Musculoskeletal

Question 1

Fibromyalgia

Answer 1

Sx: Aches & stiffness in 3+ sites >3m, reproducible tender points (11/18) near knees, elbows, neck/breasts, exclusion of other dz.
PE: Normal neuro, assess trigger its
Imx: EMG -normal
Labs: Normal (to ro); CMP, CBC, RF, Thyroid, ANA, UA
Ddx: Rheumatoid arthritis, SLE, Lyme, Hypothyroid
Tx: Exercise/stretch, Improve sleep, Lyrica Rx, Mg, CoQ10

Question 2

Herniated Disc

Answer 2

Sx: Pin point pain worse w coughing/valsalva, mb radiating pain past knee
PE: Valsalva to see if pain increases, Check sharp/dull & reflexes, + Straight leg raise with heel flexed (aka “Braggart’s)
Imx: X ray or MRI
Labs: None
Ddx: Osteoporosis, Lesion, Lumbar stenosis, Osteoarthritis
Tx: Emotional support, Physical therapy, Cortisone, Surgery

Question 3

Herniated Disc vertebrae specifics

Answer 3

L4: Weak patellar reflex, weak quadriceps

L5: Foot drop, weak anterior & posterior tibial and perineal muscles, Sensory loss over skin and dorsal foot, Difficulty walking on heels, Loss of all reflexes in legs

S1: Weak medial gastrocnemius muscle, Impaired ankle plantar flexion, loss of ankle jerk, Sensory loss over lateral calf and foot, Difficulty walking on toes

Question 4

Osteoarthritis

Answer 4

Sx: Back pain, MC affects knees/hips/fingers/neck, Pain worse w rest, Bone growths in DIPs (Herberden’s nodes) or PIP (Bouchards nodes)
PE: Assess hands and nails (nails indicate psoriasis), Lymph nodes to ro infx, Cervical spine RoM
Imx: Xray
Labs: To r/o: Lyme, US, CBC, RF, HLA-B27
Ddx: Psoriatic arthritis (sausage digits), AS, Reiter’s (urethritis and conjunctivitis), RA (DIP unaffected)
Tx:Exercise*, Capsaicin cream, Nightshade free diet, Selenium

Question 5

Osteoporosis

Answer 5

Sx: Slumped posture, Asx until fracture, Decline in ADLs, Pain in low back
PE: Examine hands and nails to ro psoriasis, OA, RA
Imx: Xray, DEXA
Labs: Gliadin ab. and other tests to ro
Ddx: Multiple myeloma, Stress fracture, Herniated disk, Hyperparathyroidism
Tx: GF, Wt bearing exercise, Reduce alcohol/coffee. Mb hormone tx

Question 6

Ankle/Wrist Sprain

Answer 6

We can diagnose but we don’t know how to brace so who cares.

Ankle: Bedside test, Anterior & posterior drawer test, Compression test, Percussion test, Kleiger’s test, Talar tilt test

Wrist: Bracelet (+ is fracture), Finkelstein’s to ro tenosynovitis

Imx: Xray
Ddx: Tendonitis, Fracture, Tenosynovitis, Arthritis
Tx: Immobilize, RICE

Question 7

Tension HA

Answer 7

Sx: BL pressing non-pulsating pain, not < w routine activity, less N/V, photo & phonophobia absent or only 1 present.
PE: Normal HEENT, Neuro, Cranium palpation
Imx: MRI if lesion expected
Labs: None
Ddx: Migraine, Leson, TMJ, Eye strain
Tx: Massage, yoga, Mg, Sleep hygiene, meals TID

Question 8

Thoracic Outlet

Answer 8

Sx: Paresthesias of arm/neck, deep aching pain, no numbness or motor weakness
PE: Adson’s & Reverse Adson’s(+ w pain and decrease radial pulse), Phalens/Tinels to ro Carpal tunnel, Assess pulses and reflexes, Look for cyanosis, Listen over subclavian artery for bruit
Imx: MRI or Xray
Labs: N conduction studies
Ddx: Subluxation, Carpal tunne Brachial neuritis
Tx: Decrease meat (ARA causes inflammation), Hypericum topically, Manipulationl