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

Question 1

Why is Erectile dysfunction such an important topic to disscuss with the patient ?

Answer 1

• affects patient’s sexual life;
• affects patient’s self image;
• effective treatments now available;
• ED may be a sign of important comorbid CV disease !
• Ed is a strong predictor ob both : coronary artery disease and peripheral artery disease as endothelial dysfunction contributes to all three conditions !

Question 2

Erectile dysfunction - key history ?

Answer 2

1. Duration ?
2. Severity ?
3. Presence/absence of nocturnal erections ?
4. Change in libido ?
5. Stress or depression ?
6. Trauma ?
7. Associated incontinence ?
8. Gynecomastia or loss of body hair ?
9. Medications (and recent changes) ?
10. Medical history (hypertension, diabetes, high cholesterol, known atherosclerotic vascular disease, prior prostate surgery, liver disease, thyroid disease, neurologic disease) ?
11. SAD : Smoking, Alcohol, Drug use.

Question 3

What is the key physical exam in erectile dysfunction ?

Answer 3

1. Vital signs;
2. Cardiovascular exam;
3. Genital and rectal exams;

Question 4

What should be your differential diagnosis when tackling an erectile dysfunction case ?

Answer 4

1. Psychogenic ED
2. Vascular ED
3. Drug induced ED
4. Hormonal ED - thyroid, pituitary, gonadal
5. Hormonal ED - diabetics
6. Neurogenic ED
7. Other causes :
   
   1. urologic
   2. renal disease
   3. sickle cell disease
   4. sleep disorders
   5. liver disorders

Question 5

How tactfully you can start an interview with a patient c/o erectile dysfunction ?

Answer 5

1. Many men have occasional problems getting or keeping an erection. Has this ever happened to you ?
2. I always ask my patients some very personal questions related to their health. Do you ever have any problems with sexual intercourse ? With erections ?
3. I’m glad you feel comfortable telling me about this . I’d like to ask you some specific questions about your sexual function to figure out what we should do.

• Be nonjudgemental;
• Use professional language;
• Normalize your questions by reminding patients how common ED is !
• It’s common, it’s treatable, it’s an appropriate topic to discuss with your doctor;
• Sometimes its good to overcome patient hesitance by asking direct questions first and later returning to open questions;

Question 6

What alarm symptoms you must seek in a patient presenting with ED ?

Answer 6

1. Concurrent hip and buttock cramps with walking :
   
   1. Abdominal aortic aneurysm
   2. Intermittent claudication
   3. Spinal stenosis
2. Leg weakness or numbness, perineal numbness :
   
   1. Spinal cord compression or pelvic mass
   2. Nerve root compression
   3. Peripheral neuropathy
3. Bowel or bladder incontinence :
   
   1. Spinal cord compression or pelvic mass
   2. Bladder infection
   3. Fecal impaction
4. Galactorrhea :
   
   1. Pituitary tumoe
5. Abnormal secpndary characteristics : loss of beard, loss of body hair, female body habitus :
   
   1. Pituitary tumor
6. Visual fields cuts - loss of portions of vision :
   
   1. Pituitary tumor

Question 7

What focused questions do you have to ask to a patient presenting with erectile dysfunction ?

Answer 7

1. History of depression or any other psychiatric condition ?
2. Loss of interest, trouble concentrating, trouble with memory, feelings of sadness ?
3. Difficulties with relationship with partner ?
4. Performance anxiety ?
5. Do you smoke ? drink ? use drugs ?
6. Do you have high cholesterol, hugh blood pressure, chest pain, leg pain while you walk ?
7. Do you have history of CAD ? Do any members in your family ? Is there any history of PAD ?
8. Have you ever had any pelvic trauma, surgeries, radiation tx ?
9. Do you feel any numbness in genital area ?
10. Have you been experiecing any bowels problems - like noticing any stool in your underwear ?
11. Have you ever experienced urine incontinence ?
12. Have you ever felt any foot or leg numbness or weakness ?
13. Are you taking any medications ? Like medicines to lower high blood pressure, antidepressants, antiandrogenics, antihistamines, corticosteroids, digitals ? (look for : hydrochlorothiazide, SSRI, B-blockers)
14. Do you ever drive under the influance of an alcohol ?
15. CAGE : Have you ever tried to cut down your alcohol drinking ? Do you get angry when others ask about your alcohol use ? Do you feel guilty about your drinking ? Do you drink a morning eye-opener ?
16. Do you have a history of : thyroid disorder ? heat/cold intolerance ? constipation/diarrhea ? weight loss/gain ? tremor ? gonadal disease ? gynecomastia ? loss of body hair ? decreased in testicular size ? pituitary disease ? visual field cuts ? headache ? decreased libido ? diabetes ? Polyphagia, Polyuria, Polydypsia ? renal disease ? bone pain ?
17. Do erections take longer to achieve and have shorter duration and are of less rigidity ?
18. Was the onset : sudden ? gradual ? intermittent ?
19. Do you achieve normal erection, but lose it too early ?
20. Is there a painful bending of penis with erections ?
21. Is it better with : another partner ? masturbation ? visual stimuli ? nocturnal or morning erections ?

Question 8

What is your differential diagnosis and workup plan ?

“47 yo M presents with impotence that started 3 months ago. He has hypertension and was started on atenolol 4 months ago. He also has diabetes and is on insulin”

Answer 8

• Differential diagnosis :
  
  1. Drug-related ED
  2. ED caused by hypertension
  3. ED caused by diabetes mellitus
  4. Psychogenic ED
  5. Peyronie’s disease
• Workup plan :
  
  • Genital exam
  • Rectal exam
  • Glucose
  • CBC
  • Testosterone level

Question 9

Amenorrhea - key history ?

Answer 9

1. FLAG HIV WC
   
   1. Fatigue
   2. Libido
   3. Anorexia, Anxiety&depression
   4. Gonorrhea (STDs), Galactorrhea (PRL)
   5. Hair and skin change, Headaches, Hot flushes
   6. Insomnia
   7. Visual change, Voice change
   8. WAD => Weight, Appetite, Diet
   9. Cold intolerance, Constipation
2. Primary vs. secondary ?
3. Duration ?
4. Possible pregnancy ?
5. Associated symptoms : headache, decreased peripheral vision, galactorrhea, hirsutism, virilization, hot flashes, vaginal dryness, symptoms of thyroid disease ?
6. History of anorexia nervosa, excessive dieting, vigorous exercise, pregnancies, D&Cs, uterine infections ?
7. Drug use ?
8. Medications ?

Question 10

What is the key physical exam in case of amenorrhea ?

Answer 10

1. Head and neck => oropharynx, visual field, thyroid, lymohadenopathy;
2. Abdominal => inspection, auscultation, percussion, palpation;
3. Order pelvic exam;
4. Order breat exam;

Question 11

Define primary and secondary amenorrhea !

Answer 11

• Primary amenorrhea :
  
  • If a girl is >16 yo, has developed secondary sexual characteristics, but still has’n got her period;
  • If a girl >14 and has not started developing secondary sexual characteristics;
• Seconary amenorrhea :
  
  • If a female has had periods for at least 9 months and has been missing them for the past 3 months !
  • Or missing 3 periods in a female with previous oligomenorrhea;

Question 12

Define Hypothalamic or functional amenorrhea.

Answer 12

Disorder of GnRH release resulting from loss of the LH surge and anovulation.

Question 13

What are the major constitutients of PCOS ?

Answer 13

1. Hirsutism - excessive body and facial hair
2. Overweight
3. Menstrual abnormalities
4. Infertility
5. Enlarged ovaries

Question 14

What is a postpill amenorrhea ?

Answer 14

Failure to resume ovulation 6 months after discontinuing hormonal contraception.

Question 15

Give differential diagnosis of primary and secondary amenorrhea!

Answer 15

• Primary amenorrhea :
  
  1. Pregnancy
  2. Gonadal dysgenesis
  3. Contitutional delay
  4. Mullerian dysgenesis
  5. Androgen insensitivity
  6. Prolactin-secreting tumor
  7. Stress, weight loss, anorexia - hypothalamic amenorrhea
  8. Congenital adrenal hyperplasia
  9. Obstructed outflow tract - transverse vaginal septum, imperforate hymen
  10. Kallman syndrome
• Secondary amenorrhea :
  
  1. Pregnancy
  2. Ovarian disease - PCOS, Premature ovarian failure
  3. Hypothalamic dysfunction - stress, weight loss, anorexia, bulimia
  4. Infiltrative lesions or tumors
  5. Pituitary disease - Prolactin-secreting tumor, empty sella syndrome, Sheehan syndrome, Adrenocorticotropic hormone secreting tumor, GH-secreting tumor
  6. Uterine : Asherman’s syndrome
  7. Other : nonclassic adrenal hyperplasia, drug induced, postpill amenorrhea

Question 16

List reversible and irreversible causes of amenorrhea.

Answer 16

• Reversible :
  
  • Imperforate hymen
  • Ascherman’s syndrome
  • PCOS
  • Hyperprolactinemia
  • Postpill amenorrhea
  • Drug induced
  • Exercise, stress, weight loss induced
  • Systsemic ilness
• Irriversible :
  
  • Empty sella syndrome
  • Cushing’s syndrome
  • Kallmann syndrome
  • Gonadal dysgenesia
  • Mullerian defects
  • Andrgen insensitivity syndrome

Question 17

How should you start taking history form a patient c/o amenorrhea ?

Answer 17

• Let the patient speak with her own words and as always start with open-ended questions and do not interrupt !
• Assess overall health;
• Tell me more about your periods.
• At what age did your periods begin ?
• When did your last period begin ?
• Do you have regular periods ?
• What is your usual cycle lenght ?
• Could you be pregnant ?

Question 18

What important aspects come to your mind when you think you are about to interview a patient c/o amenorrhea ?

Answer 18

1. Explore the possibility of pregnancy !
2. Assess for alarm symptoms : recent unprotected intercourse (pregnancy), headaches + galactorrhea + loss of peripheral vision (pituitary tumor), body weight 15% below ideal and impaired body image (anorexia);
3. Classify : primary (congenital, genetic) or secondary amenorrhea ?
4. Detailed O&G history :
   
   1. LMP RTV CS PAP
   2. LMP
   3. Menarche
   4. Period
   5. Regularity
   6. Tampoons and pads
   7. Vaginal - discharge, itching, dryness
   8. Cramping
   9. Spotting
   10. Pregnancy
   11. Abortion, miscarriage
   12. PAP smear and gynecological exam

Question 19

What focused questions will you ask a patient presenting with amenorrhea ?

Answer 19

1. Have you had an unprotected intercourse ?
2. Have you had morning nausea ?
3. Have you noticed that most of your friends have developed pubic hair and breats before you ?
4. Are most of your firends taller than you ?
5. Have you lost/gained weight recently ?
6. Have you been told that you exercise too much ?
7. Have you been under greater than usual psychosocial stress ?
8. Do you have impaired sense of smell ?
9. Have you been diagnosed with chornic kidney disease, thyroid disease, sarcoidosis, lymphoma, histiocytosis X, juvenile rheumathoid arthritis ?
10. Are you taking any medications ?
11. Have you taken OCPs in the past year ?
12. Have you ever had a uterine surgical procedure, infection, abortion ?
13. Have you been pregant recently ?
14. If you recently gave birth, were there any complications ?
15. Have you ever been exposed to high doses of radiation ?
16. Have you ever received chemotherapy ?
17. Have you recently experienced hot flashes, night sweats, mood changes, vaginal dryness ?
18. Have you noticed acne or facial hair ?
19. Have you noticed heat or cold intolerance, a change in energy level, weight loos or gain, diarrhea or constipation, heart palpitations, change in hair or skin texture ?
20. Have you had headaches, changes in your mood or personality ?
21. Have you experienced fatigue, anorexia, weight loss, fever ?
22. Do you have a chronic cough or difficulty breathing ?
23. Have you had depressed mood lately ?

Question 20

What is your differential diagnosis and workup plan ?

“40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception”

Answer 20

• Differential diagnosis :
  
  • Pregnancy
  • Prolactinoma
  • Anovulatory cycle
  • UTI
  • Hyperthyroidism
• Workup plan :
  
  • Urine hCG
  • U/s - abdomen, pevis
  • Pevlic exam
  • CBC, UA, urine culture
  • Prolactin, TSH, FSH, LH
  • PAP smear
  • Cervical cultures, rubella antibody, HIV antibody/p24 antigen, hepatitis B surface antigen, VDRL/RPR

Question 21

What is your differential diagnosis and workup plan ?

“23 yo obese F presents with amenorrhea for 6 months, facial hair, infertility for the past 3 yrs”

Answer 21

• Differential diagnosis :
  
  • Polycystic ovary syndrome
  • Hyperandogenism
  • Thyroid disease
  • Hyperprolactinemia
  • Pregnancy
  • Ovarian or adrenal malignacy
  • Premature ovarian failure
• Workup plan :
  
  • Urine hCG
  • LH/FSH, TSH, prolactin
  • Pelvic exam
  • Testosterone, DHEAS

Question 22

What is your differential diagnosis and workup plan ?

“35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months”

Answer 22

• Differential diagnosis :
  
  • Amenorrhea secondary to prolactinoma
  • Pregnancy
  • Thyroid disease
  • Premature ovarian failure
  • Pituitary tumor
• Workup plan :
  
  • Urine hCG
  • LH/FSH, TSH, prolactin
  • MRI—brain
  • Pelvic and breast exams

Question 23

What is you differential diagnosis and workup plan ?

“48 yo F presents with amenorrhea for the past 6 months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia”

Answer 23

• Differential diagnosis :
  
  • Menopause
  • Pregnancy
  • Pituitary tumor
  • Thyroid disease
• Workup plan :
  
  • Urine hCG
  • LH/FSH, TSH, prolactin
  • Testosterone, DHEAS
  • Pelvic exam
  • CBC
  • MRI—brain

Question 24

What is your differential diagnosis and workup plan ?

“35 yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a history of abruptio placentae followed by hypovolemic shock and failure of lactation 2 years ago”

Answer 24

• Differential diagnosis :
  
  • Sheehan’s syndrome
  • Premature ovarian failure
  • Pituitary tumor
  • Thyroid disease
  • Asherman’s syndrome
• Workup plan :
  
  • Urine hCG
  • LH/FSH, prolactin
  • CBC
  • Pelvic exam
  • TSH, FT4
  • ACTH
  • MRI—brain
  • Hysteroscopy

Question 25

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 25

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

Question 26

What is your differential diagnosis and workup plan ?

“29 yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident in which she was a passenger”

Answer 26

• 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

Question 27

Vaginal bleeding - key history ?

Answer 27

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.

Question 28

Vaginal bleeding - key physical exam ?

Answer 28

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;

Question 29

Give differential diagnosis of Abnormal Uterine Bleeding.

Answer 29

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

Question 30

Define :

1. Menometrorrhagia
2. Menorrhagia
3. Metrorrhagia
4. Oligomenorrhea
5. Ovulation bleeding
6. Polymenorrhea

Answer 30

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.

Question 31

Give full differential diagnosis of Abnormal Vaginal Bleeding.

Answer 31

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

Question 32

Define abortion types : Threatened, Missed, Inevitable and Completed.

Answer 32

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.

Question 33

List questions you will ask a patient presenting with Abnormal Uterine Bleeding ?

Answer 33

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 ?

Question 34

What diagnostic test will you order in a abnormal vaginal bleeding case ?

Answer 34

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

Question 35

What is your differential diagnosis and workup plan?

“17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly within the past 6 months”

Answer 35

• 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

Question 36

What is your differential diagnosis and workup plan ?

“61 yo obese F presents with profuse vaginal bleeding for the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous”

Answer 36

• 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

Question 37

What is your differential diagnosis and workup plan?

“45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs”

Answer 37

• 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

Question 38

What is your differential diagnosis and workup plan?

“28 yo F who is 8 weeks pregnant presents with lower abdominal pain and vaginal bleeding”

Answer 38

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

Question 39

What is your differential diagnosis and workup plan?

“32 yo F presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was 5 weeks ago. She has a history of pelvic inflammatory disease and unprotected intercourse”

Answer 39

• 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

Question 40

Vaginal discharge - key history ?

Answer 40

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;

Question 41

Key physical exam - vaginal discharge ?

Answer 41

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

Question 42

What is your differential diagnosis and workup plan ?

“28 yo F presents with a thin, grayish-white, foul- smelling vaginal discharge”?

Answer 42

• 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

Question 43

What is your differential diagnosis and workup plan ?

“30 yo F presents with a thick, white, cottage cheese–like, odorless vaginal discharge and vaginal itching”

Answer 43

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

Question 44

What is your differential diagnosis and workup plan ?

“35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort”?

Answer 44

• 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

Question 45

Dyspareunia - key history ?

Answer 45

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;

Question 46

Dyspareunia - key physical exam ?

Answer 46

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

Question 47

What is your differential diagnosis and workup plan ?

“54 yo F c/o painful intercourse. Her last menstrual period was 9 months ago. She has hot flashes”

Answer 47

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

Question 48

What is your differential diagnosis and workup plan ?

“37 yo F presents with dyspareunia, inability to con- ceive, and dysmenorrhea”

Answer 48

• 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

Question 49

Abuse - key history ?

Answer 49

• SAFE GARDS :
  
  • Safety, Sex => Do you feel SAFE at home ? Was ever SEXual 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;

Question 50

What interview strategies should one use in domestic abuse case ?

Answer 50

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;

Question 51

When should you suspect domestic violence ?

What concerning signs suggest abuse ?

Answer 51

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;

Question 52

Give examples of questions you will ask to a patient with history of domestic abuse.

Answer 52

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 ?

Question 53

Key physical exam ?

Answer 53

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;

Question 54

Closing the “domestic abuse encounter” - what should you bear in mind ?

Answer 54

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.

Question 55

What diagnostic studies one should offer a patient presenting with history of abuse ?

Answer 55

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

Question 56

What is your differential diagnosis and workup plan ?

“28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for physical injuries 7 months ago. She presents with her husband”

Answer 56

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

Question 57

What is your differential diagnosis and workup plan ?

“30 yo F presents with multiple facial and physical injuries. She states that she was attacked and raped by 2 men”

Answer 57

• 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

Question 58

What questions should you ask to a vicim of a sexual assault ? What part of physical examination do you have to perform ?

Answer 58

• 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)

Question 59

Give a sample closure of a sexual abuse case.

Answer 59

“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?”

Question 60

Joint/limb pain - key history ?

Answer 60

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 ?

Question 61

Key physical exam - joint/limb pain ?

Answer 61

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

Question 62

Patient presents with shoulder pain ? Why shouldn’t you assume is strictly involves the “shoulder joint”?

Answer 62

• 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.

Question 63

Explain the term : rotator cuff.

Answer 63

• 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

Question 64

Explain the difference between intrinsic and extrinsic shoulder pain.

Answer 64

• 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.

Question 65

What is an impngment syndrome ?

Answer 65

• 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;

Question 66

Subacromial bursitis

Answer 66

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

Question 67

Rotator cuff tendinopathy

Answer 67

• 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.

Question 68

Calcific tendinitis

Answer 68

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

Question 69

Biceps tendinitis

Answer 69

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

Question 70

Acromioclavicular arthritis

Answer 70

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.

Question 71

Acromioclavicular joint separation

Answer 71

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.

Question 72

Adhesive capsulitis (also called frozen shoulder)

Answer 72

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.

Question 73

Name possible causes for an extrinsic shoulder pain.

Answer 73

• 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

Question 74

Name causes for intrinsic shoulder pain, start form the most common.

Answer 74

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

Question 75

Recall common causes of shoulder pain

Answer 75

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

Question 76

What are some important aspects of an interview with a patient with shoulder pain ?

Answer 76

• “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;

Question 77

What questions will you ask a patient with shoulder pain ?

Answer 77

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?

Question 78

What physical examination will you perform in a patient presenting with shoulder pain ?

Answer 78

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;

Question 79

What is your differential diagnosis and workup plan ?

“50 yo M presents with right shoulder pain after falling onto his outstretched hand while skiing. He noticed deformity of his shoulder and had to hold his right arm”

Answer 79

• 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

Question 80

Differential Diagnosis: Forearm and Elbow Pain

Answer 80

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

Question 81

Differential Diagnosis: Wrist Pain

Answer 81

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

Question 82

Differential diagnosis : hand pain.

Answer 82

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

Question 83

What questions will you ask to patient presenting with arm/wrist/hand pain ?

Answer 83

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?

Question 84

What is your differential diagnosis and workup ?

“30 yo F secretary presents with wrist pain and a sen- sation of numbness and burning in her palm and the first, second, and third fingers of her right hand. The pain worsens at night and is relieved by loose shaking of the hand. There is sensory loss in the same fingers. Exam reveals a positive Tinel’s sign”

Answer 84

• 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

Question 85

What is your differential diagnosis and workup plan ?

“28 yo F presents with pain in the interphalangeal joints of her hands accompanied by hair loss and a rash on her face”

Answer 85

• 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

Question 86

What is your differential diagnosis and workup plan ?

“28 yo F presents with pain in the metacarpophalangeal joints of both hands. Her left knee is also painful and red. She has morning joint stiffness that lasts for an hour. Her mother had rheumatoid arthritis”

Answer 86

• 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

Question 87

What is your differential diagnosis and workup plan ?

“18 yo M presents with pain in the interphalangeal joints of both hands. He also has scaly, salmon-pink lesions on the extensor surface of his elbows and knees”

Answer 87

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

Question 88

What is your differential diagnosis and workup plan ?

“55 yo M presents with pain in the elbow when he plays tennis. His grip is impaired as a result of the pain. There is tenderness over the lateral epicondyle as well as pain on resisted wrist dorsiflexion (Cozen’s test) with the elbow in extension”

Answer 88

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

Question 89

What is your differential diagnosis and workup plan ?

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

Answer 89

• 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

Question 90

Buttock pain - differential diagnosis ?

Answer 90

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;

Question 91

Hip and Thigh Pain - differential diagnosis ?

Answer 91

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

Question 92

What do you need to ask the patient presenting with buttock/hip/tight pain ?

Answer 92

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?

Question 93

What will be alarming in a patient with buttock/hip/tight pain ?

Answer 93

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 !

Question 94

What is your differential diagnosis and workup plan ?

“65 yo F presents with inability to use her left leg or bear weight on it after tripping on a carpet. Onset of menopause was 20 years ago, and she did not receive HRT or calcium supplements. Her left leg is externally rotated, shortened, and adducted, and there is tenderness in her left groin”

Answer 94

• 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)

Question 95

What is your differential diagnosis and workup plan ?

“40 yo M presents with pain in the right groin after a MVA. His right leg is flexed at the hip, adducted, and internally rotated”

Answer 95

• 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

Question 96

What is your differential diagnosis and workup plan :

“60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery 6 months ago and continues to smoke heavily”

Answer 96

• 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

Question 97

What is your differential diagnosis and workup plan ?

“55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia”

Answer 97

• 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

Question 98

What do the following terms used in knee/calf pain cases mean :

Buckling, Effusion, Giving way, Intermittent claudication, Locking, Pseudolocking ?

Answer 98

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.

Question 99

What is differential diagnosis of knee pain ?

Answer 99

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

Question 100

What cause will you suspect in case of : anterior knee pain, posterior knee pain, medial knee pain, lateral knee pain ?

Answer 100

• 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

Question 101

What will be your differential diagnosis of a knee pain when patient is presenting with the following symptom : Knee laxity, Knee locking or clicking, Acute swelling, Delayed swelling, Swelling without known trauma ?

Answer 101

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

Question 102

What questions will you ask a patient presentigs with knee pain ?

Answer 102

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 :)

Question 103

Recall differential diagnosis of knee pain, mention single clue for each diagnosis.

Answer 103

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

Question 104

What is your differential diagnosis and workup plan ?

“56 yo obese F presents with right knee stiffness and pain that increases with movement. Her symptoms have gradually worsened over the past 10 years. She has noticed swelling and deformity of the joint and is having difficulty walking”

Answer 104

• 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

Question 105

What is your differential diagnosis and workup plan ?

“45 yo M presents with fevers and right knee pain with swelling and redness”

Answer 105

• 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

Question 106

Give differential diagnosis of calf pain.

Answer 106

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

Question 107

What questions will you ask during calf pain encounter ?

Answer 107

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?

Question 108

What is your differential diagnosis and workup plan ?

“60 yo F presents with pain in both legs that is in- duced by walking and is relieved by rest. She had cardiac bypass surgery 6 months ago and continues to smoke heavily”

Answer 108

• 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

Question 109

What is your differential diagnosis and workup plan ?

“45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs 2 months ago for dysfunctional uterine bleeding”

Answer 109

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

Question 110

What is your differential diagnosis and workup plan ?

“55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia”

Answer 110

• 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

Question 111

Foot and ankle pain - explain the following terms :

Callus, Corn, Deltoid ligament, Eversion, Inversion, Forefoot, Midfoot, Hindfoot, Sprain, Pronation, Supination ?

Answer 111

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;

Question 112

What is your differential diagnosis of ankle pain according to the location of the pain: lateral, medial, posterior ankle ?

Answer 112

• 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

Question 113

What is your differential diagnosis of foot pain depending on its location ?

Answer 113

• 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

Question 114

What are some alarm symptoms of foot/ankle pain ? What diagnosis can these indicate ?

Answer 114

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;

Question 115

What questions will you ask during foot/ankle/heel encounter ?

Answer 115

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?

Question 116

What is your differential diagnosis and workup plan ?

“65 yo M presents with right foot pain. He has been training for a marathon”

Answer 116

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

Question 117

What is your differential diagnosis and workup plan :

“65 yo M presents with pain in the heel of the right foot that is most notable with his first few steps and then improves as he continues walking. He has no known trauma”

Answer 117

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

Question 118

Once again, what will be you differential diagnosis of heel pain and what facts will support any given diagnosis ?

Answer 118

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;