Rheum SAEs Flashcards
A 55-year-old postal worker with a 1-year history of increasing left knee pain and decreasing
ability to ambulate arrives at your office. Her history is significant for 30 minutes of morning
stiffness and a left medial meniscal tear that was repaired arthroscopically 5 years ago. Her exam
is significant for a body mass index of 35, left knee varus deformity, and mild quadriceps
weakness. Her radiograph demonstrates medial compartment narrowing and bony sclerosis. She
has
(a) rheumatoid arthritis.
(b) osteoarthritis.
(c) parvovirus infection.
(d) pseudogout.
Answer: (b)
Commentary: Osteoarthritis (OA) is the leading cause of impaired mobility in elderly persons.
Risk factors include obesity, malalignment, prior trauma or surgery, and occupational bending or
lifting. Radiographs of knee OA demonstrate joint space narrowing, osteophytes, bony sclerosis
and cysts.
A 25-year-old man with a history of plantar fasciitis complains of low back and buttock pain.
The pain is worse at rest and better with activity. Schober test (signifying restricted lumbar
flexion) is positive. The laboratory or radiology result that would help confirm your most likely
diagnosis is a positive
(a) antinuclear antibody (ANA).
(b) human leukocyte antigen (HLA) B27.
(c) discogram.
(d) myelogram.
Answer: (b)
Commentary: The patient may have ankylosing spondylitis (AS). Enthesitis, such as plantar
fasciitis, is common in patients with AS. HLA B27 is usually positive in this condition, which is
a seronegative spondyloarthropathy. Schober test is performed by marking a point 5 cm below
the iliac crest line and 10 cm above. On forward flexion, the line should increase by more than 5
cm. An ANA test, discogram and myelogram would not help to diagnosis AS.
A 60-year-old man has first metatarsophalangeal joint pain. Joint fluid analysis confirms your
suspected diagnosis. What lifestyle or medication changes would reduce flare-ups of his
condition?
(a) Increase seafood intake
(b) Decrease alcohol intake
(c) Increase diuretic use
(d) Decrease vitamin C use
Answer: (b)
Commentary: Alcohol increases uric acid production and can provoke an acute gout attack.
Seafood and red meat contain purines which increase serum uric acid levels and thus increase
gout flares. Gout can also be provoked by trauma and drugs such as thiazide diuretics. In
contrast, vitamin C has been found to decrease gout attacks.
A 35-year-old woman sustained an ischemic stroke and is currently undergoing workup in the
acute care hospital. Systemic lupus erythematosus (SLE) is suspected. An immunoglobulin G
(IgG) or IgM anticardiolipin antibody analysis is ordered to evaluate for which associated
condition?
(a) Antiphospholipid antibody syndrome
(b) Activated protein C resistance
(c) Antinuclear antibody
(d) Antithrombin III deficiency
Answer: (a)
Commentary: Antiphospholipid antibody is associated with systemic lupus erythematosus (SLE)
and can increase risk of thrombosis. SLE is diagnosed with an abnormal serum level of IgG or
IgM anticardiolipin antibodies, positive lupus anticoagulant, or false-positive serologic test for
syphilis. Activated protein C resistance and antithrombin III deficiency are risk factors for
thrombosis and stroke, but do not have the same association with SLE. Antinuclear antibody is
usually positive in SLE and is part of the diagnostic criteria, but is not associated with
thrombosis.
The ulnar deviation of her fingers at the metacarpal phalangeal joints is due to the rupture of the
(a) lateral retinaculum of the extensor tendon sheath.
(b) central slip of the extensor tendon.
(c) radial retinaculum.
(d) ulnar collateral ligament.
Answer: (c)
Commentary: Rupture of the radial retinaculum produces ulnar subluxation of the metacarpal
phalangeal (MCP) joints. Rupture of the lateral retinaculum of the extensor tendon sheath at the
proximal interphalangeal joints produces swan-neck deformities. Rupture of the central slip of
the extensor tendon produces boutonniere deformities. Rupture of the ulnar collateral ligament
would result in radial deviation of the fingers.
- A 70-year-old obese gentleman presents to your office for follow-up with a several month history
of increasing left hip and groin pain that occurs with walking. His history is significant for prior
alcoholism, hypothyroidism, gout, and right knee osteoarthritis. He completed a physical therapy
course that did not help much. He now has difficulty even standing or walking for a few minutes
and complains of pain with moving his leg. Radiographs taken today demonstrate sclerosis and
slight collapse of the femoral head. What is his main risk factor for developing the condition
found on his radiographs?
(a) Obesity
(b) Alcoholism
(c) Hypothyroidism
(d) Older age
Answer: (b)
Commentary: The radiographic findings are typical for avascular necrosis which can be due to
trauma, high doses and/or prolonged use of steroids, heavy alcohol use, and certain systemic
diseases (diabetes, systemic lupus erythematosus). Obesity and older age are risk factors for
developing osteoarthritis. Typical radiographic findings of osteoarthritis include joint space
narrowing, osteophytes, subchondral cysts and sclerosis; collapse of bone is not seen.
Hypothyroidism is not a risk factor for avascular necrosis.
In Lyme disease, beyond the initial erythema migrans lesion from infection with the spirochete
Borrelia burgdorfer what other findings may be seen later on?
(a) Facial nerve palsy
(b) Renal insufficiency
(c) Pleural effusion
(d) Cardiomyopathy
Answer: (a)
Commentary: Lyme disease is the result of a bite from a tick infected with Borrelia burgdorferi.
Erythema migrans lesion is typically the initial skin lesion seen. Other findings from systemic
infection include mono-/polyarticular arthritis, facial nerve palsy, aseptic meningitis,
radiculopathy, or heart block. Renal insufficiency and pleural effusion are not seen.
A 47-year-old woman develops complex regional pain syndrome (CRPS) type I following a fall
at work which resulted in a distal radius fracture. Although no established gold-standard
treatment for CRPS currently exists, which option has been studied in multiple, large-scale
randomized trials?
(a) Bisphosphonates
(b) Gabapentin
(c) Stellate/lumbar sympathetic blocks
(d) Calcitonin
Answer: (a)
Commentary: While all of the listed options have been used for the treatment of CRPS, only
bisphosphonates have been investigated in multiple, large-scale randomized trials. Clear benefits
have not been reported with gabapentin or stellate/lumbar sympathetic blocks. Available evidence
does not support the use of calcitonin.
You receive a call from your 70-year-old patient with osteoporosis. She has been taking
alendronate (Fosamax) for 3 years. The news reports and her friends are all talking about hip
fractures in patients taking biphosphonates. You state that based upon scientific evidence there is
(a) increased risk of femoral fractures.
(b) increased risk with the initiation of bisphosphonates at a younger age.
(c) no increased risk in patients with prior fractures.
(d) no increased risk of femoral fractures
Answer: (d)
Commentary: Recent secondary analysis of 3 large, randomized biphosphonate studies did not
find increased risk of subtrochanteric or femoral fractures. Proposed risk factors such as younger
age upon initiation of biphosphonate treatment has not been confirmed or studied. A risk factor
for future fractures is a history of prior fractures.
- The use of a magnetic knee wraps in patients suffering with mild to moderate knee osteoarthritis
has been shown to
(a) decrease edema.
(b) increase walking distance.
(c) increase isokinetic strength.
(d) increase range of motion.
Answer: (c)
Commentary: The application of magnetic knee wraps has been shown to increase isokinetic
strength and improve pain scales. Edema, walking distance and range of motion were not
outcome measures.
A 35-year-old gentleman with a history of Lyme disease that was treated adequately with antibiotics 1 year ago complains of continued muscle aches, joint pain, fatigue, and difficulty concentrating. His repeat Lyme serologies have been negative, as have all other laboratory tests. He has had a full medical work-up from his internist that has been unremarkable. You recommend
(a) intravenousceftriaxone for 28 days.
(b) sulfasalazine for his muscle and joint pains.
(c) intra-articular cortisone injections for joint pain.
(d) emotional support and symptom management.
Answer: D
Commentary: The patient has postLyme disease syndrome, which occurs in a minority of patients who have had Lyme disease. There is no specific treatment. Physicians should provide support and management of patient complaints. Antibiotic treatment is contraindicated. Sulfasalazine is not a treatment for Lyme disease.
A 75-year-old manwith a recent calcaneal stress fracture after starting a walking program presents to your clinic. Initially, you should
(a) order a bone mineral density test.
(b) prescribe a lower extremity strengthening program.
(c) obtain a nuclear bone scan.
(d) prescribe a swimming program
Answer: A
Commentary: The initial assessment should include checking his bone density to establish a diagnosis of osteopenia/osteoporosis and then identifying secondary risk factors (such as hypogonadism, corticosteroid use, excessive alcohol use). Once a diagnosis is established, prescribing weight-bearing and strengthening exercises are important. Obtaining a nuclear bone scan is not as helpful. Swimming is a non-weight bearing exercise.
- Which factor is a criterion for hip osteoarthritis?
(a) Periarticularosteopenia
(b) Femoral head erosions with sclerosis
(c) Acetabular osteophytes
(d) Erythrocyte sedimentation rate above20mm/hr
Answer: C
Commentary: The American College of Rheumatology states that the criteria for osteoarthritis of the hip are hip pain along with 2 of the three findings: erythrocyte sedimentation rate less than 20mm/hr, radiographic evidence of femoral/acetabular osteophytes, radiographic evidence joint-space narrowing.
- The most common clinical manifestation of Lyme disease is
(a) monoarticular or oligoarticular arthritis.
(b) facial-nerve palsy.
(c) atrioventricular block.
(d) erythema migrans.
(d)Erythema migrans (EM) is a skin lesion that is erythematous, and may be round or oval, flat or raised, and possibly have
central clearing. Of persons with untreated EM, sixty percent will have monoarticular or oligoarticular arthritis. Ten percent
will have a neurologic presentation, such as facial-nerve palsy. Approximately 5 percent will have a cardiac manifestation
such as atrioventricular block.
- Myositis is defined as
(a) muscle aching.
(b) muscle aching with weakness.
(c) muscle symptoms with creatine kinase elevation.
(d) muscle symptoms with creatine kinase and creatinine elevations.
Myopathy refers to a disease or an abnormal condition of striated muscle, whereas myalgia is defined as muscle aching or weakness without serum creatine kinase (CK) elevations. Myositis implies muscle symptoms accompanied by CK elevations. Rhabdomyolysis signifies muscle complaints with CK elevations 10 times the upper limits of normal (ULN) with creatinine elevation. Clinically important myopathy with CK elevations greater than 10 times ULN is estimated to occur in approximately 0.1% of patients who receive statin monotherapy. Clinically important myopathy and rhabdomyolysis have been reported with all statins with an overall death rate of .15 per 1 million prescriptions.
The most significant risk factor for continued structural destruction of the knee in osteoarthritis is
(a) joint malalignment.
(b) obesity.
(c) prior surgery.
(d) occupational bending and lifting.
(a) Joint malalignment is the most significant risk factor for further joint deterioration, since it creates uneven focal loading.
A 35-year-old man with history of psoriatic arthritis complains of localized low back pain of insidious onset. The pain is worse in the morning and improves as the day progresses. What is the most likely cause of his back pain?
(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis
(b) Spondylonegative spondylarthropathies, such as psoriatic arthritis, are often associated with sacroiliitis. The Gelling phenomenon, characterized by stiffness after prolonged immobility, occurs with many inflammatory arthropathies
The arthropathy in persons with systemic lupus erythematosus (SLE) generally is in the wrists, knees and small joints of the hands. It is also
(a) symmetric and non-erosive.
(b) symmetric and erosive.
(c) asymmetric and non-erosive.
(d) asymmetric and erosive.
(a) The arthritis in SLE is symmetric and non-erosive. It is also generally non-deforming and reducible due to its involvement of the para-articular tissues.
In addition to routine weight-bearing exercises and calcium supplements, vitamin D is important in persons with osteoporosis because it
(a) decreases the amount of calcium supplementation needed.
(b) enhances muscle strength and reduces the risk of falling.
(c) decreases bone turnover.
(d) improves the mechanism of action of bisphosphonates
(b) Vitamin D is essential for skeletal maintenance and has been shown to enhance muscle strength and reduce the risk of falling.
A 24-year-old college student reports low back and lower limb joint pain for the past several months. His heels are especially painful, which makes it difficult for him to walk or stand for prolonged periods of time. He recalls an episode of gastroenteritis requiring hospitalization 6 months ago. Upon further questioning, he admits to some mild dysuria. His neurologic exam is normal. Radiographs of his ankles will most likely demonstrate
(a) a normal joint.
(b) osteophytes and subchondral cysts in the tibiotalar joint.
(c) periosteal reaction and bony erosions of the calcaneus.
(d) avascular necrosis of the talus.
(c) The diagnosis is reactive arthritis / seronegative spondyloarthropathy that develops after certain genitourinary or gastrointestinal infections, most commonly in young men. Non-gonococcal urethritis and conjunctivitis is the remainder of the clinical triad. Heel pain is one of the most frequent and distinctive clinical features, along with low back pain radiating into the buttocks. Periostitis and erosions occur in the ankle joint in individuals with a several month history of heel pain. Osteophytes and subchondral cysts are typical of osteoarthritis. Avascular necrosis is not typical.
What articular abnormality is associated with systemic lupus erythematosus and its treatment?
(a) Avascular necrosis
(b) Erosions with subchondral sclerosis
(c) Erosions with overhanging edges
(d) Syndesmophytes
(a) Avascular necrosis (or ostenecrosis) is the second form of joint disease that occurs in persons with SLE; it is associated with use of corticosteroids. Erosions are not seen with systemic lupus erythematosus. Erosions with subchondral sclerosis are seen in rheumatoid arthritis and overhanging edge in gout. Syndesmophytes occur in spondyloarthropathies at the anterior and posterior longitudinal ligaments of the spine.
A patient presents to your office with knee pain from a flare of rheumatoid arthritis. She has a mild effusion and warmth at her knee. The therapist wants to use ultrasound to her knee for treatment. You advise that ultrasound
(a) accelerates healing.
(b) helps with pain control.
(c) is contraindicated.
(d) will not help with the pain.
(c) Ultrasound use is contraindicated in acute rheumatoid arthritis. Ultrasound has been shown to help with pain, but not in the context of acute inflammation.
- The initial treatment for osteoarthritis is
(a) medication to reverse articular cartilage damage.
(b) surgical correction of joint deformities.
(c) therapy to relieve joint symptoms.
(d) immobilization of the joint to prevent deformity.
(c) General treatment principles of osteoarthritis include medications and/or therapy to relieve joint symptoms, along with maintaining or improving function and minimizing drug toxicity. To date, no medications can reverse or repair damaged articular cartilage. Exercises, such as range of motion and strengthening, are part of nonpharmacologic therapy of osteoarthritis. Surgical correction is not an initial treatment strategy.
- Myositis is defined as
(a) muscle aching.
(b) muscle aching with weakness.
(c) muscle symptoms with creatine kinase elevation.
(d) muscle symptoms with creatine kinase and creatinine elevations
(c) Myopathy refers to a disease or abnormal condition of striated muscle; whereas, myalgia is defined as muscle aching or weakness without serum creatine kinase (CK) elevations. Myositis implies muscle symptoms accompanied by CK elevations. Rhabdomyolysis signifies muscle complaints with CK elevations 10 times the upper limits of normal (ULN) with creatinine elevation. Clinically important myopathy with CK elevations greater than 10 times ULN is estimated to occur in approximately 0.1% of patients who receive statin monotherapy. Clinically important myopathy and rhabdomyolysis have been reported with all statins with an overall death rate of .15 per 1 million prescriptions.
- Which injury level is the most common location for an osteoporotic vertebral compression fracture?
(a) Upper thoracic spine
(b) Middle thoracic spine
(c) Thoracolumbar junction
(d) Middle lumbar spine
(b) The most common location for vertebral compression fractures due to osteoporosis is the midthoracic spine, followed by the thoracolumbar junction. If fractures are seen at other levels, a higher degree of suspicion for a pathologic (due to cancer) fracture should be raised.
- Which of the following is the most important lifestyle modification for prevention of osteoporosis?
(a) Avoiding cigarette smoking and high intake of caffeine
(b) Decreasing the intake of alcohol
(c) Minimizing the use of nonsteroidal anti-inflammatory medications
(d) Eating a diet high in protein and phosphorus
(a) Factors that impact bone mineral density negatively are smoking and high intake of caffeine, protein, and phosphorus. An active lifestyle with regular weight-bearing exercise is advised. Eliminating fall hazards such as throw rugs throughout the home is also essential.
A 40-year-old man with psoriatic arthritis consults you regarding his hand pain. On examination, you notice that his left index finger is noticeably shorter than all of his other fingers and has extra folds of skin. The most likely diagnosis is
(a) arthritis mutilans.
(b) Auspitz’s sign.
(c) dactylitis.
(d) Jaccoud’s arthritis.
(a) Arthritis mutilans is osteolysis of the phalanges and metacarpals, which results in telescoping, or shortening, of the involved digit. It is a highly characteristic feature of psoriatic arthritis. Auspitz’s sign is pinpoint bleeding after scraping a psoriatic plaque. Dactylitis, or “sausage digits,” is a combination of tenosynovitis and arthritis of the distal or proximal interphalangeal joint. Jaccoud’s arthritis is a non-erosive deforming arthritis in systemic lupus erythematosus.
(a) Boumpas DT, Illei GG, Tassiulas IO. Psoriatic arthritis. In: Klippel JH, editor. Primer on the rheumatic diseases. 12th ed. Atlanta (GA): Arthritis Foundation; 2001. p233-8.
(b) Nicholas JJ. Rehabilitation of patients with rheumatological disorders. In: Braddom
A 66-year-old woman with rheumatoid arthritis is admitted to inpatient rehabilitation following a right total knee arthroplasty (TKA). On her initial day of therapy, she had difficulty walking with her physical therapist. Her medications included methotrexate (Trexall), etanercept (Enbrel), ezetimibe (Zetia), multi-vitamin, calcium with vitamin D, alendronate (Fosamax), acetaminophen/hydrocodone (Norco), and warfarin (Coumadin). Re-examination shows hip flexion 5/5, knee extension 4/5, knee flexion 4/4, ankle dorsiflexion 1–2/5, ankle plantar flexion 5/5. You suspect
(a) sciatic nerve stretch injury.
(b) posterior tibialis tendon rupture.
(c) inadequate pain control.
(d) peroneal nerve injury.
(d) Temporary weaknesses of peri-articular muscles typically occurs after knee arthroplasty along with loss of full flexion and extension due to pain, edema, and the procedure itself. Ankle dorsiflexion is not typically weak following TKA and therefore peroneal nerve injury due to a hematoma would be suspected, especially since the patient is on warfarin. This injury requires surgical exploration and decompression. Sciatic nerve stretch injury, posterior tibialis tendon rupture, and inadequate pain control would not present as ankle dorsiflexion weakness
- Which statement is TRUE regarding complex regional pain syndrome (CRPS)?
(a) Pain is characterized by allodynia.
(b) Local osteopenia is a common early occurrence.
(c) CRPS type 1 is also known as causalgia.
(d) Adults with CRPS have a better prognosis than children with CRPS.
(a) Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy, as well as by other names, is characterized by a preceding noxious event; allodynia is an exaggerated pain response (ie, hyperesthesia) in response to a non-noxious stimulus or to vascular changes such as those indicated by paleness and coolness or by edema. Sudeck’s atrophy is a name previously given to late stage CRPS when osteopenia is present. Osteopenia is a rare and late occurrence with CRPS. CRPS type 2 is also referred to as causalgia and is instigated from an initial nerve injury. Children with CRPS have a better prognosis than adults
- A 65-year-old woman describes a 6-year history of progressive pain and stiffness in her left knee,
right hip, and distal fingers. Plain radiographs of her left knee and right hip demonstrate
osteophytes and asymmetric joint space narrowing with subchondral bony sclerosis. The most
likely diagnosis is
(a) systemic lupus erythematosus.
(b) rheumatoid arthritis.
(c) gouty arthropathy.
(d) osteoarthritis.
(d) Arthritis in systemic lupus erythematosus is non-erosive and does not have articular cartilage
involvement. In rheumatoid arthritis, periarticular bony erosions and osteopenia are seen on
radiographs. Radiographic changes in gouty erosions are usually slightly removed from the joint
space and have atrophic and hypertrophic features (an overhanging edge and soft-tissue tophus).
Characteristic radiographic findings of osteoarthritis include bony proliferation at the joint margin,
asymmetric joint-space narrowing, and subchondral bone sclerosis.
Klippel JH, Weyand CM, Crofford LJ, Stone JH, Arthritis Foundation, editors. Primer on the rheumatic
diseases. 12th ed. Atlanta (GA): Arthritis Foundation; 2001. pp 220, 291, 318, 337.
- A 42-year-old woman presents with a 3-month history of difficulty walking up stairs and rising from
chairs. She has no headaches or scalp pain and is currently on no medications. Physical
examination reveals bilateral weakness of her proximal legs and arms. Laboratory studies reveal a
markedly elevated creatine phosphokinase (CPK) level and a normal erythrocyte sedimentation rate
(ESR). The most likely diagnosis is
(a) myasthenia gravis.
(b) polymyalgia rheumatica.
(c) polymyositis.
(d) rhabdomyolysis.
(c) The hallmark features of polymyositis, or idiopathic inflammatory myopathy, are symmetric muscle
weakness of the shoulder and pelvic girdles, occasionally accompanied by mild pain and
tenderness. Eventually, weakness of the proximal leg and arm muscles follows. The symptoms
usually appear insidiously, with no identifiable precipitating event. Laboratory examination shows
an elevation in skeletal muscle enzymes, especially creatine phosphokinase. Electromyographic
changes are consistent with inflammatory myopathy: short small, polyphasic motor units;
filbrillations; positive waves; and high frequency, repetitive discharges. The absence of headaches
and scalp pain makes polymyalgia rheumatica less likely. Rhabdomyolysis is typically more acute
in onset and is associated with trauma or use of certain medications such as the statins.
- Which surgical option would be most appropriate for a patient with rheumatoid arthritis who has
severe uncontrollable knee pain and loss of function?
(a) Synovectomy
(b) Hemiarthroplasty
(c) Total knee arthroplasty
(d) Arthrodesis
(c) Total knee arthroplasty is the surgery of choice in persons with severe pain and loss of function. A
synovectomy provides temporary pain relief and decreased swelling. Hemiarthroplasty is
contraindicated in rheumatoid arthritis due to total joint involvement. Arthrodesis would not
provide the range of motion needed for stairs, ambulation, and dressing.
- Which of the following is a rare extra-articular manifestation of rheumatoid arthritis?
(a) Rheumatoid nodules
(b) Keratoconjunctivitis sicca
(c) Glomerular disease
(d) Microcytic anemia
(c) Rheumatoid nodules are present in up to 50% of persons with rheumatoid arthritis (RA).
Keratoconjunctivitis sicca and microcytic anemia are also very common. Glomerular disease is
very rare in RA, but requires management when found.
- A 35 year-old man with ankylosing spondylitis develops a painful left red eye with photophobia and
blurred vision. What is the most likely reason for urgently referring this man to an ophthalmologist
in an effort to prevent vision loss or impairment?
(a) Viral conjunctivitis
(b) Blepharitis
(c) Subconjunctival hemorrhage
(d) Acute anterior uveitis
(d) An ophthalmologist is needed to evaluate for acute anterior uveitis. Acute anterior uveitis is
usually unilateral, and occurs at some time in one-third of patients with ankylosing spondylitis
(AS). It may also be recurrent. If untreated, it may lead to scarring, pupil irregularity, and vision
loss. The other options are also reasons for visiting an ophthalmologist but are not associated with
vision loss in patients with AS.
- Which seronegative spondylarthropathy frequently follows enteric or urogenital infections?
(a) Ankylosing spondylitis
(b) Reiter’s syndrome
(c) Psoriatic arthritis
(d) Juvenile spondyloarthropathy
(b) Reiter’s syndrome or reactive arthritis most frequently follows certain urogenital infections with
Chlamydia trachomatis or enteric infections such as Shigella, Salmonella, and Campylobacter
organisms. The other choices are not associated with such infections.
- Which statement regarding complex regional pain syndrome (CRPS) is TRUE?
(a) Pain is characterized by allodynia.
(b) Local osteopenia is a common early occurrence.
(c) Causalgia is also known as CRPS type 1.
(d) Adults have a better prognosis than do children with CRPS.
(a) Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy as
well as by other names, is characterized by a preceding noxious event; allodynia (exaggerated pain,
ie, hyperesthesia) in response to a non-noxious stimuli; vascular changes such paleness and
coolness; and edema. Sudeck’s atrophy is a name previously given to late stage CRPS when
osteopenia is present. Osteopenia is a rare and late occurrence with CRPS. CRPS type 2 is also
referred to as causalgia and is instigated from an initial nerve injury. Children have a better
prognosis than adults
- Which treatment or medication is effective in treating both the skin and joint disease in persons with
psoriatic arthritis?
(a) Photochemotherapy
(b) Nonsteroidal anti-inflammatory drugs
(c) Intra-articular injections of corticosteroids
(d) Methotrexate (Rheumatrex, Trexall)
(d) Methotrexate is effective for both skin disease and peripheral arthritis treatment.
Photochemotherapy is for the treatment of skin disease, or psoriasis, only. Nonsteroidal antiinflammatory
drugs are effective as the initial treatment option for persons with mild joint disease.
For persons with limited joint involvement (1 or 2 joints), intra-articular steroids are a treatment
choice for joint disease only.
- What is the most effective type of medication for treating pain in patients with fibromyalgia?
(a) Tricyclic antidepressants
(b) Serotonin reuptake inhibitors
(c) Narcotics
(d) Anticonvulsants
(a) Tricylic antidepressants are more effective than serotonin reuptake inhibitors in the treatment of
chronic pain syndromes. There is no definitive evidence that narcotics or anticonvulsants are
effective in fibromyalgia
- What is the most likely diagnosis in a 45-year-old man with a rash over the upper and lower eyelids
who complains of insidious onset of difficulty getting out of a chair and ascending stairs?
(a) Inclusion body myositis
(b) Ankylosing spondylitis
(c) Dermatomyositis
(d) Guillain-Barré syndrome
(c) Individuals with dermatomyositis commonly present with slowly progressive proximal weakness. A
heliotrope rash affecting the eyelids occurs in 30% to 60 % of patients with dermatomyositis.
Inclusion body myositis primarily affects upper extremities distally and occurs in the older
population. Ankylosing spondylitis and Guillain-barré syndrome would not present in the fashion
described.
- A 45-year-old man complains of wrist, thumb, and elbow pain and swelling after being on a highprotein
diet for 12 weeks. Aspiration of the elbow reveals negatively birefringent intracellular
crystals on microscopic examination. What would you expect to see on radiographs of his hands
and wrists?
(a) Distal interphalangeal joint osteophytes
(b) Pencil-in-cup deformity
(c) Juxtarticular osteopenia
(d) Joint erosion with sclerotic borders
(d) This patient has gout, and radiographs of the hands and wrists would likely demonstrate joint
erosions with sclerotic borders. The finding in option (b) describes psoriatic arthritis. Juxtarticular
osteopenia may be a finding on radiographic studies in patients with rheumatoid arthritis. Distal
interphalangeal joint osteophytes are characteristic of osteoarthritis.
- A 60-year-old woman with diabetes and hypertension complains of right foot swelling and mild
discomfort on ambulation. There is no history of trauma. Examination demonstrates decreased
sensation in the foot and a plantar ulcer. There is no sinus tarsi tenderness and no ankle instability.
What is the most likely diagnosis?
(a) Charcot’s joint
(b) Lateral ankle sprain
(c) Tarsal tunnel syndrome
(d) Plantar fasciitis
(a) Charcot’s joints often present as painless swelling in patients with diabetes. Other illnesses
associated with Charcot’s joint include tabes dorsalis and syringomyelia.
- A 55-year-old woman complains of bilateral thumb pain with activities. Examination reveals pain
with axial grinding of the first carpometacarpal joints as well as Heberden and Bouchard nodes in
the hands. What is an appropriate initial treatment?
(a) Resting wrist splints in neutral
(b) Thumb spica splints
(c) Compression gloves
(d) Buddy taping the digits
(b) The carpometacarpal joint is a common location for osteoarthritis in the upper extremity. While
cumbersome, a thumb spica splint will often alleviate the pain. The other options listed would not
be considered appropriate initial treatment options.
- A 70-year-old man with severe bilateral knee osteoarthritis states that over the counter nonsteroidal
anti-inflammatory drugs and aceteminophen are not controlling his knee pain. He inquires about a
more potent anti-inflammatory medication he saw on a television commercial. Once treatment has
been initiated, which recommendation would be most appropriate?
(a) Check kidney function and a hematocrit for anemia every 6 months.
(b) Start concomitant anti-hypertensives if the patient develops high blood pressure.
(c) Switch to a cyclooxygenase-2 inhibitor if the patient is on aspirin for cardioprotective effects.
(d) Start concomitant proton pump inhibitor or histamine H2-receptor antagonists.
(a) Older patients on nonsteroidal anti-inflammatory drugs are at a high risk for medication-induced
side effects. Kidney function and gastrointestinal (GI) bleeds (causing anemia) should be
monitored every 6 months. The purported gastroproctective effects of cyclooxygenase-2 inhibitors
may be lost with concomitant aspirin use. Gastritis side effects, especially in the elderly, should be
worked up for a GI bleed prior to instituting histamine H2-receptor antagonists or a proton pump
inhibitor.
- Which agent acts on osteoblasts to increase bone formation?
(a) Calcium
(b) Calcitonin
(c) Vitamin D
(d) Estrogen
(c) Bone remodeling has 5 phases; activation, resorption, reversal, formation, quiescence. Vitamin D
will increase this process and acts on the osteoblasts, whereas the other choices act on the
osteoclasts to stabilize bone.
- A 25-year-old nulliparous woman with a history of psoriasis complains of low-back pain and
occasional groin discomfort. There is no history of recent trauma. Which finding would you
expect on pelvic radiographs?
(a) Avulsion fracture at the pubic tubercle
(b) Osteitis condensans ilii
(c) Traction apophysitis
(d) Sacroiliitis
(d) Psoriatic arthritis is a seronegative spondyloarthropathy. Sacroilitis must be ruled out in these
patients when they complain of back pain. Osteitis condensans ilii occurs in women with pelvic
pain after pregnancy, avulsion fracture would typically be seen after a traumatic or high-impact
event, and apophysitis is seen in the adolescent before full maturation of the end plates.
- A 40-year-old woman with history of Hodgkin’s lymphoma was treated with radiation 20 years
ago. She complains of left groin and thigh pain aggravated by weight-bearing. Symptoms have
been insidious in onset and there is no evidence of recurrent cancer. She has limited active hip
flexion, abduction, and external rotation. She has no back pain with passive hip extension and knee
flexion in the prone position. What is the most likely diagnosis?
(a) Avascular necrosis of the femoral head
(b) Herniated nucleus pulposus at L3/L4
(c) Iliotibial band friction syndrome
(d) Snapping hip syndrome
(a) The patient has avascular necrosis. Radiation, alcohol use, trauma, infections, and pancreatitis
increase the risk of developing avascular necrosis. With a normal neurologic examination and a
negative femoral stretch as described, a herniated disc is less likely.
- Which finding supports a diagnosis of complex regional pain syndrome type I?
(a) Sensory deficits in a dermatomal distribution
(b) Cutaneous allodynia
(c) Focal motor weakness
(d) Side-to-side symmetry of dermal temperature
(b) The Task Force on Taxonomy convened by the International Association of Pain developed the
descriptor “chronic regional pain syndrome, type I” (CRPS I) to refer to sympathetically maintained
pain that is not associated with a nerve injury. The presence of motor or sensory deficits suggests
the presence of complex regional pain syndrome, type II which requires the presence of nerve
compromise. The four criteria for CRPS I are: (1) the presence of an intiating noxious event, or a
cause of immobilization; (2) continuing pain, allodynia, or hyperalgesia with which the pain is
disproportionate to any inciting event; (3) evidence at some time of edema, changes in skin blood
flow, or abnormal sudomotor activity in the region of the pain; and 4) CRPS I is excluded by the
existence of conditions that would otherwise account for the degree of pain and dysfunction.
- A 35-year-old man with history of psoriatic arthritis complains of localized low back pain
insidious in onset. The pain is worse in the morning and improves as the day progresses. What is
the most likely cause of his back pain?
(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis
(b) Sacroiliitis occurs in patients with spondyloarthropathies such as psoriatic arthritis, reactive
arthritis, enteropathic arthritis, and ankylosing spondylitis.
- A 28-year-old woman, who is 35 weeks pregnant, complains of right thigh and groin pain with
weight bearing. You diagnose her with idiopathic transient osteoporosis of the femoral neck.
What is the course of treatment?
(a) Recommend labor induction
(b) Prescribe protected weight bearing
(c) Recommend bedrest until delivery
(d) Prescribe alendronate (Fosamax)
(b) Patients with idiopathic transient osteoporosis of the femoral neck may ambulate as tolerated but
may need protective weight bearing for pain relief. Symptoms and pathology resolve within 6
months.
- In patients with osteoporosis, which treatment reduces incidence of vertebral compression
fracture?
(a) Weight reduction
(b) Cash brace
(c) Strengthening of spinal extensors
(d) Strengthening quadriceps
(c) Weak extensor muscles increase risk of compression fracture. Risk increases with immobilization
longer than 2 days. There is no association between osteoporotic compression fractures and weight
or family history
- A 40-year-old woman with irritable bowel syndrome and tension headaches complains of
increasing fatigue and diffuse muscle soreness in her neck, shoulders, and low back. She has a
nonfocal neurologic examination. She does not feel rested in the morning. The most appropriate
initial recommendation is
(a) lorazapam (Ativan) at bedtime.
(b) amitriptyline (Elavil) at bedtime.
(c) zolpidem (Ambien) at bedtime.
(d) acetaminophen with codeine (Tylenol #3 ) at bedtime.
(b) This patient has fibromyalgia. Neuropathic medications such as trycyclic antidepressant
medications are recommended.
- A 40-year-old woman who runs 30 miles per week wants to prevent symptoms of hip and knee
osteoarthritis. Proven methods include
(a) avoidance of estrogen replacement.
(b) maintaining optimal flexibility.
(c) use of medial wedge orthotics.
(d) nonsteroidal anti-inflammatory medications.
(b) Major risks for knee and hip osteoarthritis include major injury, obesity, and occupations that
require repetitive motion of the joint. Proper training techniques for building strength and
flexibility can reduce risk of major injury and thus prevent osteoarthritis. Estrogen may have a
protective effect.
- A 43-year-old alcoholic man complains of left hip pain that is increased with weight bearing. He
has had progressive symptoms for about 3 months. Additional medical history reveals no trauma,
but the patient has oxygen dependent chronic obstructive pulmonary disease (COPD). On
examination, internal and external rotation of both hips is painful. The patient ambulates with a
lateral lean to the left. He uses a walking stick, which helps his pain. What radiologic evaluation
would be most useful in diagnosing this patient’s problem?
(a) Ultrasound of the left hip
(b) Magnetic resonance imaging of both hips
(c) Arthrography of the left hip
(d) Tagged white blood cell scan of the hip
(b) This patient has multiple risk factors for osteonecrosis of the hip (avascular necrosis). Risk factors
for this condition include steroid use, alcohol use, trauma, rheumatoid arthritis, sickle cell disease,
radiation, chronic pancreatitis, systemic lupus erythematosus, Gaucher disease, and Crohn’s
disease. It typically occurs in the third to fifth decades and affects 10,000 to 20,000 new patients
per year in the US. This condition is often bilateral. Radiologic evaluation should include plain
anterior-posterior pelvis and frog lateral views of the hip. If collapse of the femoral head is seen, no
additional radiographic evaluation is necessary. If these are negative, magnetic resonance imaging
of the hip may be more sensitive and should be performed on both hips. Ultrasound and
arthrography are not indicated for this condition. Tagged white blood cell scan would evaluate for
infection of the hip.
- A 25-year-old man with localized low back pain and knee pain that are worse with rest and
improve with activities is noted to have recent history of salmonella gastroenteritis. The most
likely diagnosis is
(a) enteropathic arthritis.
(b) ankylosing spondylitis.
(c) reactive arthritis.
(d) septic arthritis.
c) Reactive arthritis is a form of peripheral arthritis that has 1 or more extra-articular manifestations
and appears 2 to 4 weeks after gastrointestinal or genitourinary infections including salmonella,
shigella, and campylobacter in young males. It is a type of spondyloarthropathy, which also
includes enteropathic arthropathy, anklosing spondylitis, and psoriatic arthritis.
- An 18-year-old girl presents with a 2 week history of fever, chills, and right knee pain. On
examination you note her right knee is hot and swollen. She has a painless, red maculopapular rash
on her trunk. She denies trauma, but has an antalgic gait. What is the most likely cause of her
symptoms?
(a) Staphylococcus epidermidis
(b) Neisseria gonorrhoeae
(c) Monosodium urate monohydrate crystals
(d) Haemophilus influenza
(b) This patient has fever, chills, and rash. She likely has an infectious cause for her monoarthropathy.
She denies traumatic etiology of knee swelling. She may be sexually active, and she should be
questioned about this. Her symptoms most closely match the diagnosis of gonoccocal arthritis. This
condition occurs following infection with gonorrhea, which presents as monoarthropathy in 25% of
patients. The Neisseria gonorrhoeae organism can be recovered in less than 50% of purulent
effusions. It affects women as often as men (1:1), and its highest incidence is among sexually active
adolescents and young adults. It is the most common cause of septic arthritis in patients younger
than 30 years. If the strain of bacteria is not antibiotic-resistant, recovery is expected. Single joint
arthritis follows generalized spread (dissemination) of the gonococcal infection. Dissemination is
associated with symptoms of fever, chills, asymmetric polyarthralgias (which may be migratory),
and rashes (1-mm to 2-cm red macules). The most commonly involved joints are the large joints
such as the knee, wrist, and ankle. Tenosynovitis may also be seen with disseminated disease.
Gouty arthritis does not present with rash, fever and chills. In neonates, the most common cause of
joint infection is Haemophilus influenzae.
- Which recommendation promotes correct posture in patients with ankylosing spondylitis?
(a) Daily corner wall stretches
(b) Soft mattress
(c) Sidelying
(d) Full sit ups
(a) Spinal extension should be promoted so that patients fuse in the most functional position. This also
includes lying prone on a firm mattress.
- What is the mechanism of action of alendronate (Fosamax) in treating osteoporosis?
(a) Inhibits osteoclasts
(b) Binds to estrogen receptors
(c) Increases calcium absorption
(d) Promotes osteoblasts
(a) Fosamax inhibits osteoclasts at doses used for osteoporosis
- A recovering alcoholic complains of a painful swollen right knee. She has no history of trauma
but tells you she has recently lost 10 pounds on the Atkins diet. You aspirate her knee and expect
to find a 20,000 white blood cell count with
(a) gram-negative rods.
(b) positive birefringent rods.
(c) 100,000 red blood cells.
(d) negative birefringent rods.
(d) This patient has gout. These crystals are intracellular, rod-shaped, with negative birefringence
when parallel in a light microscope. There is no history of trauma, therefore, excessive red blood
cells would not be expected
- What is the most common form of arthritis in adults?
(a) Crystal arthritis
(b) Septic arthritis
(c) Osteoarthritis
(d) Rheumatoid arthritis
(c) Osteoarthritis
- After aspirating 10cc of cloudy fluid from a patients knee, you find a white blood cell count of
20,000/cc, with intracellular, negatively birefringent rod-shaped structures under the polarized light
microscope. Your diagnosis is
(a) septic arthritis.
(b) gout.
(c) pseudo-gout.
(d) anterior cruciate ligament tear.
(b) A septic joint would reveal a white blood cell count greater than 50,000/cc, pseudogout has
positive-birefringent crystals, an anterior cruciate ligament tear would reveal a bloody aspirate.
Urate crystals from gout are negatively birefringent, needle- or rod-shaped crystals that can be
intracellular.
- Mr. Jones comes to your office complaining of a hot, painful, swollen left wrist. Additional findings
on physical examination include swan-neck and boutinierre deformities, subluxation of the
metacarpophalangeal joints with ulnar deviation of the digits. What will x-ray findings of his wrist
reveal?
(a) Chondrocalcinosis of articular cartilage
(b) Severe marginal erosions with juxta-articular osteopenia
(c) Bony erosion with an overhanging edge
(d) Pencil-in-cup deformity
(b) This patient has rheumatoid arthritis which shows juxta-articular osteopenia. Gout characteristically
reveals “overhanging edge” lytic lesions. Chondrocalcinosis is seen in pseudo-gout, and pencil-incup
deformity is seen with psoriatic arthritis.
- A 40-year-old woman with a history of irritable bowel syndrome and tension headaches complains of
increasing fatigue and diffuse muscle soreness in her neck, shoulders, and low back. She has a
nonfocal neurologic examination. Initial recommendations should include
(a) craniosacral manipulation.
(b) closed kinetic chain exercises to strengthen the shoulder girdle.
(c) electrical stimulation to the upper and mid back.
(d) walking on a daily basis.
(d) Promoting a restorative sleep and 20–30 minutes of aerobic activity daily is recommended to treat
fibromyalgia. Passive modalities are not the optimal therapeutic intervention.
- Which of the following is NOT associated with a Charcot joint?
(a) Diabetes
(b) Syringomyelia
(c) Tabes dorsalis
(d) Rheumatoid arthritis
(d) Destruction of a joint due to loss of nociceptive input describes a Charcot joint.
- A 23-year-old man complains of localized low back pain that is worse in the morning and improves
as the day progresses with activities. He has no radicular symptoms and a nonfocal neurologic
examination. Which finding unequivocally supports your diagnosis
(a) A positive human leukocyte antigen B27
(b) Bilateral sacroiliitis on a radiograph of the pelvis
(c) An elevated erythrocyte sedimentation rate
(d) Atlantoaxial subluxation on a radiograph of the cervical spine
(b) Bilateral spondylitis is diagnostic of ankylosing spondylitis. HLA-B27 is not helpful because a
percentage of the normal population is positive for HLA-B27 and not all patients with ankylosing
spondylitis are positive. Erythrocyte sedimentation rate is a general marker of inflammation.
Enthesopathies may occur in a wide variety of inflammatory disorders, including
spondyloarthropathies.
- Juvenile rheumatoid arthritis (JRA) differs from adult onset rheumatoid arthritis: in JRA
(a) joint destruction occurs earlier.
(b) large joint involvement is less frequent.
(c) the cervical spine is involved less frequently.
(d) systemic features are more common.
(d) Children with juvenile rheumatoid arthritis are more likely to have systemic features, have large
joints involved, and have cervical spine involvement. Adults with rheumatoid arthritis have joint
destruction earlier.
- A 70-year-old man comes to your office complaining of posterior neck and bilateral shoulder pain
worse in the morning. Radiographs of his shoulders reveal glenohumeral osteoarthritis, and his
erythrocyte sedimentation rate is 70. Your initial management is to
(a) perform bilateral glenohumeral corticosteroid injections.
(b) prescribe Codman exercises.
(c) obtain a cervical spine magnetic resonance image.
(d) prescribe prednisone 20mg per day.
(d) This patient has polymyalgia rheumatica. When you diagnose polymyalgia rheumatica the patient
is placed on daily prednisone and should note dramatic improvement within a few days
- Of the 4 disorders described below, which definitions is NOT correct?
(a) Hyperesthesia is an exaggeration of any sensory modality response.
(b) Allodynia is the experience of pain in response to a normally nonpainful stimulus.
(c) Paresthesia is a perversion of sensation, producing a perception that is abnormal in character.
(d) Hypesthesia is a diminution to painful stimuli.
(d) All the definitions are correct except for the definition of hypesthesia, which is not only diminution
to painful stimuli but also diminished sensation to any sensory modality. Paresthesias can also be
described as abnormal sensations in the absence of stimulation.
- Extraskeletal manifestations of ankylosing spondylitis include
(a) Achilles enthesopathy.
(b) tricuspid regurgitation.
(c) cataracts.
(d) nail pitting.
(a) Extraskeletal manifestations of ankylosing spondylitis include uveitis/iritis, aortic regurgitation, and
Enthesopathy
- Regarding Bell’s palsy, which statement is TRUE?
(a) It usually develops over days.
(b) It can recur in a small percentage of patients.
(c) Women are more commonly affected than men.
(d) Bilateral cases frequently occur.
(b) Most patients with Bell’s palsy usually present with sudden unilateral facial weakness. Persons of
any age can be affected. Men and women are affected equally and in about 2%–9% of patients the
condition can be recurrent. Very rarely it affects both the facial nerves.
- What is the World Health Organization definition of osteoporosis?
(a) Bone mass 2.5 standard deviations below normal
(b) Bone mass 2.0 standard deviations below normal
(c) Bone mass 1.5 standard deviations below normal
(d) Bone mass 1.0 standard deviation below normal with history of fracture
(a) The World Health Organization defines osteoporosis as bone mass 2.5 standard deviations below
normals. A history of fracture is not part of the definition.
- Which pharmacologic agent is a secondary cause of osteoporosis?
(a) Heparin
(b) Diltiazem
(c) Naproxen
(d) Hydrochlorothiazide
(a) There are many secondary causes of osteoporosis. Drug induced osteoporosis is seen with alcohol,
heparin, steroids, phenytoin and tobacco. Other causes include immobilization, multiple myeloma,
and endocrine related syndromes such as hyperthyroidism, hyperparathyroidism, and diabetes
mellitus type II.
- Trials on the use of glucosamine and chondroitin for knee and hip osteoarthritis have shown that
these compounds
(a) reduced subchondral sclerosis, as evidenced by x-ray.
(b) decreased proteoglycan synthesis in articular cartilage.
(c) had a moderate effect on pain symptoms.
(d) had an immediate effect on symptom severity.
(c) A meta-analysis of randomized controlled studies on the treatment of knee and hip osteoarthritis
with glucosamine and chondroitin found moderate effects on symptoms. These effects take a
minimum of 4 weeks. Glucosamine and chondroitin are capable of increasing proteoglycan
synthesis in articular cartilage.
- A 70-year-old woman complains of acute localized mid back pain. She has a non-focal neurologic
examination. An anteroposterior and lateral thoracic spine x-ray confirms your clinical suspicion of
an acute T8 compression fracture. Which recommendation would best help her to reduce her risk of
future fractures?
(a) Swimming laps 20-30 minutes daily
(b) Isotonic abdominal strengthening program
(c) A weight reduction diet
(d) Avoidance of tobacco use
(d) The National Osteoporosis Foundation (NOF) established guidelines to reduce risk of osteoporotic
fractures. These recommendations include, participating in weight bearing exercise, ingesting
adequate calcium (1200mg/day) and vitamin D (400-800IU), and avoiding tobacco use.
- An otherwise healthy elderly woman with history of osteoporosis presents with the acute onset of
focal thoracic spine pain. Your management program should include
(a) William’s flexion exercises.
(b) epidural steroid injections.
(c) spinal extension brace.
(d) steroid iontophoresis.
(c) Spinal flexion will increase pain related to vertebral compression fractures. An extension brace will
promote a position of comfort during the healing process. These braces may include a Jewett brace,
cruciform anterior spinal hyperextension brace, and a chairback or warm and form brace.
- A 20-year-old man complains of 4-month history of low back pain that radiates into the buttocks. The
pain began insidiously, is worse in the morning, and eases up after a hot shower. The neurologic
exam is normal. Which finding will help support your likeliest diagnosis?
(a) A negative HLA-B27
(b) Symmetric wrist swelling
(c) A negative Schober test
(d) Acute iritis
(d) Acute iritis is an extra-skeletal manifestation of ankylosing spondylitis (AS). HLA-B27 is not
necessary to make the diagnosis of AS. Involvement of peripheral joints is infrequent and, when
present, is asymmetric. The Schober test is typically positive.
- A person with Paget’s disease typically has
(a) alternating osteoblastic and osteoclastic phases.
(b) equivocal radiographs.
(c) evidence of syndesmophytes.
(d) blue sclera.
(a) Radiographs will show a mottled appearance. The skull, tibia, pelvis and vertebral bodies are most
commonly invloved. Syndesmophytes are seen with spondyloarthropathys. Blue sclera is seen in
osteogenesis imperfecta.
- A 52-year-old African American woman presents with a 3-month history of fatigue, weight loss,
proximal weakness, and muscle pain. Laboratory studies reveal an elevated creatine kinase level.
Which treatment would NOT be considered appropriate?
(a) Glucocorticoids
(b) Methotrexate
(c) Plasmapheresis
(d) Intravenous gamma globulin
(c) In the treatment of inflammatory myopathies such as polymyositis and dermatomyositis,
glucocorticosteroids are considered the first drug of choice. Patients refractory to steroids or unable
to tolerate high doses because of complications require an immunosuppressive agent.
Immunoglobulins are effective and are also used in patients with recurrent relapses. Plasmapheresis
and leukapheresis are ineffective in these patients.
- Which of the following synovial fluid findings is most specific for infection?
(a) White blood cell count of 5,000/mm3
(b) Transparent, straw-colored fluid
(c) Ninety-eight percent neutrophils on a differential leukocyte count
(d) Negatively birefringent crystals under a polarizing microscope
(c) All synovial fluid removed for diagnostic purposes should be sent for gram stain and cell count.
Noninflammatory synovial fluid typically has white blood cell counts of less than 2000/mm3, is
transparent or yellow colored, and has less than 50% neutrophils. Inflammatory fluid usually is
translucent or opaque, can have very high cell counts (up to 100,000/mm3), and usually has less
than 90% neutrophils. Synovial fluid that has cell counts over 100,000/mm3, is purulent and has
more than 95% neutrophils should be considered infected.
- You are asked to see a 35-year-old woman with systemic lupus erythematosus who has severe left
groin pain. She underwent a cadaveric renal transplant 4 years ago. She has a Trendelenburg gait
and pain upon internal rotation of the hip. There is reproduction of the groin pain with hip flexion.
Your diagnosis is
(a) L5 radiculopathy.
(b) trochanteric bursitis.
(c) avascular necrosis.
(d) femoral neuropathy.
(c) The patient has aseptic necrosis of the femoral head. Her symptoms will be resolved with a hip
replacement. Before surgery, a program of isometric strengthening and endurance exercise is
appropriate. Trochanteric bursitis presents as lateral hip pain extending down the leg, worse with
walking or lying on that side. There is tenderness over the greater trochanter and pain with endrange
adduction or resisted abduction. Femoral neuropathy presents with weakness of the knee
extensors. An L5 radiculopathy typically presents with leg pain that extends to the dorsum of the
foot and is not worsened with hip rotation.
- Fibromyalgia is a systemic disorder that affects primarily the musculoskeletal system and results in
pain and stiffness. Which of the following statements is true about the diagnosis and treatment of
fibromyalgia?
(a) It has an equal distribution in both men and women.
(b) The “tender points” associated with this condition cause radicular pain.
(c) Severe sleep disturbances and fatigue are common complaints.
(d) Palpable taut bands, which exhibit local twitch responses, are characteristic.
(c) Fibromyalgia is found predominantly in women, and 16 paired tender points are identified by the
American Rheumatism Association. They do not show referred pain patterns. Palpable taut bands
are seen with myofascial pain but are not specific for fibromyalgia. Sleep disturbances and
depression are very common in patients with this diagnosis.
- The American College of Rheumatology (ACR) criteria for fibromyalgia include all of the
following EXCEPT
(a) widespread pain.
(b) nonrestorative sleep.
(c) at least 11 of 18 tender points.
(d) symptom duration of at least 3 months.
(b) The ACR criteria for fibromyalgia include the presence of widespread pain (both sides of the body,
above and below the waist) for at least 3 months and tenderness at 11 of 18 points. Disturbed sleep,
fatigue, various neurologic symptoms, and gastrointestinal complaints are common but not part of
the criteria. A complete history and physical is usually adequate to make the diagnosis; screening
laboratory testing should exclude hypothyroidism, connective tissue diseases (such as polymyalgia
rheumatica or rheumatoid arthritis), and metabolic myopathies. Treatment involves restoration of
sleep, reduction of psychologic variables (such as stress and depression), physical conditioning,
stretching, and postural training. Nonsteroidal anti-inflammatory drugs, muscle relaxants,
narcotics, and passive modalities are not useful and their use should be minimized.
