Joint/limb pain Flashcards
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
Key physical exam in joint/limb pain
Vital signs; HEENT and musculoskeletal exams; relevant neurovascular exam
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
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
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
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
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
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)
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
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
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
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
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
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
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
