random cases Flashcards
cases from everywhere! (not just MSK)
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 spondilitis
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 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 -> acute bursitis
Gout may also present as acute bursitis, especially in the olecranon and prepatellar bursae. Chronic tophaceous gout may cause inflammatory destructive polyarthritis. This usually occurs in people with a long-standing history of attacks (mean 10 years) and with higher uric acid levels.
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. 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.
psudogout (calcium pyrophosphate deposition)
Arthritis associated with CPP crystals is often called the great mimic and can have a wide variety of presentations.[1] Although the acute mono-articular arthritis resembling gout is perhaps the most commonly recognised form of CPP arthritis, it is not the most common form of the disease. The most common form of CPP arthritis presents as a chronic degenerative arthritis that resembles osteoarthritis and may occur with or without inflammatory episodes. CPP arthritis typically affects joints not commonly affected by osteoarthritis, such as the wrists or shoulders. In addition to its presentation as an acute mono-articular or oligo-articular arthritis, it can present with a polyarticular, symmetrical inflammatory arthritis similar to rheumatoid arthritis; or, less commonly, with the diffuse aching similar to that seen in polymyalgia rheumatica.
CPPD is associated with an increased risk of vascular calcification, and low bone mineral density.[5][6] The neuropathic form is rare but is characterised by severe destructive arthritis with bone fragmentation and loose bodies.
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
Less common peripheral musculoskeletal manifestations include a monoarthritis or polyarthritis, pitting oedema of the hand, carpal tunnel syndrome, and tenosynovitis.[3] A second presentation is the presence of the characteristic neck, shoulder girdle, and hip girdle symptoms associated with normal serum markers of systemic inflammation (i.e., ESR or CRP).
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.
GCA (giant cell arteritis)
When present, symptoms of jaw claudication and diplopia are powerful predictors of a positive temporal artery biopsy result.[1] Neurological manifestations occur in about one third of patients and may include stroke, transient ischaemic attack, or neuropathy. Respiratory tract symptoms are uncommon but may include cough or sore throat. Rarely, dental pain, tongue pain, or infarction of the tongue may be present. An older person may present with a new headache. In addition, some patients who predominantly have polymyalgia rheumatica can have subtle evidence of GCA that could be missed.[2] GCA can rarely present as an unexplained systemic illness or fever of unknown origin with elevated levels of inflammatory markers without headache, jaw claudication, shoulder or hip girdle stiffness, or visual disturbances.
Patients with large-vessel stenoses (approximately 10% to 15% of patients) may present with claudication of (usually) upper extremities, asymmetric blood pressures, or decreased pulses.[3] Rarely, involvement of lower extremity vessels results in leg claudication
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 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 63-year-old man with sun-damaged skin presents with a small nodule on the left aspect of his forehead. He mentions that it is itchy at times, and he thinks that he may have seen a colleague 2 years previously for removal of some keratoses or scabs. The patient indicates that these were either cauterised or frozen. On examination there is a pearly white nodule with prominent telangiectasia on its surface.
basal cell carcinoma
A woman in her mid-40s with dark, leathery skin and intense wrinkling of the lower neck (signifying excessive sun exposure either in a form of frequent sun tanning beds or perhaps frequent beach visits) presents at your office. She reports she has had multiple facial lifts, to decrease wrinkles. The plastic surgeon she has consulted performed other cosmetic procedures, including botulinum toxin type A injections. She complains about a mole on her jaw that has recently started to bleed.
basal cell carcinoma
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 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 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 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
RA can sometimes present in large joints like the knees and shoulders but this is less common. There is some evidence that elderly-onset RA may present this way more often.[3] Elderly-onset RA has also been grouped with polymyalgia rheumatica (PMR) and may represent a continuum of clinical features of both RA and PMR.[4] Rheumatoid nodules can be seen at presentation in some patients who have very active disease with large numbers of joints involved; these patients also have a higher incidence of rheumatoid vasculitis, presenting mostly as skin manifestations, with ulcerations and other rashes.
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
Multisystem involvement is characteristic, but pulmonary involvement usually dominates. Skin, eyes, and peripheral lymph nodes are involved in 15% to 30% of patients. Clinically significant involvement of spleen, liver, heart, CNS, bone, or kidney occurs in a few patients. Incidental diagnosis on routine CXR also occurs.
