Pain Is More Than a Symptom: A Photo Quiz

March 20, 2014

Pain affects more Americans than diabetes, heart disease, and cancer combined. It may be a part of a disease, or it may be the disease itself. Here, test your knowledge of this troubling diagnostic challenge.

Question 1:

A 33-year-old woman complained of frontotemporal headaches and neck pain without stiffness. Later, she presented with a worsening headache and nausea, vomiting, ankle pain with swelling, and fevers. A new rash appeared as erythematous, tender patches on the anterior aspect of her lower extremities. She returned with new-onset diffuse chest pain, abdominal pain, and worsening headache. Biopsy of lung tissue was significant for granulomatous disease.

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Question 2:

A 43-year-old man who recently had traveled to the Caribbean complained of fever, headaches, body aches, and rash all over his body. He denied any cough, sore throat, runny nose, vomiting, photophobia, or diarrhea. His symptoms all waxed and waned. The clinical presentation of his condition typically involves high spiking fevers associated with severe body aches.

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Question 3:

A woman had “refractory” right flank and abdominal pain that had not been relieved by a cholecystectomy. The pain worsened with inspiration and twisting movement or lying on her side. She also had had a cough productive of yellow phlegm and occasional blood that was the result of bronchitis. Her chest x-ray film shows an elevated right hemidiaphragm, a finding seen with pulmonary embolism.

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Question 4:

A 59-year-old woman with a history of peptic ulcer disease had mild, burning, and nonradiating pain in the epigastrium that worsened with food intake. She had nausea and some postprandial vomiting and a sensation of abdominal bloating and subjective weight loss. A succussion splash was heard over the upper abdomen. Upper endoscopy showed a normal gastric remnant and an ulcer at the anastomotic site and a large bezoar on the gastric side of anastomosis.

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Question 5:

A 24-year-old man with a recent diagnosis of HIV infection presented with a 24-hour history of left ear pain. There had been no suggestion of ear infection. Now his pain was worse and his ear was red and swollen. He felt dizzy and vomited twice as a result. He described the dizziness as a “spinning” feeling. There was 1+ erythema and swelling of the entire left auricle with multiple areas of superficial vesicles. The oropharynx was clear without thrush.

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Question 6:

Complex regional pain syndrome (CRPS) arises at least in part after some 30% of fractures and may occur after orthopedic surgery. Inflammatory processes and a pattern of disuse may be more important than previously thought. Early diagnosis and aggressive treatment are important.

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ANSWER KEY:

Question 1. A

Question 2. C

Question 3. E

Question 4. A

Question 5. D

Question 6. F