EMQs in Clinical Medicine.pdf - Peshawar Medical College

Joint pain – answers 125
triggered by an infection, e.g. a sexually transmitted infection or gastroenteritis.
Cutaneous manifestations include keratoderma blenorrhagica,
circinate balanitis and mouth ulcers. Enthesitis causing plantar fasciitis is
also well recognized.
A
A 45-year-old woman presents with bilateral painful deformed DIP
joints. Examination reveals discoloration and onycholysis of the nails.
Psoriatic arthritis is one of the seronegative spondyloarthritides. It is
important to remember that the skin manifestations may occur subsequent
to joint involvement. The patient in the question shows a typical
presentation of DIP joint involvement with signs of nail dystrophy.
Radiologically, the affective joints show central erosion rather than the
juxta-articular involvement that is seen in rheumatoid arthritis.
About 5 per cent of patients with psoriasis may present with marked
deformity in the fingers caused by severe periarticular osteolysis. This is
known as arthritis mutilans.
43 Joint pain
Answers: L F K J D
L
F
K
A 64-year-old patient who has recently been started on medication
for hypertension presents with a very painful, hot, swollen metatarsophalangeal
joint.
Gout is associated with hyperuricaemia and therefore acute attacks may
be precipitated by impaired excretion/increased production of uric acid.
Drugs that impair the excretion of uric acid include thiazide diuretics and
aspirin. States of increased cell turnover and thus increased purine
turnover, e.g. myelo-/lymphoproliferative states or carcinoma, can predispose
to gout. Obesity, diabetes mellitus, high alcohol intake and
hypertension are associated with hyperuricaemia.
A 12-year-old haemophiliac presents to A&E with severe pain after
falling over and banging his right knee.
Bleeding into the joint (haemarthrosis) may occur in all patients but is
more common in those with acquired/inherited disorders of coagulation
such as haemophilia.
A 55-year-old man presents to A&E with fever and an exquisitely
painful right knee. On examination his right knee is red, hot and
swollen. Purulent fluid is aspirated from the joint.
The differential diagnosis of a monoarthritis is septic arthritis,
osteoarthritis, crystal-induced arthritis, or trauma-related or a single
joint manifestation of a multi-joint disease.