A 27-year-old male presents with lower back pain and painful feet that feel like walking on pebbles. He has been generally healthy, but he recently returned from a trip to Corfu where he had a diarrheal illness. He admits to infrequently taking ecstasy but takes no other medication. On examination, he has limited movement and pain in the sacroiliac joints and soreness in the soles of his feet upon deep palpation. What is the most probable diagnosis?
A 61-year-old woman comes to the clinic with complaints of warm, swollen, and painful knuckles, as well as large subcutaneous nodules near her elbows. She also reports experiencing joint stiffness lasting more than an hour in the morning. Upon examination, her PIP joints are hyperextended, and her DIP joints are flexed. If a biopsy were performed on the nodules, what would be the most likely histological appearance?
A 54-year-old man was diagnosed with rheumatoid arthritis and started on methotrexate. After six months, there was no improvement. He was switched to a combination of methotrexate and sulfasalazine, but there was still no improvement after a similar period of therapy.
What is the most effective treatment option at this point?
A 65-year-old woman complains of discomfort at the base of her left thumb. The right first carpometacarpal joint is swollen and tender.
What could be the probable diagnosis?
A 76-year-old woman, who was previously in good health, presents for review. For the past 2–3 months, she has suffered from increasing pain and stiffness, particularly in the early part of the day, affecting her shoulders and, most recently, her hips. There has also been low-grade fever and she has lost 4 kg in weight. Examination reveals normal proximal muscle strength.
Investigations:
Investigation Result Normal value
Haemoglobin 111 g/l 115–155 g/l
Mean corpuscular volume (MCV) 96 fl 76–98 fl
White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
Platelets 345 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 75 mm/h 0–10mm in the 1st hour
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 5.0 mmol/l 3.5–5.0 mmol/l
Creatinine 130 μmol/l 50–120 µmol/l
Creatine kinase 31 IU/l 23–175 IU/l
Alanine aminotransferase (ALT) 45 IU/l 5–30 IU/l
Chest X-ray (CXR) Slight cardiomegaly, otherwise normal
Which of the following is the most likely diagnosis?
An 80-year-old man comes to the doctor with complaints of widespread aches, bone pains, headaches, and nerve entrapment syndromes that have been bothering him for several years. His blood work reveals an elevated serum alkaline phosphatase, and his urine test shows an increased urinary hydroxyproline. The X-ray of his skull displays a mix of lysis and sclerosis with thickened trabeculae. What medication would be appropriate for this patient?
You are asked to see a 35-year-old man with a three year history of recurrent episodes of asymmetrical joint pains involving his knees, ankles and elbows. Two to four joints tend to be affected at any one time and each joint may be affected from two to four weeks each time.
In the last decade he has also had recurrent painful mouth sores. On this occasion, he also complains of a severe occipital headache, mild abdominal pain and some discomfort on passing urine.
On examination, his temperature is 38°C. His left knee and right ankle joints are painful, swollen and tender. Superficial thrombophlebitis is noted in the right leg.
Investigations show:
Hb 99 g/L (130-180)
WCC 11.6 ×109/L (4-11)
Platelets 420 ×109/L (150-400)
ESR 60 mm/hr (0-15)
Plasma sodium 138 mmol/L (137-144)
Plasma potassium 4.3 mmol/L (3.5-4.9)
Plasma urea 6.9 mmol/L (2.5-7.5)
Plasma creatinine 95 µmol/L (60-110)
Plasma glucose 5.8 mmol/L (3.0-6.0)
What is the most likely diagnosis?
An 81-year-old woman presents to Accident and Emergency with recurrent chest infections over the last year. She has suffered from rheumatoid arthritis for a long time and is on methotrexate and sulfasalazine. On examination, there are some crepitations at the right lung base and splenomegaly. She has some abnormal discolouration on her legs.
Full blood counts showed:
Investigation Result Normal value
Haemoglobin (Hb) 96 g/l 115–155 g/l
White cell count (WCC) 3.2 × 109/l 4–11 × 109/l
Neutrophils 0.8 × 109/l 1.7–7.5 × 109/l
Lymphocytes 1.5 × 109/l 1.0–4.5 × 109/l
Eosinophils 0.6 × 109/l 0.0–0.4 × 109/l
Which of the following is the most likely diagnosis?
A 65-year-old woman complains of bilateral knee pain that has persisted for 4 months, despite taking paracetamol PRN. Her recent knee X-rays reveal moderate degenerative changes, and she has requested physiotherapy. What additional treatment should be initiated while waiting for physiotherapy?
A 68-year-old man visits his doctor’s office, reporting a recent onset of a red, swollen, and hot great left toe. He denies any injury to the toe and has a medical history of hypertension, which is being treated with a single medication. The doctor suspects acute gout as the diagnosis.
What medication is most likely responsible for triggering the acute gout?