AKT – Rheumatology

Jacob McLean, aged 52, presents with a 6-month history of progressive pain and stiffness in his shoulders, neck and hips, particularly worse in the morning. He reports fatigue and low-grade fevers but no weight loss or recent infections.

Relevant Past history: Hypertension controlled on perindopril

Relevant Examination findings: Restricted active movement of shoulders and hips with normal passive range. No joint swelling or synovitis. Normal neurological findings. Normal fundus.

Relevant Investigations: CRP 98 mg/L, ESR 72 mm/hr, ANA negative, RF negative. Creatinine kinase normal.

What is the MOST likely diagnosis?

Sharon Fielding, aged 64, presents with a 3-week history of painful, swollen left knee. She has no preceding trauma. She had similar episodes affecting different joints over the past few years, usually resolving in a few days. She drinks wine regularly and recently returned from a cruise.

Relevant Examination: Warm, erythematous left knee joint with restricted range of movement

Relevant Investigations: CRP 56 mg/L, serum urate 0.52 mmol/L, X-ray shows soft tissue swelling but no joint erosions or chondrocalcinosis.

What is the MOST appropriate next step in management?

Linda Downey, aged 46, presents with a history of dry eyes and dry mouth, ongoing for more than 6 months. She also reports mild fatigue. She is not on any regular medications.

Relevant Past history: None

Relevant Examination: Normal vital signs, dry mucous membranes. No salivary gland swelling or joint synovitis.

Relevant Investigations: ANA positive 1:320, anti-Ro/SSA positive, anti-La/SSB positive. ESR 58 mm/hr, CRP 10 mg/L. FBE and renal function normal.

What is the MOST likely diagnosis?

Kylie Harper, aged 35, presents with a 4-week history of worsening right ankle pain and swelling following an episode of gastroenteritis overseas. She now has bilateral conjunctivitis and occasional dysuria.

Relevant Examination: Right ankle effusion with tenderness. Conjunctival injection bilaterally. No genital ulceration or rash.

Relevant Investigations: CRP 85 mg/L, ESR 60 mm/hr. STI screen pending. HLA-B27 positive.

What is the MOST likely diagnosis?

Michael Roche, aged 69, presents with new onset bilateral wrist and MCP joint pain, with swelling and morning stiffness for 90 minutes. He reports mild fatigue but no systemic features. No prior joint symptoms.

Relevant Family history: His mother had ‘arthritis’ from age 60

Relevant Examination: Swollen, tender wrists and MCPs bilaterally. No nodules or deformities.

Relevant Investigations: RF positive, anti-CCP positive, CRP 45 mg/L, X-ray shows soft tissue swelling but no erosions.

What is the MOST appropriate initial management?

Tracey Nguyen, aged 29, presents with a one-week history of a red, swollen, painful big toe joint after a night of heavy drinking. She has no past medical history and is not taking any medications.

Relevant Examination: Left first MTP joint is hot, swollen, and extremely tender. She is afebrile and well-appearing.

Relevant Investigations: Serum urate 0.48 mmol/L, CRP 38 mg/L, X-ray unremarkable.

What is the MOST likely diagnosis?

Adam Freestone, aged 31, presents with chronic low back pain and morning stiffness for over 6 months. He reports improvement with activity and worsening with rest. He has no neurological symptoms.

Relevant Family history: Brother has Crohn disease

Relevant Examination: Reduced lumbar flexion and positive Schober’s test. No peripheral joint findings or skin changes.

Relevant Investigations: HLA-B27 positive, CRP 22 mg/L, pelvic X-ray shows bilateral sacroiliitis.

What is the MOST likely diagnosis?

Vera Khouri, aged 58, presents with progressive tightness of the skin over her fingers and face. She also reports cold-induced digital colour changes in her fingers.

Relevant Examination: Skin thickening over distal fingers, reduced oral aperture, telangiectasias on the face

Relevant Investigations: ANA positive, anti-centromere antibody positive, normal FBE and renal function

What is the MOST likely diagnosis?

Mark Sadiq, aged 67, presents with gradually worsening pain and stiffness in both knees, especially after activity. He has difficulty with stairs and getting out of chairs.

Relevant Past History: Obesity, Type 2 Diabetes

Relevant Examination: Bilateral crepitus, mild effusions, and reduced range of motion in both knees. No warmth or erythema.

Relevant Investigations: Knee X-ray shows joint space narrowing, subchondral sclerosis, and osteophyte formation.

What is the MOST likely diagnosis?

Jasmine Rawiri, aged 42, presents with symmetrical small joint pain in hands and wrists. She reports prolonged morning stiffness and fatigue. Symptoms have been present for 3 months.

Relevant Family History: Mother with hypothyroidism

Relevant Examination: Swollen and tender MCP and PIP joints bilaterally. No rash or nodules.

Relevant Investigations: RF negative, anti-CCP positive, CRP 28 mg/L, X-ray shows early periarticular osteopenia without erosions.

What is the MOST likely diagnosis?

Connor Willis, aged 60, presents with acute onset left knee pain and swelling. He denies trauma. He has a history of chronic kidney disease and is not on anticoagulants.

Relevant Examination: Swollen, tender left knee with decreased range of motion. No systemic signs of infection.

Relevant Investigations: Synovial fluid aspirate shows positively birefringent, rhomboid-shaped crystals. Gram stain negative.

What is the MOST likely diagnosis?

Michelle D’Angelo, aged 50, presents with widespread pain, fatigue, and poor sleep. Symptoms have been present for several months. She denies any joint swelling or morning stiffness.

Relevant Past History: Anxiety, managed with sertraline

Relevant Examination: Tenderness at multiple soft tissue points. No joint swelling or synovitis. Normal strength and reflexes.

Relevant Investigations: Normal CRP, ESR, FBE, thyroid function and vitamin D

What is the MOST likely diagnosis?

Troy Enoka, aged 37, presents with dactylitis of the right second toe, heel pain and morning stiffness. He denies a personal or family history of psoriasis.

Relevant Examination: Tender right Achilles tendon insertion. Swelling of entire second toe (sausage digit). No rash or nail pitting.

Relevant Investigations: HLA-B27 positive, CRP 18 mg/L. X-ray of foot shows periostitis and joint space narrowing at DIP joint.

What is the MOST likely diagnosis?

Elizabeth Rowe, aged 56, presents with dyspnoea on exertion and dry cough for the past 2 months. She also reports dry eyes and dry mouth.

Relevant Examination: Fine inspiratory crackles at the lung bases. No joint swelling. Dry oral mucosa.

Relevant Investigations: ANA positive, anti-Ro/SSA positive, HRCT chest shows interstitial lung disease pattern with ground-glass opacities.

What is the MOST likely underlying diagnosis?

Olivia Grant, aged 62, presents with digital pallor and pain triggered by cold exposure. She reports progressive thickening of the skin on her fingers and face over the past year.

Relevant Examination: Sclerodactyly, telangiectasias, and reduced oral aperture. No joint synovitis or nodules.

Relevant Investigations: ANA positive, anti-topoisomerase I (Scl-70) antibody positive, CRP 28 mg/L, ESR 48 mm/hr

What is the MOST likely diagnosis?

Benji Wallace, aged 48, presents with joint pain in the knees, elbows, and wrists, along with a red, scaly rash on his scalp and extensor elbows. He reports morning stiffness for about 45 minutes.

Relevant Examination: Tender, swollen wrists and knees. Mild nail pitting. Psoriatic plaques noted on elbows and scalp.

Relevant Investigations: CRP 34 mg/L, RF and anti-CCP negative. X-ray shows joint space narrowing with pencil-in-cup changes.

What is the MOST likely diagnosis?

Melanie Fraser, aged 66, presents with pain and swelling in the MCP and PIP joints bilaterally. She reports fatigue and morning stiffness lasting over 90 minutes. Symptoms have persisted for 6 months.

Relevant Examination: Swollen and tender MCP and PIP joints, mild ulnar deviation, and Z-thumb deformity.

Relevant Investigations: RF 90 IU/mL, anti-CCP positive, CRP 65 mg/L. X-ray shows joint erosions.

What is the MOST appropriate initial long-term treatment?

Angela Brown, aged 40, presents with worsening fatigue, arthralgia, and a facial rash that worsens with sun exposure. She also complains of intermittent mouth ulcers and hair thinning.

Relevant Examination: Macular malar rash sparing the nasolabial folds, mild non-deforming arthralgia in wrists and MCPs

Relevant Investigations: ANA positive 1:1280, anti-dsDNA positive, low C3 and C4. Normal renal function.

What is the MOST likely diagnosis?

Marcus Tang, aged 59, presents with long-standing tophaceous gout with frequent flares despite dietary efforts. He has been on colchicine intermittently and takes NSAIDs during flares.

Relevant Examination: Large tophi on elbows and ears, tender right first MTP joint.

Relevant Investigations: Serum urate 0.61 mmol/L, eGFR 50 mL/min/1.73m², CRP 45 mg/L

What is the MOST appropriate next step in long-term management?

Natalie Kerr, aged 35, presents with a 3-month history of dry eyes, dry mouth, and a new parotid gland swelling. She denies fevers or weight loss.

Relevant Examination: Bilateral parotid enlargement, dry oral mucosa. No synovitis or rash.

Relevant Investigations: ANA 1:640, anti-Ro/SSA positive, anti-La/SSB positive. ESR 60 mm/hr, CRP 8 mg/L

What is the MOST likely complication to monitor for in this patient?

Jaspreet Nagra, aged 43, presents with progressive skin tightening over her hands and forearms, Raynaud phenomenon, and dysphagia. She is concerned about her risk of complications.

Relevant Examination: Thickened, taut skin over forearms and hands. No joint synovitis.

Relevant Investigations: ANA positive, anti-Scl-70 positive, normal FBE and renal function

Which of the following complications is she MOST at risk of developing?

Timothy Harris, aged 25, presents with a red, swollen right knee. He reports unprotected sex 2 weeks ago and denies trauma. He is otherwise well.

Relevant Examination: Effusion and warmth over right knee, restricted ROM. No rash or urethral discharge.

Relevant Investigations: CRP 65 mg/L, NAAT positive for Chlamydia trachomatis, joint aspirate shows WBCs, culture negative.

What is the MOST likely diagnosis?

Susan Eldridge, aged 71, presents with sudden-onset headache, jaw claudication and scalp tenderness. She reports recent visual blurring in the right eye.

Relevant Examination: Tenderness over right temporal artery, right visual acuity reduced. No joint involvement noted.

Relevant Investigations: ESR 104 mm/hr, CRP 88 mg/L, temporal artery biopsy pending

What is the MOST appropriate next step in management?

Derek Lomas, aged 69, presents with fever, weight loss, arthralgia and a new purpuric rash on his lower limbs. He also reports foot drop on the left side.

Relevant Examination: Left foot dorsiflexion weakness, palpable purpura over legs, diminished ankle reflexes

Relevant Investigations: CRP 110 mg/L, ANCA negative, creatinine normal, Hepatitis B surface antigen positive

What is the MOST likely diagnosis?

Riley Young, aged 19, presents with bilateral heel pain and morning stiffness that improves with exercise. He is a competitive runner and denies any recent trauma or systemic illness.

Relevant Examination: Tenderness at both Achilles tendon insertions, limited lumbar flexion

Relevant Investigations: HLA-B27 positive, CRP 12 mg/L, lumbar spine X-ray normal

What is the MOST likely diagnosis?

Amira Karim, aged 53, presents with a 3-month history of progressive weakness in her thighs and upper arms. She also reports difficulty climbing stairs and brushing her hair. No rash or joint pain.

Relevant Examination: Proximal muscle weakness in upper and lower limbs. No sensory deficits. Reflexes preserved.

Relevant Investigations: CK 2100 U/L, ANA positive, anti-Jo-1 positive

What is the MOST likely diagnosis?

Cynthia Marlow, aged 72, presents with widespread muscle pain, morning stiffness and fatigue. She denies weakness or rash. She has difficulty raising arms and getting out of chairs.

Relevant Examination: Normal power, no synovitis. Pain on passive movement of shoulders and hips.

Relevant Investigations: CRP 85 mg/L, ESR 92 mm/hr, CK normal

What is the MOST appropriate next step in management?

Oliver Stone, aged 47, presents with painful, red eyes and a 4-week history of morning stiffness and lower back pain. He denies trauma. He also has a history of psoriasis.

Relevant Examination: Reduced Schober’s test, bilateral sacroiliac joint tenderness, conjunctival injection

Relevant Investigations: HLA-B27 positive, CRP 30 mg/L, X-ray shows sacroiliitis

What is the MOST likely diagnosis?

Marcus Vella, aged 76, presents with a 1-month history of fatigue, arthralgia and recurrent sinusitis. He also reports haematuria and a dry cough.

Relevant Examination: Crackles in lung bases, no rash or synovitis. BP 150/90 mmHg

Relevant Investigations: CRP 110 mg/L, c-ANCA positive, urinalysis shows haematuria and proteinuria, creatinine 145 µmol/L

What is the MOST likely diagnosis?

Karen Bolton, aged 58, presents with polyarthralgia and intermittent rashes. She describes photosensitivity, oral ulcers, and recent pleuritic chest pain.

Relevant Examination: Non-deforming joint tenderness, erythematous rash on cheeks and nose, no synovitis

Relevant Investigations: ANA 1:640, anti-dsDNA positive, low C3/C4, proteinuria 1+, ESR 84 mm/hr, CRP 18 mg/L

What is the MOST appropriate next step?

Hamid Alavi, aged 33, presents with sudden onset of left knee swelling and pain. He recently recovered from a diarrhoeal illness following travel to Bali. No fever or systemic symptoms.

Relevant Examination: Swollen, erythematous left knee with reduced ROM. No other joint involvement.

Relevant Investigations: CRP 48 mg/L, NAAT negative for STI, joint aspirate culture negative, synovial fluid WBCs elevated, Gram stain negative

What is the MOST appropriate diagnosis?

Belinda Cross, aged 68, presents with generalised aches and fatigue. She denies joint swelling but reports difficulty raising her arms and standing from a chair. She has had no recent infections or trauma.

Relevant Examination: No synovitis or weakness on examination, but pain with passive movement of shoulders and hips

Relevant Investigations: CRP 65 mg/L, ESR 102 mm/hr, CK normal

What is the MOST appropriate treatment?

Ivan Petrovic, aged 45, presents with episodic arthritis, low-grade fevers, and abdominal pain. He was born in Turkey and reports a family history of similar symptoms.

Relevant Examination: Normal between flares. No rash or joint damage noted.

Relevant Investigations: CRP and ESR elevated during attacks, normal between. Genetic testing confirms MEFV gene mutation.

What is the MOST likely diagnosis?

Lesley Turnbull, aged 61, presents with progressive joint deformity, particularly in the fingers. She also has dry eyes and mouth.

Relevant Examination: Swan-neck deformities, mild bilateral parotid gland enlargement, dry mucous membranes

Relevant Investigations: RF positive, anti-CCP positive, ANA positive, anti-Ro/SSA positive

What is the MOST likely diagnosis?

Mariama Sillah, aged 57, presents with swelling of both hands and wrists for 4 months. She reports morning stiffness lasting 2 hours. She is hesitant about taking methotrexate.

Relevant Examination: Symmetric synovitis of MCP and wrist joints bilaterally. No extra-articular features.

Relevant Investigations: RF and anti-CCP positive, CRP 55 mg/L

What is the MOST appropriate next step in management?

Isobel Chan, aged 24, presents with a 2-month history of bilateral knee and ankle pain. She has also had episodes of eye redness and painful urination. She recalls a recent gastrointestinal illness while travelling in Southeast Asia.

Relevant Examination: Bilateral knee effusions, conjunctival injection, and tender Achilles tendons

Relevant Investigations: HLA-B27 positive, CRP 68 mg/L

What is the MOST likely diagnosis?

Callum Short, aged 65, presents with severe first MTP joint pain. He has a known history of gout but reports worsening attacks despite adherence to allopurinol 300 mg daily.

Relevant Examination: Tophi over the ears and olecranon, red and swollen first MTP joint

Relevant Investigations: Serum urate 0.44 mmol/L, eGFR 72 mL/min

What is the MOST appropriate next step in management?

Angela Dee, aged 59, presents with fatigue, mild dyspnoea and a non-productive cough. She has no history of asthma or smoking. On examination, fine inspiratory crackles are heard at the lung bases.

Relevant Investigations: HRCT chest shows ground-glass opacities, ANA positive, anti-Scl-70 negative, anti-Jo-1 antibody positive

What is the MOST likely diagnosis?

Linda Quade, aged 47, presents with multiple swollen joints, dry mouth and dry eyes. She has been diagnosed with primary Sjögren syndrome. You are assessing her risk of complications.

Relevant Examination: Parotid swelling, dry oral mucosa, symmetric arthritis without erosions

Relevant Investigations: Anti-Ro and anti-La positive, ANA positive, RF positive

What is the MOST serious long-term complication of her condition?

Reza Salim, aged 38, presents with joint stiffness and pain affecting the spine and sacroiliac region. He reports a 6-month history of inflammatory back pain. He also has a history of Crohn disease.

Relevant Examination: Reduced lumbar flexion, positive FABER test bilaterally

Relevant Investigations: HLA-B27 positive, CRP 38 mg/L

What is the MOST likely diagnosis?

Francesco Romano, aged 63, presents with pain and stiffness in the right shoulder and hip. He has difficulty getting out of bed and lifting objects overhead. He denies trauma or weakness.

Relevant Examination: Reduced active ROM in shoulders and hips. No swelling or synovitis. Neurologically intact.

Relevant Investigations: ESR 84 mm/hr, CRP 72 mg/L, CK normal

What is the MOST likely diagnosis?

Sophie Tran, aged 29, presents with a new malar rash and joint pain. She has intermittent fevers and oral ulcers. She reports photosensitivity but no weight loss or renal symptoms.

Relevant Examination: Macular facial rash, non-erosive synovitis in hands, shallow buccal ulcer noted

Relevant Investigations: ANA 1:1280, anti-dsDNA positive, low C3 and C4

What is the MOST likely diagnosis?

Daniel Gordon, aged 70, presents with sudden right wrist pain, swelling and redness. He has a history of chronic kidney disease and hypertension. No trauma reported.

Relevant Examination: Swollen, erythematous right wrist, tender with limited movement

Relevant Investigations: X-ray shows chondrocalcinosis. Joint aspirate reveals rhomboid-shaped, positively birefringent crystals

What is the MOST likely diagnosis?

Kate Morrison, aged 55, presents with new onset hypertension and haematuria. She also has low-grade fevers and malaise. She has no significant past medical history.

Relevant Investigations: Urinalysis shows RBC casts and proteinuria. c-ANCA positive. Creatinine 185 µmol/L

What is the MOST likely diagnosis?

Hugo Peters, aged 49, presents with pain and swelling in the left knee. He has a history of psoriasis but no recent trauma or systemic symptoms.

Relevant Examination: Left knee effusion and tenderness. Psoriatic plaques on elbows. Nail pitting present.

Relevant Investigations: RF negative, anti-CCP negative, CRP 38 mg/L. X-ray shows joint space narrowing with pencil-in-cup deformity

What is the MOST likely diagnosis?

Tomislav Novak, aged 73, presents with fever, weight loss, and progressive renal impairment. He also reports nasal congestion and recurrent epistaxis.

Relevant Examination: Saddle-nose deformity, crackles at lung bases, no rash

Relevant Investigations: c-ANCA positive, creatinine 230 µmol/L, urinalysis shows proteinuria and RBC casts

What is the MOST likely diagnosis?

Helen McCarthy, aged 64, presents with gradual onset of shoulder and hip stiffness. Symptoms are worse in the morning and improving slightly during the day. She has no joint swelling.

Relevant Examination: Decreased active ROM, normal strength, no joint effusions or deformities

Relevant Investigations: ESR 105 mm/hr, CRP 86 mg/L, CK normal

What is the MOST appropriate initial treatment?

Sarah Ku, aged 26, presents with recurrent painful oral and genital ulcers and episodes of uveitis. She also reports arthralgia and recent skin pustules on her legs.

Relevant Examination: Multiple shallow oral and vulval ulcers, no synovitis, erythematous pustules on shins

Relevant Investigations: CRP 52 mg/L, ESR 78 mm/hr, HLA-B51 positive

What is the MOST likely diagnosis?

Patrick Doyle, aged 68, presents with persistent pain in his right hip and groin. He walks with a limp and reports stiffness after sitting for long periods. He denies trauma or systemic symptoms.

Relevant Examination: Painful restricted movement in internal rotation and flexion of the right hip

Relevant Investigations: X-ray shows joint space narrowing and subchondral sclerosis in the right hip

What is the MOST likely diagnosis?

Emily Rowe, aged 39, presents with fatigue and arthralgia. She has a history of vitiligo and hypothyroidism. On examination, no joint swelling is found but her nails show pitting and onycholysis.

Relevant Investigations: CRP 12 mg/L, RF negative, anti-CCP negative, ANA negative

What is the MOST likely diagnosis?