Pain Presents in All Shapes and Sizes: A Photo Quiz

November 22, 2013

Pain has a wide variety of presentations, often making the diagnosis a significant challenge. Test your knowledge of signs and symptoms in this week's photo quiz.

Question 1:

A 22-year-old woman presented with severe pain and mild pruritus in all the toes on both feet. Her feet had gotten very cold while hiking in temperatures as low as 4.4°C (40°F) but felt better when warmed at night. Most toes had moderate erythema with some trace edema. The skin was intact without lesions, blisters, or ulcerations.

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Question 2:

A 46-year-old man with a history of HIV infection presented with left flank pain. A lateral x-ray film of his lumbar spine shows erosion of the anterior vertebral end plates both above and below the involved disc space, consistent with discitis.

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Question 3:

A 40-year-old man complained about a severely painful bump on his ear. He had trouble sleeping on that side because of the pain that occurred when he laid his head (and ear) down on the pillow. He had not had skin cancer and did not wear a helmet at work or during recreation.

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Question 4:

In patients with acute gout, severe pain, redness, and swelling develop rapidly and inflammation peaks within 1 day. When the attack occurs in the toe or foot, patients often cannot wear socks, and even the mere touch of a bed sheet may cause extreme pain.

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Question 5:

An obese woman in her thirties with a history of fibromyalgia, depression, polycystic ovarian syndrome, and diabetes presented with gradually worsening midline back pain. She had been constipated and had difficulty with urinating. Both legs had started to feel “wobbly” and numb. This MRI scan showed a spinal epidural abscess (white arrow).

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Question 6:

A 54-year-old traveling salesman sought medical attention for the acute onset of a painful scrotal rash. He had never experienced anything similar. Examination revealed grouped, crusted erosions on the scrotal skin. He also had ipsilateral, tender inguinal adenopathy.

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ANSWER KEY:

Question 1. A

Question 2. B

Question 3. C

Question 4. D

Question 5. A

Question 6. D