MSK final exam Questions and 100% Correct
Verified Answers (With Explanations)
A 56-year-old Caucasian woman presents to the emergency department for evaluation
of chest pain. Vital signs upon presentation are normal and the oxygen saturation level
is 96% on room air. Initial lab work performed in the emergency department shows a
normal troponin and normal D-dimer. EKG shows normal sinus rhythm without STT
wave changes. The patient is admitted to your service for observation of chest pain. Two
additional serial troponins are normal, and a follow-up EKG remains unchanged. Chest
X-ray is unremarkable. Cardiac monitoring has revealed normal sinus rhythm with rare
PVCs.
You now decide to reassess the patient prior to making further decisions regarding
additional testing or hospital discharge. The patient reports several months of
substernal chest pain that is aggravated by exertion or movement. The pain can last
several hours at a time and is described as sharp and moderate in intensity. It - Answer
Correct answer:
Palpation for sternal and costochondral joint tenderness.
Explanation
The correct answer is palpation for sternal and costochondral joint tenderness.
Costochondritis is inflammation of the ribs and cartilaginous material of the chest wall
and is a common cause of chest pain. The chest pain is often aggravated by exertion,
movement, or respiration. To establish a diagnosis of costochondritis, palpation of the
chest wall should reproduce the patient's presenting symptoms of chest pain.
Costochondritis may coexist with other illnesses, so potentially life-threatening causes
of chest pain still should be ruled out, especially in moderate- or high-risk age groups.
Assessment for calf tenderness to palpation and dorsiflexion is incorrect. This test has
traditionally been used to evaluate for deep venous thrombosis but lacks sensitivity and
,specificity. Lower extremity swelling is the most common physical exam finding. Patients
with DVT are at increased risk for pulmonary embolism. Risk factors for deep venous
thrombosis and pulmonary embolism include recent surgery, immobilization, cancer, or
prior DVT. Pulmonary embolism is more likely in the presence of tachycardia,
hemoptysis, prior history of PE, or an abnormal D-dimer test. In the absence of any of
these manifestations, the likelihood of deep venous thrombosis of pulmonary embolism
is decreased.
Assessment of aortic width and pulsation is incorrect, but it is indicated in evaluating for
abdominal aortic aneurysm. This patient's symptoms are unlikely to be due to
abdominal aortic aneurysm because AAA rarely causes chest pain, but it is occasionally
associated with abdominal discomfort. Most often, an abdominal aortic aneurysm is
asymptomatic unless there is an associated dissection or rupture.
Evaluation of brachial and femoral pulses is incorrect.
Case
A 27-year-old Caucasian man returns to the emergency department with unbearable left
lower leg pain; he does so approximately 6 hours after initial discharge. While playing
lacrosse, the patient sustained a closed, mid-shaft tibial fracture. After casting and an
anti-inflammatory, his pain was noted to be mild (2 out of 10 on 1 - 10 scale) at time of
discharge. He reports his pain is increasing dramatically (it is now rated at 9 out of 10)
and is unresponsive to his prescribed narcotic, acetaminophen, icing, and elevating his
leg. He also describes a feeling of tingling and numbness throughout the lower left
extremity.
Question
What is the most likely cause of this patient's severe pain? - Answer Correct answer:
Compartment syndrome
,Explanation
The most likely diagnosis is compartment syndrome, which is an emergency. Without
prompt identification and treatment, blood flow is reduced and can result in tissue
necrosis and permanent nerve and muscle damage. Compartment syndrome can occur
after a trauma, such as a fracture or burn. As increasing fluid pressures build in the area
of injury, the restrictive fascia prevents outflow. In this patient's case, his cast may have
been applied too tightly and should be removed immediately. If his symptoms do not
resolve, he may need a surgical fasciotomy. Key features of compartment syndrome
include a history of trauma (especially to an extremity), edema, and pain out of
proportion to history/findings. Pulselessness is a late finding.
Claudication is a condition in which the patient experiences lower extremity pain
secondary to poor arterial blood supply. It is associated with peripheral arterial disease.
Claudication should classically worsen with movement (such as prolonged walking) and
improve with rest. This patient's pain did not improve with rest and his history is
inconsistent with peripheral arterial disease.
Malingering or drug-seeking behaviors should be evaluated in any patient complaining
of pain out of proportion to history, as the patient may be attempting to deceive the
provider. This patient's history was not concerning for prior history of psychiatric illness
or substance abuse. The objective physical exam findings on this patient (reduced
capillary refill and sensation, edema and shiny, taut skin) help substantiate a diagnosis
of compartment syndrome.
Sepsis is concerning condition that could cause edema and pain in an extremity.
However, the patient had a history of a closed fracture (much less likely to develop
sepsis than with an open fracture) and
Case Ico-delete Highlights
A 30-year-old man presents with pain on the outer aspect of the right elbow for the past
few days. The pain was mild and initially associated with vigorous activity; however, for
, the past 2 days, he has been experiencing pain during daily activities (e.g., lifting objects
with his palm down, brushing his teeth, and shaking hands). He started doing carpentry
as a hobby 2 months ago. He has no other symptoms and is otherwise healthy. On
examination, there is point tenderness at a specific point on his right lateral elbow. An
X-ray of the elbow does not reveal any abnormal finding.
Question
What is the most likely diagnosis? - Answer Correct answer:
Lateral epicondylitis
Explanation
Tennis elbow (TE), which is also called lateral epicondylitis, is a painful condition of the
elbow caused by repetitive use of the wrist extensors. It is an overuse injury of the
extensor tendons of the forearm at their attachment at the lateral epicondyle. The
condition is associated with activities such as racquet games, carpentry, and knitting.
Symptoms include pain at the lateral elbow that worsens with activity (especially
squeezing movements), lifting objects with the palm down, turning a doorknob, and
flexing the wrist towards the forearm. Diagnosis may be made by the tennis elbow test.
X-ray is usually normal.
Tenosynovitis is an inflammation of the synovial sheath, most commonly occurring at
the wrist, hands, or feet. There is pain and swelling at the joint.
Golfer's elbow, or medial epicondylitis, is a condition of worsening pain at the medial
aspect of the elbow during forearm pronation and sudden wrist flexion. This condition is
also associated with repetitive movements such as racquet games, carpentry, or typing.
Diagnosis is made by eliciting pain on wrist flexion and forearm pronation against
resistance. X-ray is usually normal.
Radial tunnel syndrome refers to pain in the dorsal forearm due to compression of the
deep branch of the radial nerve.
Verified Answers (With Explanations)
A 56-year-old Caucasian woman presents to the emergency department for evaluation
of chest pain. Vital signs upon presentation are normal and the oxygen saturation level
is 96% on room air. Initial lab work performed in the emergency department shows a
normal troponin and normal D-dimer. EKG shows normal sinus rhythm without STT
wave changes. The patient is admitted to your service for observation of chest pain. Two
additional serial troponins are normal, and a follow-up EKG remains unchanged. Chest
X-ray is unremarkable. Cardiac monitoring has revealed normal sinus rhythm with rare
PVCs.
You now decide to reassess the patient prior to making further decisions regarding
additional testing or hospital discharge. The patient reports several months of
substernal chest pain that is aggravated by exertion or movement. The pain can last
several hours at a time and is described as sharp and moderate in intensity. It - Answer
Correct answer:
Palpation for sternal and costochondral joint tenderness.
Explanation
The correct answer is palpation for sternal and costochondral joint tenderness.
Costochondritis is inflammation of the ribs and cartilaginous material of the chest wall
and is a common cause of chest pain. The chest pain is often aggravated by exertion,
movement, or respiration. To establish a diagnosis of costochondritis, palpation of the
chest wall should reproduce the patient's presenting symptoms of chest pain.
Costochondritis may coexist with other illnesses, so potentially life-threatening causes
of chest pain still should be ruled out, especially in moderate- or high-risk age groups.
Assessment for calf tenderness to palpation and dorsiflexion is incorrect. This test has
traditionally been used to evaluate for deep venous thrombosis but lacks sensitivity and
,specificity. Lower extremity swelling is the most common physical exam finding. Patients
with DVT are at increased risk for pulmonary embolism. Risk factors for deep venous
thrombosis and pulmonary embolism include recent surgery, immobilization, cancer, or
prior DVT. Pulmonary embolism is more likely in the presence of tachycardia,
hemoptysis, prior history of PE, or an abnormal D-dimer test. In the absence of any of
these manifestations, the likelihood of deep venous thrombosis of pulmonary embolism
is decreased.
Assessment of aortic width and pulsation is incorrect, but it is indicated in evaluating for
abdominal aortic aneurysm. This patient's symptoms are unlikely to be due to
abdominal aortic aneurysm because AAA rarely causes chest pain, but it is occasionally
associated with abdominal discomfort. Most often, an abdominal aortic aneurysm is
asymptomatic unless there is an associated dissection or rupture.
Evaluation of brachial and femoral pulses is incorrect.
Case
A 27-year-old Caucasian man returns to the emergency department with unbearable left
lower leg pain; he does so approximately 6 hours after initial discharge. While playing
lacrosse, the patient sustained a closed, mid-shaft tibial fracture. After casting and an
anti-inflammatory, his pain was noted to be mild (2 out of 10 on 1 - 10 scale) at time of
discharge. He reports his pain is increasing dramatically (it is now rated at 9 out of 10)
and is unresponsive to his prescribed narcotic, acetaminophen, icing, and elevating his
leg. He also describes a feeling of tingling and numbness throughout the lower left
extremity.
Question
What is the most likely cause of this patient's severe pain? - Answer Correct answer:
Compartment syndrome
,Explanation
The most likely diagnosis is compartment syndrome, which is an emergency. Without
prompt identification and treatment, blood flow is reduced and can result in tissue
necrosis and permanent nerve and muscle damage. Compartment syndrome can occur
after a trauma, such as a fracture or burn. As increasing fluid pressures build in the area
of injury, the restrictive fascia prevents outflow. In this patient's case, his cast may have
been applied too tightly and should be removed immediately. If his symptoms do not
resolve, he may need a surgical fasciotomy. Key features of compartment syndrome
include a history of trauma (especially to an extremity), edema, and pain out of
proportion to history/findings. Pulselessness is a late finding.
Claudication is a condition in which the patient experiences lower extremity pain
secondary to poor arterial blood supply. It is associated with peripheral arterial disease.
Claudication should classically worsen with movement (such as prolonged walking) and
improve with rest. This patient's pain did not improve with rest and his history is
inconsistent with peripheral arterial disease.
Malingering or drug-seeking behaviors should be evaluated in any patient complaining
of pain out of proportion to history, as the patient may be attempting to deceive the
provider. This patient's history was not concerning for prior history of psychiatric illness
or substance abuse. The objective physical exam findings on this patient (reduced
capillary refill and sensation, edema and shiny, taut skin) help substantiate a diagnosis
of compartment syndrome.
Sepsis is concerning condition that could cause edema and pain in an extremity.
However, the patient had a history of a closed fracture (much less likely to develop
sepsis than with an open fracture) and
Case Ico-delete Highlights
A 30-year-old man presents with pain on the outer aspect of the right elbow for the past
few days. The pain was mild and initially associated with vigorous activity; however, for
, the past 2 days, he has been experiencing pain during daily activities (e.g., lifting objects
with his palm down, brushing his teeth, and shaking hands). He started doing carpentry
as a hobby 2 months ago. He has no other symptoms and is otherwise healthy. On
examination, there is point tenderness at a specific point on his right lateral elbow. An
X-ray of the elbow does not reveal any abnormal finding.
Question
What is the most likely diagnosis? - Answer Correct answer:
Lateral epicondylitis
Explanation
Tennis elbow (TE), which is also called lateral epicondylitis, is a painful condition of the
elbow caused by repetitive use of the wrist extensors. It is an overuse injury of the
extensor tendons of the forearm at their attachment at the lateral epicondyle. The
condition is associated with activities such as racquet games, carpentry, and knitting.
Symptoms include pain at the lateral elbow that worsens with activity (especially
squeezing movements), lifting objects with the palm down, turning a doorknob, and
flexing the wrist towards the forearm. Diagnosis may be made by the tennis elbow test.
X-ray is usually normal.
Tenosynovitis is an inflammation of the synovial sheath, most commonly occurring at
the wrist, hands, or feet. There is pain and swelling at the joint.
Golfer's elbow, or medial epicondylitis, is a condition of worsening pain at the medial
aspect of the elbow during forearm pronation and sudden wrist flexion. This condition is
also associated with repetitive movements such as racquet games, carpentry, or typing.
Diagnosis is made by eliciting pain on wrist flexion and forearm pronation against
resistance. X-ray is usually normal.
Radial tunnel syndrome refers to pain in the dorsal forearm due to compression of the
deep branch of the radial nerve.
