1. The official SPM answer key is required to score each response, and item A1 is not fully legible.
2. A percentile or grade requires the patient’s age, the exact SPM edition/norm table used, and ideally the local normative reference.
3. The note “shaky → attention ↓” is clinically important. Reduced attention, tremor, anxiety, delirium, medication effects, fatigue, visual impairment, or poor motor control can lower performance. The result should therefore be reported as potentially invalid or an underestimate unless testing conditions were adequate.

Responses transcribed from the photo

Suggested clinical report wording

Raven’s Standard Progressive Matrices was attempted, with all 60 items apparently answered. Testing behavior was notable for shakiness and reduced attention. Because attention was compromised, the obtained score, if calculated, should be interpreted cautiously and may underestimate the patient’s nonverbal reasoning ability. A repeat assessment under optimized conditions may be appropriate if the result will affect diagnosis, capacity assessment, educational planning, or treatment decisions.

• A: 6, 5, 1, 3, 6, 3, 6, 6, 6, 6, 4, 5
• B: 6, 6, 6, 6, 2, 3, 6, 6, 6, 3, 1, 3
• C: 8, 6, 3, 3, 4, 4, 4, 4, 3, 3, 6, 3
• D: 3, 4, 4, 3, 8, 3, 3, 3, 2, 3, 4, 3
• E: 2, 4, 8, 4, 4, 3, 3, 4, 8, 3, 3, 3

• First photo: patient’s selected responses only.
• Second photo: official blank answer sheet only. It contains item labels A-01 to E-12, but no indicated correct options or marks.

• Correct answers in each set A-E
• Total raw score out of 60
• Error pattern across item difficulty
• Interpretation, once you also give the patient’s age and the relevant SPM norm table/edition.

• 1 if the selected option matches the official answer key
• 0 if it does not
• Total = sum of correct items, out of 60

Septic Arthritis - Orthopedic Notes

Definition

Etiology and routes of infection

Routes

1. Hematogenous spread - most common
2. Direct inoculation - penetrating injury, intra-articular injection, arthroscopy, surgery
3. Contiguous spread - osteomyelitis, cellulitis, abscess

Common organisms

Risk factors

• Diabetes mellitus
• Rheumatoid arthritis, osteoarthritis, gout, or other pre-existing joint disease
• Immunosuppression, corticosteroid therapy, malignancy, HIV
• Chronic kidney or liver disease
• Intravenous drug use
• Recent joint injection, arthroscopy, trauma, or surgery
• Skin infection, infected wound, bacteremia
• Prosthetic joint
• Extremes of age

Clinical features

Symptoms

• Acute onset severe joint pain
• Pain markedly aggravated by both active and passive movement
• Swelling, warmth, erythema, and tenderness
• Restricted range of movement
• Fever, malaise, anorexia, or inability to bear weight

Important findings

• Knee: painful swollen joint with effusion, held in slight flexion
• Hip: painful limitation of all movements, especially internal rotation; patient may keep hip flexed, abducted, and externally rotated
• Children: refusal to walk or use limb, pseudoparalysis
• Fever may be absent, particularly in elderly or immunocompromised patients

Any acute atraumatic painful joint with marked restriction of passive movement should be treated as septic arthritis until excluded.

Investigations

1. Blood tests

• CBC: leukocytosis may be present but is non-specific
• CRP: useful baseline and for monitoring response
• ESR: supportive but rises and falls more slowly
• Blood culture: obtain at least two sets before antibiotics if this does not delay treatment

2. Joint aspiration - most important test

1. Gram stain
2. Culture and sensitivity, including inoculation into blood-culture bottles if available
3. White-cell count and differential
4. Crystal analysis

Typical synovial-fluid features

3. Imaging

• Plain radiograph: baseline evaluation, excludes fracture, may show soft-tissue swelling or joint-space widening early; later joint-space loss, erosions, and subchondral destruction.
• Ultrasound: detects effusion and guides aspiration, particularly for hip, shoulder, and deep joints.
• MRI: detects adjacent osteomyelitis, pyomyositis, abscess, cartilage/bone involvement, or deep-joint infection.
• CT is useful when MRI is unavailable or for complex anatomy and surgical planning.

Differential diagnosis

• Crystal arthritis: gout or CPPD
• Hemarthrosis
• Acute flare of rheumatoid arthritis or osteoarthritis
• Reactive arthritis
• Transient synovitis of hip in children
• Cellulitis/bursitis
• Osteomyelitis
• Fracture or internal derangement
• Avascular necrosis

Management

Principles

Initial approach

1. Assess for sepsis or septic shock, begin resuscitation where needed.
2. Obtain blood cultures.
3. Aspirate the involved joint urgently.
4. Start empiric IV antibiotics immediately after samples are obtained.
5. Consult orthopedics early for drainage.
6. Modify antibiotic regimen according to culture and susceptibility results.
7. Monitor clinical status, CRP, WBC count, cultures, and range of movement.

Empiric antibiotics

• Cover S. aureus in all patients.
• Add MRSA coverage where prevalent or if patient-specific risk is high.
• Add Gram-negative coverage in elderly, immunocompromised patients, intravenous drug users, or when Gram-negative infection is suspected.
• Narrow therapy as soon as cultures are available.

Drainage options

Antibiotic duration

• Uncomplicated native-joint infection often requires approximately 2 to 4 weeks total therapy after adequate drainage, tailored to clinical and microbiological response.
• Longer treatment is needed with osteomyelitis, abscess, resistant organisms, immunosuppression, delayed control, or persistent infection.
• In uncomplicated pediatric native-joint infection responding promptly, SANJO suggests a minimum of 2-4 days IV treatment and 2-3 weeks total treatment, but local pediatric and infectious-disease protocols take priority.

Indications for repeat aspiration or repeat washout

• Persistent fever or systemic illness
• Ongoing severe pain/swelling
• Rising or non-falling CRP
• Persistent positive cultures/bacteremia
• Re-accumulation of effusion
• Failure to regain movement
• Inadequate initial drainage
• Associated osteomyelitis or abscess

Complications

• Articular cartilage destruction
• Joint stiffness and reduced range of movement
• Secondary osteoarthritis
• Osteomyelitis
• Growth-plate damage in children
• Avascular necrosis of femoral head, especially with hip involvement
• Pathological dislocation or subluxation
• Sepsis and death

Exam-oriented summary