NMS Q&A Family Medicine

Rheumatology in Primary Care 16710. The answer is B. To test for Ehlers–Danlos syndrome,one should assess for passive hyperextension at the knee,elbow, and MCP joints. There are no characteristic jointdeformities or effusions in patients with Ehlers–Danlossyndrome, although many affected patients can develop asecondary osteoarthritis. In fact, the greatest morbidityover time is osteoarthritis.11. The answer is E. Plantar fasciitis is well described inthis vignette. Ten percent of the U.S. population suffersfrom this malady at some time in their lives. Calcanealepiphysitis causes heel pain in adolescents but no plantarpain. Lumbar radiculopathy causes referred pain thatradiates from the lumbar area to the foot when it isreferred to that extent. Referred pain is not aggravated bylocal factors. Osteomalacia is a systemic disease that causesbone pain in multiple sites and total body weakness. Thepain of claudication is made worse by exercise and, wheninvolving the lower extremities, generally is felt in the calf,more than the foot proper. Plantar fasciitis is worst afterinactivity, usually improving with usage.12. The answer is B. Fibromyalgia is a diagnosis of exclusion.The two themes that appear consistently are multiplemusculoskeletal pains without weakness and sleepdysfunction. Patients affected with fibromyalgia usuallyhave decreased delta-wave sleep on sleep studies. There isno physical or laboratory evidence of joint inflammationin these patients and no documentable neuropathies,even though patients frequently complain of paresthesias.NSAIDs are only useful if the patient has somesuperimposed osteoarthritis or other NSAID-responsivecondition.13. The answer is C. Osteoarthritis is more likely to beseen if significant trauma has occurred to the affectedjoint. Osteoarthritis is frequently asymptomatic for years.The typical stiffness of osteoarthritis lasts less than 5 minutes.Women are more likely to have more severe diseasethan men, with increased numbness of joints involvedand deformities. Both passive and active range of motionproduces pain in the involved joint. Besides osteophyticspurs, hence the name osteoarthritis, x-ray findings mayinclude asymmetrical joint spaces. Osteoarthritis mayexist without symptoms. However, such cases have a wayof popping into view with precipitating trauma, whichmay be relatively mild in and of itself.14. The answer is E. In gout, aspirated joint fluid showsnegatively birefringent, needle-shaped crystals withinWBCs when viewed with a polarizing microscope. It istrue that the vast majority of patients who present withisolated acute first MTP joint pain will have gout. However,such a description of pain is not 100% specific forgout. Many patients have hyperuricemia (from overproductionor underexcretion) and yet never have attacks ofgouty arthritis. Septic joints are also erythematous withfever and serum leukocytosis.15. The answer is A. Its incidence is increased withadvanced patient age. CPDD, especially in its idiopathicform, is seen more with increasing age. CPDD is also associatedwith hyperparathyroidism, gout, hypothyroidism,and hemochromatosis. It is more likely to be polyarticularthan gout is, and it does not have a predilection for theweight-bearing joints.MATCHING THE NUMBERED CAUSES WITHTHE LETTERED DESCRIPTIONS16. Fat pad atrophy: The answer is E, pain in the area ofa thinned plantar aspect of the heel.17. Heel contusion: The answer is D, history of trauma.18. Plantar fascia rupture: The answer is C, intense tearingsensation on the bottom of the foot.19. Posterior tibial tendonitis: The answer is B, pain inthe inside of the foot and ankle.20. Retrocalcaneal bursitis: The answer is A, the pain isretrocalcaneal.ReferencesChokkalingam S , Velasquez C , Mody A , et al. Diagnosing monoarthritisin adults: A practical approach for the family physician. Am Fam Physician. 2003 ; 68 : 83 – 90 .Cole C , Seto C , Gazewood J . Plantar fasciitis: Evidence basedreview of diagnosis and therapy . Am Fam Physician. 2005 ;72 : 2237 – 2242 , 2247 – 2248 .Derk CT , Vivino FB . A primary care approach to Sjogren’s syndrome. Postgrad Med. 2004 ; 116 : 48 – 65 .Emery P , Suarez-Almazor , ME . Rheumatoid arthritis . Am FamPhysician. 2003 ; 68 : 1821 –1823.Family Medicine Board Review . Kansas City, Missouri ; May3–10; 2009 .Seigel LB , Gall EP . Approach to the patient with rheumatic disease. In: Rudy DR , Kurowski K , eds. Family Medicine: HouseOfficer Series . Baltimore : Williams & Wilkins ; 1997 : 413 – 438 .