Np Test 5: Musculoskeletal

People with gouty arthritis are advised to avoid foods high in purine because purine is broken down into uric acid in the body. High levels of uric acid can lead to the formation of urate crystals, which can accumulate in the joints and cause painful inflammation. Therefore, avoiding purine-rich foods can help reduce the risk of gout attacks and manage the symptoms of gouty arthritis.

Loss of bowel and bladder control in a patient with low back pain is a red flag symptom that suggests cauda equina syndrome. Cauda equina syndrome is a rare but serious condition caused by compression of the nerve roots at the end of the spinal cord. It can result in severe neurological symptoms, including weakness or paralysis of the legs, numbness in the groin area, and loss of bowel and bladder control. Immediate medical attention is necessary to prevent permanent damage, and surgical intervention may be required to relieve the compression and restore function.

Joint overuse is the most common cause of acute bursitis. Bursitis occurs when the bursae, which are small fluid-filled sacs that cushion the joints, become inflamed. This inflammation is often a result of repetitive motions or excessive stress on the joints. Joint overuse can lead to irritation and inflammation of the bursae, causing acute bursitis. Inactivity, fibromyalgia, and bacterial infection are not typically associated with the development of acute bursitis.

The correct answer is "Greatest swelling and pain along the median border of the joint." In acute gouty arthritis, the affected joint, in this case, the base of the great toe, shows characteristic symptoms. The swelling and pain are most prominent along the median border of the joint. This is a distinguishing feature of gouty arthritis and helps differentiate it from other causes of joint pain. The slow onset of discomfort over many days and improvement of symptoms with joint rest are also common features of gouty arthritis. However, the presence of fever is not typically associated with gouty arthritis.

The Tinel test is a diagnostic test used to assess for nerve compression or injury. It involves tapping or percussing the affected area along the course of a nerve. In the case of the Tinel test for the median nerve, abnormal tingling or a "pins and needles" sensation is elicited when the nerve is tapped. This abnormal tingling suggests nerve irritation or compression along the pathway of the median nerve. The test helps to identify conditions such as carpal tunnel syndrome, where the median nerve is compressed at the wrist.

Joint aspiration is not typically part of the initial treatment for a meniscal tear. Initial treatment usually focuses on reducing pain and inflammation, which can be achieved through the use of NSAIDs, applying ice, and elevating the affected joint. Joint aspiration, on the other hand, involves removing fluid from the joint using a needle and syringe, and it is typically done for diagnostic or therapeutic purposes in certain conditions, but not for the initial treatment of a meniscal tear.

In patients with osteoarthritis (OA), narrowing of the joint space on a radiograph is a common finding. This narrowing occurs due to the degeneration of cartilage in the joint, leading to a reduction in the space between the bones. It is a characteristic feature of OA and helps in confirming the diagnosis. Anemia of chronic disease, elevated CRP level, and elevated antinuclear antibody (ANA) test are not specific to OA and may be seen in other conditions as well. Therefore, the presence of narrowing of the joint space on a radiograph is the most anticipated finding in patients with OA.

In caring for a patient with OA of the knee, it is advised to perform quadriceps-strengthening exercises. This is because strengthening the quadriceps muscles helps to stabilize and support the knee joint, reducing stress on the joint and improving overall function. These exercises can help to alleviate pain, improve mobility, and slow down the progression of OA. Straight-leg raising should be avoided as it can put excessive strain on the knee joint. Heat should be applied to painful joints after exercise to help relax muscles and reduce pain. Physical activity should not be avoided completely, but rather modified to accommodate the patient's condition and limitations.

The correct answer is symmetrical early-morning stiffness. This is because one of the hallmark symptoms of rheumatoid arthritis (RA) is stiffness in the joints, particularly in the morning. This stiffness is often symmetrical, meaning it affects the same joints on both sides of the body. This presentation is characteristic of RA and helps differentiate it from other forms of arthritis. The other options listed in the question, such as worst symptoms in weight-bearing joints later in the day or sausage-shaped digits with characteristic skin lesions, are not typically associated with RA.

The likely sequelae of intrabursal corticosteroid injection include soreness at the site of injection. This is because the injection can cause localized irritation and inflammation, leading to discomfort and soreness in the area where the injection was administered. However, the other options such as irreversible skin atrophy, infection, and inflammatory reaction are less likely to occur as sequelae of this specific type of injection.

Glucosamine and chondroitin are OTC nutritional supplements that are commonly used to manage osteoarthritis (OA). OA is a degenerative joint disease that causes the breakdown of cartilage in the joints. These supplements are believed to help reduce pain and improve joint function in individuals with OA. While they may provide some relief for other types of arthritis, such as rheumatoid arthritis, Reiter syndrome, or gouty arthritis, their primary use is for managing OA.

Quadriceps-strengthening exercises can help prevent a meniscal tear because the quadriceps muscles play a crucial role in stabilizing the knee joint. Strengthening these muscles can help improve overall knee stability and reduce the risk of injury. This is why advising individuals to engage in quadriceps-strengthening exercises is an effective preventive measure against meniscal tears. Limiting participation in sports, using a knee brace, and applying ice to the knee before exercise may have their benefits, but they do not specifically target the strengthening of the quadriceps muscles.

The correct answer is "Reproduction of symptoms with forced flexion of the wrists." This is because the Phalen test is a diagnostic test used to assess for carpal tunnel syndrome. In this test, the patient is asked to forcefully flex their wrists and hold them in that position for a minute. If the patient experiences tingling, numbness, or pain in the median nerve distribution (thumb, index, middle, and half of the ring finger), it suggests a positive test and indicates possible carpal tunnel syndrome. Therefore, the reproduction of symptoms with forced flexion of the wrists is the characteristic feature of the Phalen test.

Joint splinting is the initial therapy for patients with CTS because it helps to immobilize the affected joint, reducing pressure on the median nerve. This can help alleviate symptoms such as pain, numbness, and tingling in the hand and fingers. Splinting also promotes rest and allows for the inflammation to subside. Intra-articular injections and systemic corticosteroids may be used as additional treatment options if splinting alone is not sufficient. Referral for surgery is typically considered if conservative measures fail to provide relief.

The straight leg raising test is used to evaluate tension on the L5 and S1 nerve roots. This test involves raising the patient's leg while keeping it straight, which stretches the sciatic nerve. If the patient experiences pain or discomfort in the lower back or leg during this test, it suggests irritation or compression of these specific nerve roots.

NSAIDs cause gastric injury primarily by thinning the protective gastric mucosa. The protective gastric mucosa acts as a barrier between the stomach lining and the acidic gastric contents. NSAIDs inhibit the production of prostaglandins, which are responsible for maintaining the integrity of the gastric mucosa. This inhibition leads to a decrease in the production of protective mucus and bicarbonate secretion, making the gastric mucosa more susceptible to injury from the acidic environment. As a result, NSAIDs can cause gastric ulcers and other gastrointestinal complications.

Elevated levels of rheumatoid factor are the most specific test for the diagnosis of rheumatoid arthritis (RA). Rheumatoid factor is an antibody that is present in the blood of many individuals with RA. While it is not present in all cases of RA, its presence is highly indicative of the disease. Abnormally high ESR (erythrocyte sedimentation rate) and depressed total white blood cell count can be seen in various inflammatory conditions, not just RA. Positive ANA (antinuclear antibody) titer can also be found in other autoimmune diseases, not specifically RA. Therefore, elevated levels of rheumatoid factor are the most specific to the diagnosis of RA.

The correct answer is L4 to L5 and L5 to S1. Lumbar disc herniation refers to the displacement of the intervertebral disc in the lumbar spine, causing compression of the spinal nerves. The most common sites for lumbar disc herniation are the L4 to L5 and L5 to S1 levels. These levels are located in the lower back, where the lumbar spine meets the sacrum. Herniation at these levels can result in symptoms such as lower back pain, leg pain, and numbness or weakness in the lower extremities.

The first-line treatment options for bursitis usually include NSAIDs. NSAIDs are nonsteroidal anti-inflammatory drugs that help reduce inflammation and relieve pain. They work by inhibiting the production of prostaglandins, which are responsible for causing inflammation and pain. By reducing inflammation, NSAIDs can help alleviate the symptoms of bursitis and promote healing. They are often recommended as an initial treatment because they are easily accessible, have a low risk of side effects, and can provide effective relief for many individuals with bursitis.

The 72-year-old man who takes aspirin 4 times a day for control of OA is at the highest risk for NSAID-induced gastropathy. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can cause damage to the lining of the stomach and increase the risk of gastrointestinal bleeding. The fact that he takes aspirin four times a day suggests that he is using a high dose, which further increases his risk. Additionally, his age may also contribute to a higher risk as older individuals are generally more susceptible to the adverse effects of NSAIDs on the gastrointestinal system.

Joint erosions are often evident on radiographs or MRI in patients with rheumatoid arthritis (RA). This is because RA is a chronic autoimmune disease that primarily affects the joints, leading to inflammation, synovial hypertrophy, and destruction of cartilage and bone. Radiographs and MRI scans can show characteristic signs of joint erosions, such as narrowing of joint spaces, bone destruction, and soft tissue swelling. These imaging modalities are useful in diagnosing and monitoring the progression of RA, as well as assessing the effectiveness of treatment interventions.

The patient's symptoms of decreased tearing, "gritty"-feeling eyes, and a dry mouth are consistent with Sjogren syndrome. Sjogren syndrome is an autoimmune disorder that primarily affects the salivary and lacrimal glands, resulting in dry mouth and dry eyes. It commonly occurs in patients with rheumatoid arthritis (RA), which the patient already has. Systemic lupus erythematosus and vasculitis can cause similar symptoms, but the combination of dry eyes and dry mouth is more characteristic of Sjogren syndrome. Scleroderma can also cause dry eyes and dry mouth, but it typically presents with other symptoms such as skin thickening and Raynaud phenomenon.

An MRI (Magnetic Resonance Imaging) test yields the greatest amount of information in a patient with acute lumbar radiculopathy. This is because an MRI provides detailed images of the soft tissues, bones, and nerves in the lumbar spine. It can help identify the specific cause of the radiculopathy, such as a herniated disc or nerve compression, and provide information about the severity and extent of the condition. In contrast, a lumbosacral radiograph series only provides images of the bones and may not show soft tissue abnormalities. ESR measurement and bone scan are not specific tests for lumbar radiculopathy and may not provide as much detailed information as an MRI.

Thiazide diuretic use is a risk factor for acute gouty arthritis. Thiazide diuretics are commonly prescribed medications for hypertension and can increase the levels of uric acid in the blood, leading to the development of gout. Uric acid is a waste product that is normally excreted by the kidneys, but thiazide diuretics can interfere with this process, causing uric acid to accumulate in the joints and form crystals, triggering an inflammatory response and resulting in gouty arthritis. Therefore, individuals who are taking thiazide diuretics are at an increased risk of developing acute gouty arthritis.

Patients with osteoarthritis (OA) typically experience worsening symptoms in weight-bearing joints later in the day. This is because the joints have been subjected to increased stress and activity throughout the day, leading to inflammation and pain. The other options do not accurately describe the presentation of a patient with OA. Symmetrical early morning stiffness is more characteristic of rheumatoid arthritis, sausage-shaped digits with skin lesions are seen in psoriatic arthritis, and back pain with rest and anterior uveitis are more commonly associated with ankylosing spondylitis.

Spurling test is demonstrated when the examiner applies pressure to the top of the head with the neck bending forward, producing pain or numbness in the upper extremities. This test helps in diagnosing cervical radiculopathy, a condition where the nerves in the neck are compressed or irritated, leading to symptoms such as pain, weakness, or numbness in the upper extremities.

Patients with olecranon bursitis typically present with swelling and redness over the affected area. This is because olecranon bursitis is inflammation of the bursa, a small fluid-filled sac located at the tip of the elbow. Inflammation causes fluid to accumulate in the bursa, leading to swelling and redness. Other symptoms may include limited range of motion (ROM) of the elbow, but nerve impingement and destruction of the joint space are not typically associated with olecranon bursitis.

Lateral epicondylitis, also known as tennis elbow, is a condition characterized by inflammation and pain on the outside of the elbow. Risk factors for this condition typically include activities that involve repetitive movements and strain on the tendons in the forearm. Playing tennis and hammering are both examples of activities that can contribute to the development of lateral epicondylitis. However, gout is a type of arthritis caused by the buildup of uric acid crystals in the joints and is not directly associated with the development of tennis elbow. Therefore, gout is the exception among the given options.

Bouchard nodes are a deformity of the proximal interphalangeal joints that are commonly found in elderly patients with osteoarthritis (OA). These nodes are bony enlargements that develop on the middle joints of the fingers, causing pain, stiffness, and limited range of motion. Unlike Heberden nodes, which affect the distal interphalangeal joints, Bouchard nodes specifically affect the proximal interphalangeal joints. Hallus valgus refers to a deformity of the big toe, and Dupuytren contracture is a condition that causes the fingers to bend inward.

During the use of hydroxychloroquine sulfate, a dilated eye retinal exam should be periodically obtained. This is because hydroxychloroquine can cause retinal toxicity, which can lead to irreversible vision loss. Therefore, regular eye exams are necessary to monitor for any signs of retinal damage and to ensure early detection and intervention if needed.

Loss of posterior tibial reflex may indicate a lesion at L5. The posterior tibial reflex is mediated by the S1 nerve root, which is responsible for the ankle jerk reflex. However, the reflex arc also involves the L5 nerve root, which carries the afferent impulses from the muscle spindle to the spinal cord. Therefore, if there is a lesion at the L5 level, it can disrupt the reflex arc and lead to the loss of the posterior tibial reflex.

Patients with subscapular bursitis typically present with localized tenderness under the superomedial angle of the scapula. This is a characteristic symptom of subscapular bursitis, which is inflammation of the bursa located between the subscapularis muscle and the scapula. Limited shoulder range of motion may also be present due to pain and inflammation. Heat over the affected area is another common symptom, as inflammation often leads to increased blood flow and warmth in the affected area. However, cervical nerve root involvement is not typically associated with subscapular bursitis.

A complete median meniscus tear refers to a tear in the cartilage in the middle of the knee joint. This tear can cause instability and pain in the knee, making it difficult for the patient to kneel. Therefore, the best description of the presentation of a patient with a complete median meniscus tear is the inability to kneel.

Most episodes of low back pain are caused by muscle or ligamentous strain. This is because the muscles and ligaments in the back can be easily strained or injured due to factors such as poor posture, lifting heavy objects incorrectly, or sudden movements. These strains can lead to inflammation and pain in the affected area. While disk herniation and nerve impingement can also cause low back pain, they are less common causes compared to muscle or ligamentous strain.

Loss of the posterior tibial reflex is a clinical finding that suggests a problem with the L5 nerve root. The posterior tibial reflex is mediated by the S1 nerve root, but the absence of this reflex indicates a lesion at a higher level, specifically at the L5 level. Lesions at the L3, L4, or S1 levels would not directly affect the posterior tibial reflex, making L5 the most likely location for the lesion causing the loss of this reflex.

Loss of Achilles tendon reflex most likely indicates a lesion at the level of L5 to S1. The Achilles tendon reflex is mediated by the S1 nerve root, which is responsible for the contraction of the calf muscles when the Achilles tendon is tapped. Therefore, if there is a lesion at the level of L5 to S1, it can affect the function of the S1 nerve root and result in the loss of this reflex.

The correct answer is early use of disease-modifying antirheumatic drugs (DMARDs) to slow or halt joint damage. This principle is based on the understanding that early intervention with DMARDs can help slow down the progression of joint damage in patients with rheumatoid arthritis (RA). DMARDs are a class of medications that work to suppress the immune system and reduce inflammation, thereby preventing further damage to the joints. By starting DMARD therapy early, healthcare providers aim to minimize joint destruction and improve long-term outcomes for patients with RA.

Medial epicondylitis, also known as golfer's elbow, is a condition characterized by pain and inflammation on the inner side of the elbow. The answer "Golf" is correct because golf involves repetitive swinging motions, which can put stress on the tendons and muscles in the forearm. The forceful impact between the golf club and the ball can strain the tendons, leading to the development of golfer's elbow. Playing other sports like tennis, baseball, or volleyball may also involve repetitive arm movements, but golf is specifically associated with this condition.

The given answer, "Peak age for disease onset in individuals age 50 to 70 years," is not characteristic of rheumatoid arthritis (RA). Rheumatoid arthritis typically affects individuals between the ages of 30 and 50, with a peak onset in the 40s. The disease is more common in women at a 3:1 ratio, and a family history of rheumatoid disease is often reported by patients. Additionally, RA commonly affects the wrists, ankles, and toes.

Patients with gluteus medius or deep trochanteric bursitis typically present with increased pain from resisted hip abduction. This is because the gluteus medius muscle is responsible for hip abduction, and when it is inflamed or irritated, resisted abduction can exacerbate the pain. Limited hip range of motion may also be present due to the pain and inflammation. Sciatic nerve pain and heat over the affected area are not typically associated with gluteus medius or deep trochanteric bursitis.

Stretching and toning exercises are included in the primary prevention of carpal tunnel syndrome (CTS) because they help to improve flexibility and strength in the muscles and tendons of the wrist and hand. By doing these exercises regularly, it can help to reduce the risk of developing CTS by keeping the wrist and hand in proper alignment and reducing strain on the median nerve. Additionally, these exercises can also help to improve blood circulation and reduce inflammation in the wrist, further preventing the development of CTS.

During an acute lumbosacral strain, it is generally recommended to avoid exercising until you are free of pain. However, once the pain subsides, back-strengthening exercises can be beneficial. These exercises may cause mild muscle soreness initially, which is normal and expected. It is important to start conditioning exercises gradually and under the guidance of a healthcare professional to prevent further injury and promote healing.

Naproxen sodium is the correct answer for first-line therapy in treating patients with acute gouty arthritis. This medication is a nonsteroidal anti-inflammatory drug (NSAID) that helps reduce pain, inflammation, and swelling associated with gout attacks. It works by inhibiting the production of certain chemicals in the body that cause inflammation. Naproxen sodium is commonly prescribed for acute gouty arthritis due to its effectiveness in relieving symptoms and its relatively low risk of side effects compared to other NSAIDs. Aspirin, allopurinol, and probenecid are not recommended as first-line therapies for acute gouty arthritis.

A 66-year-old patient with a gastric ulcer is the best candidate for local corticosteroid injection because systemic corticosteroids, which are commonly used to treat acute gouty arthritis, can worsen gastric ulcers. Local corticosteroid injections target the affected joint directly, providing relief without affecting the gastric ulcer. This treatment option minimizes the risk of exacerbating the gastric ulcer and ensures effective management of the gouty arthritis symptoms.

Osteoarthritis is a degenerative joint disease that commonly affects weight-bearing joints such as the knees and hips. However, in this question, the most likely joint to be affected by osteoarthritis is the distal interphalangeal joint. This joint is located at the end of the fingers and is frequently affected by osteoarthritis, especially in older individuals. Osteoarthritis in the distal interphalangeal joint can cause pain, stiffness, and swelling, making it the most likely joint to be affected in this scenario.

The first-line pharmacological intervention for milder OA should be a trial of Acetaminophen. Acetaminophen is a commonly used medication for pain relief and is considered a safe and effective option for managing mild to moderate osteoarthritis pain. It works by reducing pain signals in the brain and is generally well-tolerated with minimal side effects. Other options like Naproxen, Celecoxib, and intra-articular corticosteroid injections may be considered for more severe cases or when acetaminophen does not provide sufficient pain relief.

Reactive arthritis, also known as Reiter syndrome, is typically caused by an infection in another part of the body, such as the urinary tract or gastrointestinal tract. Therefore, the most appropriate treatment for reactive arthritis in a sexually active man would involve antimicrobial therapy to target and eliminate the underlying infection. This can help alleviate the symptoms and prevent further complications. Corticosteroid therapy, antirheumatic medications, and immunosuppressive drugs may be used in some cases to manage inflammation and pain, but they are not the primary treatment for reactive arthritis.

COX-1 is an enzyme that plays a crucial role in the production of prostaglandins, which are important for maintaining the integrity of the gastric mucosal layer. This layer acts as a protective barrier in the stomach, preventing the acidic gastric juices from damaging the underlying tissues. COX-1 inhibitors, such as aspirin, can disrupt the production of prostaglandins and increase the risk of gastric ulcers and bleeding. Therefore, COX-1 contributes to the maintenance of the gastric protective mucosal layer.

COX-2 is an enzyme that is involved in the production of prostaglandins, which are important mediators of inflammation and pain. It is also responsible for renal arteriole constriction, which helps regulate blood flow to the kidneys. However, COX-2 does not play a role in the maintenance of the gastric protective mucosal layer. This layer is primarily maintained by other factors such as mucus production and bicarbonate secretion.

Patients with lateral epicondylitis typically present with decreased hand grip strength. Lateral epicondylitis, also known as tennis elbow, is a condition characterized by inflammation and pain in the tendons that attach to the lateral epicondyle of the humerus. This inflammation can lead to weakness in the muscles responsible for gripping objects, resulting in decreased hand grip strength. Other common symptoms of lateral epicondylitis include pain that is worsened with elbow flexion, reduced joint range of motion, and tenderness over the lateral epicondyle. However, the most specific and characteristic finding is the decreased hand grip strength.