June 26th, 2009
A 76 year old man presents with atrial fibrillation which is permanent. He is lucid and has specifically made an appointment with you to discuss the best way of stopping him “dying ” as a result of the AF.
PMHx:
Hypertension (treated), Mild COPD. Nil else of note.
DHx
Verapamil (as treatment for AF)
Amlodipine
Simvastatin
PRN inhalers
SHx
Lives alone. Independent. Can carry out all ADL’s (activities of daily living)
What is the anticoagulation schedule you would recommend to prevent stroke?
a. Clopidrogel
b. Warfarin
c. Aspirin
d. No anticoagulation
e. Warfarin and Aspirin
June 16th, 2009
At Medical Educator we are always looking to push the boundaries of what we can do on the web to further medical student e-learning in preparation for medical student finals.
We’re pretty excited about the potential our new technology (in collaboration with the kind folks at iSpring) has to offer medical students an even richer learning experience.
Have a go at our free interactive MCQ picture quiz above to get a feel of the kind of things we will be producing in future – that’s ontop of our established base of over 1000 MCQs for medical students, practical video guides for medical finals, podcasts, and one-minute revision downloads!
June 11th, 2009
Five students are planning a 4 day marathon bike ride, for cancer research in Wales. What a great commitment – all friends, all doing something fun and challenging, for the benefit of charity. They are hoping to raise £1500 for the cause – Medcical Educator salutes them.
Wales Online reports that Huw Morgan, a fourth year medical student, said: “We know cancer is one of the leading causes of death in Wales, and affects so many people. We believe Cancer Research Wales is a great cause and can make a real difference for people suffering with the illness.”
Have any of you med students out there done anything similar or are planning anything similar? We would love to get involved.
June 9th, 2009
The answer is…. b. Rheumatoid arthritis
Symmetrical disease?
Erosions?
This is classical of RA X-ray changes that include
1. Erosions
2. Reduced joint space
3. Peri-articular osteoporosis
4. Nodules
So from the initial history of disease [small joints, both hands], the likely diagnoses would be
- RA
- PsA
- (less likely) gout.
Erosive changes are not specific to RA however but the findings were symmetrical
- both gout and PsA tend to be asymmetrical
Don’t be put off by the fact he’s male, although RA is roughly 3x commoner in women. You dont get a mention of which joints are affected here: RA has a penchant for the wrists and MCP joints. Erosions of the ulnar styloid are very common.
Common x-ray changes of the different arthritides are shown below:
Non Inflammatory
Primary OA: Asymmetrical
There are classically 4 signs of OA on an X-ray: Occurs in classic joints eight bearing e.g. Hips& Knees. May not be symmetrical.
1. Subchondral bone sclerosis
2. Cystic Change
3. Osteophytes
4. Reduced Joint Space
Charcot Joints:
1. Destruction of the joint
2. Disorganisation (bones not arranged in the correct /usual arrangement through gross destruction e.g. cuniforms of the foot.
3. Increased density (sclerosis)
4. Debris (boney debris from a destroyed joint: often with well defined margins
5. Dislocation
Secondary OA
As per primary OA but occurring in a joint that has been previously damaged from any other disease process (inflammatory disease etc)
Inflammatory
Gout: Asymmetrical
The classical signs of gout on an Xray are: Erosions with sclerotic margins. Asymmetrical.
1. A relatively preserved joint space
2. Minimal periarticular osteoporosis
3. Nodules (these are in fact tophi)
Psoriatic Arthritis: Asymmetrical
The X-ray Changes are similar to rheumatoid but they differ in their distribution, and the formation of pencil in cup deformities along with osteolysis.
1. Asymmetrical distribution of disease
2. Often affects PIP and DIP joints
3. relative absence of peri-articular osteoporosis
4. Erosions seen at the distal interphalangeal joints joints
5. Reduced joint space
6. Pencil in cup deformity (arthritis mutilans with telescoping of the fingers)- this is a result of osteolysis
7. Loss of the terminal tufts of the phalanges (acro-osteolysis)
8. Sacroiliac and spondylitic changes (similar to those of Ank. Spond.)
Rheumatoid Arthritis: Symmetrical
1. Erosions
2. Reduced joint space
3. Periarticular osteoporosis
4. Nodules
Septic Arthritis: Asymmetrical
1. Periarticular osteoporosis
2. Loss of joint space
3. Deformity/subluxation
4. Erosions
5. Effusion
6. Usually just 1 joint
June 2nd, 2009
A 64 year old male presents with a symmetrical arthritis of both hands (history from the GP letter) with early morning stiffness. His X-rays of his hands done before clinic show the following:
Periarticular osteoporosis of the MCP joints
Erosion on the ulnar styloid
Symmetrical distribution of disease
Reduced joint space at the carpal bones
What is the most likely diagnosis?
a. Ankylosing Spondylitis
b. Rheumatoid arthritis
c. Gout
d. Secondary Osteoarthritis
e. Psoriatic Arthritis