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Joints ache all the time.  But what happens when they’re acutely painful????  Gosh … 

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acute joint pain

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Question 1

Stem 1 of 4

A 57 year old male presents with 8hr onset “incredible” pain at the first right metatarsophalangeal joint. The joint is stiff and warm to the touch. He denies any history, or family history, of this occurring before. The patient is on therapy for hypertension, but states it has “taken a few pills to get it right”.

Of the medications below, which are more likely taken by this patient if we assume it has exacerbated this presentation?
A
Acetazolamide
B
Bendroflumethiazide
C
Captopril
D
Mannitol
E
Nifedipine
Question 1 Explanation: 
Loop diuretics and thiazides are known to potentiate the underlying condition alluded to in the patient’s history.
Question 2

Stem 2 of 4

Which test should be requested first?
A
Arthrocentesis
B
CT foot and ankle
C
Serum uric acid
D
Ultrasound foot
E
XR foot and ankle
Question 2 Explanation: 
In all hot, swollen joints, the first test is to “tap” the joint for the three C’s of cells, cultures and crystals.
Question 3

Stem 3 of 4

Joint aspiration reveals mildly elevated white cells and negatively birefringent needle-shaped crystals. What is the most likely diagnosis?
A
Calcium pyrophosphate arthritis
B
Haemarthrosis
C
Monosodium urate arthritis
D
Osteoarthritis
E
Osteomyelitis
Question 3 Explanation: 
Negatively birefringent, needle-shaped crystals in an acute monoarthritis joint that is hot and swollen is classic of gout. The patient’s crystals are most likely formed of monosodium urate.
Question 4

Stem 4 of 4

Which would be the least appropriate therapy for this patient?
A
Allopurinol
B
Colchicine
C
Ibuprofen
D
Naproxen
E
Prednisolone
Question 4 Explanation: 
Although a classic anti-uric acid former, allopurinol should not be given in an acute attack of gout. It can potentiate the symptoms with “rebound gout”. First line management of acute gout is a mix of colchicine, steroids and NSAID.
Question 5

Stem 1 of 4

A 52 year old female presents with swelling of all her metacarpophalangeal, proximal interphalangeal joints and bilateral wrists for several years. She reports stiffness in the fingers in the morning that lasts about two hours.

What is the most likely diagnosis?
A
Arthritis mutilans
B
Osteoarthritis
C
Pseudogout
D
Reactive arthritis
E
Rheumatoid arthritis
Question 5 Explanation: 
This is the correct answer. Reactive would present similarly, but more acutely, and especially with an infective prodrome (ie urethritis or an upper respiratory infection for instance). Osteoarthritis has minimal morning stiffness and is characteristically asymmetrical. Arthritis mutilans is a late-feature of erosions in psoriatic arthritis. Pseudogout is formed of calcinosis in the joint and cartilage. Rheumatoid arthritis, a very common occurrence, presents with symmetrical, polyarthritic pain and swelling. The morning stiffness is said to last no longer than thirty minutes.
Question 6

Stem 2 of 4

The hand is examined with deformities present. Which of the following is most likely in this patient?
A
Bouchard node
B
Heberden node
C
Paronychia
D
Splinter haemorrhage
E
Ulnar deviation
Question 6 Explanation: 
Hand findings are rare nowadays. This is due to the success of disease modifying therapies as first line agents in rheumatoid arthritis. Swan neck, ulnar deviation, boutonniere deformity and sparing of the distal interphalangeal joints were once common rheumatological presentations for this diagnosis.
Question 7

Stem 3 of 4

Of the following tests, which is most specific for most likely diagnosis?
A
Anti-cyclic citrullinated peptide antibody
B
Anti-tumour necrosis factor alpha
C
Interleukin six and seven elevation
D
Rheumatoid factor
E
Tetany immunoglobulin
Question 7 Explanation: 
aCCP is elevated in 70% of rheumatoid arthritis patients versus 30% for the now-sadly named rheumatoid factor. Source: BMJ Best Practice, 2021.
Question 8

Stem 4 of 4

Study the radiograph below:

Which of the following features, on this radiograph, support the most likely diagnosis? Select all that may apply.
A
Joint erosions
B
Joint subluxation
C
Loss of joint space
D
Osteopenia
E
Soft tissue swelling
Question 8 Explanation: 
This radiograph, provided from the creative commons licence of Radiopedia (link) contains classic features of rheumatoid arthritis. Including, but not limited to, the above options.
Question 9

Stem 1 of 4

This is a classic presentation. Which condition should this be “assumed to be until proven otherwise”?
A
Acute flare of gout
B
Osteomyelitis
C
Psoriatic arthritis
D
Septic arthritis
E
Still’s disease
Question 9 Explanation: 
A hot, swollen, large joint with reduced movement is septic arthritis until proven otherwise. Due to the severity of the condition, and its often overlooked status in clerking, add this to the top of the differential list.
Question 10

Stem 2 of 4

Given the diagnosis, what is the most likely causative organism?
A
Coagulase-negative staphylococcal species
B
Neisseria gonorrhoea
C
Parvovirus
D
Staphylococcus aureus
E
Streptococcus pneumoniae
Question 10 Explanation: 
The vast majority of septic arthritis patients can be found to have staph or strep - with staph aureus the major causative organism.
Question 11

Stem 3 of 4

Select all of the following investigations you may order first line
A
Blood cultures
B
ESR, CRP
C
Liver function test
D
MRI knee
E
Procalcitonin
F
Synovial culture
G
Synovial gram stain
H
Synovial PCR
I
White cell count
Question 11 Explanation: 
The septic arthritis patient requires the following investigations. At the bedside, synovial fluid microscopy, culture, sensitivity, gram staining, white count. Within blood requests, white cell count, blood culture and sensitivity, acute phase proteins, UE, LFT. With imaging, a joint ultrasound and plain radiograph (non-urgently). PCT can be elevated in bacterial endotoxin presence. PCR may be considered if the aetiology is ?gonorrhoea.
Question 12

Stem 4 of 4

Whilst you are speaking to the patient, his observations are recorded and a deterioration occurs. The following is noted:
HR105, RR24, SBP 110, temp 39.3ÂşC, sats 98% air. The patient appears to be increasingly drowsy during the history.

What is the patient’s qSOFA score?
A
0
B
1
C
2
D
3
E
4
Question 12 Explanation: 
qSOFA requires sorting your HAT out. Hypotension, altered level of consciousness and tachypnoea. The patient has a lower than expected blood pressure, but not to the ≤100SBP. He has an altered level of consciousness - which is declining - and is tachypnoeic at 24. This gives him a total score of ⅔ which is considered a 3-14 fold increase in in-hospital mortality. The patient requires testing for organ dysfunction, but not delaying the Sepsis Six protocol. Septic arthritis most commonly transfers to the joint via the haematogenous route - inferring from this that the patient has bacteria in the bloodstream (septicaemia).
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