Mike is a 45 year old man who has worked as a labourer at one of the steel plants in Hamilton for years. The work requires frequent heavy lifting, particularly overhead. Mike smokes 1 pack of cigarettes per day. He has had a 1 year history of shoulder pain, which seems to be getting gradually worse. He has had to give up baseball and now is having trouble performing his job. He has not tried any treatment for his shoulder, other than Tylenol plain and icing it. On physical exam there is no muscle wasting. He is tender over the anterolateral aspect of the humeral head. Range of motion is good, but terminal flexion and abduction reproduce his typical pain. Muscle strength testing shows weakness in abduction, which also reproduces his typical pain. Provocative tests for impingement syndrome are positive, but provocative A-C joint and biceps tendon tests are negative. X-rays are done to evaluate the bony anatomy, and an ultrasound is performed to evaluate the rotator cuff.

Brock is a 25-year-old man who sustained a laceration to the upper third of his right forearm when he accidentally put his arm through a plate glass window. He presents to the emergency room. On examination, the ER physician finds Brock has significant weakness dorsal and palmar interossei, resulting in weakness of abduction and adduction of the index, middle and ring finger of the right hand.

Joshua is a 48-year-old man who suffered a motor vehicle accident while riding his motorcycle. Joshua was unable to stop in time at a red light and rear-ended into an SUV, causing him to be thrown from his motorcycle, landing on his right side. He has a large laceration to the lateral thigh. He also notices some weakness to certain movements of his right lower extremity. He is taken to the trauma centre and the physical exam reveals that he is unable to dorsiflex his ankle, evert the foot, and extend the toes on the right side. All other muscles are normal. On sensory examination, it is noted that sensation is slightly impaired over the front of the leg and foot. An x-ray reveals that he has sustained a mid-femur shaft non-displaced fracture.

Gayle Parker is a 12-year-old girl who was recently noted by her dance instructor to have shoulder asymmetry. She has no pain, neurological symptoms such as dysesthesias, or bladder/bowel dysfunction. The deformity has not changed since it was first noticed.Gayle has recently started her menses

Ryan Smith is a two week old baby brought to your office by his parents. He was noted to have bilateral feet abnormalities on prenatal ultrasound. Family is anxious and worried about whether the child "Will walk, play soccer etc." Physical exam show that both feet are adducted, supinated, equines and the hindfoot is in varus. The feet are moderately flexible but not completely correctable

Gayle Parker is a 12-year-old girl who was recently noted by her dance instructor to have shoulder asymmetry. She has no pain, neurological symptoms such as dysesthesias, or bladder/bowel dysfunction. The deformity has not changed since it was first noticed.Gayle has recently started her menses

Ryan Smith is a two week old baby brought to your office by his parents. He was noted to have bilateral feet abnormalities on prenatal ultrasound. Family is anxious and worried about whether the child "Will walk, play soccer etc." Physical exam show that both feet are adducted, supinated, equines and the hindfoot is in varus. The feet are moderately flexible but not completely correctable

Ronnie Olchuk is a 6-year-old boy who was hit by a car while crossing the street. A witness at the scene said he was hit on the left side and thrown approximately 20 m. He is healthy, has no allergies, and has never had surgery. He last ate eight hours ago. He has been stabilized by the trauma team, is alert and oriented, and has no injuries except to his right forearm and left thigh. His distal right forearm is badly deformed. His left thigh has a 2 cm laceration located medially and is also badly deformed. He is in excruciating pain, especially in the right forearm.

Ronnie Olchuk is a 6-year-old boy who was hit by a car while crossing the street. A witness at the scene said he was hit on the left side and thrown approximately 20 m. He is healthy, has no allergies, and has never had surgery. He last ate eight hours ago. He has been stabilized by the trauma team, is alert and oriented, and has no injuries except to his right forearm and left thigh. His distal right forearm is badly deformed. His left thigh has a 2 cm laceration located medially and is also badly deformed. He is in excruciating pain, especially in the right forearm.

Daniel Gatto is a 41-year-old stockbroker. Once a top level soccer player, he now plays the game only over weekends, though he is sometimes able to get out for his club's midweek practice session. He enters your walk-in clinic on a Tuesday morning, limping slightly and reporting that he has been having increasing problems with his right knee over the past month. The knee has been intermittently painful and has seemed swollen from time to time. He has also been concerned about what he describes as "a feeling of weakness" of the knee, as though it was about to "give way"

Ann Green is a 66-year-old woman who was referred to the rheumatology outpatient clinic by her family physician, Dr. Mac Grad. In his referral note, Dr. Grad states that Mrs. Green has been experiencing joint achiness for the past several years, involving mostly her hands and knees. From time to time, she has also reported low back pain. Her symptoms have always been relatively mild and have never stopped her from carrying on with her general daily activities or her charitable work in the community. What currently concerns Dr. Grad is that Mrs. Green's symptoms have progressed. Usually a rather stoic person, she is now complaining of increased pain in her fingers and both knees. Because of her knee pain, she is having increasing difficulty walking. Whereas previously her pain would always settle after she took some Tylenol, this is no longer the case. On physical examination, Dr. Grad elicits tenderness at several of the proximal (PIP) and distal interphalangeal (DIP) joints of both hands and at the carpometacarpal joint of the left thumb. Heberden's nodes are evident at the DIP joints bilaterally. Tenderness is also present at the joint lines of both knees; and there is (chronic) puffiness on both sides, but more pronounced on the left. Knee flexion is reduced and there is bony crepitus. Radiographs demonstrate osteoarthritic changes at the wrists, the PIP and DIP articulations of the fingers, and moderately severe (tri-compartmental) degenerative changes at both knees.

Mike is a 45 year old man who has worked as a labourer at one of the steel plants in Hamilton for years. The work requires frequent heavy lifting, particularly overhead. Mike smokes 1 pack of cigarettes per day. He has had a 1 year history of shoulder pain, which seems to be getting gradually worse. He has had to give up baseball and now is having trouble performing his job. He has not tried any treatment for his shoulder, other than Tylenol plain and icing it. On physical exam there is no muscle wasting. He is tender over the anterolateral aspect of the humeral head. Range of motion is good, but terminal flexion and abduction reproduce his typical pain. Muscle strength testing shows weakness in abduction, which also reproduces his typical pain. Provocative tests for impingement syndrome are positive, but provocative A-C joint and biceps tendon tests are negative. X-rays are done to evaluate the bony anatomy, and an ultrasound is performed to evaluate the rotator cuff.

Mike is a 45 year old man who has worked as a labourer at one of the steel plants in Hamilton for years. The work requires frequent heavy lifting, particularly overhead. Mike smokes 1 pack of cigarettes per day. He has had a 1 year history of shoulder pain, which seems to be getting gradually worse. He has had to give up baseball and now is having trouble performing his job. He has not tried any treatment for his shoulder, other than Tylenol plain and icing it. On physical exam there is no muscle wasting. He is tender over the anterolateral aspect of the humeral head. Range of motion is good, but terminal flexion and abduction reproduce his typical pain. Muscle strength testing shows weakness in abduction, which also reproduces his typical pain. Provocative tests for impingement syndrome are positive, but provocative A-C joint and biceps tendon tests are negative. X-rays are done to evaluate the bony anatomy, and an ultrasound is performed to evaluate the rotator cuff.

Ann Green is a 66-year-old woman who was referred to the rheumatology outpatient clinic by her family physician, Dr. Mac Grad. In his referral note, Dr. Grad states that Mrs. Green has been experiencing joint achiness for the past several years, involving mostly her hands and knees. From time to time, she has also reported low back pain. Her symptoms have always been relatively mild and have never stopped her from carrying on with her general daily activities or her charitable work in the community. What currently concerns Dr. Grad is that Mrs. Green's symptoms have progressed. Usually a rather stoic person, she is now complaining of increased pain in her fingers and both knees. Because of her knee pain, she is having increasing difficulty walking. Whereas previously her pain would always settle after she took some Tylenol, this is no longer the case. On physical examination, Dr. Grad elicits tenderness at several of the proximal (PIP) and distal interphalangeal (DIP) joints of both hands and at the carpometacarpal joint of the left thumb. Heberden's nodes are evident at the DIP joints bilaterally. Tenderness is also present at the joint lines of both knees; and there is (chronic) puffiness on both sides, but more pronounced on the left. Knee flexion is reduced and there is bony crepitus. Radiographs demonstrate osteoarthritic changes at the wrists, the PIP and DIP articulations of the fingers, and moderately severe (tri-compartmental) degenerative changes at both knees.

Mike is a 45 year old man who has worked as a labourer at one of the steel plants in Hamilton for years. The work requires frequent heavy lifting, particularly overhead. Mike smokes 1 pack of cigarettes per day. He has had a 1 year history of shoulder pain, which seems to be getting gradually worse. He has had to give up baseball and now is having trouble performing his job. He has not tried any treatment for his shoulder, other than Tylenol plain and icing it. On physical exam there is no muscle wasting. He is tender over the anterolateral aspect of the humeral head. Range of motion is good, but terminal flexion and abduction reproduce his typical pain. Muscle strength testing shows weakness in abduction, which also reproduces his typical pain. Provocative tests for impingement syndrome are positive, but provocative A-C joint and biceps tendon tests are negative. X-rays are done to evaluate the bony anatomy, and an ultrasound is performed to evaluate the rotator cuff.

Ann Green is a 66-year-old woman who was referred to the rheumatology outpatient clinic by her family physician, Dr. Mac Grad. In his referral note, Dr. Grad states that Mrs. Green has been experiencing joint achiness for the past several years, involving mostly her hands and knees. From time to time, she has also reported low back pain. Her symptoms have always been relatively mild and have never stopped her from carrying on with her general daily activities or her charitable work in the community. What currently concerns Dr. Grad is that Mrs. Green's symptoms have progressed. Usually a rather stoic person, she is now complaining of increased pain in her fingers and both knees. Because of her knee pain, she is having increasing difficulty walking. Whereas previously her pain would always settle after she took some Tylenol, this is no longer the case. On physical examination, Dr. Grad elicits tenderness at several of the proximal (PIP) and distal interphalangeal (DIP) joints of both hands and at the carpometacarpal joint of the left thumb. Heberden's nodes are evident at the DIP joints bilaterally. Tenderness is also present at the joint lines of both knees; and there is (chronic) puffiness on both sides, but more pronounced on the left. Knee flexion is reduced and there is bony crepitus. Radiographs demonstrate osteoarthritic changes at the wrists, the PIP and DIP articulations of the fingers, and moderately severe (tri-compartmental) degenerative changes at both knees.

Ann Green is a 66-year-old woman who was referred to the rheumatology outpatient clinic by her family physician, Dr. Mac Grad. In his referral note, Dr. Grad states that Mrs. Green has been experiencing joint achiness for the past several years, involving mostly her hands and knees. From time to time, she has also reported low back pain. Her symptoms have always been relatively mild and have never stopped her from carrying on with her general daily activities or her charitable work in the community. What currently concerns Dr. Grad is that Mrs. Green's symptoms have progressed. Usually a rather stoic person, she is now complaining of increased pain in her fingers and both knees. Because of her knee pain, she is having increasing difficulty walking. Whereas previously her pain would always settle after she took some Tylenol, this is no longer the case. On physical examination, Dr. Grad elicits tenderness at several of the proximal (PIP) and distal interphalangeal (DIP) joints of both hands and at the carpometacarpal joint of the left thumb. Heberden's nodes are evident at the DIP joints bilaterally. Tenderness is also present at the joint lines of both knees; and there is (chronic) puffiness on both sides, but more pronounced on the left. Knee flexion is reduced and there is bony crepitus. Radiographs demonstrate osteoarthritic changes at the wrists, the PIP and DIP articulations of the fingers, and moderately severe (tri-compartmental) degenerative changes at both knees.

Part One: A thin 65-year-old woman presents complaining of back pain that began 5 days ago while lifting her wash. The pain becomes worse when she rolls over in bed or when she stands up. She has noticed that the hems of her skirts seem longer and on measurement she appears to have lost 6 cm in height. Part Two: The patient reports she got over that last "attack" after around 3 months. She was commenced on a bisphosphonate, calcium, and vitamin D. She now returns 2 years later because of another attack of acute back pain after falling on the ground.

Part One: A thin 65-year-old woman presents complaining of back pain that began 5 days ago while lifting her wash. The pain becomes worse when she rolls over in bed or when she stands up. She has noticed that the hems of her skirts seem longer and on measurement she appears to have lost 6 cm in height. Part Two: The patient reports she got over that last "attack" after around 3 months. She was commenced on a bisphosphonate, calcium, and vitamin D. She now returns 2 years later because of another attack of acute back pain after falling on the ground.

Diane Bainbridge, a 32 year old woman, complains of fatigue and weakness, lower back, and hip pain which she describes as a gnawing ache. She has noticed that this has become progressively worse over the past few months and she finds that getting up from a chair is difficult. She has noticed that her gait has changed. She has known celiac disease and has had associated weight loss and intermittent diarrhea

Part One: A thin 65-year-old woman presents complaining of back pain that began 5 days ago while lifting her wash. The pain becomes worse when she rolls over in bed or when she stands up. She has noticed that the hems of her skirts seem longer and on measurement she appears to have lost 6 cm in height. Part Two: The patient reports she got over that last "attack" after around 3 months. She was commenced on a bisphosphonate, calcium, and vitamin D. She now returns 2 years later because of another attack of acute back pain after falling on the ground.

Diane Bainbridge, a 32 year old woman, complains of fatigue and weakness, lower back, and hip pain which she describes as a gnawing ache. She has noticed that this has become progressively worse over the past few months and she finds that getting up from a chair is difficult. She has noticed that her gait has changed. She has known celiac disease and has had associated weight loss and intermittent diarrhea

Diane Bainbridge, a 32 year old woman, complains of fatigue and weakness, lower back, and hip pain which she describes as a gnawing ache. She has noticed that this has become progressively worse over the past few months and she finds that getting up from a chair is difficult. She has noticed that her gait has changed. She has known celiac disease and has had associated weight loss and intermittent diarrhea

Part One: A thin 65-year-old woman presents complaining of back pain that began 5 days ago while lifting her wash. The pain becomes worse when she rolls over in bed or when she stands up. She has noticed that the hems of her skirts seem longer and on measurement she appears to have lost 6 cm in height. Part Two: The patient reports she got over that last "attack" after around 3 months. She was commenced on a bisphosphonate, calcium, and vitamin D. She now returns 2 years later because of another attack of acute back pain after falling on the ground.

Diane Bainbridge, a 32 year old woman, complains of fatigue and weakness, lower back, and hip pain which she describes as a gnawing ache. She has noticed that this has become progressively worse over the past few months and she finds that getting up from a chair is difficult. She has noticed that her gait has changed. She has known celiac disease and has had associated weight loss and intermittent diarrhea

Richard Strang, a 50-year-old male with a two-day history of sudden onset of acute pain and swelling of the left great toe, is seen at his family physician's office. It seemed to suddenly start when he awoke two days ago. It is so painful that he could not even tolerate the bed-sheet touching it. Richard works in construction, and routinely enjoys a few beers at the end of the day with his buddies. He had a similar attack in the right knee about 3 months ago, and right 1st MTP about 6 months. He was told that he had "the gout".

Joan Spaulding is a 32 year old lady who arrives at your clinic with a history of joint pains in the hand. The pain in her hands was predated by a viral flu that manifested itself as generalized arthralgias and fatigue. The pain has been ongoing for 10 weeks and transformed itself from generalized arthralgias to symptoms in the hands and feet associated with morning stiffness that lasts approximately 1 hour.

Jane Young is a 3 1/2 year-old girl, brought to the Pediatric Medicine Clinic by her mother. For the past 10 days, her right knee has been swollen and stiff. There was no preceding trauma. She seems to have most symptoms in the morning, getting better when she is up and about playing. She seems to have less energy since the swelling was first noted. Her mother has been giving her children's Tylenol but has not noticed any improvement in her symptoms. Her mother thinks her ankles are also "puffy" at times. On examination, Jane appears well, afebrile and is on the 50th percentile for height and weight. No fever or skin rashes. Cardiovascular, respiratory and abdominal examinations unremarkable. Right knee is swollen, warm and effused and Jane stands with this knee slightly flexed. There are mild effusions of both ankles which are also slightly swollen. The pediatrician decides to order a few investigations. Baseline CBC, renal and liver function is unremarkable. ESR moderately elevated at 30. Rheumatoid Factor is negative, but Antinuclear Antibody (ANA) is positive at 1:160.

Joan Spaulding is a 32 year old lady who arrives at your clinic with a history of joint pains in the hand. The pain in her hands was predated by a viral flu that manifested itself as generalized arthralgias and fatigue. The pain has been ongoing for 10 weeks and transformed itself from generalized arthralgias to symptoms in the hands and feet associated with morning stiffness that lasts approximately 1 hour.

Joan Spaulding is a 32 year old lady who arrives at your clinic with a history of joint pains in the hand. The pain in her hands was predated by a viral flu that manifested itself as generalized arthralgias and fatigue. The pain has been ongoing for 10 weeks and transformed itself from generalized arthralgias to symptoms in the hands and feet associated with morning stiffness that lasts approximately 1 hour.

Part One: Jake Gamble, an obese 65-year-old man, presents complaining of back pain that began 5 days ago while shovelling snow. The pain becomes worse when he stands. Part Two: The patient reports he got over that last "attack" in less than a week but has had low back pain ever since. He now returns 2 years later because of another attack of acute back pain after chopping wood. Part Three: The patient returns in 6 weeks because the pain has not decreased. His legs feel "heavy," and he has had some incontinence in the last week.

Part One: Jake Gamble, an obese 65-year-old man, presents complaining of back pain that began 5 days ago while shovelling snow. The pain becomes worse when he stands. Part Two: The patient reports he got over that last "attack" in less than a week but has had low back pain ever since. He now returns 2 years later because of another attack of acute back pain after chopping wood. Part Three: The patient returns in 6 weeks because the pain has not decreased. His legs feel "heavy," and he has had some incontinence in the last week.

Fred Newman, a 32-year-old man, complains of severe low back pain of gradual onset over the past few years. The pain is much worse in the morning and gradually decreases during the day. He denies fever or weight loss but does feel fatigued.

Joan Spaulding is a 32 year old lady who arrives at your clinic with a history of joint pains in the hand. The pain in her hands was predated by a viral flu that manifested itself as generalized arthralgias and fatigue. The pain has been ongoing for 10 weeks and transformed itself from generalized arthralgias to symptoms in the hands and feet associated with morning stiffness that lasts approximately 1 hour.

David Beatty is a 5 year old boy brought to his family doctor by his mother. She is concerned about his clumsiness. He had always been a little 'slow' with his gross-motor milestones. His mother recalled that he did not start walking until he was 20 months old. As he has gotten older, he has seemed less able to keep up with other children his age. As an example she explains that she sees other kindergarten children at the school playground who all seem to be able to run, climb and hop without difficulty. But not David. He is slow, cannot climb well, and falls very often. He also tires out quickly. She worries that maybe he has a problem with the bones in his legs, or maybe a problem with his hips. On examination, David is 111 cm tall (50th percentile), weighs 21 kg (75th percentile), and has a head circumference of 52 cm (75th percentile). He is a happy boy and is eager to tell stories about his teacher and classmates. When standing he has a prominent lordotic curve to his back. He has difficulty climbing up on the examination table, but insists on doing it himself. His heart, lungs and abdomen appear normal. His joints have full range of motion and he does not appear to have any joint or bone pain. His muscle bulk appears to be good - in fact he has large, muscular-looking calves. His deep tendon reflexes are normal (grade 2 out of 4).