MSK cases Flashcards
A 55-year-old woman presents with a 1-week history of pain and swelling in her left wrist. She was diagnosed with rheumatoid arthritis at the age of 36 years but the rest of her joints are currently asymptomatic. Her rheumatoid arthritis is well controlled on her current medication. On examination her left wrist is found to be hot, swollen, tender, and highly restricted in its range of movement. There is no sign of inflammation in any of her other joints. She has a temperature of 37.5˚C (99.5˚F).
Septic arthritis
A 16-year-old black female presents to her general practitioner with symptoms of fatigue, musculoskeletal pain, and a facial rash. On examination she is noted to be thin with malar skin changes. No other abnormality is found.
SLE
A 38-year-old white woman presents to the accident and emergency department with 24 hours of dyspnoea and pleuritic chest pain. On further questioning, she reports a 3-year history of Raynaud’s disease, polyarthralgia, and intermittent migraine. Physical examination reveals hypoxia, tachycardia, and normal blood pressure. Ventilation perfusion scanning confirms a pulmonary thromboembolism.
SLE
A 25-year-old man presents with painful forefeet, a swollen right knee, and a swollen index finger. These symptoms developed over 2 months. He has had a history of psoriasis since the age of 18 years. Examination reveals psoriatic plaques at the knees and elbows, as well as at the posterior hair line, and psoriatic nail changes of both fingers and toes. There is dactylitis of the right index finger and several toes, as well as synovitis of the right knee.
Psoriatic arthritis
A 57-year-old woman presents complaining of pain and stiffness in both knees and the left foot. Past medical history is notable for severe dandruff and an episode of apparent gout in the left first toe 6 months ago, which never resolved. Examination confirms scalp psoriasis, synovitis of the knees, and a dactylitis of the left first toe.
Psoriatic arthritis
A 46-year-old woman presents with a 6-week history of progressive weakness in her thighs and upper arms. She describes difficulty getting out of a chair unaided and complains of fatigue and breathlessness. Over the past 3 months she has noticed swelling of her eyelids and a rash on her face, elbows, and hands. On examination she has a periorbital heliotrope rash, violaceous plaques over the extensor surfaces of both elbows, violaceous papules on the metacarpophalangeal joints, and nail fold capillary dilatation. Proximal muscle strength is symmetrically reduced to 4/5; distal muscle strength is normal. Chest examination reveals fine bilateral basal crepitations.
Dermatomyositis
A 55-year-old man complains of persistently aching legs. He is initially diagnosed with fibromyalgia. However, his blood tests reveal an elevated serum alkaline phosphatase. Subsequent x-ray of the tibia and fibula shows defects in the cortical and cancellous bone, with some degree of tibial bowing.
Paget’s disease of the bone
A late middle-aged woman presents with chronic right hip and anterior thigh pain, with increased localised temperature. Lately she has needed a walking stick. During the past 6 months her relatives have noticed a progressive hearing loss on her left side, as well as some facial changes - mostly enlargement of her mandible.
Paget’s disease of the bone
A previously healthy 61-year-old woman presents with a 3-month history of sinusitis and nasal drainage. She has noted only marginal, temporary improvement despite multiple courses of antibiotics. The nasal drainage is purulent and frequently haemorrhagic. She also has a 2-week history of migratory joint pain, mainly affecting wrists, knees, and ankles. She does not describe joint swelling. She reports having less energy and has lost 10 pounds in weight over the past 2 months. She has no respiratory, urinary, neurological, or other symptoms. Bleeding and inflammation of the nasal mucosa is noted, along with tenderness to percussion over both maxillary sinuses. The remainder of the physical examination is unremarkable. In-office urinalysis reveals 3+ microscopic haematuria and 2+ proteinuria.
Granulomatosis with polyangitis
A 52-year-old woman presents with a 2-month history of bilateral hand and wrist pain, and swelling in her fingers. She has also recently noted similar pain in the balls of her feet. She finds it hard to get going in the morning and feels stiff for hours after waking up. She also complains of increasing fatigue and is unable to turn taps on and off or use a keyboard at work without a significant amount of pain in her hands. She denies any infections before or since her symptoms started.
Rheumatoid arthritis
A 60-year-old woman presents complaining of bilateral knee pain almost daily for the past few months. The pain was gradual in onset. The pain is over the anterior aspect of the knee and gets worse with walking and going up and down stairs. She complains of stiffness in the morning that lasts for a few minutes, and a buckling sensation at times in the right knee. On examination, there is a small effusion, diffuse crepitus, and limited flexion of both knees. Joint tenderness is more prominent over the medial joint line bilaterally. She has a steady but slow gait, slightly favouring the right side.
Osteoarthritis
- Morning stiffness only lasts a few minutes
- Old female
- Limited range of motion e.g. limited flexion of both knees
- Usually affecting the hip and knee joints
- Instability –> gait favouring right side
A 55-year-old woman has had pain and swelling in several fingers of both hands for the past 2 months. She describes morning stiffness lasting for 30 minutes. Her mother tells her that she had a similar condition at the same age. She denies any other joint pain or swelling. On examination, she has tenderness, slight erythema, and swelling in one proximal interphalangeal joint and two distal interphalangeal joints in each hand. She has squaring at the base of her right thumb (the first carpometacarpal joint). There is no swelling or tenderness in her metacarpophalangeal joints.
Osteoarthritis
A 54-year-old man complains of severe pain and swelling in his right first toe that developed overnight. He is limping because of the pain and states that this is the most severe pain he has ever had (‘even covering my foot with the bed sheet hurts’). He has had no previous episodes. His only medication is hydrochlorothiazide for hypertension. He drinks 2 to 3 beers a day. On examination, he is obese. There is swelling, erythema, warmth, and tenderness of the right first toe. There is also tenderness and warmth with mild swelling over the mid foot.
Gout
An 85-year-old man presents with several days of swelling and severe pain in both hands limiting his ability to use his walking frame. On examination, he has a temperature of 37.8°C (100.1°F). There is diffuse warmth, mild erythema, and pitting oedema over the dorsum of both hands. There is tenderness and limited hand grip bilaterally. There are multiple nodules around several of the proximal interphalangeal and distal interphalangeal joints, and effusion and tenderness in his left olecranon bursa with palpable nodules
Gout
- Male
- Warm, swollen joint
- Tophi (around the PIP and DIP, left olecranon bursa
A 72-year-old woman presents with polyarticular joint pain. She has long-standing mild joint pain, but over the last 10 years notes increasing discomfort in her wrists, shoulders, knees, and ankles. She has had several recent episodes of severe pain in one or two joints, with swelling and warmth of the affected areas. These episodes often last 3-4 weeks.
Pseudogout
- 70+ Female
- Polyarticular joint pain in knee, wrist and shoulder
- Warm, swollen, painful joints
A 70-year-old woman presents to the emergency department after falling while getting out of bed. She sustained an intertrochanteric fracture of the right hip. Preoperative chest x-ray reveals that she had existing asymptomatic vertebral fractures before her fall.
Osteoporosis
-Asymptomatic vertebral fractures
- Multiple fractures
- 50 + woman
A 70-year-old man, 6 months after renal transplantation and on corticosteroid treatment, presents with severe back pain. X-ray evaluation of the thoracic and lumbar spine shows multiple vertebral compression fractures.
Osteoporosis
-Most common cause of vertebral compression fractures
- Corticosteroid treatment can result in bone loss
A 38-year-old woman sees her physician with 4 years of widespread body pain. The pain began after a motor vehicle accident and was initially limited to her neck. Gradually, the pain has spread and she now complains of hurting all over, all the time. She does not have any joint swelling or systemic symptoms. She does not sleep well and has fatigue. She has irritable bowel syndrome but is otherwise healthy. Physical examination reveals a well-appearing woman with normal musculoskeletal examination, except for diffuse tenderness to palpation. Routine laboratory testing is normal.
Fibromyalgia
A 45-year-old man is referred to the rheumatology clinic with a 3-year history of widespread pain, fatigue, and sleep disturbance. The pain started gradually in his neck before later involving both shoulders and upper arms, neck, lower back, and legs. He additionally reports daily headaches, severe fatigue, and unrefreshing sleep, to the point that he has had to quit his job as a custodian to the local school. He denies skin changes, weight loss, joint swelling or redness, personal or known family history of autoimmune or rheumatological disease. Physical examination revealed minimal muscle tenderness of palpation and no evidence of inflammation or joint damage. His blood tests are normal.
Fibromyalgia
