a) increase the dose of the NSAID
b) order determination of erythrocyte sedimentation rate
c) order determination of rheumatoid factor
d) order x-ray films of the cervical spine
e) refer her for psyciatric counseling

View Answer B: Order ESR

Explanation by Chris:

76 y/o woman presents with "aching" & "weakness" in her arms...
apparently with difficulty raising small objects and perform light
exercise. Pt reports "scalp tenderness." Admits to improvement with
NSAIDs. PMHx is negative. P.E. is apparently unremarkable.
- We should ask for how long as this complaint been present ?
- Its onset ? Duration (constant vs. occasional) ? Weight loss ? H/A ?
************************************
Entities which should arouse our suspicion:
- Rheumatoid Arthritis ??
- Polymialgia Rheumatica
- Giant Cell Arteritis (Temporal Arteritis)
- Polymiositis
************************************
We will first R/O the most common causes first...
- R/A: no joint pain, limitation is noted, and since the PE is
apparently negative, we assume that no nodules our observed as are other
manifestations of R/A -- essentially ruled out.

- PM: the complete PE (including neuro exam) would have detected any
proximal muscle weakness, any tenderness or muscle atrophy...none is
documented, and no skin lesions (ie. knuckles) described... just in case
an associated dermatomyositis were to be expressing itself, thus PE is
relegated to the bottom of the Diff Dx list.

- PMR-GCA: can manifest itself with weakness, usually with the shoulder
girdle being most affected (A point in favor), improvement with NSAIDs
(A point in favor), and scalp tenderness (A point in favor)... WE ARE
OBLIGED TO INTERROGATE FOR H/A AND JAW CLAUDICATION (ie. during chewing)
..but MOST IMPORTANTLY... LOSS OF VISON !!!
$ BTW Some researches have postulated that PMR and GCA are the same
disease process, but different stages.

*************************************
We now seem to have our culprit... PMR - GCA. Therefore (B) "ESR" is
the best answer, although I believe that we would all agree to begin a
course of prednisone stat before the patho report of an obligated
temporal artery biopsy were available.

- Chris

17. (17-18) A 38 year old homemaker and mother of four children (ages 5-12 years) has been coming to you for tension headaches that have not improved much with trials of several appropriate medications. She has been married to a policeman for the past 6 years. You ask if she has been under extra stress, and she begins to cry. You notice bruises on her arms. On further questioning, you learn that her husband hits her whenever he is drunk, which is at least 2 nights per week. She syas, "he is nice...a good husband when he's sober. But when he drinks, oh he's awful! He accuses me of cheating on him. Last night he said he would kill me if I try to leave." Her husband is also a patient of yours.

17. The most appropriate intervention would be to

a) advise her to leave her home with her children and move in with her relatives
b) contact her husband's supervisor to discuss recent stress levels on the job
c) gather more information while remaining neutral, since both the husband and wife are your patients
d) refer her to a battered women's program
e) seek a restraining order against her husband on her behalf

View Answer d: Refer her to a battered women's program

18. The most vital question to ask at this time is:

a) "Do you think this might be causing your headaches?"
b) "Has your husband also lost his temper with any of the children?"
c) "Have you been drinking at the time of the fights?"
d) "Have you or your husband been receiving any kind of counseling?"
e) "Why have you stayed in this marriage?"

View Answer B: Has your husband lost his tember with any of the children

20. On physical examination there is most likely to be

a) increased anterior laxity with anterior pressure on the tibia
b) increased posterior laxity with posterior pressure on the tibia
c) a painful clicking sensation with inward rotation of the foot and extension of the knee
d) pain during forced abduction of the leg below the knee
e) pain during internal and external rotation of the tibia while compressing it against the femur

View Answer D: Pain during forced abduction of the leg below the knee

 

21. The most accurate statement concerning this patient's condition is that he will need

a) to choose a different type of activity for his exercise program
b) initial treatment with rest, ice packs and isometric exercises
c) treatment with knee immobilizaton and crutches
d) referral for an orthotic device
e) referral for arthroscopy

View Answer B: Initial treatment with rest, ice packs and isometric exercises

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