ANNE DANG, CCPAO RT HO PA E DI C S U RGE RY P H YSI C I A N A SS I STAN T

M C M A S T E R U N I V E R S I T Y P H Y S I C I A N A S S I S T A N T E D U C A T I O N P R O G R A M C L A S S O F

2 0 1 1A N N E C C PA @ G M A I L . C O M

LAST UPDATED JUNE 24 , 2013

SPECIAL THANKS TO:D R . C L A R K , P H Y S I A T R I S T

O H O O D E L Z I B A K . , M C M A S T E R PA E P C L A S S O F 2 0 1 0J A C O B E A P P E N. , M C M A S T E R PA E P C L A S S O F 2 0 1 4

MF3 CRE Practice Questions

MSK

Disclaimer

All of these names and cases are fictitious but based on clinical presentations that real patients may present with. Similarities to anyone in real life is coincidental and unintended.

The opinions expressed on this PowerPoint are those of the author, and they do not reflect in any way those of the institutions to which they are affiliated.

This PowerPoint is for educational purposes only. It is not intended as a substitute for the diagnosis, treatment and advice of a qualified licensed professional. In no way should anyone consider that this presentation represents the "practice of medicine." The author assumes no responsibility for how this material is used. Also note that the information is updated on occasion and due to a variety of reasons, therefore, some information may be out of date.

Obligatory Preamble

Written in the style of CRE (was called CAE back in 2010) based on case studies that were given to the Class of 2011 in MF3 for the Orthopaedics section

MSK is an enormous topic, in addition to typical cases you’d see in Orthopaedics, there is a lot of overlap with Rheumatology, Physiatry, Neurology… you name it! With that being said, do not limit your differential to just “Muscles and bones”, think metabolic, systemic, inflammatory, neoplastic just like you would in a real clinical scenario.

This in no way reflects the kind of questions you will receive on the CRE, purpose is to have you practice answering the question style and to review important topics in MSK.

I am open to feedback about the cases, please contact me (anneccpa@gmail.com) if you have any questions or concerns.

Study Tips

Rather than memorizing a checklist of etiology, symptoms & investigations - try to understand the pathophysiology or why, the former then comes more easily

As JC puts it “Broad Brush Strokes”! Don’t get bogged down by the nitty gritty details. Try to think about what is will be relevant in understanding what is going on with the patient, and how that affects your choice of management

Outline

Case 1: Shoulder Pain Case 2: Knee PainCase 3: Joint PainCase 4: Developmental abnormalityCase 5: Back PainOutline Review

REFERENCE CASEMF3 : CASE 16C MIKE CHIASSON

45 YEAR OLD MALE WITH SHOULDER PAIN

Case 1: Shoulder Pain

Case 1: Shoulder Pain

John, a 62-year-old male electrician presents to your family doctor’s office with a 3 year history of right shoulder pain. He cannot recall any specific injury or inciting event, but notes the pain has been getting worse over time. He says the pain is aggravated at work, especially when he is lifting above the level of the shoulder or doing any work overhead for a long period of time and is better with rest. He localizes the pain to the anterolateral aspect of the shoulder with no radiation. He has tried ice and heat with no relief, and has not tried any other modalities of treatment. He denies any numbness or tingling. Review of systems is otherwise unremarkable. He is a non-smoker and non-drinker.

Questions

Case 1: Shoulder Pain________________

John, a 62 year old male electrician presents to your family doctor office with a 3 year history of right shoulder pain. He cannot recall any specific injury or inciting event, but notes the pain has been getting worse with time. He says the pain is aggravated at work, especially when he is lifting above the level of the shoulder or doing any work overhead for a long period of time and is better with rest. He localizes the pain to the anterolateral aspect of the shoulder with no radiation. He has tried ice and heat with no relief, and has not tried any other modalities of treatment. Review of systems is otherwise unremarkable. He is a non-smoker and non-drinker

1. Based on this gentleman’s history, name three differential diagnosis and the reasoning for why you included each on your differential in the order of most likely to least likely.

2. What findings on physical exam would you expect to observe based on what you think is the most likely diagnosis?

3. What investigations would you order? What would you expect to find based on what you think is the likely diagnosis?

4. Briefly explain what treatment options are available to John.

Answers to Case 1QUESTION 1

Concepts to Review:

• Rotator Cuff Tears

• Shoulder Anatomy/ Rotator Cuff Muscles

Helpful (Quick) Reads• American Family

Physician: Management of Shoulder Impingement Syndrome & Rotator Cuff Tears

• Examples of Differential Diagnosis for Acute/traumatic presentations of shoulder pain: American Family Physician

• Diagnosing Rotator Cuff Tears: American Family Physician

At the top of your Differential: Rotator Cuff Pathology (tear or impingement)

can be traumatic or atraumatic (chronic); commonly aggravated by overhead activities; pain typically localized to anterolateral aspect of

shoulder; AC joint osteoarthritis

pain usually presents over the AC joint (superolateral aspect of shoulder)

Shoulder Osteoarthritis (OA) Usually presents in elderly or after an injury (post-

traumatic OA) Painful & stiff in the morning and gets better

throughout the day Patients often describe “grinding” in the shoulder

(this is a result of ‘bone on bone’ arthritis) Adhesive Capsulitis (“Frozen Shoulder”)

Can present very similarly to rotator cuff tears, except patients may explain “stiffness” is their most predominant complaint.

Risk factors including smoking and Diabetes, can be idiopathic

Biceps Tendinopathy/Tendon Partial Tear

Answers to Case 1QUESTION 2

Concepts to Review:

• Shoulder Physical Exam (inspection, palpation, range of motion, power, neurovascular assessment)

• Shoulder Exam “Special Tests”

• Impingement• Biceps testing – biceps

pathology• Labral testing – rule out

SLAP/labral tears• Apprehension test – rule

out shoulder instability (e.g. recurrent shoulder dislocations)

Helpful Resource:

• Physical exam of the shoulder: AAFP http://www.aafp.org/afp/2000/0515/p3079.html

Based on a Diagnosis of Rotator Cuff Tear/Impingement

Inspection: You may or may not see rotator cuff muscle wasting,

depending on severity of the tear or chronicity of the problem

Palpation Tenderness over the superolateral aspect of shoulderActive Range of Motion If its just impingement or rotator cuff tear alone, range of

motion may be full, but painful Forward flexion and abduction are either limited or painful

above 90 degrees.Power Should be at least 3+/4- on the Oxford power scale, and

limited by pain; you may be dealing with something else if power is less than this.

Neurovascular Status Rotator cuff tears/impingement does NOT cause numbness

or tingling on the affected extremity in most cases! If a patient presents with this, you must adjust your differential diagnosis! (e.g. Thoracic Outlet Syndrome, Brachial Plexus Neuropathies, etc.)

Special/Provocative Tests Positive Impingement Sign/Testing

Answers to Case 1QUESTION 3

Question 3: What investigations would you order? What would you expect to find based on what you think is the likely diagnosis?

Quick Reference about Imaging

X-rays – evaluates bone

Ultrasounds – evaluates soft tissue (e.g. muscles); but sound radar is blocked by bone – so you cannot see the entire anatomy of the shoulder.

MRI – evaluates bone and muscle – can appreciate entirety of shoulder; used to evaluate muscle pathology in greater detail in Orthopaedics.

CT scan – for evaluating bony anatomy in detail; usually ordered by Orthopaedic Surgeons for surgical planning for certain fractures, or presentations of arthritis.

Based on diagnosis of Rotator Cuff Tear/Impingement

X-Ray: Rule out any bony abnormalities. X-rays in rotator cuff tears may be normal or demonstrate narrowing of the subacromial space. If the problem is chronic, there will be long term changes (extra details:

superior migration of the humeral head, narrowing of the subacromial space, spurring on the undersurface of the acromion).

Ultrasound: Will often display tendinosis, partial or complete tearing of the supraspinatus tendon or other rotator cuff muscles.

MRI: Usually a more definitive test to determine more precisely the size & location of the rotator cuff tear/impingement/tendon inflammation. Useful if you plan on referring to a specialist for a surgical opinion (i.e. orthopaedic surgeon).

In clinic: we usually order x-ray and ultrasound together first since they are the fastest and cheapest, MRI waiting list in Hamilton is 2-3 months)

Other (extra knowledge) CT Scan: If the x-ray comes back abnormal (e.g. bony

lesions/depressions). Usually ordered in a specialist setting. Bone Scan: If you suspect a fracture (e.g. proximal humeral

fracture) that did not appear on x-ray Blood work: If you are suspicious for a rheumatological cause of

the pain (e.g. Rheumatoid Arthritis), inflammatory or neoplastic cause, etc.

Answers to Case 1QUESTION 4

Question 4: Briefly explain what treatment options are available to John.

Based on a diagnosis of Rotator Cuff Tear/impingement

Non-Operative Management Anti-inflammatories: for pain relief; John has no risk

factors, but we would advise him to take any NSAIDs with food, issues with blood pressure, ensure he has no kidney disease or liver problems.

Physiotherapy (if you’re American – physical therapy): Specific exercises will help strengthen muscles at the front & back of the shoulder, to reduce impingement and offload the supraspinatus muscle

Modified Activities: John may benefit from reducing his overhead activities and work as an electrician. He may ask his employer to switch to a more administrative role which does not require lifting or overhead activities for several weeks.

Cortisone Injection: A steroid is injected into the subacromial space to reduce inflammation and provide temporary pain relief.

Operative Management Surgical Repair: if non-operative management fails,

John may consider surgical repair of the torn rotator cuff, with debridement (cleanup) of the subacromial space. Surgery may be open or arthroscopic.

Fongemie, A. Buss, D. Rolnick, S. Management of Shoulder Syndrome and Rotator Cuff Tears. Am Fam Physician. 1998 Feb 15; 57(4):667-674

Hide, G. Ultrasonography for Rotator Cuff Injury. Medscape. 2011 Jul 29 Accessed from http://emedicine.medscape.com/article/401595-overview#a22

Miller, M. 2008. Review of Orthopaedics 5th ed. Saunders Elseiver Philadelphia.

Shoulder Case Study References

REFERENCE CASEMF3 : CASE 17ADANIEL GATTO

41-YEAR-OLD MALE WITH KNEE PAIN

Case 2: Knee Pain

Case 2: Knee Pain

Alex is a 26-year-old male who presents to a family medicine practice two weeks after “twisting his knee” during a basketball game. He recalls the pain was “sharp” and “hard to forget”. He is currently taking Naproxen for pain and icing the knee. He feels the knee “gives way” sometimes while walking and especially going down stairs. He reports occasional locking of the knee. He has a history of Asthma and Tonsillectomy at age 5. He has no known drug allergies. He works at a desk job.

On physical exam, you note he has antalgic gait. On inspection you notice decreased quadriceps muscle bulk on the left compared to the right. The left knee is slightly more swollen than the right but there is no redness. Range of motion is full. He knee has neutral alignment. Testing of his MCL and LCL are within normal limits. He has medial joint line tenderness to palpation. Posterior sag sign is negative. He has a positive Lachman’s and Anterior Drawer Test, and positive McMurray and Apley Test medially. He is distally neurovascularly intact.

Questions

Case 2: Knee Pain________________

Alex is a 26-year-old male who presents to a family medicine practice two weeks after “twisting his knee” during a basketball game. He recalls the pain was “sharp” and “hard to forget”. He is currently taking Naproxen for pain and icing the knee. He feels the knee “gives way” sometimes while walking and especially going down stairs. He reports occasional locking of the knee. He has a history of Asthma and Tonsillectomy at age 5. He has no known drug allergies. He works at a desk job.

On physical exam, you note he has antalgic gait. On inspection you notice decreased quadriceps muscle bulk on the left compared to the right. The left knee is slightly more swollen than the right but there is no redness. Range of motion is full. He knee has neutral alignment. Testing of his MCL and LCL are within normal limits. He has medial joint line tenderness to palpation. Posterior sag sign is negative. He has a positive Lachman’s and Anterior Drawer Test, and positive McMurray and Apley Test medially. He is distally neurovascularly intact.

1. Based on the Alex’s initial clinical presentation, what are your top three on your differential diagnosis? Give evidence for each.

2. How would you explain the decrease in quadriceps muscle bulk on physical exam?

Answers to Case 2QUESTION 1

Question 1: Based on the Alex’s initial clinical presentation, what are your top three on your differential diagnosis? Give evidence for each

Concepts

• Knee Anatomy

• ACL tear vs. PCL tear

• Meniscal Tear

• Osteoarthritis of the knee

At the top of your Differential for Medial Knee Pain: ACL Tear: tear of the anterior cruciate ligament

is common in sudden deceleration or twisting injuries. Evidence: Alex had a twisting injury He has the sensation of “giving way” and swelling in

the area Positive anterior drawer and Lachman Test on

physical exam

Meniscal Tear: meniscal tears common in twisting injuries, can happen in conjunction with ACL tears. Locking of the knee is a common symptom, when

tears of the meniscus protrude and obstruct the knee from extending and flexing

McMurray and Apley tests are positive for medial side.

Medial joint line pain

Medial Collateral Ligament (MCL) Tear or Strain MCL injuries occur when there is a valgus force to the knee.

You would have experienced laxity of the medial side when applying a valgus force on physical exam – this exam was normal on Alex’s exam.

Answers to Case 2QUESTION 2

Question 2: How would you explain the decrease in quadriceps muscle bulk on physical exam?

Muscle wasting can be caused by various factors

In Alex’s case, most likely:

Deconditioning/disuse of the muscle due to pain and guarding of the knee. This may happen even if he is neurovascularly intact.

Decrease in quadriceps muscle strength following his ACL injury may contribute to sensation of functional instability of the knee (i.e. “giving way”).

Knee Case Study References

Calmbach, W. Hutchens, M. Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests. Am Fam Physician. 2003 Sept 1; 68(5): 907-912

Calmback, W. Hutchens, M. Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis. Am Fam Physician. 2003 Sep 1;68(5):917-922.

REFERENCE CASE: ANN GREEN

Case 3: Joint Pain

Case 3: Joint Pain

Janice, a 52-year-old female comes to your office with bilateral shoulder pain worse on the right than the left for the past several months. She also notes the knees and hands have been bothering her recently. She notes stiffness in her joints in the morning, and trying to get up or move after driving or sitting for prolonged periods of time. She also reports a long-standing history of difficulty with opening jars, writing and computer work. She has not had any investigations or treatments done. Review of systems otherwise negative.

Upon further questioning, Janice smokes 1 pack per day for the past 20 years. She used work as a project manager for an IT company but has had to discontinue due to her progressive joint pain, blaming it on “old age”. She is allergic to Penicillin.

On physical exam, you note she has swelling on bilateral wrists which are soft and warm to touch, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. You also note swan neck deformities in several finger PIP, ulnar deviation of the MCP, and Boutonniere deformity of thumb.

Questions

Case 3: Joint Pain________________

Janice, a 52-year-old female comes to your office with bilateral shoulder pain worse on the right than the left for the past several months. She also notes the knees and hands have been bothering her recently. She notes stiffness in her joints in the morning, and trying to get up or move after driving or sitting for prolonged periods of time. She also reports a long-standing history of difficulty with opening jars, writing and computer work. She has not had any investigations or treatments done. Review of systems otherwise negative.

Upon further questioning, Janice smokes 1 pack per day for the past 20 years. She works as a project manager for an IT company. She is allergic to Penicillin.

On physical exam, you note she has swelling on bilateral wrists, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. You also note swan neck deformities in several finger PIP, ulnar deviation of the MCP, and Boutonniere deformity of thumb.

1. What two diagnoses are on the top of your differential after reviewing Janice’s History and Physical Exam?

2. What investigations would you order? What parameters are you looking for to confirm the most likely diagnosis?

3. What treatment options are available to Janice?

4. Why is Janice’s presentation unlikely to be osteoarthritis?

Answers to Case 3QUESTION 1

Question 1: What two diagnoses are on the top of your differential after reviewing Janice’s History and Physical Exam?

References:

American College of Rheumatology 1987 revised classification material for rheumatoid arthritis

Most likely diagnosis: Rheumatoid Arthritis (RA):

Based on Janice’s presentation, the clinical presentation that is consistent with rheumatoid arthritis include:

Bilateral presentation Ulnar deviation at the MCPs, Boutonniere

deformity and swan neck deformities are classic findings of RA.

Insidious onset / no history of trauma

Morning and startup stiffness Multiple joints affected

Seronegative Polyarthritis Reactive Arthritis (Reiter’s Syndrome) Systemic Lupus Erythematous Pseudogout

Answers to Case 3QUESTION 2

Question 2: What investigations would you order? What parameters are you looking to confirm the most likely diagnosis?

Based on the most likely diagnosis being Rheumatoid Arthritis:

Blood work: Elevated ESR and C-reactive proteinPositive Rheumatoid Factor (RF)Positive anti-CCP antibodyTo rule out other rheumatologic disorders: Uric Acid (rule out pseudogout/CPPD)

Investigations:X-ray: Bone erosions; ulnar deviation of MTPs, absence of Heberden’s Nodes, Swan Neck Deformity of PIPs. MRI: may show synovitis of affected jointsJoint aspiration: rule out presence of CPPD crystals (pseudogout)

Image 1: UptoDateImage 2: http://ra-ss.blogspot.ca/p/30-years-of-ra.html

Answers to Case 3QUESTION 3

Question 3: What treatment options are available to Janice?

Referral to Rheumatologist

Early use of DMARD (Disease Modifying Antirheumatic Drug) e.g. Methotrexate; may take four to six weeks to take effect

Or use of Biologics if she does not respond to use of DMARDs include Etanercept, Adalimumab, infliximab, golimumab (TNF inhibitors); effects are more rapid than DMARD

NSAIDs (nonsteroidal anti-inflammatory drugs) as an adjunct for initiating DMARD therapy or controlling Janice’s flares.

Short term use of Glucocorticosteroid Prednisone, with caution against the risks of chronic use e.g. GI bleeding, risk for osteoporosis and fractures, diabetes mellitus, infections, cataracts and impaired HPA axis response,

Smoking cessation counseling for Janice

Answers to Case 3QUESTION 4

Question 4: What reasons is this unlikely osteoarthritis?

Osteoarthritis may present very similarly to Rheumatoid Arthritis, however, there are important distinctions:

Feature Rheumatoid arthritis Osteoarthritis

Heberden’s Nodes Absent Present

Stiffness Worse after resting (e.g. morning stiffness)

Evening stiffness or worse after activity

Positive Lab Findings Positive Rheumatoid FactorPositive anti-CCP AntibodyIncreased ESR and CRP

Negative Rheumatoid FactorAnti-CCP Antibody negativeNormal ESR and CRP

Joints Soft, warm and tender (synovitis)

Hard and bony

Joints in hands affected MCP and PIP DIP and CMC

Extra-articular manifestations Present Absent

Image 1: http://www.bio.davidson.edu/courses/immunology/students/spring2006/dresser/ra.htmlImage 2: http://www.cedars-sinai.edu/Patients/Health-Conditions/Osteoarthritis.aspxTable from UptoDate

Case 3 References

Lipsky P. Algorithms for the diagnosis and management of musculoskeletal complaints: A new tool for the primary-care provider. (See www.swmed.edu/home_pages/cme/endurmat/lipsky/index.html.)

O’Dell, J. Use of glucocorticoids in the treatment of rheumatoid arthritis. UptoDate. 2012 Dec 17. Accessed April 12, 2013 from http://www.uptodate.com/contents/use-of-glucocorticoids-in-the-treatment-of-rheumatoid-arthritis?source=see_link

Schur, P & Moreland, L. General Principles of management of rheumatoid arthritis in adults. UptoDate. 2013 Feb 4. Accessed April 12, 2013 from http://www.uptodate.com/contents/general-principles-of-management-of-rheumatoid-arthritis-in-adults?source=related_link

Venables, P. Maini, R. Clinical features of rheumatoid arthritis. UptoDate. 2012 Oct 6. Accessed April 12, 2013 from http://www.uptodate.com/contents/clinical-features-of-rheumatoid-arthritis?source=see_link

Venables, P. Maini, R. Diagnosis and differential diagnosis of rheumatoid arthritis. UptoDate. 2012 Mar 28. Accessed April 12, 2013 from http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis?source=search_result&search=rheumatoid+arthritis&selectedTitle=1%7E150

REFERENCE CASE: ANN GREEN

Case 4: Developmental Abnormality

Case 4: Joint Pain

You are in your second year PA clerkship and have decided to do a rotation overseas with a supervisor who is looking to bring health care to underserviced areas. While doing home visits to administer vaccinations in one of the local villages, you meet Jane, a lovely 8-year-old female accompanied by her mother.

Starvation and poverty are endemic in Jane’s village. Jane’s mother has explained food has been difficulty to come by, and Jane has had trouble growing as fast as some of her classmates. Upon further questioning, you learn that Jane is sick frequently with infections.

On physical examination you note that Jane is small in stature for her age. You notice significant varus alignment of the knees, as well as bowing of the tibia and fibula.

Questions

Case 4: Developmental Abnormality________________

You are in your second year PA clerkship and have decided to do a rotation overseas with a supervisor who is looking to bring health care to underserviced areas. While doing home visits to administer vaccinations in one of the local villages, you meet Jane, a lovely 8-year-old female accompanied by her mother.

Starvation and poverty are endemic in Jane’s village. Jane’s mother has explained food has been difficulty to come by, and Jane has had trouble growing as fast as some of her classmates. Upon further questioning, you learn that Jane is sick frequently with infections.

On physical examination you note that Jane is small in stature for her age. You notice significant varus alignment of the knees, as well as bowing of the tibia and fibula.

1. What is the likely diagnosis? What other questions would you ask to clarify this diagnosis?

2. Explain the pathophysiology behind the disease.

3. How would the disease process present differently if Jane was an adult at the time of onset? When Jane was a neonate?

4. What investigations would you order to confirm the diagnosis and what specific findings would you expect?

5. What treatment options and education would you recommend for Jane and her mother?

Answers to Case 4QUESTION 1

Question 1: What is the likely diagnosis? What other questions would you ask to clarify this diagnosis?

Most likely diagnosis is Rickets as a result of Vitamin D Deficiency (Calcipenic Rickets)

Rule out causes of Vitamin D Deficiency: Decreased nutritional intake: Ask about diet, e.g.

what a typical breakfast, lunch, and dinner consists of to understand over time what Jane’s nutritional picture looks like

Decreased synthesis: i.e. those with darker pigmented skin in low sunlight times of the year or clothing coverage

Constitutional symptoms to rule out neoplasms that may be causing hormonal imbalances

Maternal Factors: (1) Maternal Vitamin D deficiency; (2) Prematurity; (3) Exclusive breast feeding

Ask about family history (rule out inherited Vitamin D resistance)

Medications: Anticonvulsants, antiretroviral drug use for HIV, glucocorticosteroids, Antifungal agents such as Ketoconazole

Do a thorough review of systems to rule out kidney disorders, liver disorders parathyroid hormone problems

Rule out causes of malabsorption (e.g. Celiac’s Disease, inflammatory bowel disease, pancreatic insufficiency, cholesstasis, post-gut resection or bariatric surgery)

Answers to Case 4QUESTION 2Question 2: Explain the pathophysiology behind the disease.

Vitamin D Metabolism Overview: Vitamin D3 (dietary and synthesized in skin

from sunlight exposure) and Vitamin D2 Carried to the liver by D-binding protein to the

liver where it is converted into 25(OH)-D a storage form of Vitamin D

In the kidney, 25(OH)-D is converted to1-25(OH)2D regulated by PTH, serum Calcium & Phosphate.

Vitamin D increases calcium absorption from gut & reasborption from kidney.

Pathophysiology: For Jane, there is likely a significant dietary role for her disease process. There are two subtypes of rickets: Calcipneic Rickets: due to low intestinal

absorption of calcium but not necessarily to hypocalcemia

Phosphophenic

Image from http://www.uptodate.com/contents/image?imageKey=ENDO/65360&topicKey=ENDO%2F2021&source=outline_link&utdPopup=true

Answers to Case 4QUESTION 1Question 3: How would the disease process present differently if Jane was an adult at the time of onset? When Jane was a neonate?

Vitamin D Deficiency in a:Neonate – delayed closure

of the fontanellesAdult –Presents as

Osteomalacia Presentation is difference since

growth plates are closed including “bone pain”, and joint pain muscle weakness, difficult walking

Answers to Case 4QUESTION 4Question 4: What investigations would you order to confirm the diagnosis?

Blood work: Serum Calcium, Vitamin D levels of 25(OH)D,

Parathyroid Hormone (PTH), ALP, Phosphorus, Kidney Function Tests

X-rays to rule out pathologic fractures in areas of pain Blood work Findings: Expected findings highlighted in

red with Vitamin D deficiency with child who has normal kidney and liver function

Image from http://www.uptodate.com/contents/image?imageKey=PEDS/56687&topicKey=PEDS%2F14590&source=outline_link&search=rickets&utdPopup=true

Case 4 – Question 4: Supplementary Slide

Image from: http://www.uptodate.com/contents/image?imageKey=PEDS/81032&topicKey=PEDS%2F5856&source=outline_link&search=search+rickets&utdPopup=true

Answers to Case 4QUESTION 5Question 5: What treatment options and education would you recommend for Jane and her mother?

Treatment: Vitamin D Replacement (D3): for

Jane’s age, it would be 2000 IU/day for six weeks, followed by maintenance of 600 to 1000 IU/day

Since Jane is also presenting with clinical manifestations of rickets, she should have Calcium along side her Vitamin D supplementation (10-20 mg/kg/day)

Resources

Carpenter, T. Overview of rickets in children. UptoDate. 2013, Mar 28. Accessed April 19, 2013 from http://www.uptodate.com/contents/overview-of-rickets-in-children?source=search_result&search=vitamin+d+deficiency+neonate&selectedTitle=3%7E150

Menkes, CJ. Clinical Manifestations, diagnosis and treatment of osteomalacia. UptoDate. 2013, Apr 3. Accessed April 19, 2013 from http://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-treatment-of-osteomalacia?source=search_result&search=osteomalacia&selectedTitle=1%7E117

REFERENCE: MF3 MSK JACK GAMBLECASE STUDY

REVIEWED BY DR. CLARK, MD, FRSCS(C) PHYSICAL MEDICINE AND

REHABILITATION / PHYSIATRY MD

Case 5: Back Pain

Case 5: Back Pain

50 year old male Donald presents to the Emergency room with an acute on chronic episode of low back pain. He has worked in construction for 30 years and despite “strains” in the past, has never sought treatment for his low back pain. He has had longstanding intermittent numbness and tingling down the lateral lower leg made worse with walking, and better with rest, sitting or lying in a supine position which you identify as “neurogenic claudication”. He does not take any medications, and has an otherwise benign past medical history.

Inspection of spine curvature is normal. He has pain with forward flexion of the lower back. He is tender to palpation of his lumbar paraspinals and midline structures at the level of L5/S1. He can walk on his heels and perform a full squat. However, he was unable to stand up on his toes on the left side (weak plantarflexion).

His hip, knee, and ankle exam is unremarkable. He reports decreased pinprick and light touch over the posterior calf and lateral foot, but also reports he has decreased sensation near the groin area bilaterally. Straight raise leg reproduces his symptoms at 30 degrees of elevation. Romberg testing is negative. Upper extremity testing was unremarkable. Muscle strength is 2+ at the hips, knees and ankles, with normal muscle stretch reflexes at the knees. Absent ankle reflex on the left. Peripheral pulses are palpable.

Upon further questioning, he has noted urinary retention and difficulty with bowel movement in the past week. He also notes new onset erectile dysfunction within the past 24 hours. He denies any constitutional symptoms, hearing or vision changes.

Questions

Case 5: Back Pain

1. a) What red flags appeared in Donald’s clinical presentation that would have you worried about a potential medical emergency? b)What other urgent conditions would you want to rule on your differential diagnosis in an ER setting?

2. What investigations would you order to rule out serious conditions?

3. a) What are the potential differential diagnosis if Donald presented without the red flags, in a primary care setting with chronic low back pain? b) What investigations would you order in that circumstance?

4. If the most likely serious condition is confirmed from your investigations, what treatment options are available to Donald?

BONUS: Explain the various findings on Donald’s physical exam, and the rationale for performing those tests.

BONUS 2: Explain a diagnostic approach to presentations of non-specific low back pain

Answers to Case 5QUESTION 1 a)

Question 1: a) What red flags appeared in Donald’s clinical presentation that would have you worried about a potential medical emergency?

B) What would you want to rule out first on your differential diagnosis?

American College of Radiology: “Red Flags” for potentially serious underlying cause for low back pain:

Trauma (cumulative) Underlying Systemic Diagnosis: (1) Age > 50

years; (2) Unexplained weight loss; (3) Duration longer than 6 weeks; (4) Night Pain; (5) History of Cancer

Unexplained fever, history of urinary or other infections

Immunosuppression/Diabetes Mellitus IV Drug Use Prolonged use of corticosteroids,

osteoporosis Focal neurologic deficits with progressive or

disabling symptoms, cauda equina syndrome (bowel or bladder dysfunction)

New onset “bilateral groin pain” could represent saddle anesthesia

Prior Surgery RULE OUT CAUDA EQUINA SYNDROME

OR SPINAL CORD COMPRESSION DDx: Spinal Cord Neoplasma, Diabetic

Neuropathy, ALS, Traumatic Peripheral Nerve Lesions, Osteomyelitis, Perineural Cysts

Answers to Case 5QUESTION 1b)

Question 1: a) What red flags appeared in Donald’s clinical presentation that would have you worried about a potential medical emergency?

B) What would you want to rule out first on your differential diagnosis?

RULE OUT CAUDA EQUINA SYNDROME

Other Urgent Differential Diagnosis for Low Back Pain: Spinal Cord Neoplasma Perineural Cysts Aortic Aneurysm Costochondritis GI Disease: Pancreatitis, Cholecystitis,

Penetrating Ulcer Infection: Osteomyelitis, septic discitis,

epidural abscess, bacterial endocarditis Pelvis Organs: Prostatitis, Endometriosis, *Renal Disease: Neophrolithiasis,

Pyelonephritis

Answers to Case 5QUESTION 2

Question 2: What investigations would you order to rule out serious conditions.

Investigations in a ER setting Blood work: CBC, chemistries, fasting blood sugar

(rule out anemia, infection, and kidney dysfunction) + ESR (rule out inflammatory pathology such as infection)

Catheterize bladder and measure post-void residual (> 50-100cc is abnormal): rule out urinary retention from other causes (e.g. atonic bladder from certain meds)

Imaging: Urgent MRI and/or CT scan Lumbar spine x-ray to rule out trauma, fracture,

disc space narrowing and spondylolysis Bone Scan – may detect malignant tumor or

metastases, infection and occult fractures

Other Tests Meningitis (causing spinal cord compression)

workup unlikely necessary unless patients present with neck symptoms

Syphilis/Lyme serologies (rule out meningovascular syphilis)

Lumbar puncture to rule out meningitis (CSF Exam)

Answers to Case 5QUESTION 3 a)_

Question 3: a) What are the potential differential diagnosis if Donald presented without the red flags, in a primary care setting with chronic low back pain?

b) What investigations would you order in that circumstance?

Mechanical Back Pain Lumbar Strain Herniated Disc Osteoporosis Fractures Sciatica: numbness and tingling of sciatic nerve to

foot or ankle Piriformis Syndrome: the piriformis muscle

compresses/irritates the sciatic nerve S1 radiculopathy: impairment of a nerve root Spondylosis (arthritis of spine) Spondylolisthesis (anterior displacement of vertebra

90% degenerative) Spondylolysis: fracture usually at L5 of the pars

interarticularis Spinal Stenosis: narrowing of the central spinal canal

by bone or soft tissues Congenital: Lordosis, kyphosis, scoliosisNeoplasia: multiple myeloma, metastatic carcinoma, lymphoma/leukemia, spinal cord tumors, retroperitoneal tumors. Inflammatory Arthritis: IBD, Ankylosing Spondylitis, Reiter’s Syndrome. Paget’s Disease

Answers to Case 5QUESTION 3 b)Question 3: a) What are the potential differential diagnosis if Donald presented without the red flags, in a primary care setting with chronic low back pain?

b) What investigations would you order in that circumstance?

Investigations (outpatient): MRI of lumbar spine – r/o fracture, tumor,

infection, structural abnormality of the spinal cord

X-ray of lumbar spine Blood work (if systemic disease is suspected)

with or without rheumatologic markers

Outpatient setting: EMG and nerve conduction studies:

not appropriate in an emergency setting, any nerve damage in arms takes 5-10 days before showing up on EMG, and 2 weeks for peripheral legs.

Any same day acute pain you are trying to investigate may appear normal on EMG and nerve conduction studies.

Answers to Case 5QUESTION 4

Question 4: If the serious condition is confirmed from your investigations, what treatment options are available to Donald?

Determine underlying cause of cauda equina syndrome

If Urgent Surgery Required: Admit patient to appropriate service from Emergency within 24 hours (Orthopaedic Surgery or Neurosurgery)

Answers to Case 5BONUS QUESTIONBONUS: Explain the various findings on Donald’s physical exam, and the rationale for performing those tests

Assessing lumbar spine range of motion

Romberg Testing rule out dorsal column abnormalities

Lumbar Nerve Root Irritation tests Straight Leg Raise: rule out sciatica Femoral stretch test

Nerve Root Conduction Tests L5 – hip abduction (Trendelenburg test),

ankle dorsiflexion, great toe extension S1 – hip extension, great toe flexion, ankle

reflex Upper Motor Neuron Test (absent

Babinski is normal) Lower sacral nerve root tests

Saddle sensation Muscle strength testing Muscle stretch reflexes

Image from: http://www.uptodate.com/contents/image?imageKey=PC%2F68791&topicKey=PC%2F7782&rank=1%7E132&source=see_link&search=low+back+pain&utdPopup=true

Answers to Case 5BONUS Q 2

Approach to Non-Specific Back Pain

Back Predominant: more likely mechanical Back Buttock Trochanteric (hip) Groin (SI joint)

Leg Predominant: anywhere below gluteal fold radicular pain peripheral neuropathy entrapment neuropathy

References

Dawodu, S. Cauda Equina and Conus Medullaris Syndromes Treatment & Management. MedScape Reference: Drugs, Diseases and Procedures. 2013, Mar 6. Accessed April 19, 2013 from http://emedicine.medscape.com/article/1148690-overview

Hall, H. Rampersaud, R. The Practical Management of Low Back Pain. Family Medicine Forum. Accessed April 23, 2013 from http://www.spinecanada.ca/assessing_tlb_web2011.pdf

Wheeler, S. Wipf, J. Staiger, T. Deyo, R. Approach to the diagnosis and evaluation of low back in adults. UptoDate. 2012, Apr 5. Accessed April 19, 2013 from http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults?source=search_result&search=approach+to+low+back+pain&selectedTitle=1%7E150

Resources

Larsen, Betty. The diagnosis and pharmacologic management of low back pain. JAAPA 2012 [PDF available] http://www.jaapa.com/the-diagnosis-and-pharmacologic-management-of-low-back-pain/article/229325/

Case 6: Red, Swollen Joint

Case 6: Red, Swollen Joint

64 year-old-male David presents to a walk-in clinic complaining of 14 hour history of sudden redness and swelling after “bumping his foot” on a concrete ledge the night before. Past medical history includes Type II Diabetes, which is well-controlled and he is currently taking Metformin and ASA 81. He works as an executive and has a history of alcohol abuse.

He has no known drug allergies. His speech is slightly slurred, and upon further questioning, you learn that David had come straight from a family outing and had some “meat, potatoes, and a few drinks”.

On physical examination, Davis afebrile, there is significant swelling, warmth and erythema over the first MTP with decreased range of motion and pain with ambulation. You determine this is monoarticular and no other joints are affected. There are no lacerations or open wounds on inspection around the joint.

Questions

Case 6: Red, swollen joint

1. Based on David’s presentation, list the top three diagnoses on your differential and rationale for each.

2. What is the pathophysiology for the most likely diagnosis?

3. What investigations would you order and why?

4. What treatment options are available to David and what management should be initiated to prevent recurrence?

Answers to Case 6 QUESTION 1

Question 1: Based on David’s presentation, list the top three diagnoses on your differential and rationale for each.

Septic Arthritis: Infection of the MTP joint may be less likely due to lack of open wound that results in bacteria seeding into the joint. However, this is not a prerequisite for septic arthritis. Assume it is septic arthritis until otherwise proven, which would result in rapid destruction of joint if not treated.

Acute gouty attack: caused by hyperuricemia in blood and other bodily fluids (synovial fluid) resulting in precipitation in connective tissue throughout the body. His risk factors include high urate intake – including meat, alcohol, as well as Diabetes.

Cellulitis: A cellulitis infection may be coincidentally located over the MTP joint and may mimic an acute gouty attack or cellulitis.

Answers to Case 6 QUESTION 2

Question 2: What is the pathophysiology for the most likely diagnosis?

For Pathophysiology of Acute Gouty AttackHyperuricemia caused by: Excessive production of uric acid

(alcohol, tumor lysis, obesity) Excessive consumption of uric acid

results in excessive nucleid acid turnover (glutamine hypoxanthine xanthine uric acid)

Impaired renal excretion of uric acid (intrinsic: dehydration, renal disease; secondary to drugs: thiazides, alcohol)

Hyperuricemia results in formation of monosodium urate crystals.

Answers to Case 6 QUESTION 3What investigations would you order and why?

Arthrocentesis: aspiration of joint fluid for fluid analysis (cell count and differential, gram stain, culture sensitivity & microscopic analysis for crystals – under polarized light to differentiate crystal type

Blood Work: CBC (elevated ESR), WBC (left shift); renal, liver function tests (before initiating anti-gout therapy)

Serum uric acid is often misused to diagnose gout: attacks triggered by crystal formation are not related to serum levels of uric acid. 10% of patients who have gout do not have hyperuricemia. Elevated Uric acid levels in blood do not predict gout.

Answers to Case 6 QUESTION 3What investigations would you order and why?

IMAGING STUDIES

Imaging Studies: X-ray & CT scans are adjuncts

but not necessary for diagnosing gout

X-ray: plain radiographs may show some soft tissue swelling, tophi development but may be negative in first year of disease You may see erosions with

overhanging edges

Image from http://emedicine.medscape.com/article/329958-workup

Answers to Case 6 QUESTION 4What treatment options are available to David and what management should be initiated to prevent recurrence?

Treatment Acute gouty attacks treat with

pharmacologic therapy within 24 hours of attack onset.

For severe pain (polyarticular/large joints) : 1) Colchicine and NSAIDs or 2) Oral corticosteroids & colchicine or

3) intra-articular steroid Mild to moderate pain (few small

joints, 1 joint). Monotherapy with topical ice as needed: 1) NSAID (or COX2 inhibitor) 2) Systemic corticosteroids 3) Colchicine

Khanna, D. et al ACR: Guidelines for Management of Gout. Vol. 64, No. 10, October 2012, pp 1447–1461

Answers to Case 6 QUESTION 4What treatment options are available to David and what management should be initiated to prevent recurrence?

Prophylaxis Initiate urate lowering therapy (see

table below, if presence of gout, frequent attacks, CKD stage 2, previous urolithiasis)

Pharmacologic choices: First line: Low dose colchicine or low

dose NSAIDs Second line: Low dose prednisone or

prednisoloneAvoid Limit Encourage

Organ meats high in purine content (liver, kidney)

Serving sizes of:Beef, lamb, seafood (e.g. sardines, shellfish)

Low fat or non-fat dairy products

High fructose corn syrupAlcohol

Sweet fruit juices, table sugar, table salt

Vegetables

AlcoholKhanna, D. et al ACR: Guidelines for Management of Gout. Vol. 64, No. 10, October 2012, pp 1447–1461

Case 6 References

Rothschild, B. 2013 June 17. Gout and Pseudogout. Accessed June 24, 2013 from http://emedicine.medscape.com/article/329958-workup#aw2aab6b5b8

Khanna, D. et al ACR: Guidelines for Management of Gout. Vol. 64, No. 10, October 2012, pp 1447–1461

Outline Review

Case 1: Shoulder Pain [Rotator Cuff Disease] Case 2: Knee Pain [ACL tear/meniscus tear]Case 3: Joint Pain [Rheumatoid Arthritis]Case 4: Developmental abnormality [Rickets /

Vitamin D Deficiency and Metabolism]Case 5: Low Back Pain [Cauda Equina/L5/S1

radiculopathy]Case 6: Red Swollen Joint [Acute Gouty

Attack]

Other Resources

I’ve written a resource on Rotator Cuff Pathology based on experience from working in Orthopaedic Surgery outpatient clinic, you can view it here: http://anneccpa.wordpress.com/2013/02/11/shoulder-impingement-syndrome/