A 68-year-old woman presents with a one-month history of non-specific malaise. She experiences stiffness, particularly in the mornings, and has difficulty lifting her arms to comb her hair. She also has constant pain in her arms, shoulders, and jaw when chewing. She has lost 4 kg in weight and has a persistent headache. She smokes 10 cigarettes a day and drinks 10 units of alcohol per week. On examination, she has tenderness with reduced mobility in the proximal muscles of her arms and legs. Her investigations reveal a low Hb, high WCC, and elevated ESR. What is the most likely diagnosis?
MSFinals-5919
A 30-year-old white man comes to his general practitioner complaining of progressive low back pain over the past four years. The pain is worse at night when he lies down and improves as he moves around during the day, but it does not go away with rest. Upon further questioning, he reports having experienced three episodes of acute eye pain with sensitivity to light and blurry vision in the past two years. He sought treatment from an ophthalmologist, and the symptoms resolved with steroids and eye drops. X-rays reveal some inflammatory and arthritic changes in the sacroiliac joints. Despite treatment, the disease has continued to progress, and ten years later, x-rays show calcification of the anterior spinal ligament. What is the most likely positive finding in this patient?
MSFinals-5918
A 30-year-old woman had chronic inflammatory disease that affected her spine, sacroiliac joints and large peripheral joints. X-rays confirmed a diagnosis of ankylosing spondylitis. The majority of patients with this disease are positive for which one of the following molecules?
MSFinals-5924
In which joint would the presence of osteoarthritic changes be atypical?
MSFinals-5917
A 65-year-old woman presents to the Emergency department with increasing breathlessness and coughing up of small amounts of blood over the past one week. She also complains of frequent nosebleeds and headaches over the past two months. She feels generally lethargic and has lost a stone in weight.
She is noted to have a purpuric rash over her feet. Chest expansion moderate and on auscultation there are inspiratory crackles at the left lung base.
Investigations show:
Haemoglobin 100 g/L (115-165)
White cell count 19.9 ×109/L (4-11)
Platelets 540 ×109/L (150-400)
Plasma sodium 139 mmol/L (137-144)
Plasma potassium 5.3 mmol/L (3.5-4.9)
Plasma urea 30.6 mmol/L (2.5-7.5)
Plasma creatinine 760 µmol/L (60-110)
Plasma glucose 5.8 mmol/L (3.0-6.0)
Plasma bicarbonate 8 mmol/L (20-28)
Plasma calcium 2.23 mmol/L (2.2-2.6)
Plasma phosphate 1.7 mmol/L (0.8-1.4)
Plasma albumin 33 g/L (37-49)
Bilirubin 8 µmol/L (1-22)
Plasma alkaline phosphatase 380 U/L (45-105)
Plasma aspartate transaminase 65 U/L (1-31)
Arterial blood gases on air:
pH 7.2 (7.36-7.44)
pCO2 4.0 kPa (4.7-6.0)
pO2 9.5 kPa (11.3-12.6)
ECG Sinus tachycardia
Chest x ray Shadow in left lower lobe
Urinalysis:
Blood +++
Protein ++
What is the most likely diagnosis?
MSFinals-5916
A 24-year-old Caucasian farmer presents to the outpatient department with a complaint of lower back pain that has been bothering him for the past two months. He reports that the pain is at its worst in the morning. He also experiences intermittent pain and swelling in his right ankle, which he injured while running a year ago. Two weeks ago, he visited the Emergency department with a painful red eye, which was treated with eye drops. He is a heavy smoker, consuming 45 cigarettes a day, and drinks five pints of beer every weekend. He denies any skin rashes or mucosal ulceration. His mother had rheumatoid arthritis, and his father had severe gout. On direct questioning, he admits to being diagnosed with chlamydia four months ago. During the examination, his right ankle was swollen at the site of Achilles’ tendon insertion, but all other joints were unremarkable. Flexion of the lumbar spine was reduced. What is the most likely diagnosis for this man?
MSFinals-5915
A middle-aged man without prior medical history is experiencing increasing back pain and right hip pain for the past decade. The pain worsens towards the end of the day. He has bony enlargement of the distal interphalangeal joints. Radiographs reveal prominent osteophytes involving the vertebral bodies and sclerosis with narrowing of the joint space at the right acetabulum. What is the most likely pathologic process occurring in this patient?
MSFinals-5913
A 27-year-old construction worker complains of worsening pain in his feet over the past two weeks, describing it as feeling like he is walking on gravel. He also reports experiencing lower back pain.
The patient recently returned from a trip to Spain two months ago and recalls having a brief episode of urethral discharge, but did not seek medical attention for it.
What is a possible diagnosis?
MSFinals-5912
A 35-year-old married man was on a business trip in Thailand when he developed diarrhoea that lasted for 1 week. He returned to the United States and, a few weeks later, visited his primary care physician (PCP) complaining of pain in his knee and both heels. His eyes have become red and he has developed some painless, red, confluent plaques on his hands and feet, which his PCP has diagnosed as psoriasis. What is the most probable diagnosis?
MSFinals-5923
A 33-year-old paediatric nurse presents with complaints of fatigue, joint discomfort throughout her body, and a rash on her face that has worsened since returning from a recent trip to Portugal. On examination, there is no evidence of small joint synovitis, but the facial rash is prominent. Blood tests reveal a haemoglobin level of 103 g/l, MCV of 88.8 fl, platelet count of 99 × 109/l, and a WCC of 2.8 × 109/l. What is the most appropriate treatment option at this stage?