MBChB Clinical Scenarios

Show Learning Points most relevant to Phase 1:

Swollen and tender joints

Clinical Discipline(s)/Organ System(s)
Musculoskeletal System, Rheumatology

Progress Test Topic(s)
Musculoskeletal

Description

A 40 year old Fijian Indian woman presents to her GP with a several week history of painful, stiff joints in her hands and feet. It takes her over an hour in the morning to 'get going'. She is feeling much more tired than usual and has lost 3 kg in weight over the last 2 months. Clinical examination revealed 22 swollen joints (all the MCP, PIP and wrist joints) and 22 tender joints (all the MCP, PIP and wrist joints). The metatarsal squeeze test was positive.

Progress Test-Type Questions: Question 1 | Question 2

Applied Science for Medicine
   - Structure, function and common pathologies of synovium
   - Structure, function and common pathologies of small joints of the hands and feet
   - Pathogenesis of rheumatoid arthritis, including the role of cytokines
   - Genetic basis of autoimmune disease, including relevance of HLA groups
   - Immune mechanisms of acute and chronic inflammation

Clinical and Communication Skills
   - History relevant to a patient with a connective tissue disorder
   - Musculoskeletal examination including an examination of an acute joint
   - Perform and record a Gait-Arms-Legs-Spine (GALS) screen
   - Differential diagnosis of acute and chronic joint pain
   - Blood tests in diagnosing inflammatory arthritis
   - X-ray and MRI in assessing patients with inflammatory arthritis
   - Clinical features and extra-articular complications of rheumatoid arthritis
   - Clinical features of osteoarthritis
   - Multidisciplinary approach in a patient with inflammatory arthritis
   - The use of simple analgesia, non-steroidal anti-inflammatory drugs and their side effects in long-term use
   - The use of disease modifying drugs and biological therapies in inflammatory arthritis

Personal and Professional Skills
   - How far to investigate in general practice; how to accomplish an appropriate referral and what important points to include in the referral letter
   - Potential for joint destruction with inflammatory arthritis and the need for active treatment to maintain employment
   - Balancing side-effects of powerful medications against need to control inflammation
   - The effect of rheumatoid arthritis on life-expectancy

Hauora Māori
   - Awareness of impact of socioeconomic deprivation on Māori and appropriate response
   - Understanding of inequities in access to health services and quality of medical care for Māori, including delay in specialist referral
   - Awareness that hospitalisation rates for arthritis (including gout, osteoarthritis and rheumatoid arthritis) are higher for Māori than non-Māori

Population Health
   - Smoking as the most important environmental trigger for rheumatoid arthritis
   - Epidemiology of rheumatoid arthritis, risk factors, prognosis, time trends
   - Cost-effectiveness of disease-modifying antirheumatic drugs
   - Management, audit and monitoring of chronic arthritis

Conditions to be considered relating to this scenario

Common
rheumatoid arthritis, systemic lupus erythematosus (SLE), Sjögren’s syndrome, psoriatic arthritis, acute viral polyarthritis (hepatitis, parvovirus B19, rubella), reactive arthritis, osteoarthritis, polyarticular gout

Less common but 'important not to miss'
septic arthritis, enteropathic arthritis (associated with inflammatory bowel disease)

Uncommon
palindromic rheumatism, chikungunya (in a recent traveller), polymyalgia rheumatica, paraneoplastic disease, sarcoid arthropathy