Question of the Week # 477

477) A 39-year-old woman presents to clinic with a history of long-standing right leg pain. She complains of “achy” pain at the hip radiating down her femur to the knee, which is exacerbated on exertion, especially with jogging more so than climbing stairs, but also present during rest. She takes acetaminophen for it, which helps her pain. Her past medical history is significant for systemic lupus erythematosus diagnosed at age of 20, for which she has been taking on and off oral prednisone. She does not smoke cigarettes but he drinks alcohol 2 or 3 times per week. She denies any drug use. Physical examination is significant for limited range of motion of the right hip, especially with external rotation. A plain x-ray shows a dulling of the femoral head but no other pathology. What is the next step in diagnosis?
A. Bone scan
B. CT scan
C. MRI scan
D. PET scan
E. Ultrasound

Question of the Week # 407

407)  A 62 year old woman with history of bilateral knee osteoarthritis  presents with complaints of progressively increasing pain of her left knee for the past one week. Her knee hurts more on standing and walking down the stairs. She denies any fever or trauma. She has no other significant medical problems. She takes acetaminophen for her osteoarthritis pain. for urinary problems. On examination, she is afebrile. Left knee is normal with out any swelling, erythema or warmth. There is severe tenderness on the medial aspect of the left leg approximately two inches below her left knee joint. When passively stretched, she has full range of motion with out any pain. Which of the following is the most likely explanation of this patient’s presentation?

A) Anserine Bursitis

B) Pre-Patellar bursitis

C) Medial Meniscus injury

D) Medial Collateral ligament injury

E) Trochanteric bursitis

Question of the Week # 331

331) A 16 year old girl is evaluated in the office for mild to moderate pain in her left ankle.  She reports that she heard a pop sound followed by the pain when she was about to walk briskly on her way to college. She is unable to walk normally and cannot lift up on to her toes while weight bearing. Her past medical history is significant for recurrent episodes of urinary tract infections. On examination, she is afebrile. There is no bruising or swelling in her left foot. There is tenderness at the back of her left foot about 2 cm above the posterior calcaneus.  Squeezing of the left calf muscle fails to result in passive plantar flexion at the ankle.  Which of the following element if obtained from the patient’s history would help in determining the cause of her presentation?

A) Eating habits

B) Menstrual History

C) Sexual History

D) Recent antibiotic use

E) Family history of Muscular Dystrophy

Question of the week # 305

305) You have recently been posted by your employer to serve as a school physician in a school that is few miles away from your office. The school has about 250 students of whom 55% are girls and the rest are boys. The school teacher reports that they have not had a scoliosis screening program in place and wonders if you can implement such a program in the school. Which of the following is the most appropriate course of action?

A) Arrange scoliosis screening for all students between 10 and 16 years of age.

B) Arrange scoliosis screening for all students 10, 12, 14 and 16 years of age.

C) Contact the school nurse and review skills for scoliosis screening procedures.

D) Visually inspect for severe curves only when the back is examined for other reasons.

E) Screen girls for scoliosis at 15 years of age and boys at 16 years of age.


Question of the week # 304


A 16-year-old male who presents to your office for his regular health checkup and for clearance before participation in then high school basketball team. During the physical examination, you note a mild convexity in the thoracic region of his spine with forward flexion at the hips. You ask him to lean forward with his feet together and bend 90 degrees at the waist. Based on your clinical examination, you estimate a lateral spinal curvature of about 5 degrees. You discuss these findings with the patient and his mother. Which of the following is the most appropriate action?

A. Recommend back-strengthening exercises.

B. Refuse medical clearance for participation in sports.

C. Order a radiograph of the back to quantify the curvature

D. Observation alone.

E. Refer for orthopedic consultation.

Question of the week # 303

303) A 11 year old girl is evaluated in your office for progressing lateral curvature of her spine. She denies any back pain or neurological symptoms. Her mother is very concerned about the child’s appearance.  On physical examination, there is gross convexity in the thoracic region of her spine with forward flexion at the hips. There is no tenderness or neurological deficits. An x-ray of the spine reveals 25º curvature ( cob angle) . Which of the following is the most appropriate management at this time?

A) Repeat Clinical exam and x-rays at 6 months

B) Refer to orthopedic evaluation

C) Bracing

D) Spinal fusion surgery

E) Recommend back strengthening exercises

Question of the week # 302

302) A 16 year old girl is evaluated in your office for one day duration of fever, cough and left pleuritic chest pain. On examination, her temperature is 100.5F, respiratory rate is 18/min, pulse 100/min and blood pressure 120/60 mm hg. Breath sounds are decreased in the left lower lobe. A Chest x-ray is obtained which reveals left lower lobe infiltrate. Incidentally, a 7 ° lateral curvature is seen on the chest x-ray. The patient is started oral azithromycin for her pneumonia and is discharged home. Which of the following is the most appropriate management for her  incidentally discovered scoliosis?

A) Clinical follow up  alone

B) Repeat x-rays every 6 months

C) Refer to orthopedic surgery

D) Bracing

E) No follow up required

Question of the week # 298

298) A 6 year old boy presents to your office with a limp on the right side. He denies any falls or trauma. Mother reports that the limp has been present for several weeks. She reports that the patient was seen in the Emergency Room when the limp was first observed. X-rays obtained at that time were normal and so, he was discharged. There is no history of fever. He denies any pain. Family history is unremarkable. On examination, he is afebrile . His right lower extremity appears one inch shorter than the left. Upon standing and walking, his pelvis appears to be tilted towards the left. Which of the following is most likely to be abnormal in this condition?

A) External rotation of hip

B) Tibial tuberosity

C) X-ray of the Knee

D) Erythrocyte Sedimentation Rate

E) Internal rotation and abduction of hip

Question of the week # 280

280) A 2 year old child is brought by her mother to the emergency department because the child has not been ambulating since yesterday after he tripped over an object and fell. Physical examination reveals tenderness and swelling in left mid-thigh. Eyes are normal without any hemorrhages. Skin reveals several bruises. Teeth are translucent and show yellow discoloration. Moderate scoliosis is evident. A skeletal survey reveals rib fractures and multiple fractures in various stages of healing. There is diffuse osteopenia. There is a spiral fracture of left femur shaft.  The limb is splinted and an orthopedic consult is obtained. Which of the following is the most appropriate action?

A) Contact social services

B) Contact Child Protection Services

C) Place the child in foster care

D) Obtain Head CT

E) Obtain detailed family history

Question of the week # 279

279 ) A 14 month-old child is brought by her concerned father to the Emergency department with a history that the child slipped out and fell on the ground from a table that is 10 feet in height. He says the accident occurred last night when he let the child stand on the table. The child cries when the right thigh is touched and does not move the right lower extremity. Rest of the physical examination is normal. There are no suspicious bruises or contusions on the skin. An x-ray of the right femur is shown below.

A skeletal survey is obtained and does not show any other fractures. There are no skull fractures or retinal hemorrhages or neurological deficits.

Based on the x-ray findings and the history, which of the following is the most likely diagnosis?

A) Osteogenesis Imperfecta

B) Fibrous Dysplasia

C) Accidental Injury

D) Child Abuse

E) Pathological Fracture from Ewing Sarcoma

Question of the week # 278

278) A 34 year old mother brings her 18 month old child to the emergency room. She is in tears and reports that the child was playing on the sofa and has fallen down 1 day ago landing on his left foot and since then has not been moving his left lower extremity. The child is crying incessantly. Physical examination reveals tenderness and swelling in the left mid-thigh. An x-ray of the left lower extremity shows a non-displaced hair line fracture of the femur shaft and the fracture age consistent with reported history of time of injury. Which of the following is the most appropriate next step in management?

A) Contact Child Protection Services

B) Skeletal Survey

C) Open reduction and internal fixation

D) Bone scan

E) CT head

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