Key History
Duration, timing; associated symptoms (vaginal discharge, rash, painful menses, GI symptoms, hot flashes); adequacy of lubrication, menopausal status, libido; sexual history, history of sexual trauma or domestic violence; history of endometriosis, pelvic inflammatory disease, or prior abdominal/pelvic surgeries.
Key Physical Exam
Vital signs; abdominal exam; complete pelvic exam.
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DYSPAREUNIA (cant'd) |
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■ 54 yo F c/o painful intercourse. Her last menstrual period was 9 months ago. She has hot flashes. |
Atrophic vaginitis Endometriosis Cervicitis Depression Domestic violence |
Pelvic exam LH/FSH Wet mount, KOH prep Cervical cultures |
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■ 37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea. |
Endometriosis Cervicitis Vaginismus Vulvodynia Pelvic inflammatory disease Depression Domestic violence |
Pelvic exam Wet mount, KOH prep Cervical cultures U/S—pelvis Laparoscopy Endometrial biopsy |
Key History
Establish confidentiality; directly question about physical, sexual, or emotional abuse and about fear, safety, backup plan; history of frequent accidents/injuries, mental illness, drug use; firearms in the home.
Key Physical Exam
Vital signs; complete exam ± pelvic exam.
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■ 28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for physical injuries 7 months ago. She presents with her husband. |
Domestic violence Osteogenesis imperfecta Substance abuse Consensual violent sexual behavior |
XR—skeletal survey CT—maxillofacial Urine toxicology CBC |
Key History
Location, quality, intensity, duration, pattern (small vs. large joints; number involved; swelling, redness, warmth); associated symptoms (constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash, focal numbness/weak- ness, morning stiffness); exacerbating and alleviating factors; trauma (including vigorous exercise); medications; DVT risk factors; alcohol and drug use; family history of rheumatic disease.
Key Physical Exam
Vital signs; HEENT and musculoskeletal exams; relevant neurovascular exam.
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ABUSE (cant'd) |
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■ 30 yo F presents with multiple facial and physical injuries. She states that she was attacked and raped by 2 men. |
Rape Domestic violence |
Forensic exam (sexual assault forensic evidence [SAFE] collection kit) Pelvic exam Urine hCG Wet mount, KOH prep Cervical cultures Chlamydia and gonorrhea testing XR—skeletal survey CBC HIV antibody Viral hepatitis serologies |
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■ 30 yo F presents with wrist pain and a black eye after tripping, falling, and hitting her head on the edge of a table. She looks anxious and gives an inconsistent story. |
Domestic violence Factitious disorder Substance abuse |
XR—wrist CT—head Urine toxicology |
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JOINT/LIMB PAIN (cont'd) |
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■ 30 yo F secretary presents with wrist pain and a sensation of numbness and burning in her palm and the first, second, and third fingers of her right hand. The pain worsens at night and is relieved by loose shaking of the hand. There is sensory loss in the same fingers. Exam reveals a positive Tinel’s sign. |
Carpal tunnel syndrome Median nerve compression in the forearm or arm Radiculopathy of nerve roots C6 and C7 in the cervical spine De Quervain’s tenosynovitis |
Phalen’s maneuver and Tinel’s sign Finkelstein’s test Nerve conduction studies EMG |
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■ 28 yo F presents with pain in the interphalangeal joints of her hands accompanied by hair loss and a rash on her face. |
Systemic lupus erythematosus (SLE) Rheumatoid arthritis Psoriatic arthritis Parvovirus B19 infection |
ANA, anti-dsDNA, ESR, C3, C4, RF, CCP CBC XR—hands UA Antibody titers for parvovirus B19 |
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■ 28 yo F presents with pain in the metacarpophalangeal joints of both hands. Her left knee is also painful and red. She has morning joint stiffness that lasts for an hour. Her mother had rheumatoid arthritis. |
Rheumatoid arthritis SLE Disseminated gonorrhea Arthritis associated with inflammatory bowel disease |
XR—hands, left knee ANA, anti-dsDNA, ESR, RF, CCP CBC Cervical culture Arthrocentesis and synovial fluid analysis |
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■ 18 yo M presents with pain in the interphalangeal joints of both hands. He also has scaly, salmon-pink lesions on the extensor surface of his elbows and knees. |
Psoriatic arthritis Rheumatoid arthritis SLE Gout |
ANA, ESR, RF, CCP CBC XR—hands XR—pelvis/sacroiliac joints Uric acid |
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■ 65 yo F presents with inability to use her left leg or bear weight on it after tripping on a carpet. Onset of menopause was 20 years ago, and she did not receive HRT or calcium supplements. Her left leg is externally rotated, shortened, and adducted, and there is tenderness in her left groin. |
Hip fracture Hip dislocation Pelvic fracture |
XR—hip/pelvis CT or MRI—hip CBC, type and cross Serum calcium and vitamin D Bone density scan (DEXA) |
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JOINT/LIMB PAIN (cont'd) |
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■ 40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is flexed at the hip, adducted, and internally rotated. |
Hip dislocation— traumatic Hip fracture |
XR—hip CT or MRI—hip CBC, type and cross PT/PTT Urine toxicology and blood alcohol level |
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■ 56 yo obese F presents with right knee stiffness and pain that increases with movement. Her symptoms have gradually worsened over the past 10 years. She has noticed swelling and deformity of the joint and is having difficulty walking. |
Osteoarthritis Pseudogout Gout Meniscal or ligament damage |
XR—knee CBC ESR Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals) Uric acid MRI—knee |
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■ 45 yo M presents with fevers and right knee pain with swelling and redness. |
Septic arthritis Gout Pseudogout Lyme arthritis Trauma Reiter’s syndrome (reactive arthritis) |
CBC Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals) Blood, urethral cultures XR—knee Uric acid Lyme titers—IgG and IgM |
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■ 65 yo M presents with right foot pain. He has been training for a marathon. |
Stress fracture Plantar fasciitis Foot sprain or strain |
XR—foot Bone scan—foot MRI—foot |
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■ 65 yo M presents with pain in the heel of the right foot that is most notable with his first few steps and then improves as he continues walking. He has no known trauma. |
Plantar fasciitis Heel fracture Splinter/foreign body |
XR—heel Bone scan—foot |
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■ 55 yo M presents with pain in the elbow when he plays tennis. His grip is impaired as a result of the pain. There is tenderness over the lateral epicondyle as well as pain on resisted wrist dorsiflexion (Cozen’s test) with the elbow in extension. |
Tennis elbow (lateral epicondylitis) Stress fracture |
XR—arm Bone scan MRI—elbow |
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JOINT/LIMB PAIN (cont'd) |
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■ 27 yo F presents with painful wrists and elbows, a swollen and hot knee joint that is painful on flexion, a rash on her limbs, and vaginal discharge. She is sexually active with multiple partners and occasionally uses condoms. |
Disseminated gonorrhea Rheumatoid arthritis SLE Reiter’s syndrome (reactive arthritis) |
Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture) ANA, anti-dsDNA, ESR, RF, CCP CBC Blood, cervical cultures XR—knee |
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■ 60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery 6 months ago and continues to smoke heavily. |
Peripheral vascular disease (intermittent claudication) Leriche syndrome (aortoiliac occlusive disease) Lumbar spinal stenosis (pseudoclaudication) Osteoarthritis |
Ankle-brachial index Doppler U/S—lower extremity Angiography MRI—L-spine |
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■ 45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs 2 months ago for dysfunctional uterine bleeding. |
DVT Baker’s cyst rupture Myositis Cellulitis Superficial venous thrombosis |
Doppler U/S—right leg CBC D-dimer |
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■ 60 yo F c/o left arm pain that started while she was swimming and was relieved by rest. |
Angina/MI Tendinitis Osteoarthritis |
ECG CBC XR—shoulder CXR Echocardiography Stress test |
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■ 50 yo M presents with right shoulder pain after falling onto his outstretched hand while skiing. He noticed deformity of his shoulder and had to hold his right arm. |
Shoulder dislocation Fracture of the humerus Rotator cuff injury |
XR—shoulder XR—arm MRI—shoulder |
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JOINT/LIMB PAIN (cant'd) |
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■ 55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia. |
Rhabdomyolysis due to statins Polymyositis Inclusion body myositis |
CBC Phosphate, potassium, BUN/Cr, glucose, calcium, uric acid CPK Aldolase UA Urine myoglobin |
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