Joint/Limb Pain Flashcards by Angela Mitchell

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

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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

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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

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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

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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

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Nerve conduction study
XR - wrist
MRI - wrist

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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

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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

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Rheumatoid arthritis
SLE
Disseminated gonorrhea
Arthritis associated with inflammatory bowel disease
Osteoarthritis

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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

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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

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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

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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

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XR - hip, pelvis
CT or MRI - hip
CBC

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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

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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

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 ```

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 ```

``` 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 ```