Cox & Roper: Clinical Skills - Extended Matching Questions

Table of Contents

1. Chapter 04 - Cardiovascular System
2. Chapter 05 - Respiratory system
3. Chapter 06 - Adominal system
4. Chapter 07 - Rectal examination
5. Chapter 08 - Arms
6. Chapter 09 - Hands
7. Chapter 10 - Legs
8. Chapter 11 - Cranial Nerves
9. Chapter 12 - Necks
10. Chapter 13 - Joints
11. Chapter 14 - Spot Diagnosis
12. Chapter 15 - The electrocardiogram
13. Chapter 16 - The chest X-ray

Chapter 13 - Joints

Instructions: Each group of extended matching questions consists of lettered options followed by a list of numbered problems/questions. For each numbered problem/question select the one lettered option that most closely answers the question. You can use the lettered options once, more than once, or not at all.

Options:

1. Osteoarthritis
2. Septic arthritis
3. Reiter's syndrome
4. Rheumatoid arthritis
5. Gout
6. Pseudogout
7. Polymyalgia rheumatica
8. Ankylosing spondylitis
9. Systemic sclerosis
10. Systemic lupus erythmatosus
11. Sjogren's syndrome
12. Behcet's syndrome
13. Psoriatic arthropathy

Choose the correct diagnosis from the list of options for the following rheumatology case presentations

1

Scenario 1 a) An 82 year old woman complains of severe pain in her right knee. She has had pain on and off for several years. This is the worse it has been. Although she denies any trauma initially, she does recall jarring her knee when she almost fell a fortnight ago. On examination she is obese, has bony swellings over her proximal interphalangeal (PIP) joints and distal interphalangeal (DIP) joints. Both knees are swollen and have a valgus deformity. The deformity of the right knee is more pronounced. The swelling is predominantly bony and there is no fluid demonstrated in the knee joint. There is crepitus when the knee is passively moved through its range. Choose... Osteoarthritis Septic arthritis Reiter's syndrome Rheumatoid arthritis Gout Pseudogout Polymyalgia rheumatica Ankylosing spondylitis Systemic sclerosis Systemic lupus erythmatosus Sjogren's syndrome Behcet's syndrome Psoriatic arthropathy Correct. In osteoarthritis there are characteristic bony swellings in the hands, Bouchard's nodes over the PIP joints and Heberden's nodes over the DIP joints. Over the years degenerative changes in the weight bearing joints can lead to deformity such as genu valgum along with pain. If the patient is fit for an anaesthetic the best long term solution is a joint replacement if the pain is not controlled by analgesia. See page 390.Incorrect. See page 390.Your answer has been saved.

2

Scenario 2 a) A 52 year old man has had low back pain on and off for years. He usually finds the pain worse at night or early in the morning. This is accompanied by up to an hour of stiffness in the lower back. Initially the pain used to be experienced around the right sacro-iliac joint but in the last six month it has been around the left sacro-iliac joint. It became particularly bad following a coach journey to the coast. He does find that gentle exercise such as walking or swimming can ease the pain. On examination he was found to have limitation of all movements of the spine and lumbar flexion was impossible because of pain. The rest of his joints were unaffected. Choose... Osteoarthritis Septic arthritis Reiter's syndrome Rheumatoid arthritis Gout Pseudogout Ankylosing spondylitis Systemic sclerosis Systemic lupus erythmatosus Sjogren's syndrome Behcet's syndrome Correct. Although low back pain is common there are additional features to this case. He had limitation of all movement of the spine and not only the lumbar spine. Also the location of his pain seems to affect his sacro-iliac region. A further clue is that the pain is usually eased by exercise and aggravated by rest (such as his enforced rest on his journey to the coast). Acute traumatic back pain is usually aggravated by exercise and movement. See pages 380,389.Incorrect. See pages 380,389.Your answer has been saved.

3

Scenario 3 a) A 44 year old woman complained of pain and stiffness in both hands (affecting most fingers), her wrists, her shoulders and knees. She started initially with swelling of her PIP joints and metacarpophalangeal (MCP) joints, two weeks ago. The stiffness in her hands was worse in the mornings and could last several hours. She also felt increasingly tired. On examination her hands exhibited swelling of all her MCP and PIP joints. This swelling was warm and boggy to the touch. The fingers of both hands demonstrated ulna deviation and in addition there was a firm nodule on the ulna border of the elbow. Choose... Osteoarthritis Septic arthritis Reiter's syndrome Rheumatoid arthritis Gout Pseudogout Ankylosing spondylitis Systemic sclerosis Systemic lupus erythmatosus Sjogren's syndrome Behcet's syndrome Correct. This is a classical description of rheumatoid arthritis. Ulna deviation is one clue but a more important one is the finding of a nodule at the ulna border of the elbow. This is likely to be a rheumatoid nodule. Her tiredness could be due a non-specific feature of the disease or to anaemia which is common. The boggy swelling over the affected joints together with the associated warmth suggests that the disease is very active. See pages 241, 389-390.Incorrect. See pages 241, 389-390.Your answer has been saved.

4

Scenario 4 a) A 57 year old man has recently been diagnosed as having hypertension. He was started on bendroflumethiazide and was well controlled on it. Two nights ago he attended a works' night out where he drank plenty of wine and port. He presented to his GP with a painful, hot, first metatarsophalangeal (MTP) joint of his left foot. No other joint was affected. He rated the pain as 10/10 Choose... Osteoarthritis Septic arthritis Reiter's syndrome Rheumatoid arthritis Gout Pseudogout Ankylosing spondylitis Systemic sclerosis Systemic lupus erythmatosus Sjogren's syndrome Behcet's syndrome Correct. The distribution of the pain exclusively in the first MTP joint gives a valuable pointer to gout. The combination of a thiazide diuretic plus excessive alcohol has led to an increase in uric acid production (and decreased excretion) leading to an increase in the blood. Treatment in this case would be with analgesia until the attack settled down. See page 387-388.Incorrect. See page 387-388.Your answer has been saved.

5

Scenario 5 a) A 39 year old woman complained of pain and swelling of her wrist and hand and her right knee over the preceding 6 weeks. Initially the pain was bearable but now she finds she is dropping things at times because of pain. As an aside she also commented later about how unsightly her nails had become. On examination, there is swelling of the MCP and DIP joints of both hands together with ulna deviation bilaterally. Where her nail varnish had flaked off there was evidence of nail pitting and separation of the nail plate. Choose... Osteoarthritis Septic arthritis Reiter's syndrome Rheumatoid arthritis Gout Pseudogout Ankylosing spondylitis Systemic sclerosis Systemic lupus erythmatosus Sjogren's syndrome Behcet's syndrome Correct. Some of the distribution of joint involvement and their appearances are reminiscent of rheumatoid arthritis. However the most telling clue comes almost casually from a throw away comment regarding her nails. The nail pitting raises the possibility of psoriatic arthropathy and should lead the examiner to search for plaques of psoriasis. The absence of psoriatic plaques does not exclude the diagnosis of psoriatic arthropathy. See page 388.Incorrect. See page 388.Your answer has been saved.