Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.
Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04
• HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
• Lung: clear to auscultation
• CV: regular sinus rhythms without murmur or gallop
• Abd: soft, non-tender, liver normal,
• Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
• VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
• Cervix: friable, some petechia no cervical motion tenderness.
• Uterus: mid mobile, non-tender
• Adnexa: without masses or tenderness
• Perineum: wnl
• Rectum: wnl
• Extremities: full rom, skin clear, no edema, reflexes 1+.
• Neurological: CN II-12 grossly intact.
- What other information do you need?
- What testing would you perform/order?
- What are your initial thoughts for diagnosis?
By Day 3
1) Based on the case study scenario provided, complete a comprehensive well-woman exam and critically analyze the exam to focus attention on the diagnostic tests. Then,
2) Post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask for. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)
3) Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.
This study has several limitations. The retrospective nature of this review resulted in the exclusion of patients who did not have appropriate documentation in the electronic medical record. However, the senior author began to prospectively collect these data early in the series. Patients in our study almost exclusively underwent a 2-incision transosseus fixation technique. An intact lacertus fibrosis may also confuse the examiner, highlighting the importance of actually “hooking” the tendon rather than simply palpating for a tendon in the antecubital fossa. The contralateral “normal” elbow should always be tested for comparison. The hook test/resisted hook test have been proven that are useful tools for the quick and definitive diagnosis of distal biceps tendon ruptures, with specificity (100%) and sensivity (100%) higher than MRI. We developed Algorithm that can guide clinical to diagnosing primary distal biceps tendon tears using hook and resisted hook tests. To avoid misunderstandings, the reader must pay close attention to our definitions. Biceps avulsions were defined as complete if there were no tissues in continuity between the end of the biceps tendon and the radial tuberosity, such that the tendon could be retrieved from the wound without surgical release of tissues. Thus, if any surgical release was required to retrieve the tendon from the wound, we did not consider the avulsion to be complete. Devereaux and ElMar- reported 100% specificity and sensitivity for the hook test to detect 30 acute biceps avulsions but reported 8 false negatives in 18 chronic avulsions. Unfortunately, they did not use the same definition for complete avulsions as we originally reported. They stated that “the presence of a pseudo-tendon, often seen in chronic presentations, can also provide a ‘hookable’ cord and be mistaken for an intact tendon.” Such a pseudotendon has to be surgically released to retrieve the tendon, and therefore, we would have defined those as partial, not complete, tears, and thus, they would not have been false positives according to the original definition. However, it is not the terminology, but the correct application of the definitions of any given clinical test, that matters in reporting the hook test. To this end, the replacement of our 2 original terms (normal and abnormal) with the 3 terms proposed herein (intact, abnormal, and absent) should hopefully avoid such confusion. CONCLUSIONS In conclusion, our results would suggest that the resisted hook test is very useful tool to diagnose both complete and partial tears of primary distal biceps tendon ruptures. We developed Algorithm that can guide clinical to diagnosing primary distal biceps tendon tears using hook and resisted hook tests. Hookable and not painful hook test suggest INTACT distal biceps tendon. An ABSENT resisted hook test indicates that it is complete distal biceps tendon rupture. ABNORMAL (Painful) hook test is indication of partial tears. However if examiner perform hook test that is unhookable and afterwards perform resisted hook test which is hookable tha>GET ANSWER