A 70-year-old male from the Dominican Republic presents with constant bilateral anterior thigh pain and lower limb weakness. He reports being an active man prior to these symptoms, but is now wheelchair and bed-bound. What is the best course of treatment for his condition?
A 35-year-old woman with rheumatoid arthritis presents with feelings of malaise. She has been experiencing lethargy for the past two days and has developed a severe sore throat over the last 24 hours. The patient has been taking the following medications for the past six months: paracetamol 1g QDS, naproxen 500 mg PRN, methotrexate 15 mg once weekly, folic acid 5mg once weekly, and prednisolone 5mg OD. Upon examination, she is septic with the following vital signs: respiratory rate 26/min, heart rate 120/min, blood pressure 100/67 mmHg, and temperature 37.9ºC. She is able to tolerate oral fluids and small amounts of food. Adequate fluid resuscitation and antibiotics are initiated. What should be done regarding her regular medications?
A 29-year-old male presents after recently returning from Bangladesh with 2 weeks of daily spiking fever, a new rash on his foot and pain on bending his knees or closing his hands. He also reports lumps and bumps on his neck that he thinks are new. He denies any cough or weight loss. He has no other past medical history and is unaware of any unwell family members.
On examination, his temperature is 39.2 degrees. You note a maculopapular rash on his left sole and face. His knees and wrists are swollen and tender. His chest and cardiovascular examination are unremarkable, his abdomen is soft. However, you note a 12cm splenomegaly.
His serum tests demonstrate:
Hb 127 g/l
Platelets 450 * 109/l
WBC 17.0 * 109/l
Neuts 11.0 * 109/l
Na+ 138 mmol/l
K+ 3.5 mmol/l
Urea 7.8 mmol/l
Creatinine 70 µmol/l
CRP 30 mg/l
Ferritin 2000 µg/l
ALP 250 u/l
ALT 160 u/l
ANA negative
dsDNA negative
His chest radiograph appears unremarkable with no focal consolidation. A first induced sputum is negative for acid-fast bacilli. What is the most likely diagnosis?
A 72-year-old woman presents to the rheumatology clinic for a follow-up on her osteoporosis treatment. She was diagnosed with osteoporosis five years ago after experiencing a left Colles fracture from a fall. Alendronic acid was initiated as treatment. During the visit, the patient complains of persistent back pain for the past few weeks. She denies any recent falls or injuries.
The patient has a medical history of rheumatoid arthritis, which was diagnosed when she was 28 years old. She received prolonged corticosteroid treatment and various disease modifying drugs. Methotrexate (10 mg weekly) was eventually used to control her arthritis, and she has not required corticosteroid treatment for many years. The patient has no family history of osteoporosis or fragility fractures and does not smoke or drink alcohol.
On examination, the patient has mid-line point tenderness around the T12 – L1 level of her spine. Neurological examination of the lower limbs is normal. A thoracolumbar spine x-ray shows anterior height loss of the T12 vertebrae, but is otherwise unremarkable.
The patient’s height is 150 cm and weight is 55 kg. Her femoral neck BMD was T – 3.2 five years ago and is now T – 2.4. Her FRAX 10-year probability of major osteoporotic fracture is 27% and hip fracture is 8.7%.
What is the most appropriate management plan for this patient’s osteoporosis?
A 67-year-old man presents to his General Practitioner with bilateral shoulder aches and pains that have been ongoing for 3 months. He reports stiffness in the mornings that takes up to two hours to resolve after waking. The patient denies any symptoms of headache, jaw claudication, or visual disturbance. He has no symptoms of dry eyes or mouth, no skin or hair changes, no weight loss, and no fevers.
The patient has a past medical history of hypertension and chronic obstructive pulmonary disease. He takes ramipril, simvastatin, and inhaled salbutamol as required. He is an ex-smoker who drinks 25 units of alcohol per week. The patient recently retired after working as a train driver.
On examination, there are no inflamed joints except for slight tenderness across the shoulder girdle. There is no evidence of scalp tenderness. The cardiovascular and respiratory examination is unremarkable.
The General Practitioner orders several investigations, including haemoglobin, white cell count, neutrophils, platelets, urea, creatinine, sodium, potassium, erythrocyte sedimentation rate, rheumatoid factor, creatinine kinase, calcium, alkaline phosphatase, thyroid stimulating hormone, and protein electrophoresis.
What is the appropriate next management step for this patient?
A 25-year-old woman presents with a 2-month history of intermittent fever accompanied by chest pain, which is worse after eating. She has recently also noticed pain in the joints of her hands and feet.
She is febrile, with a temperature of 38.5 °C. Her pulse is 92/min and her blood pressure is 120/80 mmHg. The positive findings on examination are enlarged cervical lymph nodes, hepatomegaly and synovitis of the metacarpophalangeal (MCP) and ankle joints.
Investigations reveal the following:
Haemoglobin (Hb) 110 g/l 120–160 g/l
White cell count (WCC) 18 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 480 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 90 mm/hour 1–20 mm/hour
C-reactive protein (CRP) 200 mg/l < 10 mg/l
Alanine aminotransferase (ALT) 60 IU/l 5–30 IU/l
Alkaline phosphatase (ALP) 200 IU/l 30–130 IU/l
Ferritin 4000 μg/l 20–250 µg/l
Abdominal ultrasound Hepatosplenomegaly
Stool culture and blood culture –
ANA, RF, ANCA, anti CCP All –
Computed tomography (CT) chest Cardiomegaly
Which of the following is most likely diagnosis?
A 30-year-old female patient visits her primary care physician with complaints of fever, pain, and swelling in her knees, wrists, and hands for the past week. She has no significant medical history. During the examination, her blood pressure is 110/70 mmHg, and her heart rate is 94 bpm. A purplish rash is observed throughout her body. Palpation of the metacarpophalangeal and interphalangeal joints reveals swelling and tenderness, but no deformities. What is the most probable diagnosis?
A 50-year-old female has presented to your neurology clinic with complaints of difficulty lifting her arms during exercises at the gym for the past few months. She is visibly upset and tearful, mentioning that she has been using a lot of make-up to cover a new purple rash and swelling around her eyelids. She has no significant medical history or recent trauma and is generally healthy. She has had a dry cough for the past 6 months, which she attributes to her previous social smoking habit of up to 2 cigarettes every 2 weeks when going out with friends.
Upon examination, you note limited passive movement in both shoulders and hips due to tender deltoids and hip flexors. Power examination reveals 4-out-of-5 symmetrically in hip flexion and shoulder abduction. She has an elliptical erythematous rash around her eyes, and the skin around her fingers appears tough bilaterally. Auscultation of her chest reveals bibasal fine inspiratory crackles and normal heart sounds. Her observations show a low-grade temperature of 37.7 degrees. A chest radiograph shows bilateral fibrotic changes.
Her admission blood tests are as follows:
– Hb 121 g/l
– Platelets 590 * 109/l
– WBC 12.3 * 109/l
– ESR 20 mm/hr
– Creatine kinase 3000 u/l
– LDH 250 u/l
What is the most likely underlying diagnosis that unifies all of her symptoms?
A 72-year-old woman presents with vision loss in her right eye, accompanied by pain while chewing and a persistent headache. Upon examination, her visual acuity is 6/60 in the affected eye, and ophthalmoscopy reveals a swollen, pale optic disc. Her blood work shows a low hemoglobin level of 115 g/L, high platelet count of 545 * 109/L, elevated white blood cell count of 11.1 * 109/L, and an elevated ESR of 45 mm/hour. Her HbA1c level is also high at 82 mmol/mol. She has a history of hypertension and diabetes mellitus, and has not been keeping up with retinal screening. What is the most likely cause of her vision loss?
A 45-year-old woman has been diagnosed with fibromyalgia and has been experiencing severe widespread body pain, severe fatigue, and difficulty concentrating on daily activities. She had previously been prescribed pregabalin but did not feel any improvement in her symptoms. Her symptoms have been causing more problems and she has been unable to attend work as a teaching assistant. What is the next appropriate pharmacological treatment for her fibromyalgia?