EMQs in Clinical Medicine.pdf - Peshawar Medical College

128 Orthopaedics and rheumatology
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A 60-year-old woman presents with constant backache. Her ESR and
serum calcium are markedly elevated.
Back pain is common in older people and the cause is often benign.
However, constant symptoms, raised ESR and raised serum calcium raise
the suspicion of underlying myeloma.
A 65-year-old man with osteoarthritis complains of back pain worse on
walking along, with aching and heaviness in both legs that force him to
stop walking. Pain is relieved slowly after rest or leaning forward.
This is a classic description of spinal claudication (leaning forward opens
the spinal canal and relieves pain). In vascular claudication the pain is
quickly relieved on rest, whereas the relief from pain occurs later in
spinal claudication. Operative decompression can be very successful in
treating symptoms of pain in patients who are severely affected.
A 13-year-old girl complains of backache and fatigue. She is worried
that she is becoming increasingly round-shouldered. On examination,
she has a smooth thoracic kyphosis. Her radiograph shows wedgeshaped
vertebral bodies in the thoracic spine.
Scheuermann’s disease is a rare condition that typically affects females
during puberty. There is abnormal ossification of ring epiphyses of thoracic
vertebrae. The deforming forces are greatest at the anterior border
of the vertebrae giving rise to the described wedge-shaped vertebral bodies
(i.e. narrower anteriorly). Management depends on the degree of
kyphosis and ranges from back-strengthening exercises and postural
training in those mildly affected to operative correction and fusion in
those with severe kyphosis.
A 35-year-old tourist complains of severe back pain with inability to
straighten up after lifting a suitcase yesterday. He now presents with
weakness of his big toe extension and loss of sensation on the outer
side of the calf.
He is showing symptoms of compression at the L5 level.
46 Rheumatological conditions
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A 45-year-old woman complains of cold numb fingers and difficulty
in swallowing. On examination she has tight skin, thickening of the
fingers and telangiectasia.
Systemic sclerosis is a multisystem connective tissue disease that is classified
as either limited or diffuse cutaneous scleroderma.
Limited cutaneous scleroderma is the milder form and usually starts with
Raynaud’s phenomenon followed by skin changes. The characteristic