Are You Smarter Than an Intern?

1,000,000 June 1 June 2 March 3 March 4 December 5 December 6 September 7 September 8 July 9 July , ,000 50,000 10,000 1,000,000 1,000

June 1 Question / A 13 y/o boy presents with 1 month of worsening left knee and hip pain that is worse with walking. He is mildly obese. His knee exam is normal. His hip has full range of motion but very painful when externally rotated in a flexed position. What condition needs to be ruled out?

June 1 Answer / Slipped capital femoral epiphysis (SCFE) / A hip X-ray is needed / No weight bearing / Urgent referral to surgery / Slipped capital femoral epiphysis (SCFE) / A hip X-ray is needed / No weight bearing / Urgent referral to surgery

Osgood-Schlatter and Sever’s Return 8-13 y/o10-15 y/o

June 2 Question / Name 5 red flags of back pain that would indicate the need for further work up.

June 2 Answer

Sciatica Return

March 3 Question / A 36 y/o female present with left knee pain for 2 days. It started while she was coaching soccer when she planted her left leg and turned suddenly. There is a mild knee effusion and decreased flexion on range of motion testing. She has normal strength. She has pain with McMurray and a normal anterior drawer sign. What is her most likely diagnosis and how would you confirm it?

March 3 Answer / She most likely has a meniscal tear. / MRI would be the imaging study of choice. / Tx: rehab vs surgical repair / She most likely has a meniscal tear. / MRI would be the imaging study of choice. / Tx: rehab vs surgical repair

March 3 Answer Return McMurray’s

March 4 Question / A 38 y/o woman presents with left wrist pain since slipping and falling on an outstretched hand. She has tenderness over the anatomical snuff box. An X-ray of the wrist does not show a fracture. What is the next best step in treating this patient?

March 4 Answer / She should be placed in a Thumb Spica splint/cast and re-evaluated in 2 weeks.

DeQuervain’s Tenosynovitis / Example: new breast feeding mom / Tx: NSAID’s, steroid injection, splint/cast / Example: new breast feeding mom / Tx: NSAID’s, steroid injection, splint/cast Finklestein Test

Osteoarthritis of the thumb Return

December 5 Question / A 52 y/o male presents with a 3 day history of worsening right knee pain and swelling. He denies injury or trauma. He does not have a fever or chills. His knee is warm, erythematous and has a moderate effusion. It is tender to palpation as well as painful to active and passive movement. What is the best way to diagnose this patient’s problem?

December 5 Answer / Aspiration and analysis of the synovial fluid. This will differentiate gout, pseudogout, septic arthritis, and inflammatory arthritis. / Fluid should be sent for crystals, cell count, gram stain and culture. / This case is suspicious for gout. / Aspiration and analysis of the synovial fluid. This will differentiate gout, pseudogout, septic arthritis, and inflammatory arthritis. / Fluid should be sent for crystals, cell count, gram stain and culture. / This case is suspicious for gout.

December 5 Answer Return

December 6 Question / A 48 y/o male presents with 6 weeks of gradual onset right shoulder pain. He denies any injury. He has been lifting weights more frequently. He has full range of motion of his shoulder. No tenderness. Mild to moderate pain with empty can test without weakness. Speed’s is negative. Mild pain with Neer’s and Hawkins’. O’Brien’s is negative. What is the next best treatment for this patient?

December 6 Answer / He is showing signs of rotator cuff impingement / Tx: rest, NSAID’s / If not improving: PT and/or home exercises / MRI and surgical referral if it does not improve with conservative treatment / He is showing signs of rotator cuff impingement / Tx: rest, NSAID’s / If not improving: PT and/or home exercises / MRI and surgical referral if it does not improve with conservative treatment

Return O’Brien’s: SLAP Neer’s: Rotator cuff impingement Hawkins: Rotator cuff impingement

September 7 Question / A 55 y/o female secretary presents with 2 months of numbness and tingling in the fingers bilaterally that is worse first thing in the morning and at the end of her work day. She denies pain. Hand strength is normal. Phalen’s is positive and Tinel’s is negative. What is the next best step in her care?

September Answer / Her symptoms and exam are consistent with Carpal Tunnel Syndrome. / A trial of wrist splints is appropriate. / If this fails or if weakness develops, a steroid injection and surgical carpal tunnel release are options. / EMG can be helpful to confirm the diagnosis. / Her symptoms and exam are consistent with Carpal Tunnel Syndrome. / A trial of wrist splints is appropriate. / If this fails or if weakness develops, a steroid injection and surgical carpal tunnel release are options. / EMG can be helpful to confirm the diagnosis.

Phalen’sTinel’s

Cubital/Ulnar Tunnel Return

September 8 Question / A 70 y/o woman presents with acute onset low back pain. She does not have a history of back pain. The pain does not radiate to her legs. Exam reveals a thin Caucasian woman. She has pain with forward flexion of the spine. Normal strength and reflexes. Negative straight leg raises. What is the next best step in her care?

September 8 Answer / She should have a lumbar spine X-ray to rule out compression fracture or malignant process. / In a younger patient, a course of NSAID’s would be the initial treatment. / She should have a lumbar spine X-ray to rule out compression fracture or malignant process. / In a younger patient, a course of NSAID’s would be the initial treatment. Return

July 9 Question / A 20 y/o male presents with ankle pain following an inversion injury while running. He is able to limp on it now and at the time of injury. He has tenderness and swelling over the distal anterior part of the lateral malleolus. No other tenderness. What is the next best step in this patient’s care?

July 9 Answer / Rest, ice, elevation, compression, and NSAID’s as needed / Ottawa Rules are negative so an X-ray is not needed / Rest, ice, elevation, compression, and NSAID’s as needed / Ottawa Rules are negative so an X-ray is not needed

June 9 Answer Return

July 10 Question / A 45 y/o male present with knee pain and swelling after a fall while skiing. He has a right knee effusion, a positive Lachman’s and you are unable to do McMurray’s due to swelling and pain. What test would you order to further evaluate this patient?

July 10 Answer / This patient most likely has an ACL tear. An MRI would be indicated for further diagnosis. / If confirmed on MRI, surgical referral / Rest, ice, elevation, compression, NSAID’s / This patient most likely has an ACL tear. An MRI would be indicated for further diagnosis. / If confirmed on MRI, surgical referral / Rest, ice, elevation, compression, NSAID’s Return

Million Dollar Question

$1,000,000 Question / A 48 y/o male presents with 3 weeks of shoulder pain. He is tender over the anterior shoulder and anterior proximal humerus. He has good strength and range of motion. Speed’s test is positive and all other maneuvers are normal. What condition is he at high risk for?

$1,000,000 Answer / Rupture of the long head of the biceps. / He has biceps tendonitis / Tx: rest, NSAID’s / Steroid injection if not improving / Rupture of the long head of the biceps. / He has biceps tendonitis / Tx: rest, NSAID’s / Steroid injection if not improving Speed’s

Biceps rupture / Long head rupture often does not need repair Return

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