FNP Osteoarthritis Practice Questions

The patient's unilateral presentation, short duration of morning stiffness, and crepitus are hallmark clinical signs of osteoarthritis. Radiographically, osteoarthritis is characterized by subchondral bone cysts, osteophytes, and asymmetrical joint space narrowing due to mechanical wear. Option A, Option B, and Option D are classic radiographic findings associated with rheumatoid arthritis, which is an inflammatory autoimmune process that typically presents symmetrically and with prolonged morning stiffness lasting greater than one hour.

Establishing the primary diagnosis requires distinguishing between overlapping rheumatologic conditions. While proximal stiffness and elevated ESR can be seen in polymyalgia rheumatica, the presence of spongy swelling in the small joints of the hands and a positive anti-cyclic citrullinated peptide are highly specific for rheumatoid arthritis. Polymyalgia rheumatica typically spares the small peripheral joints and lacks autoantibodies like anti-CCP or rheumatoid factor. Erosive osteoarthritis can affect the hands, but it typically involves the distal interphalangeal joints, lacks spongy synovial swelling, and does not produce a highly elevated ESR or positive anti-CCP. Reactive arthritis usually presents as an asymmetric oligoarthritis in the lower extremities following a gastrointestinal or genitourinary infection, which does not fit this patient's symmetrical, upper-extremity-heavy presentation.

Evaluating this plan of care reveals that the baseline fentanyl transdermal patch is ineffective, as evidenced by high breakthrough pain medication usage and a persistently high pain score. The standard of care requires increasing the basal opioid dose by calculating the total daily breakthrough opioid requirement. Adding a corticosteroid (A) might help bone pain but does not address the inadequate basal opioid dose. Replacing morphine with an NSAID (B) is insufficient for severe breakthrough cancer pain. Decreasing the fentanyl patch (C) would worsen her already uncontrolled pain, not prevent tolerance.

The patient's age and pain with overhead activity raise suspicion for shoulder osteoarthritis. Palpable crepitus during active joint rotation is highly indicative of the cartilage loss seen in osteoarthritis. Symmetrical loss of both active and passive motion is the hallmark physical exam finding of adhesive capsulitis, not osteoarthritis. Severe pain elicited at range limits can occur in both conditions but does not reliably differentiate between the two. Visible atrophy of the deltoid muscles is a non-specific finding related to disuse and can be present in chronic rotator cuff tears, adhesive capsulitis, or advanced osteoarthritis.

This patient has symptomatic knee osteoarthritis alongside major depressive disorder and a severe allergy to all NSAIDs. Initiating oral duloxetine is the optimal choice because it is an SNRI that is FDA-approved for both musculoskeletal pain and depression, addressing both conditions simultaneously. Prescribing oral tramadol introduces opioid risks and potential serotonin syndrome, making it suboptimal. Recommending oral pregabalin is inappropriate as it targets neuropathic pain, not osteoarthritic nociceptive pain. Administering systemic methylprednisolone is not indicated for osteoarthritis management and carries significant systemic side effects.

Topical NSAIDs like diclofenac gel are strongly recommended for localized osteoarthritis in older adults because they provide effective targeted relief with minimal systemic absorption. This completely avoids the high risk of gastrointestinal bleeding associated with oral NSAIDs like meloxicam or celecoxib, which are contraindicated given the patient's ulcer history. Tramadol introduces unnecessary central nervous system risks, including falls and confusion, and should be reserved for severe pain that fails both topical and safer oral interventions.

In older adults with chronic pain, functional status improvement is the primary goal of therapy, often superseding absolute pain score reduction. Since the patient is now walking independently and sleeping better, the current plan is highly effective. Option A is correct because continuing the successful regimen is indicated. Option B is incorrect because opioids are high-risk and unnecessary given the functional gains. Option C is incorrect because invasive interventions are not indicated when conservative measures are working. Option D is incorrect because adding oral NSAIDs increases the risk of gastrointestinal and renal adverse events in older adults without offering necessary benefits over the currently effective topical and physical therapy plan.

Rheumatoid arthritis is an autoimmune condition presenting with symmetric polyarthritis, prolonged morning stiffness lasting over an hour, and classic involvement of the metacarpophalangeal and proximal interphalangeal joints. The patient's prolonged morning stiffness and specific MCP and PIP swelling are hallmark features. Primary osteoarthritis typically involves the DIP joints and presents with brief morning stiffness. Psoriatic arthropathy often involves the DIP joints and is usually asymmetrical. Erosive osteoarthritis primarily affects the DIP and PIP joints but lacks the extensive morning stiffness and MCP involvement seen in this scenario.

The patient's inability to afford medications despite having a pension, combined with relinquishing financial control to his daughter, is a red flag for financial abuse. The clinician must first gather subjective information by exploring the financial arrangement directly with the patient. Option A ignores the potential underlying abuse. Option B breaches confidentiality and could endanger the patient if abuse is occurring. Option D is a helpful intervention later but skips the essential initial assessment step.

A low-positive rheumatoid factor can frequently be found in healthy individuals, particularly as they age, and does not inherently indicate autoimmune disease in the absence of clinical symptoms. Because the patient lacks classic signs like hand pain or morning stiffness, option B is the most appropriate and reassuring response. Option A is incorrect because referring an asymptomatic patient for disease-modifying therapy is unnecessary and inappropriate. Option C is incorrect because ordering an anti-CCP without clinical suspicion of inflammatory arthritis leads to overtesting and unnecessary anxiety. Option D is incorrect because NSAIDs do not prevent joint space narrowing in osteoarthritis or rheumatoid arthritis; they only provide symptomatic relief, which this patient does not currently require for her hands.