rheum q's
patellar tendon rupture (15)
A 16-year-old boy presents to the emergency department with acute left knee pain. He was riding his bicycle when his back tire was hit by a car. He reached his left leg outward while attempting to prevent his bike from falling and felt a "pop" and then excruciating knee pain. The patient is lying in bed with his left knee slightly bent, but he is unable to move the leg or knee. There are no obvious bony deformities. You feel boggy swelling and tenderness over the patellar region. His lateral knee X-ray is shown above. What is the most likely diagnosis?
immobilization in a thumb spica splint (ER 3)
A 16-year-old boy presents with left wrist pain after a fall while skateboarding in which he landed on his outstretched hand. He has tenderness and swelling over the dorsum of the wrist on the radial side in between the abductor pollicis longus and extensor pollicis longus tendons. Wrist radiographs are negative for a fracture. Which of the following is the most appropriate management?
tenderness over the posterior edge of the distal lateral malleolus (ER 7)
A 17-year-old boy presents after injuring his left ankle while playing soccer. Which of the following indicates the need for imaging of the ankle?
anterior cruciate ligament tear (ER 8)
A 17-year-old football player presents after sustaining a knee injury during his game earlier in the evening. He has no medical problems and is not on any medications. He states he was running with the ball when he felt a "pop." Immediately after he had severe pain in his right knee, was unable to walk initially, and now has a noticeable limp. On exam, the patient has intact strength with knee extension and flexion. He has intact range of motion with exacerbation of symptoms during range of motion. There is no laxity noted with valgus or varus testing, nor is there appreciable joint line tenderness. With the patient's knee flexed to 30 degrees, there is increased translation of the proximal tibial anteriorly compared to posterior translation. What is the most likely diagnosis?
anterior shoulder dislocation (18)
A 19-year-old man presents to the emergency department with pain and difficulty moving his right shoulder. He was playing football and was tackled when his arm was extended to catch the ball. The other player landed on his right arm. On exam, the patient is holding his arm in the abducted position and externally rotated near his body. He is unable to move his right shoulder. His acromion is prominent and the shoulder has lost its round appearance. What is the diagnosis?
discharge with NSAIDs and changes in study habits (16)
A 21-year-old male college student with no medical history presents to the emergency department for elbow pain. He states that while studying for final exams, he noticed that his elbow has become more swollen over the last week. His vital signs include a temperature of 37°C, a heart rate of 70 bpm, and a blood pressure of 115/75 mm Hg. On exam, you note the swelling above. You are able to fully extend the elbow with only minimal discomfort. What is the most appropriate next step in management?
start antibiotics (ER 6)
A 24-year-old man presents after being hit by a car while walking across the street. During the secondary survey, it is noted that the right lower leg hangs at an awkward angle, concerning for a distal tibia-fibula fracture and dislocation near the ankle. He has abrasions, cuts, and punctate lacerations throughout the lower leg, including near the ankle. The patient is neurovascularly intact distal to the area of concern and has no other apparent injuries. Tetanus is updated, and the X-ray technicians and orthopedic surgery are on their way. What is the most appropriate next step regarding his right lower leg while waiting?
human leukocyte antigen B27 (IM 1)
A 25-year-old man presents to the clinic with concerns about pain in both eyes, right knee pain, and burning in his genitalia. He reports he is sexually active and recently was treated with antibiotics for a sexually transmitted infection. On physical exam, you note bilateral conjunctivitis, erythema of the right knee, and tenderness over the joint line of the knee. Genital examination reveals urethral irritation present at the meatus. Vitals are within normal limits. Which allele is implicated in the most likely diagnosis?
reactive arthritis (IM 4)
A 25-year-old man presents to urgent care with general fatigue, slight fever, and pain, warmth, and swelling to his left knee for the past two weeks. He reports an occurrence of gastroenteritis nearly one month before these symptoms presented. On exam of the left knee, there is erythema, swelling, warmth, and extreme tenderness at locations of tendon insertion. Which of the following is the most likely diagnosis?
ibuprofen (ER 13)
A 26-year-old man presents with low back pain after helping his friend move yesterday. He denies any trauma, fever, weakness, numbness, or change in bowel or urinary habits. He has no midline tenderness but has spasm and tenderness noted in the paraspinal muscles. Which of the following medications is most appropriate for this patient's pain?
popliteal artery injury (ER 6)
A 27-year-old man sustains a knee injury when he falls in a rock-climbing gym and lands on his leg, hyperextending it at the knee. He complains of severe pain in the knee and is unable to bear weight. There is no obvious deformity. The knee is grossly unstable in all directions of stress testing. X-rays are negative for a fracture. Which of the following is the most serious immediate complication of his injury?
emergent consultation with an orthopedic surgeon (ER 12)
A 28-year-old man presents complaining of intractable pain underneath his cast five days after sustaining a tibia and fibula fracture of his left leg. He reports that he was seen at his orthopedic surgeon's office yesterday for the same pain and was given another prescription for "stronger" pain medicines after an exam. A new cast was applied before discharge, and he is supposed to follow up in six days. However, he insists that the pain medicine is not helping him at all. Physical examination after cast removal reveals paresthesias of the skin between the first two toes, and intense pain with passive flexion of the toe. The anterior aspect of his lower leg feels tense and is tender. What is the most important next step in management?
Systemic lupus erythematosus (IM 22)
A 29-year-old woman presents to the clinic due to fatigue, arthralgias, and chest discomfort over the past four months. She has lost 6 lb during this same period of time. Her past medical history is insignificant, and she takes no medications. She does not use tobacco, alcohol, or illicit drugs. Her mother has rheumatoid arthritis, and her father has type 2 diabetes mellitus. Her temperature is 98.9°F, HR is 76 bpm, and blood pressure is 128/78 mm Hg. Physical examination is significant for a faint facial exanthem but is otherwise unremarkable. Which of the following is the most likely diagnosis?
supination of the forearm with flexion of the elbow (ER 4)
A 3-year-old boy presents to the emergency department due to refusal to move his left arm. His symptoms started after his parent grabbed him by the arm to stop him from running into the street. On examination, he is holding the left elbow in flexion with pronation of the forearm. He resists any attempts to move the arm. There is no noted swelling or obvious deformity. What method can be used to reduce a radial head subluxation?
T1 nerve root (ER 9)
A 32-year-old man presents with arm pain. He was practicing parkour, jumped off a ledge and caught onto an overhead bar but then slipped and fell on his wrist. His neurologic exam reveals weak finger abduction, weak thumb opposition, and decreased sensation to the ulnar aspect of the forearm. Which nerve is most likely damaged?
septic bursitis (ER 16)
A 32-year-old man presents with right-sided elbow swelling and pain. He works as a plumber and denies any specific injuries. The elbow pain and swelling developed rapidly and became worse over the last 2 days despite applying ice and using over-the-counter anti-inflammatory medications. His vital signs are HR 104 bpm, BP 110/60 mm Hg, RR 18/min, and T 100.2°F. On physical exam, his right elbow is swollen and tender to touch, with redness and fluctuance isolated to the posterior tip of the elbow. He refuses full flexion of the elbow on exam due to pain but allows passive pronation and supination. What is the most likely diagnosis?
reactive arthritis (ER 17)
A 33-year-old man presents to the emergency department with joint pain. He describes lower back and wrist pain that has progressed to pain in his left knee in the setting of feeling generally fatigued and weak. He also notes that he had mild dysuria last week. Physical exam is notable for mild conjunctival injection, pain with passive movement of the patient's left knee, and erythema and edema of both wrists. Which of the following is the most likely diagnosis?
costochondritis (ER 19)
A 35-year-old man presents to the emergency department reporting chest pain for 3 days. He says that the pain is slightly to the left of his sternum and worse with inspiration and while playing basketball. It is a dull pain that can sometimes feel like a stinging sensation. He reports no shortness of breath, cough, nausea, diaphoresis, and fever. His blood pressure is 139/74 mm Hg, heart rate is 82 bpm, temperature is 98.5°F (37°C), and oxygen saturation is 98% on room air. On exam, he has normal heart and lung sounds, but he winces when leaning forward. There is distinct pain noted with palpation over the left anterior medial third rib. His ECG is as shown above. What is the most likely diagnosis?
colles fracture (ER 5)
A 35-year-old man presents to the urgent care clinic with excruciating right wrist pain. He is an avid soccer player and fell on his outstretched hand during a game. Physical examination shows swelling, deformity, and dorsal displacement of the distal wrist. Palpation of the ulnar and radial pulses is normal. Which of the following is the most likely diagnosis?
Schedule an ophthalmologic examination within one year (IM 24)
A 35-year-old woman presents to a primary care provider with fatigue, arthralgias, and myalgias. Physical examination is significant for a malar rash. Laboratory testing reveals an antinuclear antibody titer of 1:640 and the presence of anti-Smith and anti-double-stranded DNA antibodies. The provider discusses the diagnosis and treatment plan with the patient and educates her on belimumab and hydroxychloroquine. Which of the following statements should be communicated to the patient?
cyclophosphamide (IM 8)
A 35-year-old woman presents to her primary care provider for a one-week history of dark urine. She has a past medical history of systemic lupus erythematosus but is not currently on medication due to a lapse in insurance. Her blood pressure is 165/105 mm Hg. Urine dipstick reveals 2+ protein and hematuria. Lab tests reveal low complement protein and azotemia. The patient is started on prednisone. What other medication is indicated for the treatment of this complication of systemic lupus erythematosus?
splinting of the joint in extension for six to eight weeks (ER 10)
A 37-year-old man presents to urgent care with pain and swelling in his fingertip. A football struck the patient's right fourth finger while he was playing a game of football with friends the day before. On examination, the distal interphalangeal joint of the right fourth finger has full passive range of motion, but the patient is not able to actively extend the joint. An X-ray confirms a small avulsion fracture of the dorsum of the proximal fourth distal phalanx. Which of the following is the most appropriate treatment for this fracture?
lateral ankle sprain (ER 9)
A 38-year-old woman presents to the urgent care clinic after she inverted her right ankle while stepping off a curb. She can walk on the affected foot. Physical exam is remarkable for tenderness to palpation of the right lateral malleolus. Pain worsens with ankle inversion. There are no bony deformities. What is the most likely diagnosis?
staph aureus (ER 8)
A 4-year-old boy presents to the emergency department with a limp and fever. His mother states that he began limping 2 days ago, and it has gotten progressively worse. He will no longer walk. His fever started today. His mother denies any known injuries. On physical examination, his temperature is 39°C with a heart rate of 130 beats per minute. His right hip is warm to the touch with overlying erythema present. He has limited range of motion of the right hip due to pain. Laboratory analysis reveals a leukocytosis with elevated erythrocyte sedimentation rate and C-reactive protein. X-ray of his right hip reveals periosteal thickening. An ultrasound of the right hip reveals a hip effusion. Which of the following is the most common cause of the patient's presentation?
straight leg raise, crossed straight leg raise (ER 14)
A 40-year-old man presents to the emergency department with sudden-onset back pain after lifting a box. The pain radiates down to the mid-thigh and is worse with bending and walking. Physical exam reveals left para-lumbar muscular tenderness without spasm. Which of the following exam maneuver(s) has the highest sensitivity and specificity for sciatica, respectively?
Hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint (IM 15)
A 40-year-old woman presents to her primary care provider with complaints of hand pain. She states her wrists and hands hurt and feel very stiff every morning. She does not notice the pain as much later in the day after she has been moving around for a while. Physical exam reveals ulnar deviation at the metacarpophalangeal joint bilaterally, as well as swollen, tender interphalangeal joints. What physical exam finding is most likely, given the suspected diagnosis?
Polymyositis (IM 3)
A 40-year-old woman presents to the office complaining of weakness in her muscles that for the past six months began in her legs, arms, and neck. She does not complain of any pain or changes in the skin. Her physical exam reveals bilateral weakness to proximal muscles in the hips, shoulders, and neck bilaterally without tenderness to palpation. Serologic testing is positive for anti-Jo-1 antibodies, and a muscle biopsy is ordered to confirm diagnosis. Which of the following is the most likely diagnosis?
Musculoskeletal tenderness (IM 26)
A 40-year-old woman presents with widespread pain for four months. She also reports sleep disturbance, headaches, and fatigue. Laboratory studies are within normal limits. Which of the following physical exam findings is most likely to be seen in this patient?
biceps tendon (ER 11)
A 41-year-old man has been weight lifting to compete in an upcoming bodybuilding competition. A weight lifting partner provided him with an injection to help maximize building muscle mass. During a recent intense weight lifting session, the patient felt a sudden pop in his right arm. It was immediately difficult for him to flex and supinate his arm at the level of the elbow. He decided to see a doctor after no improvement with several days of rest. On physical exam, he has significant bruising of the elbow and there is a bulge in his right upper arm. Which of the following is most likely involved in the injury presented?
lisa franc injury (ER 5)
A 42-year-old man presents with pain in his foot after falling while descending the stairs. He is unable to bear weight on the foot. Pulses and sensation are intact. He has pain with palpation of the midfoot and a small area of ecchymosis on the plantar surface of the foot. His X-ray is shown above. What is the likely diagnosis?
radial nerve (17)
A 43-year-old man presents after being struck by a motor vehicle on his right side and falling onto his left arm. His trauma evaluation is negative except for pain in the mid-right arm. A radiograph is seen above. Secondary injury to which of the following is the most common complication?
indomethacin (IM 25)
A 45-year-old Asian American man presents to the urgent care for one day of severe toe pain. He has a past medical history of obesity and hypertension. His current medications are chlorthalidone and a multivitamin. He reports his toe is painful, swollen, and sensitive to touch. On exam, the first metatarsophalangeal joint on his left foot is erythematous, swollen, and tender. Manipulation of the joint causes the patient distress. What is the first-line therapy for the suspected diagnosis?
cervical spine radiographs (IM 7)
A 45-year-old woman presents to a primary care provider with fatigue, generalized joint pain and stiffness, and multiple nodules over the extensor surface of her forearms. A complete laboratory workup is ordered and is significant for elevated levels of anti-cyclic citrullinated peptide and C-reactive protein. She is started on appropriate pharmacologic therapy. Which of the following diagnostic studies will most likely be indicated as her condition progresses, in addition to routine preoperative tests for procedures requiring sedation?
initiate varenicline (IM 13)
A 45-year-old woman presents to her primary care provider with painful discoloration of her fingers and nose when cold. She states her fingers become pale when cold and then become red and painful when they begin to warm up. She also complains of difficulty swallowing and early satiety. On physical exam, she has tight, shiny skin and multiple telangiectasias. She currently smokes one pack per day and has no significant past medical history. What clinical intervention should be recommended first?
scleroderma (IM 9)
A 45-year-old woman presents to the clinic. She appears quite somnolent and states she is in pain. She reports pain in her hands, forearms, and knees, along with abdominal discomfort. She also describes sensitivity to cold in her hands, which she says makes her hands turn white and become painful. She reports her symptoms have been present on and off for the last few years but have begun to significantly worsen. Her medical history is significant for hypertension and interstitial lung disease with home oxygen use. The patient reports no tobacco or illicit drug use. She takes lisinopril, metoprolol, hydrochlorothiazide, and mycophenolate. Physical exam reveals puffy, thickened skin over the fingers on both hands, tenderness over multiple joints, rales, labored respirations, general body atrophy, abdominal rigidity, and a systolic regurgitation murmur of grade 3 over the tricuspid area. Her vitals are a temperature of 99.5°F, HR of 95 bpm, RR of 20/minute, BP of 140/100 mm Hg, oxygen saturation of 93%, and body mass index of 14 kg/m2. Which of the following is the most likely diagnosis?
Anticentromere antibody (IM 10)
A 45-year-old woman presents with recurrent reflux and dysphagia. She reports that her fingers become cyanotic when she is exposed to cold temperatures and then hyperemic with rewarming. On exam, skin thickening and thickness over the extensor surfaces of the digits are noted. Which of the following positive laboratory results is most specific for the suspected diagnosis?
trial of NSAIDs (ER 2)
A 47-year-old man presents to the clinic with foot pain. He says the pain is worse in the morning with his first steps and gradually improves with activity. Physical examination reveals tenderness of the medial calcaneal tubercle and several areas of point tenderness upon dorsiflexing the patient's toes. Which of the following is the most appropriate next step in management?
magnetic resonance imaging (ER 7)
A 47-year-old man presents to the emergency department with a nonhealing ulcer on his heel. Past medical history is significant for uncontrolled diabetes. The patient states that the ulcer has been present for the past couple weeks but is now worsening in appearance. His vital signs are unremarkable. Physical examination demonstrates a left heel ulcer with purulent discharge and surrounding erythema. You are concerned for osteomyelitis of the calcaneus. Which of the following is the most sensitive test for suspected osteomyelitis?
polyarteritis nodosa (IM 12)
A 48-year-old woman presents to the clinic with insidious onset of fever, fatigue, decreased appetite, and generalized weakness and pain in the extremities developing over weeks to months. Skin findings include ulcerations and subcutaneous nodules on both lower legs. An arterial medium-vessel biopsy shows necrotizing arteritis. Which of the following is the most likely diagnosis?
hepatitis B (IM 23)
A 50-year-old man presents with a gradual onset of weight loss, malaise, and abdominal pain. On exam, he is noted to have painful violaceous plaques surrounded by livedo reticularis on the extremities. Laboratory studies demonstrate elevated C-reactive protein and erythrocyte sedimentation rate. Which of the following diseases should be screened for based on the suspected diagnosis?
Anti-Jo-1 antibodies (IM 28)
A 50-year-old woman presents with muscle weakness of the shoulder and pelvic girdles that has progressively worsened over the last several months. Physical exam reveals a three out of five muscle strength in the hip flexors and the deltoids. Laboratory studies demonstrate elevated aldolase and creatine kinase. Which of the following positive laboratory results would be expected?
gouty arthritis (IM 11)
A 52-year-old man presents to a primary care provider for severe joint pain in his great toe. He reports an acute onset of pain yesterday and denies any injury or trauma. He has had several similar presentations intermittently throughout the past two decades. Vital signs are T 38.1°C, BP 122/72 mm Hg, HR 86 bpm, RR 18 breaths per minute, and pulse oximetry 99% on room air. Physical examination reveals a great toe that is swollen and erythematous and exquisitely tender and warm to the touch. His WBC count is 14,600/mcL, and his uric acid level is 5.9 mg/dL. A radiograph of his toes is shown above. Which of the following is the most likely diagnosis?
Mononuclear cell infiltration (IM 27)
A 52-year-old woman presents to a primary care provider with photosensitivity, foreign body sensation, and eye fatigue bilaterally. She also reports a sore tongue and dry, peeling lips. A Schirmer test and rose bengal stain are positive in both eyes. What is the most likely finding on salivary gland biopsy?
osteoarthritis (IM 20)
A 53-year-old woman presents to a primary care provider for right knee pain. She reports a gradual onset over the last four months and describes the pain as dull and achy. She reports joint stiffness in her right knee that typically occurs every morning, but it does not last more than 15 minutes. It is aggravated by activity and alleviated with rest and acetaminophen. She denies any acute or previous injury to her right knee. She also reports joint stiffness in her fingers. She has otherwise been healthy. Physical examination of the right knee reveals decreased flexion and extension, crepitus, and mild swelling. No erythema, warmth, or ecchymosis is present. Bony enlargements over the carpometacarpal joint of the thumb and the distal interphalangeal joints of the remaining digits are present bilaterally. Her right knee radiograph is shown above. What is the most likely diagnosis?
hawkins kennedy test (ER 4)
A 55-year-old man presents to the emergency department with shoulder pain. The patient has a past medical history of hypertension and hyperlipidemia. He states the symptoms started three days ago. He denies any traumatic events leading up to his symptoms. Which positive physical exam finding is most consistent with supraspinatus tendonitis?
naproxen and topical ice (ER 18)
A 55-year-old man with a history of hyperlipidemia, diabetes mellitus, hypertension, and uric acid crystal arthropathy presents with right great toe pain, redness, and swelling. His examination reveals a right metatarsophalangeal tophus. Which of the following regimens represents appropriate medical therapy for this patient?
Non-Hodgkin lymphoma (IM 17)
A 55-year-old woman presents to her primary care clinic with complaints of chronic dry eyes. She has also noticed a dry mouth, bad breath, and swelling on the side of her cheeks. Physical exam is notable for dry mucosal membranes and parotid gland enlargement. Lab work reveals positive rheumatoid factor and positive anti-Ro antibodies. What complication is this woman at risk of developing?
prescribe low impact aerobic exercise (IM 14)
A 55-year-old woman presents to the internal medicine clinic for a follow-up visit. She reports diffuse soreness and sharp pain of both upper and lower extremities and inability to sleep. In the morning, she is significantly fatigued and experiences stiffness in her legs, arms, and shoulders. She denies any trauma. She has tried ibuprofen, but it did not help. She denies any chronic medications. Previously evaluated bloodwork is within normal limits. Physical examination reveals mild to moderate tenderness of multiple muscles and joints. Her vitals on today's visit are within normal limits. Which of the following is the most appropriate initial clinical intervention for this patient, given the most likely diagnosis?
methotrexate (IM 19)
A 55-year-old woman presents with gradual onset of joint stiffness and swelling that has progressively worsened over the last two years. Joint stiffness often affects the metacarpophalangeal joints and proximal interphalangeal joints of the fingers and is worse in the morning, lasting more than 30 minutes. On exam, a bowstring sign is noted. Anti-cyclic citrullinated peptide antibodies are present in serum. She has never been on any medication for her condition. Which of the following medications slows the progression of the suspected disease and should be initiated at the time of diagnosis?
Cyclosporine eye drops (IM 29)
A 55-year-old woman presents with worsening dry eyes over the past 6 months. She has tried using artificial tears but her ocular symptoms persist. Physical exam reveals a positive Schirmer test. Anti-La antibodies are found to be present on laboratory studies. Which of the following medications is indicated at this time?
purine (IM 6)
A 56-year-old man presents to the emergency department for an acute flare-up of gout to his right great toe. He is currently taking allopurinol and has not had a flare-up of gout in over two years. He recently went on a cruise that had an all-you-can-eat buffet for all three meals each day. Patients with gout should avoid consuming foods containing which of the following elements?
repetitive flexion (ER 3)
A 57-year-old man presents with low back pain radiating down his right lower extremity. On physical exam, he has decreased sensation in the L5 distribution. What is the most likely cause of his symptoms?
Mottled, lace-like purple discoloration (IM 5)
A 60-year-old man presents to the ER for acute abdominal pain. The patient has a significant past medical history of hepatitis B. The patient reports a history of recent malaise, 10 lb weight loss, and fevers leading up to this episode of abdominal pain. Physical exam reveals elevated blood pressure, diffusely tender abdomen, and a rash on the patient's legs. Computed tomography with IV contrast of the abdomen reveals microaneurysms with sudden cutoffs and evidence of mesenteric ischemia. What description of the rash would be consistent with the suspected diagnosis?
bony, hard swelling of the distal interphalangeal joins (ER 1)
A 60-year-old woman presents to the emergency department for progressive, bilateral hand and finger pain. While evaluating her, which of the following would be most suggestive of a diagnosis of osteoarthritis?
cloudy, yellow in appearance, 85,000 WBCs with a predominance of neutrophils, no crystals present on analysis (ER 1)
A 60-year-old woman presents to the emergency department with knee pain. She has a history of diabetes, peripheral arterial disease, CAD, and hypertension. She reports no obvious trauma to the affected knee and states this is worse than her typical arthritis pain. Vital signs are remarkable for a temperature of 39°C, HR 120 bpm, BP 100/60 mm Hg, RR 22/min, and SpO2 of 97%. Physical exam is notable for a warm, edematous, and erythematous right knee. The patient has severe pain with range of motion testing and holds the knee in slight flexion. An arthrocentesis is performed. Which group of findings on synovial fluid analysis is most expected in this patient?
Oral corticosteroid treatment (IM 18)
A 63-year-old woman presents to the emergency department for an initial presentation of a moderately severe temporal headache, scalp tenderness, and pain with chewing for six days. She has no change to her vision. She has a history of polymyalgia rheumatica with specific symptoms of neck and shoulder stiffness. Lab results indicate an elevated erythrocyte sedimentation rate and C-reactive protein. Imaging studies are pending. Which of the following is the first priority in caring for this patient, even before the diagnosis is confirmed?
urinary retention (ER 12)
A 65-year-old woman presents with back pain. She states that she slipped and fell on her back 2 days ago and reports shooting pains down both of her legs. The pain has been significant and worsening over the last 2 days. She is also experiencing increasing weakness in her legs and requires assistance to get into the room today. She has a history of diabetes mellitus, hypertension, and chronic back pain. Vital signs are within normal limits. On examination, the patient has diminished deep tendon reflexes. There is diminished sensation in the bilateral lower extremities and a palpable bladder. Which one of the following findings on her history and physical exam is most sensitive for the diagnosis described above?
immobilization in a sling (ER 2)
A 68-year-old woman presents to the emergency department complaining of right upper arm pain after a fall. She was walking down an icy sidewalk when she slipped and landed on her right arm. There is a palpable deformity in her proximal right humerus. She is neurovascularly intact. X-rays confirm nondisplaced right proximal humerus fracture without dislocation. What is the most appropriate clinical intervention?
Polymyalgia rheumatica (IM 16)
A 68-year-old woman presents to urgent care with a rapid onset of symmetrical pain and stiffness of the shoulders, neck, and hip girdle that is worse in the morning and after prolonged inactivity. Because of the stiffness and pain, she is having difficulty with daily activities, such as combing her hair, taking a shower, putting on a coat, and driving. Which of the following is the most likely explanation for these findings?
Positively birefringent calcium pyrophosphate crystals (IM 2)
A 72-year-old man presents with acute pain, stiffness, and swelling of his left knee. His medical history is significant for hypothyroidism and osteoarthritis. On physical exam, the knee is erythematous, warm, and tender to touch. Cartilage calcification is seen on plain film radiography. Which of the following findings of synovial fluid analysis is best to diagnose the suspected condition?
septic arthritis (ER 10)
A 72-year-old woman presents to the ED complaining of right knee swelling, stiffness, pain, and subjective fever. Her symptoms have developed and worsened over several days. She has no recent history of trauma to the area. Her past medical history includes type II diabetes and previous right knee replacement due to osteoarthritis. She takes metformin and sitagliptin. On exam, her temperature is 101.8°F (38.8°C); the knee is swollen with a large effusion, warmth, decreased active range of motion, and diffuse tenderness but no cellulitis. Findings on examination of synovial fluid include: cloudy, watery synovial fluid; white blood cell count 105 x 109/L with 90% neutrophils, no red blood cells, and no crystals. Gram stain is pending. What diagnosis fits these results most accurately?
decreased sensation between the first and second toe (ER 11)
A patient presents to the emergency department after a skiing collision and is diagnosed with a fibular head fracture. Which of the following findings on neurovascular examination would most likely be seen with this injury?
pain on passive extension of the affected finger (ER 13)
A patient presents to the emergency department for a painful, swollen finger. Which of the following features, if present, would be most consistent with a diagnosis of flexor tenosynovitis?
greenstick fracture (ER 14)
An 8-year-old girl presents after falling from the monkey bars onto an outstretched arm at recess. She endorses pain over her distal forearm proximal to the wrist. A plain radiograph of the forearm is shown above. What type of bony injury is most consistent with this patient's X-ray?
knee (IM 21)
Which of the following joints are most commonly affected in patients with pseudogout?
peroneal nerve (ER 15)
Which of the following neurovascular structures is frequently injured with a tibiofemoral dislocation?
