[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has attended the acute medical take on account of breathlessness.  Please examine their respiratory system and present your findings to the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191704″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has dermatomyositis with pulmonary involvement.

The clinical signs exhibited in this video include:

  • A purplish heliotropic rash around the eyes;
  • Bibasal fine crepitations in keeping with pulmonary fibrosis.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Dermatomyositis belongs to a group of muscle disease called myopathies characterized by inflammation and muscle weakness. The idiopathic inflammatory myopathy is a systemic disorder affecting muscles and skin mostly, but joints, esophagus, lungs and rarely heart may also be involved.

While the exact etiology is not known, infectious, genetic, immunologic, environmental and drug-induced aspects are all contributory factors. Possible triggers may be:

  • Viruses, toxoplasma and borellia species
  • Genetic components like specific HLA types
  • Polymorphisms of TNF (-308A specifically is linked to photosensitivity)
  • Immunologic abnormalities
  • Abnormal T cell activity
  • Antinuclear antibodies
  • Statins
  • Penicillamine
  • Interferon
  • Anti-TNF drugs
  • Cyclophosphamide
  • Quinidine

The cardinal symptom of the disease is a skin rash, with 40% of the patients presenting with skin disease as the sole complaint. This rash could be preceded, followed or accompanied with a muscle weakness. Other symptoms include:

  • Patchy rashes with purple or red discolorations on eyelids, knuckles, elbow, knees and toes
  • Red rashes on face , neck, shoulders, upper chest, back and other regions along with swelling
  • Proximal muscle weakness (initially in climbing stairs, rising from sitting position)
  • Muscle tenderness
  • Weight loss
  • Arthralgia
  • Arthritis
  • Dyspnea
  • Arrhythmia
  • Dysphagia
  • Dysphonia
  • Malignancy (in people >60)
  • GI ulcers and infections in children
  • Tiptoe gait (children)
  • Joint contractures
  • Subcutaneous calcifications (frequency higher in juvenile Dermatomyositis)

Clinical signs like Heliotrope rash (symmetrical distribution of an erythematous rash, rare in other diseases) and Gottron papules (flat topped papules on bony prominences) are pathognomonic of the disease. Other signs include:

  • Malar erythema
  • Periungual and cuticular changes
  • Poikiloderma
  • Dilated capillary loops at the base of finger nails

Investigations carried out to confirm the diagnosis are blood tests assessing muscle enzymes, autoantibodies and imaging tests including:

  • MRI
  • Chest X-ray
  • Ultrasonography
  • EMG
  • CT
  • Muscle and skin biopsy

While there is no cure for the condition, symptomatic management involves medication, physical therapy, surgery and treatment of systemic manifestations and complications. This makes use of:

  • Administering steroids
  • immunosuppressive agents to reduce inflammation
  • Avoiding sun exposure
  • Topical steroids
  • Immunomodulatory medications
  • Methotrexate
  • Physical therapy prevents atrophy

Surgical intervention is for the removal of calcinosis (children are more prone to develop), which causes nerve pain and recurrent infections.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has dermatomyositis.  He has a heliotropic rash around his eyes and also bibasal crepitations in keeping with likely pulmonary involvement or a side effect of medication.  I would like to investigate initially with a chest x-ray and pulmonary function tests.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]