Bedside Diagnostic Challenge – A 53-year-old woman with acute onset of pain and swelling of the left leg.

Paul Griner, MD, MACPBedside Diagnostic Challenge, Emergency Medicine, Family Medicine, Internal Medicine, Nurse Practitioner, Nursing RN/PN, Pediatric Medicine

bedside diagnosis ruptured baker's cyst case

Bedside Diagnostic Challenge

A 53-year-old woman with a 6-month history of morning stiffness presents with acute onset of pain and swelling of the left leg.

Test your bedside diagnostic skills with this free clinical case question.

Patient Case:

A 53-year-old woman with a 6-month history of morning stiffness involving her wrist, fingers, and knees presents with the acute onset of pain and swelling of the left leg, more pronounced on walking.

She states that she has had a large, soft lump in the back of the left knee for some weeks. It was not painful but it did restrict her ability to flex the leg. There was no trauma preceding the swelling. She has not been on any trips where she was seated for long periods.

Her joint symptoms are partially relieved with non-steroidal analgesics. She finds that taking one Motrin in the morning, before getting up, gives partial relief of the pain and stiffness in the fingers.

The patient has otherwise been in good health. She takes no medications other than the non-steroidal, does not smoke, and enjoys a glass of wine before dinner each evening.

On physical examination, vital signs are:

  • Temperature: 98.2 F.
  • Blood Pressure: 118/70 mm Hg
  • Pulse: 76 and regular
  • Respirations: 16 per minute

The patient does not appear ill but is obviously uncomfortable when walking.

Physical examination reveals mild swelling and tenderness of two of the proximal interphalangeal joints of the left hand and three on the right.

There is slight limitation of motion of these joints.

There are no abnormal findings on examination of the lungs, heart, or abdomen.

The left leg is swollen to the knee. The swelling is firm, warm, and tender and is most pronounced in the posterior compartment of the leg below the knee. The swelling does not pit.

There are no other physical findings.

    Question:

    Based on the diagnostic value of careful examination...

    Which of the following is the most likely explanation of the leg swelling?

    Answer Options:

    Thrombophlebitis

    Non-Hodgkin’s lymphoma

    Ruptured Baker’s Cyst

    Achilles tendonitis

    See the Answer:


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    About The Bedside Diagnostics Blog Series:

    Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most physicians will spend the bulk of their professional time with patients in an office setting.

    Here is where finely tuned clinical skills are most important in leading to accurate diagnoses, fewer complications resulting from unnecessary tests and procedures, and lower costs. These Bedside Diagnostic Challenges reinforces the value of these clinical skills and tests users on their knowledge of them.

    Bedside Diagnostic Challenge questions are issued periodically every month as a free benefit of Med-Challenger.

    Subscribe to the Med-Challenger blog for more Diagnostic Challenge blogs and other free clinical content from Med-Challenger.

    About the Author:

    Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He has served the University of Rochester School of Medicine as Chief Resident in Medicine and as Professor, Department of Medicine. He has served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine. Dr. Griner is board certified in internal medicine.