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1. A 34 year-old woman complains of tingling and numbness in her right hand for the past three weeks which is keeping her awake at night. The numbness is worst in the thumb, with some radiation to the right elbow.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Cervical spondylosis
B. De Quervain’s tenosynovitis
C. Median nerve entrapment
D. Multiple sclerosis
E. Ulnar nerve entrapment

Answer: C

This is a typical history of carpal tunnel syndrome which is due to median nerve entrapment in the carpal tunnel at the wrist. Symptoms are worst at night, and pain and parasthesia can extend proximally in to the elbow and shoulder in some cases which may cause some confusion or difficulty with diagnosis. Tinel’s and Phalen’s tests are useful examination tools to help confirm the diagnosis, although they can often be negative in the presence of otherwise classical symptoms. In Tinel’s test, tapping over the carpal tunnel causes tingling in the distribution of the median nerve (thumb and radial two and a half fingers). In Phalen’s test, symptoms are elicited by forcible palmar flexion of the wrist causes venous engorgement of the carpal tunnel.Cervical spondylosis is common in the elderly, but would be unlikely in a 34 year-old patient.De Quervain’s tenosynovitis is an overuse condition. It is characterised by localised tenderness over the extensor and abductor tendon sheaths of the thumb.The most common site of ulnar nerve entrapment is at the elbow, and this typically causes parasthesia and/or weakness in the ring and little fingers.

2. A 62 year-old woman presents with pain and stiffness in both shoulders for the last four weeks. Her symptoms are worse in the mornings, and she also admits to low mood and recent-onset headaches.

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: H

The history of morning stiffness points towards this being an inflammatory condition, and in this age group polymyalgia rheumatica is common. It may be associated with other systemic and non-specific features such as malaise, anorexia, low-grade fever, weight loss and depression. The history of headaches raises the possibility of associated temporal arteritis, and this requires urgent further assessment.

3. A 56 year-old man presents with bilateral shoulder pain and weakness for the last three months. He has noticed increasing difficulty in lifting himself out of his armchair at home. Investigations reveal a raised C reactive protein and creatine kinase. [Show Discussion]

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: I

The history of objective weakness here suggests a possible muscular problem. In polymyositis the limb girdle or proximal muscles are most severely affected, but typically their bulk is preserved beyond that expected from their weakness. Raised C reactive protein and creatine kinase levels reflect the acute and chronic inflammation of skeletal muscle which occur in this condition.

4. A 44 year-old woman presents with pain in all of her joints for the last four months. Her symptoms are worse in the shoulders and hips. On examination she has multiple sites of tenderness including over both trapezius muscles. [Show Discussion]

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: B

Fibromyalgia is characterised by chronic widespread pain (for more than three months) and the presence of at least 11 out of 18 specified ‘tender points’.