Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 78-year-old woman with well-controlled hypertension and dyslipidemia presents with the chief complaint of a many-month history of pain, described as achiness and stiffness in the joints of both hands, particularly towards the end of the day. A part-time seamstress, she reports this discomfort is worse on work days. She denies redness or heat in the affected regions and has no systemic complaint. Physical exam reveals Heberden’s and Bouchard's nodes bilaterally. These findings are most consistent with the diagnosis of:
A. Rheumatoid arthritis.
B. Systemic lupus.
C. Osteoporosis.
D. Osteoarthritis.
The correct answer is D. Osteoarthritis.
As we deal with each question in this series, where do you start? First, let's determine what kind of question it is. Given we're asked what disease is most likely causing these findings, this is a diagnosis question.
Now, some background information. Osteoarthritis is a degenerative disease, no matter where it occurs in the body, that affects all the tissues of a joint leading over time to a breakdown of the protective cartilage within that joint. The end product is bone-on-bone rubbing and resulting symptoms, regardless of which joint is involved. As I've mentioned many times in these podcasts, consider what the patient's risk factors are for a given disease. Aging is a major risk factor for hand OA. It’s going to be seen in about one-half of all women and one-quarter of all men will experience this stiffness and pain in the hand by age 80. This woman is in her late seventies, she is closer to 80 than she is any other milestone birthday. In particular, hand OA risk factors include a history of doing repetitive work that can stress the joints. She's reporting that she is a seamstress using her hands to do this work as well as mentioning she's more symptomatic on days when she does work.
Osteoarthritis pain is characterized, again regardless of what joint it's occurring in, as typically being worse as the day goes on and most often worse after the joint has been stressed. Like, for example, you'll hear from people with OA of the knee or the hip that their knees or hips might be a little stiff when they first get up in the morning, but they're painless. By the end of the day, they are more uncomfortable. What about additional OA risk factors aside from birth gender assignment i.e. female, aging, and joint stressing work, as I mentioned, but also a history of joint trauma, family history of OA, and obesity and overweight. And I will say that the latter two, with the obesity and overweight: those are major risk factors for okay in the knees in the hips. When the hands are involved, as in this scenario, the discomfort is usually described as an ache with stiffness, usually as we see, after the joint has been stressed, such as during the day with routine ADL or, as she reports, worse on days when her hands are used for strenuous activities.
Let's take a look at the question and provided possible answer. To recap, is this a 78-year-old woman with well-controlled hypertension and dyslipidemia presenting with the chief complaint of a many-month history of pain described as achiness and stiffness in the joints of both hands, particularly towards the end of the day. A part-time seamstress, she reports this discomfort is worse on work days. She denies redness or heat to the affected areas and has no systemic complaint. Physical exam reveals bilateral Heberden’s and Bouchard's nodes. These findings are most consistent with:
A. Rheumatoid arthritis. This is not correct. While rheumatoid arthritis, often abbreviated as R.A., can occur at any age, this is typically a disease with younger age at onset, our patient is in her late seventies, and more often in women than men, and usually during the female reproductive years. Typically with R.A., it wouldn't be just the hand joints involved. But what you would hear from the patient was my hands, my wrists, my feet, my ankles. All of these bother me. In addition, we're told she has no systemic complaints. With R.A., it is a systemic disease. Osteoarthritis is more a joint disease, but with that systemic disease, there usually is fatigue, unintended weight loss, and often anemia of chronic disease. Keep in mind, you'll be provided with just about enough information to answer a question and really nothing extra.
So, if you're thinking here, “Yeah, but there wasn't anything mentioned about her feet. Yeah, but there wasn't anything mentioned about her wrist,” etc. Squelch those yeah buts and realize you've got enough information here to answer that question.
Option B. Systemic lupus. This is also incorrect. Similar to R.A., systemic lupus is a systemic disease, hence its name, with many joints involved, and additional symptoms such as fatigue, unintended weight loss, and the like. Plus, the typical age for onset of lupus is within the female reproductive years, although late-onset disease is on occasion seen. Nearly 90% of individuals with lupus have female birth gender assignment. There are very, very few diseases that are that skewed towards females. However, two-thirds of all autoimmune diseases, and both R.A. and lupus are autoimmune diseases, two-thirds of them are seen in women.
Now, option C. Osteoporosis. Risk factors for osteoporosis include age and female birth gender, both mentioned in this patient. However, osteoporosis is typically without any symptoms until the disease is quite advanced. And when symptomatic, there will be usually a report of stooped posture and backache owing to vertebral fragility fractures. Even in a person with very advanced osteoporosis, for them to have hand symptoms would be incredibly unusual.
Well, that leaves us with D, our only remaining option. And that is, of course, the correct answer. As mentioned, she has multiple OA risk factors and you always have to read every word in the question to make sure that you're gleaning all the risk factors, all the information that would aim you towards one diagnosis or another. And the notation of Heberden’s and Bouchard's nodes are a classic finding in OA. Hand OA typically includes asymptomatic enlargement of nodules at the proximal interphalangeal joints. Those are the Bouchard’s nodes, or the distal interphalangeal joints, those are the Heberden’s nodes, usually with angulation of the joint. And by angulation, I mean you look at the joint and you can tell that it's somewhat deformed. The base of the thumb is also involved with hand OA, but the wrist is usually spared. There are mnemonics for Heberden’s nodes with Heberden, think distal interphalangeal joint, H-D, high definition for Heberden and Distal. And Bouchard’s nodes proximal interphalangeal joint, BP, Blue Picture, is one mnemonic I heard for that. Obviously, I'm taking BP for blood pressure. And another way of looking at this is Heberden is high above the Bouchard nose, so Heberden high, Bouchard’s below.
What's the key takeaway on this question class: Consider patient risk factors coupled with classic presentation of any disease. This will help you hone your differential diagnosis and clinical decision-making skills. Never forget, the NP boards are a test to see if you will be a safe entry-level NP, and that includes being an accurate diagnostician and a safe clinical decision maker.
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