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182 Diagnostic EMQs
4. O. Tarsal tunnel syndrome
Tinel’s sign at the tarsal tunnel is used to detect peripheral neuropathy involv-
ing the tibial nerve. Symptoms can be replicated by performing this test which
includes lightly tapping at the tarsal tunnel.
5. K. Pseudogout
Examination of a uid aspirate under polarised red light allows differentiation
between gout and pseudogout. Calcium pyrophosphate crystals are positively
birefringent and rhomboid shaped. Whereas gout has urate crystals which are
needle shaped and negatively birefringent.
Foot pain 3
1. E. Hammer toe
This patient has characteristic ndings on examination. This condition affects
the second, third and fourth toes. The middle joint of the toe develops a defor-
mity similar to that of a hammer.
2. D. Hallux valgus
This is a very common cause of foot pain. In this condition the affected great
toe deviates laterally over a prolonged period. Patients may present with a bony
prominence known as a bunion on the medial side of the toe.
3. I. Morton’s neuroma
Mulder’s click test is a clinical test which is used to assess for Morton’s neu-
roma. Pain and an associated click can be produced by squeezing the metatarsal
heads on either side of the neuroma together with one hand while putting pres-
sure on the affected interdigital space with the other.
4. G. Kohler disease
This condition, also known as avascular necrosis of the navicular bone, results
from damage to the navicular bone in young children. Patients typically present
with foot pain and limping.
5. M. Stress fracture
The correct answer is stress fracture. These are small cracks or bruising within
the affected bones and are usually caused by overuse. They commonly occur
when individuals change their regular activities or increase the intensity of their
physical activities.
Hand and Wrist 1
1. D. Dupuytren’s disease
This is a disorder in which there is painful nodule formation and contracture of
the digits which reduce hand function. Ahistory of manual labour is associated
with increased risk of Dupuytren’s disease development.
2. R. Scleroderma
Scleroderma is an autoimmune condition which results in thickening of skin
and connective tissue. Raynaud’s phenomenon and dysphagia are common nd-
ings. Pneumonic to help remember CREST (calcinosis cutis, Raynaud phenom-
enon, esophageal dysmotility, sclerodactyly and telangiectasia).
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Musculoskeletal 183
3. C. Chilblains
Also known as perniosis, this condition results from inammation of small
blood vessels in the skin after exposure to cold environments. Patients typically
report symptoms including discoloration, blistering, itch and pain.
4. K. Median nerve palsy
This patient has injured the median nerve, this can result in wasting of the the-
nar muscles and reduced function of the lateral three ngers, sensation can also
be reduced laterally as a result.
5. S. Systemic lupus erythematosus
This patient meets the SLICC criteria for SLE; with synovitis of two or more
joints, cutaneous manifestations, nasal ulceration, renal involvement as well as
positive serology for ANA and anti-dsDNA. For diagnosis four criteria must be
met with at least one clinical feature and one laboratory nding.
6. M. Psoriatic arthritis
This is an autoimmune condition which affects the joints. It typically affects
those with psoriasis but in a small number of people the skin disease occurs
after onset of arthritis. Dactylitis (sausage nger) is a common nding in
patients with psoriatic arthritis.
Hand and Wrist 2
1. P. Scaphoid fracture
This type of fracture is most commonly caused by a fall on an outstretched
hand. Avascular necrosis is a common complication of a scaphoid fracture, and
repeat X-rays are essential seven to ten days after injury. Anatomical snuff box
tenderness is a common exam nding.
2. L. Osteoarthritis
This patient has typical examination ndings and radiological ndings associ-
ated with osteoarthritis. Osteophytes at the PIP joints are known as Bouchard’s
nodes and those at the DIP joints are known as Heberden’s nodes.
3. N. Raynaud’s disease
Also known as primary Raynaud’s phenomenon, this condition involves an
exaggerated response to cold without a known underlying cause. Patients
with this condition usually have no abnormal ndings on serology or
examination.
4. O. Rheumatoid arthritis
This is an autoimmune condition which mainly affects the joints. This is a sym-
metrical form of arthritis which usually presents with morning stiffness which
lasts at least an hour and improves throughout the day.
5. H. Haemochromatosis
This is an inherited condition in which the body absorbs and stores more
iron than required. Arthropathy affecting the hands is a common nding and
this patient has classic radiological and physical examination ndings. Her
father also passed away from heart failure which is a cardiac complication of
haemochromatosis.
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184 Diagnostic EMQs
6. B. Carpal tunnel syndrome
This is a common syndrome which involves compression of the median nerve
as it travels through the wrist. Patients typically describe loss of sensation and
function of the lateral ngers. Pregnancy is a common cause.
Hip pain 1
1. E. Inguinal hernia
This occurs due to a bulging of the intra-abdominal contents through an area of
weakness in the lower abdominal wall. Activities which increase intra-abdom-
inal pressure such as lifting, coughing and sneezing can exacerbate symptoms.
2. O. Trochanteric bursitis
This condition involves inammation of the bursa over the greater trochanter.
Patients typically describe pain in the outside of the hip and thigh which is usu-
ally worse when lying on the affected side.
3. H. Neck of femur fracture
This patient has had acute trauma and has typical physical exam features of a
neck of femur fracture. The leg is shortened and externally rotates due to the
pull of the short external rotators.
4. I. Osteitis pubis
This condition results from inammation of the pubic symphysis and surround-
ing muscle insertions.
5. B. Developmental dysplasia of hip
The galeazzi test is used to assess for hip dislocation, a positive sign suggests
congenital hip malformation. Other examinations for hip dysplasia include the
Barlow and Ortolani maneuvers.
Hip pain 2
1. N. Transient hip synovitis
This is a common cause for limp in a child and is as a result of inammation of
the synovium of the hip joint. The differential of a septic arthritis would usually
be associated with elevated inammatory markers.
2. G. Meralgia paraesthetica
This condition results from compression of the lateral femoral cutaneous nerve
(branch of the lumbar plexus providing sensation to the anterolateral aspect of
the upper thigh) as it passes under (occasionally through) the inguinal ligament.
3. M. Slipped capital femoral epiphysis
Trethowan’s sign is a radiological feature observed when Klein’s line does not
intersect the lateral part of the superior femoral epiphysis.
4. L. Polymyalgia rheumatica
This is an inammatory condition which causes muscle pain and stiffness. This
condition is more common in those over the age of 50 and women are more
likely to develop it than men. The shoulders and the hips are common sites of
discomfort and a raised ESR level may be present.
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Musculoskeletal 185
5. J. Perthes disease
This is a condition which affects the hips of children between the ages of four
and ten. In this condition there is disruption in the blood ow to the head of the
femur resulting in avascular necrosis of the affected area.
Knee pain 1
1. A. Anterior cruciate ligament tear
This patient has had a twisting injury to a exed knee which is rmly grounded.
Atear to the anterior cruciate ligament can cause a bleed in the knee (haemar-
throsis) and immediate swelling in the affected knee.
2. R. Ruptured Baker’s cyst
A Baker’s cyst (popliteal synovial cyst) is an accumulation of uid in the bursa of
the knee joint. These can rupture causing uid to leak down the lower limb into the
calf. This can be very painful; examination usually reveals swelling and redness.
3. D. Iliotibial band syndrome
This is the most common cause of lateral knee pain in runners, it is caused by
overuse.
4. P. Prepatellar bursitis
Also known as carpenter’s knee, this condition involves inammation of a uid
lled sac known as the prepatellar bursa which is located in the anterior knee
between the patella and supercial skin.
5. L. Patellar tendinopathy
Also known as jumper’s knee, this is a form of anterior knee pain. Clinical
diagnosis relies on tenderness on palpation of the inferior pole of the patella.
Knee pain 2
1. I. Meniscal tear
This patient likely has a bucket handle tear of the meniscus. This is a full thick-
ness tear that occurs in the medial meniscus causing it to displace centrally,
resulting in the locking of the knee joint.
2. Q. Reiter’s syndrome
Also known as reactive arthritis, this is the most common form of inammatory
polyarthralgia in young males. The condition is characterised by conjunctivitis,
urethritis and joint inammation. The mnemonic “can’t see, can’t pee, can’t
climb a tree” is helpful in remembering this condition. STIs such as chlamydia
are common causes for this presentation.
3. M. Patellofemoral pain syndrome
Also known as runner’s knee, this is a pain syndrome caused by overuse. This
patient demonstrates the classic “movie sign”. Treatment is usually conservative.
4. J. Osgood–Schlatter disease
This is a common cause for knee pain particularly in young males. It occurs as
a result of inammation at the site where the patellar tendon attaches to the
tibia.
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186 Diagnostic EMQs
5. O. Posterior cruciate ligament tear
Displacement of the tibia posteriorly on a xed femur results in the rupture of
the posterior cruciate ligament. This can occur when the knee strikes a dash-
board in a motor vehicle accident. In sporting activities, the injury typically
occurs when a hyper-exed knee strikes the ground.
6. T. Septic arthritis
This is an infection in the joint uid and surrounding tissues.
Neck and Shoulder pain 1
1. B. Acute myocardial infarction
This patient has many risk factors for cardiovascular disease and acute onset of
symptoms.
2. H. Long head of biceps rupture
Popeye sign results from the bulging of the biceps muscle belly when detached.
3. I. Long thoracic nerve palsy
This is a condition which affects the shoulder and is characterised by reduced func-
tion and pain secondary to injury of the long thoracic nerve (such as from a blow to
the ribs). The nerve supplies the serratus anterior muscle (also known as the boxer’s
muscle), loss of function in this muscle results in winging of the scapula.
4. C. Adhesive capsulitis
Also known as frozen shoulder, in this condition there is a reduced ability to
move the shoulder both actively and passively. Diabetes and thyroid disease are
risk factors but most cases are idiopathic. The condition typically resolves on its
own but may take months to years to do so.
5. K. Posterior shoulder dislocation
In this injury the head of the humerus is forced posteriorly in internal rotation
while the arm is abducted. Electrocution is a classic cause of this presentation.
Neck and Shoulder pain 2
1. L. Supraspinatus tendon rupture
This patient has physical ndings which are typical of this type of injury.
2. E. Biceps tendinitis
This condition involves the inammation of the tendinous part of the long head
of the biceps as it travels within the bicipital groove.
3. J. Polymyalgia rheumatica
This is an inammatory condition which causes muscle pain and stiffness. This
condition is more common in those over the age of 50 and women are more
likely to develop it than men. The shoulders and the hips are common sites of
discomfort and a raised ESR level may be present.
4. Q. Torticollis
Also known as wry neck this occurs as a result of muscle spasms in the neck. It
is a common cause of neck pain in young individuals.
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DOI: 10.1201/9781003459941-8 187
8
Cardiology
CHEST PAIN 1
A. Angina pectoris
B. Da Costa’s syndrome
C. Dissecting thoracic aortic aneurysm
D. Dressler’s syndrome
E. Oesophageal rupture
F. Oesophageal spasm
G. Myocardial infarction
H. Pericarditis
I. Pneumothorax
J. Pulmonary embolism
K. Slipping rib syndrome
L. Takotsubo cardiomyopathy
M. Tietze’s syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 27-year-old secretary presents with a one-day history of central chest pain.
The pain does not radiate and came on suddenly, she also has mild shortness
of breath. The pain is 7/10 at its worst. Her medical history is unremarkable
and the only medication she takes is the oral contraceptive pill. On examina-
tion, she is comfortable, talking in full sentences, she has a blood pressure
of 124/82 mmHg, heart rate of 112 beats per minute, oxygen saturation of
98% at room air and lungs are clear to auscultation. Calves are soft and
non-tender.
2. A 68-year-old male presents complaining of episodes of central chest pain with
radiation to his left arm. He explains that the symptoms started a week ago, last
about two to three minutes and are relieved by rest. He has a history of ischemic
heart disease, hyperlipidaemia and hypertension. He is currently using aspi-
rin, atorvastatin and perindopril. He has had no recent medication changes and
reports that he is otherwise well.
3. You are a medical doctor supervising a local basketball competition, you are
called urgently to the courtside just before halftime. A 21-year-old player
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188 Diagnostic EMQs
complains of sudden onset right sided chest pain associated with shortness of
breath; he tells you that the pain is worse with inspiration. He denies trauma.
4. A 39-year-old woman presents with a six-month history of sudden, sharp, non-
exertional central chest pain, associated with dysphagia of solids and uids. The
episodes last for about one to two minutes and then spontaneously resolve. You
arrange for a barium swallow which reveals a corkscrew appearance.
See page 203 for answers.
CHEST PAIN 2
A. Angina pectoris
B. Da Costa’s syndrome
C. Dissecting thoracic aortic aneurysm
D. Dressler’s syndrome
E. Oesophageal rupture
F. Oesophageal spasm
G. Myocardial infarction
H. Pericarditis
I. Pneumothorax
J. Pulmonary embolism
K. Slipping rib syndrome
L. Takotsubo cardiomyopathy
M. Tietze’s syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 47-year-old man presents complaining of central chest pain. He explains that
it started earlier in the day. The pain is described as sharp in nature and worse
when lying down or taking a big breath in, he nds relief when sitting forward
and also while exhaling. He had an upper respiratory tract infection ve days
ago but has been otherwise well.
2. A 61-year-old woman attends ED complaining of central chest pain which
started 20 minutes ago, her daughter who attends with her explains that she
described the pain initially as a tearing type pain which was radiating into her
back. On examination she has a blood pressure of 202/116 in her left arm and
an absent right sided radial pulse.
3. A 48-year-old electrician presents with left sided chest pain for the past three
days. He has had no recent illness and no history of trauma. The pain is sharp
and intermittent initially then becomes constant and can last for several hours
at a time. The pain is in the lower ribs on the left side and there is a signicant
tenderness on palpation of a spot over the costal margin.
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Cardiology 189
4. A 71-year-old male presents to your emergency department complaining of
central chest pain radiating to his left arm. He describes the pain as severe
and constant and it started 30 minutes ago. He tried sublingual GTN at home
and after the third dose he contacted the ambulance service. On examina-
tion he is diaphoretic, has a regular pulse of 114, blood pressure of162/96,
temperature of 36.1
o
C, respiratory rate of 20 and saturations of 96% at
room air. He has a history of IHD, angina, hyperlipidaemia and hyper-
tension. You perform an ECG which reveals STelevation in leadsII, III
a nd AV F.
See page 203 for answers.
CARDIAC VESSELS
A. Coronary sinus
B. Great cardiac vein
C. Left anterior descending artery
D. Left circumex artery
E. Left marginal vein
F. Left posterior ventricular vein
G. Middle cardiac vein
H. Right coronary artery
I. Superior vena cava
J. Small cardiac vein
For each of the following, what is the MOST likely vessel affected?
1. A 53-year-old truck driver presents with left jaw pain and shoulder pain, this
started 45 minutes ago. He has associated shortness of breath and is diapho-
retic. You perform and ECG which reveals STelevation in leads I, aVL, V5
and V6.
2. A 73-year-old type 2 diabetic presents with worsening shortness of breath and
epigastric discomfort, she reports that it started one hour ago and is worsening,
she has no associated chest pain. You perform an ECG which reveals STeleva-
tion in leads V1, V2, V3 and aVR.
3. A 46-year-old presents to your emergency department complaining of sud-
den onset central chest pain which started 30 minutes ago, he reports that
it radiates to his left jaw and arm. He has a history of hyperlipidaemia and
hypertension. You perform an ECG which reveal STelevation in leads II, III
and aVF.
See page 203 for answers.
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190 Diagnostic EMQs
COLLAPSE 1
A. Addisonian crisis
B. Cardiac tamponade
C. Diabetic neuropathy
D. Epileptic seizure
E. Hypertrophic cardiomyopathy
F. Hypoglycaemia
G. Panic attack
H. Pulmonary embolism
I. Stokes–Adams attack
J. Subclavian steal syndrome
K. Vasovagal syncope
For each of the following, what is the MOST likely diagnosis?
1. A 49-year-old type 2 diabetic woman presents complaining that she is feeling
dizzy and has been collapsing at home. She has a history of hypertension and
hyperlipidaemia. She is currently taking amlodipine, rosuvastatin, metformin and
glimepiride. On examination she has a seated blood pressure of 148/96 mmHg
and a standing blood presssure of 102/74 mmHg, you examine her feet and note
sensory loss throughout. You review her most recent bloods and note that her
HbA1c was 10.6 when measured last month and 10.2 three months earlier.
2. A 38-year-old ight attendant presents with shortness of breath and chest pain
in your waiting room and then collapses and goes into cardiac arrest. She has
no signicant medical history and is currently using the oral contraceptive pill.
Her partner explains that she returned home on a long-haul ight yesterday.
3. A 47-year-old woman is brought into your emergency department after fainting at
the local pharmacy. She appears confused on arrival with slurred speech. Her hus-
band is with her and explains that she has a history of type 2 diabetes and anxiety.
She is using metformin, gliclazide, insulin and citalopram. Her GP added insulin
to her management two days ago as her HbA1c readings were high. She took her
diabetes medications this morning but had run out of her citalopram and left home
before breakfast to run a few errands and collect her script from the pharmacy.
4. A 38-year-old man presents with a ten-day history of repeated episodes of syn-
cope and associated fatigue. He explains that he has struggled to get out of
his bed during this time. On examination you note that he has palmar hyper-
pigmentation, a blood pressure of 88/68 mmHg and he has a heart rate of 118
beats per minute. He has a nger prick BSL of 3.6. You arrange for laboratory
investigations which reveal hyponatraemia and hyperkalaemia.
See page 204 for answers.
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Cardiology 191
COLLAPSE 2
A. Addisonian crisis
B. Cardiac tamponade
C. Diabetic neuropathy
D. Epileptic seizure
E. Hypertrophic cardiomyopathy
F. Hypoglycaemia
G. Panic attack
H. Pulmonary embolism
I. Stokes–Adams attack
J. Subclavian steal syndrome
K. Vasovagal syncope
For each of the following, what is the MOST likely diagnosis?
1. A 35-year-old woman presents with central chest pain and shortness of breath.
She has a history of stage 4 breast cancer, hypothyroidism and Gilbert’s syn-
drome. While you are talking to her she collapses and becomes unresponsive.
On examination she has a blood pressure of 68/50 mmHg, mufed heart sounds
and her JVP rises on inspiration.
2. A 36-year-old woman just returned from a short distance interstate ight and
while at the luggage collection area she felt dizzy and collapsed to the oor.
She explains that she suddenly noticed her heart begin to race, she felt tightness
in her chest and reports that she felt short of breath. She remained conscious
throughout and her symptoms have now resolved. She has no signicant medi-
cal history. On examination you nd no cause for her symptoms and her labora-
tory investigations are normal.
3. You are in the middle of a consult when your practice nurse enters your room in
a hurry explaining that a 56-year-old man collapsed to the ground. You enter the
waiting room where you nd the man unresponsive and shaking uncontrollably.
He recovers after three minutes and reports that he is very disorientated. During
the episode he lost control of his bladder.
4. A 21-year-old male athlete presents to your emergency department after a col-
lapse while he was running at a training session. There were no preceding
symptoms and he has no signicant medical history. He reports that his father
passed away suddenly when he was aged 41. On examination there is a high
pitched, mid-systolic, crescendo-decrescendo murmur over the left sternal bor-
der. The murmur does not radiate to the carotids.
5. A 32-year-old male attends your clinic for his pertussis vaccination. His wife
is pregnant and their child is due shortly. You administer the vaccination, a
few minutes later he appears pale and sweaty and explains that he feels dizzy.
Before you can get him onto a chair he collapses to the ground. He is breathing
and you palpate his pulse which is 42 beats per minute.
See page 204 for answers.
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