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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3017_Библиотеки_им_академика_М_И_Перельмана
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162 Diagnostic EMQs
BACK PAIN 2
A. Ankylosing spondylitis
B. Brown–Sequard syndrome
C. Cauda equina syndrome
D. Dissecting thoracic aneurysm
E. Episacral lipoma
F. Multiple myeloma
G. Musculoligamentous strain
H. Pancreatitis
I. Pyelonephritis
J. Renal calculus
K. Retroperitoneal hematoma
L. Rheumatoid arthritis
M. Sacroiliac joint dysfunction
N. Scheuermann’s disease
O. Spina bida occulta
P. Spinal abscess
Q. Spinal canal stenosis
R. Spinal compression fracture
For each of the following, what is the MOST likely diagnosis?
1. A 29-year-old woman presents with a ve-day history of worsening lower back
pain. She has a history of anxiety and IV drug use. On examination she has a
temperature of 38.3°C and is tender in her lumbar spine.
2. A 32-year-old man presents with a six-month history of lower back pain. His
symptoms are worse when he wakes but improve throughout the day. He also
has pain in his heels when he gets out of bed. On examination there is decreased
forward exion of the spine. You arrange an X-ray of his spine which reveals a
bamboo spine appearance.
3. A 61-year-old woman presents with severe back pain after a gym session yes-
terday. During her session there was a new instructor who incorporated weight
lifting into her routine, something she normally does not do. She is struggling to
straighten her back and reports that she has a loss of sensation in her left big toe
and pain at the back of her left thigh. She has a past history of depression, osteo-
porosis and familial hyperlipidaemia. On examination you conrm the sensory
loss on her left great toe, she cannot fully extend her left toe and struggles with
dorsiexion of her left ankle.
4. A 14-year-old girl presents with back ache. She is concerned about her worsen-
ing posture. On examination she has marked thoracic kyphosis. An X-ray of the
spine reveals anterior wedging of three thoracic vertebrae.
5. A 26-year-old woman presents with lower back pain and numbness in her lower
limbs. Two days ago, she slipped down a ight of stairs, landed on her bottom
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Musculoskeletal 163
and felt a sudden shooting pain down her back. The pain has progressively
worsened, she has had difculty ambulating, has developed numbness in her
legs today and had an episode of urinary incontinence this morning.
See page 179 for answers.
ELBOW AND FOREARM 1
A. Cubital tunnel syndrome
B. De Quervain’s tenosynovitis
C. Intersection syndrome
D. Lateral epicondylitis
E. Medial epicondylitis
F. Olecranon bursitis
G. Panner’s disease
H. Posterior interosseus nerve syndrome
I. Radial tunnel syndrome
J. Valgus extension overload syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 17-year-old baseball player attends with right elbow pain for the past week.
The pain affects the posteromedial aspect of her elbow and maximal pain
occurs just as she releases the ball while pitching. On examination she is tender
over the posteromedial elbow on the right and her symptoms are reproduced by
application of valgus stress on the elbow at 20 degrees of exion while simul-
taneously forcing the elbow into extension. An X-ray reveals osteophyte forma-
tion in the posteromedial olecranon fossa.
2. A 32-year-old accountant presents with a three-month history of right forearm
pain. Initially it only occurred while playing squash but it is now impacting her
ability to work and perform household tasks. On examination there is swelling
on the dorsum of the forearm 5cm proximal to Lister’s tubercle, there is also
tenderness and crepitus over the site of irritation. She struggles to pronate her
arm secondary to pain.
3. An 8-year-old boy presents with right lateral elbow pain for the past four weeks
which has not improved. The pain is exacerbated by throwing balls when doing
baseball training. On examination he has a full range of movement in the elbow
and no obvious deformity. An X-ray reveals attening of the capitellum.
4. A 29-year-old woman attends with a four-week history of left radial side wrist
pain. She has a 6-month-old child and explains that the pain is worse when
lifting her child. On examination there is swelling and tenderness over the rst
dorsal compartment of the left wrist. Finkelstein test is positive.
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164 Diagnostic EMQs
5. A 27-year-old athlete presents with pain on the medial aspect of his right elbow.
The pain has been present for eight weeks and is associated with pins and nee-
dles on the medial side of his forearm and his 4th and 5th digits. On examina-
tion there is reduced sensation in the medial two ngers and Wartenberg’s sign
is positive.
See page 180 for answers.
ELBOW AND FOREARM 2
A. Cubital tunnel syndrome
B. De Quervain’s tenosynovitis
C. Intersection syndrome
D. Lateral epicondylitis
E. Medial epicondylitis
F. Olecranon bursitis
G. Panner’s disease
H. Posterior interosseus nerve syndrome
I. Radial tunnel syndrome
J. Valgus extension overload syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 22-year-old university student presents with weakness in his right hand and
wrist. His symptoms have developed over recent months and he has found it dif-
cult to write notes. You review his le and note that he has a two-year history
of intermittent right elbow pain without a history of trauma. He has no other
medical history. On examination he is unable to extend his ngers at the MCP
joints and he has weak extension of his wrist, there is no loss of sensation.
2. A 32-year-old receptionist attends your clinic with left elbow pain. She knocked
her elbow a few days ago after a fall and since then she has had worsening
swelling over the elbow and associated pain. On examination you note swelling
over the olecranon process which resembles a “goose egg” in appearance, there
is tenderness on palpation over the site.
3. A 32-year-old man presents with pain in his right elbow for the past two weeks
associated with a weak grip. He denies a history of trauma and has no signi-
cant past medical history other than anxiety. On examination there is swelling
over the elbow and elbow pain is provoked by resisted extension of his wrist.
4. A 37-year-old carpenter presents with a six-month history of right lateral elbow
pain. He reports that pain is worse when he is using a screwdriver or doing
heavy lifting at work. On examination there is tenderness 5cm distal to the
lateral epicondyle, the pain is made worse with elbow extension, wrist exion
and forearm pronation. There is no sensory or motor decit.
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Musculoskeletal 165
5. A 39-year-old woman presents with a three-month history of right elbow pain
and swelling. She denies a history of trauma and has been well otherwise. On
examination there is swelling in the elbow, there is also pain with resisted fore-
arm pronation and wrist exion.
See pages 180–181 for answers.
FOOT PAIN 1
A. Freiberg disease
B. Gout
C. Growing pain
D. Hallux valgus
E. Hammer toe
F. Heel fat pad syndrome
G. Kohler disease
H. Mallet toe
I. Morton’s neuroma
J. Plantar fasciitis
K. Pseudogout
L. Sever’s disease
M. Stress fracture
N. Talon noir
O. Tarsal tunnel syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 37-year-old woman presents with a six-month history of pain in her left foot
when she puts on her shoes. She denies any trauma and has no signicant medi-
cal history. On examination she has hyperexion of the distal interphalangeal
joint of the third toe.
2. A 16-year-old girl presents with a ten-month history of left forefoot pain. On
examination she has tenderness over the second metatarsophalangeal joint with
associated swelling and restricted dorsiexion. You arrange for an X-ray which
reveals attening of the second metatarsal head with subchondral sclerosis.
3. A 65-year-old man presents with a six-month history of right foot pain. The
pain is mostly in the middle of his heel and feels deep and “bruise like”. His
pain is worse with walking and after prolonged periods of standing. On exami-
nation you are able to reproduce the pain with rm palpation over the heel. You
arrange for an ultrasound which reveals a fat pad of 0.9cm thickness (normal >
1.2cm), but nil else.
4. A 43-year-old woman presents with a ve-month history of right foot pain. The
pain is in her heel and is worse rst thing in the morning when she steps out of
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166 Diagnostic EMQs
bed but gradually improves with walking. She has a history of anxiety, ankylos-
ing spondylitis and a bone spur at the base of her right foot. On examination she
has point tenderness along the anteromedial calcaneum.
5. A 57-year-old man presents with a one-day history of right great toe pain
and swelling. His pain is so severe that he is unable to walk using his right
foot. He denies any trauma and has no signicant medical history. He is a
non-smoker and drinks eight standard drinks each weekend, he has done
this for the past 15years. On examination he has a temperature of 36.6°C,
blood pressure of 126/84 mmHg, heart rate of 68 beats per minute, respira-
tory rate of 16 breaths per minute and a BMI of 34. You perform an aspira-
tion of joint uid from the toe, this reveals negatively birefringent needle
like crystals.
See page 181 for answers.
FOOT PAIN 2
A. Freiberg disease
B. Gout
C. Growing pain
D. Hallux valgus
E. Hammer toe
F. Heel fat pad syndrome
G. Kohler disease
H. Mallet toe
I. Morton’s neuroma
J. Plantar fasciitis
K. Pseudogout
L. Sever’s disease
M. Stress fracture
N. Talon noir
O. Tarsal tunnel syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 7-year-old boy attends your clinic with his parents who are very concerned.
He woke up last night complaining of bilateral foot pain, his parents gave him
paracetamol and massaged his feet which helped resolve his symptoms within
45 minutes. He has had similar episodes over the past two weeks. On examina-
tion you nd no cause for his symptoms and he is walking about comfortably.
2. A 24-year-old woman presents with discoloration in her heel. She noticed black
streaks in her left heel yesterday after basketball training. She denies any pain
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Musculoskeletal 167
or history of trauma. On examination there are two arrowhead shaped black
macules measuring 7mm and 9mm respectively.
3. An 11-year-old boy presents with bilateral heel pain. He has been symptomatic
for the past ve months and it is worse after running. On examination there is
swelling and signicant tenderness at the back of both heels.
4. A 51-year-old man presents with discomfort and pain affecting his left foot.
He has episodes of burning pain and numbness in the medial aspect of his foot
extending into his great toe. He explains that his symptoms have been present
for the past eight months. On examination Tinel’s sign is positive.
5. A 64-year-old woman presents with a two-day history of left foot pain and
swelling mostly affecting her great toe. She struggles to ambulate as a result
of the pain. She denies trauma and has no signicant medical history. She is a
non-smoker and does not drink alcohol. On examination she has a temperature
of 36.3°C, blood pressure of 136/90 mmHg, heart rate of 72 beats per minute,
respiratory rate of 18 breaths per minute and a BMI of 30. You note signicant
swelling affecting her left great toe. You perform an aspiration of joint uid
from the toe, this reveals rod shaped crystals with blunt ends which are posi-
tively birefringent.
See pages 181–182 for answers.
FOOT PAIN 3
A. Freiberg disease
B. Gout
C. Growing pain
D. Hallux valgus
E. Hammer toe
F. Heel fat pad syndrome
G. Kohler disease
H. Mallet toe
I. Morton’s neuroma
J. Plantar fasciitis
K. Pseudogout
L. Sever’s disease
M. Stress fracture
N. Talon noir
O. Tarsal tunnel syndrome
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168 Diagnostic EMQs
For each of the following, what is the MOST likely diagnosis?
1. A 28-year-old woman presents with pain in her right foot when she puts on
her shoes. Her symptoms have been present for the past six months, she denies
any trauma and has no signicant medical history. On examination she has
hyper-extension of her second metatarsophalangeal joint, exion of the proxi-
mal interphalangeal joint and extension of the distal interphalangeal joint.
2. A 42-year-old woman presents with an eight-month history of right great toe
pain. She explains that the pain has come about gradually and she has noticed
that the skin on the medial aspect of her big toe has become thickened and red.
On examination you note medial swelling over the great toe and lateral devia-
tion of the toe.
3. A 28-year-old runner presents with pain in her right foot. She explains that the
pain occurs between the third and fourth metatarsal space and is worse with
running and walking. On examination Mulder’s click test is positive.
4. A 7-year-old boy presents with his parents who explain that he has been com-
plaining of arch pain affecting his left foot. The pain is worse after activity and
at times causes him discomfort for several days after strenuous physical activ-
ity. On examination there is tenderness over the navicular bone. You organise
an X-ray which reveals that the navicular bone has a wafer like appearance and
fragmentation.
5. A 37-year-old woman presents with pain in the dorsum of her right foot for the
past two days. She explains that she has recently started running and does so for
most days of the week. She has no signicant medical history. On examination
she is tender over the shaft of the second metatarsal.
See page 182 for answers.
HAND AND WRIST 1
A. Anterior interosseous syndrome
B. Carpal tunnel syndrome
C. Chilblains
D. Dupuytren’s disease
E. Erythromelalgia
F. Guyon’s canal syndrome
G. Hypothenar hammer syndrome
H. Haemochromatosis
I. Jaccoud arthropathy
J. Kienbock’s disease
K. Median nerve palsy
L. Osteoarthritis
M. Psoriatic arthritis
N. Raynaud’s disease
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Musculoskeletal 169
O. Rheumatoid arthritis
P. Scaphoid fracture
Q. Scapholunate ligament injury
R. Scleroderma
S. Systemic lupus erythematosus
T. Wartenberg’s syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 29-year-old labourer has a painful nodule in his right palm which has been
present for the past two months. The nodule has thickened with time and the
ring nger is more exed as a result. He is struggling with his work as a result
of this condition. On examination there is a nodule in the medial aspect of the
palm and Hueston’s tabletop test is positive.
2. A 36-year-old woman presents with painful discoloration of her ngers. She
rst noticed her symptoms six months ago and reports that symptoms are made
worse with cold weather. On questioning she also reports thickening of the skin
around her hands and she has been suffering from dysphagia.
3. A 24-year-old gure skater presents with pain in her ngers. She reports that
she has developed tender bumps in her ngers which are at times itchy. They
appear mostly when she is outdoors on cold days or after ice skating sessions,
lasting up to two days after onset. She has no signicant medical history and is
a smoker. On examination there are small blanching bumps across her ngers
which are purple and red in color.
4. A 31-year-old chef attends with weakness in her hand for the past three weeks. She
was at work and accidentally cut her wrist on a kitchen knife just prior to the onset
of her symptoms. On examination you note that the thenar eminence appears at,
there is decreased ability to ex the lateral three digits and oppose the thumb.
5. A 39-year-old woman presents with a 3-month history of bilateral hand pain
and wrist swelling. She explains that she has also had intermittent ankle and
knee pain. She has no history of trauma. On examination you note swelling
in the wrist and hands. You also note a buttery rash across her face and nasal
ulcers. You arrange for pathology which is negative for anti-CCP antibodies,
negative for RF but positive for ANA and anti-dsDNA. She also has an eGFR
of 49.
6. A 42-year-old woman presents with a 4-day history of pain in her left index and
middle ngers. She has had no trauma and reports that her symptoms are affect-
ing her daily activities. On examination her left index nger and middle nger
are red and swollen with a sausage-like appearance.
See pages 182–183 for answers.
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170 Diagnostic EMQs
HAND AND WRIST 2
A. Anterior interosseous syndrome
B. Carpal tunnel syndrome
C. Chilblains
D. Dupuytren’s disease
E. Erythromelalgia
F. Guyon’s canal syndrome
G. Hypothenar hammer syndrome
H. Haemochromatosis
I. Jaccoud arthropathy
J. Kienbock’s disease
K. Median nerve palsy
L. Osteoarthritis
M. Psoriatic arthritis
N. Raynaud’s disease
O. Rheumatoid arthritis
P. Scaphoid fracture
Q. Scapholunate ligament injury
R. Scleroderma
S. Systemic lupus erythematosus
T. Wartenberg’s syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 16-year-old girl presents with worsening left wrist pain. She has had pain at
the base of her thumb for the past two weeks after a fall on an outstretched hand
while skateboarding She had an X-ray at the time of the fall and “the nurse
told me that there weren’t any broken bones so Ileft the emergency department
because the doctor was taking so long to get to me”. On examination there is
wrist swelling laterally and there is tenderness on palpation of the anatomical
snuff box.
2. A 56-year-old woman presents to your clinic complaining of bilateral hand pain
and swelling. Her symptoms have been present for the past 12 months and are
progressively worsening. She has no history of recent trauma and explains that
the pain is worse at the end of the day. On examination there is swelling in the
proximal interphalangeal (PIP) joints and distal interphalangeal (DIP) joints.
You arrange an X-ray of her hands which reveals loss of joint spaces and osteo-
phyte formation at the PIP and DIP joints.
3. A 19-year-old woman complains of painful color changes to her hands for the
past two weeks. She reports that some of her ngers turn dark purple when
exposed to the cold. She has no past medical history of note and does not use
any regular medications. On examination you are able to reproduce the discol-
oration by giving her a cup of ice-cold water to hold. Furthermore, her skin is
intact and she has no other physical ndings.
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Musculoskeletal 171
4. A 52-year-old woman presents with a three-month history of wrist and ankle
pain. She explains that her symptoms are worse in the morning and she has
associated joint stiffness, which lasts for at least an hour, improving throughout
the day. She has also been feeling fatigued. On examination she has no obvious
deformity but has wrist and ankle tenderness on palpation.
5. A 37-year-old woman complains of a ve-month history of progressively
worsening bilateral hand pain with associated metacarpal-phalangeal joint
swelling. She has no signicant medical history and reports that her father
passed away in his early 50s from heart failure. On examination there is ten-
derness over the joints of the hands bilaterally. You arrange an X-ray which
demonstrates hook like osteophytes from the radial ends of the second and
third metacarpals.
6. A 27-year-old woman presents to your clinic complaining of discomfort in her
hands. She reports that she has been having episodes of numbness affecting the
lateral three and a half ngers and decreased grip strength. Her symptoms are
particularly worse at night and she feels relief when she hangs her hands over
the edge of her bed. She has no signicant past medical history and is currently
26 weeks gestation.
See pages 183–184 for answers.
HIP PAIN 1
A. Coxa saltans
B. Developmental dysplasia of hip
C. Ewing sarcoma
D. Femoroacetabular impingement
E. Inguinal hernia
F. Labral tear
G. Meralgia paraesthetica
H. Neck of femur fracture
I. Osteitis pubis
J. Perthes disease
K. Piriformis syndrome
L. Polymyalgia rheumatica
M. Slipped capital femoral epiphysis
N. Transient hip synovitis
O. Trochanteric bursitis
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