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Health Assessment > Test 3 > Flashcards

Test 3 Flashcards

1
Q

Low back Pain with cauda equina signs and symptoms immediate ____ to r/o __________

A

Immediate MRI to r/o cauda equina syndrome

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2
Q

Low back pain with infection risk factors, symptoms/signs order a _____ to look for ____ or ________

A

MRI
abscess or
vertebral osteomyelitis

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3
Q

Low back pain with cancer risk factors, symptoms/signs? order ____ or _____ to look for

A

spine film or MRI to look for vertebral metastasis

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4
Q

low back pain with compression fracture risk factors, symptoms/signs order _____ to look for _____

A

spine film

osteoporotic compression fracture

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5
Q

low back pain with spinal stenosis symptoms/signs? with leg pain and vascular risk factors. What is your first step?

A

utilize conservative therapy for presumed spinal stenosis

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6
Q

low back pain with spinal stenosis symptoms/signs? with leg pain and vascular risk factors with no response to conservative therapy. What is your next step?

A 
MRI
perform ABIs (Ankle Brachial Index) to look for PAD (Peripheral Artery Disease)
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7
Q

low back pain with spinal stenosis symptoms/signs? with no leg pain or vascular risk factors What is your next step?

A

utilize conservative therapy for presumed spinal stenosis

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8
Q

low back pain with spinal stenosis symptoms/signs? with no leg pain and vascular risk factors with no response to conservative therapy. What is your next step?

A

MRI

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9
Q

low back pain with sciatica or abnormal neuro exam

A

treat conservatively for herniated disk or osteophytic lumbar radiculopathy

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10
Q

positive yeargason test suggests

A

bicipital tendonitis

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11
Q

positive yeargason test produces pain in the

A

bicipital groove

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12
Q

patient supinate forearm against resistance

A

Yeargason test

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13
Q

Ask patient to externally rotate and abduct shoulder

what are you looking for?

A

Rotator cuff tear

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14
Q

Ask patient to externally rotate and abduct shoulder

pt can raise arm but cannot maintain position against resistance

A

Partial rotator cuff tear

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15
Q

Ask patient to externally rotate and abduct shoulder

attempt to abduct arm will produce a shoulder shrug

A

complete rotator cuff tear

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16
Q

Contact sports, repetitive motion, rubbing or placing pressure on the elbow or overuse.

Pain over bursae

ROM normal

Joint may be warm or red

A

Think Olecranon Bursitis

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17
Q

Penetrating injury may cause _____ ______

A

septic bursitis

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18
Q

Aseptic inflammation of the bone to tendon junction
From repetitive concentric contractions that transmit force via the muscles to the origin on the lateral epicondyle
Gradual onset of pain and tenderness over the lateral epicondyle that worsens
No limited range of motion

Resisted forearm supination with the elbow flexed at 90 degrees will intensify symptoms (hook-t test)

A

Lateral humeral Epicondylitis (Tenis Elbow)

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19
Q

Upward pulling of a child’s hand or wrist causes

A

subluxation of the radial head.

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20
Q

subluxation of the radial head.

Pulled out of the ____ ligament

(children)

A

annular

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21
Q

subluxation of the radial head causes the elbow to be ______ and the forearm to be _____

(children)

A

child will hold affected arm close to body with the elbow slightly flexed and forearm pronated

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22
Q

Subluxation of the radial head
causes pain in the ______ and can cause partial dislocation of the

(children)

A

elbow
radial head

(the annular ligament that holds the radial bone in place at the elbow has slipped over the top of the bone

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23
Q

Have seated patient place heel of affected leg on knee of other leg

A

Iliopsoas

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24
Q

what are you looking for on the Iliopsoas knee maneuver

A

Pain with movement indicates muscle iliopsoas tendonitis

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25
Q

what is the nickname for subluxation of the radial head

A

Nurse maids elbow

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26
Q

what are you looking for in the foucher sign

A

Look for change in consistency of a mass in popliteal fossa that hardens with extension and softens with flexion

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27
Q

Positive foucher sign

A

with knee flexion - the cyst is soft
with knee extension - the cyst becomes hard -

(the valvular opening occurs during knee flexion, during which the fluid can flow. It is compressed and closed during knee extension due to tension in the semimembranosus and the medial head of gastrocnemius)

indicates Baker’s Cyst

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28
Q

negative foucher sign indicates

A

tumor or popliteal aneurysm

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29
Q

how do you look for bulge sign

A

Apply pressure to area adjacent to patella

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30
Q

what does a positive bulge sign look like

A

Medial bulge will appear if fluid is in knee joint

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31
Q

Pt supine, flex knee 90 degrees and hip 45 degrees with foot on table; apply slow, steady anterior pull, and in same position, gently push tibia back

A

Drawer sign

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32
Q

Positive

Drawer sign indicates

A

Positive sign movement of tibia on femur indicates ligamentous instability.
(ACL or PCL)

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33
Q

Maximally flex knee and hip; externally and internally rotate tibia, palpate joint

A

McMurray maneuver

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34
Q

Positive McMurray maneuver indicates a

A

Indicate a meniscus injury

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35
Q

Apply medial or lateral pressure when knee is flexed 30 degrees and when it is extended

A

Collateral ligament test

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36
Q

Medial or lateral collateral ligament sprain will show

A

laxity in movement and no solid end points, depending on degree of sprain on the Collateral ligament test

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37
Q

Knee flexed 30 degrees, pull tibia forward with one hand while other hand stabilizes femur

A

Lachman test (cruciate ligaments)

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38
Q

Positive Lachman test (cruciate ligaments)

A

result is a mushy or soft end feel when tibia is moved forward, indicating damage to anterior cruciate ligament (ACL)

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39
Q

Present with any condition that causes venous thrombosis

A

Homans sign - passively dorsiflex clients ankle which causes pain to the deep calf

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40
Q

what do the Gluteal muscles do

A

Upper gluteal fibers abduct the thighs

lower gluteal fibers adduct the thighs

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41
Q

what does the Iliopsoas do

A

Flexes the thigh

Hip flexion

important for standing, walking running

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42
Q

what does the Medial compartment do (medial side of knee)

A

adduct the thigh

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43
Q

what does the quadriceps femoris do

A

straightens the leg at the knee

keep your kneecap stable

helps you walk, run, jump and squat

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44
Q

What do the hamstrings do

A

flex the leg at the knee (bringing heel to buttocks)

hip extension (moving leg to the rear)

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45
Q

what does the Tibialis anterior do

A

dorsiflexes the foot

also inverter of foot in combo with the tibialis posterior

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46
Q

what does the Gastrocnemius and soleus muscles

do

A

plantar flex the foot

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47
Q

low back pain with sciatica or abnormal neuro exam that does not respond to conservative treatment

A

MRI to confirm diagnosis

consider epidural injection

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48
Q

low back pain without GI/GU/gynecologic symptoms; abdominal burit, AAA risk factors

A

mechanical back pain, treat conservatively

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49
Q

low back pain without GI/GU/gynecologic symptoms; abdominal burit, AAA risk factors with no response to conservative treament

A

Consider MRI

consider inflammatory arthritis

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50
Q

How do you calculate ABI (Ankle Brachial Index)

A

take BP on ankle and arm on same side

divide Ankle SBP/Brachial SBP

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51
Q

< ____ on an ABI = PAD

A

<0.9

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52
Q

back pain with no definite relationship between anatomic abnormalities seen on imaging and symptoms

A

Nonspecific (mechanical) back pain

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53
Q

back pain clear relationship between anatomic abnormalities and symptoms

A

Specific MSK back pain:

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54
Q

infection differentials for back pain

A

Osteomyelitis
Septic disk
Paraspinal abscess
Epidural abscess

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55
Q

The classic presentation is nonradiating pain and stiffness in the lower back, sometimes precipitated by heavy lifting or another muscular stress.
Can have pain and stiffness in the butt and hips
Improves with patient supine; usually occurs hours to days after a new or unusual exertion
Resolution within 4-6 weeks

A

What is mechanical back pain?

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56
Q

inflammatory arthritis with or Without sacroiliitis on x-ray (with sacroiliitis on MRI or HLA-B27 positive plus clinical criteria)

A

Axial spondyloarthritis

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57
Q

Inflammatory arthritis

With psoriasis

With inflammatory bowel disease

With preceding infection

Without associated condition

A

Peripheral spondyloarthritis

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58
Q

Urinary retention

Saddle anesthesia

Bilateral leg weakness

Bilateral sciatica

A

Cauda equina syndrome

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59
Q

Fever

Recent skin or urinary tract infection

Immunosuppression

Injection drug use

Spine procedure

A

Infection

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60
Q

Cancer history, especially active cancer

Unexplained weight loss

Age over 50

Duration > 1 month

Nocturnal pain

A

Malignancy

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61
Q

Age over 70

Female sex

Corticosteroid use

Aromatase inhibitor use

History of osteoporosis

Trauma

A

Compression fracture

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62
Q

Sciatica

Abnormal neurologic exam

A

Lumbar radiculopathy

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63
Q

Younger than 45 years at onset

Duration > 3 months

Insidious onset

Morning stiffness > 30 minutes

Improvement with exercise

No improvement with rest

Awakening with pain, especially during second half of night, with improvement on arising

Alternating buttock pain

A

Inflammatory back pain

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64
Q

Sciatica

Neurologic signs and symptoms, especially in L5–S1 distribution

Positive straight leg raise

A

Herniated lumbar disk

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65
Q

Test for Herniated lumbar disk

A

CT or MRI

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66
Q

radicular pain in the L5–S1 distribution

A

sciatica

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67
Q

aromatase inhibitors such as letrozole _____ bone loss and are associated with an _____risk of fractures

A

aromatase inhibitors such as letrozole increase bone loss and are associated with an increased risk of fractures

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68
Q

Duration of pain > 1 month

Age > 50

Previous cancer history

Unexplained weight loss (> 10 lbs over 6 months)

Nocturnal pain

A

Metastatic breast cancer

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69
Q

important tests for

Metastatic breast cancer

A

Spine radiograph

MRI

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70
Q

Age > 70

Female sex

Significant trauma

History of osteoporosis

Corticosteroid use

Prior fracture

Aromatase inhibitor use

A

Osteoporotic compression fracture

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71
Q

Osteoporotic compression fracture

important tests

A

Spine radiograph

MRI

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72
Q

Wide-based gait

Neurogenic claudication

Age > 65

Improvement with sitting/bending forward

A

Spinal stenosis

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73
Q

test for spinal stenosis

A

MRI

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74
Q

Duration of pain > 1 month

Age > 50

Previous cancer history

Unexplained weight loss (> 10 lbs over 6 months)

Nocturnal pain

A

Metastatic cancer

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75
Q

tests for Metastatic cancer

A

Spine radiograph

MRI

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76
Q

Vascular risk factors; leg pain with walking

A

Peripheral arterial disease

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77
Q

Peripheral arterial disease test

A

ABIs

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78
Q

Bilateral radicular pain

A

Central disk herniation

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79
Q

Test for Central disk herniation

A

MRI

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80
Q

The classic presentation is the development of constant, dull back pain that is not relieved by rest and is worse at night in a patient with a known malignancy

A

Back pain due to Metastatic Cancer

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81
Q

can be limited to the vertebral body or extend into the epidural space, causing cord compression.

A

Bone metastases

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82
Q

_____can precede cord compression by weeks or even months, but compression progresses ____ once it starts.

A

Pain can precede cord compression by weeks or even months, but compression progresses rapidly once it starts.

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83
Q

Cancer + back pain + neurologic abnormalities =

A

an emergency.

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84
Q

Most common sources that metastasize to the bone causing back pain are ___, ___, or ___ cancer.

A

Most common sources are breast, lung, or prostate cancer.

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85
Q

______lesions are seen with prostate cancer, small cell lung cancer, Hodgkin lymphoma

A

Blastic lesions are seen with prostate cancer, small cell lung cancer, Hodgkin lymphoma

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86
Q

_____ lesions are seen with renal cell, myeloma, non-Hodgkin lymphoma, melanoma, non–small cell lung cancer, thyroid cancer.

A

Lytic lesions are seen with renal cell, myeloma, non-Hodgkin lymphoma, melanoma, non–small cell lung cancer, thyroid cancer.

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87
Q

Mixed blastic and lytic lesions are seen with ______ cancer and____cancers

A

Mixed blastic and lytic lesions are seen with breast cancer and GI cancers

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88
Q

_________is the best test for diagnosing or ruling out cancer as a cause of back pain and for determining whether there is cord compression.

A

MRI scan is the best test for diagnosing or ruling out cancer as a cause of back pain and for determining whether there is cord compression.

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89
Q

What lab test is sometimes helpful for diagnosing or ruling out cancer as a cause for back pain

A

ESR

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90
Q

moderate to severe pain radiating from the back down the buttock and leg, usually to the foot or ankle, with associated numbness or paresthesias. This type of pain is called sciatica, and it is classically precipitated by a sudden increase in pressure on the disk, such as after coughing or lifting.

A

Lumbar Radiculopathy due to a Herniated Disk

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91
Q

frequently asymptomatic; pain occurs when direct contact of the disk with a nerve root provokes inflammation.

A

Disk disease

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92
Q

95% of clinically important disk herniations occur at __–__ and __–__, so pain and paresthesias are most often seen in the distributions of these nerves

A

95% of clinically important disk herniations occur at L4–L5 and L5–S1, so pain and paresthesias are most often seen in the distributions of these nerves

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93
Q

____ pain is often described as sharp, shooting or burning but can also be described as throbbing, tingling, or dull.

A

Radicular pain is often described as sharp, shooting or burning but can also be described as throbbing, tingling, or dull.

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94
Q

Neurologic abnormalities such as _____and _____ are found variably and can occur in the absence of pain

A

Neurologic abnormalities such as paresthesias/sensory loss and motor weakness are found variably and can occur in the absence of pain

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95
Q

Myofascial pain syndromes and hip and knee pathology can be difficult to distinguish from _____

A

Myofascial pain syndromes and hip and knee pathology can be difficult to distinguish from radiculopathy; many patients have both radiculopathy and other musculoskeletal conditions.

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96
Q

What can can aggravate radicular pain from a herniated disk?

A

Coughing, sneezing, or prolonged sitting

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97
Q

nonspinal causes of sciatica.

A

Traumatic injury of the nerve in pelvic fracture or hamstring injury

Gynecologic and peripartum causes such as compression from ovarian cysts or the fetal head

Compression of the nerve by the overlying piriformis muscle (piriformis syndrome), characterized by focal mid-buttock pain, tenderness over the sciatic notch, increased pain with sitting, and increased pain with external hip rotation.

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98
Q

There are no ____ or ____ symptoms with unilateral disk herniations.

A

There are no bowel or bladder symptoms with unilateral disk herniations.

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99
Q

Large midline herniations can cause

A

cauda equina syndrome.

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100
Q

rare condition caused by tumor or massive midline disk herniations.

A

Cauda equina syndrome

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101
Q

Characteristics of Cauda Equina syndrome

A

combo of measured urinary retention >500mL and at least 2 of 3 typical symptoms

1) bilateral sciatica
2) subjective urinary retention
3) rectal incontinence

other symptoms 
urinary incontinence
decreased anal sphincter tone
sensory loss in a saddle distribution
leg weakness
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102
Q

what test to determine cauda equina syndrome

A

MRI

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103
Q

Suspected cauda equina syndrome is a medical emergency that requires immediate _____ and _____.

A

Suspected cauda equina syndrome is a medical emergency that requires immediate imaging and decompression.

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104
Q

Pain in the Anteromedial thigh

is associated with what nerve root?

A

L4

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105
Q

pain the Lateral thigh, lateral lower leg, dorsum of foot is associated with what nerve root

A

L5

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106
Q

Pain in the Posterior thigh, calf, heel is associated with what nerve root

A

S1

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107
Q

Paresthesias/Sensory changes in the medial lower leg

is associated with what nerve root

A

L4

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108
Q

Paresthesias/Sensory changes in the Lateral thigh, lateral lower leg, dorsum of foot
is associated with what nerve root

A

L5

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109
Q

Paresthesias/Sensory changes in the Sole, lateral foot + ankle, fourth + fifth toes
is associated with what nerve root

A

S1

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110
Q

Motor weakness in the Knee extension, hip adduction

is associated with what nerve root

A

L4

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111
Q

Motor weakness in the Foot dorsiflexion, foot eversion + inversion, hip abduction
is associated with what nerve root

A

L5

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112
Q

Motor weakness in the Foot plantar flexion, knee flexion, hip extension
is associated with what nerve root

A

S1

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113
Q

Absent reflexes in the knee are associated with what nerve root

A

L4

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114
Q

Absent reflexes in the ankle are associated with what nerve root

A

S1

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115
Q

is performed by holding the heel in 1 hand and slowly raising the leg, keeping the knee extended.

A

Straight leg test

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116
Q

A positive Straight leg test

A

reproduces the patient’s sciatica when the leg is elevated between 30 and 60 degrees.

(The patient should describe the pain induced by the maneuver as shooting down the leg not just a pulling sensation in the hamstring muscle.)

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117
Q

Increased pain on a straight leg test

A

on dorsiflexion of the foot or large toe increases sensitivity.

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118
Q

performed by lifting the contralateral leg; a positive test reproduces the sciatica in the affected leg.

A

Crossed straight leg test

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119
Q

A straight leg raise test that elicits just back pain is positive or negative

A

negative

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120
Q

Plain radiographs are ___for diagnosing herniations.

A

Plain radiographs do not image the disks and are useless for diagnosing herniations.

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121
Q

what tests are good for diagnosing herniated disks

A

CT or MRI

similar in sensitivity and specificity

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122
Q

Primarily used to confirm lumbosacral radiculopathy and exclude other peripheral nerve abnormalities, particularly when physical exam abnormalities do not correlate with imaging abnormalities

A

Electromyography (EMG)

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123
Q

Also used to determine the severity and chronicity of a radiculopathy, and the functional significance of an imaging abnormality

A

Electromyography (EMG)

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124
Q

Most useful for subacute neuromuscular abnormalities (3 weeks to 3 months after the onset of symptoms)

A

Electromyography (EMG)

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125
Q

The physical exam findings for the diagnosis of __________

sciatica
positive crossed straight leg raise
positive ipsilateral straight leg raise
great toe extensor weakness
impaired ankle reflex
foot dorsiflexion weakness
foot plantar flexion weakness
A

disk herniation

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126
Q

for Lumbar Radiculopathy due to a Herniated Disk

In the absence of cauda equina syndrome or progressive neurologic dysfunction, conservative therapy should be tried for ___weeks. There is little evidence to guide clinicians.

A

6

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127
Q

conservative therapy for Lumbar Radiculopathy due to a Herniated Disk

A

NSAIDs are the first choice.

Gabapentin is often used but has not been well studied; pregabalin was ineffective in a recent study.

Tramadol and other opioids should be used only in patients with severe pain and for short periods of time.

Short courses of oral corticosteroids modestly improve acute pain; epidural corticosteroid injections may provide temporary pain relief.

Supervised exercise modestly reduces pain, and bed rest should be avoided.

Chiropractic manipulation has been shown to reduce pain in the short term

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128
Q

indications for surgery for Lumbar Radiculopathy due to a Herniated Disk

A

Impairment of bowel and bladder function (cauda equina syndrome)

Gross motor weakness

Progressive neurologic symptoms or signs

No response after 6 weeks of conservative therapy.

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129
Q

Surgery should/should not be done for painless herniations or when the herniation is at a different level than the symptoms.

A

should not

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130
Q

In the absence of progressive neurologic symptoms, surgery is ______

A

In the absence of progressive neurologic symptoms, surgery is elective; patients with disk herniations and radicular pain generally recover with or without surgery.

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131
Q

Lumbar Radiculopathy due to a Herniated Disk

The median time to recovery was __weeks for the surgery group and __ weeks for the conservative therapy group.

A

The median time to recovery was 4 weeks for the surgery group and 12 weeks for the conservative therapy group.

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132
Q

classic presentation is nonradiating pain and stiffness in the lower back, sometimes precipitated by heavy lifting or another muscular stress.

A

Mechanical Low Back Pain

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133
Q

risk factors for persistent low back pain

A

Maladaptive pain coping behaviors

High level of baseline functional impairment

Low general health status

Presence of psychiatric comorbidities

Presence of “nonorganic signs” (signs suggesting a strong psychological component to pain, such as superficial or nonanatomic tenderness, overreaction, non-reproducibility with distraction, nonanatomic weakness or sensory changes)

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134
Q

are effective for acute low back pain

A

nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants

acetaminophen is not effective in clinical trials.

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135
Q

have been shown to reduce acute low back pain

A

Heat and spinal manipulation

acupuncture and massage may also help.

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136
Q

Best approach for acute low back pain

A

is NSAIDs and heat during the acute phase with activity as tolerated until the pain resolves, followed by specific daily back exercises.

Bed rest may prolong the duration of pain

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137
Q

There is moderate quality evidence that exercise, yoga, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction are effective for

A

chronic low back pain.

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138
Q

There is low-quality evidence that cognitive-behavioral therapy, spinal manipulation, tai chi, progressive relaxation, and electromyography biofeedback, are effective for

A

chronic low back pain.

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139
Q

first line pharm therapy for subacute or chronic low back pain

A

NSAIDS

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140
Q

second line pharm therapy for subacute or chronic low back pain

A

Tramadol or duloxetine

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141
Q

are an option for patients who have not responded to all other therapies after a discussion of risks and benefits for subacute or chronic low back pain

A

Opioids

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142
Q

The classic presentation is acute, severe pain that develops in an older woman and radiates around the flank to the abdomen, occurring either spontaneously or brought on by trivial activity such as minor lifting, bending, or jarring.

A

Osteoporotic Compression Fracture

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143
Q

Osteoporotic Compression Fracture

Fractures are usually in the

A

mid to lower thoracic or lumbar region.

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144
Q

Fractures at T4 or higher are more often due to

A

malignancy than osteoporosis

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145
Q

Pain is often increased by slight movements, such as turning over in bed
and can also be asymptomatic

A

Osteoporotic Compression Fracture

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146
Q

Pain usually improves within 1 week and resolves by 4–6 weeks, but some patients have more chronic pain.

A

Osteoporotic Compression Fracture

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147
Q

Osteoporosis is usually related to

A

menopause and aging.

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148
Q

Most common diseases associated with osteoporosis include

A

hyperthyroidism, primary hyperparathyroidism, vitamin D deficiency, hypogonadism, and malabsorption.

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149
Q

Medications that can lead to osteoporosis include

A

corticosteroids (most common), anticonvulsants, aromatase inhibitors, and long-term heparin therapy.

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150
Q

Risk factors for osteoporosis include

A

Age (Strongest risk factor)

 Relative risk of almost 10 for women 
 aged 70–74 (compared with women m 
  under 65), increasing to a relative risk 
  of 22.5 for women over 80

Personal history of rib, spine, wrist, or hip fracture

Current smoking or use of ≥ 3 units of alcohol daily

White, Hispanic, or Asian ethnicity

Weight < 132 lbs

Parental history of hip fracture

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151
Q

T score is given with what test

A

Bone density testing

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152
Q

T score >= -1.0

A

normal

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153
Q

T score < -1.0 and > -2.5

A

osteopenia

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154
Q

<= -2.5

A

osteoporosis

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155
Q

used to estimate the 10-year probability of a hip fracture or a major osteoporotic fracture

A

The FRAX score,

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156
Q

most compression fractures are diagnosed with _______, unless there is a concern for malignancy.

A

most compression fractures are diagnosed with radiographs, unless there is a concern for malignancy.

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157
Q

Bone scan can be useful for determining ____ in Osteoporotic Compression Fracture

A

acuity

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158
Q

Total calcium intake (dietary plus supplementation, if necessary) should be ____mg daily for women over 50 years of age

A

Total calcium intake (dietary plus supplementation, if necessary) should be 1200 mg daily for women over 50 years of age

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159
Q

total vitamin D intake should be __ international units daily for women up to age 70

A

total vitamin D intake should be 600 international units daily for women up to age 70

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160
Q

total vitamin D intake should be __ international units daily for women over age 70.

A

800

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161
Q

Bisphosphonates both ____ bone density and ____fracture risk.

A

Bisphosphonates both increase bone density and reduce fracture risk.

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162
Q

___ and ___ (oral, once per week) reduce vertebral, nonvertebral, and hip fractures.

A

Alendronate and risedronate

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163
Q

_______(oral, once per month) reduces vertebral fractures

A

Ibandronate

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164
Q

________ (intravenous, once per year) reduces vertebral, nonvertebral, and hip fractures.

A

Zoledronic acid

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165
Q

______ reduces risk of spine fractures but not hip fractures.

A

Raloxifene

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166
Q

Raloxifene _____ the risk of estrogen receptor–positive breast cancer and _____the risk of venous thromboembolism

A

Raloxifene reduces the risk of estrogen receptor–positive breast cancer and increases the risk of venous thromboembolism

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167
Q

_________(teriparatide; subcutaneous, daily) increases bone density and reduces vertebral and nonvertebral fractures.

A

Parathyroid hormone (teriparatide; subcutaneous, daily) increases bone density and reduces vertebral and nonvertebral fractures.

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168
Q

_________, a monoclonal antibody RANKL inhibitor that blocks osteoclast function, (subcutaneous, every 6 months) reduces vertebral, nonvertebral, and hip fractures.

A

Denosumab, a monoclonal antibody RANKL inhibitor that blocks osteoclast function, (subcutaneous, every 6 months) reduces vertebral, nonvertebral, and hip fractures.

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169
Q

______ prevents fractures but is no longer recommended for long-term therapy due to such adverse events such as venous thromboembolism, breast cancer and MI and cerebrovascular accidents

A

Estrogen prevents fractures but is no longer recommended for long-term therapy due to such adverse events such as venous thromboembolism, breast cancer and MI and cerebrovascular accidents

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170
Q

Calcitonin does or does not significantly increase bone density or prevent fractures

A

Calcitonin does not significantly increase bone density or prevent fractures

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171
Q

Calcitonin sometimes reduces the ____from an acute vertebral compression fracture.

A

pain

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172
Q

percutaneous injection of bone cement under fluoroscopic guidance into a collapsed vertebra

A

Vertebroplasty

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173
Q

(introduction of bone cement and inflatable bone tamps into the fractured vertebral body

A

kyphoplasty

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174
Q

as reproducible, exercise-induced calf pain that requires stopping and is relieved with < 10 minutes of rest

A

Peripheral Arterial Disease (PAD)

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175
Q

classically presents with pain in the feet at rest that may be relieved by placing the feet in a dependent position.

A

Critical limb ischemia

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176
Q

Risk factors PAD

A

smoking
diabetes

HTN
hyperlipidemia
other vascular disease (ischemic heart disease, stroke)

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177
Q

skin being cooler to the touch and the presence of a foot ulcer in the affected leg

atrophic or cool skin, blue/purple skin, absence of lower limb hair

A

skin changes associated with PAD

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178
Q

presence of an iliac, femoral, or popliteal bruit associated with

A

PAD

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179
Q

Risk factor modification for PAD

A

smoking cessation, control of hypertension and diabetes, treatment with a high-intensity statin

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180
Q

Antiplatelet therapy with ___or ____ reduces myocardial infarction, stroke, and death from vascular causes; there is no additional benefit with combination therapy.

A

Antiplatelet therapy with aspirin or clopidogrel reduces myocardial infarction, stroke, and death from vascular causes; there is no additional benefit with combination therapy.

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181
Q

first-line therapy. PAD

A

Exercise, especially a supervised exercise program, can increase walking by up to 150% over 3–12 months

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182
Q

Revascularization, either surgical or percutaneous transluminal angioplasty, is indicated for the following:

A

Limb salvage in critical limb ischemia

Claudication unresponsive to exercise and pharmacologic therapy that limits patients’ lifestyle or ability to work

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183
Q

The classic presentation is a patient with a history of diabetes or injection drug use who has fever and back pain, followed by neurologic symptoms (eg, motor weakness, sensory changes, and bowel or bladder dysfunction).

A

Spinal Epidural Abscess

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184
Q

predisposing conditions of Spinal Epidural Abscess

A

underlying disease such as DM, injection drug use, ESRD, immunosuppressant therapy, cancer, HIV

invasive spine intervention (surgery, percutaneous spine procedure, trauma)

potential local or systemic source of infection (skin or soft tissue infection, endocarditis, osteomyelitis, UTI, injection drug use, epidural anesthesia, indwelling vascular access)

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185
Q

Spinal Epidural Abscess causative organism in 66% of the cases

A

Staphylococcus aureus

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186
Q

other organisms for Spinal Epidural Abscess

A

Staphylococcus epidermidis, Escherichia coli, Pseudomonas aeruginosa

Anaerobes, mycobacteria, fungi, and parasites are occasionally found

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187
Q

Classic triad of fever, spine pain, and neurologic deficits

A

Spinal Epidural Abscess

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188
Q

Spinal Epidural Abscess Occur more commonly in _____ than ____epidural space and more commonly in the ______than _____areas.

A

Occur more commonly in posterior than anterior epidural space and more commonly in the thoracolumbar than cervical areas.

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189
Q

Spinal Epidural Abscess Generally extend over – vertebrae.

A

3-5

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190
Q

back pain at the level of the affected spine

Spinal Epidural Abscess stage

A

Spinal Epidural Abscess

Stage 1

191
Q

nerve root pain radiating from the involved spinal area

Spinal Epidural Abscess stage

A

Spinal Epidural Abscess

Stage 2

192
Q

motor weakness, sensory deficit, bladder/bowel dysfunction

Spinal Epidural Abscess stage

A

Spinal Epidural Abscess

Stage 3

193
Q

paralysis

Spinal Epidural Abscess stage

A

Spinal Epidural Abscess

Stage 4

194
Q

Labs elevated/present in Spinal Epidural Abscess

A

ESR and CRP usually elevated

Leukocytosis

Bacteremia

195
Q

Best imaging study for spinal epidural abscess

A

MRI with gadolinium

196
Q

Alternative imaging if they cannot have an MRI for spinal epidural abscess

A

CT myelogram

197
Q

if you have a normal WBC and negative blood cultures does this rule out spinal epidural abscess?

A

no

198
Q

treatment for spinal epidural abscess

A

CT-guided or open biopsy, followed by percutaneous or surgical decompression and drainage

Antibiotics

199
Q

The classic presentation is somewhat vague, but persistent back and leg discomfort brought on by walking or standing that is relieved by sitting or bending forward is typically seen.

A

Spinal Stenosis

200
Q

radiographic abnormalities such as spondylolisthesis, disk-space narrowing, facet-joint hypertrophy, neural foramina osteophytes

A

Spinal Stenosis

201
Q

Neurogenic claudication, a variable pain or discomfort with walking or prolonged standing that radiates into the buttocks, thighs, or lower legs, is the most common symptom.

A

Spinal Stenosis

202
Q

Radicular or polyradicular pain can occur and is not as related to position as neurogenic claudication.

A

Spinal Stenosis

203
Q

medical term usually referring to impairment in walking, or pain, discomfort, numbness or tiredness in the legs that occurs during walking or standing and is relieved by rest

A

claudication

204
Q

vascular or neurogenic claudication

fixed walking distance before onset of symptoms

A

vascular

205
Q

vascular or neurogenic claudication

Variable walking distance before onset of symptoms

A

neurogenic

206
Q

vascular or neurogenic claudication

Improved by standing still

A

vascular

207
Q

vascular or neurogenic claudication

Worsened by walking

A

vascular

208
Q

vascular or neurogenic claudication

Painful to walk uphill

A

vascular

209
Q

vascular or neurogenic claudication

Improved by sitting or bending forward
A

neurogenic

210
Q

vascular or neurogenic claudication

Worsened by walking or standing
A

neurogenic

211
Q

vascular or neurogenic claudication

Can be painless to walk uphill due to tendency to bend forward

A

neurogenic

212
Q

vascular or neurogenic claudication

Absent pulses

A

vascular

213
Q

vascular or neurogenic claudication

Skin shiny with loss of hair

A

vascular

214
Q

vascular or neurogenic claudication

Present pulses
A

neurogenic

215
Q

vascular or neurogenic claudication

Skin appears normal
A

neurogenic

216
Q

a variable pain or discomfort with walking or prolonged standing that radiates into the buttocks, thighs, or lower legs, is the most common symptom.

A

Neurogenic claudication

217
Q

can occur and is not as related to position as neurogenic claudication.

A

Radicular or polyradicular pain

218
Q

Stenosis is seen most often in the ____ spine

A

Stenosis is seen most often in the lumbar spine, sometimes in the cervical spine, and rarely in the thoracic spine.

219
Q

Stenosis is rarely seen in the _____ spine

A

thoracic

220
Q

due to hypertrophic degenerative processes and degenerative spondylolisthesis compressing the spinal cord, cauda equina, individual nerve roots, and the arterioles and capillaries supplying the cauda equina and nerve roots

A

Spinal stenosis

221
Q

in spinal stenosis pain is ____ by extension and ____ by flexion.

A

worsened by extension

relieved by flexion

222
Q

generally have bilateral, non-­dermatomal pain involving the buttocks and posterior thighs.

A

Patients with central stenosis

223
Q

Patients with___ stenosis generally have pain in a dermatomal distribution.

A

Patients with lateral stenosis generally have pain in a dermatomal distribution.

224
Q

Repeating the physical exam after ____ might demonstrate subtle abnormalities in spinal stenosis

A

rapid walking

225
Q

Lumbar spinal stenosis does/does not progress to paralysis and should be managed based on severity of symptoms.

A

does not

226
Q

what spinal stenoses can cause myelopathy and paralysis and requires surgery more often than lumbar spinal stenosis.

A

Progression of cervical and thoracic stenoses

227
Q

______ are not necessary: they do not change management, or provide the degree of anatomic detail necessary to guide interventional treatment (such as epidural injection or surgery). (in spinal stenosis)

A

plain radiographs

228
Q

what imaging for spinal stenosis

A

CT and MRI

CT and MRI scans can rule out spinal stenosis but cannot necessarily determine whether visualized stenosis is causing the patient’s symptoms.

229
Q

Medications used for pain relief include in spinal stenosis

A

NSAIDs, tricyclic antidepressants, gabapentin, pregabalin, tramadol, and sometimes opioids.

230
Q

In spinal stenosis physical therapy improves

A

stamina and muscle strength in the legs and trunk;exercises performed with lumbar flexion, such as cycling, may be better tolerated than walking.

231
Q

spinal stenosis

epidural injections of

A

epidural injection of corticosteroids and lidocaine, vs. lidocaine alone, found that adding corticosteroids did not reduce pain at 6 weeks.

232
Q

primary indication of surgery to treat spinal stenosis

A

increasing pain that is not responsive to conservative measures.

233
Q

surgery in spinal stenosis is more effective in reducing ___ pain than ___ pain

A

More effective in reducing leg pain than back pain.

234
Q

Predictors of a positive response to surgery in spinal stenosis

A

male sex, younger age, better walking ability, better self-rated health, less comorbidity, and more pronounced canal stenosis.

235
Q

The classic presentation is unremitting back pain with fever.

A

Vertebral Osteomyelitis

236
Q

Vertebral Osteomyelitis is Most commonly from

A

hematogenous spread

237
Q

most common sources of infections that lead to Vertebral Osteomyelitis

A

Urinary tract, skin, soft tissue, vascular access site, endocarditis, septic arthritis

238
Q

Vertebral Osteomyelitis patients usually have _____ or history of _____

A

Patients usually have underlying chronic illnesses or injection drug use.

239
Q

Can also occur due to contiguous spread from an adjacent soft tissue infection or direct infection from trauma or surgery.

A

Vertebral Osteomyelitis

240
Q

Generally causes bony destruction of 2 adjacent vertebral bodies and collapse of the intervertebral space.

A

Vertebral Osteomyelitis

241
Q

Vertebral Osteomyelitis is most often found in ____, followed by _____ and _____. complicated by ______

A

lumbar spine
thoracic spine
cervical spine

epidural, paravertebral and disk space abscess

242
Q

causative agent for Vertebral Osteomyelitis in over 50% of patients

A

S aureus

243
Q

what causative agents for vertebral osteomyelitis are esp seen in diabetic patients

A

Group B and G hemolyic strep

244
Q

what causative agents for vertebral osteomyelitis are seen esp after UT instrumentation

A

Enteric gram neg bacilli

245
Q

what other agent sometimes causes vertebral osteomyelitis

A

Coagulase-negative staphylococci

246
Q

lab tests for vertebral osteomyelitis

A

leukocytosis (normal WBC does not rule out)

ESR - nearly all report elevated

CRP - nearly all elevated

Blood cultures positive in 58%

image guided spinal biopsy

247
Q

imaging for vertebral osteomyelitis

A

from highest sensitivity/specificity to lowest

MRI with gadolinium
Bone scan
Radiographs

248
Q

treatment for vertebral osteomyelitis

A

ABX for 4-6 weeks at least

Surgery is necessary only if neurologic symptoms suggest onset of vertebral collapse causing cord compression or development of spinal epidural abscess; surgery is always necessary for osteomyelitis associated with a spinal implant.
surgery is always necessary for osteomyelitis associated with a spinal implant

249
Q

______ should be considered in patients with either vertebral osteomyelitis or a spinal epidural abscess.

A

Endocarditis

250
Q

surgery is always necessary for osteomyelitis associated with a

A

spinal implant

251
Q

polyarticular joint pain with acute onset consider what kind of causes

A

infectious
postinfectious
causes

252
Q

polyarticular joint pain
chronic onset
history and physical exam consistent with an inflammatory process
what should be considered

A

rheumatologic disease

253
Q

polyarticular joint pain
chronic onset
history and physical exam consistent with an inflammatory process
anti-ds DNA present

A

SLE is likely

254
Q

polyarticular joint pain
chronic onset
history and physical exam consistent with an inflammatory process
nodules are present or ACPA positive

A

RA is likely

255
Q

polyarticular joint pain
chronic onset
history and physical exam not consistent with an inflammatory process
consider

A

OA

CPPD

256
Q

monoarticular joint pain consistent with periarticular disease, consider

A

joint-specific periarticular syndromes

257
Q

monoarticular joint pain with history and physical exam not consistent with an inflammatory process

A

Consider OA

CPPD

258
Q

monoarticular joint pain with history and physical exam consistent with an inflammatory process

at least 6 findings associated with gout

A

treat for gout

259
Q

monoarticular joint pain with history and physical exam consistent with an inflammatory process

does not have at least 6 findings associated with gout

A

Aspirate joint to differentiate crystalline arthropathy from a septic arthritis

260
Q

what does a positive crossed straight leg sign is associated with a

A

herniated lumbar disk in 97% of patients

261
Q

what are some causes of infectious inflammatory for monoarticular arthritis

A

Nongonococcal septic arthritis

Gonococcal arthritis

Lyme disease

262
Q

what are some causes of crystalline inflammatory for monoarticular arthritis

A

Monosodium urate (gout)

Calcium pyrophosphate dihydrate deposition disease (CPPD or pseudogout)

263
Q

what are some non-inflammatory causes of monoarticular arthritis

A

Osteoarthritis (OA)

Traumatic

Avascular necrosis

264
Q

what are some inflammatory causes of polyarticular arthritis that fall under rheumatologic causes

A

Rheumatoid arthritis (RA)

Systemic lupus erythematosus (SLE)

Psoriatic arthritis

Other rheumatic diseases

265
Q

what are some infectious causes of polyarticular arthritis - Bacterial

A

Bacterial endocarditis

Lyme disease

Gonococcal arthritis

266
Q

what are some infectious causes of polyarticular arthritis - Viral

A

Rubella

Hepatitis B

HIV

Parvovirus

267
Q

what are some post-infectious causes of polyarticular arthritis

A

Enteric

Urogenital

Rheumatic fever

268
Q

Men > women

Previous episodes

Rapid onset

Involvement of first

MTP joint

A

Gout

269
Q

sodium urate crystals in synovial fluid

A

Gout

270
Q

May present as chronic or acute arthritis

Demonstration of calcium pyrophosphate crystals in synovial fluid or classic radiographic findings

A

CPPD (pseudogout)

271
Q

Fever with monoarticular or polyarticular arthritis

Positive synovial (or other body) fluid cultures

A

Bacterial arthritis (gonococcal or nongonococcal)

272
Q

Exposure to endemic area

History of tick bite

Rash

A

Lyme disease

273
Q

Morning stiffness

Symmetric polyarthritis

Commonly involves the MCP joints

A

Rheumatoid arthritis

274
Q

important tests for RA

A

Rheumatoid factor

Anti-citrullinated protein antibody

275
Q

Psoriasis

Dactylitis

Spinal arthritis

Often asymmetric

Often involves the DIP joints

A

Psoriatic arthritis

276
Q

Multisystem disease

More common in women than in men

In the United States, more common in Asians, African Americans, African Caribbeans, and Hispanic Americans

A

Systemic lupus erythematosus

277
Q

Chronic arthritis in weight-bearing joints

In the hands, DIP and PIP involvement more common than MCP involvement

A

Osteoarthritis

278
Q

important imaging in osteoarthritis

A

Radiograph of affected joints

279
Q

Parvovirus infection often includes viral symptoms, joint pain and rash

A

Viral arthritis, parvovirus most common

280
Q

what labs are important in viral arthritis

A

antibody titers and serology

281
Q

Migratory polyarthritis

Carditis

Erythema marginatum

A

Rheumatic fever

282
Q

Jones criteria is used in what

A

Rheumatic fever

283
Q

Fever with monoarticular or polyarticular arthritis

A

Bacterial arthritis (gonococcal or nongonococcal)

284
Q

important tests in Bacterial arthritis

A

Positive synovial (or other body) fluid cultures

285
Q

History of recent colonic or urogenital infection

Presence of arthritis, urethritis, and iritis

A

Reactive arthritis

286
Q

Chronic pain in weight-bearing joints

A

Osteoarthritis

287
Q

Pain worse with straining

A

Inguinal hernia

288
Q

Lateral hip pain

Tenderness over the bursa

A

Trochanteric bursitis

289
Q

Positive straight leg raise

A

Lumbar nerve root compression

290
Q

imaging for

Lumbar nerve root compression

A

MRI

291
Q

Most common in young women involved in weight-bearing exercise

A

Femoral stress fractures

292
Q

imaging for Femoral stress fractures

A

MRI

Bone scan

293
Q

generally presents in older patients. It may present with an acute flare or, more commonly, as a degenerative arthritis with suspicious radiographic findings that distinguish it from OA. Patients often have other diseases associated such as hyperparathyroidism.

A

Calcium Pyrophosphate Deposition Disease (CPPD)

294
Q

Acute flare of CPPD is called

A

pseudogout

295
Q

crystal-induced arthropathy

A

Calcium Pyrophosphate Deposition Disease (CPPD)

296
Q

when CPPD is diagnosed as an incidental finding in an asymptomatic patient. What was found on what test?

A

incidental radiographic finding of chondocalcinosis, the linear calcifications of articular cartilage

297
Q

An acute, inflammatory, usually monoarticular arthritis

A

Pseudogout

presentation of Calcium Pyrophosphate Deposition Disease (CPPD)

298
Q

chronic arthritis that is clinically similar to OA

May affect joints less commonly affected by OA like the wrists, MCPs, and shoulders

A

CPPD arthropathy aka (pseudo OA)

299
Q

A chronic, inflammatory polyarthritis resembling RA

A

pseudo RA

presentation of Calcium Pyrophosphate Deposition Disease (CPPD)

300
Q

Resembles a Charcot joint

Destructive monoarthropathy is seen in this presentation.

A

Pseudoneuropathic arthropathy (rarely)

presentation of Calcium Pyrophosphate Deposition Disease (CPPD)

301
Q

similarities between pseudogout and gout.

A

oth are caused by the inflammatory response to crystals in the synovial space.

Both cause acute painful monoarticular attacks.

Both can cause polyarticular flares.

Flares can be induced by trauma or illness.

Both can potentially cause destructive arthropathy.

Incidence increases with age.

302
Q

how is pseudogout different from gout

A

Episodic “gout-like” flares only occur in a small percentage of patients.

As above, CPPD commonly manifests as a degenerative arthritis (in about 50% of patients).

It has highly specific radiologic features.

It most commonly affects the knee.

303
Q

pseudogout is most commonly associated with what diseases

A

Hyperparathyroidism

Hemochromatosis

Hypomagnesemia

Hypophosphatasia

304
Q

Acute arthritis of a large joint, especially the knee, in the absence of hyperuricemia.

Chronic arthritis with acute flares.

Chronic arthritis involving joints that would be atypical for OA such as the wrists, metacarpophalangeal (MCP) joints, and shoulders.

A

CPPD

305
Q

Evaluation of a patient with pseudogout should include testing for related diseases. The evaluation generally includes measuring the levels of the following:

A

Calcium

Magnesium

Phosphorus

Iron, ferritin, and total iron-binding capacity (TIBC)

In the right setting, markers of other rheumatologic diseases (uric acid, rheumatoid factor [RF], anti-cyclic citrullinated peptide [anti-CCP])

306
Q

Acute Calcium Pyrophosphate Deposition Disease (CPPD) attacks are managed with

A

NSAIDs

Joint aspiration with corticosteroid injection

Colchicine

307
Q

Chronic degenerative arthritis is difficult to treat. what is usually used

A

NSAIDS

308
Q

classically seen in young, sexually active women who have fever and joint pain. The most common presentation is severe pain of the wrists, hands, and knees with warmth and erythema diffusely over the backs of the hands. A rash may sometimes be present.

A

Disseminated Gonorrhea

309
Q

what gender is more likely to have Disseminated Gonorrhea

A

Women 3 times more likely then men

310
Q

Disseminated gonorrhea usually occurs in patients without a history of

A

recent sexually transmitted infection.

311
Q

Disseminated gonorrhea presents in 1 of 2 ways (with a good deal of overlap):

A

a classic septic arthritis or a triad of tenosynovitis, dermatitis, and arthralgia. (reflects a high-grade bacteremia with reactive features)

312
Q

tenosynovitis presents predominantly as

A

polyarthralgia of the hands and wrists

313
Q

rash associated with disseminated gonorrhea

A

scattered, papular, or vesicular rash.

314
Q

what labs should be sent for suspicion of disseminated gonorrhea

A

Besides synovial fluid cultures, blood cultures, pharyngeal cultures, and PCR testing of urine or genital swabs should be sent.

315
Q

Negative cultures do or do not necessarily exclude the diagnosis of disseminated gonorrhea

A

Negative cultures do not necessarily exclude the diagnosis of disseminated gonorrhea

If all cultures are negative, the disease can still be diagnosed if there is a high clinical suspicion and a rapid response to appropriate antibiotics.

316
Q

Treatment for disseminated gonorrhea

A

Ceftriaxone 1 g IV or IM every 24 hours or cefotaxime 1 g IV every 8 hours.

IV therapy is generally recommended for 24–48 hours after improvement.

317
Q

most commonly seen in young female athletes. Symptoms begin acutely with groin pain that persists and worsens as the day progresses. On physical exam, there is often mild tenderness over the proximal one-third of the femur. Range of motion of the hip is normal. Radiographs are usually normal.

A

Femoral Stress Fractures

318
Q

femoral stress fractures are most common in

A

Athletes who have recently increased their level of training

Women

Persons with decreased bone density

319
Q

The most common stress fractures are

A

tibial and metatarsal.

320
Q

diagnostic of choice for femoral stress fractures

A

MRI and bone scans

321
Q

Many stress fractures heal with

A

reduced physical activity and short-term immobilization.

322
Q

Femoral stress fractures may resolve with

A

decreased weight bearing (crutches) or may require casting or internal fixation.

323
Q

most commonly presents in older patients with severe, acute pain of the first metatarsophalangeal (MTP) joint. The pain generally begins acutely and becomes unbearable within hours of onset. Classically, patients say that they are not even able to place a bed sheet over the toe. On physical exam, the first MTP joint is warm, swollen, and red.

A

Gout

324
Q

most common inflammatory arthritis and most common crystal-induced arthropathy.

A

Gout

325
Q

attacks occur when sodium urate crystallizes in synovial fluid inducing an inflammatory response.

A

Gouty attacks

326
Q

The primary risk factor for gout is

A

hyperuricemia

327
Q

The prevalence of gout increases with ___ and is more common in ___ than ___.

A

The prevalence of gout increases with age and is more common in men than women.

328
Q

The classic location for gout is the

A

first MTP joint (podagra).

329
Q

other sites for gout that are less common though usually seen after and initial attack of podagra

A

The joints of the lower extremities and the elbows

330
Q

common causes of Gouty attacks that cause a abrupt change in uric acid levels

A

Large protein meals

Alcohol binges

Initiation of thiazide or loop diuretics

Initiation of urate-lowering therapy

Worsening kidney disease

can also be induced by trauma, illness or surgery

331
Q

The initial gouty attack nearly always involves ___ joint, while later attacks may be ___

A

The initial attack nearly always involves a single joint, while later attacks may be polyarticular

332
Q

Tophaceous gout occurs when there is

A

macroscopic deposition of sodium urate crystals in and around joints.

333
Q

what organ can be affected by gout

A

Sodium urate stones or a urate nephropathy can develop in patients. (kidney)

334
Q

most common type of gout.

A

Acute gouty arthritis

335
Q

what form of gout can develop in patients who have untreated hyperuricemia.

A

Chronic arthritis

336
Q

Patients with a new diagnosis of gout should be evaluated for

A

alcoholism, chronic kidney disease, myeloproliferative disorders, and hypertension.

337
Q

Patients in whom gout develops before the age of thirty should be evaluated for

A

disorders of purine metabolism.

338
Q

Acute, inflammatory, monoarticular arthritis is an absolute indication for

A

arthrocentesis.

339
Q

what can be done to rule out potentially joint destroying septic arthritis and usually make a diagnosis.

A

sampling synovial fluid

340
Q

Every acute, inflammatory joint effusion should be

A

aspirated

341
Q

Joint fluid should be sent for

A

cell count, Gram stain, culture, and crystal analysis.

342
Q

Yellow and clear synovial fluid

A

normal or OA

343
Q

yellow green and cloudy synovial fluid

A

RA or similar arthritides

344
Q

yellow green and opaque

synovial fluid

A

Acute crystal or septic arthritis

345
Q

what are the classifications of treatment in gout

A

abortive (treat acute flare)

prophylactic (to prevent flares and the destructive effects on the joints and kidneys).

346
Q

abortive treatment for gout and potential adverse effects

A

NSAIDS -
Nephrotoxicity
GI toxicity

Colchicine - 
GI toxicity (diarrhea)

Oral corticosteroids-
GI toxicity
Hyperglycemia

Intra-articular corticosteroids
Complications of joint -injection
Hyperglycemia

347
Q

5 basic indications for prophylactic therapy for gout

A

Frequent attacks

Disabling attacks

Urate nephrolithiasis

Urate nephropathy

Tophaceous gout

348
Q

nonpharmacologic interventions to decrease uric acid levels.

A

Decrease intake of high purine foods (red meat, shellfish, yeast rich foods)

Weight loss

Discontinuation of medications that impair urate excretion (eg, aspirin, thiazide diuretics).

349
Q

Potential prophylactic treatments for GOUT

A

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Antigout agent-
Colchicine

Xanthine oxidase inhibitors-
1)Allopurinol - contraindicated in pt with chronic kidney or liver disease

2)Febuxostat - avoid with high cardiovascular risk

Uricosuric agent
1) Probenecid (must have GFR > 30)

2)Sulfinpyrazone

Uricase agents (eg, pegloticase) - tophaceous and actively symptomatic disease

350
Q

Urate-lowering therapy does not reduce the risk of gout attacks for at least

A

6 months

351
Q

If xanthine oxidase inhibitor therapy is ineffective, uric acid excretion should be measured. Patients with low uric acid excretion (present in 80% of patients with gout) should be given a

A

uricosuric agent

352
Q

presents in different ways at different stages of the disease. A classic presentation of the joint symptoms is a patient with acute, inflammatory knee pain who has been in an area where the disease is endemic. There may be a history of a previous tick bite, rash, or nonspecific febrile illness.

A

lyme disease

353
Q

Lyme disease is caused by

A

the spirochete Borrelia burgdorferi, transmitted by a number of species of Ixodes ticks.

354
Q

The tick most commonly transmits the disease during its

A

nymphal stage

355
Q

lyme disease season

A

Peak incidence is in June and July, with disease occurring from March through October

356
Q

Transmission from a tick that has been discovered and removed is

A

very low.

357
Q

when does transmission from infected nymphal ticks generally occur

A

only after 36–48 hours of attachment (longer for adult ticks).

358
Q

what finding is most common in the early localized lyme disease

A

skin findings

usually a large area of localized erythema.

359
Q

about 50% of the time the acute rash in early lyme disease occurs where

A

below the waist

360
Q

The mean diameter of the rash for lyme disease

A

10cm

361
Q

what can the rash look like with lyme disease

A

60% homogenous erythema

30% classic target lesion

10% have multiple lesions

362
Q

symptoms for early localized lyme disease stage

A

rash

Myalgias and arthralgias (59%)

Fever (31%)

Headache (28%)

363
Q

Early disseminated disease (weeks to a couple of months after the bite) usually involves the ____ and the ____

A

CNS

Heart

364
Q

CNS symptoms lyme disease

A

headache
facial nerve palsy
lymphocytic meningitis
radiculopathy

365
Q

Cardiac disease r/t lyme disease generally involves

A

conduction abnormalities (heart block).

366
Q

Joint symptoms predominate ___ in the lyme disease.

A

late

367
Q

type of arthritis is the most common joint related finding with lyme disease

A

Monoarticular knee arthritis

368
Q

Definitive diagnosis of Lyme disease is based on

A

clinical characteristics, exposure history, and antibody titers.

369
Q

_____are insensitive early in the disease and are thus not helpful in the setting of acute infection.

A

Antibodies

370
Q

Treatment of arthritis caused by Lyme disease consists of

A

4 weeks of oral antibiotics.

371
Q

Chronic symptoms that develop after appropriate treatment of Lyme disease do not respond to

A

intensive antibiotic therapy.

372
Q

most commonly presents in older patients as chronic joint pain and stiffness. Pain is usually worse with activity and improves with rest. Knees, hips, and hands are most commonly affected. On examination of the joints, there is bony enlargement without significant effusions. Mild tenderness may be present along the joint lines. There is limited range of motion. Radiographs are diagnostic.

A

Osteoarthritis (OA)

373
Q

disease of aging, with peak prevalence in the eighth decade. However, as obesity is a risk factor, it may be seen in much younger people with severe obesity.

A

OA

374
Q

OA is More common in ____ than ___

A

More common in women than men

375
Q

often referred to as “wear and tear” arthritis

A

OA

376
Q

Joint destruction manifests as a loss of cartilage with change to the underlying bone seen as bony sclerosis and osteophyte formation.

A

OA

377
Q

OA is most common in the

A

knees, hips, hands, and spine.

378
Q

arthritis

Pain with activity

Relief with rest

A

OA

379
Q

Gelling: Joint stiffness brought on by rest and rapidly resolving with activity

A

OA

380
Q

Late in the disease, constant pain with joint deformation and severe disability is common.

A

OA

381
Q

Pain with activity

Relief with rest

Periarticular tenderness

Occasional mildly inflammatory flares

Gelling: Joint stiffness brought on by rest and rapidly resolving with activity.

Late in the disease, constant pain with joint deformation and severe disability is common.

A

OA

382
Q

there is bony enlargement, crepitus, and decreased range of motion without signs of inflammation or synovial thickening.

A

OA

383
Q

Knee

Crepitus

Tenderness on joint line

Varus or valgus displacement of the lower leg related to asymmetric loss of the articular cartilage.

A

OA

384
Q

Marked decrease first in internal and then external rotation in hip

Groin pain with rotation of the hip

A

OA

385
Q

Tenderness and bony enlargement of the first carpometacarpal joint

Joint involvement in decreasing order of prevalence is DIP, PIP, MCP.

Heberden nodes (prominent osteophytes of the DIP joints)

Bouchard nodes (prominent osteophytes of the PIP joints)

A

OA

386
Q

Spine

Pain and limited range of motion are common.

Radicular symptoms resulting from osteophyte impingement on nerve roots is seen.

Spinal stenosis with associated symptoms (radiculopathy and pseudoclaudication) can result from bony hypertrophy .

A

OA

387
Q

diagnosis of OA

A

compatible history, physical exam, and radiologic findings.

388
Q

decreases the symptoms of lower extremity OA.

A

Weight loss

389
Q

nonpharmacologic have been shown to improve pain and improve the efficacy of pharmacologic interventions in OA

A

Patient education and improved social support

390
Q

can help patients with functional impairment due to OA.

A

Physical and occupational therapy

391
Q

Frequently used as initial therapy given its low side-effect profile.

Recent data has questioned its efficacy.

for OA

A

Tylenol

392
Q

____ are probably more effective than ____ for severe OA.

A

NSAIDs are probably more effective than acetaminophen for severe OA.

393
Q

Oral combinations of ____and _____ ____ probably are modestly effective in some patients and have a very favorable side-effect profile.

A

Oral combinations of glucosamine and chondroitan sulfate probably are modestly effective in some patients and have a very favorable side-effect profile.

394
Q

intra-articular med that is very effective for pain relief in acute flares of OA

A

Intra-articular corticosteroids

395
Q

given by intra-articular injection may provide a small benefit to some patients for OA

A

Hyaluronic acid

396
Q

pain meds for severe symptoms of OA

A

Tramadol and opioid analgesics

397
Q

surgical options for OA

A

Arthroscopic surgery for OA is probably ineffective.

Hip and knee replacement can have remarkable effects on decreasing pain and improving function in patients in whom conservative therapy has failed.

398
Q

commonly seen in young people who are in contact with children (mothers, teachers, daycare workers, and pediatricians).

may present with a flu-like illness, macular rash, arthralgias/arthritis, or any combination of these symptoms. Joint symptoms generally improve over the course of weeks.

A

Parvovirus

399
Q

5 major manifestations of parvovirus infection in humans.

A

Erythema infectiosum (fifth disease) in children

Acute arthropathy in adults

Transient aplastic crises in patients with chronic hemolytic diseases

Chronic anemia in immunocompromised persons

Fetal death complicating maternal infection prior to 20 weeks gestation.

400
Q

In adults, parvovirus infection usually includes some combination of

A

viral symptoms, arthritis, and rash.

401
Q

Nonspecific viral symptoms for parvovirus

A

fever, malaise, headache, myalgia, diarrhea, and pruritus.

402
Q

The arthritis is a symmetric polyarthritis.

Commonly involved joints are elbows, wrists, knees, ankles, feet.

A

parvovirus

403
Q

rash seen in parvovirus

A

usually a peripheral macular rash that occasionally spreads to the trunk.

404
Q

incidence of parvovirus infection peaks between

A

January and June.

405
Q

Viral causes of arthritis

A

Parvovirus
Rubella
Hepatitis B
HIV

406
Q

ANA can be transiently elevated in patients with

A

parvovirus

407
Q

Common cause of “stiff neck” in patient who is otherwise well

Often noticed upon wakening

Spasm of the cervical and upper back muscles

Neck pain often worst with lateral flexion

Head tilt often present

A

Cervical strain

408
Q

Pain and stiffness of cervical spine, usually with radiation to upper back and arm

Occasionally manifests solely as pain between spine and scapula

Spurling test: sensitivity, 30%; specificity, 93%

MRI diagnostic

A

Cervical radiculopathy

409
Q

Shoulder pain, often subacute onset, often worse at night

Positive painful arc test

A

Subacromial or rotator cuff disorder

410
Q

Shoulder pain, often subacute onset, often worse at night

Occurs after injury in younger patients

Often spontaneous in older patients

A

Rotator cuff tear

411
Q

Pain over tendon insertion on medial and lateral epicondyle

Tenderness at site of pain

Exacerbated with wrist flexion (medial) or extension (lateral)

A

Lateral and medial epicondylitis

412
Q

Pain over olecranon bursa

Tenderness and swelling over the olecranon bursa

A

Olecranon bursitis

413
Q

Pain at the lateral base of the thumb

Worse with pincer grasp

Positive Finkelstein maneuver (ulnar deviation of wrist with fingers curled over thumb)

A

DeQuervain tenosynovitis

414
Q

Pain over bursa

Patient often notes pain when lying on area at night

Tenderness over bursa

Sometimes visualized on radiograph

A

Trochanteric bursitis

415
Q

Pain or numbness over lateral thigh

Often after weight gain or loss

Neuropathic-type pain

Abnormal sensation over lateral femoral cutaneous nerve distribution

A

Meralgia paresthetica

416
Q

Anterior knee pain, often worse climbing or descending stairs

Crepitus beneath patella

A

Patellofemoral syndrome

417
Q

Ligament injuries tend to be traumatic

Classically associated with the knee giving way

Meniscal injuries may be traumatic or degenerative

Knee locking is classic

Ligament injuries will manifest as laxity on exam

Meniscal injuries as a click

MRI is diagnostic

A

Meniscal and ligamentous injuries

418
Q

Pain over distal tendon

Pain and stiffness worse after inactivity

Tenderness over insertion of tendon

A

Achilles tendinitis

419
Q

Pain anterior to heel

Worse with first standing
History usually diagnostic

Radiograph may show heel spur

A

Plantar fasciitis

420
Q

Pain between the second and third or third and fourth metatarsal heads

Tenderness between the second and third or third and fourth metatarsal heads

A

Morton neuroma

421
Q

Diffuse pain syndrome

Often nonrestorative sleep

A

Fibromyalgia

422
Q

Pain and disability of large muscles of shoulder and hips

Disease is often associated with findings consistent with inflammatory disease (anemia, elevated CRP and ESR)

A

Polymyalgia rheumatica

423
Q

most commonly presents as joint pain in middle-­aged patients with a history of psoriasis. There are signs and symptoms of an inflammatory arthritis often involving the wrists, MCP, PIP, and DIP joints. Exam of the skin reveals psoriasis and psoriatic nail changes.

A

Psoriatic arthritis

424
Q

Patients with these diseases classically have a negative ANA and RF, giving the group the “seronegative” moniker.

A

Psoriatic arthritis

425
Q

Oligoarthritis often involving large joints and the hands. Dactylitis, a swelling of the entire finger causing a “sausage digit” secondary to both arthritis and tenosynovitis, is a classic finding.

A

Psoriatic arthritis

426
Q

Common involvement of DIP joints

Spine involvement that is uncommon in RA

Arthritis mutilans, a syndrome in which there is marked boney destruction around joints causing “telescoping digits.”

A

Psoriatic arthritis

427
Q

most diagnostic feature of psoriatic arthritis is the

A

presence of psoriasis.

428
Q

(pitted, “oil stained” nails).

A

Psoriasis

429
Q

The treatment of psoriatic arthritis is similar to the treatment of

A

RA

430
Q

most commonly seen in middle-aged patients with a symmetric polyarthritis manifesting itself with painful, stiff, and swollen hands. Morning stiffness is often a predominant symptom. Swollen and tender wrists, MCP, and proximal interphalangeal (PIP) joints are usually seen on exam. Laboratory evaluation may reveal an anemia of inflammation and positive RF and anti-citrullinated protein antibody (ACPA, sometimes called anti-CCP).

A

Rheumatoid arthritis (RA)

431
Q

Laboratory evaluation may reveal an anemia of inflammation and positive RF and anti-citrullinated protein antibody (ACPA, sometimes called anti-CCP).

A

Rheumatoid arthritis (RA)

432
Q

Symmetric arthritis of the hands

Presence of serum RF and ACPA

Presence of radiographic changes on hand and wrist radiographs.

Prolonged morning stiffness (> 30–60 minutes) is a classic finding in those with inflammatory arthritis.

A

RA

433
Q

Prolonged morning stiffness is a clue to an

A

inflammatory arthritis

434
Q

Joints commonly involved in RA

A 
hand (wrists, MCP, PIP joints)
Elbow
knee
ankle
cervical spine
435
Q

arthritis that when seen in cervical spine presents as neck pain and stiffness

A

RA

436
Q

what causes joint destruction in RA

A

chronic synovitis causes erosions of bone and cartilage

437
Q

Rheumatoid nodules, when present, are usually over extensor surfaces.

Dry eyes are common.

Pulmonary nodules or interstitial lung disease

Pericardial disease

Asymptomatic pericardial effusion is most common.

Restrictive pericarditis can occur.

Anemia of inflammation

A

RA

438
Q

A positive ACPA is very predictive of a diagnosis of

A

RA

439
Q

ACR criteria

score of >= ____ fulfills the criteria

A

A score of ≥ 6/10 fulfills the criteria of RA

440
Q

what drugs are used to treat RA

A

NSAIDS
Corticosteroids
DMARDS (hydroxychloroquine, methotrexate, leflunomide, sulfasalazine)

Biologic DMARDS (Etanercept, Infliximab, Abatacept, Rituximab)

441
Q

A common course of therapy for RA

A

begin with low-dose prednisone and methotrexate. In patients not adequately controlled, the next step is would be the addition of hydroxychloroquine or biologic, such as etanercept.

442
Q

classically presents as a subacute, oligoarticular arthritis, often involving the knees, ankles, and back. Physical exam reveals arthritis. There may be a history of an antecedent infection and symptoms of urethritis and conjunctivitis.

A

Reactive Arthritis

443
Q

extra-­articular manifestations of Reactive Arthritis

A

enthesitis, tendinitis, bursitis, urethritis, or conjunctivitis.

nail changes, and oral ulcers.

444
Q

Bacteria commonly implicated in reactive arthritis are

A

Shigella

Salmonella

Yersinia

Campylobacter

Chlamydia

445
Q 
history of diarrhea
urethritis
conjunctivitis
fever
arthritis in knees, ankles, feet
A

Reactive arthritis

446
Q

In most patients, symptoms of reactive arthritis resolve within

A

1 year

447
Q

in Reactive arthritispatients with a chronic arthritis, negative traditional cultures, but evidence of persistent chlamydial infection (positive synovial fluid or blood polymerase chain reaction [PCR]) be treated with

A

antibiotics.

448
Q

classically presents in a child in the weeks following streptococcal pharyngitis. The 5 cardinal manifestations are arthritis, carditis, rash, subcutaneous nodules, and chorea. The arthritis is typically migratory, involving the knees, ankles, and hands.

A

Rheumatic fever

449
Q

Rheumatic fever is an inflammatory disease that follows streptococcal pharyngitis by - weeks.

A

2-4

450
Q

in rheumatic fever clinical documentation of a previous streptococcal infection is ___in adults and the most pronounced symptoms are joint pain and stiffness.

A

rare

451
Q

Rheumatic fever may involve what organ in what way

A

any, or all, parts of the heart—pericarditis, myocarditis, endocarditis, or pancarditis.

452
Q

diagnosis of rheumatic fever is based on the

A

Jones Criteria.

453
Q

what is the mainstay of therapy for Rheumatic fever

A

ASA

454
Q

What meds are used in Rheumatic fever

A

ASA
corticosteroids for severe carditis

PCN for strep
lifelong prophylactic therapy with PCN recommended after initial therapy

455
Q

presents as subacute joint pain associated with low-grade fever and progressive pain and disability. Because the infection is usually caused by hematogenous spread, a risk factor for bacteremia (such as injection drug use) is sometimes present.

A

Septic arthritis

456
Q

what joint is the most commonly affected in septic arthritis

A

knee

457
Q

2 most common organisms in order for septic arthritis

A

Staphylococcus aureus

Streptococcus

458
Q

Fever can /cannot distinguish septic arthritis from other forms of monoarticular arthritis.

A

cannot

Patients with gout may be febrile while those with septic joints may not be.

459
Q

Definitive diagnosis for septic arthritis is

A

made by Gram stain and culture of synovial fluid

460
Q

Empiric therapy for septic arthritis should cover

A

S aureus

461
Q

Affected joints in septic arthritis should be

A

drained

462
Q

presents in a young woman with fatigue and arthritis, commonly of the hands. There are often suspicious findings in the history such as an episode of pleuritis or undiagnosed anemia.

A

Systemic Lupus Erythematosus (SLE)

463
Q

a systemic autoimmune disease primarily affecting women of childbearing age.

A

Systemic Lupus Erythematosus (SLE)

464
Q

Almost every organ can be involved, although the joints, skin, serosa, and kidneys are most commonly affected.

A

Systemic Lupus Erythematosus (SLE)

465
Q 
Arthralgia
Rashes
kidney involvement
arthritis
Raynaud phenomenon
CNS involvement (Headaches)
GI (Abd pain)
Lymphadenopathy
Pleurisy
Pericarditis
A

SLE

466
Q

4 or more criteria to standardize diagnosis of ____

malar rash
discoid rash
photosensitivity
oral ulcers
nonerosive arthritis
Serositis (pleuritis or pericarditis)
Kidney disorder (proteinuria, cellular casts)
headache, seizures, psychosis
hemolytic anemia
immunologic disorder 
positive ANA
A

SLE

467
Q

the most sensitive test for SLE. It is nonspecific.

A

ANA

468
Q

Anti-ds-DNA and anti-Sm are highly specific

A

SLE

Lupus nephritis

469
Q

A negative___essentially rules out SLE

A

A negative ANA essentially rules out SLE

470
Q

A positive____ or ____essentially rules in SLE.

A

A positive anti-ds-DNA or anti-Sm essentially rules in SLE.

471
Q

Anti-ds-DNA

A

Nephritis in SLE

472
Q

Anti–Smith

A

SLE

473
Q

Anti-RNP

A

Raynaud phenomenon and myositis in SLE

474
Q

SLE treatment

A

NSAIDs, corticosteroids, and immunosuppressants are the mainstays of therapy

Health Assessment (5 decks)

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