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Tennis, Anyone? The Wrap Up.

Katie Tsubota MSK Week 1 Friday 2.24.12
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Katie Tsubota

on 24 February 2012

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Transcript of Tennis, Anyone? The Wrap Up.

Mr. Weiser
1 month ago: almost fell while jogging on uneven terrain HPI 55 year old Caucasian male
PMH of hyperlipidemia
Atorvastatin
Family history of hypertension (father)

Sharp during exercise
Dull aching after longer exercise
Swelling after two sets of tennis
Knee "locks" and sometimes "gives out" Current pain symptoms: Exams and Tests Results McMurray test Significant pain during flexion and extension with application of varus force
Findings MRI of left knee Tear in posterior horn of medial meniscus
Focal cartilage loss over medial tibial plateau
Medial collateral ligament intact
Arthroscopic repair of meniscal tear
Rx: Acetaminophen with codeine Treatment Chief Complaint Left knee pain 2 month follow-up Pain improved
Able to exercise
Knee swell occasionally with lots of tennis Treatment Rx: Nabumetone 500 mg 2x daily

MRI of left knee ordered Meniscal tear Diagnosis
Sudden twisting injury of the knee
i.e. when runner suddenly changes direction


Recurrent knee pain
Episodes of catching or locking of the knee joint
Especially with squatting or twisting of the knee
Mild effusion
Tenderness at the medial or lateral joint line
Atrophy of the vastus medialis obliquus portion of the quadriceps muscle also may be noticeable


MRI is the radiologic test of choice because it demonstrates most significant meniscal tears. Calmbach WL, Hutchens M. Am Fam Physician. 2003 Sep 1;68(5):917-922. Mr. Weiser: 11 years later Right knee pain Chief Complaint Sharp pain during exercise
Dull aching after longer exercise
Knee does not "lock" or "give out"
Knee is swollen most of the time
Swelling worsens after 1 tennis match HPI First noticed pain 1 month ago while walking
No recollection of injury or unusual activity Current pain symptoms Symptoms of osteoarthritis Exams and Tests Findings Physical Exam Bilateral Heberden’s nodes
Left knee normal, with two 1cm well-healed scars

Right knee
Small, cool effusion and crepitus present
Mild tenderness at the medial joint line and with patellar compression
Point tenderness at the medial aspect of the right knee 2 cm below the joint line

Negative McMurray’s sign
Negative anterior and posterior drawer signs
Negative ligamentous laxity Findings X-Ray of Right Knee Mild medial joint narrowing associated with osteophyte formation
Osteophyte is also present about the patellofemoral joint space
Cannot rule out effusion on this view Recommendation Acetaminophen 1 g 4x daily

Quadriceps stregthening exercises Continues to experience significant pain, despite taking acetaminophen every 6 hours and strengthening quadriceps 6-week follow-up Focused extremity exam unchanged Treatment Naproxen 500 mg twice daily NSAID No change in symptoms Next several months Treatments Various NSAIDs - no relief Referral to rheumatologist Longitudinal follow-up HPI Rheumatology visit Morning stiffness lasting about 10 minutes
Pain worsens when he plays tennis
Pain lessens when he rests
Becomes stiff after 1 day of rest
Few minutes of movement improve stiffness
Osteoarthritis (OA) of the knee Diagnosis Common problem after 60 years of age


Knee pain aggravated by weight-bearing activities and relieved by rest
No systemic symptoms
Morning stiffness that dissipates somewhat with activity
Decreased range of motion
Mild joint effusion
Palpable osteophytic changes in knee joint


Joint-space narrowing
Subchondral bony sclerosis
Cystic changes
Hypertrophic osteophyte formation. Calmbach WL, Hutchens M. Am Fam Physician. 2003 Sep 1;68(5):917-922. Results Tests Aspiration of synovial fluid from the right knee
Injection of sodium hyalurate
The fluid is straw colored and sent for analysis Cell count
WBC = 200
RBC = 10

Crystals absent
WBC differential
Neutrophils = 25%
Lymphocytes = 15%
Macrophages = 60%

11 years later Rheumatology visit 64 year old male
PMH of poorly-controlled hypertension and gastritis
Atenolol and enapril for hypertension

Fed-Ex representative

Mr. Majors Left groin pain Chief complaint Pain started 4 or 5 months ago HPI Current pain symptoms Pain worsens when walking up long driveways
OTC Advil eases pain
Has been taking "like candy" Other symptoms Severe heartburn of 2 weeks duration
Daily symptoms not relieved by OTC anti-acids
Black stools for past few days
Exams and Tests Findings Physical Exam Moderate obesity
BP 188/100 mm HG
No postural changes
2+ bilateral pedal edema

Heberden’s and Bouchard’s nodes
Decreased external rotation of left hip
Patellofemoral crepitus in his knees

Normal prostate with palpable internal hemorrhoids
Results Laboratory tests Sodium 135 mmol/L (135-145 mmol/L)
Potassium 4.0 mmol/L (3.5-5.0 mmol/L)
BUN 20 mg/dl (10-25 mg/dl)
Creatinine 1.9 mg/dl (0.7-1.4 mg/dl)


WBC 5.1 K/ul (3.7-11.0 K/ul)
Hemoglobin 9.2 g/dl (13.0-17.0 g/dl)
Hematocrit 31% (39-51%)
Platelets 211 K/ul (150-400 K/ul)

High Low Low Findings Pelvic X-Ray Bilateral joint space narrowing (right greater than left)
Osteophyte formation Osteoarthritis (OA) of the hip Diagnosis
Mild dysplasia of femoral head or acetabulum resulting in incongruity of articular surfaces
Use of joint leads to progressive cartilage degeneration and reactive bone changes


Joint tenderness
Crepitus
Limited range of motion
Early finding is loss of internal rotation
Swelling due to synovial effusion or bony enlargement with presence of osteophytes
Referred pain to groin
Anterior thigh and knee symptoms occasionally predominate

Goldman L, Schafer AI. Goldman’s Cecil Medicine, 24th Ed. Saunders/Elsevier, 2011. Chapter 270.
Discontinue Advil
Diet and weight loss counseling Treatment Gastroenterologist confirms severe NSAID-induced gastritis NSAID-induced gastritis Dual-injury hypothesis
Gastric damage caused by NSAID-mediated direct acidic damage + suppression of prostaglandin synthesis
Irritation of the gastric mucosa weakensresistance to acid, causing gastritis, ulcers, bleeding, or perforation
Damage ranges from superficial injury to single or multiple ulcers, with or without bleeding

Clinical signs and symptoms
Dyspepsia
Diarrhea
Nausea
Vomiting

Risk factors
Elderly patients (due to multiple medical conditions and polypharmacy)
Concomitant corticosteroid or anticoagulant therapy
High doses of NSAIDs
Long-term NSAID therapy
History of peptic ulcer disease, Helicobacter pylori infection, or gastritis

The various NSAIDs differ with regard to their risk of inducing upper GI bleeding and/or perforation
Ibuprofen and diclofenac have lowest relative risk
Sulindac, aspirin, naproxen, and indomethacin have intermediate relative risk
Piroxicam has highest relative risk
A reason for these differences may be related to dose Tolstoi LG. Drug-induced Gastrointestinal Disorders: Stomach and Duodenum. Medscape Pharmacotherapy. 2002;4(1). Available online at http://www.medscape.com/viewarticle/437034_5 No edema
Normal creatinine
Slight increase in body weight Proton-Pump Inhibitor
Calcium channel blocker
Trial of acetaminophen 1 g every 4 hours Referral to gastroenterologist Rx Two month follow-up Still experiencing groin pain with no relief from acetaminophen
Cause Signs and symptoms Diagnosis Calmbach WL, Hutchens M. Am Fam Physician. 2003 Sep 1;68(5):917-922. Figure 5. NSAID HMG-CoA reductase inhibitor Non-NSAID analgesic Opiate analgesic Beta-blocker ACE inhibitor NSAID (ibuprofen) Non-NSAID analgesic For heartburn For hypertension Non-NSAID analgesic Signs and Symptoms Radiograph Symptoms of osteoarthritis No signs of inflammatory arthropathy Marginal osteophytic spurs seen in OA ACL and PLC intact Indicates damage to medial meniscus Blood in stool Prevent further NSAID damage to gastric mucosa Pain relief - less weight on joints Pain prevents him from exercising Hypertensive Marginal osteophytic spurs seen in OA Signs of osteoarthritis (OA) Cause Signs and Symptoms Signs of osteoarthritis No injury to menisci No injury to ligaments Signs of osteoarthritis Signs of osteoarthritis Calmbach WL, Hutchens M. Am Fam Physician. 2003 Sep 1;68(5):917-922.

Goldman L, Schafer AI. Goldman’s Cecil Medicine, 24th Ed. Saunders/Elsevier, 2011. Chapter 270.

"Tennis, Anyone?" CCLCM Problem Based Learning Curriculum 2012.

Tolstoi LG. Drug-induced Gastrointestinal Disorders: Stomach and Duodenum. Medscape Pharmacotherapy. 2002;4(1). Available online at http://www.medscape.com/viewarticle/437034_5 References Prezi presentation available at http://prezi.com/saskjavl0z0a/edit/#5_2814066 USMLE Step 1 Questions A 60-year-old man presents to the physician with a limp that he has had since childhood. His left hip falls whenever he lifts his right leg. He reports one major illness as a child, after which he developed this limp. Which of the following muscles is most likely affected in this patient? (A) Gluteus maximus
(B) Gluteus medius
(C) Obturator internus
(D) Piriformis
(E)Quadratus femoris Le TT, Klein J, Shivaram A. First Aid Q&A for the USMLE Step 1. 2007. The McGraw-Hill Companies, Inc. As a child this patient had polio. Patients who develop polio experience injury to the nerve roots that supply the superior gluteal nerve, which innervates the gluteus medius and minimus. These muscles typically abduct and medially rotate the thigh and keep the pelvis level. When these muscles do not function properly, the patient is unable to keep the pelvis level and develops a characteristic limp. (B) Gluteus medius The skeletal system develops via a process known as ossification, in which bones are created from preexisting mesoderm. Which of the following is the name of the mechanism by which long bones of the limbs ossify, and how can this mechanism be described? (A) Endochondral ossification - bones form directly from mesoderm
(B) Endochondral ossification - bones form on a hyaline cartilage
(C) Intramembranous ossification - bones form directly from mesoderm
(D) Intramembranous ossification - bones form on a hyaline cartilage mold
(E) Intrathoracic ossification - bones form in the thorax and migrate to the limbs Le TT, Klein J, Shivaram A. First Aid Q&A for the USMLE Step 1. 2007. The McGraw-Hill Companies, Inc. The long bones of the limbs form via endochondral ossification. In this process, mesoderm is first converted to a cartilaginous model. Bone then forms at the primary ossification center at the diaphysis. Besides the long bones, other bones that form via endochondral ossification include the sphenoid, ethmoid, incus, stapes, malleus, limb girdles, vertebrae, sternum, and ribs. (B) Endochondral ossification - bones form on a hyaline cartilage mold (A) Anterior talofibular ligament
(B) Calcaneofibular ligament
(C) Talonavicular ligament
(D) Tibiocalcaneal ligament
(E) Tibiotalar ligament A 16-year-old gymnast presents to the emergency department after landing awkwardly on her ankle. She is diagnosed with a sprained ankle. Which of the following ligaments is most commonly injured in an ankle sprain? The lateral ligaments are more commonly injured than the medial ligaments, since they are weaker. The anterior talofibular ligament is the most common of the lateral ligaments to be injured. (A) Anterior talofibular ligament Le TT, Klein J, Shivaram A. First Aid Q&A for the USMLE Step 1. 2007. The McGraw-Hill Companies, Inc. Le TT, Klein J, Shivaram A. First Aid Q&A for the USMLE Step 1. 2007. The McGraw-Hill Companies, Inc. Le TT, Klein J, Shivaram A. First Aid Q&A for the USMLE Step 1. 2007. The McGraw-Hill Companies, Inc. Le TT, Klein J, Shivaram A. First Aid Q&A for the USMLE Step 1. 2007. The McGraw-Hill Companies, Inc. Due to restored renal function following NSAID discontinuation Decreased renal function due to NSAID use
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