DDx Like House MD

Ddx like House MD

To be able to Ddx (differentially diagnose) like House MD you have to practice. This is a practice case to help hone your differential diagnosis skills. The following cases are meant to function as practice cases for students within medicine, neurology, chiropractic, osteopathy or similar healthcare professions which are involved in diagnosing medical and neurological pathology. I have many similar practice cases, just have a look at the articles on my profile page.

Be forewarned that the answers to the case is listed at the bottom of this article. Good luck!

1.

A 65-year-old male presents with buttock pain aggravated by walking. You find trigger points in the gluteus medius muscle.

If you were thinking: Myofascial pain

And then you find: A bruit over the aortoiliac artery

This hypothesis becomes: -2 (Very unlikely) -1 (Unlikely) 0 (Unchanged) +1 (More likely) +2 (Almost certain)

2.

A 25-year-old male patient presents with low back pain and morning stiffness lasting for 1 hour.

If you were thinking: Reiter’s disease

And then you find: He also has urethritis and is positive for HLA-B27

This hypothesis becomes: -2 -1 0 +1 +2

3.

Statement: ... "In a 4 year old child with hip pain, the following are likely differentials" ...:

1. Leg-Calve-Perthes disease
2. Transient synovitis
3. Slipped upper femoral epiphysis

Answer options:

A None of the answers are true

B Answer i) only is true

C Answer ii) only is true

D Answer iii) only is true

E Answers i) and ii) only are true

F Answers i) and iii) only are true

G Answers ii) and iii) only are true

H All of the answers are true

4.

Statement: ... "In a patient with a stress fracture of the hip the following examination findings are likely" ... :

1. Pain at end range PROM
2. Pain on the Anvil test
3. Normal plain radiographs

Answer options:

A None of the answers are true

B Answer i) only is true

C Answer ii) only is true

D Answer iii) only is true

E Answers i) and ii) only are true

F Answers i) and iii) only are true

G Answers ii) and iii) only are true

H All of the answers are true

5.

The following are likely causes of anteriorly located hip/groin pain:

1. Meralgia paresthetica
2. Trochanteric bursitis
3. Hip DJD

Answer options:

A None of the answers are true

B Answer i) only is true

C Answer ii) only is true

D Answer iii) only is true

E Answers i) and ii) only are true

F Answers i) and iii) only are true

G Answers ii) and iii) only are true

H All of the answers are true

6.

• A 20-year old man presents with bilateral buttock pain which extends into the posterior thighs and bilateral heel pain. On examination he has a marked thoracic kyphosis and limitation of chest expansion. ESR and CRP were raised. The most likely diagnosis is:

1. Lumbar disc herniation
2. Sacro-ilitis
3. Spondylolisthesis
4. Spinal stenosis
5. Ankylosing spondylitis
6. Abdominal aortic aneurysm
7. TB
8. MFTP in latissimus dorsi
9. RA

7

• A 60-year-old woman presents and 2 year history of bilateral and gradually worsening, knee pain, stiffness and swelling onset for no apparent reason. The stiffness is worse in the morning and lasts 30 minutes. The pain is worse at the end of the day. Knee x-rays shows narrowing of the medial joint spaces, osteophytes at the margins of the joints and sclerosis of the underlying bone. The most likely diagnosis is:

1. Rheuamtoid arthritis
2. Osteoarthritis
3. Gout
4. Infective arthritis
5. Polymyalgia rheumatica
6. CPPD
7. Patellofemoral pain syndrome

8

A 20-year-old man complains of a deep aching pain in the shoulder and axilla, and slight tingling/numbness of the inner side of his right forearm. On examination the small muscles of the hand appear wasted, abductor pollicis brevis is particularly weak on resistive testing.

From the following, which is the most likely diagnosis?

A Damage to the lower trunk of the brachial plexus

B Damage to the upper trunk of the brachial plexus

C Median nerve lesion

D Radial nerve lesion

E T1 lesion

F Ulnar nerve lesion

9.

Case: A 20-year-old man complains of a deep aching pain in the shoulder and axilla, and slight tingling/numbness of the inner side of his right forearm. On examination the small muscles of the hand appear wasted, abductor pollicis brevis is particularly weak on resistive testing.

Which one of the following is NOT a possible cause of the lesion?

A Cervical rib

B Neurofibroma

C Cervical spondylosis

D Non-Hodgkins Lymphoma

E Neurogenic thoracic outlet syndrome

F Cubital tunnel syndrome

10

A 40-year-old policeman complains of pain, numbness and tingling in the lateral aspect of his right thigh. The symptoms are worse on standing and relieved by sitting down. He finds it is worse when he is on the beat wearing his duty belt. His medical history is positive for insulin dependent diabetes mellitis. On examination there is no objective motor weakness in the lower limb.

Which one of the following is the most likely site of the neurological lesion?

A Common peroneal nerve

B Femoral nerve

C Obturator nerve

D Lateral femoral cutaneous nerve of the thigh

E L3 nerve root

F S1 nerve root

11.

A 40-year-old policeman complains of pain, numbness and tingling in the lateral aspect of his right thigh. The symptoms are worse on standing and relieved by sitting down. He finds it is worse when he is on the beat wearing his duty belt. His medical history is positive for insulin dependent diabetes mellitis. On examination there is no objective motor weakness in the lower limb.

Which one of the following tests will give the most useful information to aid your diagnosis?

A Deep tendon reflexes for the lower limb

B Sensation testing for the lower limb

C SLR

D Slumps test

E Pectineus stretch test

F Side lying passive hip extension

12

Theme: Investigation of a swollen knee

Case: A 27-year old woman complains of pain and swelling around her right knee and calf. She thinks the onset might be associated with twisting her ankle whilst rushing to catch her flight home from America 2 days ago. On examination the calf is warm on palpation. Lower limb pulses are normal. The most useful further investigation is:

Options:

1. Plain x-ray
2. MRI scan
3. CT scan
4. Doppler ultrasound
5. Diagnostic musculoskeletal ultrasound
6. ESR
7. Rheumatoid factor
8. HLA B-27
9. Arthrocentesis

13.

Using the options above (Q12 & Q13 answer options):

A 39-year-old woman with rheumatoid arthritis presents with posterior knee and leg pain. She says that it came on suddenly whilst walking her dog earlier today when she felt something “pop” in her knee. On examination she has swelling in the popliteal fossa and upper calf. Movements of the knee joint were painful and restricted. The most useful further investigation is:

14.

For each of the nerve tension tests, choose the nerve that is being tested from the options above. Each option may be used once, more than once or not at all.

1. Prone knee bend with hip extension.
2. SLR with foot plantar flexion and inversion.
3. Ankle dorsiflexion with foot eversion.
4. SLR with ankle dorsiflexion and foot inversion.
5. Prone hip extension with abduction and external rotation.
6. Side lying hip extension with adduction and internal rotation.

Options:

1. Common peroneal nerve
2. Femoral nerve
3. Saphenous nerve
4. Posterior tibial nerve
5. Sural nerve
6. Sciatic nerve
7. Lateral femoral cutaneous nerve
8. Obturator nerve

15.

Your patient is a 56-year-old carpenter who fell from a ladder injuring his right knee.

If you were thinking: You should x-ray the patient

And then you find: If the patient had an immediate inability to bear weight and on examination there is tenderness of the fibular head and an inability to flex the knee to 90 degrees

This hypothesis becomes: -2 -1 0 +1 +2

16.

• Which of the following is the most sensitive test to determine ACL laxity in a 27 year old athlete with recent knee injury?

1. Anterior draw test
2. Posterior draw test
3. Lachman test
4. Observation for a sag sign
5. Resisted knee ROM

17

• An 18-year-old male presents with a swollen, stiff and painful knee. He reports that yesterday he twisted his knee suddenly whilst playing football the but was able to get up and continued to play after a few minutes. The knee swelled up overnight and now he can hardly move it. What is the most probable cause?

1. Medial meniscus tear
2. ACL tear
3. MCL tear
4. PCL tear
5. Fracture

18.

The following are true of osteoid osteoma:

1. It has a 17% chance of undergoing malignant degeneration
2. It presents with severe pain that is commonly relieved by asprin
3. It is common in adults over 40 years old

Options:

A None of the answers are true

B Answer i) only is true

C Answer ii) only is true

D Answer iii) only is true

E Answers i) and ii) only are true

F Answers i) and iii) only are true

G Answers ii) and iii) only are true

H All of the answers are true

19.

The following are true of bone metastasis:

1. Breast cancer is the most common cause of bone metastasis in women
2. Radiological changes are seen early
3. Prostate cancer commonly causes osteolytic lesions

Answer options:

A None of the answers are true

B Answer i) only is true

C Answer ii) only is true

D Answer iii) only is true

E Answers i) and ii) only are true

F Answers i) and iii) only are true

G Answers ii) and iii) only are true

H All of the answers are true

20.

Case: A 50-year-old female presents with burning in the feet as her main complaint. She also has aching and tingling in the feet as well.

If you were thinking: Diabetes

And then you find: Fasting plasma glucose level is > 8 mmol/L

This hypothesis becomes: -2 -1 0 +1 +2

Answers:

1. -1
2. +2
3. E
4. H
5. D
6. 5
7. 2
8. E
9. F
10. D
11. B
12. D
13. E
14. Look this up
15. +2
16. C (3)
17. A
18. C
19. B
20. +2

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