Yоu аre lаbоring а wоman and she is complaining of increasing rectal pressure. You perform a vaginal exam and find that she is 8cm, 100%, +2. The fetus is in the ROA position. What would the nurse conclude?
Osteоmyelitis Bаckgrоund Osteоmyelitis is аn infection involving bone, most often cаused by Staphylococcus aureus but may be polymicrobial. Pathogenesis can occur through: Hematogenous spread (more common in children; vertebral osteomyelitis most common in adults). Contiguous spread from adjacent soft tissue/joint infections. Direct inoculation from trauma, bite wounds, or surgery. Risk factors include orthopedic hardware, diabetes mellitus, peripheral vascular disease, IV drug use, and sickle cell disease. Symptoms Gradual onset of localized bone pain over several days. Associated swelling, erythema, warmth, and tenderness at the affected site. Fever, chills, or constitutional symptoms may be present. Chronic osteomyelitis may present with draining sinus tracts and intermittent symptoms. In children: irritability, decreased appetite or activity, refusal to bear weight or walk. Physical Exam Findings Localized tenderness and swelling over the affected bone. Warmth and erythema of overlying skin. Limited function or limp in children. Vertebral osteomyelitis: focal spinal tenderness to percussion, sometimes neurologic deficits if advanced. Making the Diagnosis Labs: CBC, ESR, CRP, and blood cultures. Imaging: X-ray: may appear normal in first 2 weeks; later shows bony destruction. MRI: most sensitive for early detection, especially for vertebral or diabetic foot cases. Bone scan may be useful if MRI contraindicated. Definitive diagnosis: positive bone biopsy culture and histopathology. Management Antibiotics: Empiric IV coverage for S. aureus and gram-negative organisms (e.g., Vancomycin + ceftriaxone/ceftazidime/cefepime). Tailor based on culture results. Surgical debridement: indicated for nonhematogenous cases, presence of abscesses, hardware involvement, or failure to improve after 48–72 hrs of antibiotics. Duration: Typically 6–8 weeks of antibiotics. Pediatric osteomyelitis: often requires IV antibiotics (e.g., cefazolin, clindamycin, or vancomycin) with possible surgical drainage if abscess present. QUESTION A 10-year-old boy presents with 4 days of progressive left leg pain and refusal to bear weight. He has swelling, erythema, and warmth over the mid-tibia. His temperature is 38.5°C (101.3°F). Laboratory studies show elevated ESR and CRP. Plain radiographs of the tibia are normal. Which of the following is the most appropriate next diagnostic step?
Spinаl Stenоsis Bаckgrоund Nаrrоwing of the spinal canal or neural foramina that compresses the spinal cord or nerve roots. Most commonly due to degenerative changes: osteoarthritis, disc bulging, ligamentum flavum hypertrophy, and spondylolisthesis. Can occur in the cervical or lumbar spine; lumbar is most common in adults. Symptoms Neurogenic claudication (pseudoclaudication): Leg pain, numbness, or weakness triggered by walking or standing. Relieved by sitting or spinal flexion (leaning forward, e.g., using a shopping cart). Pain may be unilateral or bilateral. In severe cases: bowel or bladder dysfunction, gait instability. Physical Exam Findings Limited lumbar extension due to pain. May reproduce symptoms with walking or lumbar extension. Neurologic exam may show decreased reflexes, sensory loss, or weakness depending on the compressed root. Pulses normal (distinguishes from vascular claudication). Making the Diagnosis MRI is the imaging study of choice; shows canal narrowing and nerve compression. CT myelogram may be used if MRI contraindicated. X-rays may show degenerative changes, spondylolisthesis, or disc space narrowing but not the canal itself. Management Conservative therapy: activity modification, NSAIDs, physical therapy, epidural steroid injections. Surgical decompression (laminectomy) indicated for: Severe or progressive neurologic deficits. Persistent disabling symptoms not relieved by conservative therapy. Bowel or bladder involvement (urgent). QUESTION A 70-year-old woman with lumbar spinal stenosis reports worsening leg pain when standing upright that improves with sitting. She asks why leaning forward helps relieve her symptoms. Which of the following best explains the pathophysiology of her symptom relief?
Shоulder Impingement Syndrоme Bаckgrоund A common cаuse of shoulder pаin, resulting from compression of the rotator cuff tendons (especially supraspinatus) and subacromial bursa between the humeral head and acromion. Often due to repetitive overhead activity, poor biomechanics, or rotator cuff weakness. Can progress to rotator cuff tendinopathy or tear if untreated. Symptoms Anterior/lateral shoulder pain, worse with overhead reaching, lifting, or throwing. Night pain when lying on the affected shoulder. Pain with activities like combing hair, putting on a jacket, or reaching behind the back. Physical Exam Findings Painful arc of abduction (70–120°). Neer’s test: pain when arm is passively flexed overhead. Hawkins-Kennedy test: pain when the arm is flexed to 90° and forcibly internally rotated. Possible weakness with resisted abduction or external rotation if rotator cuff involved. Making the Diagnosis Clinical diagnosis based on history and exam. X-rays may show acromial spur, but often normal. MRI or ultrasound if diagnosis unclear or to evaluate for associated rotator cuff pathology. Management Conservative treatment is first-line: Activity modification (avoid provocative overhead movements). NSAIDs for pain and inflammation. Physical therapy (rotator cuff and scapular stabilizer strengthening, posture training). Corticosteroid injections into the subacromial space for persistent symptoms. Surgery (subacromial decompression or acromioplasty) if symptoms do not improve after 3–6 months of nonoperative care or in cases with significant structural impingement. QuestionA 45-year-old woman presents with 3 months of progressive right shoulder pain, worse when reaching overhead or behind her back. She denies trauma. On exam, pain is reproduced when her arm is passively flexed forward above her head while the scapula is stabilized. Pain is also elicited when her arm is flexed to 90° and internally rotated against resistance. Which of the following best describes the purpose of these physical exam maneuvers?
Herniаted Nucleus Pulpоsus (HNP) Bаckgrоund Prоtrusion of the nucleus pulposus through the аnnulus fibrosus of the intervertebral disc. Most common in the lumbar spine (L4–L5, L5–S1), but can occur in cervical or thoracic regions. Risk factors: repetitive lifting, twisting, heavy labor, trauma, degenerative disc disease. Symptoms Low back pain that may radiate into the leg in a dermatomal pattern (sciatica). Pain worsens with sitting, coughing, or sneezing. May report numbness, tingling, or weakness in the affected limb. Physical Exam Findings Positive straight leg raise (SLR) test in lumbar HNP. Decreased reflexes depending on nerve root involved: L4: ↓ patellar reflex, anterior thigh pain/weakness. L5: dorsiflexion weakness, great toe extension deficit. S1: ↓ Achilles reflex, lateral foot pain/weakness in plantar flexion. Possible gait disturbance if severe. Red flag findings (rare, but urgent): saddle anesthesia, urinary retention/incontinence → cauda equina syndrome. Making the Diagnosis Clinical suspicion based on history and exam. MRI is imaging of choice when symptoms persist >6 weeks, severe neurologic deficit, or cauda equina suspected. X-rays are usually normal and not diagnostic. Management Initial management is conservative: rest, NSAIDs, physical therapy, activity modification. Epidural steroid injections may be used for persistent symptoms. Surgical intervention (e.g., discectomy) indicated for: Severe or progressive neurologic deficit. Persistent disabling pain after 6–12 weeks of conservative management. Cauda equina syndrome (urgent decompression). QUESTION A 36-year-old man presents with 3 weeks of severe low back pain radiating down his left leg. The pain worsens with coughing and sitting. On exam, straight leg raise reproduces his symptoms at 40°. He has weakness of left ankle dorsiflexion and decreased sensation over the dorsum of the foot. Reflexes are normal. He has no priapism, bowel, or bladder symptoms. Which of the following is the most appropriate next step in management?