MSK/Rhuem

Question 1

Stress fracture

Answer 1

Pain in forefoot of 2nd-4th, metatarsal bones, sharp, localized, worse with palpation. Insidious onset of pain.

Common in female athlete triad, repetitive activity.

Manage: reduce weight bearing for 4-6 weeks. X ray may be negative.

Question 2

Morton Neuroma

Answer 2

pain in forefoot b/w plantar 3rd and 4th toes + clicking (Mulder sign) when palpating or squeezing.

Question 3

Plantar fasciitis

Answer 3

Burning pain in plantar foot, worsening with first steps in the morning. Decreases with activity, then increases with prolonged weight bearing.

Common in runners due to repetitive microtrauma, localized point tenderness

Question 4

Tarsal tunnel syndrome

Answer 4

Compression of tibial nerve due to fracture of ankle bone.

Sx burning, numbness, ache of distal plantar foot

Question 5

Vertebral osteomyelitis

Answer 5

Risks: IVDU, sickle cell, immunosuppressed
Bugs: staph aureus, gram -
Sx: tenderness to percussion, +/- fever and white count, may have elevated platelets and high ESR
Dx by MRI

Question 6

Ankylosing spondylitis

Answer 6

Back pain in young men, progressive decrease in ROM, worse in morning and improving with activity/day

Insidious onset, age 3 month. Nocturnal pain common..

Assoc with arthritis, sacroiliitis, reduced chest/spinal mobility, tedon insertion inflammation, dactylitis, anterior uveitis

Complications: osteoporosis, vertebral fracture, aortic regurg, cauda equina

Lab: elevated ESR, CRP, HLA-B27

Dx: X ray or MRI of sacroiliac joints

Question 7

Lumbar spinal stenosis

Answer 7

Narrowing of spinal canal, compression of spinal roots.

Age >60.

Pain radiating to butt/thigh, worsen with walking and extension and improve with flexion.

Question 8

Viral arthritis

Answer 8

Acute onset of morning sx, stiffness lasting

Question 9

Giant Cell (Temporal) Arteritis

Answer 9

Sc headache, muscle fatigue, jaw claudication, visual disturbance, scalp tenderness

ESR >50

Associated with aortic aneurism, follow with serial CXR

Associated with PMR

Question 10

Avascular necrosis

Answer 10

Risks: steroid use, alcohol use, SLE, APS, Hemoglobinopathy, osteomyelitis, HIV, transplant, decompression sickness

Sx: groin pain on weight bearing, pain on hip abduction & internal rotation
No erythema, swelling, or point tenderness

Lab: normal WBC, ESR, CRP

Rad: MRI, crescent sign (subchondral lucency) on plain XR if advanced

Question 11

Paget Disease of Bone

Answer 11

Most common cause of asymptomatic elevated alkphos

Sx: headache, hearing loss, spinal stenosis, arthritis/fracture of long bones

Osteoclast dysfunction –> increased bone turnover

Lab: elevated alkphos, PINP, urine hydroxyproline. Ca nad Phos nl

Image: bone scan shows focal increase in uptake, xray shows osteolytic or sclerotic lesions

Tx bisphosphonates

Question 12

Primary Raynaud’s

Answer 12

No underlying cause

Women

Question 13

Secondary Raynaud’s

Answer 13

Connective tissue disease, usually men >40y, with tissue injury

May also be due to occlusive vascular disease sympathomimetic drugs, hyperviscosity syndrome, nicotine

Tx CCB for persistent symptoms, aspirin for pts at risk of ulcers

Question 14

Managing low back pain

Answer 14

Acute: moderate activity, NSAIDS, acetaminophen. Consider muscle relaxants, spinal manipulation

Chronic: intermittent NSAIDs/acetaminophen, exercise therapy, consider TCA or duloxetine

Question 15

Lateral epicondylitis

Answer 15

Tennis elbow.

Tenderness of lateral epicondyle, pain on resisted wrist extension and hand gripping

Question 16

Medial epicondylitis

Answer 16

Golfers elbow

Tenderness of medial epicondyle, pain on resisted wrist flexion

Question 17

Cubital Tunnel Syndrome

Answer 17

Entrapment of ulnar nerve

Pain and sensory/motor loss in ulnar region

Question 18

Olecranon bursitis

Answer 18

“carpet-layers elbow”

Olecranon bursa develops effusion. Extremely tender, but no pain/restriction of ROM

Question 19

OA vs RA joints

Answer 19

OA: DIP
RA: MCP
Both may affect PIP

Question 20

Trochanteric bursitis

Answer 20

Pinpoint source (point with one finger) of hip pain over the greater trochanter of the femur. Pain with abduction of the hip.

Tx with corticosteroid.

Question 21

Meniscal tear

Answer 21

Twisting injury with popping or tearing, then swelling over several hours

Sx: clicking or locking of knee, pain on walking, esp stairs.

McMurray test: audible pop/snap, 97% specific
Pain along joint line: 76% sensitive

Question 22

Anserine bursitis

Answer 22

Focal pain on upper, inner tibia (on anteromedial aspect of lower leg below joint line of knee)

Often assoc with knee OA

Tx corticosteroid injection

Question 23

Patellofemoral pain syndrome

Answer 23

chronic knee pain, women

Anterior knee pain, worse with prolonged sitting and going up/down stairs

Question 24

PMR treatment options

Answer 24

Corticosteroids
Steroid-sparing agents: MTX

infilximab is NOT an effective steroid-sparing agent for PMR

Question 25

Gout

Answer 25

Monosidium urate crystals, needle-shaped Tx NSAIDS, corticosteroids, colchicine NSAIDS highly effective, contraindicated with renal impairment Colchicine most effective in pts with monoarticular involvement, within 24 hours Allopurinol/febuxostat: xanthine oxidase inhibitors, reduce uric acid levels. Do not use in acute attack, but do use to treat hyperuricemia. May use prophylactic colchicine/NSAID/steroid before beginning/adjusting dose to prevent flare

Question 26

Osteoarthritis of knee

Answer 26

Knee pain + age >50, morning stiffness >30min, crepitus, bony tenderness, bony enlargement, absence of palpable warmth XR osteopyts, sclerosis, cyst formation, joint-space narrowing Manage with PT, quadriceps mucle training also weight loss

Question 27

Osteoarthritis of first carpometacarpal joint

Answer 27

Localized tenderness, elicited by "grind test" (movement of thumb in circular motion). Associated with Heberden nodes (DIP) or Bouchard nodes (PIP) Tx: acute OA with NSAID, 2 tx with intraarticular steroid injections

Question 28

De Quervain tenosynovitis

Answer 28

Inflammation of abductor pollicic longus and extensor pollicis brevis Pain on palpation of distal radial styloid, and Finkelstein test: flexing thumb into palm, closing fingers over thumb, and bending wrist in ulnar direction

Question 29

Empiric treatment of CA-septic arthritis with gram + cocci?

Answer 29

Vancomycin (to cover MRSA)

Question 30

Treating early RA

Answer 30

DMARD therapy within 3 months of onset: Hydroxychloroquine Methotrexate (contraindicated with alcohol due to hepatotoxicity) Biologics: TNF alpha inhibitors, etanercept, highest efficacy in combination with MTX

Question 31

HIV associated psoriatic arthritis

Answer 31

exposive onset, widespread psoriasis with dactylitis, DIP involvement, asymmetric joint involvement

Question 32

Enteropathic arthritis

Answer 32

crampy abdominal pain, diarrhea, rectal urgency (IBD) + acute arthritis

Question 33

Whipple disease

Answer 33

Tropheryma wwhippelii Diarrhea, malabsorption, arthritis, CNS sx, constitutional sx joint involvement is chronic and migratory

Question 34

Fibromyalgia

Answer 34

Diffuse pain on both sides of body, above and below waist. 11 of 18 potential tender points. Associated with fatigue, sleep disturbance, dry eyes nad mouth, IBS pelvic pain, mandibular pain

Question 35

Polyarteritis nodosa

Answer 35

Necrotizing inflammation of medium/small arteries renal sx: HTN, renal insufficiency, proteinuria, hematoria dx by sural nerve biopsy, kidney angiography (microaneurysm, beaded pattern of narrowing/dilation on arteries) Biopsy likely to have false negative, high risk of bleeding 2/2 transsection of intrarenal aneurysm

Question 36

Cyclophosphamide

Answer 36

Alkylating agent, used as immunosuppression in SLE and vasculitis with renal or CNS symptoms AE: hemorrhagic cystitis, bladder carcinoma 2/2 acrolein, a toxic metabolite.

Question 37

PMR

Answer 37

Age >50, bilateral pain/morning stiffness involving neck, torso, shoulders, proximal thigh/arm, with constitutional sx Lab: ESR>40, high ERP, may have normocytic anemia Tx glucocorticoids

Question 38

Baker cyst

Answer 38

soft mass in the popliteal fossa, common in RA, OA, and cartilage tears. Occasionally burst, similar appearing to a DVT

Question 39

Felty syndrome

Answer 39

RA + neutropenia (ANC85, no other cause of neutropenia on smear or BM biopsy Associated with severe, seropositive RA with extra-articular manifestations

Question 40

Adult onset still disease

Answer 40

Sx: daily fever, salmon-colored rash, arthritis, multisystem, lymphadenopathy Elevated ferrritin>1000, abnl LFT, negative RF Exclusion of leukemia/lymphoma

Question 41

Pes antine bursitis

Answer 41

Pain along anteromedial aspect of proximal tibia, distal to joint line Worsens with stair climbing and at night

Question 42

Churg-Strauss

Answer 42

Eosinophilia, migratory pulmonary infiltrates, purpuric skin rash, and mononeuritis multiplex Antecedent asthma/rhinitis/sinusitis 40% have p-ANCA opsitive

Question 43

Which vasculitides involve the kidney and lung?

Answer 43

1. Microscopic polyangiitis -- rapidly progressive GN, pulmonary hemorrhage, sometimes mononeuritis multiplex. 2. Granulomatosis with polyangiitis - cavitary pulmonary infiltrates, often hemorrhage 3. Churg Strauss -- lung and kidney PLUS eosinophilia, antecedent atopy, and mononeuritis multiplex. All of these can be ANCA positive.