Msk/rheumatology Semiology

Front 1

Articular vs non-articular

Back 1

Art: Pain on active & passive ROM, limited ROM, swelling, crepitus, instability

Non-art: Pain on active ROM only, focal tenderness outside articular, rare swelling/crepitus/instab

Front 2

Back 2

Front 3

Heberden's vs Bouchard's nodes?

indicative of?

Back 3

Heberden's: DIP joint

Bouchard's: PIP joint

Both in OA

Front 4

DDx monoarticular arthritis

Back 4

Crystalline (Gout/pseudogout)

Septic

Traumatic hemarthrosis

Front 5

DDx oligoarticular arthritis (2-4 joints)

Back 5

OA

Spondyloarthropathy

RA

Lupus

Gonorrhea

Front 6

DDx diffuse poly arthritis

Back 6

Acute Viral Infections

RA

Spondyloarthropathy

Lupus

Front 7

Most common locations for OA

Back 7

Knee

Hip

CMC, PIP, DIP

Spine

Shoulder sometimes

Front 8

Hand joint involvement of OA vs RA

Back 8

OA: CMC (wrist), PIP, DIP

RA: MCP, PIP

Front 9

How to diagnose OA?

x-ray findings?

Back 9

Chronic pain/ loss of fn

Morning stiffness <30min

H&P

Xray: Asymmetric joint space narrowing

osteophytes, cortical bone thickening, subchon cysts

Front 10

Back 10

OA

Front 11

57 yo manpresents with bilateral knee pain that he has struggled with “for years”. He notes he works in the Army Corp ofEngineers and is on his feet a lot at job sites. The pain is worse at the end of the day whenhe has been walking and standing all day. His only PMHx isHTN and obesity. He takes only lisinopril forhis BP.

ROSnegative for redness, swelling, fever

Exam: NAD, no appreciable effusion of knee, noerythema, no warmth. Significantcrepitus with extension of bilateral knees. Mild ttp overjoint line. Dx?

Back 11

OA

Front 12

•A48 yowoman who is very active presents with a 2 week hx of bilateral knee pain, R>L. •Shenotes she gets the pain while doing Crossfit which she does at least 4x per week•Shedescribes the pain as a burning, “stinging” pain below both knees that is worsewith doing squats and tire throws•Examreveals no crepitus, erythema, or warmth but she does note mild “soreness” overmedial aspect of proximal tibia bilaterally; no bony prominence or swelling ispresent Dx?

Back 12

Pes Anserine Bursitis

Front 13

Pes anserine bursitis sx? dx?

Back 13

Pain just below knee at anteromedial aspect of tibia that occurs when exercising or climbing stairs

Exam reveals TTP over pes anserine bursa

Front 14

53 yo manpresents to clinic after traveling to Disney World with his family one weekago. He notes that during a parade, hewas standing still and turned with his body, but his right knee did not turnwith him. He heard a pop and since thenhis knee has been swollen. He feels thathis knee is going to “give out” and it will occasionally lock on him. Stairs are “out of the question”.

Examreveals mild swelling of right knee, no erythema, minimal warmth Dx? tests?

Back 14

Meniscal injury

+McMurray's test

Front 15

Meniscal injury sx

Back 15

Painusually occurs acutely and/or is associated with trauma A/wbuckling and “locking” of knee

Exam:tenderness over joint line, effusion (hemarthrosis)

McMurray+: clicking felt when knee compressed & rotated during varus & valgus stress

Front 16

•60yowoman comes in with 12 months of left hip discomfort, worse with standing forlong periods of time. She feels the painas a dull ache but notes that a lot of her pain is actually in her groin area. She has no PMHx.•Examreveals decreased ROM of flexion at her left hip and pain when logrolling herhip. Dx?

Back 16

OA

Front 17

42 yowoman presents with 3 month history of pain over her right hip that is worse atnight. In fact, it wakes her from sleep if she rolls onto that side. She denies any radiation of the pain. It is somewhat better with ibuprofen.•Examreveals normal ROM; logrolling does not produce pain. She is tender to palpation over the greatertrochanter dx?

Back 17

Trochanteric bursitis

Front 18

36yowoman presents with ache in her lower right back and into her hip. She notes it is worse with sitting crosslegged with her kids. Pain is worse withactivity.

FABERtest is positive on the right. ROMnormal; logrolling does not produce pain. dx?

Back 18

Sacroiliitis

Front 19

Test for shoulder OA

Back 19

NFL sign: see if pt can raise arms above head.

Compare sides.

OA: not smooth, discomfort, inability to complete

Front 20

Biceps tendonitis caused by?

confirmatory test?

Back 20

Due to impingement or instability. Pain f/ lifting, pulling, or repetitive overhead movements

TTP in bicipital groove suggests tendonitis

Front 21

45 yo presents with right shoulder stiffness and inability to get things from the topshelf of his pantry.•Ptstates he hurt his shoulder last summer while weed eating and it “hasn’t feltright since”•Onexam, he is wearing a navy over the shoulder sling. The pt has been wearing it around the house to“help with the pain” Dx?

Back 21

Adhesive capsulitis/ Frozen Shoulder

Front 22

Adhesive capsulitis/ Frozen Shoulder sx & tests?

Back 22

ROM limited on active & passive motion

Usually painless

Apley Scratch Test: reduced ROM (asses ROM f/ above to back & below to back)

Touchdown Sign is expected (inability tofully raise effected arm)

Front 23

40man comes in with right shoulder pain that came on gradually over the last fewweeks. Ptnoticed that pain is worsened after playing in church softball league and atNIGHT.•Onexam he has full ROM, pain with drop arm maneuver but able to smoothly controlhis arm, no TTP over biceps tendon.•Strengthis 5/5 in bilateral UE, DTR’s are 2+ and symmetric Dx?

Back 23

Rotator cuff tendonitis (most common shoulder pain seen)

No hx of trauma

Nighttime sx present

Front 24

54 yopsychologist sees you for finger pain. She notes it has been going on for “years”. She thinks that her hands and wrists are“fine” but her the joints of her fingers just keep getting bigger such that shecannot wear any of her rings. She deniesany erythema or warmth. PE reveals bony enlargement of DIP and PIP on 2nd and3rd digits bilaterally, no warmth orerythema. Dx?

Back 24

OA

Front 25

Back 25

CMC squaring: OA

Front 26

45yoobese woman with PMHx ofRA comes in with bilateral hand pain and numbness•Sheworks as a machinist in a factory•Shereports hand and wrist pain worse at night thatgets better after “shaking it out”, both hands are affected. Shenotes that she sometimes feels clumsy with her hands and notes numbnessalong her middle fingers. dx?

Back 26

Carpal tunnel syndrome

Front 27

Dx/tests for Carpal tunnel?

Back 27

Median n dermatomal numbness

Phalens test: fully flex both hands placing back of palms together for 60s. + is pain/paresthesia

Tinel's test: Tap firmly on median nerve. + is pain/paresthesia

Abduction weakness: Hand palm up, try to raise thumb against resistance

Front 28

35yowoman G2P1 comes into your office c/o wrist and thumb pain•Sheis 3months pregnant andaccompanied by her 11 month old daughter •PMHxnoncontributory•Ptnoticed pain while knitting her new baby a blanket•Reportspainis along thumb and wrist atbase of thumb, sharp “pinching” pain•Whatis your diagnosis?

Back 28

DeQuervain’sTenosynovitis

Front 29

DeQuervain’s Tenosynovitis cause? sx? dx?

Back 29

Extensive wrist/thumb action (gripping/grasping)

Tenderness at snuff box

Finkelstein maneuver: thumb in fist, ulnar deviation, (+) = pain

Front 30

43yowoman presents with pain at the base of her fingers x 4 weeks. She notes the pain is worse first when shewakes up and that it takes a few hours for her hands to “loosen up”. She reports that her fingers have also feltswollen over this time. •Examreveals swelling and synovitis of 2nd MCP joints bilaterally and 4th PIP on right hand. dx?

Back 30

RA

Front 31

RA features? xrays? tests?

Back 31

Symmetric polyarthritis w/ prolonged morning stiffness

Xray: Periarticular osteopenia, erosions, symmetric joint space narrowing

elevated RF & Anti-CCP

Front 32

Back 32

End stage RA: ulnar drift, MCP involvement

Front 33

Back 33

Front 34

26yowoman with PMHx ofporiasis presents with right 3rdfinger swelling. She notes that thefinger had occasionally felt “kinda sore” for months, but this morning whenshe got up her whole finger looked like a “bratwurst”. Shedenies any fevers, chills.PE reveals diffuse dactylitis ofright 3rd finger. dx?

Back 34

Psoriatic arthritis

Front 35

Back 35

Dactylitis "sausage finger" psoriatic arthritis

Front 36

Back 36

Pencil in cup deformity: psoriatic arthritis

Front 37

Back 37

Psoriasis

Front 38

Finkelstein maneuver

Back 38

pain elicited by flexing thumb into palm, closing fingers over thumb, then bending wrist in ulnar direction; a confirmatory test in DeQuervain’s tenosynovitis (also look for tenderness at anatomic snuffbox)

Front 39

Drop arm test?

Back 39

the patient raises arm to 90 degrees of abduction and lower it slowly. A suddenly dropped arm is considered positive and suggestive of a rotator cuff tear.

Front 40

Drawer sign test?

Back 40

knee flexed to 90 degrees and examiner pulls lower leg anteriorly; ability to move leg > 1 cm is consistent with ACL tear

Front 41

Gout

Back 41

causedby uric acid crystal deposition in joint, this disease usually begins acutelywith intense pain and inflammatory joint finding. 90% of patients have great toeinvolvement. Rarely occurs inpremenopausal women.

Front 42

McMurray test?

Back 42

palpable clicking with knee compression and rotation during varus and valgus stress; positive test indicates meniscal injury (acute onset of pain, often with trauma, buckling or locking sensation)