A 45-year-old female presents to your office with a 1-month history of pain and swelling posterior to the medial malleolus. She does not recall any injury, but reports that the pain is worse with weight bearing and with inversion of the foot. Plantar flexion against resistance elicits pain, and the patient is unable to perform a single-leg heel raise.
Which one of the following is true regarding this problem?
Correct Answer E: The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon’s function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity. The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture.
Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem.
While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2-3 weeks.
An 82-year-old male nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of multi-infarct dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding.
Which one of the following is the most likely cause of this patient’s bleeding?
Correct Answer B: This patient most likely has ischemic colitis, given the abdominal pain, bloody diarrhea, and cardiovascular risks. Peptic ulcer disease is unlikely because the nasogastric aspirate was negative. Diverticular bleeding and angiodysplasia are painless. Infectious colitis is associated with fever.
A 35-year-old male amateur rugby player seeks your advice because right hip pain of several months’ duration has progressed to the point of interfering with his athletic performance. The pain is accentuated when he transitions from a seated to a standing position, and especially when he pivots on the hip while running, but he cannot recall any significant trauma to the area and finds no relief with over-the-counter analgesics. On examination his gait is stable. The affected hip appears normal and is neither tender to palpation nor excessively warm to touch. Although he has a full range of passive motion, obvious discomfort is evident with internal rotation of the flexed and adducted right hip.
Which one of the following is most strongly suggested by this clinical picture?
Correct Answer D: Gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position is consistent with femoro-acetabular impingement. Reproduction of the pain on range-of-motion examination by manipulating the hip into a position of flexion, adduction, and internal rotation (FADIR test) is the most sensitive physical finding. Special radiographic imaging of the flexed and adducted hip can emphasize the anatomic abnormalities associated with impingement that may go unnoticed on standard radiographic series views.
→ Osteoarthritis (choice A) of the hip generally occurs in individuals of more advanced age than this patient, and the pain produced is typically localized to the groin area and can be elicited by flexion, abduction, and external rotation (FABER test) of the affected hip.
→ Although the pain associated with avascular necrosis (choice B) is similarly insidious and heightened when bearing weight, tenderness is usually evident with hip motion in any direction.
→ Bursitis (choice C) manifests as soreness after exercise and tenderness over the affected bursa.
→ Pathologic hip (choice E) fracture patients typically have progressive pain that is not relieved by rest and which is more pronounced at night. Most patients do have a history of cancer.
A 20-year-old girl is hospitalized following a suicide attempt. She is unhappy with her mother for not allowing her to die. Her mother mentions that she has dropped out of school two years ago, has no friends and prefers to stay at home because she feels that her nose is unsightly and makes her look ugly. She feels that her friends often laugh at the size of her nose. She spends a lot of time observing her nose in front of mirror and uses large hat and glasses while going out of the house to hide her nose. She has never dated, as she fears being rejected because of her nose. She has been under psychiatry care and has received counseling and medication. Two years ago, she consulted a plastic surgeon, who turned down her request for rhinoplasty stating that the surgery is not indicated for cosmetic purpose as her nose looks normal.
What is the most appropriate diagnosis?
Correct Answer C: Preoccupation with imaginary deficit in the appearance, leading to clinically significant stress and social impairment is the characteristic manifestation of body dysmorphic disorder (BDD), which is an increasingly recognized somatoform disorder. Persons with BDD worry about imagined or slight abnormal appearance of body parts, which may include hair, nose, chin, breast, skin, buttocks, genitalia, hands and feet. The preoccupation with appearance is typical feature of BDD and is not present in any other psychiatric disorder. Patients present to family physician seeking cosmetic procedures. Mental status examination is usually within normal limits, except that the thoughts about the perceived defect are extremely divorced from reality and cause significant distress. No specific laboratory tests or imaging studies are indicated for suspected BDD.
BDD is often considered a benign preoccupation because concern about appearance is common in adolescent girls and boys. However, if it leads to extreme preoccupation affecting mood and causing social impairment, diagnosis of BDD should be made. Cosmetic correction is rarely an effective treatment. Pharmacologic treatment with selective serotonin reuptake inhibitors and non-pharmacologic treatment with cognitive behavior therapy are effective.
→ Concern about appearance is considered normal in adolescent girls and boys (choice A). When the concern leads to preoccupation and social impairment as described in the stem, the condition is termed as BDD.
→ People with avoidant personality disorder (choice B) are extremely sensitive to what others think about them and experience constant inadequacy. The preoccupation in avoidant personality disorder is with being criticized or rejected in social situations; whereas in BDD, it is with appearance of particular body part.
→ Conversion disorder (choice D) is a condition in which a person presents neurological symptoms such as blindness, numbness or paralysis or hyperventilation that cannot be explained by medical evaluation. The manifestations are episodic unlike chronic symptoms of BDD.
→ Borderline personality disorder (choice E) is a condition characterized by symptoms such as anxiety, insecurity, depression, hostile antagonism, lack of inhibition and extreme anger. These features are absent in the case described.
Key point: Diagnosis of body dysmorphic disorder should be considered in a young adult presenting with preoccupation with his/her appearance, which leads to clinically significant stress and social impairment.
A 72-year-old female sees you for preoperative evaluation prior to cataract surgery. Her history and physical examination are unremarkable, and she has no medical problems other than bilateral cataracts.
Which one of the following is recommended prior to surgery in this patient?
Correct Answer E: According to a recent Cochrane review, routine preoperative testing prior to cataract surgery does not decrease intraoperative or postoperative complications. The CMA recommends against routine preoperative testing in asymptomatic patients undergoing low-risk procedures, since the cardiac risk associated with such procedures is less than 1%.
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