A 73-year-old man complains of right leg pain of 2 years’ duration...

A 73-year-old man complains of right leg pain of 2 years’ duration. There is no history of falls or injury. In the past he has been admitted to hospital for cardiac failure and takes inhaled bronchodilators and steroids for chronic obstructive pulmonary disease.
Examination shows a healthy elderly man with mild tenderness of his right leg only.
Routine blood tests show normal serum calcium and phosphate levels with a markedly raised alkaline phosphatase level.

What is the most likely diagnosis?
A. Osteoartritis of the hip
B. Bony metastasis from an occult malignancy
C. Multiple myeloma
D. Paget’s disease
E. Osteomalacia

Answer:

A 55-year-old woman known to suffer from severe disabling Rheumatoid arthritis has a 12-month history of dyspnoea.

A 55-year-old woman known to suffer from severe disabling Rheumatoid arthritis has a 12-month history of dyspnoea. She has also had a dry cough for that time. She has never smoked and has never been employed.
Examination shows a woman of average build with severe hand deformities and nodules at the elbow. Cardiovascular examination is normal.
Respiratory examination reveals a diffuse expiratory wheeze.
Routine blood tests, a CXR and an electrocardiogram (ECG) are all normal.

What is the most likely reason for her symptoms?
A. Bronchiolitis obliterans
B. Chronic obstructive pulmonary disease
C. Bronchiectasis
D. Asthma
E. Pleural effusion


Answer:

Septic Arthritis Following an Ear Infection....

A 25-year-old man presents in the casualty department with a two-day history of a painful and swollen left knee. He is pyrexial with a temperature of 38.5 °C. Examination of his cardiovascular and respiratory system is normal. An abdominal examination is normal. He also mentions that he developed a painful right ear and saw his doctor five days ago who told him he had an infected ear and prescribed antibiotics. His left knee is swollen, red, tender and slightly flexed. A diagnosis of septic arthritis is made.

What is the most likely causative organism?
A. Streptococcus viridans
B. Staphylococcus epidermidis
C. Staphylococcus aureus
D. Escherichia coli
E. Neisseria meningitides

Answer:

A 44-year-old male presents to the emergency room with an acutely swollen right knee

A 44-year-old male presents to the emergency room with an acutely swollen right knee. He has been in good health, and he has no chronic health conditions and no history of trauma. 

The most important evaluation should be:
A. MRI of the knee
B. Erythrocyte sedimentation rate
C. Diagnostic arthrocentesis of the knee
D. Complete blood count
E. Rheumatoid factor

Answer:

Rheumatic Fever - Long Case Study

Presenting complains:  18 years old female presents with the complains of:
- Migrating polyarthritis involving bigger joints (knee, ankle, elbow) for … days
-  Fever for … days
- Palpitation, chest pain … for days
- Malaise, weakness, fatigue for … days

History of presenting complains: According to the patient’s statement, she was quite fit and well … days back. Then she suffered from sore throat from which she recovered completely within a few days. After … days, she developed severe joint pain. Initially, it involved the right knee joint, but then sequentially the right ankle, left knee, left ankle and elbow joints were involved. The joints are
swollen, red and very painful, even with mild movement. The smaller joints are not involved. There
was no morning stiffness.
The patient also complains of fever, which is high grade, continued and reduces with antipyretic
drugs. It is not associated with chill and rigor, but there is profuse sweating. She also complains of
palpitation, chest pain, malaise, fatigue, weakness during her disease period. There is no history of
abnormal or involuntary movement (chorea) or skin changes. Her bowel and bladder habits are
normal. She denied any history of diarrhea, sexual exposure, skin rash, mouth ulcer, uveitis or any
urinary complaint.

General Physical Examination: 
- Appearance: Ill looking
-  Built: average
- Nutrition: average
-  Anemia: mildly anemic
- No jaundice, cyanosis, clubbing, leukonychia, koilonychia, edema or dehydration.
-  No lymphadenopathy, thyromegaly, etc

Vitals:
- Pulse: 110/min
-  BP: 130/75 mm Hg
-  Temperature: 39°C
-  Respiratory rate: 24/min

Cardiovascular examination ; Normal with no murmurs audible.

Loco-motor examination: (Knee joint involved)
Swollen and red with increased local temperature. Extremely tender on  palpation and restricted movements due to pain.

Other systemic examination ; Normal

Provisional Diagnosis: Acute Rheumatic Fever

Differential Diagnosis: 

A man in surgical ward develops excruciating pain in his right ankle joint, a day after cholecystectomy.

You are asked to see a 50-year-old man in the surgical ward at 6 am who underwent an uncomplicated cholecystectomy for gallstones the day before. He has developed excruciating pain in his left ankle joint. He has a history of angina and hypertension for which he takes bendroflumethiazide (bendrofluazide) and aspirin.
Examination of his cardiovascular and respiratory system is unremarkable, as is his abdomen. His left ankle is red, warm, swollen and tender. Routine blood tests show mildly impaired renal function.

What is the most likely diagnosis?
A. Cellulitis
B. Deep vein thrombosis
C. Septic arthritis
D. Gout
E. Rheumatoid arthritis


Answer:

A 58-year-old woman is admitted to hospital with a history of general muscle weakness of 12 months’ duration.

A 58-year-old woman is admitted to hospital with a history of general muscle weakness of 12 months’ duration. She also gives a history of pain in the small joints of her hand, which she has
had for more than 18 months. In addition, there is a history of difficulty swallowing.
Examination is normal except for tenderness of her upper arms and swelling of the small joints of her hands.
Her erythrocyte sedimentation rate (ESR) is 60 mm in 1 hour, her haemoglobin is 9.5 g/dl, and
her mean corpuscular volume (MCV) and mean cell haemoglobin concentration (MCHC) are
normal. Serum antinuclear antibodies and rheumatoid factor are positive. Creatine kinase is also
raised.

What is the most likely diagnosis?

A. RA
B. Sjögren syndrome
C. Polymyalgia rheumatic
D. Mixed connective tissue disease
E. Polymyositis

Answer:

What is the most common cause of sudden death, besides trauma, in an athlete less than 35 years of age?

What is the most common cause of sudden death, besides trauma, in an athlete less than 35 years of age?
A. Coronary artery disease
B. Hypertrophic cardiomyopathy
C. Status asthmaticus
D. Hyperthermia
E. Electrocution from lightning

Answer

Regarding Rheumatoid Pleural Effusion...

A 43-year-old man with a past history of hypothyroidism presents with a 3-month history of
pain and stiffness in the joints of his hands and feet. He also gives a history of dyspnoea, which
started 6 weeks ago. Examination shows swollen hand joints and signs of a right pleural effusion.
A diagnosis of RA is made. Which one of the following is characteristic of a rheumatoid pleural
effusion?

A. It is a transudate
B. It has a low glucose level
C. Long-standing rheumatoid effusions have low cholesterol levels
D. It has a high Ph
E. It should be treated by decortication

Answer:

Explanation to a patient who is reluctant to receive treatment

Case Scenario: You are a junior doctor in a medical outpatient clinic. A 30 year old female who has come for a prescription of an oral contraceptive pills is found to have high blood pressure. Her BP has been measured on several occasions and found to be consistently in the region of 180/100 mmHg. It has been explained to her that she has high BP that requires investigation and treatment, but she feels well and only wants a prescription for the oral contraceptive pill, not any tests or medication.
Your task is to inform the patient why investigations and treatment are required.

Key issues to explore
The key to a successful outpatient consultation will be to understand the reason why the patient does not want further investigation or treatment.

• Does she feel that investigation and treatment are unnecessary because she feels well?
• Is she afraid of what may be found?
• Is she concerned about the effects of treatment?

Key points to establish

• It is very important to establish a rapport with this woman so that she will trust you and thus hopefully follow the recommended management plan. 
• Explain to her that hypertension is a common and often asymptomatic condition that is frequently detected on routine screening, or incidentally as part of investigations for other medical problems. 
• It is important that she understands what hypertension is and why it should be taken seriously, even in the absence of  any complaints or limitations: the potential harmful effects of long term high BP must be explained.
• She will need reassurance and an explanation that investigations are necessary to exclude a secondary cause of high BP, which might mean that the hypertension can be cured and that she would not need long term treatment. 
• If no specific cause for hypertension is found, then simple changes to her lifestyle may be adequate to treat her BP. But in some situations this is not enough and she may require medication.
• Your advice should be accompanied by provision of reading material and help with associated programmes for smoking cessation, weight loss and dietary advice.

Appropriate responses to likely questions

Polymyalgia Rhuematic and Its Differential Diagnosis.

A 75-year-old woman presents with rather severe shoulder and hip pain that has been progressively worse over the last 3 months. She complains of morning stiffness and low-grade fevers, malaise, and weight loss. She has no headache or visual disturbance, and electromyogram (EMG) study of her
lower extremities was normal. Her labs reveal a normocytic–normochromic anemia and her erythrocyte sedimentation rate (ESR) was found to be 60mm/h.
Appropriate management at this time includes
A) Referral for a temporal artery biopsy
B) Initiation of prednisone
C) Initiation of an NSAID
D) Referral to physical therapy
E) Referral to orthopaedics for consideration of joint replacement

Answer And Discussion: The answer is B. (Initiation of prednisone)

Polymyalgia Rhuematic: The true prevalence, etiology, and pathogenesis of polymyalgia rheumatica (PMR) are not entirely known. In some, the condition is a manifestation of underlying temporal arteritis. Although most
patients are not at significant risk for the complications of temporal arteritis, they should be warned of the possibility and should immediately report such symptoms as headache, visual disturbance, and jaw muscle pain on chewing.
PMR usually occurs in patients older than 60 years, and the female:male ratio is 2:1. Onset may be acute or subacute. PMR is characterized by severe pain and stiffness of the neck and shoulders and
hips; morning stiffness; stiffness after inactivity; and systemic complaints, such as malaise, fever, depression, and weight loss.

Management In A 40 Year Old Man With Acute Pain In the Ankle

A 40-year-old man complains of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension.
On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities.
Which of the following is the best next step in management?

a. Begin colchicine and broad-spectrum antibiotics.
b. Perform arthrocentesis.
c. Begin allopurinol if uric acid level is elevated.
d. Obtain ankle x-ray to rule out fracture.
e. Apply a splint or removable cast.

Answer And Discussion:

Treatment Options For A 48 Year Old Woman With Rheumatoid Arthritis

A 48-year-old woman complains of joint pain and morning stiffness for 4 months. Examination reveals swelling of the wrists and MCPs as well as tenderness and joint effusion in both knees. The rheumatoid factor is positive, antibodies to cyclic citrullinated protein are present, and subcutaneous
nodules are noted on the extensor surfaces of the forearm. Which of the following statements is correct?

a. Prednisone 60 mg per day should be started.
b. The patient has RA and should be evaluated for disease-modifying antirheumatic therapy.
c. A nonsteroidal antiinflammatory drug should be added to aspirin.
d. The patient’s prognosis is highly favorable.
e. The patient should receive a 3-month trial of full-dose nonsteroidal anti-inflammatory agent before determining whether and/or what additional therapy is indicated.

Answer And Discussion:

A 35 Year Old Woman Complains Of Pain And Swelling In Her wrist For Last 7 Weeks

A 35-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. She mentions that after a period of rest, resistance to movement is more striking. On examination, the metacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities.There is no alopecia, photosensitivity, kidney disease, or rash.
Which of the following is correct?

a. The clinical picture suggests early rheumatoid arthritis, and a rheumatoid factor should be obtained.
b. The prodrome of lethargy suggests chronic fatigue syndrome.
c. Lack of systemic symptoms suggests osteoarthritis.
d. X-rays of the hand are likely to show joint space narrowing and erosion.
e. An aggressive search for occult malignancy is indicated.

Answer And Discussion:

Treatment Of Osteoarthritis In Elderly Patients

The preferred initial therapy for elderly patients with arthralgia due to osteoarthritis is which of
the following?

A) NSAIDs.
B) COX-2 inhibitors.
C) Acetaminophen.
D) Combination narcotic analgesics.
E) Early joint replacement.

Answer: