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Questions and Answers
Which area of the frontal lobe is primarily responsible for speech production?
Which area of the frontal lobe is primarily responsible for speech production?
- Area 44 (correct)
- Area 10
- Area 4
- Area 6
The lateral sulcus separates the temporal lobe from the frontal and parietal lobes.
The lateral sulcus separates the temporal lobe from the frontal and parietal lobes.
True (A)
What is the function of Area 6 in the frontal lobe?
What is the function of Area 6 in the frontal lobe?
Premotor area
The __________ is the primary area for motor control in the frontal lobe.
The __________ is the primary area for motor control in the frontal lobe.
Match the following areas of the frontal lobe with their functions:
Match the following areas of the frontal lobe with their functions:
Which of the following functions is NOT assessed by the mini-mental state examination (MMSE)?
Which of the following functions is NOT assessed by the mini-mental state examination (MMSE)?
The motor cortex is located in the parietal lobe.
The motor cortex is located in the parietal lobe.
What is the primary responsibility of the somatosensory cortex?
What is the primary responsibility of the somatosensory cortex?
The _________ lobe is located at the back of the brain and is responsible for processing visual information.
The _________ lobe is located at the back of the brain and is responsible for processing visual information.
Match the following brain lobes with their respective characteristics:
Match the following brain lobes with their respective characteristics:
What is the typical white blood cell (WBC) count in crystal arthritis?
What is the typical white blood cell (WBC) count in crystal arthritis?
Presence of needle-shaped crystals is indicative of septic arthritis.
Presence of needle-shaped crystals is indicative of septic arthritis.
What microscopy technique is used to identify needle-shaped crystals in crystal arthritis?
What microscopy technique is used to identify needle-shaped crystals in crystal arthritis?
In gout, the baseline condition is typically _____ in nature.
In gout, the baseline condition is typically _____ in nature.
Match the condition to its feature:
Match the condition to its feature:
What is a common treatment for mild Adult-Onset Still's Disease (AOSD)?
What is a common treatment for mild Adult-Onset Still's Disease (AOSD)?
Pancytopenia is a feature associated with Hemophagocytic Lymphohistiocytosis (HLH).
Pancytopenia is a feature associated with Hemophagocytic Lymphohistiocytosis (HLH).
What condition is indicated by an elevated ferritin level in the context of Adult-Onset Still's Disease?
What condition is indicated by an elevated ferritin level in the context of Adult-Onset Still's Disease?
Septic arthritis is most commonly associated with _____ pain and limited range of motion.
Septic arthritis is most commonly associated with _____ pain and limited range of motion.
Match the following causes of septic arthritis with their descriptions:
Match the following causes of septic arthritis with their descriptions:
What age range is most commonly affected by Adult Onset Still's Disease (AOSD)?
What age range is most commonly affected by Adult Onset Still's Disease (AOSD)?
AOSD is characterized by a clinical triad of fever, rash, and arthritis.
AOSD is characterized by a clinical triad of fever, rash, and arthritis.
What color and type of rash is associated with AOSD?
What color and type of rash is associated with AOSD?
Increased levels of _____ is found in AOSD, indicating an inflammatory response.
Increased levels of _____ is found in AOSD, indicating an inflammatory response.
Match the findings of Adult Onset Still's Disease (AOSD) with their descriptions:
Match the findings of Adult Onset Still's Disease (AOSD) with their descriptions:
What is the first-line treatment for gout pain relief?
What is the first-line treatment for gout pain relief?
Hyperuricemia is one of the ACR criteria for diagnosing gout.
Hyperuricemia is one of the ACR criteria for diagnosing gout.
What does the term 'intercritical period' refer to in gout?
What does the term 'intercritical period' refer to in gout?
A significant characteristic seen in X-ray of chronic gout lesions includes _____ margins, known as Rat bite erosions.
A significant characteristic seen in X-ray of chronic gout lesions includes _____ margins, known as Rat bite erosions.
Match the following treatments with their respective classifications:
Match the following treatments with their respective classifications:
What type of crystals are deposited in Basic Calcium Phosphate disease?
What type of crystals are deposited in Basic Calcium Phosphate disease?
Calcium oxalate crystals display strong negative birefringence.
Calcium oxalate crystals display strong negative birefringence.
What condition is associated with calcinosis cutis?
What condition is associated with calcinosis cutis?
The Milwaukee shoulder condition involves rotator cuff arthropathy and __________ destruction.
The Milwaukee shoulder condition involves rotator cuff arthropathy and __________ destruction.
Match the following types of calcium oxalate to their classifications:
Match the following types of calcium oxalate to their classifications:
Which of the following is a common characteristic of septic arthritis?
Which of the following is a common characteristic of septic arthritis?
Gonococcal arthritis typically affects older adults.
Gonococcal arthritis typically affects older adults.
What is the gold standard for diagnosing septic arthritis?
What is the gold standard for diagnosing septic arthritis?
Chronic monoarticular arthritis can be caused by _____ disease such as tuberculosis.
Chronic monoarticular arthritis can be caused by _____ disease such as tuberculosis.
Match the type of arthritis with its characteristic:
Match the type of arthritis with its characteristic:
What is typically observed in a presentation of acute monoarticular arthritis associated with CPPD?
What is typically observed in a presentation of acute monoarticular arthritis associated with CPPD?
Chondrocalcinosis is symptomatic and usually causes significant pain in affected joints.
Chondrocalcinosis is symptomatic and usually causes significant pain in affected joints.
Which gene is associated with Calcium Pyrophosphate Dihydrate (CPPD)?
Which gene is associated with Calcium Pyrophosphate Dihydrate (CPPD)?
Pseudo-gout is associated with the presence of ______ crystals in joint fluid.
Pseudo-gout is associated with the presence of ______ crystals in joint fluid.
Match the following presentations with their associated characteristics:
Match the following presentations with their associated characteristics:
Which site is the most common for tophi deposition?
Which site is the most common for tophi deposition?
Tohpi formation is usually accompanied by acute pain and inflammation.
Tohpi formation is usually accompanied by acute pain and inflammation.
What are xanthine oxidase inhibitors used for in the treatment of crystal arthropathies?
What are xanthine oxidase inhibitors used for in the treatment of crystal arthropathies?
The rate of tophus formation correlates with degree and duration of __________.
The rate of tophus formation correlates with degree and duration of __________.
Match the treatment type with its corresponding agents:
Match the treatment type with its corresponding agents:
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Study Notes
Areas on Frontal Lobe
- Area 6: Premotor area
- Area 8 (Medially): Supplementary motor area
- Area 8: Frontal eye field
- Area 9, 10, 11, 12: Prefrontal area
- Area 44, 45: Motor speech area (Broca's area) located in the inferior frontal gyrus
- Area 4: Primary motor area (Precentral gyrus)
Medial Surface
- Precuneus
- Parieto-occipital fissure
- Cuneus
- Calcarine fissure
- Lingual gyrus
- Paracentral Lobule
- Superior Frontal Gyrus
- Cingulate Gyrus
- Cingulate sulcus
- Corpus callosum
- Fornix
- Hippocampal gyrus
- Fusiform gyrus
- Inferior temporal gyrus
Inferior Surface
- Gyrus rectus
- Olfactory sulcus
- Medial orbital gyrus
- Anterior orbital gyrus
- Post.orbital gyrus
- Lateral orbital gyrus
- Orbital sulcus (H-shaped)
Functional Frontal Lobe Anatomy
- Lateral sulcus/Sylvian fissure: A fissure separating the frontal and parietal lobes from the temporal lobe
mini-mental State Examination (mmse)
- Assesses higher mental functions/cognitive status
- Based on: Orientation, Registration, Attention, Recall, Language, Copying
Superolateral surface
- Frontal lobe: The largest lobe at the front of the brain.
- Temporal lobe: Located below the frontal lobe.
- Parietal lobe: Located behind the frontal lobe.
- Occipital lobe: Located at the back of the brain.
- Central sulcus: A groove separating the frontal and parietal lobes.
- Sylvian fissure: A deep groove that separates the frontal and temporal lobes.
- Motor cortex: Located in the frontal lobe, responsible for voluntary movement.
- Somatosensory cortex: Located in the parietal lobe, responsible for processing touch sensations.
- Visual cortex: Located in the occipital lobe, responsible for processing visual information.
- Auditory cortex: (Partially visible) responsible for processing auditory information.
Adult-Onset Still's Disease & Septic Arthritis
Minor Findings:
- Sore throat
- Negative ANA, RF
Hemophagocytic Lymphohistiocytosis (HLH)
- Rheumatological emergency
- Seen in 10% of AOSD
- Hepatosplenomegaly, lymphadenopathy
- Abnormal ALT/AST
Features:
- Pancytopenia
- Unsubsiding fever
- Ferritin ↑
Complications:
- Bleeding (due to thrombocytopenia)
- Disseminated Intravascular Coagulation (DIC) with consumptive coagulopathy
Treatment:
- Steroid
- Pulse therapy → Oral therapy
- ESR ↓
- Fibrinogen ↓
- Triglycerides ↑
- Transient thrombocytopenic purpura
- AA Amyloidosis
TREATMENT OF AOSD:
- Mild: NSAID
- No response: Steroid + methotrexate
- Anti IL-1, IL-6 (Note: Sulfasalazine is avoided)
Septic Arthritis
Acute Monoarticular Arthritis
Susceptible Host:
- Children
- Elderly
- Immunocompromised
Causes:
- Infection (20%)
- Staphylococcus aureus > Streptococcus
- Pneumonia > Gram-negative bacillus
- IV drug abuse (oligo/polyarticular)
- Spread: Hematogenous
Clinical Presentation:
- Fever
- Pain + Limited range of motion (most common in the knee)
- No history of similar episode
- Trauma
- Tumor
- Osteoarthritis of a single joint
- Sarcoidosis
Crystal Arthropathies
Subsequent Attacks:
- Involvement of ankle, knee, or wrist.
- Variable course.
Investigation: Synovial Study
Definitive Diagnosis (a.Cytology, Culture & Gram Stain):
| Feature | Crystal Arthritis | Septic Arthritis |
|---|---|---|
| WBC (cells/mD) | 10,000 - 50,000 | >50,000 |
| Focus of infection | - | + |
| Culture & gram stain | Negative | Positive |
| Other features | Presence of crystals | Immunosuppression + |
b.Polarised light microscopy:
- Needle-shaped crystals with strong negative birefringence.
- Polarising light microscopy: Needle-shaped crystals kept parallel to light ray.
Adult Onset Still's Disease (AOSD)
Age:
- 25-45 years
Presentation:
- Systemic
Features:
- Prodromal Phase: Sore throat
- Clinical Triad:
- Fever: Persistent high spiking that reaches subnormal levels during the day (quotidian)
- Rash: Salmon-colored, transient, maculopapular
- Arthritis: Symmetric, polyarticular (knee > wrist > ankle > elbow). Progress to severe/destructive arthritis in 25% of cases.
Additional Features:
- Joint Erosions: Most common in children
- Serositis: Inflammation of serous membranes
- Lymphadenopathy: Enlarged lymph nodes
- Hepatosplenomegaly: Enlargement of the liver and spleen
- Blood Parameters:
- Leukocytosis: Increased white blood cell count
- ESR (Erythrocyte Sedimentation Rate) ↑ : Elevated
- CRP (C-reactive protein) ↑: Elevated
- Yamaguchi Criteria (>5):
- Fever: Greater than 39°C for 7 days
- Arthritis/Arthralgia: Joint pain/inflammation for 2 weeks
Prognosis:
- Bad prognosis.
Other Findings
- Ferritin: Increased
- Serum Albumin: Decreased
- Rash: Present
- Leukocytosis
Rheumatology and Immunology
Gout
Treatment:
First Line:
- NSAIDs: Indomethacin 50mg TDS.
- Colchicine: Prevents neutrophil migration & chemotaxis. 1.2mg Stat → 0.6mg after 1 hr → 0.6mg BD × 1 week → 0.6mg OD × 3-6 months.
- Intra-articular steroids
Second Line:
- Anakinra: Anti IL-1 injection (Single dose).
- IM ACTH: Injection (Single dose).
- IV Pegloticase: (Recombinant uricase).
ACR Criteria of Gout:
- Acute monoarticular arthritis
- Hyperuricemia
- Dramatic response to colchicine
Intercritical Period:
- Symptom-free period
- Classical feature of crystal arthropathy
Chronic Gout Investigation:
- X-ray of lesion:
- Asymmetric
- Punched out lytic
- Overhanging edges: Martel sign / G sign
- Sclerotic margins: Rat bite erosions
- Joint space maintained
Ultrasound of Knee:
- Uric acid crystals:
- Hypoechoic hyaline cartilage:
- Femoral cortex:
Additional Information:
- 60%: Second flare within a year.
- Continued deposition: of tophaceous gout & erosion.
Tophi and Crystal Arthropathies
Basic Calcium Phosphate (BCP)
- Deposition of calcium hydroxyapatite crystals.
- Non-birefringent.
Presentation:
- Chronic calcific periarthritis: most common in the supraspinatus tendon.
- Milwaukee shoulder: Rotator cuff arthropathy + Glenohumeral destruction.
- Calcinosis cutis: Subcutaneous calcification.
- Seen in: 1.CREST syndrome. 2.Juvenile dermatomyositis (Lipodystrophy, myofascial involvement).
Calcium Oxalate
- Strong positive birefringence.
- Pyramidal, envelope shaped crystals.
Types:
- Primary: Seen in hyperoxaluria.
- Secondary: Seen in CKD.
- Note: mixture of hyperoxaluria → Combined kidney & liver transplantation.
Rheumatology and Immunology
Differential Diagnosis (D/d)
- Tendinitis, bursitis (to rule out)
- Hemophilia (similar presentation)
Gonococcal Arthritis
- Young, healthy individuals
- Migratory polyarthralgia/arthritis
Septic Arthritis
- Immunocompromised individuals
- Monoarticular arthritis
Diagnosis
- Synovial fluid analysis (gold standard)
- WBC > 50000 /μL
- Treatment (Rx):
- Antibiotics: vancomycin + ceftriaxone
- Drainage
Indications for drainage:
- Thick pus
- Shoulder, hip joint involvement
Chronic Monoarticular Arthritis
Causes:
- TB
- Fungal disease
- Lymes
- Sarcoidosis
- Spondyloarthritis
- Non-inflammatory
Approach to Arthritis
Monoarticular Arthritis:
- Septic:
- High WBC
- Crystal:
- Crystal analysis
- Inflammatory:
- Elevated inflammation markers
- Infectious:
- Infectious disease evaluation
- Undifferentiated:
Polyarticular Arthritis
- Acute:
- Post viral:
- Chronic Inflammatory (e.g., RA):
- Rheumatoid arthritis (RA)
- Systemic lupus erythematosus (SLE)
- Psoriatic arthritis
Calcium Pyrophosphate Dihydrate (CPPD)
Age:
- Elderly.
Symptoms:
- Asymptomatic.
Inflammation:
- Non-inflammatory.
Gene:
- ANKH
Presentations:
- Chondrocalcinosis: Asymptomatic calcification of articular cartilage. Predominantly affects the knee.
- Acute Monoarticular Arthritis:
- Bloody aspiration
- No hematogenous source of foci
- No response to antibiotics and colchicine
- Rhomboid crystals with weak positive birefringence
- Pseudo-gout
- Chronic Inflammatory Polyarthritis:
- Waxing and waning progression
- Non-erosive
- Pseudo RA
- Involvement of MCP (2nd, 3rd), wrist:
- Hook-like osteophytes (Seen in hemochromatosis)
- Pseudo-OA
- Pseudo neuropathic disease: Presents like Charcot's disease.
- Spondyloarthritis: Crowned dens syndrome (Dens in atlas)
- Septic Arthritis (m/c knee): Fever
Associations:
- Hyperparathyroidism
- Hypophosphatasia (differential diagnosis of rickets with decreased alkaline phosphatase)
- Hypomagnesemia (Seen in Gitelman syndrome)
- Hemochromatosis
Crystal Arthropathies
Tophi
- Irregular asymmetric moderately discrete tumescence of fingers d/t s/c deposition of MSU crystals.
- Painless.
- Acute on chronic: Acute inflammation surrounding tophi.
Sites:
- Olecranon (most common)
- Prepatellar bursa
- Ulnar surface
- Achilles surface
- Myocardium
- Heart valves
Treatment
Xanthine oxidase inhibitors: Uric acid lowering agents
- Febuxostat (S/E: Cardiotoxicity)
- Allopurinol 300mg daily.
- S/E: Hypersensitivity in HLA B58-01 susceptibility.
- Hairfall.
- Liver & renal disease.
Uricosuric agents: Enhance uric acid excretion
- Probenecid
- Sulfinpyrazone
- Benzbromarone
- Losartan (ACE inhibitor)
- Lesinurad
Recombinant uricase:
- Rasburicase
- Pegloticase Also used in acute gout & TLS.
Features:
- 12 years between first attack & chronic gout.
- Rate of tophus formation correlates with degree & duration of hyperuricemia.
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