MSK/ Autoimmune Flashcards
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
ANS: D
Latent bone tumors are usually discovered as incidental findings during evaluation for
musculoskeletal injury. 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. 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
ANS: C
Patients with chordoma, which is a type of sarcoma with a predilection for the sacrum, will
have these symptoms 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. The oncologist will order a CT and body scan and possibly biopsy or
surgery.
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
ANS: A, B, C, E
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.
Which cause is implicated in patients with fibromyalgia syndrome (FMS)?
a. Autoimmune disease
b. Central nervous system dysfunction
c. Muscle dysfunction
d. Viral disease
ANS: B
Although the cause of FMS is unclear, current research suggests a CNS cause and not muscle,
autoimmune, or viral causes.
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.
ANS: A
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
ANS: A, C, D
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
ANS: A
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 hours
ANS: A
Intraarticular steroids are practical and beneficial when only one or two joints are involved
and are safe for patients who cannot use NSAIDs or colchicine. NSIADs are contraindicated
in patients with renal disease and colchicine should not be used in those with low glomerular
filtration rates. It is not necessary to discontinue urate-lowering therapy during an acute
attack.
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.
ANS: C
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 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
ANS: A
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
ANS: B
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
ANS: B
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.
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
ANS: B
Postmenopausal women are candidates for bone densitometry to assess for osteopenia and
osteoporosis. 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
ANS: A
Bisphosphonates are FDA-approved treatment for osteoporosis and will help improve bone
density and reduce the risk of fractures. Calcium and vitamin D may help prevent osteoporosis
but must be taken from an early age. Estrogen replacement is used to prevent osteoporosis.
Yoga and exercise help with balance and muscle strength to help prevent falls.
A patient has bone pain and laboratory testing reveals an elevated serum alkaline phosphatase
(SAP). Which test can help distinguish Paget’s from malignant bone disease?
a. Bone densitometry
b. Bone marrow biopsy
c. Bone radiograph
d. Bone scan
ANS: C
A plain bone radiograph will show changes pathognomonic of Paget’s disease. The other tests
are not necessary.
A 50-year-old woman reports pain in one knee upon awakening each morning that goes away
later in the morning. A knee radiograph is negative for pathology and serum inflammatory
markers are normal. What will the provider tell this patient?
a. A magnetic resonance imaging study is necessary for diagnosis
b. That the lack of findings indicates no disease process
c. To take acetaminophen 1 gram three times daily for pain
d. To use a cyclooxygenase 2-selective NSAIDs to reduce inflammation
ANS: C
Acetaminophen is the mainstay for initial treatment of osteoarthritis. Radiologic findings are
often negative in the early stages of the disease. There are no serologic markers for OA. A
COX-2-selective inhibitor has cardiovascular side effects and should not be used unless
necessary. These agents are used more for pain than for inflammation.
A patient who has osteoarthritis in the carpometacarpal joints of both thumbs asks about
corticosteroid injections to treat symptoms. What will the provider tell this patient about this
therapy?
a. Corticosteroid therapy reduces inflammation and improves joint mobility
b. Injections may be administered as needed up to 6 times per year
c. Intraarticular injections provide significant pain relief for 3 to 4 months
d. This treatment may cause a temporary increase in pain, warmth, and redness
ANS: D
Intraarticular injections of corticosteroids are helpful in decreasing pain, but may cause a
transient increase in pain, warmth, and redness. This therapy does not improve inflammation
and joint mobility. Injections are not recommended more than 3 to 4 times per year. The
duration of pain relief is variable.
A 45-year-old patient has mild osteoarthritis in both knees and asks about nonpharmacologic
therapies. What will the provider recommend?
a. Aerobic exercise
b. Glucosamine with chondroitin
c. Therapeutic magnets or copper bracelets
d. Using a cane or walker
ANS: A
Aerobic exercise helps with cardiovascular conditioning and weight reduction as well as
improved range of motion, decreased pain, and strengthening of supporting structures.
Randomized controlled studies have failed to demonstrate significant pain relief with
glucosamine. Therapeutic magnets and copper have not been proven to be effective. A young
patient with mild symptoms will not need assistive devices and should focus on conditioning.
A 50-year-old patient with diabetes mellitus has a low-grade fever and pain on one foot. The
provider notes erythema and swelling at the site along with several superficial skin ulcers
without necrosis and suspects osteomyelitis. Which type of diagnostic study will the provider
order?
a. Biopsy of bone or debridement cultures
b. Blood cultures and serologic markers of inflammation
c. Magnetic resonance imaging of the foot
d. Plain radiograph of the foot
ANS: D
A patient with diabetic foot infection suspected of having osteomyelitis should have a plain
radiograph to identify bony abnormality or soft tissue changes. MRI may be performed if
more specific evaluation is needed or if abscess is suspected. Blood cultures are not diagnostic
of osteomyelitis. Biopsy and debridement cultures increase the risk of further infection if poor
healing at the site occurs.
A 3-year-old child has marked pain in one leg localized to the upper tibia with refusal to bear
weight. The child has a high fever and a toxic appearance. Which type of osteomyelitis is
most likely?
a. Chronic osteomyelitis
b. Hematogenous osteomyelitis
c. Osteomyelitis from a contiguous focus
d. Peripheral vascular disease osteomyelitis
ANS: B
Young children are more likely to have hematogenous osteomyelitis, especially with acute
symptoms. Chronic osteomyelitis is more common with underlying diseases such as diabetes.
Contiguous focus osteomyelitis occurs when organisms are introduced from a puncture
wound, foreign body, or adjoining soft tissue infection. Peripheral vascular causes are more
common in chronically ill patients.
