CASE 1

A 70 year old man presents to clinic for progressive shoulder pain. He complains of mild bilateral shoulder discomfort for the past ‘few years’, but has had progressive worsening at the right shoulder for three months. There is no history of recent or prior trauma to this area. He has chronic lower back pain from degenerative arthritis, but outside of this area and the involved shoulders there are no new sites of joint nor muscle pain. He describes both pain and stiffness. He is uncertain if activity improves his symptoms as he has avoided overhead activity secondary to pain, and he is also not engaged in regular exercise due to his chronic back symptoms. He localizes the pain to the upper and outer portion of the right shoulder in the deltoid region.

A review of systems is otherwise negative.

Joint examination reveals normal range of motion without swelling nor tenderness at the fingers, wrists and elbows bilaterally. The right and left shoulders are without obvious effusion. There is normal passive range of motion with external rotation bilaterally, with slightly limited range of motion with internal rotation on the right. Additional shoulder examinations were performed in an effort to localize the source of pain.

Joint examination of the lower extremities was normal other than mild limitation in range of motion at the hips and discomfort at the lumbar spine through active flexion and extension.

The rest of the physical examination is normal.

1) Which of the following clinical tests is not designed to identify pathology in the subacromial space?

Provocation testing of the right shoulder revealed discomfort with Hawkins test and Neer sign, as well as during painful arc testing. Drop arm testing on the right was normal. Formal strength testing of the right shoulder revealed 5/5 strength in resisted abduction, with breakaway weakness secondary to pain. Strength was normal in internal and external rotation on the right, with discomfort noted by the patient during the examination.

Subacromial bursitis is suspected based upon the clinical and examination findings. Non-steroidal anti-inflammatory medications are recommended, along with modification of activities and rest.

2) Strengthening which of the muscles below would be most likely to provide benefit for this condition?

The patient returns for follow up three months later, but unfortunately has not improved despite good compliance with home exercises and anti-inflammatory medications. He continues to have discomfort with Hawkins, Neer, and painful arc testing, with normal strength in abduction as well as internal and external rotation. Internal rotation at the right shoulder continues to be moderately limited. A decision is made to perform a subacromial steroid injection, along with a referral to physical therapy. Upon return to clinic 4 weeks later he reports only mild, temporary improvement in his symptoms, which after 3 weeks returned to his baseline level of pain. A plain radiograph if the shoulder is obtained.

3) What finding on X-ray likely account for the patients continued symptoms?

CASE 2

A 38 year old accountant presents with symptoms of worsening anxiety and restlessness for two months. She has noticed perspiration even while at rest, with the onset coinciding with her increase in anxiety. She has a history of IBS, and believes the frequency of her loose stools has increased during this time period as well. She does not recall recent sick contacts and has not noticed fevers nor chills. She has not traveled outside of the city for the past several years.

PMH: IBS; Fibromyalgia; Mild anxiety disorder

Medications: Dicyclomine 20mg three times daily; Amitriptyline 20mg at night; venlafaxine 150mg twice daily; tramadol 100mg three times daily as needed

Exam: VS: Temperature 38.1, HR 100, RR 26, BP 135/80

Musculoskeletal exam: joint examination is normal without synovitis nor deformity.

Neuro exam: she does not exhibit involuntary movement, although a slight resting tremor at the bilateral hands is noted on exam. Muscular strength is normal. Deep tendon reflexes: patellar reflex 3+ bilaterally, Achilles 3+ bilaterally, biceps 4+ bilaterally, brachioradialis 3+ bilaterally.

The rest of her cardiovascular, pulmonary, gastrointestinal, and skin exam are normal.

Lab orders are placed: CBC, comprehensive metabolic panel, urinalysis, TSH, urine toxicology screen (to identify ingestion of illicits such as cocaine or amphetamines).

4) In conjunction with this laboratory testing, which of the options below best describes the additional work-up/management that is needed at this visit?

CASE 3

A 55 year old female presents with joint and muscle pain for the past 5 years that has been progressively worse. She describes diffuse pain in her hands, hips, and shoulders. There has been no obvious joint swelling, and the discomfort is described as being generalized to the entire region of her hip and shoulder girdle, as well as the entire hand. Pain is the predominant symptom, with report of stiffness as well. She is unable to engage in exercise or other significant physical activity because of her symptoms.

Review of systems: periodic areas of numbness in limbs, present for past year; progressive, ‘disabling’ fatigue; poor sleep attributed to pain and anxiety; poorly controlled depression (not on therapy secondary to intolerance and/or weight gain on agents in past); memory issues, complaint of ‘mental slowing’

Prior lab testing that is brought with her to the appointment:

• CBC, CMP & UA normal; ESR, CRP normal: 1 month prior
• TSH and Vitamin D level normal: 3 months prior
• ANA 1:80, with negative ‘reflex panel’; ESR, CRP normal; TSH, Vitamin B12, folate all normal: 1 year prior
• ESR, CRP normal: 2 years prior

On joint exam there is no synovitis, with full range of motion of all extremities. Muscle strength testing of the upper and lower extremities is normal. On palpation, she describes pain upon light pressure over the superior aspect of the posterior cervical muscles, trapezius, and deltoid area bilaterally. On examination of the lower body she displays similar discomfort to palpation of the gluteal and greater trochanteric region, as well as the anterior quadriceps muscle bilaterally. Palpation of regions at the anterior cervical spine and chest, as well as regions in the distal arms and legs bilaterally, did not elicit painful response. The rest of her physical examination is normal.

5) Based upon the clinical scenario above, which of the following statements best describes the suspected diagnosis?

CASE 4

A 56 year old man comes in for evaluation of right hand pain, stiffness, and swelling for two months. The pain is located diffusely across the hand from his finger tips to his wrist. He describes this as 9/10 in intensity, sharp in quality. There is a mild dull ache to the forearm and upper arm, without swelling. There is no prior history of joint swelling or stiffness. He denies trauma, as well as recent sick contacts nor recent travel. Outside of his right hand and arm symptoms, he denies other joint issues.

Past medical history: Hypertension; carpal tunnel syndrome, with surgical release 3 months ago

Review of systems: negative outside of current symptoms

On exam there are no signs of infection nor poor wound healing at the post-surgical site. The right hand is slightly cool to touch throughout, tender to touch, with diffuse soft tissue swelling. Examination of the skin reveals brisk capillary refill. There are no skin ulcerations or signs of infarct at the fingertips. Joint examination outside of the right hand is normal. The rest of the physical exam is normal.

6) Which of the following diagnostic studies is most likely to help choose the appropriate medical therapy?