Musculoskeletal 1: The Audio PANCE and PANRE Board Review Podcast Topic Specific Review Episode 37

Welcome to episode 37 of the FREE Audio PANCE and PANRE Physician Assistant Board Review Podcast.

Join me as I continue to cover topic specific PANCE and PANRE review from the Academy course content following the NCCPA™ content blueprint.

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This week we will be covering 10 topic specific Musculoskeletal board review questions.

The Musculoskeletal System accounts for 10% of your PANCE/PANRE board exam.

Below you will find an interactive exam to complement the podcast.

I hope you enjoy this free audio component to the examination portion of this site. The full genitourinary board review includes over 72 GU specific questions and is available to all members of the PANCE and PANRE Academy.

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Musculoskeletal PANCE and PANRE Podcast Quiz

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Question 1

Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle?

A	Supraspinatus
B	Infraspinatus Hint: Lateral rotation against resistance tests the infraspinatus and teres minor.
C	Teres minor Hint: See B for explanation.
D	Subscapularis Hint: Medial rotation against resistance tests the subscapularis.

Question 1 Explanation:

Abduction against resistance tests the supraspinatus.

Question 2

A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 15 degrees of flexion and external rotation at the hip. Which of the following knee maneuvers does this represent?

A	Abduction stress test Hint: The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress.
B	Anterior drawer sign Hint: The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however, the patient is supine,
C	Lachman test
D	McMurray test Hint: The McMurray test is performed to evaluate medial and lateral meniscal tears while rotating the lower leg internally and externally.

Question 2 Explanation:

The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 15 degrees of flexion and external rotation of the hip.

Question 3

A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is the most striking and consistent abnormality of which of the following?

A	Spondylolysis Hint: Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.
B	spondylolisthesis Hint: Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.
C	Scoliosis
D	Herniated disc Hint: Herniated disc presents with lumbar muscle spasm and a positive straight leg test.

Question 3 Explanation:

Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.

Question 4

Physical exam findings in a 4 year-old child that include blue sclera and recurrent fractures indicates which of the following

A	Ehlers-Danlos syndrome Hint: Physical exam findings in Ehlers-Danlos include laxity and hypermobility of joints, mitral valve prolapse, and associated degenerative arthritis.
B	Marfan syndrome Hint: Children with Marfan syndrome have hypotonia, arachnodactyly, joint laxity and dislocations.
C	Achondroplasia Hint: Children with achondroplasia are below normal standards on growth charts. They have difficulty balancing their large heads when beginning to walk.
D	Osteogenesis imperfecta

Question 4 Explanation:

Mild osteogenesis imperfecta presents with blue sclera, history of recurrent fractures and presenile deafness.

Question 5

A 65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine?

A	Radiolucent lesions Hint: Paget's disease of bone presents with bone pain, kyphosis, bowed tibias, large head, and deafness. The initial lesions are destructive and radiolucent. Paget's disease has a normal serum calcium and phosphate, but the serum alkaline phosphatase is elevated.
B	Demineralization
C	Chondrocalcinosis Hint: Chondrocalcinosis is the presence of calcium-containing salts in articular cartilage and is commonly seen in hyperparathyroidism, diabetes, hypothyroidism, and gout.
D	Subperiosteal resorption Hint: Hyperparathyroidism is frequently asymptomatic. Serum parathyroid hormone and serum calcium are elevated. X-ray findings include demineralization, subperiosteal resorption of bone especially in the radial aspects of the fingers.

Question 5 Explanation:

Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. X- ray findings demonstrate demineralization in the spine and pelvis.

Question 6

In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is

A	lateral
B	oblique Hint: The oblique view is usually not included in the initial set of x-rays taken. Bilateral supine oblique is a view that may be ordered if all seven cervical vertebrae are not seen on the lateral view.
C	anteroposterior Hint: Anteroposterior view shows < 1% of significant injuries.
D	odontoid Hint: The odontoid view reveals 10% of significant injuries.

Question 6 Explanation:

The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.

Question 7

A 38-year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done?

A	X-ray of the lower leg and ankle Hint: X-rays of the lower leg and ankle will only determine bone placement.
B	Doppler studies Hint: Doppler studies will confirm the presence of a decreased pulse.
C	Bone scan Hint: A bone scan is not indicated in the evaluation of compartment syndrome.
D	Compartment pressure

Question 7 Explanation:

Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.

Question 8

A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical exam the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis?

A	Gout Hint: Gout and pseudogout are excluded by the failure to find crystals on synovial fluid analysis.
B	Pseudogout Hint: See A for explanation.
C	Acute rheumatic fever Hint: Acute rheumatic fever commonly involves multiple joints.
D	Septic arthritis

Question 8 Explanation:

Leukocytosis and a low synovial glucose are indicative of septic arthritis.

Question 9

A 32-year-old male presents with migratory arthralgias and profound malaise and fatigue. He states that one week ago he returned from a hunting trip in Pennsylvania. He is also complaining of a lesion on his left thigh that he noticed about 3 days ago. Physical exam reveals a large annular lesion with a bright red outer border and partial central clearing. Which of the following is the most likely diagnosis?

A	Rheumatoid arthritis Hint: Rheumatoid arthritis is a symmetrical arthritis that commonly affects the proximal interphalangeal and metacarpophalangeal joints. It is not associated with the rash of erythema migrans.
B	Kawasaki disease Hint: Kawasaki disease is an acute febrile, multisystem disease of children. It is characterized by unresponsiveness to antibiotics, nonsuppurative cervical adenitis, and changes in the skin and mucous membranes such as edema, erythema of the lips and palms, and desquamation of the skin of the fingertips.
C	Lyme disease
D	Nongonococcal arthritis Hint: Nongonococcal arthritis occurs in patients with an underlying predisposition such as rheumatoid arthritis. The common presentation is involvement of a single joint

Question 9 Explanation:

After an incubation period of 3 to 32 days, erythema migrans develops at the site of the tick bite. Within days or weeks after the onset of erythema migrans the patients develop a severe headache, mild stiffness of the neck, migratory musculoskeletal pain, arthralgias and profound malaise and fatigue.

Question 10

A 22 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on. Physical exam reveals pain to palpation over the posterior tibialis muscle body. What is the most likely diagnosis?

A	Shin splint
B	Stress fracture Hint: See A for explanation.
C	Osgood-Schlatter disease Hint: Osgood-Schlatter disease is an injury occurring at the insertion of the patellar tendon on the tibial tuberosity in a younger age group.
D	Patellofemoral pain syndrome Hint: Patellofemoral pain syndrome is the most common cause of chronic anterior knee pain, more commonly seen in females.

Question 10 Explanation:

Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.

Question 11

A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has

A	carpal tunnel syndrome Hint: Carpal tunnel is diagnosed by a positive Tinel's or Phalen's maneuver.
B	radial tunnel syndrome Hint: Radial syndrome is demonstrated by simultaneously extending the patient's wrists and fingers while the examiner passively flexes the patient's long finger, which causes pain.
C	tenosynovitis
D	gamekeeper's thumb Hint: Gamekeeper's thumb is the most common injury to the metacarpophalangeal collateral ligaments, causing a sprain.

Question 11 Explanation:

Tenosynovitis is diagnosed using Finkelstein maneuver. The patient's thumb is placed in the palm of the hand and the wrist is abruptly deviated to the ulnar aspect of the wrist, causing pain on the radial aspect.

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