A 68-year-old male patient has been experiencing painful right knee and difficulty in walking for the past three years. He has a medical history of diabetes, hypertension, and CKD 3 with an eGFR of 45 ml/min. The patient is currently taking aspirin, amlodipine, metformin, and citalopram. During a routine check-up, his serum urate level was found to be 521 μmol/L (210-415). What should be the next course of action in his treatment plan?
A 49-year-old man presents with complaints of pain and limited range of motion in his right elbow. He denies any recent injury or trauma. He has no significant medical history and works as a plumber. He is a non-smoker but consumes 35 units of alcohol per week and is not interested in exercising.
Upon examination, there is no swelling or effusion present. The patient experiences increased pain during wrist extension and supination while the elbow is extended. There are no motor or sensory deficits noted.
What is the probable diagnosis?
A 55-year-old patient has recently been diagnosed with rheumatoid arthritis during a severe flare-up. The patient has been prescribed methotrexate 15 mg once a week, folic acid 5mg once a week, hydroxychloroquine 200mg twice a day, naproxen 250 mg three times a day, and prednisolone 15mg once a day. After a month, the patient reports experiencing mouth ulcers. The patient’s blood test results are as follows:
– Hemoglobin (Hb): 142 g/l
– Platelets: 225 * 109/l
– White blood cells (WBC): 6 * 109/l
– Sodium (Na+): 136 mmol/l
– Potassium (K+): 4.2 mmol/l
– Urea: 4 mmol/l
– Creatinine: 95 µmol/l
– Bilirubin: 6 µmol/l
– Alkaline phosphatase (ALP): 105 u/l
– Alanine transaminase (ALT): 92 u/l
What is the most appropriate action to take in response to the patient’s symptoms and blood test results?
A 67-year-old man presents to an outpatient respiratory clinic with a 3-month history of weight loss, cough, weakness and intermittent haemoptysis. His past medical history includes type 2 diabetes and hypertension. He is on regular amlodipine, ramipril and metformin. He has smoked 15 cigarettes daily for approximately 40 years. He denies alcohol or recreational drug use.
On clinical examination, he appears underweight. His observations demonstrate a heart rate of 87 beats per minute, blood pressure 145/82 mmHg, respiratory rate 15/minute, oxygen saturations of 97% on room air and temperature of 36.7ºC. Chest auscultation reveals a monophonic wheeze in the left upper lobe. His heart sounds are normal and there are no murmurs or peripheral oedema. There is no evidence of lymphadenopathy or organomegaly. His fingers are clubbed. Power is 3+/5 proximally in the upper and lower limbs. He finds it difficult to get up off his chair. Sensation is preserved, reflexes are normal and plantar reflexes are downgoing. There is no rash.
Blood tests:
Hb 111 g/L Male: (135-180)
Female: (115 – 160)
Platelets 444 * 109/L (150 – 400)
WBC 8.4 * 109/L (4.0 – 11.0)
Na+ 129 mmol/L (135 – 145)
K+ 4 mmol/L (3.5 – 5.0)
Urea 8.1 mmol/L (2.0 – 7.0)
Creatinine 111 µmol/L (55 – 120)
CRP 8 mg/L (< 5)
Creatine kinase 5891 U/L (40-320)
TSH 5.9 miU/L (0.2 – 5.5)
Free T4 11.1pmol/L (10 – 24.5)
A chest x-ray demonstrates a coin lesion in the upper zone of the left lung.
What is the most appropriate initial treatment?
A 68-year-old man presents to the medical unit with an acutely swollen and hot joint. The swelling is localized to the first metatarsophalangeal joint (MTPJ) and is causing him significant discomfort. He reports having experienced this problem before and having it successfully treated, but the medication used caused him to have severe diarrhea.
Upon examination, the first MTPJ is swollen, red, and extremely tender to the touch. There is limited mobility, and walking causes severe pain.
The patient’s medical history includes chronic kidney disease, gout, osteoarthritis, and angina.
Blood tests taken upon admission reveal:
– Hb 140 g/L (Male: 135-180, Female: 115-160)
– Platelets 300* 109/L (150-400)
– WBC 10.4* 109/L (4.0-11.0)
– Na+ 138 mmol/L (135-145)
– K+ 4.8 mmol/L (3.5-5.0)
– Urea 14 mmol/L (2.0-7.0)
– Creatinine 230 µmol/L (55-120)
– CRP 32 mg/L (<5)
Based on the symptoms and medical history, the suspected diagnosis is an acute gout flare. What is the most appropriate treatment?
A 70-year-old man presents to the emergency department with complaints of visual disturbance in his left eye, accompanied by peripheral vision loss. He reports constant headaches over the past two weeks, which are worse on the left side of his skull and exacerbated by pressure. He is unable to lie on his left side due to the pain. On examination, he exhibits peripheral loss of vision in the temporal lower quadrant of his left eye and tenderness in the left temporal region and shoulders. He experiences mild difficulty in rising from a seated position, but is otherwise neurologically intact. Blood tests reveal elevated CRP levels and an ESR of 79 mm/h.
What is the most appropriate next step in managing this patient’s condition?
A 68-year-old Caucasian patient with Granulomatosis with polyangiitis has been receiving monthly i.v. cyclophosphamide and oral prednisolone for six months, resulting in well-controlled vasculitis. The next step is to start him on azathioprine. All his blood tests, including full blood count, urea electrolytes, creatinine, and liver function tests, are normal. What screening test should be done before initiating azathioprine therapy?
A 65-year-old woman presents with a 4-year history of Raynaud’s phenomenon affecting the fingers and, to a lesser extent, the toes. Recently this has become a lot worse, with attacks coming on unprovoked by temperature changes and lasting longer. She has noticed some swallowing difficulties and symptoms of acid reflux recently. Her fingers have become increasingly restricted over 4 years, but now they are more swollen and painful. She feels tired, with a recent onset of headaches and has lost 7 pounds in weight with loss of appetite.
Examination of the fingers reveals acrocyanosis of the digits with splinter haemorrhages in a warm examination room. Her blood pressure is 210/115 mmHg. The rest of the examination is unremarkable.
Which of the following is the most important initial investigation with respect to determining prognosis?
A 44-year-old man with a diagnosis of chronic hepatitis C presents to hepatology clinic with complaints of lethargy and generalised muscle pain for the past 3 weeks. During examination, erythematous macules and purpuric papules are observed on both lower limbs, with some small areas of ulceration. Additionally, there is a reduction in light touch and pain sensation in the toes bilaterally. What is the probable cause of these symptoms?
A 32-year-old woman presents with three days of right-sided loin pain and two episodes of blood in her urine. She feels unwell and lethargic but denies any fevers or urinary dysuria.
She has a history of two urinary tract infections and is currently being seen by the anticoagulants clinic due to several miscarriages. Her maternal aunt has a history of renal calculi. She is not taking any regular medication at present.
On examination, she is tender in the right loin only. Her blood pressure is 180/105 mmHg, heart rate 85/min, respiratory rate 22/min, and temperature 37.0ºC.
Lab results show Na+ 138 mmol/l, K+ 4.2 mmol/l, urea 5.6 mmol/l, creatinine 87 µmol/l, and positive anti-cardiolipin antibodies.
A urine dip reveals +++ blood and no leukocytes. An ultrasound of the kidneys, ureters, and bladder shows no hydronephrosis or renal lesion.
What is the likely diagnosis?