When a psoas abscess is suspected, CT abdomen is the recommended diagnostic test. Tom has presented with right-sided abdominal pain that is relieved by hip flexion, along with a positive psoas sign and a low-grade fever, which are indicative of psoas abscess. Although MRI has a similar sensitivity to contrast CT, it is less accessible. Retrocaecal appendicitis is less likely based on Tom’s history and examination. While abdominal ultrasound is preferred for investigating appendicitis in children and pregnant women, abdominopelvic CT is preferred for other adults. Hip x-ray is not the most useful test in this case, as osteomyelitis or avascular necrosis are less likely based on Tom’s clinical presentation. Colonoscopy is not the most appropriate test to order next, as his symptoms are unlikely to be caused by a flare-up of his Crohn’s disease.

An iliopsoas abscess is a condition where pus accumulates in the iliopsoas compartment, which includes the iliacus and psoas muscles. There are two types of iliopsoas abscesses: primary and secondary. Primary abscesses occur due to the spread of bacteria through the bloodstream, with Staphylococcus aureus being the most common cause. Secondary abscesses are caused by underlying conditions such as Crohn’s disease, diverticulitis, colorectal cancer, UTIs, GU cancers, vertebral osteomyelitis, femoral catheterization, lithotripsy, endocarditis, and intravenous drug use. Secondary abscesses have a higher mortality rate compared to primary abscesses.

The clinical features of an iliopsoas abscess include fever, back/flank pain, limp, and weight loss. During a clinical examination, the patient is positioned supine with the knee flexed and the hip mildly externally rotated. Specific tests are performed to diagnose iliopsoas inflammation, such as placing a hand proximal to the patient’s ipsilateral knee and asking the patient to lift their thigh against the hand, which causes pain due to contraction of the psoas muscle. Another test involves lying the patient on the normal side and hyperextending the affected hip, which should elicit pain as the psoas muscle is stretched.

The investigation of choice for an iliopsoas abscess is a CT scan of the abdomen. Management involves antibiotics and percutaneous drainage, which is successful in around 90% of cases. Surgery is only indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.

Felty’s syndrome is characterized by the presence of rheumatoid arthritis, splenomegaly, and a decreased white blood cell count. It is crucial to recognize this condition as patients may experience frequent and severe infections. The current patient is likely septic due to pneumonia.

Rheumatoid arthritis (RA) is a condition that can lead to various complications beyond joint pain and inflammation. These complications can affect different parts of the body, including the respiratory system, eyes, bones, heart, and immune system. Some of the respiratory complications associated with RA include pulmonary fibrosis, pleural effusion, and bronchiolitis obliterans. Eye-related complications may include keratoconjunctivitis sicca, scleritis, and corneal ulceration. RA can also increase the risk of osteoporosis, ischaemic heart disease, infections, and depression. Less common complications may include Felty’s syndrome and amyloidosis.

It is important to note that these complications may not affect all individuals with RA and the severity of the complications can vary. However, it is essential for individuals with RA to be aware of these potential complications and to work closely with their healthcare providers to manage their condition and prevent or address any complications that may arise. Regular check-ups and monitoring of symptoms can help detect and manage any complications early on.

When a patient is suspected to have cauda equina syndrome, it is crucial to conduct an urgent MRI of the spine for investigation. This is the preferred method of investigation to determine the cause of the syndrome. The most common cause is a herniated intravertebral disc that compresses the cauda equina. Other possible causes include primary or metastatic spinal tumors, infections like epidural abscesses, or hematomas. Imaging is necessary to identify the specific pathology causing the syndrome, determine the level of pathology, and guide the appropriate intervention. The article Cauda equina syndrome by Lavy C and Wilson-MacDonald J in BMJ 2009;338:b936 provides further information on this topic.

Cauda equina syndrome (CES) is a rare but serious condition that occurs when the nerve roots in the lower back are compressed. It is crucial to consider CES in patients who present with new or worsening lower back pain, as a late diagnosis can result in permanent nerve damage and long-term leg weakness and urinary/bowel incontinence. The most common cause of CES is a central disc prolapse, typically at L4/5 or L5/S1, but it can also be caused by tumors, infections, trauma, or hematomas. CES can present in various ways, and there is no single symptom or sign that can diagnose or exclude it. Possible features include low back pain, bilateral sciatica, reduced sensation in the perianal area, decreased anal tone, and urinary dysfunction. Urgent MRI is necessary for diagnosis, and surgical decompression is the recommended management.

Pain in the distribution of the lateral cutaneous nerve of the thigh is a common symptom of Meralgia parasthetica. This pain is often worsened by standing and relieved by sitting, and is accompanied by altered sensation in the anterolateral aspect of the thigh. Meralgia parasthetica can be caused by pregnancy, obesity, tense ascites, trauma, or surgery, and is more prevalent in individuals with diabetes.

In contrast, fibromyalgia typically presents with pain in the neck and shoulders, along with other symptoms such as fatigue, muscle stiffness, difficulty sleeping, and cognitive impairment. Fibromyalgia pain does not typically affect the lateral thigh.

L3 lumbar radiculopathy, on the other hand, causes pain in the lower back and hip that radiates down into the leg, often accompanied by muscle weakness.

Osteoarthritis is characterized by joint pain and stiffness in the hips or knees, and is more common in older individuals, females, and those who are overweight. It does not typically cause changes in sensation in the thigh.

Understanding Meralgia Paraesthetica

Meralgia paraesthetica is a condition characterized by paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN). It is caused by entrapment of the LFCN, which can be due to various factors such as trauma, iatrogenic causes, or neuroma. Although not rare, it is often underdiagnosed.

The LFCN is a sensory nerve that originates from the L2/3 segments and runs beneath the iliac fascia before exiting through the lateral aspect of the inguinal ligament. Compression of the nerve can occur anywhere along its course, but it is most commonly affected as it curves around the anterior superior iliac spine. Meralgia paraesthetica is more common in men than women and is often seen in those aged between 30 and 40.

Patients with meralgia paraesthetica typically experience burning, tingling, coldness, or shooting pain, as well as numbness and deep muscle ache in the upper lateral aspect of the thigh. Symptoms are usually aggravated by standing and relieved by sitting. The condition can be mild and resolve spontaneously or severely restrict the patient for many years.

Diagnosis of meralgia paraesthetica can be made based on the pelvic compression test, which is highly sensitive. Injection of the nerve with local anaesthetic can also confirm the diagnosis and provide relief. Ultrasound is effective both for diagnosis and guiding injection therapy. Nerve conduction studies may also be useful. Overall, understanding meralgia paraesthetica is important for prompt diagnosis and management of this condition.

The appropriate management for osteomalacia, which is likely caused by chronic kidney disease, involves vitamin D supplementation with an initial loading dose regime. Blood tests for osteomalacia typically reveal low levels of calcium and phosphate, as well as high levels of alkaline phosphatase. Calcium supplementation may also be prescribed if the patient’s dietary intake is insufficient. Intravenous fluids and bisphosphonates are not recommended for the treatment of hypocalcaemia, while levothyroxine is used to manage hypothyroidism and oral bisphosphonates are used for osteoporosis.

Understanding Osteomalacia

Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.

The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.

The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.

The patient’s symptoms suggest an S1 lesion, as evidenced by sensory loss in the posterolateral aspect of the leg and lateral aspect of the foot, weakness in plantar flexion of the foot, reduced ankle reflex, and a positive sciatic nerve stretch test. L3, L4, and L5 are not the correct answer as their respective nerve root involvement would cause different symptoms.

Understanding Prolapsed Disc and its Features

A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.

The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.

The patient’s symptoms of swelling and pain in the distal interphalangeal joints and dactylitis suggest a diagnosis of psoriatic arthritis. This is further supported by her use of a prescription coal tar shampoo for psoriatic lesions on her scalp. Psoriatic joint disease can cause a distinct X-ray appearance known as a pencil-in-cup deformity, characterized by periarticular erosions and bone resorption.

In contrast, erosions with overhanging edges, also known as rat-bite erosions, are associated with gout and tophi, typically affecting the first metatarsal joint in the foot. Joint effusion may be present in the early stages of septic arthritis, which should be ruled out for any hot, painful swollen joint. However, the patient’s lack of systemic illness and unchanged swelling over time make septic arthritis less likely.

Osteoarthritis, a non-inflammatory degenerative arthritis that worsens with age, does not typically present with dactylitis and is characterized by X-ray features such as loss of joint space, osteophytes, and subchondral sclerosis.

Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is known to have a poor correlation with cutaneous psoriasis. In fact, it often precedes the development of skin lesions. This condition affects both males and females equally, with around 10-20% of patients with skin lesions developing an arthropathy.

The presentation of psoriatic arthropathy can vary, with different patterns of joint involvement. The most common type is symmetric polyarthritis, which is very similar to rheumatoid arthritis and affects around 30-40% of cases. Asymmetrical oligoarthritis is another type, which typically affects the hands and feet and accounts for 20-30% of cases. Sacroiliitis, DIP joint disease, and arthritis mutilans (severe deformity of fingers/hand) are other patterns of joint involvement. Other signs of psoriatic arthropathy include psoriatic skin lesions, periarticular disease, enthesitis, tenosynovitis, dactylitis, and nail changes.

To diagnose psoriatic arthropathy, X-rays are often used. These can reveal erosive changes and new bone formation, as well as periostitis and a pencil-in-cup appearance. Management of this condition should be done by a rheumatologist, and treatment is similar to that of rheumatoid arthritis. However, there are some differences, such as the use of monoclonal antibodies like ustekinumab and secukinumab. Mild peripheral arthritis or mild axial disease may be treated with NSAIDs alone, rather than all patients being on disease-modifying therapy as with RA. Overall, psoriatic arthropathy has a better prognosis than RA.

Calcium supplementation should only be prescribed alongside bisphosphonate treatment for osteoporosis if the patient’s dietary intake is insufficient.

Bisphosphonates: Uses and Adverse Effects

Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.

To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.

Septic arthritis is most commonly found in the knee joint in adults.

The symptoms described in the scenario, such as acute swelling, pain, redness, and fever, are indicative of septic arthritis. In adults, the knee joint is the most frequently affected site for this condition. The patient’s systemic illness rules out gout as a possible diagnosis, which typically presents differently and is less common in females. Pseudogout, which is more common in women and can also affect the knee joint, is another possible differential diagnosis. However, given the patient’s overall presentation, septic arthritis is the most likely diagnosis. Ankle joint septic arthritis is possible but less common, while the base of the big toe is more commonly associated with acute gout attacks. Although septic arthritis can affect large joints like the hip, the knee joint is still the most commonly affected site in adults.

Septic Arthritis in Adults: Causes, Symptoms, and Treatment

Septic arthritis is a condition that occurs when bacteria infect a joint, leading to inflammation and pain. The most common organism that causes septic arthritis in adults is Staphylococcus aureus, but in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism. The infection usually spreads through the bloodstream from a distant bacterial infection, such as an abscess. The knee is the most common location for septic arthritis in adults. Symptoms include an acute, swollen joint, restricted movement, warmth to the touch, and fever.

To diagnose septic arthritis, synovial fluid sampling is necessary and should be done before administering antibiotics if necessary. Blood cultures may also be taken to identify the cause of the infection. Joint imaging may also be used to confirm the diagnosis.

Treatment for septic arthritis involves intravenous antibiotics that cover Gram-positive cocci. Flucloxacillin or clindamycin is recommended if the patient is allergic to penicillin. Antibiotic treatment is typically given for several weeks, and patients are usually switched to oral antibiotics after two weeks. Needle aspiration may be used to decompress the joint, and arthroscopic lavage may be required in some cases.

The most specific autoantibody associated with dermatomyositis is anti-Jo-1. This is consistent with the patient’s symptoms, which include proximal myopathy, Gottron’s papules, mechanic’s hands, and a heliotrope rash. Anti-Ro antibody, anti-Smith antibody, and antinuclear antibody are not specific to dermatomyositis and are associated with other rheumatological conditions.

Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.

The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.

Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.

The most likely diagnosis for this case is reactive arthritis, which is a type of arthritis that occurs after a distant infection in the gastrointestinal or urogenital area. It is characterized by joint pain, urethritis, and uveitis, and is more common in individuals who have the HLA-B27 gene. The infections that commonly trigger reactive arthritis are caused by Salmonella, Shigella, Yersinia, and Campylobacter organisms.

Other possible diagnoses were ruled out based on the absence of certain symptoms. Behcet’s disease, which presents with oral and genital ulcers and uveitis, was unlikely due to the lack of ulcers or visual symptoms. Septic arthritis, which causes joint swelling and pain, was also considered but was less likely because it typically affects only one joint and is accompanied by fever and other signs. Systemic juvenile idiopathic arthritis and systemic lupus erythematosus were also considered but were ruled out due to the absence of their characteristic symptoms.

Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, further studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA). Reactive arthritis is defined as arthritis that occurs after an infection where the organism cannot be found in the joint. The post-STI form is more common in men, while the post-dysenteric form has an equal incidence in both sexes. The most common organisms associated with reactive arthritis are listed in the table below.

Management of reactive arthritis is mainly symptomatic, with analgesia, NSAIDs, and intra-articular steroids being used. Sulfasalazine and methotrexate may be used for persistent disease. Symptoms usually last for less than 12 months. It is worth noting that the term Reiter’s syndrome is no longer used due to the fact that Reiter was a member of the Nazi party.

Hydroxychloroquine can cause severe and permanent retinopathy, leading to a ‘bull’s-eye maculopathy’ in its advanced form. This damage is irreversible and may continue to progress for over a year even after discontinuing the drug. Therefore, it is crucial to regularly monitor for early changes to prevent irreversible visual deterioration. The patient’s eye examination did not reveal any signs of dry age-related macular degeneration or cytomegalovirus retinitis. Lupus retinopathy is also unlikely as the patient has no other symptoms of poorly controlled lupus, and there were no signs of cotton wool spots, microaneurysms, hard exudates, or neovascularization on fundoscopy.

Hydroxychloroquine: Uses and Adverse Effects

Hydroxychloroquine is a medication commonly used in the treatment of rheumatoid arthritis and systemic/discoid lupus erythematosus. It is similar to chloroquine, which is used to treat certain types of malaria. However, hydroxychloroquine has been found to cause bull’s eye retinopathy, which can result in severe and permanent visual loss. Recent data suggests that this adverse effect is more common than previously thought, and the most recent guidelines recommend baseline ophthalmological examination and annual screening, including colour retinal photography and spectral domain optical coherence tomography scanning of the macula. Despite this risk, hydroxychloroquine may still be used in pregnant women if needed. Patients taking this medication should be asked about visual symptoms and have their visual acuity monitored annually using a standard reading chart.

After being diagnosed with temporal arthritis, it is important to conduct vision testing as a crucial investigation. This autoimmune condition affects blood vessels and can be effectively treated with steroids, with an initial dose of 40-60 mg being recommended to alleviate symptoms and prevent further progression. If left untreated, temporal arthritis can lead to irreversible blindness due to occlusion of the ophthalmic artery, which may be preceded by transient visual problems. Unlike renal function, which is not significantly impacted by temporal arthritis, aspirin and a CT head are typically used to diagnose ischemic stroke or TIA. While co-codamol can effectively treat tension headaches, an MRI head is not a primary investigation for temporal arthritis due to its high cost. Additionally, fludrocortisone is not the first line of treatment for this condition.

Temporal arthritis, also known as giant cell arthritis, is a condition that affects medium and large-sized arteries and is of unknown cause. It typically occurs in individuals over the age of 50, with the highest incidence in those in their 70s. Early recognition and treatment are crucial to minimize the risk of complications, such as permanent loss of vision. Therefore, when temporal arthritis is suspected, urgent referral for assessment by a specialist and prompt treatment with high-dose prednisolone is necessary.

Temporal arthritis often overlaps with polymyalgia rheumatica, with around 50% of patients exhibiting features of both conditions. Symptoms of temporal arthritis include headache, jaw claudication, and tender, palpable temporal artery. Vision testing is a key investigation in all patients, as anterior ischemic optic neuropathy is the most common ocular complication. This results from occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins. Other symptoms may include aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.

Investigations for temporal arthritis include raised inflammatory markers, such as an ESR greater than 50 mm/hr and elevated CRP. A temporal artery biopsy may also be performed, and skip lesions may be present. Treatment for temporal arthritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is used. If there is evolving visual loss, IV methylprednisolone is usually given prior to starting high-dose prednisolone. Urgent ophthalmology review is necessary, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin.

The 2016 NICE guidelines suggest considering oral non-steroidal anti-inflammatory drugs (NSAIDs) for the management of low back pain, while taking into account potential differences in toxicity for the gastrointestinal, liver, and cardio-renal systems, as well as the individual’s risk factors, including age. When prescribing oral NSAIDs for low back pain, appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment should be considered. It is recommended to prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period of time. Weak opioids (with or without paracetamol) should only be considered for managing acute low back pain if an NSAID is contraindicated, not tolerated, or has been ineffective. Paracetamol alone should not be offered for managing low back pain.

Management of Non-Specific Lower Back Pain

Lower back pain is a common condition that affects many people. In 2016, NICE updated their guidelines on the management of non-specific lower back pain. The guidelines recommend NSAIDs as the first-line treatment for back pain. Lumbar spine x-rays are not recommended, and MRI should only be offered to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected.

Patients with non-specific back pain are advised to stay physically active and exercise. NSAIDs are recommended as the first-line analgesia, and proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs. For patients with sciatica, NICE guidelines on neuropathic pain should be followed.

Other possible treatments include exercise programmes and manual therapy, but only as part of a treatment package including exercise, with or without psychological therapy. Radiofrequency denervation and epidural injections of local anaesthetic and steroid may also be considered for acute and severe sciatica.

In summary, the management of non-specific lower back pain involves encouraging self-management, staying physically active, and using NSAIDs as the first-line analgesia. Other treatments may be considered as part of a treatment package, depending on the severity of the condition.

The combination of fever, back pain, and pain when extending the hip suggests the presence of an iliopsoas abscess. The patient may also exhibit a limp while walking. Iliopsoas abscesses can be caused by primary or secondary factors. While Pott’s disease, a form of tuberculosis affecting the vertebrae, could explain the back pain and fever, the examination findings are more indicative of an iliopsoas abscess. Mechanical back pain would not typically produce constitutional symptoms like fever. Pyelonephritis is a potential differential diagnosis, but the examination findings are more consistent with an iliopsoas abscess. It may be helpful to rule out pyelonephritis with a urine dip and ultrasound. Although kidney stones can cause severe pain and fever if infected, the duration of the patient’s symptoms makes this possibility less likely.

An iliopsoas abscess is a condition where pus accumulates in the iliopsoas compartment, which includes the iliacus and psoas muscles. There are two types of iliopsoas abscesses: primary and secondary. Primary abscesses occur due to the spread of bacteria through the bloodstream, with Staphylococcus aureus being the most common cause. Secondary abscesses are caused by underlying conditions such as Crohn’s disease, diverticulitis, colorectal cancer, UTIs, GU cancers, vertebral osteomyelitis, femoral catheterization, lithotripsy, endocarditis, and intravenous drug use. Secondary abscesses have a higher mortality rate compared to primary abscesses.

The clinical features of an iliopsoas abscess include fever, back/flank pain, limp, and weight loss. During a clinical examination, the patient is positioned supine with the knee flexed and the hip mildly externally rotated. Specific tests are performed to diagnose iliopsoas inflammation, such as placing a hand proximal to the patient’s ipsilateral knee and asking the patient to lift their thigh against the hand, which causes pain due to contraction of the psoas muscle. Another test involves lying the patient on the normal side and hyperextending the affected hip, which should elicit pain as the psoas muscle is stretched.

The investigation of choice for an iliopsoas abscess is a CT scan of the abdomen. Management involves antibiotics and percutaneous drainage, which is successful in around 90% of cases. Surgery is only indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.

A mutation in the fibrillin-1 protein is responsible for causing Marfan’s syndrome. This protein is coded by the Marfan syndrome gene (MSF1) located on chromosome 15. Connective tissue contains fibrillin, which is a glycoprotein. Synovial fluid contains hyaluronic acid, while elastin is an extracellular matrix protein found in connective tissue. Laminin is another extracellular matrix protein that forms part of the basement membrane.

The optimal surgical approach for intertrochanteric (extracapsular) proximal femoral fracture is the use of dynamic hip screws. These screws are considered dynamic due to their ability to tighten as the bone heals. Hemiarthroplasty is not the preferred option for this type of fracture, as it is typically reserved for displaced intracapsular fractures in patients with significant comorbidities or immobility. Internal fixation is also not the preferred approach, as it is typically used for undisplaced intracapsular fractures in mobile patients without serious comorbidities. Intramedullary nails are not the preferred approach for intertrochanteric fractures, as they are typically used for subtrochanteric fractures.

Hip fractures are a common occurrence, particularly in elderly women with osteoporosis. The femoral head’s blood supply runs up the neck, making avascular necrosis a potential risk in displaced fractures. Symptoms of a hip fracture include pain and a shortened and externally rotated leg. Patients with non-displaced or incomplete neck of femur fractures may still be able to bear weight. Hip fractures can be classified as intracapsular or extracapsular, with the Garden system being a commonly used classification system. Blood supply disruption is most common in Types III and IV fractures.

Intracapsular hip fractures can be treated with internal fixation or hemiarthroplasty if the patient is unfit. Displaced fractures are recommended for replacement arthroplasty, such as total hip replacement or hemiarthroplasty, according to NICE guidelines. Total hip replacement is preferred over hemiarthroplasty if the patient was able to walk independently outdoors with the use of a stick, is not cognitively impaired, and is medically fit for anesthesia and the procedure. Extracapsular hip fractures can be managed with a dynamic hip screw for stable intertrochanteric fractures or an intramedullary device for reverse oblique, transverse, or subtrochanteric fractures.

Dermatomyositis is often associated with an underlying malignancy, making it crucial to thoroughly investigate patients for cancer. A CT scan of the chest, abdomen, and pelvis is the most reliable and efficient method for detecting any potential malignancy. While a chest x-ray may identify lung cancer, it is not as accurate and may miss tumors in other areas. An MRI of the brain is unlikely to be helpful as intracerebral pathology is not typically associated with dermatomyositis. The most common cancers associated with dermatomyositis are lung, breast, and ovarian cancer. A PET scan may be used for staging and detecting metastases after an initial CT scan. An ultrasound of the MCP joints is unnecessary for diagnosis confirmation and would not be a reliable method for evaluating Gottron papules. A biopsy may be necessary if diagnostic uncertainty remains.

Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.

The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.

Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.

To assess for an Achilles tendon rupture, Simmonds’ triad can be used. This involves three components: palpating the Achilles tendon to check for a gap, observing the angle of declination at rest to see if the affected foot is more dorsiflexed than the other, and performing the calf squeeze test to see if squeezing the calf causes the foot to plantarflex as expected. It’s important to note that struggling to stand on tiptoes or having an abnormal gait are not part of Simmonds’ triad.

Achilles tendon disorders are a common cause of pain in the back of the heel. These disorders can include tendinopathy, partial tears, and complete ruptures of the Achilles tendon. Certain factors, such as the use of quinolone antibiotics and high cholesterol levels, can increase the risk of developing these disorders. Symptoms of Achilles tendinopathy typically include gradual onset of pain that worsens with activity, as well as morning stiffness. Treatment for this condition usually involves pain relief, reducing activities that exacerbate the pain, and performing calf muscle eccentric exercises.

In contrast, an Achilles tendon rupture is a more serious condition that requires immediate medical attention. This type of injury is often caused by sudden, forceful movements during sports or running. Symptoms of an Achilles tendon rupture include an audible popping sound, sudden and severe pain in the calf or ankle, and an inability to walk or continue the activity. To help diagnose an Achilles tendon rupture, doctors may use Simmond’s triad, which involves examining the foot for abnormal angles and feeling for a gap in the tendon. Ultrasound is typically the first imaging test used to confirm a diagnosis of Achilles tendon rupture. If a rupture is suspected, it is important to seek medical attention from an orthopaedic specialist as soon as possible.

Dermatomyositis is characterized by the presence of Gottron’s papules, which are roughened red papules primarily located over the knuckles.

Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.

The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.

Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.