Daily question

[Scott Rand]

.  This 16 year old football player presented with complaints of severe left groin pain which occurred as he was sprinting on the football field yesterday.  He can bear weight but has severe pain when he tries to flex his hip. 

 

 

 

--

Scott E Rand, MD  FAAFP CAQSM

Director, Primary Care Sports Medicine Fellowship

Co Director of Sports Medicine, Houston Methodist Orthopedics and Sports Medicine Willowbrook

Assistant Professor of Clinical Family Medicine  Houston Methodist Academic Institute

Adjunct Assistant Professor of Family and Community Medicine, Texas A&M University

Assistant Professor of Family Medicine in Clinical Medicine  Weill Cornell Medical College.

13802 Centerfield Dr  Suite 300

Houston, TX  77070

[Scott Rand]

1.        Please identify the structures and explain what is being demonstrated. 

 

 

[Scott Rand]

Please identify the anatomic structures labeled.  When performing a knee injection, where are you trying to place the needle?

[Scott Rand]

Please identify the anatomic structures labeled in the wrist.   What is the condition seen if the cross sectional area of the structure with the solid arrow is greater than 13 mm squared?

--

[Scott Rand]

Daily Question

 On the way to a recompression chamber, what is the recommended initial medical treatment?

 

--

[Scott Rand]

You and your friends were out fishing in the gulf and had a great day catching mackerel and grouper.  You decide to have the fish for dinner and even experiment with some sushi that used the fish.  By the next day, everyone in your group is experiencing nausea and vomiting and odd neurological symptoms.  The cold beer you are drinking feels incredibly hot and the hot coffee feels strangely cold as you hold the cups.  What is wrong and what is the treatment?

[Scott Rand]

Briefly differentiate type 1 and type 2 decompression sickness

 

[Scott Rand]

.  

What are the Ottawa rules for determining x-ray imaging of the acute knee?

What are the Pittsburgh Decision rules for determining x-rays of the knee, and is there a significant difference in sensitivity or specificity compared to the Ottawa rules?

[Scott Rand]

The OARSI (Osteoarthritis Research Society International) in 2018 recommended which treatment as first line for osteoarthritis of the knee?

 

1. Hyaluronan injections
2. Corticosteroid injections
3. NSAIDs/Acetaminophen
4. Resistance/strength training of the lower extremities
5. Non-NSAID analgesics

 

--

[Scott Rand]

A 50 year old female patient presents to your office with exertional pain in her right calf.  She has noted the pain during exercise for the past several weeks.  Which of the following historical and physical findings would you expect with a diagnosis of popliteal artery entrapment syndrome?

 

 

A.     Diminished foot pulses at rest

B.      Pain more closely associated with volume of exercise rather than intensity of exercise

C.      Slow resolution of symptoms at conclusion of exercise

D.     Patients may have normal pulses that disappear or decrease with plantar flexion or dorsiflexion of the foot

E.      Markedly elevated compartment pressure

 

[Scott Rand]

A Segond fracture is pathogonomic for which ligamentous injury

A.     Medial collateral ligament

B.      Lateral collateral ligament

C.      Anterior cruciate ligament

D.     Posterior cruciate ligament

 

[Scott Rand]

 

A 20 year old male soccer player presents with 4 months of right groin pain.  Its described as a deep ache just to the side of his pubic bone and radiates down the medial thigh when he plays soccer. He also reports some paresthesias along the medial thigh after exercise and difficulty with jumping.  On exam he is weak on hip adduction and tender with stretching his adductors.  You decide to order an EMG which shows a denervation pattern of the adductor longus and brevis consistent with entrapment of which nerve?

A.      Obturator Nerve

B.      Ilioinguinal Nerve

C.      Superior Gluteal Nerve

D.      Inferior Gluteal Nerve

 

[Scott Rand]

An avid 25 year old male cyclist cycling 120 miles/week complains of left testicular pain and some perineal numbness for the past two months.  He has never experienced this before and reports no recent change in his equipment, training intensity or duration in the recent month.  He reports his pain as 6-8 out of 10 and is relieved by standing or walking.  He has discussed this with his cycling teammates and they have advised he consider changing his seat set-up and brand to a split seat to relieve his symptoms. 

 

The likely cause of his symptoms is:

A.      Pudendal Nerve Compression

B.      Adductor Tendinopathy

C.      Ischial Periositis

D.      Scrotal Ischemia

E.       Testicular Torsion

[Scott Rand]

Which of the following statements is true regarding hip flexor injury?

A.      In adolescents with the possible diagnosis of hip flexor pain and tenderness over the ischial tuberosity should have an x-ray to rule-out hip flexor origin avulsion

B.      A hop test with pain in the ipsilateral groin is indicative of a hip flexor strain

C.      Patients with large, palpable defects in the rectus femoris rarely need surgery

D.      Hip flexor strains are commonly accompanied by a tingling sensation in the anterior thigh because of irritation of the lateral femoral cutaneous nerve

E.       Significant weakness is usually seen on exam with most hip flexor strains

[Scott Rand]

Skeletal muscles that function as a group to stabilize the scapula against the posterior thoracic wall during upper extremity overhead activities include:

A.      Levator scapulae, rhomboid major, rhomboid minor, and serratus anterior

B.      Supraspinatus, infraspinatus, subscapularis and teres minor

C.      Thoracic paraspinals, trapezius, latissimus dorsi and posterior intercostals

D.      Deltoid, triceps brachii, pectoralis major and pectoralis minor

 

[Scott Rand]

You are evaluating a 27 year old recreational tennis player.  She felt some searing chest wall pain on her dominant side while extending for a forehand shot three days ago.  One her exam today, you notice substantial bruising along the anterior chest wall suggesting some soft tissue injury.  You begin by palpating the pectoralis major muscle.  Of the following points, which one is least helpful when trying to palpate the the pectoralis major:

A.      Sternum

B.      Clavicle

C.      2nd-6th ribs

D.      Humerus

E.       Coracoid Process

[Scott Rand]

Where is the purest area for sensory testing of the radial nerve on the hand located?

A.      Dorsal web between the thumb and the index finger

B.      Radial side of the hand

C.      Dorsum of the wrist

D.      The thenar eminence

[Scott Rand]

Pain originating from the facet joint complex is a common cause of back pain.  The purpose of the facet joint in its protection of the lumbar intervertebral disk is best characterized as which of the following:

A.      protection against axial rotation and loading

B.      protection against shearing forces

C.      protection against anterior translocation

D.      protection against caudal translocation

--

[Scott Rand]

A 34 year old, African American Florida native is visiting her cousin in Colorado in early January – temperatures are near record lows (-80 degrees F). While her cousin is at work, she decides to go out snowshoeing with cotton socks and bindings that are a bit tight. After about 5 minutes she notices numbness in her toes. She comes in to urgent care with white, cold, and firm toes. Further questioning reveals that she has smoked 1 pack per day since age 18. The definitive treatment is:

 

 

 

A.     Vigorously rub the toes with warm hands to stimulate circulation

B.      Warm the toes by immersion in 40 degree C whirlpool

C.      Immediate amputation of the affected toes

D.     Wrap the affected toes with warm blankets

E.      Use a small heater to warm the toes

 

[Scott Rand]

What is the role of calcium in muscle contraction?

A.     calcium binds troponin, moving tropomysin and allowing crossbridge linkages and contraction

B.      calcium binds troponin allowing for release of ATP and therefore initiating contraction

C.      calcium binds tropomysin, moving troponin and allowing crossbridge linkages and contraction

D.     calcium binds tropomysin allowing for release of ATP and therefore initiating contraction

 

[Scott Rand]

During high-intensity exercise (>85% VO₂ max), which energy system predominates and what is its main limitation?

--

[Scott Rand]

Explain the role of the ventilatory threshold in prescribing exercise intensity for athletes.

[Scott Rand]

A marathon runner collapses at mile 20 with confusion, core temperature of 40°C, and tachycardia. Labs show elevated CK and mild

hyponatremia. Explain the physiological mechanism behind their condition and outline the

immediate exercise-related management strategy.

 

A) Administer antipyretics and observe

B) Rapid whole-body cooling and IV fluids

C) Provide oral hydration and rest

D) Delay cooling until hospital arrival

[Scott Rand]

 

A 15 year old High School football player was hit on his blind side as he was running with the football.  He landed on the side carrying the football, and the tackler landed on top of him.  After needing assistance to the sideline, he became tachycardic, hypotensive and there was a clear change in his mental status.  He was transported to the nearest hospital where he was re-evaluated.

The patient is initially stabilized with IV hydration.  However, the patient's pain is persistent.  From the list below, which testing type is LEAST appropriate?

 

CT Abdomen and pelvis

Peritoneal lavage

MR abdomen

Plain films of abdomen and chest

Abdominal ultrasound

[Scott Rand]

Which pair of objective findings is most suggestive of increased intracranial pressure?

A.      Tachycardia, low blood pressure

B.      Bradycardia, elevated blood pressure

C.      Tachycardia, elevated blood pressure

D.      Bradycardia, low blood pressure

 

[Scott Rand]

 

.  A tall thin wide receiver is tackled hard on the field.  He comes off the field complaining of shortness of breath and some right sided upper chest pain.  His chest wall is non tender to palpation.  You choose to observe him and then are distracted by another injury on the field.  On your return, you find him markedly short of breath.  He is mildly cyanotic, has distended neck veins and you note the trachea deviated to the left.  What diagnosis are you most concerned about and what is the indicated emergency procedure?

 

[Scott Rand]

An obese patient (BMI>30) without other comorbidities presents to your office.  To improve compliance, one strategy for the patient’s exercise prescription could include which of the following:

A.      Incorporating high-impact aerobic activities

B.      Emphasizing exercising after their AM meal

C.      Strict cardiovascular prescription at 85% maximum HR for at least 30 minutes five times per week

D.      Increasing weight-bearing activities very rapidly to increase metabolism

E.       Start with non-weight bearing activities such as swimming and recumbent bike

--

[Scott Rand]

 

Which of the exercise prescription below should you advise against for an HIV infected individual with mild to moderate symptoms or CD4 count < 200?

 

A.      moderate exercise (40 -60 % VO2max)

B.      weight training

C.      intense exercise (>75% VO2 max)

D.      Three times per week

[Scott Rand]

An important aspect of the Preparticipation Physical Exam is the blood pressure reading.  Which statement below is true regarding blood pressure readings in children?

A.      The JNC 7 classification of hypertension in adults can be also be used for children under age 18

B.      Stimulant use is rarely a cause for blood pressure elevation in children under age 18

C.      One isolated elevation in a child's BP greater than 95th percentile should fully restrict sports participation

D.      Blood pressure charts based on sex, age and height percentile should be used for children under age 18

[Scott Rand]

 

An 800 meter open water swim is part of a short-course triathlon with over 800 registered athletes. It will be held in a shallow, protected lake that is usually calm but has been notorious for sudden weather changes. The race was cancelled the prior year because of excessive wave chop and poor visibility and a duathlon (bike & run race) was held in its place. Since that time, you have implemented some changes to improve safety in the case of any adverse events. Which of the following is an adequate safety measure for this race?

A.      Local volunteer swim club members will be on hand at the finish to deal with common minor conditions

B.      A "mass start" will begin the swim to assure the race finishes at an early time

C.      There will be one certified lifeguard for every 50 swimmers in this non-ocean race

D.      There will be large, highly visible buoys positioned 1000 meters or so apart and secured in a manner that will limit their movement in the most severe wave conditions in that body of water

E.       A highly mobile, powered watercraft will be "on-call" in the area to facilitate any emergency plan that is implemented

 

 

--

[Scott Rand]

A 36 year old female recreational soccer player presents with insidious onset of left posterior heel pain and a limp.  She is wearing flip flops because shoes make the pain worse.  Examination reveals swelling and erythema of the posterior heel.  There is no palpable defect in the Achilles tendon and a Thompson test is negative.  The most likely diagnosis is:

A.     Stress fracture of the calcaneus

B.      Plantar fasciitis

C.      Achilles tendon avulsion

D.     Sural neuritis

E.      Retrocalcaneal bursitis

 

[Scott Rand]

 

Your high school soccer player reports proximal medial ankle pain that has developed gradually since the start of preseason training.  You suspect she has a navicular stress fracture.  Which of the following clinical clues besides the history would lead you to this conclusion?  You may choose more than one answer

 

1. Tenderness at the N spot
2. significant pes planus
3. normal/negative x-rays of the foot
4. Pain when standing on toes

[Scott Rand]

A 50 year old female patient presents to your office with exertional pain in her right calf.  She has noted the pain during exercise for the past several weeks.  Which of the following historical and physical findings would you expect with a diagnosis of popliteal artery entrapment syndrome?

 

 

A.     Diminished foot pulses at rest

B.      Pain more closely associated with volume of exercise rather than intensity of exercise

C.      Slow resolution of symptoms at conclusion of exercise

D.     Patients may have normal pulses that disappear or decrease with plantar flexion or dorsiflexion of the foot

E.      Markedly elevated compartment pressure

 

[Scott Rand]

A patient presents to your office unable to dorsiflex his great toe.  Which of the following is true?

A.     The extensor hallucis longus which inserts on base of the distal phalanx of the great toe is the muscle responsible for extending the great toe

B.      The motor function for this is from L4 and L5

C.      The muscles that allow this action are all contained in the lateral compartment of the lower leg

D.     The muscles that allow this action are inervated by the tibialis anterior nerve