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Flashcards in Joint/limb pain Deck (20):
1

Key history in joint/limb pain

Location, quality, intensity, duration, pattern (small vs. large joints; number involved; swelling, redness,
warmth), associated symptoms (constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash,
focal numbness/weakness), exacerbating and alleviating factors; trauma (including vigorous exercise);
medications; DVT risk factors; alcohol and drug use; family history of rheumatic disease

2

Key physical exam in joint/limb pain

Vital signs; HEENT and musculoskeletal exams; relevant neurovascular exam

3

30 yo F with wrist pain and black eye after tripping, falling and hitting head on edge of table
+ anxious
+ inconsistent story

Domestic abuse
Factitious disorder
Substance abuse

XR—wrist
CT—head
Urine toxicology

4

30 yo F secretary with wrist pain and sensation of numbness and burning in palm and first, second and third fingers of R hand
+ pain worst at night and relieved by loose shaking of hand
+ sensory loss in same fingers
+ positive Tinel's sign

Carpal tunnel syndrome
Median nerve compression in forearm or arm
Radiculopathy of nerve roots C6 and C7 in cervical spine
De Quervain's tenosynovitis

Phalen's maneuver and Tinel's sign
Finkelstein's test
Nerve conduction study
EMG

5

28 yo F with pain in interphalangeal joints of hands
+ hair loss
+ butterfly rash on face

Systemic lupus erythematosus (SLE)
Rheumatoid arthritis
Psoriatic arthritis
Parvovirus B19 infection

ANA, anti-dsDNA, ESR, C3, C4, rheumatoid factor (RF), CCP
CBC
XR—hands
UA
Antibody titers for parvovirus B19

6

28 yo F with pain in metacarpophalangeal joints of hands
+ left knee also painful and red
+ morning joint stiffness lasting about one hour
+ mother had rheumatoid arthritis

Rheumatoid arthritis
SLE
Disseminated gonorrhea
Arthritis associated with inflammatory bowel disease

XR—hands, left knee
ANA, anti-dsDNA, ESR, RF
CBC
Cervical culture
Arthrocentesis and synovial fluid analysis

7

18 yo M with pain in interphalangeal joints of both hands
+ scaly, salmon-pink lesions on extensor surfaces of elbows and knees

Psoriatic arthritis
Rheumatoid arthritis
SLE
Gout

ANA, ESR, RF, CCP
CBC
XR—hands
XR—pelvis/sacroiliac joints
Uric acid

8

65 yo F with inability to use L leg and bear weight on it after tripping on carpet
+ onset of menopause was 20 years ago
+ did not receive HRT or calcium supplementation
+ L leg is externally rotated, shortened and adducted
+ tenderness in L groin

Hip fracture
Hip dislocation
Pelvic fracture

XR—hip/pelvis
CT or MRI—hip
CBC, type and cross
Serum calcium and vitamin D
Bone density scan (DEXA)

9

40 yo M with pain in R groin after MVA
+ R leg is flexed at the hip, adducted and internally rotated

Hip dislocation—traumatic
Hip fracture

XR—hip
CT or MRI—hip
CBC, type and cross
PT/PTT
Urine toxicology and blood
alcohol level

10

56 yo obese F with right knee stiffness and pain that increases with movement
+ symptoms gradually worsened over ten years
+ swelling and deformity of joint
+ difficulty walking

Osteoarthritis
Pseudogout
Gout
Meniscal or ligament damage

XR—knee
CBC
ESR
Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals)
Uric acid
MRI—knee

11

45 yo M with right knee pain with swelling and redness

Septic arthritis
Gout
Pseudogout
Lyme arthritis
Trauma
Reiter’s syndrome (reactive arthritis)

CBC
Knee arthrocentesis and synovial fluid analysis (see above)
Blood, urethral cultures (for chlamydia)
XR—knee
Uric acid
Lyme titers - IgG and IgM

12

65 yo M with right foot pain
+ training for a marathon

Stress fracture
Plantar fasciitis
Foot sprain or strain

XR—foot
Bone scan—foot
MRI—foot

13

65 yo M with pain in heel of R foot
+ worst with his first few steps, then improves with walking
+ no known trauma

Plantar fasciitis
Heel fracture
Splinter/foreign body

XR—heel
Bone scan - foot

14

55 yo M with pain in elbow when playing tennis
+ grip is impaired due to pain
+ tenderness over lateral epicondyle
+ pain on resisted wrist dorsiflexion (Cozen's test) with elbow in extension

Lateral epicondylitis ("tennis elbow")
Stress fracture

XR—arm
Bone scan
MRI—elbow

15

27 yo F with painful wrists and elbows, a swollen and hot knee joint that is painful on flexion
+ rash on limbs
+ vaginal discharge
+ sexually active with multiple partners and occasionally uses condoms

Disseminated gonorrhea
Rheumatoid arthritis
SLE
Reiter’s syndrome (reactive arthritis)

Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture)
ANA, anti-dsDNA, ESR, RF, CCP
CBC
Blood, cervical cultures
XR—knee

16

60 yo F with pain in both legs induced by walking and relieved by rest
+ had cardiac bypass surgery six months ago
+ continues to smoke

Peripheral vascular disease (intermittent claudication)
Leriche syndrome (aortoiliac occlusive disease)
Lumbar spinal stenosis (pseudoclaudication)
Osteoarthritis

Ankle-brachial index
Doppler U/S—lower extremity
Angiography
MRI—lumbar spine

17

45 yo F with R calf pain
+ calf is tender, warm, red and swollen compared to L side
+ started OCPs two months ago for dysfunctional uterine bleeding

DVT
Baker’s cyst rupture
Myositis
Cellulitis
Superficial venous thrombosis

Doppler U/S—right leg
CBC
D-dimer

18

60 yo F with L arm pain that started while swimming and relieved by rest

Angina/MI
Tendonitis
Osteoarthritis

ECG
CBC
XR—shoulder
CXR
Echocardiography
Stress test

19

50 yo M with R shoulder pain after falling onto outstretched hand while skiing
+ deformity of R shoulder and had to hold R arm

Shoulder dislocation
Fracture of the humerus
Rotator cuff injury

XR—shoulder
XR—arm
MRI—shoulder

20

55 yo M with cramping bilateral thigh and calf pain, fatigue and dark urine
+ on simvastatin and clofibrate for HLD

Rhabdomyolysis due to statins
Polymyositis
Inclusion body myositis

CBC
Phosphate, potassium, BUN/Cr, glucose, calcium, uric acid
CPK
Aldolase
UA
Urine myoglobin