Rheumatology 🦴🔬

 A 45 year old woman has complaints of fatigue over the past few months. She has had intermittent joint pains in both hands over the past year, often with morning stiffness. In the past, she has been investigated for microscopic haematuria and proteinuria. Her blood results are significant for a positive ANA, negative ANCA and a raised ESR. What is the SINGLE most likely diagnosis?

A 25 year old woman presents with easy fatigability, even with little exertion. She complains of headaches that comes and goes. She finds it difficult to sleep and feels body aches “everywhere”. She describes feeling tired throughout the day with difficulty concentrating. She has no previous medical conditions of note. Her symptoms have been persistent for the past 6 months. She remembers the symptoms starting after a viral infection which gradually worsen over time. Blood test such as full blood count, urea and electrolytes, liver function test, thyroid function test, C-reactive protein, random blood glucose, creatine kinase and urinalysis have returned with normal ranges. What is the SINGLE most likely diagnosis?

A 70 year old man attends the GP surgery with pain in his left knee. The pain started 3 days ago and is associated with knee swelling and redness. He has no history of any injury to the knee. The symptoms are accompanied by malaise. The joint is extremely tender with overlying erythema. His medical history includes systolic heart failure, ankle oedema and Raynaud’s syndrome. He takes regular losartan, bisoprolol, nifedipine, digoxin and indapamide. Which medication is likely to have contributed to his symptoms of knee pain?

A 32 year old woman has had a febrile illness and sudden onset of pain and swelling of the small joints of her feet and knees for the past two days. She has a maculopapular rash on her soles of her feet. She was previously well. There is no history of relevant travel outside the UK. On examination, conjunctivitis is noted. What is the SINGLE most likely diagnosis?

A 55 year old man has developed a red, tender swollen left foot over the past 2 days. The pain is severe enough that he is unable to weight bear. He has had a myocardial infarction 4 weeks ago and has been diagnosed with heart failure. He was recently prescribed medications by his cardiologist. Which of the medications is likely the cause of his left foot swelling?

A 26 year old avid badminton player presents to the GP surgery with a gradual onset of pain in her wrist that is exacerbated by gripping and raising objects. On examination, she has normal wrist motion and some tenderness over the radial styloid process. The pain is exacerbated on ulnar deviation while the thumb is gripped with the fingers of the affected hand. Which of the following is the most appropriate diagnosis?

A 63 year old lady has a generalised headache. The symptoms started suddenly over a day. She describes pain in her jaw muscles minutes after chewing. Examination reveals scalp tenderness on her left. She has no significant medical history. What medication would be most suitable to administer?

A 65 year old lady has severe pain along one side of her head and jaw. She complains that she is unable to comb her hair because of severe pain when the comb touches her scalp. She has no neurological deficits on examination. What is the SINGLE most likely cause of her symptoms?

A 30 year old man attends the GP surgery with pain at the base of his first right toe that started 5 days ago. On examination, there is swelling and redness of the surrounding the joint. He denies any fever. This is his first episode of pain at that area and there is no history of injury at that area. He has not taken any medication for pain relief. What is the SINGLE most appropriate first line management?

A 62 year old lady presents to the GP surgery with right-sided headache and decreased, blurry vision over the past 2 days. She also has pain around her jaw especially when chewing. Over the past 6 weeks, she has been feeling stiff over her neck, shoulders and hips especially in the morning. She struggles to get out of bed and out of her chair as she feels her hips are stiff. On examination, there is tenderness over parts of her right scalp. Her blood pressure is 130/80 mmHg. She has reduced power in the proximal muscles of her arms and legs. What is the SINGLE most appropriate initial investigation?

A 16 year old boy has had vague abdominal pain and myalgia over the past 6 months. He has a persistent unexplained fever. He is experiencing joint pain in multiple areas. He has widespread maculopapular rash on his trunk. He has a few subcutaneous nodules on his arms. His blood pressure is 144/93 mmHg. He has proteinuria. What is the SINGLE most likely diagnosis?

A 27 year old man has recurrent lower back pain and stiffness. The pain is worse in the morning and improves when he exercises. He finds it difficult to bend his back. It has been gradually worsening over the past 6 months. He has no history of trauma to his back. What is the SINGLE most appropriate investigation to perform?

A 15 year old boy was referred to the medical team with painful joints and a rash. The pain initially started on both sides of his knees a few days ago and progressed to his ankles and elbows. Ibuprofen seems to help with the pain in his joints. He had a sore throat and a fever two weeks ago which has resolved on its own. On examination, a pansystolic murmur can be heard in the mitral area. There are pink annular rashes on the trunk and upper arms and legs. Blood tests were taken and sent to the laboratory. What is the SINGLE most likely laboratory value to be abnormal?

A 27 year old female complains of intermittent pain in her fingers usually brought about in cold weather. She describes episodes of numbness and burning of the fingers. Her fingers usually become very pale if she does not wear gloves when going outdoors. What is the SINGLE most likely diagnosis?

A 47 year old woman has pallor followed by bluish discolouration of her hands when she goes out into the cold. She has been suffering with this discolouration for the past 3 years. She has symmetrical peripheral arthropathy which has been present for the last year. She also has small pink and red spots on her lips and her fingertips. What is the SINGLE most likely diagnosis?

A 52 year old woman with a history of systemic lupus erythematosus complains of dry eyes and altered sense of taste. Her voice becomes hoarse when she speaks for long periods of time. What is the SINGLE most likely diagnosis?

A 38 year old man recently had an appendicectomy and has now developed severe pain in his right big toe. He is noted to consume an average of 30 units of alcohol in a week. On examination, the joint of the right big toe is red and swollen. What is the SINGLE most likely diagnosis?

A 55 year old man has numbness in hands and feet. His medical history is significant for a asthma associated with nasal polyps and facial pain. Eosinophilia was shown on his last blood test. A pulmonary CT scan shows ground-glass inflammation. What is the SINGLE most likely diagnosis?

A 48 year old woman with a history of rheumatoid arthritis complains of dry eyes. A Schirmer’s test shows decreased tear production. And a rose Bengal stain documents corneal ulcerations. What is the SINGLE most likely diagnosis?

A 63 year old man presents with muscle weakness. He finds it difficult to walk for long periods of time or climb stairs. Activities such as rising from a seated position is difficult. He also finds difficulty in swallowing foods. His blood results show:

Alkaline phosphatase (ALP) 149 U/L

Aspartate transaminase (AST) 37 U/L

Alanine transferase (ALT) 44 U/L

Creatine kinase 440 U/L

Erythrocyte sedimentation rate (ESR) 16 mm/h

What is the SINGLE most likely diagnosis?

A 45 year old woman complains of pain in her hands precipitated by exposure to the cold weather. She also has breathlessness on walking. When she eats, she can feel food sticking to her throat. She finds it difficult to swallow. It is usually relieved with a drink of water. What is the SINGLE most likely cause of her dysphagia?

A 57 year old pianist presents to the GP surgery with a painful swelling of his right index finger. The swelling started 9 months ago. He has had previous stiffness of the joint. At present, he is unable to move the distal interphalangeal joint because of stiffness and pain. He does not take any medications. A picture of his right index finger is seen below:

What is the SINGLE most likely diagnosis?

A 60 year old woman attends the rheumatology outpatient clinic after being referred by her GP for fatigue and worsening joint pain. Her joint pain has been worsening from the last visit with the GP. She has bilateral hip, shoulder, elbow and wrist pain and stiffness that started 2 months ago. The pain is felt within her joints especially after prolonged periods of rest. She has been using naproxen for pain relief. On examination, there is tenderness at the metacarpophalangeal joints and proximal interphalangeal joints. There is obvious swelling of the proximal interphalangeal joints. Blood test requested a week ago show the following:

Haemoglobin 116 g/L (115-160 g/L)

Erythrocyte sedimentation rate (ESR) 84 (< age/2 mm/hour)

CRP 30 mg/L (< 10 mg/L)

Creatine kinase (CK) 150 U/L (5-170 U/L)

Which is the SINGLE most appropriate medication to prescribe to reduce symptoms

rapidly?

A 76 year old who is on medication for hypertension comes to clinic suffering from pain and redness at the metatarsophalangeal joint of his right first toe. Which of the following antihypertensive medication is like most likely to have caused his symptoms?

A 74 year old woman has a 2-day history of right-sided headache, right scalp tenderness and pain on chewing. She lost vision in her right eye 20 hours ago. Her ESR is 90 mm/hour. She was subsequently started on high dose oral steroids. What is the SINGLE most appropriate investigation?

A 39 year old man has been coughing up specks of blood for the past 4 weeks. He has been feeling fatigued over the past 4 months. He has been suffering with pain around his sinuses with nasal obstruction over the past 2 years. Occasionally, he has bloody rhinorrhoea. He has a saddle nose deformity. There are subcutaneous nodules on his elbows. What is the SINGLE most likely diagnosis?

A 44 year old woman complains of a sandy feeling under her eyes that has been present for the last year. She also says that she has difficulty swallowing. On examination, bilateral enlargement of the parotid glands were noted. What is the SINGLE most likely diagnosis?

A 62 year old lady has a right-sided headache and blurry vision over the past two days. She says it started with tenderness on her scalp when combing her hair. Blood test was requested and the results of her ESR came back elevated. What is the SINGLE most appropriate management?

A 43 year old woman has been having low moods and widespread muscle aches since her husband died 9 months ago. She has been extremely fatigued over the past 3 months. She becomes progressively tired, and resting does not improve her fatigue. She has difficulty sleeping and finds it difficult to concentrate. Her son has moved out of the house to stay at the university campus 2 months ago which has exacerbated her symptoms of pain. She wakes up tired. She has vague back pains. She also describes cramps in her abdomen. On examination, she is tender at specific points of her shoulder girdle, hips, upper and lower arms, legs, back, chest and neck. Her blood test show:

Haemoglobin 130 g/L (115-160)

White cell count 9 x 109/L (4-11)

Platelets 250 x 109/L (150-400)

Serum urea 4.5 mmol/L (2.0-7)

Serum creatinine 93 μmol/L (70-150)

Serum calcium 2.22 mmol/l (2.1-2.6)

Sodium 136 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5)

eGFR 90 mL/min (>90)

Thyroid stimulating hormone 4.0 mU/L (0.5-5.7)

Serum alkaline phosphatase (ALP) 110 U/L (30-150)

Serum alanine transferase (ALT) 32 U/L (5-35)

HbA1c 42 mmol/mol (<48)

Creatine kinase: 123 U/L (25-195)

Rheumatoid factor negative

Antinuclear antibodies negative

Anti-CCP negative

What is the SINGLE most likely diagnosis?

A 60 year old man presented with a spontaneous painful swelling of his right knee which appears hot and very tender on touching. The swelling became worse over the last few days. About a week ago, he had an inguinal hernia repaired as a day case. His regular medications include Ramipril 10mg daily, Bendroflumethiazide 2.5mg daily and Glyceryl trinitrate tablets when required. He is apyrexial on examination. What is the SINGLE best method for confirming the diagnosis?

A 69 year old woman with a medical history of rheumatoid arthritis for 25 years presents with left shoulder pain and swelling for 3 days. She has a low grade fever. On examination, there is decreased range of motion of the left shoulder joint and movement elicits pain. She takes regular low dose steroids for the past year to manage her flare of rheumatoid arthritis. She has no known drug allergies. Joint aspiration has been sent for microscopy and culture. Her blood results show:

CRP 168 mg/L

White cell count 14 x 109/L

What is the SINGLE most appropriate management?

A 45 year old man presents with complaints of fatigue, rash and diarrhoea. He states that he has had non-bloody diarrhoea for the past week. His rash is confined to the legs below the shorts-line. His pulse is 92 bpm and BP is 121/83mm Hg. He has dry skin and a dry tongue. He has a history of joint pain on his hands for the past few months. Blood sample results show decreased complement levels and the following additional findings:

Haemoglobin 110g/L (130-175)

Platelet count 90 x 109/L (150-400)

Serum urea 8.1 mmol/L (2.5-7.8)

Serum creatinine 123 micromol/L (60-120)

ESR 78 (<23)

CRP 14 (<10)

What is the most likely diagnosis?

A 61 year old man who suffers from rheumatoid arthritis is complaining of severe pain in the joints of his hands, feet and knees. He has been given intramuscular glucocorticoid 4 days ago when he attended the clinic which have improved his pain. He also takes senna daily to manage his ongoing constipation. He would like to know if there are any other medications he could use to manage his pain. Which medication(s) is appropriate to manage his pain?

A 29 year old man has been having chronic diarrhoea for the past year. He also complains of redness and pain in his right eye. He also has lower back pain and he experiences stiffness and pain which wakes him during early hours of the morning. On examination he is seen to have aphthous ulcers and perianal skin tags. His blood tests show:

Haemoglobin 100 g/L

White cell count 15 x 10^9/L

CRP 43 mg/L

Erythrocyte sedimentation rate (ESR) 22

What is the SINGLE most likely diagnosis?

A 33 year old woman presents with muscle and joint pains and fatigue over the past year. She also gives a history of losing hair. On examination, a purplish rash is seen on the bridge of the nose and cheeks sparing the nasolabial folds. A urinalysis was checked and was positive for proteinuria and haematuria. What is the SINGLE most appropriate initial investigation?

A 55 year accountant presents to the GP surgery with a spontaneous painful swelling of his right index finger. The swelling started three days ago and has worsened. He is apyrexial on examination. Attach is the picture of his ring finger:

There is increased warmth on the affected joint. He had a similar milder episode on that joint 6 years ago with joint stiffness which resolved by itself. He takes bendroflumethiazide for his high blood pressure. What is the SINGLE most likely diagnosis?

A 38 year old male presents to his GP with the complaint of coughing up blood. He says that he coughed up a few droplets of blood twice in the past three days and that he was concerned. Further questioning also reveals that he has been suffering from fatigue, malaise and generalised joint pains for about three months now. He takes over the counter paracetamol for his aches and joint pain. He has been suffering from chronic sinusitis and has been treated with several courses of antibiotics in the past. On examination, crusting in and around the patient’s nose is noted. A urine dipstick done shows the presence of blood. What is the SINGLE most likely diagnosis?

A 35 year old man has recently been diagnosed as having asthma. He has attended clinic with complains of having deep and aching pains in his lower back especially at night for the past 6 months. His medical notes include having a nasal polyp removed by ENT 3 years ago. He also suffers from allergic rhinitis. On examination, there are skin lesions present in the form of tender subcutaneous nodules on his legs. Investigations were performed and he was started on corticosteroids. What is the SINGLE most likely diagnosis?

A 78 year old woman is referred by her general practitioner to A&E with a 3-day history of unilateral headache and pain on chewing. Her ESR is 70 mm/hour. She was subsequently started on high dose oral steroids and discharged to her general practitioner. What is the SINGLE most appropriate additional treatment?

A 65 year old man has a generalized rash, fever, joint pain, and muscle pain. His medical history is significant for a late onset asthma associated with nasal polyps. He recently has been diagnosed with heart failure. Eosinophilia was shown on his last blood test. A chest X-ray shows fleeting peripheral pulmonary infiltrates and bilateral multifocal consolidations. What is the SINGLE most likely positive antibody?

A 34 year old woman has intermittent pain in her fingers usually brought about in cold weather. The colours of her fingers change when she is exposed to cold. First, it turns pale, after a few hours it becomes blue then red with a burning sensation before returning to a normal colour. Which is the SINGLE most appropriate drug to prescribe which would benefit her symptoms?

A 45 year old man with severe pain and redness at the metatarsophalangeal joint of his right big toe comes to the Emergency Department. He has never suffered from any form of arthritis before. He has hypertension and was recently started on bendroflumethiazide by his GP. What is the SINGLE most appropriate management?

A 59 year old man has a 4-day history of right-sided headache and blurry vision. He also has pain around his jaw especially when chewing. He was seen in A&E and had a blood test which showed elevated ESR. Corticosteroids were started. What is the SINGLE most appropriate medication to be added?

A 33 year old lady who has recently given birth presents with pain in the base of her thumb. The pain is worse on movements. The pain is particularly felt when she picks up her baby or while changing the diapers. What is the SINGLE most likely diagnosis?

A 33 year old woman comes in with a 6 month history of painless bilateral swelling of the face and a mild grade fever. The swelling has been progressively increasing in size. She also complains of having worsening symptoms of dry mouth. On a routine chest X- ray, she is found to have bilateral perihilar lymphadenopathy. What is the SINGLE most likely diagnosis?

A 59 year old male is in the CCU (Cardiac Care Unit). He suffered from a myocardial infarction 2 days ago which is now complicated by cardiac failure. He has now developed sudden onset of pain, redness and swelling of his right knee joint. What is the SINGLE best method for confirming the diagnosis of his swollen knee joint?

A 55 year old woman presents to the GP surgery with a history of feeling stiff over her neck, shoulders and hips in the morning over the past 8 weeks. She struggles to get out of bed and out of her chair since her symptoms started. She finds it difficult lifting her arm above her head. Over the past 3 days, she developed pain in her left jaw on chewing and a headache. She is usually fit and healthy. On examination, the power of her proximal arms and legs are reduced. She has tenderness on her left scalp. What is the most appropriate treatment?

A 49 year old woman with a medical history of diabetes and rheumatoid arthritis presents with left knee pain which has been worsening over the last 24 hours. There is no history of trauma to the knee. She has fever and rigors. On examination, there is decreased range of movement and the left knee joint is red and oedematous. Septic arthritis is suspected. What is the SINGLE most common organism responsible for septic arthritis?

A 55 year old lady with a medical history of hypertension and rheumatoid arthritis presents with an acutely hot, swollen, and tender right knee joint to the Emergency Department. The pain started 2 days ago. There is pain on movement and there is decreased passive and active range of motion. She reports a mild fever for the past 3 days. What is the SINGLE most appropriate investigation to perform?

A 79 year old woman has been started on prednisolone 60 mg for her recent diagnosis of giant cell arteritis. She is asked to take omeprazole for gastric protection. She reached menopause at age 49 years old. She has no history of fractures. Her recent DEXA scan shows a bone mineral density T-score of -3.1. Which medication is the most appropriate medication to add?