NMS Q&A Family Medicine

166 NMS Q&A Family MedicineExamination Answers1. The answer is B. Elevated serum albumen is not a poorprognostic sign. In fact, low albumen is one of the factorsthat presage a poor prognosis. Each of the other choices isassociated with poor survival prognosis; other poor prognosticsigns besides those given include anemia andrefractoriness to therapy.2. The answer is D. Uric acid level 7.5 mg/dL, althoughpresent at some point (75% of the time in a given patient)in 95% of cases, in itself it is not an indication for uric acidlowering agents. Each of the other factors is such an indication(number of attacks/2 years or more).3. The answer is D. One hour of morning stiffness; threeswollen joints; joint erosions on XR; rheumatoid nodules.Specifically, the diagnosis can be made by presence of anyfour of seven criteria – those of choice D and the three inchoice E: more than 6 weeks of symptoms; hand involvement,symmetric involvement. Early diagnosis of RA preventssuffering, deformity, progression, and it alsoprolongs life and improves quality of life. The mechanismfor prolonging life in large part is preventing stroke andheart disease by decreasing inflammation and thereby stabilizingplaques rendering them less likely to rupture andocclude vessels.4. The answer is E. At the point at which this patiententers the system, the patient presents with a monoarthralgiathat may or may not be a monoarthritis. Monoarthritisis defined as arthritis existing in one joint for morethan a few days. The first priorities are to obtain a completehistory and physical examination to ascertain thatthe pain indeed originates in the (knee) joint. If a determinationis made that monoarthritis exists, then plainx-rays and joint aspiration should be obtained, along withbasic laboratory studies (complete blood cell count, sedimentationrate, and uric acid level), before a magneticresonance imaging study is ordered. Many patients complainof pain in the regions of joints whose pains are nottruly arthralgias.5. The answer is D. Gonococcal arthritis is the mostcommon form of nontraumatic monoarthritis. It is threetimes as common in women as in men. RA may passbriefly through a monoarticular phase but generallyaffects joints in a symmetrical fashion. Nongonococcalarthritis is most often caused by Staphylococcus aureusand is much more destructive to the joint than is gonococcalarthritis. It is also monoarticular in 80% of casesand most often affects the knee. Osteoarthritis of severityto produce an effusion would be unusual in a youngwoman without significant history of trauma.6. The answer is A. Monoarticular septic arthritis (asopposed to traumatic arthritis or gout, among others) inwhich Gram-negative or anaerobic bacteria, Lyme disease,or tuberculosis organisms grow from joint fluid, must beinvestigated for the possibility of immunodeficiency.7. The answer is D. Cox-2 NSAIDs are not disease modifying,although they are anti-inflammatory as well asanalgesic. Each of the other drugs or categories is diseasemodifying. Other DMARDs besides those mentionedinclude leflunomide, methotrexate, azathioprine, penicillamine,and sulfasalazine as well as other tumor necrosisfactor (TNF) antagonists besides etanercept and otherantimalarials besides hydroxychloroquine.8. The answer is E . The Schober test. This is a test ofmobility of the spine, performed by marking the spinousprocess of L5 and marking at a point 10 cm above the L5spine. The patient is directed to bend forward, and normally,the two marks are observed to move apart by 5 cmor more. Although the test is nonspecific, when back painexists in the presence of spine immobility and extraarticularmanifestations, the Schober test may clinch thediagnosis of ankylosing spondylitis. The differential diagnosisincludes, besides ankylosing spondylitis, reactivearthritis (Reiter syndrome) as well as psoriatic arthritis.The eponym Schober test in this case is more convenientthan a descriptive term; therefore, the student will expectto hear mention of the Schober test in practice and training.An upper motor neuron sign such as the Babinski ishardly likely in the vignette presented. The Murphy andRovsing signs are relevant in the surgical diagnosis ofabdominal pain, and the Schirmer test is for adequacy oflacrimal response in the eye.9. The answer is A. The retrocalcaneal would be the locationof pain in the foot area associated with ankylosingspondylitis. Two common sites of inflammation of theattachment of tendon to bone (enthesitis) in ankylosingspondylitis are the Achilles tendon at the calcaneus andplantar fascia at the calcaneus. Enthesitis occurs also withReiter syndrome and psoriatic arthritis, but not withspondyloarthropathy related to inflammatory boweldisease.