MSK Flashcards
pain in right shoulder and upper arm for 6 weeks. worsens when elevating arm above head
no deformity, tenderness or reduced range of movement. pain on abduction of right shoulder that is worse with the arm in internal rotation and when abduction is resisted. he is treated with ibuprofen
next step in management?
Refer for physiotherapy.
diagnosis = right supraspinatus tendinopathy. no further inestigations required to confirm. can be managed in primary care. general advise and home exercises or physio
A 48 year old man has 8 months of a painful, stiff left shoulder. The pain is dull and worse at night. There is no history of trauma. He has type 1 diabetes mellitus.He has reduced passive and active range of movement in the left shoulder with pain at extremes of range of motion. Neck movements are normal. Power and sensation are normal.Investigations:CRP 6
Which is the most likely diagnosis?
A. Adhesive capsulitis
B. Glenohumeral osteoarthritis
C. Polymyalgia rheumatica
D. Rotator cuff tear
E. Subacromial bursitis
UKMLA PPQ
Adhesive capsulitis (frozen shoulder) presents with dull shoulder pain, that often disturbs sleep, followed by stiffness and loss of shoulder mobility. Adhesive capsulitis is unlikely in patients younger than 40 years of age, and patients older than 70 are more likely to have rotator cuff tears or glenohumeral osteoarthritis. Patients with subacromial pathology often give an occupational or athletic history of heavy lifting or repetitive movements, especially above shoulder level. Patients with rotator cuff tendinopathy and subacromial bursitis often complain of activity-related pain and problems performing usual activities. Adhesive capsulitis is more common In diabetics
A 40 year old woman has 1 day of a painful, swollen left elbow and fever. She has rheumatoid arthritis and takes methotrexate and infliximab.Her temperature is 38.2°C, pulse rate 100 bpm and BP 119/83 mmHg. The left elbow is swollen and erythematous.Investigations:White cell count 16.4 × 109/L (3.8–10.0)Urea 6.7 mmol/L (2.5–7.8)
Creatinine 98 μmol/L (60–120)
CRP 171 mg/L (<5)Joint aspiration: no organisms on Gram stain, white cell count 2043/μL (<200), mostly neutrophils, no crystals.She is advised to take oral paracetamol.
Which is the most appropriate additional management?
UKMLA ppq
IV flucloxacillin
A 24 year old man develops low back pain the day after falling while playing tennis . He is usually well and takes no regular medication. He is a laboratory technician.
Which is the most appropriate advice?
Continue usual activity!,,
Notttt referral for physio.
Short duration acute low back pain in fit person. Therefore most appropriate response would be to continue usual activity and to provide appropriate safety netting advice
Acute Gout. patient has chronic kidney disease stage 4. first line management?
oral prednisolone!!
nsaids would be option but CKD
acute gout treatment: oral steroids, NSAIDS and colchicine
classic polymyalgia rhuematica symptoms. management?
prednisolone!
Acute Gout first line treatment
Start naproxen
70 yo. 6 months increasing pain at base of left thumb. No other joint painful. 1st carpometacarpal joint swollen and tender with reduced opposition of thumb. Most likely diagnosis?
Osteoarthritis!!!
6 months not acute so less likely to be gout.
OA fits with joint affected. Not multiple joints so RA unlikely
A 73 year old man has 3 months of increasing weakness of his right hand with
reduced sensation of the forearm.
There is wasting of all the intrinsic muscles of the right hand. There is
weakness of finger abduction and adduction, and thumb adduction. Finger
flexion is normal. There is mild altered light touch sensation along the ulnar
aspect of the forearm. The biceps, supinator and triceps reflexes are normal.
The lower limbs and the left arm are normal
where is the most likely site of the lesion causing his symptoms?
T1 nerve root
The intrinsic hand muscle wasting suggests
T1. The normal reflexes and normal other arm are against a cord lesion. The
sensory loss on the forearm excludes median and ulnar nerve lesions. T1
dermatome is often thought to be higher in the arm medially.
A 44 year old dentist complains of right elbow pain. He has tenderness over the right lateral epicondyle. You suspect lateral elbow tendinopathy (tennis elbow). Which clinical test is likely to reproduce pain?
resisted wrist EXTENSION
resisted wrist flexion = for medial epicondyle/golfers elbow
(try moves out on your hand)
empty can test = supraspinatus tendinopathy
Finklestein’s test is a test for tenosynovitis of the 1st extensor compartment at the wrist (De Quervain’s tenosynovitis).
polmyositis = weakness rather than pain/muscle aches in polymyalgia rheumatica.
polymyositis = raised CK
A 42 year old man comes to see you with swelling at his right elbow. He has a long history of episodes of arthritis affecting his 1st MTP joint, with pain and swelling lasting ~5 days and responding to ibuprofen. More recent episodes have affected his ankles and right knee. Which is the most likely diagnosis?
gout
Gout reflect inflammation caused by deposition of sodium urate crystals, usually within joints but also with in bursae (fluid sacs). It typically first presents at the 1st MTP joint. Crystal formation is favoured by degenerate cartilage and this may be one reason for early involvement of the 1st MTP joint. This patient may have developed an olecranon bursitis explaining the swelling at the right elbow. The transient episodes of inflammation are typical for a crystal arthritis. ‘Flares’ of arthritis in other forms of inflammatory arthritis typically last longer than this.
A 65 year old woman has a bone density scan. This shows T scores of -1.8 at the neck of femur, -1.6 at the total hip and -2.3 at the lumbar spine. What is the diagnosis?
osteopenia!!!
A T score above -1.0 is defined as ‘normal bone density’, a T score between -1.0 and -2.5 is defined as ‘osteopenia’ and a T score of -2.5 and below is defined as osteoporosis.
fibromyalgia presentation?
widespread pain and on the experience of fatigue/waking unrefreshed/cognitive symptoms/headaches, abdominal pain or depression. These are set out in the 2016 diagnostic criteria. Blood tests and imaging studies will be normal.
A 65 year old woman has a bone density scan. This shows T scores of -1.8 at the neck of femur, -1.6 at the total hip and -2.3 at the lumbar spine, with readings of -2.1, -2.1, -2.4 and -2.6 at L1-4 respectively. Which reading do you enter into the WHO FRAX calculator in order to obtain an estimate of fracture risk?
Neck of femur reading (-1.8)
The FRAX calculator uses the neck of femur reading to calculate fracture risk. Readings at the lumbar spine and total hip can be falsely elevated in the presence of degenerative change and so are less reliable as a predictor of fracture.
