A 39-Year-Old Man with Ankle Pain and Stiffness

Test your diagnostic skills...

Background

A 39-year-old man presents to his primary care physician with a 6-month history of pain in his right ankle. The pain has been insidious, and it is accompanied by stiffness and swelling of the ankle joint. The patient cannot move his ankle well. Additionally, despite using a crutch, he cannot perform his daily activities. The patient has no history of trauma to the affected joint. There is no history of fever, back pain, or any other joint involvement. He has no history of sexually transmitted diseases, and his family history is negative for arthritis.

On physical examination, the patient has normal vital signs. The cardiac findings are negative for murmurs or rubs. No rash or penile discharge is observed. Examination of the right ankle elicits discomfort with passive range of motion, revealing limitations with inversion and eversion and with flexion and extension. On palpation, the patient has mild tenderness. There is obvious swelling of the joint, which feels firm. There is no warmth or redness over the joint. The remainder of the physical examination is unremarkable.

A plain radiograph of the ankle is obtained (see Image 1). After the results of the plain radiograph are interpreted, the primary care physician orders a follow-up magnetic resonance imaging (MRI) scan of the joint (see Images 2 through 4).



What is the diagnosis?

See Answer

Routine Screening Radiograph in a 60-Year-Old Smoker

Here's a way to check your diagnostic skills..

Background

A 60-year-old man presents to the emergency department (ED) for pain in the right side of his chest after accidentally tripping over a sidewalk curb and falling. The patient states that when he fell he hit the right side of his chest on the sidewalk. On the review of systems, the patient does not report any shortness of breath or difficulty breathing, but he does report occasionally having a dry cough. He states that he has had the cough “for quite some time,” and he attributes it to his 40-pack-year history of smoking cigarettes. On further questioning, he denies having any weight loss, hemoptysis, or shortness of breath.

On physical examination, the patient’s vital signs are noted to be normal and stable; his heart rate is 85 bpm, his blood pressure is 120/85 mm Hg, and he has an oxygen saturation of 99% while breathing room air. The patient is a man of moderate build in no apparent distress. He has normal breath sounds. The findings of the chest and abdominal examinations are unremarkable except for mild tenderness to palpation over the right chest wall; the general physical examination is otherwise unremarkable.



Chest radiographs are obtained to evaluate for possible injuries to the patient’s ribs and lungs. As a result of the radiographic findings (see Images 1-2), a complete blood count (CBC) and chemistry panel are ordered, but the results are unremarkable. The abnormality noted on the plain radiographs, combined with poor follow-up for the patient, prompts a contrast-enhanced computed tomography (CT) scan of the chest (Image 3).

Hint

The diagnosis is the most common benign tumor of the lung.

Answer

See Answer

Painless Penile Lesion in a 52-Year-Old Man

By Anthony
This is another one of those interesting Guess my diagnosis game. If you're up to it, check this out...

Background

A 52-year-old man with no clinically significant medical history presents to the emergency department (ED) with a chief complaint of a “rash” on his penis. The patient states that the rash first appeared 1 week before presentation. He denies any dysuria, urethral discharge, pruritus or pain in the area of the lesion. This is the first time he has had such a rash. He admits to having had several recent sexual partners.

On physical examination, his vital signs are normal. The patient has a well-demarcated, ulcerated lesion on the ventral aspect of his penis (see Image). The lesion is not tender to palpation. No other lesions are noted, and no discharge is observed from the urethra. The findings of his testicular examination are unremarkable, with the exception of bilateral prominent inguinal lymphadenopathy. The remaining physical findings, including the cardiac and abdominal findings, are unremarkable.

What do you think is the diagnosis, and what empiric treatment is necessary?

Hint

The lesion is characteristically painless.

Image



See Answer

A Toddler With Fever and Abdominal Tenderness

Who's work is much harder? Is it of the nurse or of the physician? Well, some say that the work of a nurse is much more difficult compared to a physician's, that is since physicians only tend to diagnose diseases while nurses take on the front line, which is where real labor takes place. Some might even go as far as saying that physicians always leave their work to nurses, nurses do the rounds while they go home to rest. Some others say that nurses have also studied medicine as part of their course curriculum and thus are also capable of diagnosing a patient.

Well, if the latter statement is correct... as a nurse, can you really diagnose a patient using your skills in critical thinking? Well, let's find out... Let's play guess my disease... Here we go...

Situation

A 14-month-old boy is brought to the emergency department (ED) by his parents for an evaluation of persistent fever, vomiting, and diarrhea that has lasted for 3 days. The mother states that the child was examined by his pediatrician 2 days before this presentation for a “viral illness“; however, the child has appeared increasingly ill since then. He has become irritable, and he has been minimally active and feeding poorly. He has had a normal stool output and appearance, as well as normal urination frequency. The parents deny observing a runny nose or any coughing, wheezing, or stridor in the patient. The child lives at home with his parents, he is not in day care, and he has had no contact with people who are sick.

On physical examination, the boy is crying, fussy, and poorly consoled. His vital signs include a rectal temperature of 101°F (38.33°C), a respiratory rate of 32 breaths/min, a blood pressure of 98/56 mm Hg, and a heart rate of 168 bpm. His oxygen saturation is 100% while he is breathing room air. The patient’s weight is 22 lb (10 kg). Palpation reveals diffuse abdominal tenderness without rigidity or guarding. The patient has diffusely hypoactive bowel sounds. His stool is negative for occult blood. The rest of the physical findings are otherwise unremarkable.

Conventional abdominal radiography and computed tomography (CT) scanning are performed (see image). The laboratory investigation reveals the following results: white blood cell (WBC) count, 19.4 × 109/L, with a predominance of neutrophils; hemoglobin, 8.4 g/dL; hematocrit, 26.6%; platelets, 310 × 109/L; sodium, 136 mmol/L; potassium, 3.8 mmol/L; chlorine, 105 mmol/L; CO₂, 20 mmol/L; blood urea nitrogen (BUN), 6 mmol/L; creatinine, 17.7 µmol/L (0.2 mg/dL); and glucose, 4.1 mmol/L (73 mg/dL). The urinalysis shows trace ketones, but the results are otherwise normal.


Hint

The patient’s symptoms developed approximately 2 days after the mother dropped a box of pins on the carpet at home.

Okay doc nurse... go figure... If you can figure what the diagnosis is, then that means you're not only an excellent nurse but a good doctor as well, if not... then just leave the work to a physician. lol.

See if your diagnosis is correct. See the answer.