Differential diagnosis and mini cases - Erectile dysfunction, Amenorrhea, Vaginal bleeding, Vaginal discharge, Dyspareunia, Abuse, Limb/joint pain Flashcards

Question

What is your differential diagnosis and workup plan ? "18 yo F presents with amenorrhea for the past 4 months. She is 5 feet, 6 inches (167.6 cm) and weighs 90 lbs (40.9 kg). She has a history of exercise and heat intolerance"

Answer 1

* Differential diagnosis : * Pregnancy * Anerexia nervosa * Hyperthyroidism * Workup plan : * Urine hCG * CBC * TSH, FT4 * LH/FSH

Answer 2

* Differential diagnosis : * Anxiety-induced amenorrhea * Posttraumatic stress disorder * Depression * Hyperthyroidism * Workup plan : * CBC * TSH, FT4 * Urine cortisol level * Progesterone challenge test * LH/FSH, estradiol levels

Answer 3

1. Pre- vs. postmenopausal status ? 2. Duration ? 3. Amount ? 4. Menstrual history and relation to last discharge; 5. Pelvic or abdominal pain ? 6. Urinary symptoms; 7. Trauma; 8. Medications (especially blood thinners, contracep- tives); 9. History of easy bleeding or bruising; 10. History of abnormal Pap smears.

Answer 4

1. Vital signs and general appearence : body habitus - is the patient over or underweight ? 2. HEENT : other sites of bleeding ? 3. Skin : look for petachiae or purpura; notice hair distribution and quality; 4. Abdominal exam : distention, bowel sounds, liver and spleen size, abdominal masses and tenderness; 5. Complete pelvic exam;

Answer 5

1. Structural : **PALM** 1. Polyps 2. Adenomyosis 3. Leiomyoma 4. Malignancy and hyperplasia 2. Nonstructural : **COEIN** 1. Coagulopathy 2. Ovulatory dysfunction 3. Endometrial infection or inflammation 4. Iatrogenic 5. Not yet classified 3. Pregnancy and pregnancy related : 1. Placental abruption 2. Ectopic pregancy

Answer 6

1. _Menometrorrhagia_ - Irregular or excessive bleeding during menstruation and between periods; 2. _Menorrhagia_ - Bleeding of **excessive** flow and **duration** that occurs at _regular_ intervals. 3. _Metrorrhagia_ - Bleeding that occurs at **irregular** intervals. 4. _Oligomenorrhea_ - Bleeding that occurs at intervals \> 35 days. 5. _Ovulation bleeding_ = single episode of spotting between regular menstrual periods. 6. _Polymenorrhea_ = Bleeding that occurs at intervals \< 21 days.

Answer 7

1. Complications related to pregnancy : 1. Normal intrauterine pregnancy 2. Ectopic pregnancy 3. Gestational trophoblastic disease 4. Spontaneous abortion 5. Placenta previa 6. Retained products of conception after therapeutic abortion 2. Abnormalities of the reproductive tract : 1. Benign lesions (cervical, endometrial, adenomyosis) 2. Malignant lesions (cervical, endometrial) 3. Infection (cervicitis, endometritis) 4. Trauma (laceration, abrasion, foreign body) 3. Systemic disease : 1. Endocrinopathy (hypothyroidism, hyperprolactinemia, Cushing's disease, PCOS, adrenal dysfunction/tumor) 2. Coagulopathy 3. Renal disease 4. Hepatic disease 4. Iatrogenic factors/medications : 1. Anticoagulation therapy 2. Intrauterine device 3. Hormone therapy 4. Psychotropic agents 5. DUB

Answer 8

1. **Threatened** abortion : diagnostic criteria for spontaneous abortion have not been met, but vaginal bleeding has occurred and the cervical os is closed; 2. **Missed** abortion : refers to clinical abortion in which the products of conception are not expelled spontaneously from the uterus - the woman has a nonviable intrauterine pregnancy that has not been passed and her cervical os is closed; Women may notice that symptoms associated with early pregnancy (eg, nausea, breast tenderness) have abated and they do not "feel pregnant" any more; 3. **Inevitable** abortion : The term inevitable abortion refers to cases in which the patient has vaginal bleeding, typically accompanied by crampy pelvic pain, and the cervix is dilated. Products of conception can often be felt or visualized through the internal cervical os. 4. **Complete** abortion : refers to cases in which the products of conception are entirely out of the uterus and cervix, and on examination the cervix is closed and the uterus is small and well contracted; vaginal bleeding and pain may be mild or may have resolved.

Answer 9

1. **Tell me more** about your bleeding. 2. Do you have any **other symptoms**? 3. What are you **most worried** about? 4. **When** did the bleeding start? 5. Was the onset **gradual or sudden**? 6. Can you **describe** the bleeding for me? =\> bright red? brownish? spotting? clots? 7. Is the bleeding **continous or intermittent**? 8. How many **tampoons or pads** do you have to use daily? 9. Have you noticed you have been passing some **tissues**? 10. When was your **LMP**? Is your period late? 11. Are your menstrual cycles **regular**? 12. What is the usual **interval** between periods? 13. Describe your **typical cycle** : how often? how regular? how many days? how heavy? 14. Do you have bleeding occurring **irregularly** between menstrual cycles? 15. Are you sexually active? Do you use condoms? 16. Do you have bleeding after **sexual intercourse**? 17. Do you have the following symptoms a few days before your period: breast fullness or tenderness, stomach bloating, low back pain, weight gain, mood changes? 18. Do you have : Fever? Vaginal discharge or itching? Milky nipple discharge? 19. Do you have easy bruising or **bleeding** from other sites? 20. Do you experience **hot flashes or night sweats**? Heat or cold intolerance? 21. What **medications** are you taking? Do you use OCPs? Have you recently started **OCPs**? Have you missed a pill? 22. Have you had any recent change in weight, chronic illness, or stress? 23. Have you recently stopped taking hormonal therapy? 24. Is it possible that you are pregnant ? Have you had a previous ectopic pregnancy or PID? 25. Have you had a recent pregnancy or a recent abortion? 26. Have you been forced to have sexual relations, or have you had sex that was rough or painful? 27. Are you having abnormal bleeding from any other site? Have you bruised easily recently? 28. Do you have a kidney or liver disease ?

Answer 10

1. CBC, platelet count 2. Urine bhCG 3. Blood type and cross 4. THS, prolactin 5. FSH/LH 6. INR/PT, aPTT 7. Transvaginal ultrasound 8. Endometrial biopsy if indicated 9. PAP smear

Answer 11

* Differential diagnosis : 1. **Dysfunctional uterine bleeding** 2. Coagulation disorder (von Willebrand’s disease, hemophilia, thrombocytopenia) 3. Cervical cancer 4. Molar pregnancy 5. Hypothyroidism 6. Diabetes mellitus * Workup plan : * Urine hCG * Pelvic exam * Cervical culture, Pap smear * CBC, ESR * Glucose * PT/PTT * LH/FSH, TSH, prolactin * U/S—pelvis

Answer 12

* Differential diagnosis : 1. Endometrial hyperplasia 2. Endometrial carcinoma 3. Cervical cancer 4. Atrophic endometrium 5. Leiomyoma 6. Endometrial polyp 7. Anticoagulant medications * Workup plan : 1. Pelvic exam 2. Pap smear 3. Endometrial biopsy 4. Endometrial curettage 5. U/S—pelvis 6. Colposcopy 7. Hysteroscopy

Answer 13

* Differential diagnosis : * Cervical cancer * Endometrial hyperplasia * Endometrial carcinoma * Cervical polyp * Cervicitis * Trauma - cervical laceration * Workup plan : * Pelvic exam * Pap smear * Colposcopy and biopsy * HPV testing * Endometrial biopsy

Answer 14

* Differential diagnosis : * Spontaneous abortion * Ectopic pregnancy * Molar pregnancy * Workup plan : * Urine hCG * Quantitative serum hCG * U/S—abdomen/pelvis * Pelvic exam * CBC * PT/PTT

Answer 15

* Differential diagnosis : 1. Ectopic pregnancy 2. Ruptured ovarian cyst 3. Ovarian torsion 4. Pelvic inflammatory disease * Workup plan : * Urine hCG * Quantitative serum hCG * U/S—abdomen/pelvis * Pelvic exam * Cervical cultures

Answer 16

1. Amount, color, consistency, odor, duration; 2. Associated vaginal burning, pain, pruritus; 3. Recent sexual activity; 4. Onset of LMP; 5. Use of contraceptives, tampons, douches; 6. History of similar symptoms; 7. History of STDs;

Answer 17

1. Vital signs; 2. Abdominal exam; 3. Complete pelvic exam;

Answer 18

* Differential diagnosis : * Bacterial vaginosis * Vaginitis—candidal * Vaginitis—trichomonal * Cervicitis (chlamydia, gonorrhea) * Workup plan ? * Pelvic exam * Wet mount, KOH prep, “whiff test” * pH of vaginal fluid * Cervical cultures

Answer 19

* Differential diagnosis : * Vaginitis - candidal * Bacterial vaginosis * Vaginitis - trichomonal * Workup plan ? * Pelvic exam * Wet mount, KOH prep, “whiff test” * pH of vaginal fluid * Cervical cultures

Answer 20

* Differential diagnosis : * Vaginitis - trichomonal * Vaginitis - candidal * Bacterial vaginosis * Cervicitis (chlamydia, gonorrhea) * Workup plan : * Pelvic exam * Wet mount, KOH prep, “whiff test” * pH of vaginal fluid * Cervical cultures

Answer 21

1. Duration, timing ? 2. Associated symptoms : 1. vaginal discharge 2. rash 3. painful menses 4. GI symptoms 5. hot flashes 3. Adequacy of lubrication; 4. Menopausal status; 5. Libido; 6. Sexual history; 7. History of sexual trauma or domestic violence; 8. History of endometriosis, pelvic inflammatory disease; 9. Prior abdominal/pelvic surgeries;

Answer 22

1. Vital signs; 2. Abdominal exam; 3. Complete pelvic exam;

Answer 23

* Differential diagnosis : * Atrophic vaginitis * Endometriosis * Cervicitis * Depression * Domestic violence * Workup plan : * Pelvic exam * LH/FSH * Wet mount, KOH prep * Cervical cultures

Answer 24

* Differential diagnosis : * Endometriosis * Cervicitis * Vaginismus * Vulvodynia * Pelvic inflammatory disease * Depression * Domestic violence * Workup plan : * Pelvic exam * Wet mount, KOH prep * Cervical cultures * U/S—pelvis * Laparoscopy * Endometrial biopsy

Answer 25

* **_SAFE GARDS_** : * Safety, Sex =\> Do you feel **SAFE** at home ? Was ever **SEX**ual contact forced on you? * Alcohol, Addiction =\> Does your husband abuse **ALCOHOL**? Does you husband have any **ADDICTIONS** - recreational drugs ? * Friends/Family, Fractures =\> Does anyone from your **FAMILY/FRIENDS** know about this ? Have you had any **FRACTURES**? * Emergency plan, Ever tried =\> Do you have an **EMERGENCY PLAN/EMERGENCY CONTACTS**? Have you **EVER TRIED** to escape ? * Guns at home =\> Are there any **GUNS**/weapons at home ? Are you afraid that / Do you think they could be used against you ? * Afraid/Attack =\> Are you **AFRAID** of your husband ? Has he ever **ATTACKED** your children or you ? * Relationships with husband =\> How is your **RELATIONSHIP** with your husband ? * **Depression** =\> Have you felt sad recently ? (SIGME CAPT), Have you lost weight ? How is your appetite ? * **Suicidal** (idea/plan/attempt) =\> Have you ever felt like ending it all up ? 1. Establish **confidentiality**; 2. Directly question about : **physical, sexual, emotional** abuse; 3. Directly question about : fear, safety, backup plan; 4. History of frequent accidents/injuries, mental illness, drug use; 5. Firearms in the home;

Answer 26

1. Establish confidentiality; 2. Ensure privacy; 3. Remain nonjudgemental; 4. Be emphatic; 5. Ask open-ended questions; 6. No pressure to disclose, report, press charges, or leave partner; 7. Ask if patient feels safe; 8. Determine if the patient has emergency safety plan; 9. Provide referrals for shelters, domestic violence agencies, ental health assistance;

Answer 27

1. Location of injuries : genitals, breasts, abdomen, head, neck, teeth; 2. Inconsistent explanation of injuries; 3. STDs; 4. Chronic pelvic pain; 5. Nonadherence to visits and treatment; 6. Frequent ED visits; 7. Overly attentive/intrusive partner; 8. Partner refuses to let the patient be seen alone; 9. Discomfort or refusal to undress or consent to genital/rectal examination; 10. Distressed affect : fearful, tearful, evasive;

Answer 28

1. I noticed you have a number of bruises, could you please tell me how did these occur ? 2. Are you currently in a relationship you are physically, emotionally or sexually hurt ? 3. Do you feel threatened ? Do you feel safe ? 4. Have you ever been attecked with a weapon ? 5. How long have you been in this relationship ? 6. Has this ever happened before ? 7. Are you afraid it will happen again ? 8. Has anyone ever made you have sex when you didn't want to ? 9. How are things btw your children and your partner ? Has he ever used violence against them ? 10. Does the person you live with use alcohol or drugs ? 11. Have you ever left home ? Have you ever felt you could leave ? What prevented you from doing this ? 12. Are you planning to leave your partner ? 13. Has your partner ever threatened or tried to commit suicide ? 14. Do you think of suicide as a way to escape this relationship ? 15. Do you have a plan that involves suicide or homocide ? 16. Are your friends or family aware of this situation ? 17. Who lives at home with you now ? 18. Where do you go when you are not at home ? 19. Smoking / alchohol / recreational drug use ?

Answer 29

1. Vital signs 2. Complete exam 3. Pelvic exam * Patient with history of domestic abuse may refuse to undress/disrobe =\> when this happens =\> explain the reason why you want to perform physical examination and why you and patient need this =\> if patient is still resistant =\> abide by these wishes and move on;

Answer 30

1. Patient is ashamed, fearful, often believes that there is no alternative and feels abuse is deserved; 2. Affirm that **any abuse is wrong** but **avoid counseling** the patient in a directive way; 3. Confrontation of denial, pressuring the patient to report the abuse, or urging the patient to leave the partner is **_inappropriate_**. 4. Physicians also should **_not confront or discuss suspected abuse_** with the partner as this can endanger the patient. 5. Physicians should **assess the immediate and future safety** of patients with intimate partner violence. 6. The most important initial intervention is **_identification of an emergency safety plan_** (eg, "Where is a safe place that you can go when you are afraid?"); 7. Discuss **community resources**, including domestic violence shelters and counseling services.

Answer 31

1. Remember =\> **_You should not order tests that are not otherwise medically indicated_** "just in case" 2. Plain film radiographs; 3. CT scan in case of craniofacial injuries; 4. Nucleic acid amplification testing for chlamydia and gonorrhea (swab sites of exposure); 5. HIV screen 6. Hepatitis B screen 7. VDRL or RPR screen for syphilis 8. Pregnancy test

Answer 32

* Differential diagnosis : * Domestic violence * Osteogenesis imperfecta * Substance abuse * Consensual violent sexual behavior * Workup plan : * XR : skeletal survey * CT : maxillofacial * Urine toxicology * CBC

Answer 33

* Differential diagnosis : 1. Rape 2. Domestic violence * Workup plan : * Forensic exam (sexual assault forensic evidence [SAFE] collection kit) * Pelvic exam * Urine hCG * Wet mount, KOH prep Cervical cultures * Chlamydia and gonorrhea testing * XR : skeletal survey * CBC * HIV antibody * Viral hepatitis serologies

Answer 34

* Questions you will ask : * When did this happen ? * Did you know, recognize the person who did this to you ? Did you recognize the assailants? * Where did it happen ? * Did you report it ? * Could you please describe what happened using your own words ? I know it must be difficult, but will tell me what could have happened to you and how can I help. * Did they physicaly hurt you, did they use objects ? did they use any kind of weapon ? * Did they force you to have sex ? * Did they use condoms ? * Did ejaculation occur ? * What type of intercourse was it ? * Did they use foreign objects ? * When was your LMP ? * Do you use OCPs ? * Do you feel any pain ? =\> if yes =\> location, radiation, quality, intensity, alleviating, aggreviating, precipitating factors; * Have you noticed any bleeding ? * Have you noticed any bruises ? * Have you lost consciousness ? * Associated symptoms : * headache, dizziness * changes in vision, hearing * weakness/numbenss/tingling * SoB, chest pain, palpitations, any breathing problems * Blood in stool, urine ? * Vaginal bleeding ? * Nasuea, vomiting ? * Belly pain ? * Joint pain ? * PMH, Meds, Allergies, PSH, HITS, FH, SH; * Physical exam to perform : 1. Head and neck : inspect, palpate (20 sec) 2. Oropharynx : inspect (5 sec) 3. CV : auscultate (20 sec) 4. Chest : inspect, palpate, percuss, aucultate (1 min) 5. Abdomen : inspect, auscultate, palpate (1 min) 6. Neuronal : mental status, cranial nerves, gross motor (1 min) 7. Musculoskeletak : inspect, palpate (30 sec)

Answer 35

"Ms. X, **I am really sorry** for what happened to you. I want to emphasize that **it is not your fault**, and you should **not feel guilty** about it. I _recommend_ that you **report** the incident to the police. In the meantime, I will need to do a **pelvic examination** _to_ make sure you have no injuries in the genital area. In addition, I will need to collect some **specimens and swabs** from your body and genital area _so that_ they can be used as evidence if you choose to file charges, and also to look for **STDs**. We will run some blood tests for potential STDs and will order a **pregnancy test** and some **x-rays.** If your pregnancy test is negative, we will offer you some **options for emergency contraception**. It would also be prudent to give you some **antibiotics** to protect you from infections. Finally, I can have our **social worker** come talk to you and provide you with phone numbers for **support groups** and other resources. Do you have **any questions** for me?"

Answer 36

1. Location, quality, intensity ? 2. Duration, pattern ? 3. **Small** vs. **large** joints ? 4. **Symmetrical** or unsymmetrical ? 5. **Number** of joints involved ? 6. Associated **swelling, redness, warmth**? 7. Associated symptoms : 1. **Constitutional** - fever, chills, weight loss, night sweats; 2. Red **eyes**? Skin discoloration ? 3. Oral or genital **ulceration**? 4. **Diarrhea**? vomiting, nausea ? 5. **Dysuria**? 6. Jaundice, rash ? 7. Focal numbness/weakness ? 8. Morning stiffness ? 8. Exacerbating and alleviating factors ? 9. Trauma (including vigorous exercise) ? 10. Medications ? 11. DVT risk factors; 12. Alcohol and drug use ? 13. Family history of rheumatic disease ?

Answer 37

1. Vital signs 2. HEENT 3. Musculoskeletal exams 4. Relevant neurovascular exam

Answer 38

* Msny **nonmusculoskeletal** disorders _refer pain_ to the shoulder; * Shoulder ROM involves **4 articulations :** * ****glenohumeral * acromioclavicular * sternoclavicular * scapulothoracic * Think of associated **ligaments**, **tendons**, **bursae**, **muscles**, and **neurovascular** bundles; * Most shoulder pain can be diagnosed by **history and physical examination**.

Answer 39

* **Musculotendinous** structure blending into the glenohumeral joint capsule; * Provides range of motion and strenght; * Composed of the insertions of the following **4 tendons** : 1. Supraspinatus 2. Infraspinatus 3. Teres minor 4. Subscapularis

Answer 40

* Intrinsic pain = moving parts pain * Extrinsic pain = referred shoulder pain * Intrinsic pain = pain related to structures of the shoulder, including bones, joints, muscles, bursae, tendons, ligamnets; typically exacerbated by shoulder movement. * Extrinsic pain = pain referred from a process in a nonshoulder area or organ perceived as shoulder discomfort. Typically, pain is unrelated to shoulder movement.

Answer 41

* collection of symptoms and signs; * these S&S result from compression of the rotator cuff tendons (supraspinatus, infraspinatus, teres minor, subscapularis) and subacromial bursa btw the humeral head and lateral acromion process; * occurs in many different shoulder conditions;

Answer 42

* inflammation of subacromial bursa; * usually causes symptoms of impingement syndrome, and often coexists with rotator cuff tendinoptahy;

Answer 43

* Degenerative changes within the rotator cuff tendons leading to pathology ranging from simple **inflammation to fibrosis** with resultant rotator cuff tears. * Patients usually have the impingement syndrome.

Answer 44

**Calcification** of a rotator cuff tendon, usually the supraspinatus, proposed to be part of the degenerative process of rotator cuff tendinopathy.

Answer 45

Overuse syndrome of the long head of the biceps tendon, usually producing **anterior shoulder pain**.

Answer 46

Osteoarthritis in the joint between the acromion and clavicle. Usually develops in people who do repetitive **overhead work** or lots of **overhead lifting** (eg, bodybuilders). Usually produces focal pain over the acromioclavicular joint and pain when reaching across the body.

Answer 47

Disruption of the ligaments that attach the acromion to the clavicle, resulting in "separation" of the **acromioclavicular** joint. Usually caused by fall or blow to tip of the shoulder or fall on an outstretched hand.

Answer 48

Painful restriction of both active and passive range of motion of the glenohumeral joint in all planes of motion. Usually the end result of other shoulder disorders.

Answer 49

* Chest disorders : * Myocardial infarction * Angina pectoris * Pericarditis * Aortic dissection * Pulmonary embolism * Pneumothorax * Pneumonia * Pleuritis * Pancoast tumor * Mesothelima * Mediastinal or lung neoplasm * Esophageal disease * Abdominal and Pelvic disorders * Left shoulder pain : Splenic infarction, Splenic rupture; * Right shoulder pain : Hepatic abscess, Cholecystitis, Hepatic hematoma; * Left and/or Right shoulder pain : subphrenic abscess, intraabdominal hemorrhage, ruptured abdominal viscus, aneurysm, vascular insufficiency including arteritis, venous thrombosis, peptic ulcer, pancreatitis, abdominal neoplasms, ectopic pregnancy; * Neurologic causes : * cervical radiculopathy * brachial plexopathy * entrapment neuropathy * herpes zoster * cervical spinal stenosis * thoracic outlet syndrome

Answer 50

1. **Impingement syndrome**/**rotator cuff tendinitis** =\> includes full and partial tears 2. **Frozen shoulder/capsulitis** 3. **Calcific tendinitis** 4. Rotator cuff tear 5. Biceps tendinitis 6. Glenohumeral instability 7. Acromioclavicular syndromes 8. Glenoid labrum tear 9. Inflammatory arthritides including rheumatoid, crystal-associated, reactive, etc 10. Infection of joint or soft tissues 11. Osteoarthritis 12. Polymyalgia rheumatica 13. Osteonecrosis

Answer 51

1. **Rotator cuff impingement or tendinopathy :** * ****Pain with abduction, external rotation * Subacromial tenderness * Normal range of motion with positive impingement tests (Neer, Hawkins) 2. **Rotator cuff tear :** 1. Similar to rotator cuff tendinopathy 2. Weakness with external rotation 3. Age \>40 3. **Adhesive capsulitis (frozen shoulder)** 1. Decreased passive & active range of motion 2. More stiffness than pain 4. **Biceps tendinopathy/rupture :** 1. ****Anterior shoulder pain 2. Pain with lifting, carrying, or overhead reaching 3. Weakness less common 5. **Glenohumeral osteoarthritis** 1. Uncommon & usually caused by trauma 2. Gradual onset of anterior or deep shoulder pain 3. Decreased active & passive abduction & external rotation

Answer 52

* "Tell me about your shoulder pain, starting from when you very first felt it" * Detail the **nature of the onset** of the shoulder pain, particularly if there was any **preceding trauma**. * **Key features** of the shoulder pain: location, pain character, duration, frequency, exacerbating factors, especially movement of the shoulder, alleviating factors; * Occupational or recreational activities; * **Overhead** work or play (eg, **carpentry, painting, throwing**) predisposes to impingement syndrome or rotator cuff tendinopathy. * Pain in **other joints =\>** systemic condition. * Obtain **PMH** : injuries, prior surgery, history of arthritis, DM =\> predisposes to adhesive capsulitis; * Effect of shoulder pain on patient's functioning;

Answer 53

1. Tell me about your pain. 2. When did this pain begin? 3. Did the pain come on suddenly, or was it more gradual? 4. Did you injure your shoulder recently or fall? 5. Point to the location of pain in your shoulder. 6. Does the pain radiate? How severe is the pain? 7. What does the pain feel like? 8. What makes it better or worse? 9. Is it constant or intermittent? 10. Have you noticed redness or swelling in the shoulder? 11. What movements make the pain worse? Is it all motions or only certain directions? 12. Does reaching over your head aggravate your pain? 13. Do you have night pain or difficulty sleeping on the affected side? 14. What other joints are involved? 15. Do you notice any associated symptoms such as fever, night sweats, or weight loss? 16. Do you have stiffness relieved by activity and worsened by rest? 17. Do you have stiffness in the morning lasting greater than 60 minutes that improves with activity? 18. Is your shoulder constantly stiff? 19. Have you taken high doses of glucocorticoids? 20. Is your shoulder weak? 21. Do your arms feel weak? 22. Do you notice numbness, tingling, a sensation of burning, or a pins and needles sensation? 23. What kind of work do you do? 24. What kind of recreations do you pursue? 25. Is your shoulder unstable? Does it slip or "pop out"? 26. Does your shoulder catch or lock? 27. How is this affecting your daily activities? 28. Have you taken medications for the pain? If so, did they help? 29. Do you have any other health problems?

Answer 54

1. Musculoskeletal : 1. Inspect for swelling, deformity, redness. 2. Palpate for warmth or tenderness. 3. Check range of motion (passive & active), including flexion, extension, abduction & adduction. 4. Perform specific maneuvers as appropriate. 5. Examine both shoulders for comparison. 6. Examine the cervical spine, sternoclavicular joint & elbow. 2. Skin : examine for rash; 3. Neurologic : reflexes, motor function, sensory examination in arm and hand;

Answer 55

* Differential diagnosis : 1. **Shoulder dislocation** 2. Fracture of the humerus 3. Rotator cuff injury/tear 4. Glenoid labrum tear 5. Fracture of the clavicle * Workup plan : * XR—shoulder * XR—arm * MRI—shoulder

Answer 56

1. Lateral epicondylitis (tennis elbow) 2. Medial epicondylitis (golfer's elbow) 3. Olecranon bursitis 4. Ulnar tunnel syndrome or Guyon tunnel syndrome 5. Referred pain from chest structures 6. Cubital tunnel syndrome 7. RSD/CRPS : reflex sympathetic dystrophy/chronic regional pain syndrome

Answer 57

1. Carpal tunnel syndrome 2. de Quervain tenosynovitis 3. Intersection syndrome

Answer 58

1. Trigger finger 2. Hand osteoarthritis 3. Rheumatoid arthritis 4. Raynaud's disorder 5. Thoracic outlet syndrome

Answer 59

1. Where is the pain? 2. When did it start? 3. Can you describe it for me? Is it dull? Sharp? Burning? 4. Does it ever change? 5. Is there swelling? Is there a rash or discoloration? 6. Is there anything that makes it worse/better ? 7. Show me how you use your arms at work. 8. Tell me about your leisure time activities. 9. What is your occupation? 10. Is the pain: Steady? Aching? Shooting? Sharp? Burning? Severe? Throbbing? 11. Where do you have pain? 12. Is the pain related to an activity? 13. Is there anything that makes the pain stronger or weaker ? 14. How does this affect you daily living ? 15. Do you have any associated symptoms ? 16. Do you drink? If so, how much?

Answer 60

* Differential diagnosis : * **Carpal tunnel syndrome** * Median nerve compression in the forearm or arm * **Radiculopathy** of nerve roots C6 and C7 in the cervical spine * De Quervain’s tenosynovitis * Workup plan : * Phalen’s maneuver and Tinel’s sign * Finkelstein’s test =\> used to diagnose de Quervain's tenosynovitis * Nerve conduction studies EMG

Answer 61

* Differential diagnosis : * Systemic lupus erythematosus (SLE) * Rheumatoid arthritis * Psoriatic arthritis * Parvovirus B19 infection * Workup plan : * ANA, anti-dsDNA * ESR * C3, C4 * RF, CCP * CBC * XR—hands * UA * Antibody titers for parvovirus B19

Answer 62

* Differential diagnosis : * Rheumatoid arthritis * SLE * Disseminated gonorrhea * Arthritis associated with inflammatory bowel disease * Workup plan : * XR—hands, left knee * ANA, anti-dsDNA, ESR, RF, CCP * CBC * Cervical culture * Arthrocentesis and synovial fluid analysis

Answer 63

* Differential diagnosis : * Psoriatic arthritis * Rheumatoid arthritis * SLE * Gout * Workup plan : * ANA, ESR, RF, CCP * CBC * XR—hands * XR—pelvis/sacroiliac joints * Uric acid

Answer 64

* Differential diagnosis : * Tennis elbow (lateral epicondylitis) * Stress fracture * Workup plan : * XR : arm * Bone scan * MRI : elbow

Answer 65

* Differential diagnosis : * Disseminated gonorrhea * Rheumatoid arthritis * SLE * Reiter’s syndrome (reactive arthritis) * Workup plan * Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture) * ANA, anti-dsDNA, ESR, RF, CCP * CBC * Blood, cervical cultures * XR—knee

Answer 66

1. **Coccydynia** - can follow falls, childbirth, repetitive strain, surgery 2. **Sciatica** - herniated disk, spinal stenosis, obturator foramen stenosis or hernia, piriformis syndrome; 3. **Hamstring/ischial tuberosity syndrome** - during and following activities like running, sports that require bursts of speed or rapid acceleration, such as track, soccer, and football; 4. **Piriformis syndrome;** 5. **RSD/CRPS;**

Answer 67

1. Lateral femoral cutaneous nerve (LFCN) syndrome or meralgia paresthetica; 2. Quadriceps muscle strain or tear 3. Hamstring strain; 4. Trochanteric bursitis 5. Lumbar radiculopathy (L2, L3), lumbar facet syndrome 6. Iliopsoas bursitis/tendinitis, iliopsoas syndrome ("snapping hip syndrome") 7. Hip adductor strain or "groin pull," also called "gracilis strain," 8. ITB syndrome ("runner's knee") 9. DVT of the thigh 10. Entrapment neuropathies 11. Avascular necrosis of the femoral head 12. Hip fracture 13. Hip osteoarthritis 14. Rheumatoid arthritis

Answer 68

1. Where is the pain? When did it start? 2. Can you describe it for me? Is it dull, sharp, or burning? Does it ever change? 3. Is there swelling? Is there a rash or discoloration? 4. What activity makes it better or worse? 5. Can you bear weight? 6. Tell me about your leisure time activities. Tell me about your work. 7. Quality : Steady? Aching? Shooting? Sharp? Burning? Severe? Throbbing? Related to activity? 8. Where do you have pain? In or around what joint? 9. Does the pain wax and wane? 10. Was the onset of pain: Sudden? Gradual? 11. Is the pain: Greatest in the morning? Worse with prolonged use of the joint? 12. Do you have: Fever or chills? Numbness, tingling, or burning in the leg? Swelling, redness, or dyspnea?

Answer 69

1. Loss of bowel or bladder control or persistent sensory abnormalities (eg, numbness, burning, or tingling), especially if associated with back complaints ! 2. Inability to bear weight ! 3. Painful redness and swelling of the thigh, particularly over the common femoral vein !

Answer 70

* Differential diagnosis : * Hip fracture * Hip dislocation * Pelvic fracture * Workup plan : * XR—hip/pelvis * CT or MRI—hip * CBC, type and cross * Serum calcium and vitamin D * Bone density scan (DEXA)

Answer 71

* Differential diagnosis : * Hip dislocation : traumatic * Hip fracture * Workup : * XR : hip * CT or MRI : hip * CBC, type and cross * PT/PTT * Urine toxicology and blood alcohol level

Answer 72

* Differential diagnosis : * Peripheral vascular disease (intermittent claudication) * Leriche syndrome (**aortoiliac occlusive disease**) * Lumbar spinal stenosis (pseudoclaudication) * Osteoarthritis * Workup plan : * **Ankle-brachial index** * Doppler U/S—lower extremity * Angiography MRI—L-spine

Answer 73

* Differential diagnosis : * **Rhabdomyolysis due to statins** * Polymyositis * Inclusion body myositis * Workup plan : * CBC * Phosphate, potassium, * BUN/Cr, glucose, calcium, uric acid CPK * Aldolase * UA * Urine myoglobin

Answer 74

1. **Buckling** : complete **collapse** of the knee, often secondary to pain or muscle weakness of the quadriceps. 2. **Effusion** : fluid accumulation in the knee joint causing **swelling**. 3. **Giving way** : symptom usually associated with **ligamentous** injuries. Occurs with normal walking, but may be most prominent during pivoting movements, such as quick changes in **direction**. Results from a bony structure sliding on another in an abnormal way. 4. **Intermittent claudication** : an aching, crampy, sometimes burning pain in the legs that typically occurs with walking and goes away with rest. 5. **Locking** : when the knee becomes stuck, usually in 45 degrees of flexion, and patient is unable to unlock the knee without manipulating it in some fashion. 6. **Pseudolocking** : occurs with arthritis, when an adjecent rough articular surfaces stick momentarily as they glide over one another.

Answer 75

1. Unclassified strains/sprains 2. Osteoarthritis 3. Meniscal tear 4. Collateral ligament injury 5. Cruciate ligament injury 6. Gout 7. Fracture 8. Rheumatoid arthritis 9. Infectious arthritis 10. Pseudogout

Answer 76

* Anterior knee pain * Patello-femoral syndrome * Prepatellar bursitis * Patellar fracture * Patellar tendinitis * Quadriceps femoris strain * Osteoarthritis * Posterior knee pain * Bursitis - semimemranous, popliteal, gastrocnemius * Baker's cyst rapture * Harmstring strain * Deep venous thrombosis * Popliteal aneurysm * Osteoarthritis * Medial knee pain * Osteoarthritis * Medial meniscal tear * Medial colateral ligament sprain * Anserine bursitis * Hamstring - semimembranous strain * Patello-femoral syndrome * Lateral knee pain * Lateral meniscal tear * Lateral colateral ligament sprain * Iliotibial band syndrome * Biceps femoris strain * Fibular head fracture/dislocation

Answer 77

1. Knee laxity : 1. anterior cruciate ligament tear 2. posterior cruciate ligament tear 3. lateral collateral ligament tear 4. medial collateral ligament tear 2. Knee locking or clocking : 1. medial meniscal tear 2. lateral meniscal tear 3. Acute swelling : 1. anterior cruciate ligament tear 2. posterior cruciate ligament tear 3. patellar fracture 4. tibiofemoral dislocation 4. Deleyed swelling : 1. medial meniscal tear 2. lateral meniscal tear 5. Swelling without known trauma : 1. septic knee 2. acute gout/pseudogout attack 3. degenerative meniscal tear 4. gonococcal infection

Answer 78

1. Tell me about your knee/calf problem. 2. Point with one finger to the area that is bothering you. 3. Describe the first time you felt this pain, and what exactly were you doing at that time. 4. If there was trauma : was there twisting/rotating, external force, knee in full extension ? 5. Was there anything that could cause this pain ? 6. Is it there all the time, or does it come and go ? 7. What is it like at different times of the day ? 8. Have you ever had this problem before ? 9. Did the pain have a sudden or acute onset ? 10. Can you tell me how severe is the pain - if you were to rate it from 0-10 ? 11. Is there anything that makes the pain worse or better ? 12. Have you noticed any other symptoms except for pain : like swelling ? stiffness ? redness ? warmth ? fever ? chills ? rash ? 13. Have you noticed that there are some movements that you no longer can do ? Like bending the knee ? 14. If swelling occured - was it immediate or delayed ? 15. Does it limit your daily activities ? 16. Have you noticed locking of the knee in some positions ? Have you heard any click sound while you walk ? 17. Does the pain wake you up at night ? 18. Have you tried anything to treat the pain ? 19. Do you do any sports ? 20. What do you do for work ? 21. Now I am going to ask you some personal questions, as these will be very helpful to making diagnosis. Are you sexually active ? Are your partners males/females/both ? How many partnert have you had during the last year ? Do you use condoms ? Do you use any form of contraception ? Thank you for answering :)

Answer 79

1. **_Anterior knee pain_** 1. **Patellar fracture**: history of _fall or trauma_ to the anterior knee. 2. **Patellofemoral syndrome**: pain aggravated by _walking up stairs or a hill or rising_ from a seated position. 3. **Prepatellar bursitis**: swelling over the patella with history of _kneeling_, for example, in a bricklayer or mason 4. **Patellar tendinitis**: pain at the _superior or inferior_ aspect of the patella, aggravated by _flexing and extending_ the knee 2. **_Lateral knee pain_** 1. **__****Meniscal tear**: history of trauma, a _popping sound_, and swelling of the knee _hours after_ the injury; also consider in patients who have known _osteoarthritis_ and lateral pain with _intermittent or persistent swelling_ 2. **Iliotibial band syndrome**: occurs most commonlu in _runners / joggers_; tenderness is greatest slightly distal to the lateral joint line 3. **Fibular head fracture**: history of trauma and pain over the fibular head 3. **_Medial knee pain_** 1. **Meniscal tear**: history of trauma, a popping sound, and swelling of the knee hours after the injury; also consider in patients who have known osteoarthritis and lateral pain with intermittent or persistent swelling 2. **Anserine bursitis**: pain aggravated when the patient lays on his or her side at night with legs together 4. **Posterior knee pain** 1. **Baker cyst:** fullness or tightness in the posterior knee with decreased flexion 2. **Hamstring strain**: increased activity level or recently started a new activity 3. **Deep venous thrombosis**: pain and swelling in the corresponding calf

Answer 80

* Differential diagnosis : * Osteoarthritis * Pseudogout/Gout * Meniscal or ligament damage * Workup plan : * XR - knee, MRI - knee * CBC, ESR * Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals) * Uric acid

Answer 81

* Differential diagnosis : * **Septic arthritis** * Gout/Pseudogout * Lyme arthritis * Trauma * Reiter’s syndrome (reactive arthritis) * Workup plan : * CBC * Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals) * Blood, urethral cultures * XR—knee * Uric acid * Lyme titers—IgG and IgM

Answer 82

1. **Intermittent claudication** 2. **DVT - Deep Vein Thrombosis** 3. **Cellulitis** 4. Popliteal artery entrapment syndrome (young individuals without atherosclerotic risk factors) 5. Gastrocnemius or soleus muscle tear or contusion 6. Distal dissection of a Baker cyst 7. Soft tissue sarcoma

Answer 83

1. Plese describe your calf pain for me? 2. Where is it localized? Can you please show me where it hurts? 3. Does the pain go anywhere? Can you feel the pain somewhere else as well? 4. How long have you been having this pain? 5. Was it sudden/acute in onset? Or it was progressively getting worse? Is it steady now? 6. Is it there all the time or it comes and goes? 7. Can you think of anything that could couse this pain? 8. Do you recall the first time you felt this pain? Can you describe what you were doing when you first felt this pain? 9. Is there anything that makes the pain become greater? 10. Does the pain occur with walking? How much distance / for how long can you walk before you feel the pain? Can you feel the pain while you are resting? 11. Is there anything that makes the pain become lesser/smaller? Is the pain relieved with rest? 12. Do you feel the pain after the same distance every time? 13. Is the pain on one side or both sides? 14. Have you ever had a wound on your leg that was difficult to heal ? 15. How does this pain affect you? your daily activities? What concerns you most about this pain? Were you forced to change your lifestyle because of this pain? 16. Is it difficult for you to move your leg? 17. Have you had any recent surgeries? Were you ill recently and had to stay in bed for a while? Were you hospitalized recently? 18. Have you had any leg injuries? 19. Were you diagnosed with any medical conditions? Like cancer, high blood pressure, blood disorder, heart problems, joint problem? Do you have diabetes? 20. Have you noticed that your leg is swollen? red? more warm than usually? stiff? painful when you touch it? 21. Do you have any varicose veins? enlarged veins/vessels on your legs? 22. Do you take any medications ? Do you take OCPs ? anabolic steroids? 23. Do you do any sports? What do you do for living?

Answer 84

* Differetntial diagnosis : * **Peripheral vascular disease (intermittent claudication)** * Leriche syndrome (aortoiliac occlusive disease) * Lumbar spinal stenosis (pseudoclaudication) * Osteoarthritis * Workup plan : * Ankle-brachial index * Doppler U/S : lower extremity * Angiography * MRI : L-spine

Answer 85

* Differential diagnosis : * **DVT** * Baker’s cyst rupture * Myositis * Cellulitis * Superficial venous thrombosis * Workup plan : * Doppler U/S : right leg * CBC * D-dimer

Answer 86

* Differential diagnosis : * Rhabdomyolysis due to statins * Polymyositis * Inclusion body myositis * Workup plan : * CBC * Phosphate, potassium, * BUN/Cr, glucose, calcium, uric acid * CPK * Aldolase * UA * Urine myoglobin

Answer 87

1. _Callus_ - a surface of a hardened skin which is found in areas of the body subjected to pressure or friction; 2. _Corn_ - an area of thickened and hard skin found on or btw the toes; 3. _Deltoid ligament_ : is a triangular-shaped ligament found on the medial side of the ankle, it connects the tibia to navicular, calcaneous and talus; 4. _Eversion_ : turning outward of the ankle; the plantar aspect of the foot is directed medially; 5. _Inversion_ : turning inward of the ankle; the plantar aspect of the foot is directed lateraly; 6. _Forefoot_ : includes toes and the distal aspect of metatarsals; 7. _Midfoot_ : area between distal metatarsals and beginning of the calcaneus; 8. _Hindfoot_ : includes the entire heel; 9. _Sprain_ : an injury to a **ligament** caused by sudden **stretching;** 10. _Pronation_ : the act of turning the foot outward so that the lateral margin of the foot is elevated; 11. _Supination_ : the act of turning the foot inward so that the medial margin is elevated;

Answer 88

* Lateral ankle pain : 1. Lateral ligament sprain =\> anterior talofibular ligament (**ATFL**) sprain MC; 2. Distal fibular fracture 3. Chornic ankle instability 4. Peroneal tendonitis * Medial ankle pain : 1. Deltoid ligament sprain 2. Posterior tibial tendinitis 3. Tarsal tunnel syndrome 4. Distal tibial fracture * Posterior ankle pain : 1. Achilles tendinitis 2. Achilles tendon rupture 3. Haglund's deformity 4. Retrocalcaneal bursitis 5. Pre-Achilles bursitis * Chronic ankle pain : * Rheumatoid arthritis (RA) * Gout * Pseudogout * Reactive arthritis

Answer 89

* Forefoot pain : 1. Ingrown toenails 2. Metatarsalgia 3. **Interdigital neuromas**: Morton neuroma 4. Hallux rigidus 5. Sesamoiditis 6. Bunionette 7. Callus, Corn, Warts 8. Metatarsal stress fracture * Midfoot pain : 1. Osteoarthritis 2. Midfoot plantar fasciitis 3. Plantar fibromas 4. Tarsal tunnel syndrome 5. Pes planus, Pes cavus * Hindfoot pain : * Pain at plantar anterior heel or arch : Plantar fasciitis * Posterior heel pain : Achilles tendinitis, Haglund's deformity, Retrocalcaneal bursitis, Pre-Achilles bursitis, Achilles rupture * Plantar heel : calcaneal fracture * Plantar surface : plantar warts

Answer 90

1. _Fever, ulceration, skin redness and warmth_: Cellulitis, Septic arthritis; 2. _History of trauma with inability to bear weight_: Fracture; benign: bone contusion, sprain; 3. _Pain on weight bearing, swelling after a recent increase in activity_: Stress fracture; benign: plantar fasciitis; 4. _Persistent rolling in or out of the foot_: Ligamentous instability; Posterior tibial dysfunction; benign: weakness of the muscles supporting the ankle; 5. _Pain on the medial aspect of the ankle anterior to the medial malleolus_: Deltoid ligament sprain; 6. _Inability to walk 4 steps immediately after injury or during initial evaluation_: Ankle fracture; 7. _Numbness, weakness in the foot_: Fracture with compromise of a nerve; 8. _Feeling of being shot or kicked in the back of the ankle, sometimes with an audible pop_: Achilles tendon rupture;

Answer 91

1. Where does it hurt? 2. What does the pain feel like? 3. How severe is the pain? 4. Can you rate the pain on a scale of 0 to 10? 5. What is the pain like at different times during the day or with different activities? 6. Did the pain develop quickly over hours or insidiously (over weeks or months)? 7. Is it intermittent or constant? 8. What aggravates the pain? 9. What relieves the pain? 10. Do you have any associated symptoms such as swelling, stiffness, or fever? 11. What type of work do you do now? What work have you done in the past? What sports do you play? What have you played in the past? 12. What activities can you not do now that you could do before developing the pain? Are there any activities you have stopped due to the pain? 13. Are you having problems wearing your shoes? 14. Do your shoes rub on your big toe? 15. Is there rubbing on any other toes? 16. Does the weight of a sheet cause pain in your toe? 17. Are any of your toes numb? 18. Is there pain between your toes? 19. Do tight shoes make your toes tingle? =\> Tarsal tunnel 20. Do you have diabetes mellitus? 21. Do you have pain at night? 22. Do you have burning? 23. Do you have tingling? 24. Do you have progressive deformity? 25. Is the pain in your heel at its worst when you first step on it? 26. Does the pain improve with non–weight bearing? 27. Do you have tingling and burning along the bottom of your foot? 28. Was there any twisting or rotation of the ankle? 29. Did you land on the side of your foot? 30. Do have any lumps on the back of your heel? 31. Does the back of your ankle hurt when climbing stairs? 32. Is there swelling around the back of your ankle? 33. Are your shoes rubbing the inside of your ankle? 34. Have you had any past injuries to your ankle?

Answer 92

* Differential diagnosis : * Stress fracture * Plantar fascitis * Foot sprain or strain * Workup : * XR - foot * MRI - foot

Answer 93

* Differential diagnosis : * Plantar fasciitis * Heel fracture * Splinter/foreign body * Workup plan : * XR - heel Bone scan - foot

Answer 94

1. **Plantar fasciitis**: pain maximum upon first stepping out of bed; local point tenderness with dorsiflexion of the toes; 2. **Ruptured plantar fascia**: sudden-onset pain; loss of height of the arch, visible swelling or ecchymosis; 3. **Bone infection/metastasis**: constant throbbing pain, nocturnal worsening; 4. **Calcaneal stress fracture**: worse with activity, palpation of the bone elicits tenderness; 5. **Tarsal tunnel syndrome**: pain, paresthesia & numbness on the sole of the foot, percussion tenderness over the posterior tibial nerve in the tarsal tunnel;

Differential diagnosis and mini cases - Erectile dysfunction, Amenorrhea, Vaginal bleeding, Vaginal discharge, Dyspareunia, Abuse, Limb/joint pain Flashcards

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