Joint/Limb Pain Flashcards
What key history would you obtain from a patient that complained of joint or 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
What key physical exams would you perform on a patient that complained of joint or limb pain?
Vital signs
HEENT exam
MSK exam
Relevant neurovascular exam
30 yo F presents with wrist pain and a black eye after tripping, falling and hitting her head on the edge of a table. She looks anxious and gives an inconsistent story. Differentials?
Domestic violence
Factitious disorder
Substance abuse
30 yo F presents with wrist pain and a black eye after tripping, falling and hitting her head on the edge of a table. She looks anxious and gives an inconsistent story. Differentials: domestic violence, factitious disorder, substance abuse. Workup?
XR - wrist
CT - head
Urine toxicology
30 yo F secretary presents with wrist pain and a sensation 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. Differentials?
Carpal tunnel syndrome
Median nerve compression in forearem or arm
30 yo F secretary presents with wrist pain and a sensation 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. Differentials: carpal tunnel syndrome, median nerve compression in forerem or arm. Workup?
Nerve conduction study
XR - wrist
MRI - wrist
28 yo F presents with pain in the interphalangeal joints of her hands together with hair loss and a butterfly rash on her face. Differentials?
Systemic lupus erythematous (SLE)
Rheumatoid arthritis
Psoriatic arthritis
Parvovirus B19 infection
28 yo F presents with pain in the interphalangeal joints of her hands together with hair loss and a butterfly rash on her face. Differentials: SLE, rheumatoid arthritis, psoriatic arthritis, parvovirus B19 infection. Workup?
ANA Anti-ds DNA ESR C3, C4 Rheumatoid factor (RF) CBC XR - hands UA
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. Differentials?
Rheumatoid arthritis SLE Disseminated gonorrhea Arthritis associated with inflammatory bowel disease Osteoarthritis
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. Differentials: rheumatoid arthritis, SLE, disseminated gonorrhea, arthritis associated with inflammatory bowel disease, osteoarthritis. Workup?
ANA Anti-ds DNA ESR Rheumatoid factor (RF) CBC XR - hands, left knee Cervical culture
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. Differentials?
Psoriatic arthritis
Rheumatoid arthritis
SLE
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. Differentials: psoriatic arthritis, rheumatoid arthritis, SLE. Workup?
RF AND ESR CBC XR - hands
65 yo F presents with inability to use her left leg and 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. There is tenderness in her left groin. Differentials?
Hip fracture
Hip dislocation
Pelvic fracture
65 yo F presents with inability to use her left leg and 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. There is tenderness in her left groin. Differentials: hip fracture, hip dislocation, pelvic fracture. Workup?
XR - hip, pelvis
CT or MRI - hip
CBC
40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is flexed at the hip, adducted and internally rotated. Differentials?
Hip dislocation - traumatic
Hip fracture
40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is flexed at the hip, adducted and internally rotated. Differentials: hip dislocation, hip fracture. Workup?
XR - hip
CT or MRI - hip
CBC
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 noticed swelling and deformity of the joint and is having difficulty walking. Differentials?
Osteoarthritis
Pseudogout
Gout
Meniscal or ligament damage
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 noticed swelling and deformity of the joint and is having difficulty walking. Differentials: osteoarthritis, pseudogout, gout, meniscal or ligament damage. Workup?
XR - knee CBC ESR Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals) MRI - knee
45 yo M presents with right knee pain with swelling and redness. Differentials?
Septic arthritis Gout Pseudogout Lyme arthritis Trauma Reiter's arthritis
45 yo M presents with right knee pain with swelling and redness. Differentials: septic arthritis, gout, pseudogout, lyme arthritis, trauma, Reiter’s arthritis. Workup?
CBC Knee artherocentesis and synovial fluid analysis (cell coutn, Gram stain, culture, crystals) Blood, urethral cultures XR - knee Uric acid Lyme antibody
65 yo M presents with right foot pain. He has been training for a marathon. Differentials?
Stress fracture
Planta fasciitis
Foot sprain or strain
65 yo M presents with right foot pain. He has been training for a marathon. Differentials: stress fracture, plantar fasciitis, foot sprain or strain. Workup?
XR - foot
Bone scan - foot
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. Differentials?
Plantar fasciitis
Heel fracture
Splinter/foreign body
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. Differentials: plantar fasciitis, heel fracture, splinter/foreign body. Workup?
XR - heel
Bone scan
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 with the elbow in extension. Differentials?
Lateral epicondylitis (tennis elbow) Stress fracture
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 with the elbow in extension. Differentials: lateral epicondylitis, stress fracture. Workup?
XR - arm
Bone scan
MRI - elbow
27 yo F presents with a 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. Differentials?
Disseminated gonorrhea Rheumatoid arthritis SLE Psoriatic arthritis Reiter's arthritis
27 yo F presents with a 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. Differentials: disseminated gonorrhea, rheumatoid arthritis, SLE, psoriatic arthritis, Reiter’s arthritis. Workup?
Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture) ANA Anti-ds DNA ESR RF CBC Blood, cervical cultures XR - knee
60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery six months ago and continues to smoke heavily. Differentials?
Peripheral vascular disease (intermittent claudication)
Leriche’s syndrome (aortoiliac occlusive disease)
Lumbar spinal stenosis (pseudoclaudication)
Osteoarthritis
60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery six months ago and continues to smoke heavily. Differentials: peripheral vascular disease, Leriche’s syndrome, lumbar spinal stenosis, osteoarthritis. Workup?
Doppler U/S - lower extremity
Ankle-brachial index
Angiography
MRI - lumbar spine
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 two months ago for dysfunctional uterine bleeding. Differentials?
DVT Baker's cyst rupture Myositis Cellulitis Superficial venous thrombosis
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 two months ago for dysfunctional uterine bleeding. Differentials: DVT, Baker’s cyst rupture, myositis, cellulitis, superficial venous thrombosis. Workup?
Doppler U/S - right leg
CBC
CPK
D-dimer
60 yo F complains of left arm pain that started while she was swimming and was relieved by rest. Differentials?
Angina/MI
Tendonitis
Osteoarthritis
Shoulder dislocation
60 yo F complains of left arm pain that started while she was swimming and was relieved by rest. Differentials: angina/MI, tendonitis, osteoarthritis, shoulder dislocation. Workup?
EKG CPK-MB Troponin CBC ESR XR - shoulder CXR Stress test
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. Differentials?
Shoulder dislocation
Fracture of the humerus
Rotator cuff injury
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. Differentials: shoulder dislocation, fracture of the humerus, rotator cuff injury. Workup?
XR - shoulder
XR - arm
MRI - shoulder
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia. Differentials?
Rhabdomyolysis due to simvastatin or clofibrate
Polymyositis
Inclusion body myositis
Thyroid disease
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia. Differentials: rhabdomyolysis, polymyositis, inclusion body myositis, thyroid disease. Workup?
CBC CPK Aldolase US Urine myoglobin TSH
