USMLE Step 2 CK Board Preparation: Diseases of the Musculoskeletal System

45-year-old patient is being treated for tuberculosis. She is experiencing central scotomata, a loss of green-red color perception, and decreased visual acuity. What agent is most likely responsible?

Ethambutol

A 55-year-old woman was diagnosed with small cell cancer of the lung 2 months ago; she now presents with increasing dysphagia, respiratory difficulties, and weakness of the upper limb. Her vital signs are pulse 85/min, BP 120/90 mm Hg, resp. 12/min, and temp. 37.7° C. On examination, she has ptosis of both eyes, and she reports diplopia. Her pupillary responses are normal. The strength in the muscles of her arm on testing is 2/5; on repeated testing, the strength improves to 4/5. Sensation is intact in both upper limbs. Of the following treatments, what would be most effective in treating the patient's symptoms?

Plasmapheresis

34-year-old woman presents to your clinic with a 3-month history of a mildly tender mass on the dorsocentral aspect of her dominant right wrist. She says the lump "comes and goes," but this time it has stayed and become tender. She denies any known trauma of the wrist or hand. What examination technique would help to show that this mass is a ganglion cyst?

Transilluminating the mass

A 45-year-old man presents with a 3-month history of weakness of his shoulder muscles; he also reports tingling sensations in his feet. He is not taking any medications; he lives alone and drinks alcohol every day. On examination, his BP is 140/90 mm Hg and P is 92/min. He is obese and pale, with a tinge of jaundice and telangiectasia. Laboratory analysis reveals elevated GGT levels. An electromyogram is normal. What is the most likely cause of his muscle weakness?

Alcoholism

27-year-old man presents with knee instability. During a game of basketball, the man jumped up for the ball and landed incorrectly. He felt and heard a "pop". He experienced instant swelling and pain; when he attempted to apply weight, it felt like his knee was going to "give out". On exam, he has a positive Lachman sign and anterior drawer sign. McMurray's sign, posterior drawer sign, and varus and valgus stress test are all negative. What type of injury does this patient have?

Anterior cruciate ligament

A 39-year-old woman presents after getting hurt at her karate class the night before. She had been doing kick-jumps and landed on the outside of her left plantarflexed and inverted foot with all of her weight. There was a popping sound, and sharp pain set in immediately. The instructor had ice put on the ankle and elevated it right away. Before leaving the facility, a compression wrap was applied. Treatment was sought about 14 hours later because of pain and swelling. On examination, swelling in the area in front of the lateral ankle is visible. The anterior drawer test shows a difference of 5 mm between injured and non-injured ankle. The talar tilt test reveals no instability, and weight-bearing ability is only slightly restricted. What ligament is most likely affected? Refer to the image.

Anterior talofibular ligament

An 86-year-old man presents with a history of a dislocated right hip. For the past 3 weeks, he has noticed pain where his hip dislocated when putting weight onto it. He reports a history of alcohol abuse and use of steroids for his rheumatoid arthritis. Upon physical exam, there is limited range of motion in the right hip but he is afebrile. An X-ray of the right hip shows sclerosis of the bone; however, a synovial fluid analysis is normal. What is the most likely diagnosis?

Avascular necrosis

A 5-year-old African American girl with sickle cell disease presents due to right leg pain. She began to experience right thigh pain and a slight limp following a playground injury 2 weeks ago. Upon sustaining the injury, she was taken to a local ER; X-rays were negative for evidence fracture. She was diagnosed with and treated for a leg contusion. Over the past 2 weeks, the pain has become more severe and she has experienced fever; temperatures have been as high as 102°F, and she has experienced episodic chills. On physical examination, her temperature is 101°F; her right leg is swollen, tender, and erythematous over the anterior aspect of the thigh. The remainder of the PE is unremarkable. CBC with differential reveals a leukocytosis; there is a predominance of neutrophils and a bandemia. What is the most appropriate empiric treatment?

Ceftriaxone and vancomycin

An 18-year-old man presents 30 minutes after falling on his outstretched arm while skateboarding. He is guarding his left forearm near his wrist with his right hand, and he has his left arm against his body for support. There is a deformity similar to the image with edema and ecchymosis at the wrist. He is neurovascularly intact and the skin is closed. His left elbow and shoulder exam are normal. With this type of deformity, what fracture is most likely?

Colles' fracture

A 27-year-old Caucasian man returns to the emergency department with unbearable left lower leg pain; he does so approximately 6 hours after initial discharge. While playing lacrosse, the patient sustained a closed, mid-shaft tibial fracture. After casting and an anti-inflammatory, his pain was noted to be mild (2 out of 10 on 1 - 10 scale) at time of discharge. He reports his pain is increasing dramatically (it is now rated at 9 out of 10) and is unresponsive to his prescribed narcotic, acetaminophen, icing, and elevating his leg. He also describes a feeling of tingling and numbness throughout the lower left extremity. What is the most likely cause of this patient's severe pain?

Compartment syndrome

12-year-old presents with an injury of his left arm and leg. He states that he felt dizziness during the 2nd mile of the long distance run organized by the school. He fell and lost the consciousness for several seconds, but after that he felt "normal". His father has been diagnosed with Emery-Dreifuss muscular dystrophy type 1. On examination, you find a few superficial excoriations; there is also symmetric humero-peroneal weakness involving the biceps, triceps, and peroneal muscles. There is also atrophy and contractures of Achilles-heel, elbows, and posterior neck. After taking care of his injuries, what test should you order?

EKG

25-year-old Caucasian male landscaper presents with a 2-week history of generalized malaise and an "unusual rash" on his right thigh. The patient reports that this rash has been widening, but he denies any pruritus or pain in association with his complaints. In the past week, he has also noticed a constant headache and mild fever. The past medical history is unremarkable. The physical exam reveals vital signs within the normal limits, enlarged non-tender diffuse lymph nodes in cervical and inguinal areas, and an erythematous rash with central clearing and few satellite lesions. Given this patient's diagnosis, how would this patient's clinical stage be defined?

Early localized

20-year-old woman presents for counseling after being diagnosed as a carrier of Emery-Dreifuss muscular dystrophy. She manifests a mild form of the disease, with only contractures of the Achilles' heels and elbows. Both her brother and her father have been diagnosed with the disease. What test will help to change the course of the disease in this young woman?

Electrocardiography

50-year-old woman presents with a painful red foot. She does not have a significant past medical history. 2 nights ago, she went to an office party. She ate and drank throughout the evening and later spent a great deal of time on the dance floor. Throughout the night, she felt fine and continued to enjoy herself. Over the next 2 days, she began to have increased pain and swelling in her right foot. The pain became so severe that she could not put her foot flat on the ground to walk. On examination, it is noted that the largest toe on her right is red, swollen, and painful to touch. She cannot bend the toe or bear her full weight on that foot. Her blood pressure is 122/84 mm Hg, and pulse is 80/min; respiration is 14/min, and temperature is 38.2° C. A CBC is done and is within normal range. An analysis of her synovial fluid shows an elevated white blood cell count and crystals are strongly negatively birefringent, with elongation when viewed under polarized light. What is the most likely diagnosis?

Gout

A 28-year-old man presents at an urgent care clinic first thing in the morning. He notes a left ankle sprain. The patient describes walking in the woods the day before while wearing flip-flops; he inadvertently stepped into a hidden hole. The patient immediately noticed pain with weight bearing on the left ankle, making it mildly difficult for him to walk out of the woods. Ambulation is only slightly difficult at this time. He describes it as a 6 - 7/10 on a 1 - 10 pain scale. He has noted mild swelling and some tenderness to touch. He has treated this with elevation, ice for 20 minutes at a time, and ibuprofen 200 mg every 8 hours. Physical examination reveals a moderate degree of ecchymosis of the left ankle, with mild mechanical instability, and slight restriction of range of motion. Based on the history and physical examination findings, how would you classify this ankle sprain based on the traditional ankle sprain grading system?

Grade II

A 34-year-old man is brought to the emergency department after a single-car motor vehicle collision. Preliminary radiologic studies show a comminuted fracture of the left tibia. The patient is describing a markedly increasing amount of pain felt in the injured extremity. He describes the pain as being a 10/10 that is becoming worse with each passing minute. With anguish on his face, he describes it as a deep achy burning pain. You quickly examine the left leg and note pallor, a tense "wood-like" feeling of the extremity, diminished sensation, and muscle weakness. Based on the most likely diagnosis, what is the best pharmaceutical intervention for this patient's pain?

IV opioids

47-year-old woman with a history of obesity presents to the emergency department due to pain in her right ankle after a fall 2 days ago. Upon physical exam, she has pain and tenderness at the tip of the medial malleolus and has the inability to bear weight for at least 4 steps. The patient does not present with pruritus or any rashes, but the ankle appears swollen. The patient's foot appears to be neurologically intact. She does not present with a fever or erythema of the ankle. According to the Ottawa Ankle Rule, she qualifies for X-rays. What first-line treatment can be used to help treat this condition?

Immobilization

A 70-year-old man with a history of type II diabetes presents with a 2-day history of a red, hot, painful, and swollen left toe. He cannot recall any recent injury or illness, but states that he has been eating a lot of protein-rich foods and consuming alcohol against medical advice. His only complaint is the painful foot. He denies fever, chills, headache, or problems with his right foot. An X-ray of the foot reveals no evidence of fracture, and analysis of the synovial fluid shows crystals that are negatively birefringent and needle-shaped. The patient begins treatment and is able to put pressure on the foot once again. What is the most likely initial treatment for the patient?

NSAIDs

A 63-year-old man presents with pain in both knee joints that began almost 1 year ago. It was mild and present only during activity, but it has worsened and is present during rest. There is no joint stiffness. He has diabetes and has been on insulin treatment for 10 years. BMI is 30. Vitals are within reference ranges. Examination reveals pale conjunctivae. On examination of the knee joints, crepitus is present and range of motion is reduced, but there is no tenderness, warmth, or erythema. Osteoarthritis is suspected and lab investigations and x-ray are ordered. Meanwhile, exercises and ibuprofen as a pain reliever are prescribed. What is a risk factor for osteoarthritis in this patient?

Obesity

75-year-old Caucasian woman arrives in the Emergency Department after a fall down the front steps of her building. She complains of intense pain in her left hip. When she tried to stand, she was unable to put weight on her left leg. The patient had been previously healthy and had no significant past medical history. Lab tests were performed including TSH, urine studies, blood chemistries, CBC, and WBC. These were all within normal limits. A radiograph was performed and a fracture of the femoral neck was clearly visible. Addition tests were performed including a bone density test. The patient was found to have a T-score of -2.8. The most likely cause of this patient's fracture is

Osteoporosis

A 21-year-old Caucasian man presents with upper extremity pain. He describes the pain as appearing after he had worked at the chicken factory for the last year. His position requires him to use the same motion in his shoulder over and over. As time goes on the pain is gradually getting worse, limiting his movement of his arm. He states there was no trauma. What is the most likely diagnosis?

Overuse

34-year-old woman presents Monday morning with knee pain. She states that she was playing with her two children in their backyard over the weekend and fell onto solid ground, landing directly on her knees. She noted immediate and significant right knee pain. She notes significant swelling; it accompanies the knee pain, which she rates as an 8/10 on a numerical pain scale. Physical examination reveals significant obvious joint effusion and exquisite focal tenderness to palpation over the patellar area of the right knee; the left knee has no obvious abnormalities. Results of the anterior drawer, McMurray, and varus/valgus stress testing are within normal limits. Given the history and physical examination findings, what is the most likely diagnosis?

Patellar fracture

A 20-year-old woman presents with asthenia, difficulty in breathing, cyanosis of the extremities, and bilateral ptosis. On physical examination, the patient is in acute distress, but she is alert and oriented. She has difficulty holding her head upright and speaks in whispers. Vital signs are as follows: BP 110 / 80 mmHg, HR 94 bpm, RR 23 rpm temperature 36.6 °C (97.9 °F). On physical examination, there is bilateral ptosis and loss of ocular motility, tachypnea, distal cyanosis, and generalized weakness. A lab workup shows the following: Ht 44%, Hb 14 mg/dL, MCV 86 fl platelets 310,000 /mm3, SaO2 92%, pH 7.34, pO2 90 mmHg, pCO2 50 mmHg, HCO3- 29 mmol. Myasthenia gravis is suspected. An injection of edrophonium brings transient improvement in symptoms. What is most likely to induce a rapid response?

Plasmapheresis

82-year-old man presents with left knee pain which has progressively worsened during the last 2 months. He states that the pain is constant and worsens with activity, especially walking. His right knee feels normal. He denies fever and has no surgical history. His medical history is notable for hypertension, for which he takes low-dose metoprolol. On examination, he has a rounded structure on the back of his knee. It is mildly fluctuant, tender on palpation, and limits both active and passive knee flexion. These findings are most consistent with what diagnosis?

Popliteal cyst

10-year-old boy presents with a possible arm fracture. While playing baseball at school, he slid into another student and hit his upper arm on the other student's leg. An X-ray of the patient's right arm reveals that he has a fracture at the distal third of the humerus. You also note that the patient cannot extend his wrist. What structure has most likely been injured?

Radial nerve

Parents bring their 4-year-old daughter in because of knock-knee. She is otherwise healthy, and her height is in the 50th percentile for age. On examination, she has about 10 degrees of valgus. What should you recommend?

Reassurance that this is normal for age

17-year-old boy presents with pain and swelling over the left shin that started 1 week after a training session with his soccer team. The patient relates that the pain is dull, and it worsens at night. On examination, the upper anterior tibial region is swollen, worm, and painful. Lab results indicated elevated levels of alkaline phosphatase, normal electrolytes, and normal PTH levels. Refer to the image for an X-ray of the left knee. Biopsy results are pending. What is the patient's condition most likely associated with?

Retinoblastoma

A 5-year-old boy presents with an ankle injury. While on his school's playground, he was playing on the swings and decided to jump off. An X-ray of the ankle demonstrates a fracture line through the metaphysic plate of the superior aspect of the distal fibula, ending before the epiphyseal plate. What type of Salter-Harris fracture does this child have?

Salter-Harris type II

56-year-old man wakes up in the morning to find that he has a swollen, red, and painful big toe on his left foot. He had been on a cruise to the Bahamas 2 days earlier, and he spent much of the time eating and drinking. He normally has 1 glass of wine with dinner on the weekends, but his alcohol consumption increased substantially while on the cruise. He also did a great deal of walking in an attempt to make up for his excesses. He goes into his physician's office, and tests are run. An X-ray shows no acute fracture, and his vital signs are within normal limits. Blood work shows an increase in uric acid, but it is otherwise normal. He begins treatment and feels better within 24 hours. What most accurately describes the typical presentation of this disease?

Small lower extremity joints

A 4-year-old girl presents 30 minutes after falling from a 4-foot-tall slide on her outstretched right dominant arm with her elbow fully extended. There was no loss of consciousness, but there was immediate extreme pain; there is an obvious deformity at the elbow. On presentation, the girl is holding her right elbow and she will not allow passive movement. Radiographs demonstrate displacement with a major deformity in the sagittal plane. Posterior cortex and posterior periosteal hinge still intact. What classification of the most likely diagnosis is this case describing?

Type II

A 45-year-old woman presents with a 4-week history of malaise. Her serum creatinine is 3.8 mg/dL and urea nitrogen is 40 mg/dL. Her cytoplasmic anti-nuclear cytoplasmic antibody (c-ANCA) is positive. She has had an episode of hemoptysis. A chest X-ray reveals a reticulonodular pattern of infiltrates. A lung biopsy reveals necrotizing granulomas with vasculitis. What is the most likely diagnosis?

Wegener's granulomatosis

An 82-year-old man with rheumatoid arthritis, HIV, and diabetes mellitus has developed fever, severe pain, and swelling to his right knee. He denies any history of trauma, injuries or accidents, sexual activity, and denies prior episodes. A joint aspiration was done which revealed the following finding. What would be the most likely additional manifestation in this patient?

Limited range of joint motion

A 16-year-old boy presents following the striking of a wooden door with a closed fist an hour ago when he was angry at his mother. He is neurovascularly intact, and the skin is closed. There is an obvious deformity with a loss of small finger metacarpal knuckle. Radiographs reveal an oblique mid-shaft fracture of the fifth metacarpal with a palmar angulation of 45°. What physical exam technique must be performed to check for rotation of the fracture?

Look for finger malposition when the fingers are flexed into the palm.

A 24-year-old man presents with radial-sided wrist pain following a fall on his outstretched hand 3 days ago. He did not seek immediate medical attention due to a lack of swelling. Despite self-treatment with ice and analgesics, his wrist still hurts, especially with ulnar deviation and while trying to open a jar or grip the steering wheel of his car. On examination, his tenderness seems to be in the anatomic snuffbox of the wrist. Radiographs are normal in all views. What is the proper treatment for this patient at this time?

Thumb spica splint and referral to an orthopedic surgeon

35-year-old man presents with knee pain that makes him unable to move his knee. The pain began 3 days ago and has increased markedly; it was preceded by a flu-like illness 1 week ago, along with a skin rash on his thigh that has red margins and a pale center. The patient states that the symptoms started 2 weeks after he came back from a hiking trip last month. He denies any urinary or GI symptoms. He has no other significant past history. What is the mode of transmission of this patient's condition?

Tick bite

You are evaluating a 34-year-old man who was brought to the emergency department after being the driver in a single car motor vehicle accident. Preliminary radiology studies show a comminuted fracture of the right tibia, but right now the patient describes a dramatically increasing amount of pain felt in that extremity. He describes the pain as being a 10/10, becoming worse with each passing minute, and as a deep, achy, burning pain. You quickly examine the right leg and note pallor, a tense "wood-like" feeling of the extremity, diminished sensation, and muscle weakness. These findings are consistent with what diagnosis?

Acute compartment syndrome

35-year-old man presents with knee pain that makes him unable to move his knee. The pain began 3 days ago and has markedly increased. The knee pain was preceded by a flu-like illness 1 week ago. The illness was accompanied by a rash on his thigh that had red margins and a pale center. It started 2 weeks after he came back from a hiking trip last month. He denies any urinary or GIT symptoms. He has no other significant past history. What could be a complication of the patient's illness?

Bell's palsy

A 40-year-old woman presents occasional constipation that she relates to her diet. She is married with two sons. Aside from mild anxiety, she is dealing appropriately with her duties as a librarian. She does not smoke, she consumes alcohol only recreationally, and she weighs 187 lb. She is well-nourished and communicates well. Lung, cardiac, abdominal, and neurological examinations are unremarkable. Thyroid is normal in size and consistency. Menses are normal, and drug history is negative except for "hormone pills" for contraception. What imaging modality would you recommend for osteoporosis screening and when should it be done?

Bone densitometry at age 65

13-year-old girl presents for her school physical. On examination, you notice the posterior curvature of her thoracic spine to be very prominent and bulging backward. What type of deformity of the spine does she have?

Kyphosis

20-year-old man presents with a dull ache in his lower back. He states that the pain has been getting steadily worse. The man states that his symptoms began approximately 3 months ago. He developed a constant, dull pain in his lower back that he initially treated with over the counter anti-inflammatory medications. Over the next few weeks, the pain grew steadily worse, and medication no longer seemed to be helping with symptom relief. He denies any history of back injury and has no significant past medical history. On examination, he is found to have slight tenderness over the lumbar spine at the L4-L5 region. He also has decreased range of motion with forward flexion being about 0 to 45 degrees. He has a negative straight leg raise test, and his gait is relatively normal. A radiograph of the L/S spine shows a radiolucent mass at L5 with a surrounding area of soft tissue swelling. A biopsy of the tumor determines it to be an osteoblastoma, and a wide excision of the mass is performed. What is the recurrence rate of this type of tumor?

10 - 20%

76-year-old man presents with a 2-day history of a red, hot, and swollen ankle. He denies fever, chills, headache, and any other symptoms. He is unable to put his weight on the foot, and he denies any trauma. He is a diabetic with poor glucose control. Laboratory analysis shows negatively birefringent crystals in the synovial fluid; there is no evidence of bacterial growth. The patient receives treatment, and his condition improves rapidly, but he has a similar attack 6 months later. What treatment is used in the prophylaxis of this condition?

Allopurinol

A 14-month-old girl presents in the middle of the night. Her mother tells you that she has been fussy and has not been feeding well for the past 48 hours. In the last 4 hours, she has developed a high fever; it was 102 degrees Fahrenheit when measured at home. Her mother also notices that the child appears reluctant to move her right leg; the girl appears to keep it rotated outward. Examination reveals a distressed, febrile child. Her cardiovascular, abdominal, and respiratory exams appear normal. Her right leg is held fixed in external rotation and partial flexion, with minimal hip joint effusion. A needle aspirate of the joint fluid reveals the following; WBC count - 60,000/cc, neutrophils 95% No crystals Gram stain is positive for Gram-positive cocci in clusters What is the most important step in preventing destruction of the joint?

Arthrotomy and irrigation of joint space

38-year-old man presents with insidious onset of non-specific left groin pain for 6 weeks. The pain is worse with weight bearing, and there is pain at rest. He has noticed having night pain for the past 4 weeks. The patient has a history of high dose corticosteroid use throughout his life for recurrent lung infections. On exam, there is decreased range of motion with internal rotation of the left hip. Subchondral radiolucency is noted on plain radiographs. What is the most likely diagnosis?

Avascular necrosis

24-year-old man presents with severe headache, fever and chills, fatigue, and pain in his joints. His wife states that he has 'the flu'. During the physical exam, his doctor discovers a rash on the patient's thighs and arms. The patient says he has had it for 'a while'. The rash consists of large red indurated lesions with bright red outer borders and pale centers. The patient believed it to be poison ivy or sumac, because last month he and his wife spent the July 4th weekend with his brother camping and hiking in the Catoctin Mountains of Northern Maryland. What microorganism is probably causing this illness?

Borrelia burgdorferi

A 73-year-old woman is evaluated with severe lower back and shoulder pain. As it is her 2nd visit for these symptoms in the past 1 month, she is admitted for further evaluation. She was previously healthy; she was taking daily calcium with vitamin D for mild osteoporosis. She is found to be anemic; there are multiple sites of bone tenderness. Lab values show hypercalcemia; total immunoglobulin level is raised. An X-ray of her humerus is shown in the image. A decision is made in conjunction with her medical team, and she is declared fit to undergo treatment. What is the next step in therapy?

Bortezomib

10-year-old boy is brought to his pediatrician's office after he complained to his parents of neck pain and numbness in his arms. The child had been previously healthy, but upon questioning, it is learned that he had been having dull pain in the back of his neck for about 1 month. Over the past 2 days, the pain had increased to the point that he was unable to ignore it. The arm numbness began at about 1 week ago. On physical examination, the boy appeared to be well-developed and well-nourished, but in mild distress. He had slight tenderness over the cervical spine and decreased range of motion with forward flexion. He also has decreased sensation in his hands bilaterally with the right being worse than the left. A radiograph shows a 2 cm well-circumscribed radiolucent lesion at the C-6, C-7 level. A T2-weighted MRI image shows a hyper-intense image that measures approximately 2 cm in diameter. After surgical excision of the mass, a biopsy is done. What concerning the patient's diagnosis is true?

Caucasians and African Americans develop these tumors in approximately equal numbers.

23-year-old man presents with a 2-day history of a red, swollen, and painful right knee. The pain and swelling have steadily progressed since they began. He has been feeling feverish for the last few hours. He admits to having unprotected sexual intercourse with multiple women over the past few months. On examination, temperature is 100.4°F (38°C) and BP is 110/70 mm Hg. Cardiovascular, respiratory, and abdominal exams are normal. Right knee demonstrates clinical signs of an effusion, with severe tenderness and surrounding muscle spasm. An aspirate of the joint fluid yields the following findings: WBC count 60,000/cc, neutrophils 95% No crystals Gram stain is negative Synovial fluid culture: Gram-negative diplococci on Thayer-Martin media Considering the most likely diagnosis, what is the most appropriate pharmacotherapy?

Ceftriaxone

34-year-old man presents with leg swelling and pain. The patient states that he is an avid runner who began feeling pain in his left lower leg approximately 6 hours ago. He also noticed that the leg was swollen, and his skin was taut. He denies any recent illness or injury, and he states that he has never had anything like this in the past. Physical exam reveals a well-developed man in moderate distress. The left lower extremity appears swollen, and there is pain with passive flexion of the knee and ankle. There is no erythema or pitting edema. The skin appears to be unbroken; there are no signs of infection. All lab work (including a CBC, WBC, chemistry panel, and urinalysis) is within normal limits. What is the most likely cause of this patient's symptoms?

Compartment syndrome

Your patient is 3-month-old male infant with failure to thrive. His family and prenatal history were uneventful. He was born by spontaneous vaginal delivery with an APGAR score of 10, and he has been breastfed since birth. The mother states that he has no appetite and cries when feeding. On examination, the baby does not seem to be in acute distress, his HR is 130/min, RR is 26 breaths/min, temperature 36.9 C, and BP is 125/70. Physical examination reveals hypotonia and the absence of subcutaneous fat; his skin is wrinkled, and his abdomen is prominent. He weighs 6 lbs (below the 3rd percentile for the age). His height is 22 inches (below the 3rd percentile for the age), and head circumference is 14.80 in (below the 3rd percentile for the age). The rest of the examination is normal. His laboratory tests show hypercalcemia (total calcium of 18.0 mg/dL, whereas the normal range is 9 - 10.5 mg/dL), low phosphate (4.4 - 4.5 mg/dL), low alkaline phosphatase (100 mg/dL, whereas the normal range is 143 - 320 mg/dL), and oxygen saturation of 75% at room levels. His chest X-ray shows irregular metaphyses, severe metaphyseal flaring, and osteopenia. Your initial diagnosis is hypophosphatasia. What laboratory finding will support your diagnosis?

Elevated urine phosphoethanolamine

24-year-old man is brought to the emergency room in shock. A quick history from his girlfriend reveals that he has had a "blister on his left foot" for the past couple of days. According to the girlfriend, the patient developed a fever earlier in the day; he felt weak and eventually collapsed. He last passed urine the evening prior to presentation. On examination, his BP is 70/40 and pulse is 130/minute; his hands feel cold and clammy. Except for a swollen left foot, systemic examination is normal. His lab values are as follows: Total WBC count: 21,000/mm3Neutrophils: 55%Lymphocytes: 25%Hemoglobin: 11.0 g/dLCRP: 165 mg/LSerum Creatinine: 2.3 mg/dLUrine Myoglobin: positiveSerum K: 5.9 Meq/dLSerum Na: 133 Meq/dLECG: sinus tachycardia What is the critical component in management of this patient?

Extensive early surgical debridement

61-year-old Caucasian man presents with upper extremity pain. He describes the pain as coming on gradually, limiting the movement of his arm. He also has pain that wakes him up at night. He states there was no trauma or past history of trauma. He is not involved any particular sports, exercise regimen, or other activities where he uses the motion of his shoulder repeatedly. He has a sedentary job. The pain just started and is gradually getting worse. What is the most likely diagnosis?

Frozen shoulder

The parents of a 3-year-old child bring him in for exam. They report "he has knock knees and seems to stumble a lot". Your gait analysis shows he walks with his knees together and his ankles inches apart. You assure the parents this is not rare in his age group. This diagnosis is

Genu valgum

The parents of a 3-month-old newborn bring him in for exam. The report "he is bow legged". While lying supine, his ankles touch and his knees are inches apart. His legs have a curved appearance. You assure the parents this is not rare in his age group. The diagnosis is

Genu varum

22-year-old woman presents with painful right wrist movement and swelling of the dorsum of her hand since morning. Over the past 2 days, she developed pain in the right shoulder and right wrist. Other symptoms include pharyngitis, fever, chills, malaise, and myalgia. She is sexually active with multiple partners. She denies contact with ill persons, intravenous drug use, and recent travel. Vitals are as follows: Temp: 100°F; PR: 92/min; BP: 120/80 mmHg; and RR: 20/min. Systemic exam is within normal limits. Dermatological exam reveals a few small, erythematous macules and papules near the wrists and feet. Left wrist is mildly erythematous and tender to palpation. Passive flexion of the wrist elicits pain. You send for CBC, ESR, blood cultures, and wrist joint X-ray. Noting joint effusion in the wrist, you also order arthrocentesis. With respect to the wrist, what is the most likely diagnosis?

Gonococcal tenosynovitis

27-year-old Caucasian man returns to the emergency department with unbearable left lower leg pain approximately 6 hours after initial discharge. While playing lacrosse, the patient sustained a closed mid-shaft tibial fracture. After casting and an anti-inflammatory, his pain was noted to be mild (2/10) at time of discharge. He reports his pain is increasing dramatically (it is now rated 9/10) and is unresponsive to his prescribed narcotic, acetaminophen, icing, and elevating his leg. He also describes a feeling of tingling and numbness throughout the lower left extremity. The patient arrived on crutches and appears in obvious pain. He is afebrile; he has a pulse of 105. The cast is intact and the remainder of the left leg and foot is examined. The patient is tender to palpation of the left foot and ankle, with swollen firm tissue. The skin appears shiny. Pulses are normal, but capillary refill and sensation are decreased on the left foot compared to the right. With passive movement of the patient's left toes, he cries out in pain. There is no ecchymosis or visible skin lesions on the left foot or ankle. What explains the physiologic basis for this patient's severe pain?

Increased pressure within the tissue space, leading to venous obstruction

34-year-old man presents with joint pain in his right foot. It began the other night when the pain woke him. On physical exam, you note redness and swelling of the first metatarsophalangeal (MTP) joint. What would be an appropriate treatment for this patient?

Indomethacin

47-year-old man is hospitalized with a 2-week history of coughing, weight loss, severe joint pain, and painless lesions in the oral mucosa and genitals. The patient has erythematous lesions on the hands and soles of his feet as well as bilateral eye irritations. He also states that he had severe joint pain, mainly in the shoulders, hips, and knees. Physical examination demonstrates exfoliating lesions of the skin, with grayish adhesive crusts on the forehead. Exfoliating lesions are present in the genital areas. There are crusty and erythematous lesions of intense exfoliation and hyperkeratosis on the hands as well as bilateral exfoliation with pustules and hyperkeratosis on the feet. The patient denies dysuria and other urinary symptoms. There is bilateral erythema noted in both eyes with no discharge. Laboratory tests reveals anemia (Hb: 6.4 g/dl), leucocytosis (13,500 cells/mm3), hyponatremia (Na: 132 mEq/l). What is true regarding the patient's condition?

It is often associated with HLA-B27

A 37-year-old man presents with pain in his left shoulder after a motor vehicle accident. The ER doctor suspects that the left shoulder pain is secondary to splenic rupture. What is this sign called?

Kehr's sign

75-year-old man presents to his pain management office for follow-up after a lumbar laminectomy 2 weeks ago. He states that he has had a fever for the past 6 days. He denies any headache, chest pain, shortness of breath, cough, abdominal pain, nausea, diarrhea, vomiting, or extremity pain. He has a past medical history of hypertension, hyperlipidemia, chronic lumbar stenosis (now status post laminectomy), and type 2 diabetes mellitus. He also has a history of intravenous drug use. He was referred for an MRI of the spine, which revealed destruction of the vertebral body of L4 with significant collapse. What is the most likely additional clinical manifestation in this patient?

Lower back pain

32-year-old woman returns from a 2-week camping trip along the Appalachian Trail in New York; she presents with a low-grade fever and a non-pruritic rash on her back and buttocks. Physical exam reveals 2 large 5 cm erythematous lesions, with central clearing on her low back and buttocks. There is no lymphadenopathy. CBC with differential and ESR are normal. What is the most likely diagnosis?

Lyme disease

A 35-year-old man presents with knee pain that makes him unable to move his knee. The pain began 3 days ago and has increased markedly; it was preceded by a flu-like illness 1 week ago, along with a skin rash on his thigh that has red margins and a pale center. The patient states that the symptoms started 2 weeks after he came back from a hiking trip last month. He denies any urinary or GI symptoms. He has no other significant past history. What is the most likely diagnosis?

Lyme disease

A 27-year-old man presents with knee pain that started while he was playing basketball the previous afternoon. The patient states that he twisted his left knee with his left foot still planted on the floor as he attempted to pass the ball to a teammate. He describes a popping sensation at the time of the injury, but he could still bear weight on his leg. He does not recall any immediate swelling. The morning of presentation, the patient noted swelling of the knee and pain that was significantly worse than it was the day before. He has taken 600 mg ibuprofen for the pain but has experienced only mild relief. Upon examination of the left knee, there is a limitation in range of motion, the presence of medial joint line tenderness, and an effusion. McMurray's test is positive. What is the optimal imaging modality or procedure for confirming the suspected diagnosis?

Magnetic resonance imaging (MRI)

38-year-old man presents with pain and the inability to extend his middle finger DIP joint following a sudden jamming-type injury when attempting to catch a football 3 hours ago. His radiographs are normal. Based on the patient history, what is the most likely diagnosis?

Mallet finger

25-year-old woman presents with pain and tingling sensation in her right hand. Her symptoms are especially intense at night. By holding her hand flexed for about a minute, you can provoke the symptoms. The paresthesia is extended to the palmar area of the thumb, index and middle finger, as well as half of the ring finger; thumb adduction and apposition are weakened on the right. What nerve is affected?

Median

48-year-old woman was admitted to the hospital because of pain in the shoulder-girdle muscles and progressive difficulty combing her hair, climbing stairs, walking uphill, and rising from a chair. She denies fever, joint pains, cough and breathing problems, skin rash, gastrointestinal problems (including difficulty with swallowing), and sensory system disturbances. Her past medical history is significant for the presence of differentiated thyroid cancer, for which she was treated with total thyroidectomy and regional neck dissection. She takes levothyroxine daily, does not smoke, does not drink alcohol, does not use illicit drugs, and her family history is negative for neuromuscular diseases. Her physical examination revealed 3/5 muscle strength in the proximal upper and lower extremities with normal deep tendon reflexes, muscular tone, and sensation. Laboratory results show elevated plasma creatine kinase (CK), aldolase, transaminase, and lactic dehydrogenase (LDH). What is the best next diagnostic step?

Muscle biopsy

25-year-old man presents with back pain and stiffness. He states he has had longstanding issues with back pain. He denies any trauma to his back. He has noticed associated increasing stiffness and general fatigue. He feels that these issues have gradually worsened over the last several months and are more persistent recently. He notes that the pain is much worse first thing in the morning, rating it a 6-7/10. Radiation occasionally occurs into the buttock areas and the patient feels the symptoms actually lessen with activity. Physical examination shows marked forward stooping of the thoracic and cervical spine with the lower spine showing the presence of a substantial reduction in lateral flexion. What would be the first-line pharmaceutical treatment to consider in this patient?

NSAIDs

13-year-old boy presents with a 5-month history of intermittent right knee pain. He notes that his pain is poorly localized over the anterior knee, but it is provoked by activities such as running, jumping, squatting, and climbing or descending stairs. As a result, he has had to curtail recreational games at recess and home. He denies any history of trauma, falls, injury, fever, chills, swelling, skin changes, hip pain, or ankle pain. His physical exam reveals a boy with an appropriate build. His right knee is notable for point tenderness over an enlarged and prominent tibial tubercle. There is associated focal swelling. An in-office X-ray is performed, demonstrating the following image. What is the most appropriate pharmacotherapeutic agent at this time?

Oral ibuprofen

14-year old girl presents due to right leg pain. She is a competitive gymnast and works out in the gym 6 days a week. Upon physical exam, there is knee pain, swelling, and tenderness at the tibial tubercle. The patient's muscles are very tight in front and behind her thigh. All laboratory findings are within normal limits. What is the most likely diagnosis?

Osgood-Schlatter disease

A 40-year-old male carpenter presents with a 9-month history of worsening bilateral knee pain. He feels stiff in the morning when he first wakes up, but this subsides quickly. By the end of the workday, he has significant pain in his knees and has to go home and elevate his legs for some relief. This seems to be worse in colder weather. There is tenderness over the medial aspect of both knees, with the right knee being more tender and edematous. Varus deformity is noted. An arthrocentesis shows the synovial fluid white blood cell count to be 1200/mcL. On plain radiographs, subchondral cysts are present. What is the most likely diagnosis?

Osteoarthritis

An afebrile 76-year-old man has a history of pain and stiffness in his knees bilaterally and in his right hip. The pain is worse after an activity or first thing in the morning. Otherwise, he is healthy and has no other complaints. Upon physical exam, the patient has limited range of motion, joint line tenderness of knees, and mild swelling in the painful joints without warmth. 2 of 18 "tender points" are tender to palpation. A synovial fluid analysis was conducted and it was negative for urate crystals. X-rays of the knees and right hip do not show sclerosis of the bone. Additionally, a Gram stain was conducted and was negative for any bacteria. What is the most likely diagnosis?

Osteoarthritis

19-year-old woman presents with hip pain. She states that she has been having pain in the right hip for several months and has been taking over-the-counter pain medicines to treat her symptoms. Over the past month or so, she has noticed an increase in the severity of pain. Her symptoms are not relieved with medication, and she now has trouble sleeping. She also states that she has no prior history of leg trauma and has no significant past medical history. A radiograph of the hip shows an area of opacity in the greater trochanter that has a mottled appearance. A T2 weighted MRI shows an area of edema surrounding the greater trochanter and a 3 cm by 3 cm lesion that is well circumscribed and has sclerotic borders. A bone biopsy is performed, and there are irregular spicules of mineralized bone with eosinophilic osteoid material. There is no cartilage visible, and the stroma is vascular with pleomorphic spindle cells. What is the tumor responsible for this woman's symptoms called?

Osteoblastoma

89-year-old Caucasian man is brought in by his daughter due to pain in his left shin. He bumped his leg on a coffee table about 3 weeks ago; he developed some mild discomfort, bruising, and a small gash in the skin. It seemed as if he was healing well, but his condition has worsened over the past few days. Now he is moaning due to pain, and he says it hurts to walk on the leg. He describes the pain as "horrible" and an 8/10. The daughter reports the pain keeps him up at night and is unresponsive to ibuprofen and narcotic pain pills. He denies fever and chills. On physical exam, the patient is in obvious pain and is assisted to the exam table with limited weight bearing on his left leg. The lower extremities are examined; significant findings include healing and a scabbed lesion of approximately 3 cm in length across mid-tibia, with surrounding erythema and edema. Tenderness is elicited along the shin, extending well past the area of erythema. Homan's sign is negative. Distal pulses, temperature, coloration, knee range of motion, and lower extremity reflexes are symmetric and normal. Right lower extremity is normal. What is the most likely diagnosis?

Osteomyelitis

An 18-month-old boy presents with a 9-month history of progressively increasing pallor and failure to gain weight. Weight is 7.5 kg, length is 73 cm, head circumference is 44 cm. Physical examination reveals liver palpable 4 cm below costal margin and spleen palpable 3.5 cm below costal margin. Skeletal survey reveals diffuse bone sclerosis with loss of differentiation between cortex and medullary cavity. Lab results: Hemoglobin 6 g/dL Total leukocyte count 3900/mm3 Platelet count 52,000/mm3 Normal MCV and MCH What is the most likely diagnosis?

Osteopetrosis

34-year-old man presents for evaluation of right calf pain after being struck by a car. He reports burning pain in his calf and numbness and tingling in his right foot. Physical exam is remarkable for calf swelling, increased pain with passive muscle stretching, and muscle weakness and decreased sensation in his right ankle and foot. What other findings are expected in this patient?

Pain out of proportion to exam

56-year-old Caucasian woman presents to the emergency department for evaluation of chest pain. Vital signs upon presentation are normal and oxygen saturation level is 96% on room air. Initial lab work performed in the emergency department shows a normal troponin and normal D-dimer. EKG shows normal sinus rhythm without ST/T wave changes. The patient is admitted to your service for observation of chest pain. Two additional serial troponins are normal, and a follow-up EKG remains unchanged. Chest X-ray is unremarkable. Cardiac monitoring has revealed normal sinus rhythm with rare PVCs. On reassessment, the patient reports several months of substernal chest pain aggravated by exertion or movement. The pain can last several hours at a time and is described as sharp and moderate in intensity. It is not worsened by deep breathing. She denies associated shortness of breath, nausea, vomiting, diaphoresis, and lightheadedness. She has never had a cardiac stress test. Past medical history: Cholecystectomy 5 years ago. No prior history of cardiac disease, hypertension, dyslipidemia, or diabetes. Social history: Patient denies recent travel or surgery. Family history: Her father had an MI at age 72. Cardiac exam shows a nondisplaced point of maximal impulse (PMI) with a normal S1 and S2 and a regular rate and rhythm. Lungs are clear to auscultation and percussion. What physical examination procedure would most likely reveal her diagnosis?

Palpation for sternal and costochondral joint tenderness

16-year-old girl presents with severe right knee pain; it started during a softball game 3 days ago after the patient swung to hit the ball. She reports hearing a popping sound before the pain began. There is no significant past medical history. Examination of the right knee reveals a positive 'apprehension sign'; Lachman, McMurray, valgus, and varus tests are negative. X-rays show a lateral tilt of the right patellar and subluxation. What is the most likely diagnosis?

Patellar dislocation

32-year-old woman with no significant past medical history presents with a 3-month history of right anterior knee pain described as a dull and aching pain that is "right under the kneecap." Provocative activities include bending movements, descending stairs, and performing squatting maneuvers. Pain is relieved during rest. She notes that she loves the outdoors and her hobbies include running and hiking; her symptoms began following a run. She denies a history of falls, prior surgeries or instrumentation, fever, chills, malaise, myalgias, changes in weight, joint swelling, skin changes or rashes, or other joint pains. Her physical exam is normal with the exception of a tender undersurface of the patella, with crepitus upon passive range of motion of the right knee. There is abnormal patellar tracking upon right knee flexion and apprehension of the patient upon passive manipulation of the patella. Additionally, there is a positive patellar grind test. McMurray's, Lachman, the anterior and posterior drawer, Apley's compression and distraction tests, and varus/valgus tests are all negative. There is no joint line tenderness, effusion, or restriction of range of motion of the right knee. What is the most likely diagnosis?

Patellofemoral pain syndrome

An orthopedic surgeon visits a school for a scoliosis screening; he finds the following while reviewing the case history of 5 students: Patient #1: A 14-year-old boy with a 15° right lateral curvature of the thoracic spine, Risser grade 3, has a history of seasonal allergies, but is otherwise healthy. He takes no medications and has no functional impairment from his scoliosis. Patient #2: A 15-year-old boy with a 22° left lateral curvature of the lumbar spine, Risser grade 2, has a history of a broken arm after a bicycle fall, but is otherwise healthy. He occasionally uses over-the-counter ibuprofen for back pain, but his activities are generally not limited by his scoliosis. Patient #3: A 13-year-old girl with a 20° left lateral curvature of the thoracic spine, Risser grade 3, had menarche 6 months ago, and an appendectomy at age 7. She is occasionally stiff in the morning, but an exercise regimen keeps her limber. Patient #4: A 16-year-old girl with a 33° right lateral curvature of the lumbar spine, Risser grade 4, had menarche at age 14, and has a history of mild asthma. She reports that she has trouble performing gymnastics due to pain and stiffness, and notes that she seems to have respiratory infections more often than her classmates. Patient #5: A 13-year-old girl with a 31° right lateral curvature of the thoracic spine, Risser grade 2, had a recent growth spurt but has not yet attained menarche. She is healthy and takes no medications. What patient is most likely to experience progression of their spinal curvature in the future?

Patient #5

18-year-old man with no significant past medical history presents with pain and swelling over the upper right knee for 5 months. The pain was initially insidious, dull, and achy. Over the past several weeks, however, it has gradually become progressively more severe and unremitting, often waking the patient at night. He also notes increased swelling, warmth, and erythema. He denies a history of injuries, accidents, trauma, surgeries, or sexual encounters. His physical exam reveals a noticeable limp, reduced right knee range of motion, and localized tenderness and swelling to the distal anterior femur. What is the next step in the management of this patient?

Perform a right knee radiograph.

A 17-year-old boy develops progressively abnormal muscle fatigability. He is diagnosed as having myasthenia gravis and is admitted to a hospital. In the course of his treatment with pyridostigmine, he develops increased weakness, nausea, vomiting, sweating, and bradycardia. What is the best management for this patient?

Withdraw pyridostigmine.

A 12-year-old Caucasian girl presents with a sore throat. The onset of symptoms was about 24 hours ago. The patient experiences pain in her throat, especially with talking or swallowing. She is fatigued because throat pain prevented her from sleeping last night. Throat lozenges have not been helpful. Several classmates have been out sick recently. She denies nasal congestion, rhinorrhea, and cough and is unsure of fevers. This patient has no chronic medical conditions, takes no medications, and has no known drug allergies. On physical exam, she appears slightly ill and fatigued. HEENT exam is positive for bilateral cervical lymphadenopathy and inflamed posterior oropharynx without exudate. She does have normal range of motion of the neck without eliciting pain. Her heart, lung, and abdominal exams are normal. No other lymph nodes are palpable. Weight 92 lb, height 4'8", pulse 95, BP 102/60, temperature 99.2°F/37.3°C. What is the most appropriate next step in the care of this patient?

Perform rapid antigen testing for group A streptococcus.

A 75-year-old woman with a past medical history of hypertension, hyperlipidemia, and obesity presents with insidious but progressive bilateral knee pain for the past several months. She states that her pain is worsened with movement and relieved by rest. She reports "cracking" sounds in her knees upon ambulation and minimal stiffness lasting 10 minutes. Her physical exam is remarkable for bilateral knee crepitus, joint line tenderness, and an antalgic gait; there is no swelling, erythema, or warmth noted. What is an expected diagnostic test result in this patient?

Plain radiograph subchondral sclerosis

47-year-old man presents with a history of worsening burning left heel pain for the last few weeks. He states that it is worse in the morning after getting out of bed and beginning to walk; it improves with exercise. He denies any foot numbness, tingling, or known injury. He states that he recently began a jogging regimen. What is the most likely diagnosis?

Plantar fasciitis

A 52-year-old woman, with a body mass index of 35, presents for evaluation of back pain that has been present for several months. The pain becomes worse at night and is accompanied by stiffness. For the past week, she has been experiencing night sweats and fever. She relates that she had a positive PPD test a year ago and did not follow up as directed. An X-ray of her lumbar spine reveals osteopenia, lytic and sclerotic lesions, and cortical breakdown of vertebral bodies L4 and L5. What is the most likely diagnosis?

Pott Disease

10-year-old Caucasian boy presents with fever and a severe throbbing pain and swelling in the right sole since morning. He accidentally stepped on a nail while playing in the backyard 1 week previously. Since he was wearing rubber-soled shoes, his father assumed that the wound would not be deep; he dressed the wound at home. The pain, redness, and swelling at the wound have increased over the last few hours. Vitals are as follows: temp 101° F; PR 92/min; BP 120/80 mm Hg; and RR 19/min. Systemic exam is unremarkable. Examination of the right sole reveals a 2 x 2 cm wound with drainage of pus over the 2nd metatarsal; there is surrounding edema and redness. There is extreme tenderness and limitation of movement of the entire right foot. CBC, ESR, X-ray of the right foot, and culture of secretions from the wound are ordered. X-ray reveals soft tissue swelling over the 2nd metatarsal. Osteomyelitis is suspected. What is the most likely causative organism?

Pseudomonas aeuroginosa

A 33-year-old man presents with a painful, swollen right knee. The swelling has occurred rapidly over the past 24 hours, and there is no history of trauma or previous joint disease. He feels generally ill and also has painful red eyes. He has had no significant previous medical illnesses, is on no medications, and has no known drug or food allergies. He works as a computer programmer and has just return from an international computer science conference in Singapore. He is married with 3 children. He smokes 1 pack of cigarettes per week and drinks about 12 units of alcohol per week. There is no history of illicit drug use. The remainder of the review of systems is noncontributory. Examination reveals a tempaerature of 98.6 °F; BP is 140/89 mm Hg; P is 89; RR is 17. Both eyes appear red. There is a brown macular rash on his palms and soles. Examination of cardiovascular, respiratory, abdominal, and neurological systems is unremarkable. His right knee is swollen, hot and tender with limitation in range of motion. No other joint appears to be affected. Diagnostic investigations / CBC reveal: Hemoglobin: 13.8 g/dL N13.3-17.7 g/dL Mean corpuscular volume (MCV): 87 fL (N80-99 fL) White cell count: 13.6 cells/uL N 4,500-10,000/uL Erythrocyte sedimentation rate (ESR): 64 mm/h (N10 mm/h) Urinalysis: no protein, no blood, no glucose Blood cultures: negative X-ray of the right knee: soft-tissue swelling around joint Platelets: 345 /uL (N150-440 per uL) What is the most likely diagnosis?

Reactive arthritis

33-year-old man with no significant past medical history presents with a 2-month history of persistent right knee pain. The knee pain is located in the anterior part of the knee; "behind the kneecap," according to the patient. Pain is worse as he descends stairs, performs squatting maneuvers, and sits for excessive periods of time. He is an avid runner and states that running also increases pain. He denies any trauma, falls, accidents, or prior surgeries. He further denies any fever, chills, insect bites, rashes, effusions, grinding, popping, or clicking sensations in the knee. He denies any hip or ankle pain. The physical exam reveals tenderness to palpation along the medial undersurface of the right patella and a positive patellar apprehension test. The anterior and posterior draw tests, McMurray's test, and Apley's compression and distraction tests are all negative. What is the most appropriate clinical intervention for this patient at this time?

Reduction of running exercises

A 21-year-old male presents with a 3-week history of pain in his left shoulder. The pain began when he started spring training and has gradually worsened. In addition, the patient is now having difficulty lifting the arm above his head. He denies injury to the shoulder itself; he states that ibuprofen provides some relief. On physical exam, the patient has tenderness to palpation of the lateral left shoulder just under the acromion, limited abduction of the left shoulder, and a negative drop-arm sign and crossover test. What is the next appropriate step in the management of this patient?

Refer for physical therapy

68-year-old man presents with progressive onset of lower back pain, unsteady gait, and numbness and occasional weakness in his lower extremities. His symptoms seem worse after a day at work, where he stands for hours at a time. He finds that resting, especially sitting, helps alleviate the symptoms. He has not had any other treatment. Diffuse narrowing of the spinal canal is seen on recent MRI, and the patient now wishes to discuss management of this issue. What first-line management should be discussed?

Regular exercise

34-year-old man presented at his primary care physician's office with worsening eye irritation, urethritis, and joint pain. The patient's past medical history was significant for urethritis secondary to chlamydia trachomatis infection that was followed by painless genital sores and joint pain in the left ankle and both knees. He was a carrier of the HLA-B27 gene. The patient's past ocular history was significant for recurrent episodes of bilateral uveitis over the past 10 years treated with corticosteroids. The patient states that his symptoms began about 3 weeks ago. The urethritis was his initial symptom, which was followed by joint pain approximately 2 weeks later. The eye irritation began about a week ago. The patient denied rash, fever, chills, nausea, or vomiting and had been in reasonably good health up until recently. He also denied any recent travel. What is the most likely cause of this patient's symptoms?

Reiter's Syndrome

29-year-old man presents with unilateral swelling of the knee and a 1-month history of urethral discharge. Physical examination is unremarkable with the exception of marked swelling of the left knee. Urethral swabs show pus and culture are negative for Neisseria gonorrhoeae, chlamydia, and Mycoplasma. What is the most likely diagnosis?

Reiter's syndrome

34-year-old pregnant woman presents with what she describes as "tingling in her right arm." She is at 34 weeks of gestation. This is her second pregnancy. It comes on along her palm, and it has been increasing in severity. She also notices it more at night and while attempting to carry her shopping bags. Her pain has been so bad lately that she has been losing sleep. Examination reveals a positive Phalen's test; there is no weakness or atrophy of the thenar muscles. She is not known to have diabetes or hypertension, and she is otherwise healthy. Her thyroid function is normal. Her primary care physician advised treating with NSAIDs and vitamin supplements, neither of which have worked after 3 months of regular use. What is the next step in management?

Rest and neutral splinting

21-year-old man presents with a 3-month history of pain in his left shoulder. He is a left-handed pitcher for his college baseball team. The pain began when he started spring training a few months ago, and it has gradually worsened since that time. In addition to the pain, the patient is now having difficulty lifting his left arm above his head. He denies any injury to the shoulder itself, and he states that ibuprofen provides some relief. On physical exam, the patient has tenderness to palpation of the lateral left shoulder just under the acromion, limited abduction of the left shoulder, a negative drop-arm sign, and a negative crossover test. What condition best explains the patient's symptoms?

Rotator cuff tendinitis

A 47-year-old man presents with numbness, tingling, and pain anterior and to the left side of his left thigh. Pain is provoked even with light touch, and tingling continues for several minutes after the touch. Symptoms started a couple of months ago and worsen when he wears a belt and walks down slopes and stairs, as well as after prolonged standing. Symptoms are relieved when he puts a pillow between his thighs. Patient also assumes hunched posture while standing to avoid unpleasant sensory symptoms. His BMI is 40, and he has a protruding pendulous abdomen. What else do you expect to find on examination?

Sensory loss in anterolateral thigh down to left upper knee

A sexually active woman with multiple partners presents with a 2-day history of red swollen left knee. On examination there is tenderness and decreased range of motion. There is no history of trauma, no affectation of other joints, and she has inflamed right achillis tendon. The most likely diagnosis is:

Septic arthritis

A 3-day-old male infant is seen in the NICU. He was a breech delivery, but the birth was otherwise uneventful. He had a normal Apgar score and is feeding well. Physical examination is remarkable for excessive plantar flexion of both feet with the soles facing inward. What is the best management option for this condition?

Serial cast application

A 38-year-old man has suffered from redness and swelling of the first metatarsophalangeal joint 3 times over the past 2 years. In the past, the attacks subsided without treatment, but this time the pain is persistent. What investigation would be useful in the diagnosis of this patient?

Serum uric acid

You are evaluating a 32-year-old man who presents with an 11-day history of progressive, atraumatic, left hip pain. His PMH is unremarkable with the exception of intravenous drug use. He complains of increasing pain that originally was aggravated with movement, but now he has pain at rest. He is ambulatory with a limp and exam shows no edema, crepitus, rash, or erythema. Pain is reproduced with hip ROM. Distal CMS is fully intact. Vital signs show a BP of 124/93, HR 134, RR 20, Temp 39.4, and O2 sat of 96% RA. Laboratory studies show a leukocytosis and elevated ESR. What finding would you expect on his hip X-ray?

Soft tissue swelling with periosteal elevation

68-year-old man presents due to lower back pain. The patient reports the pain has been present for the past 3 months and seems to be getting worse. Upon physical exam, the patient appears to get relief of pain when bending forward. Upon standing and extension of the lumbar spine, the patient reports pain. He denies decreased range of motion in the shoulders, neck, and hips. The spine is not in an S or C shape. T2 weighted imaging shows disc degeneration. X-rays show symmetrical joint spaces. C-reactive protein (<1.0 mg/L) and ESR (<40 mm/hr) are in normal range. Gram stain is negative for Staphylococcus aureus. What is the most likely diagnosis?

Spinal stenosis

49-year-old Caucasian man is well known to your practice; he presents with pain in his left lower extremity. Upon further questioning, the patient describes doing construction work 3 months prior when he jumped onto his feet from a height of about 5 feet. Since this episode, he has noted issues of increasing left sided hip and knee pain. He describes the pain as radiating into the left groin and front middle thigh area. The pain is relieved with sitting, and it is aggravated by walking and climbing up stairs. The patient denies any paresthesias, numbness, bowel/bladder dysfunction, fever, night sweats, or chills. Radiographic interpretation includes the presence of a crescent sign as well as marked irregularity of the left femoral head with sclerosis. Given these findings, what would you expect to see on a radiographic image taken of the left hip?

Subchondral collapse

A 4-year-old girl presents after a fall from a 4-foot slide 30 minutes ago. She fell with her right dominant arm outstretched and her elbow fully extended. There was no loss of consciousness, but there was extreme pain. She immediately grabbed her right forearm and her right elbow. There is an obvious deformity at the elbow. What is the most likely diagnosis?

Supracondylar humerus fracture

23-year-old woman presents with an extremely painful right arm. She also reports numbness and tingling of her right hand and fingers. She burned her arm on the stove 1 week ago and was prescribed a silver-containing cream. Physical exam is remarkable for swelling and tenderness of the right forearm. She also has decreased sensation in her right hand and weakness of the right thenar muscles. Tissue pressure in the arm is 55 mm Hg (normal <8 mm Hg). What is the treatment for this patient's symptoms?

Surgery

A 55-year-old Caucasian woman presents with a 3-week history of dull pain in her left femur; she does not remember any trauma to her leg. She has been on HRT for 5 years, and she takes Enalapril to control her hypertension. X-ray reveals a tumor in the epiphyseal part of the left femur, and the obtained bone biopsy shows poorly-to-well-formed cartilage-like cells with a bizarre appearance. What is the treatment plan?

Surgery

44-year-old woman presents with what she describes as "tingling in her right arm." It comes on along her palm and it has been increasing in severity. She also notices it more at night and while attempting to carry her shopping bags. Her pain has been so bad that she has been losing sleep. Examination reveals a positive phalen's test, with weakness and atrophy of the thenar muscles. She is not known to have diabetes or hypertension, and she is otherwise healthy. Her thyroid function is normal. Her primary care physician advised a splint and vitamin supplements, neither of which have worked after 3 months of regular use. An EMG shows evidence of severe carpal tunnel syndrome. What is the next step in management?

Surgical release

21-year-old man presents with a 3-month history of pain in his left shoulder. He is a left-handed pitcher for his college baseball team and states that the pain began at spring training and has gradually worsened since that time. In addition to the pain, the patient is now having difficulty lifting his left arm above his head. He denies any injury to the shoulder itself and states that ibuprofen provides some relief. You suspect rotator-cuff tendinitis. What physical exam finding would you expect to find in this patient?

Tenderness to palpation just under the acromion

A 32-year-old man presents with pain in his right shoulder. He tells you he plays softball every weekend and does a lot of shoveling around his house. The shoulder has been sore for some time, but now it hurts to the point where he tries to avoid using it. The drop arm test is negative, and there is no redness, warmth, or obvious swelling, but the patient is unable to lift his arm up to 90° without pain. What is the most likely diagnosis?

Tendinitis

25-year-old landscaper who lives in Rhode Island presents with a 2-week history of generalized malaise and an "unusual rash" on the right thigh. The patient reports that this rash has been widening but they deny any pruritus or pain in association with their other symptoms. In the past week, the patient has also noticed a constant headache and mild fever. Past medical history is unremarkable. The physical exam reveals vital signs within the normal limits and enlarged non-tender diffuse lymph nodes in cervical and inguinal areas, as well as an erythematous rash with central clearing. Based on the most likely diagnosis, what would you suggest as the initial line of therapy?

Tetracyclines

38-year-old woman goes to her physician's office with complaints of arm pain and swelling. She states that she has noticed tenderness and swelling of her upper arm that began about 2 months ago. She denies any injury to the area and states that the pain has been getting steadily worse. Now she is unable to write without having severe, dull pain in her right upper arm near her shoulder. Over-the-counter NSAIDs did not help to relieve her symptoms. The left arm is normal. A radiograph of the arm shows a 1.5 cm diameter well-circumscribed, radiolucent lesion that contains a thin shell of new bone around the periphery. A MRI shows an area of edema and soft tissue swelling surrounding the lesion. A biopsy is performed, and the diagnosis of osteoblastoma is made. Which of the following about this patient's diagnosis is true?

There is very little mitotic activity seen in these tumors.

6-year-old boy presents for evaluation; the patient was referred by an ophthalmologist. The boy's father describes his son's health as frustrating. He has been taking him to special education classes, where the instructors noticed his defective vision. The ophthalmologist diagnosed him as having bilateral downward dislocated lens. The father has also noted urinary troubles, for which the patient has been treated over the last year. What is a major cause of fatality in this case?

Thromboembolic manifestation

49-year-old Caucasian man presents with pain in his left lower extremity. During questioning, the patient states that while doing construction work 3 months ago, he jumped from an elevated height of 6 feet. Ever since this episode, he has noted increased issues with left-sided hip and knee pain. He describes the pain as radiating into the left groin and front middle thigh area. The pain is relieved with sitting and aggravated by walking and climbing up stairs. The patient denies any paresthesias, numbness, bowel or bladder dysfunction, fever, night sweats, or chills. Pertinent medical history includes a 20-year extensive history of alcohol. A radiograph interpretation shows the presence of a crescent sign and marked irregularity of the left femoral head with sclerosis. Considering the most likely diagnosis, what would be the ultimate clinical intervention necessary for this patient?

Total hip replacement

A 20-year-old man presents after taking a fall during a skiing trip 2 days ago. The presenting problem is pain in the right thumb. On examination, you note gross laxity in the first metacarpophalangeal joint when moving the right thumb into abduction. An X-ray reveals no fracture. What structure is injured?

Ulnar collateral ligament of the thumb

A 33-year-old man presents with palpitations and severe abdominal pain, cramping, and vomiting with constipation. He has had similar episodes in the past, and even underwent a surgical exploration, but states that 'nothing has been found'. He also has 'attacks of shoulder weakness' and a tingling sensation in a 'bathing trunk' distribution, sometimes precipitated by emotional and physical stress. His doctor prescribed diazepam that the patient took several hours ago. An aunt and a cousin have had similar episodes of abdominal pain. On examination, the patient has a distended abdomen with decreased bowel sounds, and a surgical scar. Neurologic examination reveals mild weakness in the upper arms. What is the next diagnostic step?

Urine porphobilinogen

A 70-year-old man on vacation in the US presents for what appears to be suspicious skin lesion on his cheek. He has had a longstanding discolored patch; it has recently enlarged in size, and there is crusting. A biopsy confirms your suspected diagnosis. After undergoing treatment, he wants to take measures to prevent a recurrence. What is the most appropriate advice for prevention of recurrence?

Wear protective clothing and avoid midday sun.