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Normal walking involves stance and swing phases of the lower legs sequentially in a smooth rhythm. Degenerative knee arthritis causes a painful limp, particularly during the stance phase on the affected knee. A supportive stick, held usually on the unaffected side, will help stabilise the affected knee by additional weight transfer. Physical treatment monitoring and a gait rehabilitation program can improve weight transfer and reduce pain, and is likely to be the most helpful initial management via a physiotherapist. Orthopaedic evaluation for arthroscopic clarification of diagnosis may be thereby delayed initially, but referral would be appropriate for persisting and worsening symptoms. Rest is helpful via relief of weightbearing but can lead to additional stiffness and impaired mobility, as can reliance on wheelchair support. Support strapping may provide additional relief if a painful effusion or a feeling of giving way are prominent symptoms. The normal gait through stance and swing is illustrated below. The right leg progresses from push-off to heel-strike – the first half of a full stride. Simultaneously, the left leg completes the second half – from heel-strike to push-off. (缺图)

A male patient of this age needs investigation for a secondary cause of his osteoporosis, rather than acceptance of the diagnosis of idiopathic osteoporosis. Thiazide diuretics have beneficial effects on bone density. Multiple myeloma often presents as osteoporosis; but a malignant cause is not suggested by the imaging. Hypogonadism, as an effect of radiation to the groin, is the most likely reason for this patient's osteoporosis in this setting. Body weight is associated with bone density, and obesity may have a protective effect on bone loss. Type 2 diabetes mellitus has no specific associations with osteoporosis. (缺图)

A male patient of this age needs investigation for a secondary cause of his osteoporosis, rather than acceptance of the diagnosis of idiopathic osteoporosis. (缺图)

A patient presents with systemic symptoms and a swollen joint.

Femoral neck fractures can be classified into two major types – intertrochanteric/pertrochanteric basal extracapsular fractures, and subcapital basicervical fractures, which occur within the joint capsule.

Sudden onset of neurological deficit in a patient who has multiple vascular risks is highly suggestive of a cerebrovascular accident (CVA). An older person who develops acute confusion should be investigated for underlying physical causes of delirium. A CVA in a person who is confused and on warfarin could be from a cerebral haemorrhage from a high INR. This patient's computed tomography (CT) scan, done without contrast, demonstrates cerebral infarction with secondary haemorrhage. (缺图)

This scenario is one of acute monoarticular gout in the right knee, with the clinical presentation as an acute effusion and the diagnostic findings of negatively birefringent crystals on microscopy, negative microbiological culture and excellent and prompt response to indomethacin. (缺图)

Progressive muscle weakness and skin rashes in a female of this age group is highly suggestive of dermatomyositis. Her hands show the typical Gottron sign – erythematous, scaly eruptions over the knuckles of interphalangeal and metacarpophalangeal joints. (缺图)

Progressive muscle weakness and skin rashes in a female of this age group is highly suggestive of dermatomyositis. Her hands show the typical Gottron sign - erythematous, scaly eruptions over the knuckles of interphalangeal and metacarpophalangeal joints. The creatine kinase (CK) is also raised. (缺图)

This 36-year-old man has a chronic multisystem disease with joint, neurological and skin manifestations, fever and hypertension. The clinical features are highly suggestive of polyarteritis nodosa with vasculitis and mononeuritis - the key features of the arteritis. This is an uncommon condition but the constellation of symptoms and signs is classical. Differential diagnosis would include another form of systemic vasculitis, and perhaps bacterial endocarditis. (缺图)

Aortic dissection is relatively uncommon (compared to myocardial infarction) but has to be recognised to avoid serious consequences. Patients are usually 60 to 80-year-old men; women present at an older age. Pre-existing aortic aneurysm is a risk factor. Inflammatory vasculitides (giant cell arteritis, syphilitic aortitis and Takayasu arteritis) are other predisposing factors. Collagen diseases such as Marfan syndrome should be suspected in a younger age group. Patients present with severe 'sharp chest pain'. Depending on the aortic branches affected, limb or organ ischaemia can follow. A pulse deficit is often seen, such as radio-radial delay or weak carotid, brachial or femoral pulses. With the scenario as described, the widening of the aorta on the chest X-ray should be diagnostic. This patient had a subsequent CT of the chest, which confirmed the aortic dissection. (缺图)

Acute gripping nocturnal calf pain is a common clinical condition of middle age, associated with muscular cramping and spasm, such that the pain is often intense and acute and associated with a firm, painful knotting of the affected calf. The pain is acute in onset and eases over a few minutes, sometimes leaving significant residual soreness. Relief is also obtained by getting up and walking or extending the ankle and foot. There is no specific association with systemic illness or vascular disease.

If this patient's problem was only ischaemic intermittent claudication, then conservative measures including cessation of smoking and encouragement of exercise would be beneficial. However, this man has rest pain and an ankle-brachial index suggestive of critical ischaemia. Active intervention is required if he is not to lose his limb. Certainly his lipid profile must be measured and, if necessary, measures taken such as the use of lipid-lowering agents. His blood sugar levels must be measured. His hypertension needs treatment.

The scenario is that of an arrhythmia occurring 24 hours after an acute non-ST segment elevation myocardial infarction (non-STEMI). This is a time when patients are at increased risk of cardiac arrhythmias, and particularly concerning are episodes of ventricular tachycardia, as illustrated in Rhythm strip A, showing a short period of sinus rhythm followed by ventricular tachycardia at a rate of 180/min. This may be associated with haemodynamic compromise, as in this patient, and require urgent DC reversion. (缺图)

If this patient's problem was only ischaemic intermittent claudication, then conservative measures including cessation of smoking and encouragement of exercise would be beneficial. However, this man has rest pain and an ankle-brachial index suggestive of critical ischaemia. Active intervention is required if he is not to lose his limb. Certainly his lipid profile must be measured and, if necessary, measures taken such as the use of lipid-lowering agents. His blood sugar levels must be measured. His hypertension needs treatment. The most important observation is that this man warrants an arteriogram and further assessment. Duplex Doppler venous studies will not identify an arterial blockage, which is the most likely diagnosis. For uncomplicated claudication any abnormal lipid profile, diabetes or hypertension should be treated. The most useful therapy is to persuade the patient to stop smoking and to try and improve the walking distance. There may be a role for pentoxifylline, but a number of randomised control trials have shown only a moderate benefit with this drug. Antiplatelet drugs (clopidogrel, aspirin) are often prescribed to reduce the overall risk of myocardial infarction and stroke.

The scenario is that of an arrhythmia occurring 24 hours after an acute non-ST segment elevation myocardial infarction (non-STEMI). This is a time when patients are at increased risk of cardiac arrhythmias, and particularly concerning are episodes of ventricular tachycardia, as illustrated in Rhythm strip A, showing a short period of sinus rhythm followed by ventricular tachycardia at a rate of 180/min (A is correct). This may be associated with haemodynamic compromise, as in this patient, and require urgent DC reversion. All of the other arrhythmias may occur following an acute myocardial infarction but do not carry the same risk of progression to ventricular fibrillation and cardiac arrest. Atrial fibrillation, as illustrated in rhythm strip B, would exhibit an irregular pulse rhythm. The acute haemodynamic instability exhibited in this patient is not usually so striking a feature with atrial flutter (rhythm strip C), supraventricular tachycardia (rhythm strip D) or heart block (rhythm strip E). (缺图)

An episode of rapid palpitations in a young patient following strenuous exercise is most likely due to an episode of paroxysmal supraventricular tachycardia, confirmed by the electrocardiogram (ECG) in Rhythm strip D with a regular pulse of 160/min (D is correct). The presence of ventricular tachycardia (Rhythm strip A) in the absence of any cardiac disease is much less likely. Atrial fibrillation (Rhythm strip B) is excluded on the basis of a regular rhythm. Atrial flutter with 4:1 block (Rhythm strip C) and complete heart block (Rhythm strip E) would not cause rapid palpitations. (缺图)

This older man has an asymptomatic arrhythmia presenting on a background of long-standing well-controlled hypertension. The pulse is regular, which rules out atrial fibrillation and the lack of symptoms of palpitations would tend to exclude a supraventricular tachycardia. The lack of any symptoms would also be most unusual in ventricular tachycardia or complete heart block. The ECG demonstrates atrial flutter with a 4:1 block (C is correct). Atrial flutter is a common complication of hypertension and hypertensive heart disease, and may be nonsymptomatic as in this scenario. (缺图)

The recurrent arrhythmia is most likely to be that of paroxysmal supraventricular tachycardia as demonstrated by his current ECG which shows a regular tachycardia at a rate of 180/min. The term supraventricular tachycardia is used to describe a range of regular tachyarrhythmias that have a narrow QRS complex on electrocardiogram (ECG), and are characterised by a re-entry circuit or automatic focus involving the atria. Paroxysmal supraventricular tachycardia may be managed by manoeuvres that increase vagal tone, including stimulation of nasopharyngeal afferents by immersing the face briefly in cold water, something he had discovered. Other methods of enhancing vagal tone are carotid sinus massage (caution is required in the elderly), and the Valsalva manoeuvre. If these are ineffective, the first line therapy is either adenosine or verapamil given intravenously (D is correct). This will restore sinus rhythm in most cases. If unsuccessful at first use, manoeuvres to increase vagal tone can be repeated, followed by further bolus injections of verapamil or adenosine. Verapamil must never to given to a patient with an undiagnosed wide-complex tachycardia. Other second line agents include the beta-blockers (for example, propranolol, atenolol, metoprolol, sotalol) and flecainide. Digoxin is rarely used and quinidine should not be used in supraventricular tachycardia. If attacks are frequent, prophylactic oral therapy with verapamil, beta-blocker, flecainide or amiodarone may be considered. (缺图)

Mitral stenosis is the heart lesion most likely to cause problems in pregnancy (A is correct). The pregnancy-induced increase in blood volume, cardiac output, and elevation of the pulse can lead to pulmonary hypertension and pulmonary oedema in mitral stenosis in pregnancy. There is an increased risk of atrial fibrillation and tachycardias. In contrast regurgitant mitral, aortic and tricuspid valvular diseases are generally well tolerated in pregnancy, with the pregnancy-induced decrease in peripheral vascular resistance reducing the risk of cardiac failure in these valvular lesions. Ventricular septal defect is usually well tolerated in pregnancy, in the absence of pulmonary hypertension, provided pre-pregnancy cardiac status is satisfactory.