Musculoskeletal Exam (Nursing Answers 31-35)

Rationale: The lateral ligaments are more commonly injured than the medial ligaments, since they are weaker. The anterior talofi bular ligament is the most common of the lateral ligaments to be injured.

B is Incorrect.
Rationale: The calcaneofi bular ligament is a lateral ligament that is injured frequently, but less frequently than the anterior talofi bular ligament.

C is Incorrect.
Musculoskeletal Exam Rationale: The lateral ligaments are more commonly injured than the medial ligaments, since they are weaker. The talonavicular ligament is a medial ligament so it is much less likely to be injured.

D is Incorrect.
Rationale: The lateral ligaments are more commonly injured than the medial ligaments, since they are weaker. The tibiocalcaneal ligament is a medial ligament so it is much less likely to be injured.

32) C - Correct
Musculoskeletal Exam Rationale: The most likely diagnosis is osteogenesis imperfecta (OI). OI is characterized by multiple spontaneous bone fractures, retarded wound healing, and characteristically blue sclerae. This disease is caused by a variety of gene defects leading to abnormal collagen synthesis. The most common form of OI is an autosomal dominant defect in type I collagen synthesis. Type I collagen has high tensile strength and is found in skin, bone, tendons, eyes, ears, and teeth. Other symptoms of type I OI include hearing impairment
and joint laxity. Thinning of the sclerae from reduced type I collagen causes the characteristic blue tint noted in the whites of these patient’s eyes.

A is Incorrect.
Rationale: Type III cartilage is characterized by thin, pliable fibrils found in blood vessels, skin, and the uterus. This collagen is not abnormal in type I OI.

B is Incorrect.
Rationale: Interstitial tissue is composed of types V and VI collagen. Cartilage contains type II and IX collagen. Of these tissues only bone contains type I cartilage, the type of cartilage affected by type I OI.

D is Incorrect.
Rationale: Type II collagen is primarily found in cartilage and vitreous humor. Blood vessels contain collagen types III and V, thus none of these tissues are affected in type I OI.


33) D Correct
Musculoskeletal Exam Musculoskeletal Exam Rationale: This patient has systemic lupus erythematosus (SLE), which is diagnosed by the presence of 4 of the following 11 findings designated by the American Rheumatism Association, and summarized by the mnemonic “BRAIN SOAP, MD”: Blood dyscrasias (such as hemolytic anemia or thrombocytopenia), Renal disorder, Arthritis (in two or more peripheral joints), Immunologic disorder (such as anti-DNA antibody and anti-Smith antibody), Neurologic disorder, Serositis (such as pleuritis or pericarditis), Oral ulcers, Antinuclear antibody (elevated titers in the absence of drugs associated with drug-induced lupus syndrome), Photosensitivity, Malar rash, and Discoid rash. Many patients with SLE have antiphospholipid antibodies, which are actually believed to be antibodies against proteins that complex to phospholipids. Since these antibodies also bind to the cardiolipin antigen used in syphilis serology, patients with SLE may test false-positive for syphilis.

A is Incorrect.
Rationale: Polyarteritis nodosa, a necrotizing immune complex vasculitis that usually affects small or medium-sized muscular arteries, commonly presents with fever, malaise, myalgias, and hypertension. Findings may include pericarditis, myocarditis, palpable purpura, and cotton-wool spots (white opacities in the retina).

B is Incorrect.
Rationale: The American Rheumatism Association diagnostic criteria for rheumatoid arthritis requires four out of the following seven findings: (1) Morning stiffness for more than 6 weeks; (2) Arthritis of hand joints for more than 6 weeks; (3) Arthritis involving three or more joint areas for more than 6 weeks; (4) Symmetric arthritis for more than 6 weeks; (5) Rheumatoid nodules (small lumps of tissue most commonly found over bony prominences, that are histologically characterized by a center of fibrinoid necrosis surrounded
by histiocytes, numerous lymphocytes, and plasma cells); (6) Positive serum rheumatoid factor; and (7) Radiologic changes (such as bony erosion in or near the area of symptomatic joints).

C is Incorrect.
Rationale: Secondary syphilis often develops 6 weeks after an untreated primary chancre of syphilis has healed and is characterized by fever, lymphadenopathy, skin rashes (widespread small, flat lesions that particularly involve the palms, soles, and oral mucosa), and condylomata lata (painless wartlike lesions that present in the vulva, the scrotum, or other warm, moist areas of the body).

34) D - Correct
Musculoskeletal Exam Rationale: X-linked recessive inheritance shows affected male individuals inheriting a defective copy of the X chromosome from heterozygous (asymptomatic) mothers. There is no male-to-male transmission. Heterozygous females may be affected, but usually not as severely as males. Becker’s muscular dystrophy is a milder, slower-developing form of dystrophinopathy with manifestations similar to those of Duchenne’s muscular dystrophy.
 
A is Incorrect.
Rationale: Autosomal dominant inheritance shows disease in many generations, with both males and females affected. It is possible for a male or a female to transmit the defective gene to their offspring. Becker’s muscular dystrophy is not inherited in this manner.

B is Incorrect.
Rationale: In autosomal recessive inheritance, a defective gene from each carrier parent is transmitted to the offspring. Disease is often seen in only one generation. Males and females are equally likely to be affected. Becker’s muscular dystrophy is not inherited in this manner.

C is Incorrect.
Rationale: In mitochondrial inheritance, all children (male and female) of an affected mother exhibit the disease. The disease is not transmitted from fathers to any of their children (only maternal transmission). Becker’s muscular dystrophy is not inherited in this manner.


35) B - Correct
Musculoskeletal Exam Rationale: This patient has erythema nodosum, an inflammation of subcutaneous fat that is often accompanied by fever and malaise that is described clinically and pathologically in the question stem. The exact mechanism is unknown, but it often occurs together with inflammatory bowel disease (Crohn’s disease or ulcerative colitis), sarcoidosis, certain drugs (such as oral contraceptives and sulfonamides), certain malignant neoplasms, and certain infections (such as tuberculosis, -hemolytic streptococci, coccidioidomycosis, histoplasmosis, and leprosy).

A is Incorrect.
Rationale: Acne vulgaris is a disorder of the epidermis that has both inflammatory and noninflammatory variants. It is associated with the bacterium Propionibacterium acnes.

C is Incorrect.
Rationale: Eczema is an inflammatory skin disorder that is associated with contact allergies, asthma, ultraviolet light exposure, repeated physical skin rubbing, and certain drugs. It is not associated with erythema nodosum.

D is Incorrect.
Rationale: Pancreatitis, which is associated with many cases of biliary tract disease and alcoholism, is not associated with erythema nodosum.


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