EMQ: 5
Arthritis
a)
Rheumatoid arthritis
b)
Osteoarthritis
c)
Gout
d)
Ankylosing spondylitis
e)
Psoriatic arthropathy
f)
Reiter’s syndrome
g)
Septic arthritis
h)
Rheumatic fever
i)
Systemic lupus erythematosus
j)
Pseudogout
Select the most likely cause of arthropathy from the list
above to match each of the scenarios given below:
1) A 24-year-old male presents with a gradual onset of
backache and morning stiffness that is improved by exercise. On examination of
his spine there is decreased spinal mobility and when he stands with his back
to a wall, the occiput does not touch the wall.
Answer: d) ankylosing spondylitis
When a patient has backache in the context of a question
on arthritis consider the spondyloarthropathies (i.e.) a group of inflammatory
diseases that predominantly affect the axial skeleton, the peripheral joints
and the entheses.
No underlying cause for the spondyloarthropathy has been
mentioned. In a young male with no underlying cause presenting with an
inflammatory spondyloarthropathy one should consider the diagnosis to be
ankylosing spondylitis.
2) A 50-year-old female presents with pain and stiffness
of her hands and wrists. The stiffness is worse in the morning and gets better
as the day progresses. On examination she has swelling of her
metacarpophalangeal joints and there is ulnar deviation at the
metacarpophalangeal joints. Joint movement is impaired.
Answer: a) rheumatoid arthritis
In a female presenting with pain in her joints one should
consider an inflammatory arthropathy. Stiffness, which is worse in the
morning, is in favour of an inflammatory arthropathy rather than
osteoarthropathy, which is worse in the latter part of the day.
The metacarpophalangeal joints being affected would be in
favour of rheumatoid arthritis and the fact that there is ulnar deviation at
these joints is also a point in favour of rheumatoid arthritis.
3) A 45-year-old man presents with pain and deformity of
the joints of his hands. On examination the nails show pitting and the distal
interphalangeal joints are painful and deformed on both sides.
Answer: e) psoriatic arthropathy
Pitting of the nails should alert one to the fact that
this arthropathy is in relation to a skin condition. Pitting of the nails may
occur in psoriasis and in alopecia areata. Immediately, one should think of
psoriatic arthropathy. Indeed psoriatic arthropathy is one of the conditions
that cause arthropathy affecting the distal interphalangeal joints.
4) A 70-year-old male presents with severe pain in the
right first metatarsophalangeal joint. The pain woke him up from his sleep. On
examination the joint is swollen red and painful and tender.
Answer: c) gout
There are not many causes of a small joint
monoarthropathy (gout and very rarely septic arthritis). In an elderly patient
the most likely condition is gout. The fact that there is redness over the
joint is also a sign in favour of crystal arthropathy although it may also
occur in septic arthritis.
5) A 75-year-old man who has had long-standing problems
with his joints presents with pain and swelling of his right knee. On
examination he is febrile, the skin overlying the knee looks red, it is hot
and there is evidence of fluid within the joint.
Answer: g) septic arthritis
The fact that he is febrile should alert one to the fact
that there is a systemic disturbance probably due to infection. Redness over
joint may be due to crystal arthropathy but with the other features given the
most likely diagnosis is septic arthritis.
Revision Tip
When considering a very broad topic such as arthritis it
is essential to have an understanding of how the different types of arthritis
may present
Look up ACES for PACES (pages 546-547). This gives a summary of the
presentation of arthropathy, which will enable one to rapidly categorise
arthropathy and thus narrow down the possibilities with ease.
The causes of pitting of the nails is given on page 128
of ACES for PACES
Read pages 555-557 of ACES
for PACES to revise the different ways in which arthropathies of
the hand may present.
Revise the clinical features of ankylosing spondylitis
using the A's of ankylosing spondylitis ACES for
PACES page 565
