complications.
Radiologic studies are performed if improvement does not occur in 4 to 6 weeks.
Traction may be used for patients with radicular symptoms to help resolve neurological deficits, although systematic review of research has not clearly identified a benefit to this therapy
A patient has recurrent lumbar pain which is sometimes severe. The patient reports that prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) is no longer effective for pain relief. What will the provider recommend?
a. Adjunctive treatment with physical therapy
b. Beginning treatment with opioid analgesics
c. Complementary and alternative therapies
d. Referral to an interventional spine physician
d. Referral to an interventional spine physician
Patients with recurrent or chronic lower back pain may benefit from lumbar epidural corticosteroid injection performed by an interventional spine physician.
Physical therapy is often used for ACUTE injury if no improvement in 4 to 6 weeks.
Opioid analgesics are not usually effective.
An adult patient who has been taking high-dose corticosteroids reports a dull, aching pain in the groin and presents with a limp. What condition does the provider suspect, based on this history?
a. Avascular necrosis of the femoral head
b. Infectious arthritis of the hip
c. Osteoarthritis of the hip
d. Slipped capital femoral epiphysis (SCFE)
a. Avascular necrosis of the femoral head
Avascular necrosis has the symptoms listed above and is common among patients who have been taking corticosteroids. Infectious arthritis will typically be accompanied by fever and intense pain. Osteoarthritis causes progressively worsening pain with activity and improvement with rest. SCFE is common in adolescents.
A patient with chronic hip pain cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) and tells the provider that acetaminophen is minimally helpful. What might the provider recommend initially to improve pain relief?
a. A fentanyl patch
b. Capsaicin
c. Glucosamine
d. Lidocaine patches
b. Capsaicin
Topical capsaicin has been shown to provide short-term pain relief and has fewer side effects than oral agents. It is an appropriate initial therapy. Fentanyl is a narcotic analgesic and should be reserved for more severe pain. Glucosamine and lidocaine may be helpful for some patients.
A high school soccer player sustains a knee injury when kicked on the lateral side of the knee by another player. The provider notes significant swelling of the knee, with pain at the joint line on the medial aspect of the knee. What will the provider do to treat this injury?
a. Instruct about RICE management and follow up in 1 week
b. Refer for a same-day orthopedic consultation
c. Schedule a magnetic resonance imaging (MRI) exam
d. Splint the knee and refer for orthopedic consultation in 1 to 2 weeks
b. Refer for a same-day orthopedic consultation
bases off of symptoms: sounds like either Meniscus or MCL.
This patient has an injury caused by a traumatic event associated with swelling and should have a same-day orthopedic consultation.
Simple sprains may be managed with RICE. MRI may be ordered by the orthopedist.
Which maneuver during a physical examination is used to assess the anterior cruciate ligament (ACL)?
a. Anterior drawer test
b. Posterior drawer test
c. Valgus stress on knee joint
d. Varus stress on knee joint
a. Anterior drawer test
The anterior drawer test, in which the examiner pulls the tibia forward while the knee is flexed, is used to assess anterior cruciate ligament laxity.
The posterior drawer test is used to determine posterior cruciate ligament laxity.
The valgus stress test assesses the medial collateral ligament (MCL) laxity
The varus stress test assesses the lateral collateral ligament (LCL) laxity.
A previously healthy patient reports a sensation of one knee locking or feeling like it will give way when descending stairs. The patient has no recollection of injury to the knee and denies pain. What is the most likely treatment for this disorder?
a. Conservative management with RICE and activity modification
b. Immediate referral to an orthopedic surgeon for possible repair
c. Intraarticular injections of corticosteroids three times yearly
d. Restricting participation in sports and strenuous workouts indefinitely
a. Conservative management with RICE and activity modification
Test= McMurry’s test
This patient has symptoms consistent with chronic degenerative meniscal injury and is without pain or significant disability. Conservative management is indicated.
Immediate referral is indicated for severe pain or disability. Intra-articular injections of corticosteroids are used for patients with concomitant osteoarthritis.
Patients should be encouraged to continue sports and exercise to improve overall muscle tone and minimize disability.
The primary care provider is assessing a 45-year-old postmenopausal woman who has a family history of osteoporosis. Which test will be most useful to screen for this disease in this patient?
a. Biochemical markers of bone resorption and bone formation
b. Bone densitometry of the hip and posteroanterior lumbar spine
c. Plain radiographs of the hips and lumbar and thoracic spine
d. Serum calcium and serum 25-hydroxyvitamin D
b. Bone densitometry of the hip and posteroanterior lumbar spine
Postmenopausal women are candidates for bone densitometry to assess for osteopenia and osteoporosis.
SX fractures with no history of trauma
decrease levels of Estrogen decreases bone remolding
osteoporosis- osteoclast (destroys old bone and repairs then increases ca in blood) activity rate exceeds that of osteoblast (bone rebuilders)
Biochemical markers are generally ordered by specialists; their role in primary care is uncertain.
Plain radiographs are used to determine fracture.
Serum calcium and vitamin D levels are useful in the general population as a preventive measure.
A patient is diagnosed with osteoporosis. What is the recommended treatment once the diagnosis is made?
a. Bisphosphonate therapy
b. Calcium and vitamin D
c. Estrogen replacement
d. Yoga and weight-bearing exercises
a. Bisphosphonate therapy
Bisphosphonates are FDA-approved treatment for osteoporosis and will help IMPROVE bone density and reduce the risk of fractures. PREVENT FRactures
**take biphoshates on an empty stomach with 6-8 ounzes of water
Calcium and vitamin D may help prevent osteoporosis but must be taken from an early age.
Estrogen replacement is used to PREVENT bone loss.
Yoga and exercise help with balance and muscle strength to help prevent falls.
