KFP – Rheumatology

Kate Hollingsworth, aged 45, presents with a 6-month history of bilateral hand and wrist pain associated with morning stiffness lasting more than 60 minutes. She reports that her symptoms are worse in the morning and improve with activity as the day progresses. She has noted difficulty opening jars and buttoning her shirt in the morning. She also mentions increasing fatigue and recent unintentional weight loss of 3 kg.

Medications: Occasional ibuprofen

Allergies: Nil known

Past history: Nil significant

Family history: Mother with hypothyroidism and osteoarthritis

Social history: Non-smoker, drinks one glass of wine per week. Works as a primary school teacher. No recent travel.

Examination findings: Bilateral swelling and tenderness of MCP and PIP joints. Mild ulnar deviation of fingers. Warmth noted over wrists. No skin rash or nodules. No signs of psoriasis. BP 124/78 mmHg, HR 76 bpm, afebrile.

Investigations: RF positive at 85 IU/mL (normal <14), anti-CCP positive, ESR 48 mm/hr, CRP 25 mg/L, ANA negative, FBC: normocytic anaemia (Hb 110 g/L), WCC and platelets normal. LFTs and renal function normal. X-ray hands: periarticular osteopenia and marginal erosions at MCP joints.

What is the most appropriate next step in management? Select three (3) from the following list:

Joseph Ang, a 68-year-old retired mechanic, presents with a 2-year history of chronic low back pain that has worsened over the past six months. He describes the pain as deep and aching, localised to the lower lumbar spine and buttocks, with some stiffness in the morning lasting about 15 minutes. He denies leg radiation, neurological symptoms, weight loss, or fever. The pain worsens with activity and improves with rest. He has tried paracetamol and ibuprofen with partial relief. He smokes 10 cigarettes daily and drinks socially.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Hypertension, controlled on amlodipine

Family history: Father had osteoarthritis and underwent a hip replacement

Social history: Lives with wife, independent in ADLs. No recent travel.

Examination findings: Normal gait, mild tenderness over L4-L5 spinous processes, restricted lumbar flexion. Straight leg raise negative bilaterally. Reflexes intact. No motor or sensory deficits in lower limbs.

Investigations: Lumbar spine X-ray: reduced disc height at L4-L5 and L5-S1, marginal osteophyte formation, no vertebral collapse or lytic lesions.

What are the most appropriate next steps in managing this patient’s condition? Select three (3) from the following list:

Sarah Dumont, aged 29, presents with a 3-month history of joint pain affecting her hands, wrists, knees, and ankles. She describes swelling and stiffness in the mornings lasting over an hour. She also complains of fatigue and a photosensitive rash on her face. She reports intermittent low-grade fevers and a 4 kg unintentional weight loss. She denies recent travel or infection.

Medications: Nil regular

Allergies: Nil known

Past history: Nil significant

Family history: Mother has hypothyroidism; no family history of autoimmune diseases

Social history: Works as an accountant, non-smoker, occasional alcohol, no recreational drugs

Examination findings: Temperature 37.8°C, HR 92 bpm, BP 112/68 mmHg. Malar rash, oral ulcers, synovitis of MCP and PIP joints bilaterally, tender knees and ankles with mild effusions, no joint deformities or nodules. No lymphadenopathy or hepatosplenomegaly.

Investigations: ANA positive (1:640, homogenous), anti-dsDNA positive, anti-Smith antibody positive, CRP 38 mg/L, ESR 72 mm/hr, Hb 98 g/L, WCC 3.2 x10^9/L, Platelets 110 x10^9/L, creatinine 78 µmol/L, urine dipstick: +2 protein, +1 blood.

What are the most appropriate next steps in management? Select four (4) from the following list:

Robert Whittaker, a 33-year-old professional rugby league player, presents with acute onset of severe pain, redness, and swelling in his right first metatarsophalangeal (MTP) joint. He woke up with intense pain that prevents him from putting weight on the foot. He reports similar but less severe episodes over the past year that resolved spontaneously. He admits to drinking heavily on weekends and recently started a high-protein diet. He has no significant past medical history.

Medications: Occasional protein supplements

Allergies: Nil known

Family history: Father has gout and hypertension

Social history: Lives with partner, drinks 6–8 standard drinks most weekends, no smoking

Examination findings: Afebrile, BP 136/88 mmHg, HR 72 bpm. Right first MTP joint is erythematous, swollen, warm, and extremely tender to touch. No other joints involved. No rash or systemic symptoms.

Investigations: Serum uric acid 0.52 mmol/L (normal <0.45), CRP 48 mg/L, WCC 11 x10^9/L. X-ray of right foot shows soft tissue swelling around first MTP, no erosions or calcifications.

What are the most appropriate next steps in managing this acute presentation? Select three (3) from the following list:

Jill Freeman, a 59-year-old office administrator, presents with gradually worsening right shoulder pain over the past year. The pain is aggravated by overhead activities and reaching behind her back. She denies trauma or systemic symptoms. The pain has progressively limited her ability to dress and manage personal grooming.

Medications: Irbesartan for hypertension

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Mother had osteoarthritis

Social history: Non-smoker, drinks socially, lives independently

Examination findings: No joint swelling. Tenderness over the right subacromial region. Painful arc between 70–120 degrees of abduction. Passive range of motion preserved. Neer’s and Hawkins–Kennedy tests positive. No weakness on resisted external rotation. No neck tenderness.

Investigations: Shoulder X-ray shows mild acromioclavicular joint degenerative change, otherwise unremarkable. No calcific deposits or joint space narrowing.

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Ritchie, a 23-year-old university student, presents with a 3-month history of intermittent lower back pain and morning stiffness lasting more than 45 minutes. The pain improves with exercise but not with rest. He also reports occasional heel pain and red, painful eyes that self-resolved a few weeks ago. He denies trauma, recent infections, or weight loss. He has no significant medical history.

Medications: Nil

Allergies: Nil known

Family history: Father has ankylosing spondylitis

Social history: Plays recreational soccer, non-smoker, minimal alcohol

Examination findings: Tenderness over sacroiliac joints bilaterally. Schober’s test reveals 2 cm of lumbar flexion. Chest expansion is reduced at 2.5 cm. No peripheral joint involvement. Cardiorespiratory and neurological exams are normal.

Investigations: ESR 38 mm/hr, CRP 22 mg/L, HLA-B27 positive, X-ray sacroiliac joints: bilateral sacroiliitis (grade 2–3 changes)

What are the most appropriate next steps in management? Select three (3) from the following list:

Linda Pearson, a 61-year-old woman, presents with increasing pain and stiffness in both hands over the past year. She reports difficulty with fine motor tasks such as writing and opening jars. The stiffness lasts less than 15 minutes in the morning and worsens with use throughout the day. She denies systemic symptoms. There is no history of trauma.

Medications: Atorvastatin, calcium carbonate + vitamin D

Allergies: Nil known

Past history: Hyperlipidaemia, hysterectomy (age 48)

Family history: Mother had osteoarthritis in hands and knees

Social history: Retired schoolteacher, lives with husband, non-smoker

Examination findings: Bony enlargement of DIP and PIP joints, Heberden’s and Bouchard’s nodes. Squaring of the thumb base bilaterally. No warmth or synovitis. Full range of motion but crepitus with movement.

Investigations: Normal CRP, ESR, RF and anti-CCP negative. Hand X-rays show joint space narrowing and osteophyte formation at DIP and PIP joints with subchondral sclerosis. First CMC joint narrowing present bilaterally.

What are the most appropriate management options? Select three (3) from the following list:

Aliyah Hussein, a 35-year-old woman, presents with a 3-month history of widespread musculoskeletal pain, fatigue, and poor sleep. She reports waking unrefreshed and feeling ‘foggy’ throughout the day. Her symptoms began gradually and are exacerbated by stress. There are no signs of joint swelling or morning stiffness. She denies fevers, rashes, or weight loss.

Medications: None regularly

Allergies: Nil known

Past history: Anxiety (managed without medication)

Family history: Mother with osteoarthritis, sister with irritable bowel syndrome

Social history: Works as a retail assistant, lives with partner, non-smoker, occasional alcohol use

Examination findings: Vitals normal. No synovitis or joint deformities. Multiple tender points in characteristic locations (trapezius, lateral epicondyles, hips). Normal neurological exam.

Investigations: FBC, CRP, ESR, TFTs, calcium, vitamin D all normal. RF and ANA negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

George Kassis, a 72-year-old retired builder, presents with a 6-month history of bilateral knee pain. He reports that the pain is worse with walking, especially on uneven ground and stairs, and improves with rest. He has also noticed stiffness after sitting for long periods, which resolves within 5–10 minutes. He denies joint locking, instability, or systemic symptoms.

Medications: Perindopril, simvastatin

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Father had osteoarthritis

Social history: Lives with wife, walks daily, non-smoker

Examination findings: Bilateral crepitus and bony enlargement at knees, mild varus deformity, no effusion or instability. Pain on flexion beyond 90 degrees. Normal gait with slight antalgic pattern.

Investigations: Knee X-rays show joint space narrowing, subchondral sclerosis, and osteophyte formation, most marked in medial compartments.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Zhang, a 42-year-old woman, presents with dry eyes and dry mouth for over a year. She reports gritty, painful eyes and difficulty swallowing dry foods without water. She also complains of fatigue and joint aches, particularly in her hands and wrists, though without swelling. She denies photosensitivity, rash, or oral ulcers.

Medications: Occasional ibuprofen

Allergies: Nil known

Past history: Nil significant

Family history: Mother had rheumatoid arthritis

Social history: Works as a lawyer, non-smoker, drinks one glass of wine on weekends

Examination findings: Dry, erythematous conjunctivae; dry buccal mucosa; no synovitis or deformities in joints. Schirmer’s test positive (reduced tear production). Rest of exam unremarkable.

Investigations: ANA positive (1:320, speckled pattern), Anti-Ro (SSA) positive, Anti-La (SSB) positive, RF positive, ESR 45 mm/hr, CRP 6 mg/L. FBC and renal function normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael O’Brien, a 65-year-old man, presents with sudden onset of pain, swelling, and redness in his right knee over the past 24 hours. He denies trauma, fever, or recent illness. He has a history of chronic kidney disease stage 3 and hypertension. He reports a similar episode in his left ankle 6 months ago, which resolved spontaneously.

Medications: Irbesartan, frusemide

Allergies: Nil known

Past history: Hypertension, chronic kidney disease

Family history: Nil significant

Social history: Retired teacher, non-smoker, drinks wine occasionally

Examination findings: Afebrile, BP 138/82 mmHg, HR 78 bpm. Right knee is erythematous, warm, swollen with moderate effusion. Extremely tender to palpation and painful on passive movement. No other joints involved.

Investigations: Serum uric acid 0.62 mmol/L (high), CRP 78 mg/L, WCC 12.5 x10^9/L. Knee joint aspirate: turbid fluid with elevated WCC, negatively birefringent monosodium urate crystals on polarised microscopy. Culture pending.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amira Khalil, a 50-year-old woman, presents with a 2-month history of painful, red, and swollen fingers, particularly affecting the distal interphalangeal (DIP) joints. She has also noticed scaly patches on her scalp and behind her ears, which she attributes to ‘dandruff’. She denies eye symptoms or nail trauma. She has occasional morning stiffness that lasts around 20–30 minutes.

Medications: Nil regular

Allergies: Nil known

Past history: Mild eczema as a child

Family history: Brother with psoriasis

Social history: School librarian, non-smoker, no alcohol use

Examination findings: Scaly erythematous plaques on the scalp and behind ears. Mild pitting noted in fingernails. DIP joints of 2nd and 3rd fingers on the right hand are swollen, red, and tender. No synovitis in other joints. No dactylitis or enthesitis. No eye redness.

Investigations: ESR 38 mm/hr, CRP 12 mg/L, RF and anti-CCP negative. X-ray of hand shows periostitis and new bone formation at DIP joints.

What are the most appropriate next steps in management? Select three (3) from the following list:

Peter Nguyen, a 76-year-old man, presents for a routine review. He has no active complaints but recently tripped over a rug and fractured his wrist. He reports a gradual decrease in height over the past few years and increasing kyphosis. He denies back pain or neurological symptoms.

Medications: Amlodipine, rosuvastatin

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Mother had a hip fracture in her 80s

Social history: Lives independently, non-smoker, minimal alcohol, regular walker

Examination findings: BMI 21 kg/m², thoracic kyphosis, reduced height (noted from past records). No focal tenderness or neurological signs. Gait stable.

Investigations: FBC and metabolic panel normal. X-ray spine: anterior wedging of T11 and T12 vertebrae. No evidence of malignancy or lytic lesions.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jessica Fielding, a 47-year-old school teacher, presents with a 6-week history of bilateral ankle pain, swelling, and stiffness. She describes morning stiffness lasting over an hour. She also reports a new non-itchy red rash over her cheeks and nose that worsens with sun exposure. She has experienced fatigue and mild hair thinning over the past month.

Medications: Nil regular

Allergies: Nil known

Past history: Migraine

Family history: Sister has Hashimoto’s thyroiditis

Social history: Non-smoker, rarely drinks alcohol, no recent travel

Examination findings: Temperature 37.5°C, BP 120/76 mmHg, HR 85 bpm. Bilateral ankle synovitis, malar rash sparing nasolabial folds. No oral ulcers or lymphadenopathy. No joint deformities or nodules.

Investigations: FBC: normocytic anaemia (Hb 102 g/L), WCC 3.4 x10^9/L, platelets 140 x10^9/L. CRP 18 mg/L, ESR 62 mm/hr. ANA positive (1:640, homogenous), anti-dsDNA positive, low C3 and C4. Urine dipstick: +1 protein, trace blood.

What are the most appropriate next steps in management? Select three (3) from the following list:

Ben Carter, a 31-year-old delivery driver, presents with pain and swelling in his left knee and right ankle for the past 3 weeks. He reports a red, painful right eye two weeks ago that resolved spontaneously. He also mentions a painless penile lesion that appeared and disappeared around the same time. He denies urethral discharge but recalls a recent episode of diarrhoea after eating takeaway food overseas.

Medications: Nil regular

Allergies: Nil known

Past history: Nil significant

Family history: Uncle with ankylosing spondylitis

Social history: Lives with partner, smokes 5 cigarettes/day, drinks alcohol on weekends

Examination findings: Left knee warm and swollen with limited flexion. Right ankle with tenderness and mild swelling. No active urethral discharge. No oral ulcers. No rash noted. No back pain.

Investigations: CRP 42 mg/L, ESR 60 mm/hr, HLA-B27 positive, RF and anti-CCP negative. STI screen pending. X-ray: soft tissue swelling around left knee; no erosions or chondrocalcinosis.

What are the most appropriate next steps in management? Select three (3) from the following list:

Teresa Long, a 56-year-old woman, presents with bilateral shoulder and hip stiffness and pain that is worse in the morning and improves slightly with activity. The stiffness lasts more than one hour each morning and has been present for about 3 weeks. She denies any joint swelling, jaw pain, visual changes, or headache. She feels generally fatigued but has had no fever or weight loss.

Medications: None

Allergies: Nil known

Past history: Mild osteoarthritis

Family history: Nil significant

Social history: Retired, lives alone, non-smoker

Examination findings: Normal vital signs. No joint synovitis or swelling. Active movement limited due to pain in shoulders and hips. No temporal artery tenderness. Neurological examination normal.

Investigations: ESR 84 mm/hr, CRP 46 mg/L, FBC: normocytic anaemia (Hb 108 g/L), WCC and platelets normal. RF, anti-CCP, ANA negative. CK normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

David Jamal, a 70-year-old man, presents with a 3-month history of progressive pain and swelling in his right first metatarsophalangeal (MTP) joint. He has a history of gout and has experienced multiple flares over the past 5 years, affecting different joints. He stopped taking allopurinol 6 months ago due to side effects. He has noticed the development of firm nodules around his MTP and elbow over the last few months. He denies fevers or systemic symptoms.

Medications: Irbesartan, aspirin

Allergies: Rash with allopurinol

Past history: Hypertension, ischaemic heart disease, chronic gout

Family history: Father had gout

Social history: Retired, lives with wife, occasional alcohol use

Examination findings: Swollen, erythematous, and tender right MTP joint. Firm nodular deposits over right elbow and toe. No signs of infection or systemic illness. Gait antalgic.

Investigations: Uric acid 0.65 mmol/L (elevated), eGFR 52 mL/min/1.73m², CRP 28 mg/L, X-ray of foot: erosions and tophus deposition at MTP joint.

What are the most appropriate next steps in management? Select three (3) from the following list:

Naomi Walters, a 48-year-old woman, presents with a 2-month history of symmetrical joint pain and swelling affecting her wrists, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints. She reports morning stiffness lasting over an hour, which improves throughout the day. She also describes fatigue and difficulty with daily activities like dressing and typing.

Medications: Paracetamol as needed

Allergies: Nil known

Past history: Mild asthma

Family history: Mother had rheumatoid arthritis

Social history: Works in administration, non-smoker, occasional alcohol

Examination findings: Symmetrical synovitis of wrists, MCP, and PIP joints bilaterally. No deformities. No skin rash or nodules. No eye symptoms.

Investigations: RF positive, anti-CCP strongly positive, ESR 58 mm/hr, CRP 38 mg/L. FBC: mild normocytic anaemia, normal WCC and platelets. X-ray hands: mild periarticular osteopenia and early erosions at MCP joints.

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Rowe, a 67-year-old woman, presents with a 4-month history of pain and swelling in her right wrist and MCP joints. She has also noticed digital colour changes—her fingers turn white, then blue, and then red on exposure to cold. She reports dry, tight skin on her hands and mild heartburn. She denies muscle weakness or recent infections.

Medications: Esomeprazole

Allergies: Nil known

Past history: Gastro-oesophageal reflux disease (GORD)

Family history: Mother had hypothyroidism

Social history: Retired, lives with partner, non-smoker

Examination findings: Thickened, tight skin over fingers and dorsum of hands. Digital pitting scars noted. Mild synovitis in right MCP joints. Bibasilar fine inspiratory crackles on lung auscultation. No muscle wasting or weakness.

Investigations: ANA positive (1:640, nucleolar pattern), anti-centromere antibody negative, anti-Scl-70 (anti-topoisomerase I) positive. ESR 42 mm/hr, CRP 12 mg/L. Chest X-ray: reduced lung markings at bases. FBC, renal function, CK normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Marcus Hill, a 39-year-old man, presents with lower back pain that began insidiously 6 months ago. The pain is worse in the morning and improves with activity. He also describes alternating buttock pain and stiffness lasting over 45 minutes each morning. He denies injury, leg weakness, or bladder symptoms. He reports intermittent episodes of red, painful eyes that resolve spontaneously.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Father has ankylosing spondylitis

Social history: Works as a carpenter, non-smoker, drinks socially

Examination findings: Reduced lumbar flexion (Schober’s test: 3 cm increase), limited chest expansion at 2 cm. Tenderness over sacroiliac joints bilaterally. No peripheral joint involvement or enthesitis.

Investigations: ESR 36 mm/hr, CRP 28 mg/L, HLA-B27 positive, X-ray pelvis: bilateral sacroiliitis (grade 2–3 changes)

What are the most appropriate next steps in management? Select three (3) from the following list:

Susan Tran, a 64-year-old woman, presents with gradually worsening pain in both hips and knees. The pain is worse at the end of the day and after activity, particularly after gardening or walking for extended periods. Morning stiffness lasts less than 10 minutes. She denies joint swelling, systemic symptoms, or past injury.

Medications: Paracetamol as needed

Allergies: Nil known

Past history: Type 2 diabetes, hypertension

Family history: Mother had knee osteoarthritis

Social history: Lives independently, retired teacher, BMI 31 kg/m²

Examination findings: Bony enlargement of both knees, crepitus on movement, reduced internal rotation of both hips, no joint effusion or warmth. Gait is slow but steady.

Investigations: Knee and pelvic X-rays: joint space narrowing and osteophytes in medial tibiofemoral compartments and superior hip joints, with subchondral sclerosis. Blood tests including CRP, ESR, and FBC all normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Clare Morrison, a 54-year-old woman, presents with a 3-month history of generalised bone pain, fatigue, and muscle weakness. She describes difficulty climbing stairs and getting out of chairs. She spends little time outdoors and follows a vegan diet. There is no joint swelling or stiffness.

Medications: Multivitamin occasionally

Allergies: Nil known

Past history: None significant

Family history: Nil relevant

Social history: Office worker, lives alone, does not smoke or drink

Examination findings: Normal vital signs. Proximal muscle weakness in both lower limbs, no synovitis or rash. Gait slow but non-antalgic. No spinal tenderness or deformity.

Investigations: Serum calcium 2.12 mmol/L (low), phosphate 0.78 mmol/L (low-normal), ALP 220 U/L (elevated), 25-hydroxyvitamin D <25 nmol/L (deficient), PTH elevated. Renal function normal. X-ray femur: Looser zones (pseudofractures) in proximal femur.

What are the most appropriate next steps in management? Select three (3) from the following list:

Daniel Farrow, a 58-year-old man, presents with chronic right elbow pain and swelling that has gradually worsened over the past year. He reports occasional flare-ups of warmth and tenderness in the elbow joint, particularly after alcohol consumption. He also has intermittent discomfort in his knees and ankles. He denies fevers, rash, or systemic symptoms. He has a history of haemochromatosis diagnosed 3 years ago, which has been managed with regular venesection.

Medications: Nil regular

Allergies: Nil known

Past history: Hereditary haemochromatosis

Family history: Brother has type 2 diabetes

Social history: Retired welder, drinks 2–3 beers daily, ex-smoker

Examination findings: Right elbow shows swelling, reduced range of motion, and mild warmth without overt redness. No tophi, nodules, or deformities noted. Other joints are normal on examination.

Investigations: X-ray of right elbow: chondrocalcinosis, joint space narrowing, and hook-like osteophytes. Serum uric acid 0.34 mmol/L (normal), ESR mildly elevated, joint aspirate (from prior episode): positively birefringent rhomboid-shaped crystals.

What are the most appropriate next steps in management? Select three (3) from the following list:

Fatima Al-Hassan, a 36-year-old woman, presents with a 6-month history of bilateral heel pain. The pain is worse in the mornings and after periods of rest and improves with movement. She also reports recent episodes of low back pain that improve with exercise and worsen with inactivity. She denies any joint swelling or trauma. She has a history of psoriasis diagnosed in her early 20s, currently affecting her scalp and elbows.

Medications: Topical corticosteroids

Allergies: Nil known

Past history: Psoriasis

Family history: Brother with ankylosing spondylitis

Social history: Works as a pharmacist, non-smoker, does not drink alcohol

Examination findings: Tenderness at insertion of the Achilles tendons bilaterally (enthesitis), reduced lumbar flexion, no peripheral synovitis. Psoriatic plaques over scalp and elbows.

Investigations: CRP 24 mg/L, ESR 36 mm/hr, HLA-B27 positive, X-ray pelvis: early bilateral sacroiliac joint sclerosis without erosions

What are the most appropriate next steps in management? Select three (3) from the following list:

John Weatherall, a 71-year-old man, presents with persistent pain and swelling in his left knee that developed gradually over the last 3 weeks. He denies any trauma, fevers, or systemic symptoms. He reports a history of haemodialysis for end-stage renal disease. He has had similar knee pain episodes in the past, usually resolving within a few days. There is no history of psoriasis, inflammatory bowel disease, or gout.

Medications: Calcium acetate, erythropoietin injections, cinacalcet

Allergies: Nil known

Past history: Chronic kidney disease stage 5 (on dialysis), secondary hyperparathyroidism

Family history: Nil significant

Social history: Retired accountant, non-smoker, minimal alcohol use

Examination findings: Left knee is swollen, warm, and tender with moderate effusion and reduced range of motion. No erythema or systemic signs of infection.

Investigations: Serum calcium 2.42 mmol/L, phosphate 1.90 mmol/L, PTH 85 pmol/L (elevated), CRP 34 mg/L. X-ray left knee: calcification of articular cartilage (chondrocalcinosis). Joint aspirate: weakly positively birefringent rhomboid-shaped crystals, no organisms seen.

What are the most appropriate next steps in management? Select three (3) from the following list:

Chloe Redman, a 27-year-old woman, presents with recurrent episodes of painful swelling in her knees and ankles over the past 6 months. She also reports a persistent genital ulcer that is painful and has not healed in 2 weeks. Over the past year, she has experienced recurrent oral ulcers and intermittent blurred vision. She denies any known STIs or gastrointestinal symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Nil significant

Social history: School teacher, non-smoker, no recent travel

Examination findings: Tender swelling of both knees and right ankle with mild effusion. Shallow genital ulcer on labia minora with erythematous base. Two healing oral ulcers on buccal mucosa. Fundoscopy shows mild anterior uveitis. No rash or dactylitis.

Investigations: CRP 38 mg/L, ESR 66 mm/hr, FBC: mild normocytic anaemia. HLA-B51 positive. STI screen negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Li, a 44-year-old man, presents with a 2-week history of progressive swelling, pain, and erythema of the left wrist and third finger of the same hand. He also reports fatigue and recent weight loss of 3 kg. He works as a butcher and mentions a small laceration to his left hand several weeks ago that has since healed. He denies fevers but reports night sweats.

Medications: Nil regular

Allergies: Nil known

Past history: Type 2 diabetes

Family history: Nil significant

Social history: Lives alone, smokes 10 cigarettes/day, no recent overseas travel

Examination findings: Left wrist is swollen, erythematous, and warm with reduced range of motion. There is fusiform swelling of the third digit (dactylitis). No systemic rash or lymphadenopathy.

Investigations: CRP 96 mg/L, ESR 88 mm/hr, FBC: normocytic anaemia, WCC 11.2 x10^9/L. X-ray left hand: soft tissue swelling, joint space preservation. Synovial aspirate: turbid fluid, no crystals seen. Awaiting culture and sensitivity.

What are the most appropriate next steps in management? Select three (3) from the following list:

Karen Doyle, a 63-year-old woman, presents with a 2-month history of progressive weakness in her shoulders and hips. She finds it increasingly difficult to rise from a seated position or lift objects overhead. She also reports mild shortness of breath and red, scaly patches on her knuckles. She denies joint pain or stiffness.

Medications: Nil

Allergies: Nil known

Past history: Hypertension

Family history: Nil autoimmune disease

Social history: Lives with partner, retired, non-smoker

Examination findings: Symmetric proximal muscle weakness in upper and lower limbs. Gottron’s papules present over MCP and PIP joints. No synovitis. Mild inspiratory crackles at lung bases. No rash on face or chest.

Investigations: CK 1120 U/L (elevated), ESR 54 mm/hr, CRP 32 mg/L. ANA positive (1:160, speckled pattern), Anti-Mi-2 antibody positive. CXR: possible early interstitial changes. Normal renal function and blood glucose.

What are the most appropriate next steps in management? Select three (3) from the following list:

Lucas Petrou, a 29-year-old man, presents with a 4-week history of joint pain, stiffness, and swelling affecting his knees, ankles, and several toes. He describes a recent episode of urethritis and dysuria following unprotected intercourse abroad. He has also noticed a scaly rash on the soles of his feet and reports one red, painful eye that self-resolved.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Nil significant

Social history: Builder, drinks occasionally, smokes socially

Examination findings: Right knee and left ankle with mild effusions and tenderness. Dactylitis noted in 2nd and 3rd right toes. Keratoderma blennorrhagica (hyperkeratotic rash) on soles. No synovitis in hands or axial tenderness.

Investigations: CRP 44 mg/L, ESR 58 mm/hr, FBC normal. HLA-B27 positive. STI screen: Chlamydia trachomatis detected via NAAT. RF and anti-CCP negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Grace, a 33-year-old woman, presents with progressive bilateral hand stiffness and skin tightening over the past 4 months. She reports that her fingers turn white and then blue in the cold, followed by redness and pain. She has difficulty fully opening her hands and complains of occasional heartburn. She denies joint swelling or muscle weakness.

Medications: Omeprazole

Allergies: Nil known

Past history: Nil significant

Family history: Mother has rheumatoid arthritis

Social history: Non-smoker, works as a florist, lives with partner

Examination findings: Sclerodactyly with tight shiny skin over the fingers and dorsum of the hands. Nailfold capillary dilatation noted. Positive pitting scars on fingertips. No synovitis. No muscle weakness.

Investigations: ANA positive (1:1280, centromere pattern), anti-centromere antibody positive. ESR and CRP mildly elevated. FBC, renal function, and CK normal. Chest X-ray normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Anthony Rossi, a 73-year-old man, presents with right shoulder pain that began suddenly two days ago after gardening. He describes the pain as constant, worse at night, and limiting his ability to raise his arm. He also reports some stiffness but no neck pain, fevers, or systemic symptoms. He has a known history of osteoarthritis in the knees and hypertension.

Medications: Perindopril, paracetamol PRN

Allergies: Nil known

Past history: Osteoarthritis, hypertension

Family history: Nil significant

Social history: Retired, lives with wife, non-smoker, no alcohol use

Examination findings: Right shoulder with reduced active range of motion, particularly in abduction and external rotation. Passive range of motion preserved. Localised tenderness over greater tuberosity. No redness or warmth. No neurological deficit.

Investigations: Shoulder X-ray: mild glenohumeral OA, no fracture or dislocation. Ultrasound: full-thickness tear of supraspinatus tendon.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sarah Willcox, a 41-year-old woman, presents with widespread musculoskeletal pain and profound fatigue for the past 6 months. She reports poor sleep, waking unrefreshed, and difficulty concentrating at work. Pain is diffuse, involving her neck, shoulders, back, and thighs, and worsens with stress or cold weather. She denies joint swelling, weight loss, or morning stiffness. She has a history of anxiety.

Medications: Occasional ibuprofen

Allergies: Nil known

Past history: Anxiety

Family history: Mother with irritable bowel syndrome

Social history: Office worker, lives alone, non-smoker, drinks wine socially

Examination findings: Normal vital signs. Diffuse tenderness on palpation over multiple soft tissue points including trapezius, lumbar spine, and thighs. No synovitis or muscle weakness. Normal neurological exam.

Investigations: CRP and ESR normal. FBC, renal, liver, thyroid function, and vitamin D all within normal limits. ANA and RF negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

Martin Keane, a 68-year-old man, presents with a 2-week history of pain and swelling in his right great toe. He describes the onset as sudden, waking him at night with severe pain. The toe is now red, swollen, and very tender. He has had two similar episodes in the past year affecting the same joint. He drinks beer most evenings and has a history of hypertension and stage 3 chronic kidney disease (CKD).

Medications: Perindopril, hydrochlorothiazide

Allergies: Nil known

Past history: Hypertension, CKD

Family history: Father had gout

Social history: Retired mechanic, drinks 3–4 beers most days, ex-smoker

Examination findings: Right first MTP joint is red, swollen, and exquisitely tender. No other joint involvement. Afebrile. No tophi visible.

Investigations: Serum uric acid: 0.54 mmol/L (elevated), CRP 45 mg/L, eGFR 48 mL/min/1.73m². Joint aspiration (done during a prior episode): negatively birefringent monosodium urate crystals.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jenny Matthews, a 37-year-old woman, presents with a 4-month history of intermittent right knee swelling and pain. She also describes generalised fatigue and a history of recurrent early miscarriages. She has no significant joint stiffness or redness. She denies fevers, rashes, or Raynaud’s phenomenon. She is otherwise well and not on any regular medications.

Medications: Nil

Allergies: Nil known

Past history: Three first-trimester miscarriages

Family history: Mother with systemic lupus erythematosus

Social history: Teacher, non-smoker, moderate alcohol intake

Examination findings: Right knee with mild effusion, non-erythematous, mildly tender on palpation. No synovitis elsewhere. No skin changes or mucosal ulcers. No neurological signs.

Investigations: CRP 12 mg/L, ESR 28 mm/hr, FBC: mild thrombocytopenia, ANA positive (1:320, speckled), lupus anticoagulant positive, anticardiolipin antibody positive. RF and anti-CCP negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

Hassan Karim, a 62-year-old man, presents with gradual onset of right hip and thigh pain over the past 6 months. The pain worsens with activity and improves with rest. He has noticed increasing stiffness in the mornings lasting around 15 minutes. There is no joint swelling, redness, or systemic symptoms. He has no history of trauma or autoimmune disease.

Medications: Amlodipine, atorvastatin

Allergies: Nil known

Past history: Hypertension, dyslipidaemia

Family history: Father had osteoarthritis

Social history: Retired accountant, non-smoker, moderate alcohol use

Examination findings: Antalgic gait, reduced internal rotation and abduction of the right hip. No warmth, swelling, or effusion. Normal neurological exam.

Investigations: X-ray pelvis and right hip: joint space narrowing, subchondral sclerosis, and osteophyte formation at the right femoral head.

What are the most appropriate next steps in management? Select three (3) from the following list:

Natalie Chen, a 46-year-old woman, presents with progressive tightness and discolouration of the skin on her fingers over the past 5 months. She also reports difficulty swallowing solids and frequent heartburn. She has experienced cold-induced colour changes in her fingers (white, then blue, then red) for several years but reports it has worsened recently. There is no joint swelling, muscle weakness, or chest pain.

Medications: Esomeprazole

Allergies: Nil known

Past history: Gastro-oesophageal reflux disease (GORD)

Family history: Sister with hypothyroidism

Social history: Works as a florist, non-smoker, lives with husband

Examination findings: Sclerodactyly and pitting scars at fingertips. Telangiectasia on cheeks. No synovitis. Normal respiratory and cardiovascular exams.

Investigations: ANA positive (1:1280, centromere pattern), anti-centromere antibody positive, ESR mildly elevated, FBC and renal function normal. Chest X-ray normal. Echocardiogram: normal ejection fraction, mild pulmonary hypertension.

What are the most appropriate next steps in management? Select three (3) from the following list:

James Ellery, a 52-year-old man, presents with an 8-month history of pain and stiffness in both hands, wrists, and knees. He describes morning stiffness lasting more than 60 minutes and swelling in his fingers. He has difficulty opening jars and using his hands for fine motor tasks. He reports unintentional weight loss and fatigue.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother had rheumatoid arthritis

Social history: Accountant, non-smoker, drinks wine occasionally

Examination findings: Symmetrical synovitis of MCP, PIP joints bilaterally, wrist tenderness and swelling. No nodules or deformities. Cardiovascular and respiratory exams normal.

Investigations: RF positive, anti-CCP strongly positive, CRP 64 mg/L, ESR 72 mm/hr. FBC: normocytic anaemia, mild thrombocytosis. X-ray hands: periarticular osteopenia, early erosions at MCP joints.

What are the most appropriate next steps in management? Select three (3) from the following list:

Leo Fernandez, a 60-year-old man, presents with chronic lower back pain and stiffness that has progressively worsened over the past year. The pain is worse in the morning and improves with movement throughout the day. He reports difficulty taking deep breaths and recent episodes of anterior uveitis. He denies peripheral joint symptoms or neurological complaints.

Medications: Ibuprofen as needed

Allergies: Nil known

Past history: None

Family history: Brother has ankylosing spondylitis

Social history: Works as a truck driver, ex-smoker, drinks beer on weekends

Examination findings: Reduced lumbar flexion (Schober’s test 2.5 cm), decreased chest expansion (2 cm). Tenderness over sacroiliac joints. Normal peripheral joints. No rash or dactylitis.

Investigations: ESR 48 mm/hr, CRP 36 mg/L, HLA-B27 positive, X-ray pelvis: bilateral sacroiliitis (grade 3 changes). Chest X-ray unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Olivia Zhang, a 49-year-old woman, presents with persistent dryness of her mouth and gritty eyes for the past 8 months. She also reports fatigue and difficulty swallowing dry foods. She denies photosensitivity, oral ulcers, or joint swelling. She uses artificial tears regularly but still experiences discomfort. She has no history of autoimmune disease.

Medications: Nil regular

Allergies: Nil known

Past history: Nil significant

Family history: Sister has rheumatoid arthritis

Social history: Accountant, non-smoker, lives with husband

Examination findings: Dry oral mucosa with multiple dental caries. Reduced tear production on Schirmer’s test. No lymphadenopathy, synovitis, or rash. Cardiopulmonary and neurological exams normal.

Investigations: ANA positive (1:640, speckled), anti-Ro (SSA) and anti-La (SSB) antibodies positive, ESR 42 mm/hr, CRP 10 mg/L, RF positive. FBC, renal function, and LFTs normal. Urinalysis unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Daniela Russo, a 57-year-old woman, presents with a 2-month history of progressive muscle weakness, particularly in her thighs and shoulders. She struggles with climbing stairs and combing her hair. She denies pain, rashes, or visual symptoms. She has noticed occasional difficulty swallowing solid food. No joint swelling or fever.

Medications: Nil regular

Allergies: Nil known

Past history: Hypertension, well controlled

Family history: Father had type 2 diabetes

Social history: Retired nurse, non-smoker, drinks wine occasionally

Examination findings: Symmetrical proximal muscle weakness in upper and lower limbs. Normal tone, reflexes, and sensation. No skin rash, joint swelling, or respiratory abnormalities.

Investigations: CK 2380 U/L (elevated), ESR 58 mm/hr, CRP 34 mg/L, ANA positive (1:320, speckled), Anti-Jo-1 antibody positive. FBC, renal and liver function normal. Chest X-ray unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amelia Foster, a 45-year-old woman, presents with episodes of painful red eyes and joint stiffness. She reports morning stiffness lasting over an hour, swelling in her wrists and MCP joints, and several past episodes of anterior uveitis. She has no skin rash or bowel symptoms. She notes significant fatigue and unintentional weight loss over the last three months.

Medications: Ibuprofen as needed

Allergies: Nil known

Past history: Recurrent iritis

Family history: Brother has ankylosing spondylitis

Social history: School principal, non-smoker, moderate alcohol intake

Examination findings: Swelling and tenderness of wrists and MCP joints bilaterally. Reduced lumbar flexion. Positive sacroiliac tenderness bilaterally. No rash or dactylitis. Visual acuity normal but photophobia noted.

Investigations: CRP 52 mg/L, ESR 60 mm/hr, HLA-B27 positive, RF and anti-CCP negative. X-ray pelvis: bilateral sacroiliitis (grade 2–3), X-ray hands: periarticular osteopenia, no erosions.

What are the most appropriate next steps in management? Select three (3) from the following list:

Linda Munro, a 65-year-old woman, presents with a 3-month history of pain and stiffness in both shoulders and hips, particularly in the morning. She reports difficulty getting out of bed and dressing herself due to stiffness and aching, which improves by midday. She denies joint swelling, jaw claudication, or visual symptoms. She has no fever, weight loss, or scalp tenderness.

Medications: Amlodipine, atorvastatin

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Father had type 2 diabetes

Social history: Retired librarian, lives with husband, non-smoker

Examination findings: Normal vital signs. Restricted active range of motion in both shoulders and hips due to pain. No synovitis or muscle weakness. Temporal arteries non-tender. No visual deficits.

Investigations: ESR 85 mm/hr, CRP 48 mg/L, CK normal, RF and anti-CCP negative. FBC shows mild normocytic anaemia.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jacob Elias, a 59-year-old man, presents with a one-week history of pain, swelling, and redness in his left knee. The onset was sudden and he describes the pain as severe and limiting his ability to walk. He denies recent trauma, systemic symptoms, or prior similar episodes. He has a history of type 2 diabetes and chronic kidney disease stage 3.

Medications: Metformin, irbesartan, frusemide

Allergies: Nil known

Past history: Type 2 diabetes, CKD, hypertension

Family history: Brother has gout

Social history: Retired delivery driver, drinks 2–3 beers daily, ex-smoker

Examination findings: Left knee warm, erythematous, and swollen with moderate effusion. Severe pain on flexion. Afebrile. No other joints affected.

Investigations: Serum uric acid: 0.49 mmol/L (elevated), CRP 75 mg/L, ESR 68 mm/hr. Joint aspirate: turbid fluid, needle-shaped negatively birefringent crystals, no organisms seen. Gram stain negative. Renal function: eGFR 48 mL/min/1.73 m².

What are the most appropriate next steps in management? Select three (3) from the following list:

Kylie Brennan, a 39-year-old woman, presents with a 2-month history of progressive joint pain and morning stiffness affecting her hands and wrists. She reports difficulty with household tasks such as turning door handles and using a keyboard. She also describes a persistent dry cough and shortness of breath on exertion. She has no significant past medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother has rheumatoid arthritis

Social history: Office worker, non-smoker, no alcohol

Examination findings: Synovitis of MCP and PIP joints bilaterally, decreased air entry and fine bibasal crackles on auscultation. No rash or muscle weakness.

Investigations: RF positive, anti-CCP strongly positive, CRP 62 mg/L, ESR 78 mm/hr. Chest X-ray: bibasal reticular opacities. HRCT: early interstitial lung disease. FBC: normocytic anaemia.

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael Watson, a 74-year-old man, presents with a 6-week history of progressively worsening right shoulder and hip pain. He reports profound morning stiffness lasting over an hour and generalised fatigue. He denies joint swelling, trauma, visual symptoms, or headache. He has no history of autoimmune disease or recent infections.

Medications: Perindopril, simvastatin

Allergies: Nil known

Past history: Hypertension

Family history: Nil autoimmune disease

Social history: Retired teacher, lives with wife, non-smoker, walks daily

Examination findings: Reduced active range of motion in both shoulders and hips due to pain. Passive range normal. No joint effusions, synovitis, or neurological deficits. No temporal artery tenderness or visual changes.

Investigations: ESR 96 mm/hr, CRP 58 mg/L, CK normal, FBC: normocytic anaemia. RF and anti-CCP negative. ANA negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

Elena Mihailov, a 62-year-old woman, presents with a 1-year history of pain and swelling in multiple small joints of her hands and feet. She describes prolonged morning stiffness lasting over an hour and fatigue that worsens throughout the day. She has noticed worsening joint deformity, and her grip strength has declined significantly. She was previously diagnosed with rheumatoid arthritis but discontinued follow-up due to relocation.

Medications: None currently

Allergies: Nil known

Past history: Rheumatoid arthritis (diagnosed 3 years ago)

Family history: Mother had osteoarthritis

Social history: Retired cook, lives alone, non-smoker

Examination findings: Ulnar deviation and swan-neck deformities of both hands. Synovitis in MCP and PIP joints. Tender MTP joints bilaterally. No nodules or skin rash. Normal cardiovascular and respiratory findings.

Investigations: RF and anti-CCP both positive, CRP 48 mg/L, ESR 78 mm/hr, FBC shows normocytic anaemia. X-ray hands and feet: joint space narrowing, periarticular osteopenia, and erosions at MCP and MTP joints.

What are the most appropriate next steps in management? Select three (3) from the following list:

Harriet Browne, a 66-year-old woman, presents with recurrent swelling and pain in her knees and wrists over the past year. The episodes last several days and resolve spontaneously. She also describes a chronic dry mouth and gritty eyes. She has been diagnosed with osteoarthritis in the past but reports that these episodes are more inflammatory in nature. She denies fevers, rash, or photosensitivity.

Medications: Paracetamol as needed

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Family history: Daughter has coeliac disease

Social history: Retired school teacher, lives alone, non-smoker

Examination findings: Mild swelling and tenderness in both knees, no erythema. Dry oral mucosa and conjunctiva. No synovitis in small joints. Normal cardiovascular and respiratory exams.

Investigations: ANA positive (1:640, speckled pattern), anti-Ro (SSA) and anti-La (SSB) positive, RF positive, ESR 56 mm/hr, CRP 22 mg/L. FBC and renal function normal. Joint aspirate: calcium pyrophosphate crystals, positively birefringent rhomboid-shaped crystals.

What are the most appropriate next steps in management? Select three (3) from the following list:

Steven Moloney, a 61-year-old man, presents with a 3-day history of sudden-onset pain, swelling, and redness in his left ankle. He describes the pain as severe and notes that it began overnight. He has had similar episodes affecting his big toe and ankle in the past. He consumes 3–4 beers daily and enjoys red meat regularly. He was advised to start allopurinol a year ago but never commenced therapy.

Medications: Hydrochlorothiazide, perindopril

Allergies: Nil known

Past history: Hypertension, hyperuricaemia

Family history: Brother has gout

Social history: Works part-time in retail, drinks alcohol daily, non-smoker

Examination findings: Left ankle swollen, erythematous, warm, and tender to touch. Limited range of motion due to pain. No systemic signs of infection.

Investigations: Serum uric acid: 0.58 mmol/L (elevated), CRP 68 mg/L, ESR 64 mm/hr. Joint aspirate: negatively birefringent monosodium urate crystals. No organisms on Gram stain.

What are the most appropriate next steps in management? Select three (3) from the following list:

Meera Patel, a 50-year-old woman, presents with a 4-month history of generalised fatigue, arthralgia, and episodic swelling of her fingers and wrists. She also reports increased sensitivity to sunlight, occasional mouth ulcers, and patchy hair thinning. She denies Raynaud’s phenomenon or dry eyes. Her symptoms are worse in the mornings and improve as the day progresses.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Mother has rheumatoid arthritis

Social history: Office worker, non-smoker, vegetarian

Examination findings: Mild synovitis in wrists and MCP joints bilaterally. No rash, but healing oral ulcer noted on hard palate. No lymphadenopathy or organomegaly. Cardiopulmonary and neurological exams unremarkable.

Investigations: ANA positive (1:1280, homogenous), anti-dsDNA positive, low C3 and C4 levels, CRP 12 mg/L, ESR 54 mm/hr. FBC: mild anaemia and leukopenia. Urinalysis: trace protein, no haematuria.

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Goh, a 70-year-old man, presents with persistent pain, swelling, and deformity of his fingers and toes. He reports a long-standing history of psoriasis and notes that his nails have become thickened and pitted. He denies eye symptoms or bowel issues. The joint symptoms have worsened gradually over the past year, and he now struggles with buttoning shirts and using cutlery.

Medications: Topical corticosteroids for psoriasis

Allergies: Nil known

Past history: Psoriasis (diagnosed 25 years ago)

Family history: Sister with type 1 diabetes

Social history: Retired engineer, non-smoker, drinks occasionally

Examination findings: Dactylitis in several fingers and toes (‘sausage digits’), nail pitting and onycholysis. Tenderness and swelling of DIP, PIP, and MCP joints. No rash or uveitis. No synovitis in knees or other large joints.

Investigations: CRP 38 mg/L, ESR 62 mm/hr, RF and anti-CCP negative. X-ray hands and feet: joint space narrowing, erosions, and pencil-in-cup deformities. Uric acid: normal.

What are the most appropriate next steps in management? Select three (3) from the following list: