2
NURS 524 Final Exam with accurate detailed solutions
|| || || || || || ||
Straight leg test - ✔✔tests for presence of disk herniation
|| || || || || || || || ||
Calcium/Vitamin D dose for adults - ✔✔Calcium: 1000-1200mg/day; Vitamin D: 400 IU daily
|| || || || || || || || || || || ||
Back pain "red flags" - ✔✔Unrelenting night pain
|| || || || || || ||
Pain at rest
|| ||
History or suspicion of CA|| || || ||
Fever >38 degrees X 48 hours
|| || || || ||
Osteoporosis
Other systemic disease
|| ||
Neuromotor or sensory deficit || || ||
Chronic oral steroids || ||
Immunosuppresssion
Serious accident or injury || || ||
Clinical suspicion of ankylosing spondylitis
|| || || ||
>50 years old or <20 at onset of pain
|| || || || || || || ||
Drug/ETOH abuse ||
Failure to respond to 4-6 weeks of therapy
|| || || || || || ||
Back Pain imaging - ✔✔DO NOT perform unless positive red flags
|| || || || || || || || || ||
Order AP/Lateral Spinal Xray
|| || ||
DO NOT order oblique view (adds minimal information, doubles radiation)
|| || || || || || || || ||
MRI only if pt. is potential candidate for surgery or epidural steroid injection (suspected
|| || || || || || || || || || || || || ||
radiculopathy)
,2
Differential diagnosis for back pain - ✔✔Reactive Arthritis
|| || || || || || ||
Osteomyelitis (fevers, pain at rest) || || || ||
Malignancy/Metastasis/Multiple myeloma (unexplained weight loss) || || || ||
Postural backaches (obese, pregnancy) (dull, persistent, stiffness that worsens as day
|| || || || || || || || || || ||
progresses)
Herniated disk (sudden onset, pain radiates to buttock/down leg/possibly to foot; sharp
|| || || || || || || || || || || ||
pain; may have paresthesias or muscle weakness; may increase pain with coughing/sneezing,
|| || || || || || || || || || ||
sitting, and lateral bending)
|| || || ||
Degenerative disk disease (aggravated by flexion and sitting) || || || || || || ||
Facet Joint (mechanism of injury extension, rotation, compression; aggravated by extension
|| || || || || || || || || || ||
and rotation)
||
Lumbosacral arthritis (gradual onset, morning stiffness, radiation less common)
|| || || || || || || ||
Spinal stenosis (pain worsens with walking and prolonged standing, spinal extension; may
|| || || || || || || || || || || ||
report relief when leaning forward on shopping cart; May not complain of back pain, but of
|| || || || || || || || || || || || || || || ||
aching and cramping in thighs and calves)
|| || || || || ||
Ankylosing spondylitis ||
Intervertebral Sprain (sudden onset often related to lifting, turning, twisting; aggravated by
|| || || || || || || || || || || ||
flexion)
Compression fracture/osteoporosis ||
Spondylolithesis (displacement of vertebrae) || || ||
Sacroiliac joint (mechanism of injury fall onto buttocks; aggravated by walking and sitting)
|| || || || || || || || || || || ||
Nerve Root Irritation (mechanism of injury flexion and compression; aggravated by flexion
|| || || || || || || || || || || ||
and sitting)
||
Depression
Renal colic ||
AAA
GU problem (prostatitis, PID)
|| || ||
IBS
,2
(INFLAMMATORY BACK PAIN OFTEN IMPROVES WITH EXERCISE, MECHANICAL PAIN || || || || || || || || ||
WORSENS WITH EXERCISE) || ||
(RECTAL AND PELVIC EXAMS should be performed, especially in pts over 40)
|| || || || || || || || || || ||
Reiter's syndrome / Reactive arthritis - ✔✔an autoimmune acute arthritis in response to an
|| || || || || || || || || || || || || ||
enteric or urogenital infection; more common in MEN ages 18-35; present with low-grade
|| || || || || || || || || || || || ||
fever, asymmetric arthralgia and stiffness, low back pain that increases with rest, and
|| || || || || || || || || || || || ||
urethritis
Ankylosing Spondylitis - ✔✔chronic multisystem inflammatory disorder involving SI joint and
|| || || || || || || || || || ||
axial skeleton; chronic inflammation leads to granulation tissue that invades the joints and is
|| || || || || || || || || || || || ||
gradually replaced by cartilage and then ossification; usual onset before age 40; insidious
|| || || || || || || || || || || || || ||
onset of low back pain; more common in men; hereditary; present with presence of
|| || || || || || || || || || || || || ||
symptoms > 3 months; symptoms worse in morning or with inactivity; improvement of
|| || || || || || || || || || || || ||
symptoms with exercise; fatigue, uveitis, renal/pulmonary/neurologic/CV/GI diseases
|| || || || || ||
Differential diagnosis of pelvic girdle pain - ✔✔Degenerative disk disease with facet
|| || || || || || || || || || || ||
impingement (buttock/posterior thigh pain, worse with pelvic extension)
|| || || || || || ||
Degenerative disk disease with nuclear prolapse dysfunction || || || || || ||
Sacroiliitis (buttock or posterior thigh pain that is worse with rest and relieved with activity)
|| || || || || || || || || || || || || ||
OA of hip (pain in groin, buttock, knee worse with activity, relieved by rest)
|| || || || || || || || || || || || ||
Meralgia paresthetica anterosuperior (injury to lateral cutaneous nerve of thigh - obesity or
|| || || || || || || || || || || || ||
pregnancy; tenderness over iliac spine) || || || ||
Trochanteric bursitis (pain in lateral thigh, worse at night with activity; tenderness over
|| || || || || || || || || || || || ||
greater trochanter) ||
Cauda equina syndrome - ✔✔Caused by pressure on unmyelinated fibers - surgical
|| || || || || || || || || || || ||
emergency; SX= central back pain, leg weakness, impotence, urinary
|| || || || || || || || ||
frequency/retention/incontinence, saddle anesthesia, and loss of sphincter tone. || || || || || || ||
, 2
Treatment for herniated disk - ✔✔About 90% of pts with back pain respond with
|| || || || || || || || || || || || || ||
conservative treatment; May take up to 2 months; NSAID X 2 weeks (Naproxen or Ibuprofen
|| || || || || || || || || || || || || ||
- no more than 600mg TID) and muscle relaxant (Flexoril) X 3 days; Teach don't drive;
|| || || || || || || || || || || || || || || || ||
bedrest not encouraged (48 hours max); No lifting > 5 lbs; No twisting or bending; Follow
|| || || || || || || || || || || || || || || ||
up frequently (2 weeks); Weight loss if needed; When pain decreases, start stretching and
|| || || || || || || || || || || || || ||
strengthening exercises; Teach dont sit for longer than 20 minutes; Sleep on side in knee-
|| || || || || || || || || || || || || ||
chest position with pillow between legs; apply moist heat to back of legs 3-4 times daily;
|| || || || || || || || || || || || || || ||
Anterior/Posterior Drawer Test - ✔✔To perform: Hips flexed 45 degrees, knees flexed 90 || || || || || || || || || || || || ||
degrees, feet flat on table; examiner sits on pts feet and holds leg above calf with both
|| || || || || || || || || || || || || || || || ||
hands; pull forward (anterior) and push back (posterior); normal = 6-8 mm of laxity; If
|| || || || || || || || || || || || || || ||
positive, may indicate ACL or PCL rupture || || || || || ||
Lachman Test - ✔✔Flex knee 20-30 degrees; grasp femur with one hand, and grasp calf
|| || || || || || || || || || || || || || ||
with other hand; firmly pull to displace tibia on femur; assess laxity; may indicate ACL tear
|| || || || || || || || || || || || || || ||
McMurray's Test - ✔✔Assesses for tear in medial or lateral meniscus; Flex knee and hip,
|| || || || || || || || || || || || || || ||
and have pt. relax. Palpate joint space with one hand. Hold heel of pts foot with other
|| || || || || || || || || || || || || || || || ||
hand; externally rotate tibia and slowly extend leg, feeling for a click in the knee joint; then
|| || || || || || || || || || || || || || || || ||
repeat with tibia internally rotated
|| || || ||
Valgus/Varus stress - ✔✔Valgus = "knock knees" || || || || || ||
Varus = "bow-legged" || ||
Tests MCL and LCL integrity
|| || || ||
Apley's Test - ✔✔Pt. lies prone; Leg flexed 90 degrees; Compression test = lean on pts foot
|| || || || || || || || || || || || || || || || ||
and apply pressure to heel; internally and externally rotate tibia; popping and crepitus with
|| || || || || || || || || || || || || ||
pain is a positive sign and indicates a meniscus tear
|| || || || || || || || ||
Differential Diagnosis of Knee Pain - ✔✔ACL tear || || || || || || ||
MCL tear (often injured when ACL torn)
|| || || || || ||
NURS 524 Final Exam with accurate detailed solutions
|| || || || || || ||
Straight leg test - ✔✔tests for presence of disk herniation
|| || || || || || || || ||
Calcium/Vitamin D dose for adults - ✔✔Calcium: 1000-1200mg/day; Vitamin D: 400 IU daily
|| || || || || || || || || || || ||
Back pain "red flags" - ✔✔Unrelenting night pain
|| || || || || || ||
Pain at rest
|| ||
History or suspicion of CA|| || || ||
Fever >38 degrees X 48 hours
|| || || || ||
Osteoporosis
Other systemic disease
|| ||
Neuromotor or sensory deficit || || ||
Chronic oral steroids || ||
Immunosuppresssion
Serious accident or injury || || ||
Clinical suspicion of ankylosing spondylitis
|| || || ||
>50 years old or <20 at onset of pain
|| || || || || || || ||
Drug/ETOH abuse ||
Failure to respond to 4-6 weeks of therapy
|| || || || || || ||
Back Pain imaging - ✔✔DO NOT perform unless positive red flags
|| || || || || || || || || ||
Order AP/Lateral Spinal Xray
|| || ||
DO NOT order oblique view (adds minimal information, doubles radiation)
|| || || || || || || || ||
MRI only if pt. is potential candidate for surgery or epidural steroid injection (suspected
|| || || || || || || || || || || || || ||
radiculopathy)
,2
Differential diagnosis for back pain - ✔✔Reactive Arthritis
|| || || || || || ||
Osteomyelitis (fevers, pain at rest) || || || ||
Malignancy/Metastasis/Multiple myeloma (unexplained weight loss) || || || ||
Postural backaches (obese, pregnancy) (dull, persistent, stiffness that worsens as day
|| || || || || || || || || || ||
progresses)
Herniated disk (sudden onset, pain radiates to buttock/down leg/possibly to foot; sharp
|| || || || || || || || || || || ||
pain; may have paresthesias or muscle weakness; may increase pain with coughing/sneezing,
|| || || || || || || || || || ||
sitting, and lateral bending)
|| || || ||
Degenerative disk disease (aggravated by flexion and sitting) || || || || || || ||
Facet Joint (mechanism of injury extension, rotation, compression; aggravated by extension
|| || || || || || || || || || ||
and rotation)
||
Lumbosacral arthritis (gradual onset, morning stiffness, radiation less common)
|| || || || || || || ||
Spinal stenosis (pain worsens with walking and prolonged standing, spinal extension; may
|| || || || || || || || || || || ||
report relief when leaning forward on shopping cart; May not complain of back pain, but of
|| || || || || || || || || || || || || || || ||
aching and cramping in thighs and calves)
|| || || || || ||
Ankylosing spondylitis ||
Intervertebral Sprain (sudden onset often related to lifting, turning, twisting; aggravated by
|| || || || || || || || || || || ||
flexion)
Compression fracture/osteoporosis ||
Spondylolithesis (displacement of vertebrae) || || ||
Sacroiliac joint (mechanism of injury fall onto buttocks; aggravated by walking and sitting)
|| || || || || || || || || || || ||
Nerve Root Irritation (mechanism of injury flexion and compression; aggravated by flexion
|| || || || || || || || || || || ||
and sitting)
||
Depression
Renal colic ||
AAA
GU problem (prostatitis, PID)
|| || ||
IBS
,2
(INFLAMMATORY BACK PAIN OFTEN IMPROVES WITH EXERCISE, MECHANICAL PAIN || || || || || || || || ||
WORSENS WITH EXERCISE) || ||
(RECTAL AND PELVIC EXAMS should be performed, especially in pts over 40)
|| || || || || || || || || || ||
Reiter's syndrome / Reactive arthritis - ✔✔an autoimmune acute arthritis in response to an
|| || || || || || || || || || || || || ||
enteric or urogenital infection; more common in MEN ages 18-35; present with low-grade
|| || || || || || || || || || || || ||
fever, asymmetric arthralgia and stiffness, low back pain that increases with rest, and
|| || || || || || || || || || || || ||
urethritis
Ankylosing Spondylitis - ✔✔chronic multisystem inflammatory disorder involving SI joint and
|| || || || || || || || || || ||
axial skeleton; chronic inflammation leads to granulation tissue that invades the joints and is
|| || || || || || || || || || || || ||
gradually replaced by cartilage and then ossification; usual onset before age 40; insidious
|| || || || || || || || || || || || || ||
onset of low back pain; more common in men; hereditary; present with presence of
|| || || || || || || || || || || || || ||
symptoms > 3 months; symptoms worse in morning or with inactivity; improvement of
|| || || || || || || || || || || || ||
symptoms with exercise; fatigue, uveitis, renal/pulmonary/neurologic/CV/GI diseases
|| || || || || ||
Differential diagnosis of pelvic girdle pain - ✔✔Degenerative disk disease with facet
|| || || || || || || || || || || ||
impingement (buttock/posterior thigh pain, worse with pelvic extension)
|| || || || || || ||
Degenerative disk disease with nuclear prolapse dysfunction || || || || || ||
Sacroiliitis (buttock or posterior thigh pain that is worse with rest and relieved with activity)
|| || || || || || || || || || || || || ||
OA of hip (pain in groin, buttock, knee worse with activity, relieved by rest)
|| || || || || || || || || || || || ||
Meralgia paresthetica anterosuperior (injury to lateral cutaneous nerve of thigh - obesity or
|| || || || || || || || || || || || ||
pregnancy; tenderness over iliac spine) || || || ||
Trochanteric bursitis (pain in lateral thigh, worse at night with activity; tenderness over
|| || || || || || || || || || || || ||
greater trochanter) ||
Cauda equina syndrome - ✔✔Caused by pressure on unmyelinated fibers - surgical
|| || || || || || || || || || || ||
emergency; SX= central back pain, leg weakness, impotence, urinary
|| || || || || || || || ||
frequency/retention/incontinence, saddle anesthesia, and loss of sphincter tone. || || || || || || ||
, 2
Treatment for herniated disk - ✔✔About 90% of pts with back pain respond with
|| || || || || || || || || || || || || ||
conservative treatment; May take up to 2 months; NSAID X 2 weeks (Naproxen or Ibuprofen
|| || || || || || || || || || || || || ||
- no more than 600mg TID) and muscle relaxant (Flexoril) X 3 days; Teach don't drive;
|| || || || || || || || || || || || || || || || ||
bedrest not encouraged (48 hours max); No lifting > 5 lbs; No twisting or bending; Follow
|| || || || || || || || || || || || || || || ||
up frequently (2 weeks); Weight loss if needed; When pain decreases, start stretching and
|| || || || || || || || || || || || || ||
strengthening exercises; Teach dont sit for longer than 20 minutes; Sleep on side in knee-
|| || || || || || || || || || || || || ||
chest position with pillow between legs; apply moist heat to back of legs 3-4 times daily;
|| || || || || || || || || || || || || || ||
Anterior/Posterior Drawer Test - ✔✔To perform: Hips flexed 45 degrees, knees flexed 90 || || || || || || || || || || || || ||
degrees, feet flat on table; examiner sits on pts feet and holds leg above calf with both
|| || || || || || || || || || || || || || || || ||
hands; pull forward (anterior) and push back (posterior); normal = 6-8 mm of laxity; If
|| || || || || || || || || || || || || || ||
positive, may indicate ACL or PCL rupture || || || || || ||
Lachman Test - ✔✔Flex knee 20-30 degrees; grasp femur with one hand, and grasp calf
|| || || || || || || || || || || || || || ||
with other hand; firmly pull to displace tibia on femur; assess laxity; may indicate ACL tear
|| || || || || || || || || || || || || || ||
McMurray's Test - ✔✔Assesses for tear in medial or lateral meniscus; Flex knee and hip,
|| || || || || || || || || || || || || || ||
and have pt. relax. Palpate joint space with one hand. Hold heel of pts foot with other
|| || || || || || || || || || || || || || || || ||
hand; externally rotate tibia and slowly extend leg, feeling for a click in the knee joint; then
|| || || || || || || || || || || || || || || || ||
repeat with tibia internally rotated
|| || || ||
Valgus/Varus stress - ✔✔Valgus = "knock knees" || || || || || ||
Varus = "bow-legged" || ||
Tests MCL and LCL integrity
|| || || ||
Apley's Test - ✔✔Pt. lies prone; Leg flexed 90 degrees; Compression test = lean on pts foot
|| || || || || || || || || || || || || || || || ||
and apply pressure to heel; internally and externally rotate tibia; popping and crepitus with
|| || || || || || || || || || || || || ||
pain is a positive sign and indicates a meniscus tear
|| || || || || || || || ||
Differential Diagnosis of Knee Pain - ✔✔ACL tear || || || || || || ||
MCL tear (often injured when ACL torn)
|| || || || || ||
