A 30-year-old science teacher is diagnosed with tenosynovitis of the fingers of the left hand, although she is not experiencing any tenderness or swelling of the affected fingers.
In which one of the following conditions can tendinitis/tenosynovitis present without being swollen and tender?
What is the most probable diagnosis for a 70-year-old woman who presents with bilateral shoulder pain and stiffness, fatigue, weight loss, and elevated ESR levels?
A 35-year-old woman presents with increasing early-morning bilateral knee pain and stiffness and generalised fatigue. On examination, she is noted to have flat erythema over the malar eminences with sparing of the nasolabial folds. Multiple painless oral ulcers are also noted. Examination of the knee joints reveals tenderness and suprapatellar effusions bilaterally.
Which of these is most specific for the underlying condition?
A 58-year-old woman has been scheduled for a left total knee replacement in one month’s time. She has a past medical history significant for rheumatoid arthritis (RA), for which she takes methotrexate and hydroxychloroquine.
Which of the following investigations would be most important before the patient’s operation?
A 35-year-old man presents to the outpatient department with complaints of lower back pain. He used to be an active soccer player but has had to give up due to the pain.
During the examination, there is no skin rash or history of gastrointestinal or genitourinary symptoms. The patient reports difficulty standing straight and walking in a stooped position for hours each morning before being able to stand up straight. Additionally, there is redness and pain around the right heel, and Schober’s test is positive.
What abnormalities may be found on the patient’s ECG?
A 68-year-old woman who has suffered many years from aggressive rheumatoid arthritis presents for review. Most recently, she has suffered from two severe respiratory tract infections (which have been treated with oral clarithromycin) and has had worsening left upper quadrant pain. She currently takes low-dose prednisolone for her rheumatoid. On examination, there are obvious signs of active rheumatoid disease. Additionally, you can feel the tip of her spleen when you ask her to roll onto her right-hand side.
Investigations:
Investigation Result Normal value
Haemoglobin 91 g/l 115–155 g/l
White cell count (WCC) 1.9 × 109/l (neutrophil 0.9) 4–11 × 109/l
Platelets 90 × 109/l 150–400 × 109/l
Rheumatoid factor +++
Erythrocyte sedimentation rate (ESR) 52 mm/h 0–10mm in the 1st hour
Which of the following is the most likely diagnosis in this case?
A 63-year-old woman visits her GP complaining of pain and swelling in her fingers and wrists. The pain has been gradually worsening over the past few months, and she is having difficulty opening jars at home. She reports that her fingers are stiff when she wakes up but gradually loosen throughout the morning.
Upon examination, the GP notes symmetrical swelling of the MCP and PIP joints, which are tender to pressure and have stress pain on passive movement. The patient also has swan neck and boutonnière deformities of the fingers. The GP diagnoses the patient with rheumatoid arthritis and refers her to a rheumatologist. The GP prescribes anti-inflammatory medications and advises the patient to rest her fingers and wrists.
What is the most common ocular extra-articular manifestation of rheumatoid arthritis in a patient who is 63 years old?
A 55-year-old carpet layer presented with acute pain and swelling affecting his left knee. There is no history of trauma. Past medical history includes haemochromatosis for which he receives regular venesection.
Examination reveals a hot, tender, swollen left knee.
Investigations:
Investigation Result Normal value
Haemoglobin 135 g/l 135–175 g/l
White cell count (WCC) 4.0 × 109/l 4–11 × 109/l
Platelets 200 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 12 mm/h 0–10mm in the 1st hour
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 5.0 mmol/l 3.5–5.0 mmol/l
Creatinine 120 μmol/l 50–120 µmol/l
Knee aspirate: 12 000 white blood cells/ml (majority neutrophils); rhomboid-shaped, weakly positively birefringent crystals. No growth on culture.
Which of the following is the most likely diagnosis in this case?
A 38-year-old woman presents to the clinic with symmetrical polyarthritis affecting her fingers, wrists and elbows. She also reports significant morning stiffness which lasts for up to 90 minutes and is finding it very difficult to get up for work in the morning. There is a history of deep vein thrombosis during her second pregnancy, but no other significant past medical history. Her only medication of note is the oral contraceptive pill.
On examination, she has evidence of active synovitis affecting her wrists and the small joints of her fingers.
Investigations:
Investigation Result Normal value
Haemoglobin 121 g/l 115–155 g/l
White cell count (WCC) 8.1 × 109/l 4–11 × 109/l
Platelets 193 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 110 μmol/l 50–120 µmol/l
Rheumatoid factor Positive
Anti-nuclear factor Weakly positive
Which of the following is the most likely diagnosis?
A 65-year-old man visits his General Practitioner (GP) complaining of a swollen and painful first metatarsophalangeal joint that has been bothering him for a week. He reports that the pain became unbearable last night. The patient denies any fever or toe injuries. Upon examination, the joint appears red, swollen, and warm to touch. The patient has a history of gout, peptic ulcer, and is currently taking allopurinol 300 mg once a day for gout prophylaxis. What is the most appropriate next step in management?