Ep #175: Test Your Musculoskeletal Knowledge: An NP Boards Lightning Round

Anna: Welcome to the Real Deal Nurse Practitioner Club, the podcast for nurses who are ready to pass their boards and thrive in their careers as real deal nurse practitioners. I’m Anna, and I’m the Director of Nursing Content at Blueprint Test Prep. Whether you’re deep in exam prep or stepping into practice, I’ve got you. It is time to become the confident, knowledgeable NP that you’re meant to be. Let’s dive in. 

Hello, hello. Welcome back to another episode. I’m Anna.

Alex: And I’m Alex. Thank you for joining us for another episode.

Anna: And today we’re doing something a little different, but something we’ve done before, and it’s honestly one of my favorite ways to study. And we’ve gotten such good feedback on this style of episode when we’ve done it in the past. And that is one of our like rapid-fire quizzing, lightning round episodes. This one is going to be a musculoskeletal themed lightning round.

Now, if you’ve ever been a part of our live study groups, you know exactly what we’re talking about. But really these rapid-fire review sessions really just force you to think quickly and make connections about important topics and really assess what you know and what you don’t know.

Alex: Exactly. And they’re also really similar to what we do in our one-to-one readiness sessions. Those are much more personalized, but this rapid back and forth style helps us identify where students are really solid and where they might need just a little bit more review before their boards.

Anna: Yeah. Today’s episode, I’m going to give this big caveat. It is not meant to cover every musculoskeletal diagnosis. This is really just a sampler. Like we are going to hit some of the highest yield board topics and explain a few extra things along the way, but please, if you need more or you realize some of these areas you need more studying on, go ahead and check out our courses.

All right, Alex, are you ready to be asked some questions?

Alex: Let’s do it.

Anna: All right, first question for you. And for all of you listeners, we’re going to pause just very briefly for a second for you to answer the question in your head wherever you’re listening to this. All right, what is the gold standard test for diagnosing osteoporosis?

Alex: So that’s going to be a DEXA scan. And here’s a board pearl. Don’t just know the test, know how to interpret it, right? So a T-score of -2.5 or lower indicates osteoporosis, while between -1 and -2.5 indicates osteopenia.

Anna: You’ve got it. All right, what lifestyle recommendations should you almost always include for patients with osteopenia or osteoporosis?

Alex: So there are several good ones here, right? Weight-bearing exercise. Walking is a great example. Swimming is a wonderful exercise, but because it isn’t weight-bearing, it doesn’t stimulate bone remodeling the same way. So if we’re going to pick something, we’re going to pick the weight-bearing exercise, right? And don’t forget adequate calcium intake, vitamin D supplementation, and smoking cessation if warranted.

Anna: Yeah, absolutely. All right, let’s shift gears a little bit to osteoarthritis versus rheumatoid. Which one of these typically presents with morning stiffness that lasts less than 30 minutes?

Alex: That’s going to be osteoarthritis.

Anna: Exactly. And then rheumatoid arthritis on the other hand is more likely to present with morning stiffness lasting over an hour. And here’s another one, which condition tends to improve with movement?

Alex: That’s going to be rheumatoid arthritis. OA hurts more with activity, but rheumatoid arthritis actually tends to loosen up as patients start moving.

Anna: And the first-line medication class for OA?

Alex: So that’s typically NSAIDs unless there’s a contraindication, right? And it’s going to be oral or topical NSAIDs, and that really depends on what joint or joints are affected.

Anna: Absolutely. Now, what about for RA? What’s our first-line drug class there?

Alex: So that’s going to be DMARDs, most commonly methotrexate, right? Remember, rheumatoid arthritis is an autoimmune disease, so you’re treating the immune system, not just the pain.

Anna: All right, let’s shift gears again. We’re going to talk about gout. So true or false? You should start allopurinol during a gout flare.

Alex: That’s false. And that’s one of the classic board questions. You don’t initiate allopurinol during an acute flare because it can actually worsen symptoms. But if they’re already taking it chronically, keep them on it, don’t stop it.

Anna: All right, what is the most confirmatory diagnostic test for gout?

Alex: So the key word there is confirmatory, and that’s going to be joint aspiration with crystal analysis. I know that sounds like a lot. You’ll hear about serum uric acid, and while that can certainly support the diagnosis, it is not the most reliable. It can actually be normal during an acute attack.

Anna: Yeah, and remember that question did say most confirmatory. That does not mean you are doing a joint aspiration for every single patient. A lot of times this diagnosis can be made clinically. So I’m just throwing that out there. Make sure you’re reading what the question is asking you.

All right, next question. Let’s say we have a patient come in with severe low back pain with saddle anesthesia. Make sure you know what that means, by the way, if you don’t. And new urinary retention. What is this? What do we do?

Alex: So that’s going to be cauda equina syndrome until proven otherwise. This is an absolute medical emergency. The patient needs immediate evaluation because delayed treatment can lead to permanent neurological damage.

Anna: And this again is just my little pearl. Make sure you know what the medical term means. The patient is not going to just verbatim say that they have saddle anesthesia, right? They’re going to say they have numbness or tingling, that they’re losing bladder control. And so when you hear those medical terms, just know that they could be written a little bit differently in an exam question.

All right, let’s do another one, still along the lines of back pain, but which condition is commonly relieved by leaning forward?

Alex: So this can be a tricky one, but that is spinal stenosis, right? Patients will often tell you walking uphill or leaning over a shopping cart actually makes them feel better.

Anna: Yeah, sitting is also another one there that I hear a lot that helps it. And then what bedside maneuver helps evaluate lumbar radiculopathy?

Alex: So that’s going to be the straight leg raise. If it reproduces the patient’s symptoms radiating down the leg, that’s supportive of lumbar nerve root irritation.

Anna: All right, now let’s do some sports medicine questions. The McMurray test evaluates what?

Alex: It evaluates the meniscus. And I always remember this because McMurray and meniscus both start with M.

Anna: Yep, so what about the Lachman test then?

Alex: That evaluates the ACL. And a memory trick here I love to teach is rearrange those first three letters of Lachman. So LAC to ACL to remember this.

Anna: Okay, now we have a patient and they say, “I heard a pop,” and their knee swelled almost immediately after the injury. What is really rising to the top of your differential list?

Alex: So that’s going to be an ACL injury. Rapid swelling after a twisting injury plus that popping sensation is very very classic. Compare that to a meniscal injury, right? Where patients often describe locking, catching, or clicking with delayed swelling instead.

Anna: All right, now let’s move to wrist and hand. Let’s say we have a patient and they fall onto an outstretched hand. The x-ray is normal, but they have tenderness right in the anatomic snuffbox.

Alex: So that’s going to be a scaphoid fracture, right? So even though early x-rays can be negative, you still treat this seriously because of that risk of poor blood supply and avascular necrosis. So we’re looking at immobilization and orthopedic follow-up here. Those are key.

Anna: Yeah, and while we’re on the hands and wrist, the Phalen and Tinel tests evaluate what?

Alex: Carpal tunnel syndrome. Both are looking for median nerve compression.

Anna: You got it. Okay, let’s finish this episode with some questions involving the foot. So a patient comes in and they say it feels like there’s a pebble in my shoe between the third and the fourth toes. What is the likely diagnosis here?

Alex: So that’s a Morton neuroma, and that’s one of those descriptions boards absolutely love, especially if they wear narrow shoes or high heels.

Anna: Yeah, now what if it says that they have heel pain and it’s worse with the first few steps in the morning?

Alex: So that is classic for plantar fasciitis, and that is one of the most common causes of heel pain in primary care. Stretching, supportive footwear, activity modification, and conservative treatment are usually your starting point.

Anna: All right, and that is it for this very rapid musculoskeletal lightning round. Really, we just kind of wanted to review some of the high yield content and show you this type of studying. This style of studying, it really works because you are forcing yourself to retrieve information instead of just like reading notes.

Alex: Exactly. And that’s why we use lightning rounds so often in our live study groups and readiness sessions, right? Boards don’t ask, “Have you seen this fact before?” Right? They ask, “Can you recognize it quickly and apply it?” So practicing this kind of rapid recall really helps build that confidence. 

Anna: Yeah, and remember, I’ve said this like five times now, but today’s episode is just scratching the surface. Inside our courses, we’re going to go so much deeper into musculoskeletal conditions, into imaging, into treatment algorithms, red flags, referral decisions, and all of the board style case scenario questions. But thank you for joining us today. Keep studying, keep practicing, and remember, we are here and we are rooting for you every step of the way. See you next time.

Thanks for listening to another episode of the Real Deal Nurse Practitioner Club. If you want more information about the different types of support that we offer to students and new nurse practitioners, you can visit npreviews, with an S, dot com. We’ll see you next week.