Musculoskeletal Flashcards
A 79-year-old man presents with dyspnoea on exertion for 1 year and lower extremity oedema. As part of a cardiac work-up, the echo shows concentric left ventricular hypertrophy. Cardiac catheterisation shows normal coronary arteries and he is referred for further evaluation of non-cardiac dyspnoea.
Amyloidosis
A 62-year-old man is referred for management of atypical multiple myeloma. He has a mild anaemia of 120 g/L (12 g/dL), a urinary protein loss of 2.2 g/day with a urinary immunofixation showing free lambda light chains. However, the bone marrow shows only 5% plasma cells and does not fulfil criteria for multiple myeloma.
Amyloidosis
A 20-year-old man presents to his primary care physician with low back pain and stiffness that has persisted for more than 3 months. There is no history of obvious injury but he is a very avid sportsman. His back symptoms are worse when he awakes in the morning, and the stiffness lasts more than 1 hour. His back symptoms improve with exercise. He has a desk job and finds that sitting for long periods of time exacerbates his symptoms. He has to get up regularly and move around. His back symptoms also wake him in the second half of the night, after which he can find it difficult to get comfortable. He normally takes an anti-inflammatory drug during the day, and finds his stiffness is worse when he misses a dose. He has had 2 bouts of iritis in the past.
Ankylosing spondylitis
A 17-year-old boy presents with an 18-month history of pain in his right ankle and both heels, with early morning stiffness and fatigue. He was forced to give up sport, and walking short distances is proving difficult due to heel pain. Examination reveals marked tenderness and swelling over bilateral Achilles tendons.
Ankylosing spondylitis
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. He has a history of gout but has not experienced these symptoms before. 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
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 1 or 2 joints, with swelling and warmth of the affected areas. These episodes often last 3 to 4 weeks. Her examination shows severe bony changes consistent with osteoarthritis in many joints, and slight swelling, warmth, and tenderness without erythema in the second and third metacarpophalangeal joints, left shoulder, and the right wrist.
Pseudogout
An 80-year-old man presents with a swollen red wrist, fever, and chills. He recalls falling out of his wheelchair several days ago but seemed well until 24 hours before admission, when he developed pain in his right wrist. His daughter noted fever and some confusion and brought him to the hospital. On examination, he appears ill and has fever to 39ºC (102ºF). There is swelling, tenderness, and redness around the right wrist with oedema over the dorsum of the hand.
Pseudogout
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 the presence of tenderness in 12 out of 18 fibromyalgia tender points. Routine laboratory testing is normal.
Fibromyalgia
A 72-year-old white woman presents with partial vision loss in the right eye. She reports bitemporal headache for several weeks, accompanied by pain and stiffness in the neck and shoulders. Review of systems is positive for low-grade fever, fatigue, and weight loss. On physical examination, there is tenderness of the scalp over the temporal areas and thickening of the temporal arteries. Fundoscopic examination reveals pallor of the right optic disc. Bilateral shoulder range of motion is limited and painful. There is no synovitis or tenderness of the peripheral joints. There are no carotid or subclavian bruits, and the blood pressure is normal and equal in both arms. The remainder of the examination is unremarkable.
Giant cell arteritis
A 57-year-old man presents with a 5-year history of slowly progressive leg weakness. Recently he has had multiple falls and experiences difficulties with fine tasks using his hands. Neurological examination shows atrophy of iliopsoas, quadriceps, and finger flexors bilaterally. Manual muscle strength test finds predominant weakness in finger/wrist flexors compared with finger/wrist extensors. Additionally, it demonstrates neck flexion 3/5, neck extension 4/5, arm abduction 4/5, forearm flexion 4/5, hip extension 3/5, hip flexion 2/5, knee extension 2/5, knee flexion 2/5, ankle dorsiflexion 4/5, and ankle plantar flexion 5/5. The rest of the neurological examination is unremarkable except for reduced patellar reflexes.
Idiopathic inflammatory myopathy
A 42-year-old woman presents with progressive muscular weakness and recurrent facial oedema. The oedema started 3 months ago and worsened to the point that she was unable to open her mouth or eyes. Concomitant to her facial rash, she experiences intermittent difficulty in swallowing. Her weakness results in an inability to rise from a chair or ascend stairs. Skin examination demonstrates blue-purple discoloration on the upper eyelids with oedema. Her muscle strength is 3/5 on bilateral hip flexion and 3/5 on bilateral shoulder abduction. The rest of the neurological examination is normal.
Idiopathic inflammatory myopathy
A 60-year-old woman presents complaining of bilateral knee pain on most days of 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
A 55-year-old woman has been complaining of 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 PIP joint and two DIP 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 MCP joints.
Osteoarthritis
A 40-year-old man who suffered an open tibial fracture in a motor vehicle accident 6 months ago presents with swelling and pain in his lower leg.
Osteomyelitis
A 5-year-old boy fell off his bicycle 2 weeks ago and has stopped walking and complains of non-specific pain in his leg. His mother reports that he apparently has had flu, with fever and chills.
Osteomyelitis
A 58-year-old woman presents with a 2-week history of fatigue, anorexia, fevers, and bilateral pain and stiffness in the shoulder and hip girdles. These symptoms are worse at night. Upon awakening in the morning, she feels as if she has a bad flu. She reports difficulty getting out of bed in the morning due to stiffness. Her wrists and finger joints are also painful and swollen.
Polymyalgia rheumatica
A 21-year-old male student presents with a 4-week history of a painful, hot, and swollen left knee, low back pain with bilateral buttock pain, and left heel pain. He denies trauma and states the symptoms began acutely. He denies any fever or any other significant arthralgias. Further review of symptoms indicates the patient was treated for a chlamydia infection after he developed dysuria approximately 8 weeks ago (he was treated with a single dose of azithromycin). He admits to unprotected sexual intercourse with a new partner 2 days before the onset of his dysuria. In addition to pain and swelling, the patient reports that he has developed morning stiffness in the left knee and low back that last more than 1 hour. He continues to have episodes of dysuria. The findings of physical examination are significant for a large effusion of the left knee with warmth. Range of motion is slightly diminished. There is tenderness to palpation of the left heel at the site of the Achilles’ insertion. Laboratory findings are significant for an ESR of 35 mm/hour, and both FBC and uric acid level are within normal limits. He is HLA-B27 positive, rheumatoid factor negative, and ANA negative. The synovial fluid analysis is negative for crystals, with a total nucleated cell count of 22,000 cells/microlitre (65% neutrophils). A urethral swab was positive by PCR for Chlamydia trachomatis 9 weeks ago at initial presentation of dysuria. There was no evidence of gram-negative diplococci on Gram stain.
Reactive arthritis
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 on and off taps 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 29-year-old woman presents with shortness of breath, cough, and painful red skin lesions on the anterior surface of the lower part of both legs. CXR reveals bilateral hilar lymphadenopathy with pulmonary infiltrates.
Sarcoidosis
A 35-year-old woman presents with skin lesions around her nose, which are indurated plaques with discoloration. She also reports a red, moderately painful right eye with blurred vision and photophobia.
Sarcoidosis
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 25-year-old man who is a known intravenous drug abuser presents with a 5-day history of pain and swelling in his right leg. On examination there are multiple sites of intravenous puncture. His right leg is swollen from the knee downwards. There is a large effusion on the right knee together with significant cellulitic changes of the overlying skin.
Septic arthritis
A 45-year-old woman presents with fatigue and a history of positive ANAs. She has had recurrent sensation of sand/gravel in eyes and dry mouth every day for more than 3 months.
Sjogren syndrome
A 60-year-old man presents with diffuse paraspinal neck pain and stiffness, which has slowly worsened over 20 years. He describes significant muscle spasm in the lateral and anterior aspects of his neck, including tender, sore muscles, severe interscapular pain, and occasional headaches. The axial neck pain is worsened by activity and driving, and is improved by a heating pad and NSAIDs. He describes a grating or popping sound when moving his neck. Physical and neurological examinations reveal decreased range of motion of the neck, paraspinal muscle spasm, and normal sensory and motor function of his upper extremities.
Degenerative cervical spinal disease
A 57-year-old woman presents with primarily severe and radiating arm pain, which she describes as beginning at the shoulder, and particularly worse pain in the region of the left lateral elbow. This arm pain has been present for >3 months, and she describes it as similar to a lightning bolt coursing through the left arm. No significant neck pain is apparent on the history or examination. She has also noted some weakness of arm extension and grip of the left hand, as well as a tingling sensation in the left index and middle fingers. On examination she has reproduction of her pain on turning her head to the left, significant weakness in the left triceps and absent left triceps reflex, and minimal sensory changes in the index and middle finger.
Degenerative cervical spinal disease
A 25-year-old man presents to the emergency department after an automobile accident. He was ejected from the vehicle. He complains of numbness in both lower extremities and cannot move his legs. There is no pinprick sensation below the umbilicus except for an anal wink, and there is no rectal tone. The bulbocavernosus reflex is weakly present. Power in the lower extremities is graded at 1/5.
Spinal radiculopathy
A 40-year-old woman presents with back pain and difficulty with her gait. She has a long history of smoking and has had some haemoptysis recently. Her examination reveals diminished pinprick sensation from the nipple line caudally, power in the lower extremities of 4/5, absent joint position sense in the lower extremities, and diminished vibratory sense. Anal sphincter tone is intact.
Spinal radiculopathy
A 65-year-old retired builder has had lower back pain for 3 years. For the past 12 months he has been experiencing bilateral leg pain and a sense of heaviness in the legs when he is walking. The pain is relieved by bending over or sitting down. Over the past few months the distance he is able to walk has become progressively shorter and he has assumed a stooped posture. Physical examination is essentially unremarkable. Distal pulses are palpable and there is no appreciable weakness or muscle atrophy in the legs, or findings of hip or knee pathology.
Spinal stenosis
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 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 woman presents with Raynaud’s phenomenon for the past 5 years. She also has a history of digital ulcers and GORD. Physical examination reveals telangiectasias on the hands. She has sclerodactyly. Digital pits are present with no active ulcers. Serology tests reveal a high-titre ANA by indirect immunofluorescence, at a titre of >1:640 in a centromere pattern.
Systemic sclerosis
A 35-year-old woman presents complaining of puffy hands and feet for the past 3 months. She noted the onset of Raynaud’s phenomenon 6 months ago. Examination confirms the presence of puffy hands and feet, with subtle skin thickening of the fingers and dorsum of the hands. Serology tests reveal a positive ANA with both speckled and nucleolar patterns at a titre of >1:1280. Anti-topoisomerase (anti-Scl 70) antibody is strongly positive. Pulmonary function tests are normal (although this does not preclude the possibility of the development of fibrosis at a later date).
Systemic sclerosis
A 50-year-old woman presents with numbness and tingling in her hands. The symptoms are worse in her right (dominant) hand and with activities such as holding a book or a steering wheel, or brushing her hair. The discomfort in her hands frequently wakes her at night, and she has to shake or hang her hand out of her bed for relief.
Carpal tunnel syndrome
