Upper Extremity
This physical exam finding is pathognomonic for a biceps tendon tear
The popeye deformity
Locking, clicking, and/or catching with knee flexion or extension is commonly associated with this injury.
Double the points! - This physical exam test has the highest sensitivity for diagnosis.
Meniscal tear
Thessally test (typically described as having sensitivity >90%)
https://canadiem.org/medical-concepts-kneed-thessaly-test-meniscal-injury/
A very, very healthy person decides they need a PCP, like, in case anything ever happens. You have never before met anyone so healthy whose life is so put together. You have a great first visit, and while laughing along together, decide for no particular reason to get an EKG. The EKG shows a rate of 46, P before every QRS, PR of .22ms, QRS of .13ms, and multiple inverted T waves, and S in V1 + R V5 are >35mm. Wondering why you put yourself down this rabbit hole, you do this next.
Trick question!
Maybe nothing, maybe an echo. Depends on H&P.
This is the most commonly damaged rotator cuff muscle.
Supraspinatus
A 16 year old football player has a fever, sore throat, headache, fatigue. Symptoms started 2 days ago, and his monospot is negative. What's your next step?
Retest with EBV titers (IgM) in one week. hold from play in the meantime, and then for 4 weeks from start of symptoms if testing is positive.
A 45 year old male presents with insidous onset R shoulder stiffness, weakness, and pain which is non-radiating. He is an avid bowler (right handed), and a type 1 diabetic. He took a fall on his right arm a couple weeks ago. He thinks he tore his "rotorcuff". You do a great physical exam, and conclude he did not - in fact, he has adhesive capsulitis. The physical exam finding that suggested this was...
symmetric loss of active and passive motion
Osgood Schlatter's involves this anatomic deformity
Avulsion of the tibial tuberosity
https://richmondmom.com/2015/11/19/growing-pains-osgood-schlatter-and-severs-diseases/
This heart sound is non-concerning in otherwise healthy children and athletes, and is caused by a compliant left ventricle.
Double the points! It is also sometimes heard in this subset young, relatively healthy CFM patients
An S3.
Also heard in pregnant women
This ankle ligament is always the first to be disrupted with inversion ankle sprains
Anterior talofibular ligament
https://www.hss.edu/conditions_high-ankle-sprain-whats-different.asp
A 52 year old male complains that a few months after getting a gym membership, his feet began to itch and burn. He also notices some scaling, cracking, and peeling, as well as areas of thickened skin on the soles. You recommend an over the counter cream such as (this) for (duration).
topical -azoles, terbinafine, or tolnaftate. Most require 4 weeks; terbinafine can often be used twice daily for a week, though.
A 28 year old comes in complaining of right elbow pain. He works as a landscaper, and has been developing a pain on the lateral side of his elbow over the season. They have been doing a lot of shoveling. He took some ibuprofen, but that has not been helping. He has tenderness to palpation over the lateral epicondyle, and pain with resisted wrist extension. You diagnosis him with lateral epicondylitis and come up with a treatment plan involving this.
Double the points - Why was ibuprofen not helpful?
PT to learn eccentric muscle contractions and improve wrist mechanics, OMM, bracing.
Double points - epicondylitis is a chronic tendinosis with few inflammatory cells, due to repetitive microtrauma and vasculoneural growth in the common tendon insertion.
You are doing a pre-season physical on a 15 year old female athlete. You have her perform a two-legged squat, and her knees fall into a valgus position while squatting. She is at increased risk of what major injuries?
Knee injuries - ACL tears, meniscal tears, MCL tears
This 22 year old cyclist with coughing, inspiratory stridor, and chest and throat tightness with exercise has been treated with albuterol for many years but received little benefit. What alternative diagnosis should be considered?
A sports hernia (athletic pubalgia) will involve a strain or tear of these three muscle groups.
Hip adductors, abdominal obliques, rectus abdominus
A 13 year old boy is playing soccer in the fall, basketball in the winter, and running track in the spring. You congratulate him for staying so active, but raise concerns to him and his parents about potential for overuse injuries because ___, and recommend ___ as a winter sport.
He is doing three consecutive seasons of running sports.
Anything that is not running-based and involves more upper body activity. Swimming or wrestling would be good winter activities for him.
A 35 year old female runner tripped and fell during a sprint. Her knee scabs have resolved but she has had a nagging pain and clicking on the ulnar side of her wrist. She also notes that her wrist hurts when starting her car. Xrays are unrevealing for any fracture. This is the likely injured structure.
After "rolling his ankle", a 19 year old soccer player gets an ankle xray which finds an medial malleolar fracture and slight widening of the ankle mortise. This is the next step in imaging.
Imaging of entire fibula to rule out proximal fibular fracture (Maissoneuve fracture).
This 14 year old female soccer player complains of wheezing, coughing, and shortness of breath within minutes of starting to play. Her symptoms do not occur at other times. You prescribe an albuterol inhaler for her presumed diagnosis of ___, and if further treatment is needed would prescribe either or both of these two classes of medications.
Exercise induced bronchoconstriction
Leukotriene receptor antagonist and/or inhaled corticosteroid. Can also use LABA.
These are the two most common cardiac problems that arise in Marfan's Syndrome.
Mitral valve prolapse
Aortic aneurysm
A 15 year old falls on his head after a mid-air collision during a basketball game. After the game, he is complaining of headaches and his dad brings him to the ED. No imaging is performed as the boy has a GCS of 15, a normal physical exam, and is asymptomatic aside from his headache. Prior to discharge, his father asks what symptoms to look out for, and the ED physician gives them numerous symptoms that indicate further workup might be necessary. Name 5 of these symptoms.
Vomiting, worsening headache, increased somnolence, confusion, agitation, seizure, difficulty walking, vision changes, weakness, numbness
A right handed pitcher presents to the training room the day after a pitching a complete game that went into two extra innings with right arm swelling, erythema, and pain. He says his hand feels weak. He has been icing the shoulder and taking ibuprofen with no improvement. What’s the next step in diagnosis?
Venous duplex US to rule out upper extremity DVT
A football player presents with right foot pain and swelling the day after having his foot stepped on while running. His initial xrays are read with no acute fracture and he is diagnosed with a sprain. One week later he is still unable to bear weight and presents to clinic with increased swelling, pain, and ecchymosis an the plantar aspect of his foot. You are very concerned about this injury...
Lisfranc fracture (fracture/separation of the tarsal-metatarsal joint complex)
https://radiopaedia.org/articles/lisfranc-injury?lang=us
You are doing preparticipation physicals at UMO. Amidst the march of stethoscopes on chests, one 18 year old freshman's heart sounds are... not right. You decide to get an echo to evaluate for left ventricular outflow obstruction. You heard only an S1/S2 and no murmur, but THIS pattern during inspiration and expiration is what raises your concern.
You heard a a paradoxical split - a longer S2 split during expiration than inspiration. Suggests LV disease (aoritc stenosis, LVOT, LVH)
Other splits-
Physiologic split - Widened S2 during inspiration (delayed closure of pulmonic valve)
Fixed - Does not change with inspiration/expiration (possible ASD)
Normal murmur pattern - louding with squatting, softer with standing/valsalva.
?pathologic mumur - softer with squatting, louder with standing/valsalva
During a hard check, a hockey player hits the board hard with the top of his right shoulder, pushing his head to the left and pushing his right shoulder inferiorly. Afterward he complains of difficulty lifting his right arm and numbness/tingling in one of his fingers. You suspect injury at these nerve roots and numbess/tingling in this digit.
C5/6
Thumb
A 15 year old girl is brought in to clinic with by her mom for a pre-participation physical. She has been working hard over the summer to make the cheerleading team. Her two complaints are right sided shin pain, especially when landing jumps, and that she feels like despite how hard she has worked, her training has plateaued. She reached menarche at 13 and though her periods were always irregular, she has not had one for the past five months. She says she is not sexually active. Her mom feels like her daughter does not eat enough, though the girl says she eats as much as she can.
With this likely diagnosis, these are your initial steps in evaluation (labs/imaging) and treatment
Female Athlete Triad (menstrual dysfunction, low energy, decreased bone mineral density. Can be with or without disordered eating)
CBC, CMP, mag, phos, b-HCG, TSH
Leg xrays to evaluate for stress fracture, consider DEXA
Intervention with family, coach, patient to ensure adequate caloric intake to meet energy needs