A 55-year-old Asian woman with severe rheumatoid arthritis has not responded well to most traditional DMARD treatments. She is currently taking methotrexate 20 mg weekly and has been receiving regular infusions of the anti-TNF-alpha monoclonal antibody, infliximab, for the past six months. Her joint disease has significantly improved. However, she now presents with fevers, pleuritic chest pain, and a large pleural effusion on the left side, with little evidence of joint synovitis. What is the most probable diagnosis?
MRCP2-4687
A 40-year-old female presents with sudden onset back pain after lifting a chair. The pain is severe, worsens with movement, and spreads to both sides of the hypochondriacal region. She denies any previous fractures but reports a gradual loss of height (5 cm from her young adult height) and occasional self-limiting back pain. The patient experienced spontaneous menopause at the age of 35 and has never taken any regular medications, calcium, or vitamin D supplements in the past.
During examination, a dorsal hyperkyphosis was observed, and severe back pain was elicited on movement and local percussion. Further investigations revealed a BMD T-score of -3.0 at the lumbar spine and -2.8 at the total hip, as assessed by dual-energy x-ray absorptiometry.
What is the diagnosis?
MRCP2-4688
A 29-year-old woman with systemic lupus erythematosus is seeking advice at the pre-conception clinic regarding her medications before attempting to conceive. She has been stable on mycophenolate and hydroxychloroquine for over a year and has never been pregnant before. Additionally, she has well-controlled asthma with beclomethasone and salbutamol inhalers and takes omeprazole regularly for gastro-oesophageal reflux. What medication adjustment is most suitable?
MRCP2-4689
A 42-year-old woman comes to the clinic complaining of tightening in her fingers, mild difficulty swallowing, and mild shortness of breath when exerting herself. She is currently taking pantoprazole for her reflux. During the examination, the doctor notices tightening of the skin in her fingers, but the rest of her skin appears normal. There is no inflammation in her joints, and the rest of her examination is unremarkable, including her chest examination. Her chest X-ray also appears normal, but there is a slight decrease in DLCO on her lung function tests. Which antibodies are indicative of the underlying diagnosis?
MRCP2-4690
A 67-year-old man with a history of ischaemic heart disease presents with stiffness of the fingers and a mild photosensitive rash that has been present for two months. He has been taking procainamide for the past year. On examination, there is puffy swelling of the hands and wrists, along with tenderness of the metacarpophalangeal joints. A chest x-ray ordered by the GP shows small bilateral pleural effusions. What test is indicative of this patient’s condition?
MRCP2-4691
A 60-year-old woman has been diagnosed with class IV SLE nephritis. The renal physician has recommended starting her on i.v. methylprednisolone (1 gm/day for three days) followed by oral prednisolone 1 mg/kg/day, and fortnightly i.v. cyclophosphamide. Which of the following medications is not required to be co-administered with these two agents?
MRCP2-4692
A 44-year-old woman presents with a complaint of proximal muscle weakness that has been ongoing for 8 months. She has no significant medical history and is not taking any medications or consuming alcohol. Upon examination, she exhibits 4/5 power proximally in both arms and legs, with no other notable findings. Blood tests are unremarkable except for an elevated creatinine kinase level of 900 U/L. Electromyography reveals myopathic features, and a muscle biopsy is ordered to aid in identifying the specific myopathy. The biopsy results indicate endomysial lymphocytic infiltrates invading non necrotic muscle fibers. What is the most probable diagnosis?
MRCP2-4693
A 42-year-old man presents with a one month history of painful and swollen distal interphalangeal joints in his right hand index and middle finger. He reports a few previous episodes of finger swelling in his left hand that resolved within a week. He drinks 6 units of alcohol per week and recently returned from a trip to the USA. There is no significant medical history except for his sister having psoriasis. On examination, the distal interphalangeal joints in his right hand index and middle finger are swollen and tender. His recent blood test shows a haemoglobin level of 130 g/L (130-180), WBC count of 10.9 ×109/L (4-11), neutrophil count of 6.8 ×109/L (1.5-7), and an ESR of 45 mm/hr (0-15). Urea, electrolytes, and creatinine are normal, and rheumatoid factor is negative. What is the most likely diagnosis?
MRCP2-4694
You see a 28-year-old patient with a swollen left knee. It has been getting worse for a number of months and is now affecting her ability to work as a nurse. The pain and stiffness are worse overnight and in the morning and gets better throughout the day. She denies any trauma or fever. She also has some pain and stiffness in her toes which is also worse in the morning. Her joints are worse after rest.
She is normally fit and well and denies any previous joint problems or psoriasis. However, her mother has a history of psoriasis. She says there is no family history of joint problems to her knowledge.
On examination, her knee is red, warm and tender to palpate. There is a moderate knee effusion and flexion is limited due to pain. Her distal interphalangeal joints (DIPs) are tender and slightly swollen.
There are no skin rashes. Although her knee is painful the patient looks well and has a heart rate of 80 beats per minute and her temperature is 36.8ºC.
Blood tests reveal a raised CRP at 85 but a negative rheumatoid factor.
What is the most likely diagnosis?
MRCP2-4695
A 30-year-old woman with diffuse cutaneous systemic sclerosis presents to the emergency department with worsening shortness of breath over the past three months. She has severe Raynaud’s phenomenon, skin tightness, sclerodactyly, and skin thickening up to her shoulders. Despite having no history of orthopnea, her exercise tolerance has decreased from 500 yards to less than 50 yards. On examination, she has a raised JVP and mild bi-pedal edema. Her blood pressure is 110/70 mmHg, pulse is 109/min, SaO2 is 91% on air, and respiratory rate is 20/min. Muscle strength is normal, and examination of her heart, lungs, and abdomen is unremarkable. Her investigations show a hemoglobin level of 121 g/L (115-165), WBC count of 7.8 ×109/L (4-11), neutrophils at 70% (40-75), platelet count of 270 ×109/L (150-400), ESR of 36 mm/hr (0-20), normal U&E and creatinine, negative D-dimers, a normal CXR, and an ECG with right axis deviation. What is the most likely diagnosis?