2) An 87 year old female who is 2 weeks post TKR presents with a sore swollen knee. She has a history of atrial fibrillation. Her vital signs are:

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1 EMQ - Rheumatology For each clinical vignette match the correct diagnosis. Reiter s syndrome Pseudogout Septic arthritis Gout Haemarthrosis Traumatic effusion Ankylosing spondylitis Rheumatoid arthritis Osteoarthritis 1) A 65 year old man presents with a swollen and painful left knee. There is no history of trauma. His vital signs are: HR 86 /min BP 142/88 mmhg RR 15 /min Sats 99% RA T 37.4 o C A joint aspiration is performed and results are shown below. Appearance: Bloodstained RBC: x10 6 /L WCC: x10 6 /L % Neutrophils: 85 % Gram stain: Microscopy: no organisms seen +vely birefringent (yellow) crystals seen 2) An 87 year old female who is 2 weeks post TKR presents with a sore swollen knee. She has a history of atrial fibrillation. Her vital signs are: HR 66 /min BP 133/98 mmhg RR 12 /min Sats 99% RA T 37.1 o C A joint aspiration is performed and results are shown below. Appearance: Bloodstained RBC: x10 6 /L WCC: x10 6 /L % Neutrophils: 14 % Gram stain: Microscopy: no organisms seen nil

2 3) A 32 year old drug user presents with a painful swollen knee. Her vital signs are: HR 116 /min BP 103/62 mmhg RR 19 /min Sats 99% RA T 38.6 o C A joint aspiration is performed and results are shown below. Appearance: Turbid RBC: x10 6 /L WCC: x10 6 /L % Neutrophils: 83 % Gram stain: Microscopy: gram +ve cocci seen nil 4) A 62 year old man presents with a painful swollen knee. He has no history of trauma. His vital signs are: HR 82 /min BP 163/91 mmhg RR 14 /min Sats 99% RA T 37.2 o C A joint aspiration is performed and results are shown below. Appearance: Turbid RBC: x10 6 /L WCC: x10 6 /L % Neutrophils: 51 % Gram stain: Microscopy: no organisms seen -vely birefringent (blue) crystals seen 5) An 18 year old university student presents complaining of dysuria. He also has a sore swollen knee. His vital signs are: HR 96 /min BP 111/77 mmhg RR 10 /min Sats 99% RA T 37.9 o C A joint aspiration is performed and results are shown below. Appearance: Turbid RBC: x10 6 /L WCC: x10 6 /L % Neutrophils: 62 % Gram stain: Microscopy: no organisms seen nil

3 SAQ 1. An 86 year old female self presents to the emergency department after a fall in her garden. She has a history of rheumatoid arthritis, ischaemic heart disease and hypertension. She is complaining of midline upper neck pain. Question 1. What are your immediate actions? (3 marks) Must include: (1 mark each) - immobilize the patient s neck - arrange emergent imaging plus items from (0.5 marks each) - assess for neurologic impairment - assess for other injuries - administer analgesia Question 2. Should a plain radiograph or CT be performed? Why? (2 marks) 1 mark each for: This patient is high risk (old, rheumatoid arthritis) CT has a higher sensitivity and specificity. Question 3. There is a problem with the CT scanner, and a plain film of the neck is obtained in the interim. What is the major abnormalities? (2 marks)

4 Answer: this xray shows significant swelling anterior to C1 and C2 and loss of alignment of C1 on C2/dens fracture. Question 4. What is the injury? (1 mark) The xray shows atlantoaxial dislocation or instability, a complication of rheumatoid arthritis. These patients are at high risk of c-spine injury. An associated fracture must be suspected. Question 5. In light of the xray findings, what are your immediate actions? (2 marks) Must include (1 mark each) - arrange definitive imaging (CT or MRI) - contact neurosurgery

5 SAQ 2. A 65 year old man presents with fever dyspnoea and haemoptysis. He also describes dark discolouration of the urine and lower limb swelling. His vital signs are: HR 112 /min BP 145/85 mmhg RR 32 /min Sats 88% 15L NRB T 38.1 o C GCS 15 Question 1. His chest xray is shown below. Describe the major abnormalities and give 4 important negatives? 4 marks Answer must include: Abnormalities (1 mark each) - Diffuse consolidation across multiple lobes (RUL, LUL, RML) - ground glass appearance/some preservation of the airspaces Negatives (0.5 marks each) - no pleural effusions - no pneumothorax/surgical emphysema - no ETT/NGT - normal width mediastinum - no lobar consolidation - no fractures of the ribs/clavicles

6 Question 2. List your differential diagnoses (4 marks) Must include (1 mark each) - ARDS secondary to sepsis - Bronchopneumonia - Inflammatory lung disease: Goodpasture s syndrome, wegener s granulomatosis or another form of pulmonary vasculitis Others (0.5 marks each up to 1 mark) - viral pneumonitis - other respiratory infections - disseminated bronchoalveolar cancer **NOTE, will not accept acute pulmonary oedema as a differential** Question 3. What are your treatment priorities? (2 marks) Must include (1 mark each) - administration of appropriate antimicrobial agents, specifying drug and dose - immediate respiratory support by either NIPPV or RSI.

7 SAQ 3. A 55 year old diabetic woman presents with a painful knee. There is no history of trauma. Her vital signs are: HR 140 /min BP 85/45 mmhg RR 22 /min Sats 99% RA T 39.4 o C GCS 15 A clinical image of the knee is shown below. Question 1. What are the major abnormalities present in the image? (3 marks) Must include: - erythema extending across knee joint - small punctum/wound over anterolateral leg - knee joint effusion Question 2. What is your differential diagnosis? (2 marks) Must include: (1 mark each) - septic arthritis

8 - cellulitis Question 3. Describe your technique for aspiration of the joint. (5 marks) Must include (4 marks) - aseptic technique - medial or lateral approach - use of 23g or 21g needle, placed under patella angling towards joint space - aspiration of fluid as needle inserted Extras (1 mark, up to a maximum of 1 mark) - infiltration of local anaesthetic OR appropriate adjunct analgesia (eg nitrous oxide) - consent and documentation of procedure - ultrasound guidance

9 SAQ 4. A 26 year old man presents to the ED with painful legs and dysuria. He has swelling to both ankles, the left knee and the small joints of his right hand. His vital signs are: HR 102 /min BP 114/78 mmhg RR 14 /min Sats 98% RA T 37.4 o C GCS 15 Question 1. List your 3 most likely differential diagnoses (2 marks) Must include: - Reiter s syndrome/reactive Arthritis as suggested by stem (1 mark) Others from a reasonable list of polyarthropathies (0.5 marks each) Inflammatory - Enteropathic arthritis - Rheumatoid arthritis - Ankylosing spondylitis - Psoriatic arthritis Infective - Ross River or other arboviruses - Syphilis Inflammatory - SLE etc Question 2. What specific historical features will you ask about? (2 marks) Must include: - sexual history/symptoms of STD (1 mark) Others from reasonable list specific to polyarthropathies (0.5 marks each) - other infective Sx: cough, fever, gastroenteritis - GIT Sx, bleeding, mucus etc - Occular symptoms (association with reactive arthritis) - Skin symptoms (psoriasis) Note, if including things such as past medical history must be specific and relate to the stem, for example past history autoimmune disease. Question 3. What investigations will you perform? (2 marks) Must include: - urine PCR for Chlamydia and Gonorrhoea OR penile swabs for STD screen (1 mark) Others from reasonable list (0.5 marks each) - FBC - Renal function - Inflammatory markers

10 - Serology for RRV, chikungunya, HIV as dictated by clinical history - Autoimmune screen Question 4. A presumptive diagnosis of reactive arthritis is made. Outline your discharge plan. (4 marks) Must include: - analgesia specified in a reasonable regime (1 mark) Eg paracetamol 1g QID and ibuprofen 400mg tds +/- opiates for breakthrough - treatment of the underlying infection (1 mark) Other - extra marks for specifying appropriate treatment for STDs (Azithromycin 1g stat plus 500mg 1g IM or IV ceftriaxone) (1 mark) - communication with GP/outpatients for follow up (1 mark)

11 SAQ 5. A 39 year old man presents with a diffuse rash across both legs. He had diarrhoea a week previously. A photo of his legs is shown below. Question 1. Describe the photograph. (3 marks) Must include (0.5 marks each) - bilateral but asymmetric rash - well circumscribed - appears dark/purpuric rather than classic wheal and flare allergy - areas of confluence Extra marks (0.5 marks each to a maximum of 1) - distribution above knees - linear distribution where socks finish - plus any other reasonable comments Question 2. Select pathology results are shown below. Describe the results (4 marks) INR 1.0 PT 12 s APTT 29 s Plt count 25 x10 9 /L Fibrinogen 5.0 g/l D-dimer 0.1 mg/dl Urea 15.8 mmol/l Creatinine 120 umol/l

12 Answer must include (1 mark each) - normal coagulation values - isolated thrombocytopaenia - normal d-dimer and fibrinogen levels - elevated renal indices Question 3. Interpret the results and give the most likely diagnosis (3 marks) The results show an isolated thrombocytopaenia with renal dysfunction (2 marks) This suggests a diagnosis of haemolytic uraemic syndrome (1 mark)