Question 1: A patient presents with severe pain and swelling in his knee joint for 10 days. He also complains of pain and discomfort during urination. He says that he had diarrhea one month ago and he has been unwell since then. What is the most likely diagnosis?
- A. Psoriasis arthritis
- B. Rheumatoid arthritis
- C. Enteropathic arthritis
- D. Reactive arthritis (Correct Answer)
Explanation: Reactive arthritis
- This diagnosis is strongly supported by the triad of symptoms: **arthritis** (knee pain/swelling), **urethritis** (pain during urination), and a preceding **gastrointestinal infection** (diarrhea one month prior) [1].
- Reactive arthritis is an inflammatory arthritis triggered by an infection in another part of the body, often **gastrointestinal** or **genitourinary** [2].
*Psoriasis arthritis*
- This condition is associated with **psoriasis**, a skin disease characterized by red, scaly patches, which is not mentioned in the patient's history.
- While it can affect joints, it does not typically present with a preceding gastrointestinal infection or urethral symptoms.
*Rheumatoid arthritis*
- **Rheumatoid arthritis** typically presents with symmetric polyarticular joint involvement, often affecting smaller joints like those in the hands and feet, rather than a single large joint like the knee [3].
- It does not typically follow a gastrointestinal infection or involve urethral symptoms.
*Enteropathic arthritis*
- This type of arthritis is associated with **inflammatory bowel diseases** (IBD) like Crohn's disease or ulcerative colitis.
- While diarrhea can be a symptom of IBD, the patient's presentation with acute urethritis points away from enteropathic arthritis as the primary diagnosis, which often involves axial skeleton or peripheral joints but typically not urethral inflammation.
Question 2: Following complete ileal and partial jejunal resection, the patient is most likely to have-
- A. Constipation
- B. Gastric ulcer
- C. Folic acid deficiency
- D. Vitamin B12 Deficiency (Correct Answer)
Explanation: ***Vitamin B12 Deficiency***
- The **terminal ileum** is the primary site for **vitamin B12 absorption**, complexed with intrinsic factor [3]. Resection of this segment significantly impairs this process.
- Patients with **ileal resection** are highly susceptible to developing **megaloblastic anemia** and neurological complications due to **vitamin B12 deficiency** [3].
*Constipation*
- Complete ileal and partial jejunal resection is **more likely to cause diarrhea** rather than constipation, particularly due to malabsorption of bile salts and fats [2].
- **Bile salt malabsorption** in the colon often leads to secretory diarrhea [1].
*Gastric ulcer*
- Gastric ulcers are typically associated with *Helicobacter pylori* infection or NSAID use, and are **not a direct consequence** of ileal and jejunal resection.
- While short bowel syndrome can sometimes lead to increased gastric acid secretion, peptic ulcer formation is not the most likely or direct complication.
*Folic acid deficiency*
- **Folic acid** is primarily absorbed in the **jejunum**, and while partial jejunal resection occurred, complete ileal resection is less directly implicated in folate deficiency.
- Other sections of the small intestine can often compensate for partial jejunal loss in folate absorption, making B12 deficiency a more immediate and severe concern after complete ileal resection.