A 26-year-old man presents to the GP with a 6-month history of persistent lower back pain and stiffness. The symptoms are worse in the morning, lasting for about an hour, and improve significantly with exercise. He reports no history of trauma but says the back pain has gradually worsened and now limits his daily function. Examination reveals reduced lumbar flexion and positive Schober’s test. Inflammatory markers are mildly elevated.

What is the single most appropriate initial investigation to confirm the suspected diagnosis?

A 50-year-old man with a history of asthma presents with fatigue, weight loss, and a new rash on his legs. Blood tests show eosinophilia.

Which of the following is least likely to be a feature of eosinophilic granulomatosis with polyangiitis (EGPA)?

A 38-year-old woman presents with a 9-month history of widespread body pain, constant fatigue, non-restorative sleep, and difficulty concentrating at work. She denies weight loss or joint swelling. On examination, there is no synovitis or neurological deficit, but she reports tenderness in multiple areas. Blood tests including CRP, ESR, and thyroid function are all within normal limits.

What is the most likely diagnosis?

A 28-year-old man presents to the GP with chronic lower back pain that has persisted for the past 8 months. He describes the pain as worse in the morning, associated with prolonged stiffness, and says it improves with movement but not with rest. He denies any history of trauma. On examination, lumbar flexion is reduced and Schober’s test is positive. There are no neurological deficits.

What is the most likely diagnosis?

A 60-year-old man presents with sudden-onset pain and swelling in his right big toe that began overnight. He is unable to bear weight. On examination, the toe is red, hot, and very tender. He has a history of hypertension and chronic kidney disease (stage 3). Blood tests show normal white cell count and mildly elevated CRP. He has not had any similar episodes in the past.

What is the most likely diagnosis?

A 45-year-old woman with a recent diagnosis of fibromyalgia presents for follow-up. She continues to experience widespread pain, sleep disturbance, and low energy levels. She is currently not on any medication. Her inflammatory markers and thyroid function are normal. She is frustrated by her symptoms and asks about starting painkillers or steroids. She has no red flag symptoms or signs of another underlying condition.

What is the most appropriate next step in her management?

A 64-year-old man presents for a follow-up after his recent episode of acute gout affecting the right first metatarsophalangeal joint. The pain has resolved with colchicine, and he now asks about starting long-term treatment to prevent further flares. He has had three attacks in the past year and has visible tophi over his elbow. His renal function is stable.

When is the most appropriate time to initiate urate-lowering therapy (ULT) in this patient?

A 52-year-old man presents with a 2-month history of persistent nasal congestion, crusting, occasional epistaxis, and recent onset of haematuria. He also reports fatigue and weight loss. Examination reveals nasal septum tenderness and bilateral crackles on lung auscultation. Urine dipstick is positive for blood and protein. Blood tests show elevated CRP and ESR.

Which of the following is the most likely diagnosis?

A 48-year-old man presents with progressive shortness of breath, bilateral tingling and numbness in his feet, and unintentional weight loss over the past 2 months. He has a history of adult-onset asthma and nasal polyps. On examination, he has palpable purpura over both legs and reduced pinprick sensation in a stocking distribution. Blood tests reveal a marked eosinophilia, raised CRP, and normocytic anaemia. Chest X-ray shows bilateral patchy infiltrates. Urinalysis is normal.

What is the most likely diagnosis?

A 58-year-old man presents with his third gout flare in the past 9 months, affecting different joints including the first MTP joint and now his left ankle. He is currently being treated with naproxen and a proton pump inhibitor. His eGFR is 55 mL/min/1.73m² (CKD stage 3a). Serum urate level measured between flares has consistently been 430 micromol/L. His background is heart failure.He is not on any urate-lowering therapy.

What is the most appropriate next step in his management?

A 54-year-old woman presents with a 4-month history of rapidly progressive skin tightening affecting her trunk and both proximal and distal limbs. She reports new-onset dry cough and shortness of breath on exertion. Blood tests reveal positive anti-topoisomerase I (anti-Scl-70) antibodies.

Which subtype of systemic sclerosis does she most likely have?

A 52-year-old man presents with a 3-month history of fatigue, low-grade fever, weight loss, and myalgia. He reports new-onset right foot weakness and numbness. Examination reveals livedo reticularis over both legs and foot drop on the right. His BP is 170/100 mmHg. Urinalysis shows mild proteinuria without haematuria. ANCA is negative. Hepatitis B surface antigen is positive.

What is the most likely diagnosis?

A 35-year-old woman presents with a 5-month history of severe, persistent fatigue. She says the fatigue is not relieved by rest, and worsens after minimal physical or mental activity. She also complains of difficulty concentrating, non-refreshing sleep, and occasional dizziness when standing. Physical examination is unremarkable, and blood tests including full blood count, thyroid function, and glucose levels are normal.

Which of the following is the most likely diagnosis?

A 34-year-old woman presents with ongoing fatigue that began over four months ago. She describes the fatigue as severe and disabling, significantly affecting her ability to work and carry out household tasks. She reports that physical activity makes her symptoms worse for days afterward. She also has unrefreshing Systemic Lupusep and difficulty concentrating, but her blood tests and physical examination are unremarkable.

Based on NICE guidance, which of the following best supports a diagnosis of chronic fatigue syndrome (CFS) in this patient?

A 31-year-old man with radiographic axial spondylarthritis reports persistent spinal stiffness and back pain despite taking NSAIDs regularly for 2 months. He has difficulty with daily tasks, and examination shows reduced lumbar mobility. He remains committed to physiotherapy and has stopped smoking.

What is the most appropriate next step in his management?

A 68-year-old man with a history of ischaemic heart disease presents for follow-up after a recent episode of acute gout affecting his right first MTP joint. He reports one previous flare last year. His serum urate level is 420 micromol/L. He is currently asymptomatic. His current medications include aspirin, ramipril, and bisoprolol.

What is the most appropriate urate-lowering therapy (ULT) to initiate?

A 68-year-old woman presents to her GP with a gradual onset of right knee pain over the past year. The pain is worse after walking, improves with rest, and is associated with brief morning stiffness lasting around 10 minutes. Examination reveals bony swelling, crepitus, and preserved range of motion. There is no joint redness or systemic symptoms. Blood tests including CRP and ESR are normal.

What is the most likely diagnosis?

A 50-year-old woman presents with a long-standing history of Raynaud’s phenomenon, telangiectasia on her face, and difficulty swallowing solids. She has no skin thickening over her upper arms or trunk. Routine blood tests are normal, but a high-titre anti-centromere antibody is reported.

Which of the following late complications is she most at risk of developing?

A 62-year-old man presents with chronic bilateral knee pain that has gradually worsened over the past two years. The pain is worse with walking and relieved by rest. He reports morning stiffness lasting about 10 minutes and finds it difficult to kneel or climb stairs. Examination reveals mild varus deformity, crepitus, and bony swelling of both knees. There are no signs of joint effusion, and inflammatory markers are normal.
He has a BMI of 32 and leads a sedentary lifestyle. He asks if he should get an X-ray to confirm the diagnosis.

What is the most appropriate next step in his management?

A 68-year-old postmenopausal woman presents for evaluation after sustaining a fragility fracture of the distal radius 3 weeks ago. Her weight is is 70kg, height is 165cm and has a 30-year smoking history. She is otherwise healthy and not on corticosteroids. A recent DXA scan shows a T-score of –2.6 at the femoral neck. Her FRAX-calculated 10-year risk for a major osteoporotic fracture is 16% & hip fracture is 8%.

Which of the following is the most appropriate next step in her management?

A 72-year-old postmenopausal woman presents for routine review. She has no current complaints. She has a BMI of 18 kg/m² and has been a smoker for 40 years. She had a fragility fracture of her wrist after a fall last year. There is no family history of hip fractures. She is not on steroids.

What is the most appropriate next step in the assessment of her bone health?

A 55-year-old man presents with a sudden onset of severe pain, redness, and swelling in his right ankle, which began overnight. He has a history of hypertension and consumes alcohol regularly. Examination reveals a hot, swollen joint with restricted movement. Blood tests show mildly elevated CRP and normal white cell count. You suspect gout, but the diagnosis remains uncertain.

What is the most appropriate next step to confirm the diagnosis?

A 38-year-old woman presents to her GP with a 3-month history of worsening joint pain and stiffness, particularly affecting her wrists and small joints of both hands. She reports that morning stiffness lasts over an hour and improves gradually throughout the day. She also mentions fatigue and occasional low-grade fever. On examination, there is swelling and tenderness over the MCP and PIP joints bilaterally. There is no history of trauma or psoriasis. She has not previously sought medical attention for this issue.

What is the most appropriate next step in her management?

A 70-year-old woman is being evaluated for osteoporosis management following a recent vertebral fragility fracture. Her DXA scan shows a T-score of –2.8 at the spine. She has a history of severe gastro-oesophageal reflux disease (GORD) with oesophageal strictures. She is otherwise fit and not on corticosteroids. Her FRAX 10-year risk for major osteoporotic fracture is 21% & for hip fracture is 4%.

Which of the following is the most appropriate pharmacological management for her osteoporosis?

A 79-year-old woman with a recent diagnosis of Giant Cell Arteritis (GCA) is being treated with high-dose oral prednisolone. What complications she should be aware of in the long term related to her condition and treatment.

What is the most likely long-term complication associated with her current treatment?

A 45-year-old woman presents with a 3-month history of gradually worsening muscle weakness. She finds it difficult to climb stairs and comb her hair. She also reports mild shortness of breath and difficulty swallowing solids. There is no associated rash, joint pain, or recent illness. On examination, she has symmetrical proximal muscle weakness in the upper and lower limbs. Her creatine kinase (CK) level is 2,400 IU/L (normal <200). Chest auscultation reveals fine inspiratory crackles at the bases.

What is the most likely diagnosis?

A 73-year-old woman presents with bilateral shoulder and hip girdle stiffness lasting more than an hour each morning for the past 3 weeks. She reports fatigue and low-grade fever. There is no muscle weakness on examination. Blood tests reveal elevated ESR and CRP. There are no symptoms of headache, jaw claudication, or visual disturbance.

What is the most appropriate initial management?

A 26-year-old woman presents to her GP with a 3-month history of joint pain affecting her hands and knees, fatigue, and intermittent low-grade fever. She also complains of facial rash that worsens with sun exposure. On examination, she has symmetrical tenderness in the MCP and PIP joints without deformities. A faint erythematous rash is visible over the cheeks sparing the nasolabial folds. Initial blood tests show anaemia (Hb 10.2 g/dL), lymphopenia, and raised ESR. Urinalysis reveals proteinuria (++), and ANA is positive.

What is the most likely diagnosis?

A 48-year-old woman with biopsy-confirmed polymyositis presents for follow-up. She had initially been started on oral prednisolone 60 mg daily 4 weeks ago. Her muscle strength has slightly improved, but she still has proximal weakness. Her CK remains elevated at 2,800 IU/L (previously 4,200 IU/L). She is experiencing side effects of weight gain and mood changes on steroids.

What is the most appropriate next step in her management?

A 68-year-old man with a history of type 2 diabetes presents with acute onset of pain, swelling, and erythema in his left knee. The joint is warm and tender with a restricted range of motion. He is febrile and appears systemically unwell. Joint aspiration reveals turbid synovial fluid, and Gram stain shows Gram-positive cocci in clusters.

Which of the following is the most likely causative organism?

A 62-year-old man presents to the clinic complaining of episodes where his fingers turn pale and numb when exposed to cold weather. The episodes last for about 15 minutes and are often followed by a blue discoloration before returning to normal. He denies joint pain, skin tightening, or systemic symptoms. He has a history of hypertension and stable angina, and recently started a new medication. On examination, peripheral pulses are normal, and there are no signs of connective tissue disease.

Which of the following is the most likely contributing factor to his symptoms?

A 72-year-old woman presents with ongoing pain and stiffness in her right thumb base due to hand osteoarthritis. The pain has worsened over the past few months and now interferes with her ability to grip objects and perform household tasks. She has tried splinting and hand exercises but reports minimal improvement. There is visible joint enlargement at the first carpometacarpal joint, but no signs of acute inflammation.

What is the most appropriate management?

A 67-year-old man with hypertension and chronic osteoarthritis is being reviewed for elevated uric acid levels and a recent gout flare. He is currently taking several medications, including a diuretic for blood pressure control. His GP is considering modifying his regimen to reduce gout risk.

Which of the following diuretics is associated with the lowest risk of inducing gout?

A 45-year-old woman presents with a 2-year history of episodic finger discoloration triggered by cold and emotional stress. She describes a triphasic colour change: white (pallor), then blue (cyanosis), followed by red (hyperaemia) in multiple fingers. The episodes are painful but self-resolving. She denies joint pain, skin changes, or digital ulcers. She is a non-smoker, and her BMI is 22. Examination is unremarkable, with good peripheral pulses and no signs of connective tissue disease. She is currently using gloves but continues to have frequent attacks that interfere with daily activities.

What is the most appropriate next step in her management?

A 32-year-old man presents with ongoing right knee pain and swelling. He also reports pain at the heel and mild lower back discomfort. Examination confirms a swollen, tender right knee and tenderness over the Achilles tendon insertion. He is afebrile and systemically well. He is sexually active with multiple partners. Blood tests show mildly elevated CRP. He has no features suggestive of a chronic spondyloarthropathy.

What is the most appropriate initial management for his pain?

A 76-year-old woman with a 4-week history of bilateral shoulder pain and morning stiffness lasting over an hour is being treated for polymyalgia rheumatica with oral prednisolone 15 mg daily. She reports significant improvement in her stiffness and systemic symptoms after 5 days. However, on her 2-week follow-up visit, she now complains of a new onset of right-sided temporal headache and scalp tenderness. She also reports pain in the jaw while chewing.

What is the most appropriate next step in management?

A 40-year-old woman presents with a 2-month history of symmetrical joint pain, swelling, and morning stiffness lasting over 1 hour. Examination reveals synovitis of the MCP and PIP joints bilaterally. You suspect rheumatoid arthritis.

Which ONE of the following is the most appropriate initial investigation to support the diagnosis?

A 28-year-old woman presents to the GP with a 6-month history of episodes where her fingers turn white, then blue, and finally red, usually triggered by cold weather or emotional stress. She describes associated numbness and tingling during episodes, which last for 10–20 minutes. The symptoms are bilateral and symmetrical. She has no joint pain, skin changes, or systemic symptoms. On examination, her fingers appear normal. Her medical history is unremarkable, and she is not on any regular medications.

What is the most likely diagnosis?

A 42-year-old woman presents with a 6-month history of worsening asthma, nasal congestion, and weight loss. Over the past two weeks, she has developed diffuse wheezing, migratory pulmonary infiltrates seen on chest X-ray, and peripheral eosinophilia of 2.5 × 10⁹/L. She denies any neurological symptoms or organ-specific complaints. There are no signs of skin involvement or renal disease. CRP is elevated, and she is functionally independent.

What is the most appropriate first-line treatment?

An 80-year-old woman presents after sustaining a recent fragility fracture of the proximal humerus following a fall from standing height. She is otherwise independent and has a BMI of 18.5 kg/m². She has a long smoking history but no prior osteoporosis diagnosis or treatment.

What is the most appropriate next step in management?

A 72-year-old man presents to the Emergency Department with a 2-day history of a hot, swollen, and extremely painful left knee. He has been unable to bear weight since the onset of symptoms. He is febrile (38.5°C) and tachycardic. There is marked swelling, erythema, and restricted movement of the left knee. He has a history of osteoarthritis and type 2 diabetes mellitus. There is no history of trauma or recent travel.

What is the most appropriate next step in management?

A 31-year-old woman presents with persistent fatigue, joint pain affecting both hands, and a photosensitive malar rash. She also reports intermittent mouth ulcers and hair thinning. Her GP suspects systemic lupus erythematosus (SLE). Basic bloods reveal normocytic anaemia, lymphopenia, and a raised ESR. Urinalysis shows trace protein. You are considering specific investigations to support the diagnosis.

Which of the following is the most specific investigation for confirming SLE?

A 69-year-old man presents to his GP with a 2-day history of severe pain and swelling in his right knee. He is unable to bear weight and reports feeling feverish last night. He has a past medical history of osteoarthritis and type 2 diabetes mellitus. On examination, the right knee is red, swollen, and warm, with a limited range of motion. Temperature is 37.9°C. He has no recent trauma.

What is the most appropriate next step in management?

A 10-year-old girl is diagnosed with acute rheumatic fever following a recent episode of streptococcal pharyngitis. She presents with migratory polyarthritis, fever, and a newly detected systolic murmur consistent with carditis. Her inflammatory markers are raised and ASO titre is positive.

What is the most appropriate initial management step?

A 13-year-old girl is brought to the clinic with a 1-week history of painful, swollen knees and ankles. Her symptoms began in one joint and migrated to others. Her mother also reports that she had a sore throat about 3 weeks ago, which was not treated. On examination, she has a temperature of 38.5°C, a faint pink rash on her trunk, and a pansystolic murmur best heard at the apex. Her ESR is 76 mm/hr, CRP is elevated, and throat swab shows growth of Group A Streptococcus.

Which of the following best supports the diagnosis of acute rheumatic fever according to the Revised Jones Criteria?

A 45-year-old man presents with a 6-month history of joint pain and stiffness, predominantly affecting his distal interphalangeal joints. He also reports morning stiffness lasting about 45 minutes that improves with activity. On examination, several fingers show swelling, and there is evidence of nail pitting and onycholysis. His past medical history includes plaque psoriasis diagnosed 8 years ago. Rheumatoid factor and anti-CCP antibodies are negative.

What is the most likely diagnosis?

A 58-year-old woman presents with chronic pain in both hands and wrists. She has been engaged in hand embroidery for decades and describes aching pain that worsens by evening and is relieved with rest. Over the last two months, she reports stiffness in the wrists and fingers lasting about an hour every morning, along with increasing fatigue and occasional dryness in her eyes.
On examination, her wrists and several finger joints are swollen and mildly warm. There is reduced grip strength, and symmetrical joint involvement is observed. There are no visible joint deformities. Temperature is 37.2 °C and vital signs are otherwise normal.

Which of the following features most reliably distinguishes rheumatoid arthritis (RA) from osteoarthritis (OA) in this case?

A 66-year-old woman with well-controlled type 2 diabetes presents with 1 week of increasing left shoulder pain. She reports no trauma but mentions that she had been painting her kitchen ceiling recently. The pain is localized over the lateral shoulder and worsens when she raises her arm overhead. On examination, there is mild tenderness over the lateral aspect of the acromion, with visible swelling just inferior to it. Passive range of motion is preserved, but active abduction is painful. No fever or erythema is noted.

What is the most likely diagnosis?

A 52-year-old woman presents with progressive difficulty rising from a seated position and climbing stairs over the past 4 months. She denies pain but reports general fatigue and mild breathlessness on exertion. Examination reveals symmetrical proximal muscle weakness in both lower limbs, with preserved reflexes and no sensory deficits. Blood tests show a creatine kinase (CK) level of 3,000 IU/L and positive anti-Jo-1 antibodies. A chest X-ray reveals basal interstitial changes.

What is the most likely diagnosis?

A 28-year-old man of Middle Eastern origin presents to the rheumatology clinic with a history of recurrent oral and genital ulcers over the past year. He was recently diagnosed with Behçet’s disease after developing anterior uveitis. He is currently experiencing another flare with multiple painful oral ulcers and mild arthralgia. His vision is stable, and there is no neurological or vascular involvement.

What is the most appropriate next step in management?

A 76-year-old woman presents to the Emergency Department with increasing left shoulder pain and restricted movement over the past 3 days. She is febrile (38.6°C), confused, and has a heart rate of 110 bpm. Her past medical history includes osteoarthritis, hypertension, and recent high-dose corticosteroids for polymyalgia rheumatica. On examination, her left shoulder is warm, swollen, and tender. Blood tests show CRP 150 mg/L and WCC 17,000/mm³. Joint aspiration yields turbid synovial fluid. Gram stain is negative. She has a documented penicillin allergy.

What is the most appropriate next step in management?

A 34-year-old Turkish man presents with a 6-month history of recurrent painful oral ulcers that heal spontaneously but recur every few weeks. He also reports occasional genital sores that leave scars after healing. In the past month, he has developed redness and blurred vision in his right eye, along with joint pain in his knees and ankles. He denies any recent travel, rashes, or new medications.
On examination, there are healing ulcers on the buccal mucosa and a faint scar on the scrotum. His right eye shows mild conjunctival injection. A skin prick test performed during the clinic visit becomes pustular within 48 hours.

What is the most likely diagnosis?

A 75-year-old woman presents with acute swelling and pain in her left knee. She is afebrile and systemically well. Examination reveals a warm, swollen joint with restricted movement. An X-ray of the knee shows linear calcification within the articular cartilage.

What is the most likely diagnosis?

A 52-year-old woman presents with persistent dry eyes and dry mouth for the past year. She describes a gritty sensation in both eyes and difficulty swallowing dry foods. She also reports joint stiffness in the morning lasting around 30 minutes and increasing dental cavities despite good hygiene. On examination, her parotid glands appear slightly enlarged bilaterally, and there is reduced tear production on Schirmer’s test.

What is the most likely diagnosis?

A 47-year-old woman presents with a 3-month history of painful, swollen joints affecting her hands, wrists, and feet. She reports morning stiffness lasting over an hour. On examination, there is symmetrical synovitis of the MCP and MTP joints. Inflammatory markers (ESR and CRP) are raised. You suspect early rheumatoid arthritis and want to confirm the diagnosis.

Which ONE of the following is the most specific test for rheumatoid arthritis?

A 67-year-old woman attends for follow-up after a routine DEXA scan, which shows a T-score of −2.1 at the femoral neck. She has no history of fractures, is independently mobile, and has no significant comorbidities. Her BMI is 20, and recent blood tests (including renal function and calcium) are normal. She is not on any bone protection therapy.

What is the most appropriate next step in management?

A 42-year-old man with a 5-year history of psoriasis presents with joint pain. He complains of swelling and stiffness in several fingers, which appear sausage-like. Examination reveals tenderness at the insertion of the Achilles tendon and swelling of a distal interphalangeal joint. There is no rheumatoid factor or anti-CCP antibodies.

Which of the following features is most characteristic of psoriatic arthritis?

A 58-year-old retired carpenter presents with a 4-day history of pain and swelling over the back of his right elbow. He reports no trauma but mentions frequently leaning on hard surfaces. On examination, there is a soft, fluctuant swelling over the olecranon region, mildly tender to touch. The overlying skin is intact, with no erythema or warmth. His temperature is 36.7°C. Joint range of motion is preserved but uncomfortable at the extremes.

What is the most likely diagnosis?

A 40-year-old woman presents with widespread musculoskeletal pain for the past 6 months. She reports extreme fatigue, poor sleep, and difficulty concentrating. Examination reveals no synovitis, but she is tender to palpation across multiple soft tissue points.

What is the most likely diagnosis?

A 65-year-old man presents with gradually worsening knee pain and stiffness over the past few months, particularly after long walks or standing. He describes brief morning stiffness that lasts less than 30 minutes and denies any joint swelling or systemic symptoms. X-rays show early osteoarthritic changes with no joint space collapse. He wishes to avoid medication if possible.

What is the most appropriate next step in management?

A 22-year-old woman presents with a 3-day history of painful swelling in her right wrist that has now shifted to her left ankle. She has a low-grade fever and mild malaise. On examination, there is tenderness and swelling along the tendons of the affected joints, without obvious joint effusion or redness. She also has a few pustular lesions scattered over her trunk. She denies dysuria or vaginal discharge but reports recent unprotected sexual contact with a new partner.

What is the most likely explanation for this musculoskeletal presentation?

A 46-year-old woman presents with dry eyes and a dry mouth for the past six months. She reports needing to sip water frequently when eating and uses over-the-counter lubricating eye drops. Examination shows dry buccal mucosa and reduced tear production on Schirmer’s test. There is no evidence of arthritis, rash, or systemic features.

What is the most appropriate initial management?

A 48-year-old male plumber presents with a 4-day history of swelling over the tip of his elbow. There is no history of trauma or fever. On examination, there is a soft, fluctuant swelling at the posterior aspect of the elbow. No redness or warmth is noted, and elbow joint movement is full and pain-free.

Which of the following statements about bursitis is NOT true?

A 72-year-old woman presents with acute onset of left knee pain and swelling. She denies any trauma. She has a history of osteoarthritis and hypertension. On examination, the joint is warm, swollen, and tender with moderate effusion, but she is afebrile. Joint aspiration is performed to investigate the cause.

Which of the following synovial fluid findings is most consistent with pseudogout?

A 28-year-old woman presents to the GP with a 3-day history of joint pain in her wrists and ankles. She reports feeling generally unwell, with a low-grade fever and a few small, painless skin lesions on her trunk. On examination, there is no significant swelling, erythema, or warmth over any of the joints. However, passive movement of the fingers elicits discomfort along the tendons, despite the absence of overt inflammation.

Which of the following is the most likely diagnosis?

A 72-year-old man with a history of osteoarthritis and type 2 diabetes presents with a 2-day history of severe pain, swelling, and redness in his left knee. He is febrile at 38.4°C and unable to bear weight. Examination reveals a hot, swollen, and tender left knee with markedly reduced range of motion. Synovial fluid aspirated from the joint appears cloudy and purulent. Laboratory results show WBC 15,000/mm³, CRP 210 mg/L, and neutrophilic predominance in the aspirate.

What is the most likely causative organism in this case?

A 35-year-old man presents with low back pain and stiffness that has been gradually worsening over the past few months. He says the stiffness is worse in the morning and improves with movement. He also reports episodes of red, painful eyes in the past year. Blood tests show a normal rheumatoid factor and anti-CCP. You suspect he may have a type of seronegative arthritis.

Which one of the following conditions is classified as a seronegative arthritis?

A 48-year-old man presents to clinic with a 3-month history of progressive right hip pain. He describes a dull, aching discomfort in the groin that worsens with weight-bearing and improves with rest. He denies any trauma. Past medical history includes long-term corticosteroid use for severe asthma and heavy alcohol use. On exam, there is painful and restricted internal rotation and abduction of the right hip. Pelvic X-ray is normal.

What is the most likely diagnosis?

A 72-year-old woman presents with a 4-week history of bilateral shoulder and hip girdle stiffness and aching, particularly in the morning and lasting over an hour. She has recently developed a new right-sided temporal headache, scalp tenderness, and jaw pain when chewing. There is no visual disturbance. Examination shows no motor weakness, but she is slow to rise from a chair due to stiffness.

Which of the following is the most appropriate initial investigation?

A 48-year-old man presents with progressive right-sided groin pain for the past 3 months. The pain worsens with walking and improves with rest. There is no history of trauma. Examination reveals limited and painful internal rotation of the hip. X-ray of the pelvis appears normal, but MRI reveals crescent sign and segmental collapse of the femoral head.

Which of the following is the most likely underlying cause of this condition?

A 12-year-old boy is brought to the clinic with a 5-day history of painful, swollen knees and ankles that improve in one joint and then recur in another. His parents report that he had a sore throat about 3 weeks ago which resolved without treatment. On examination, he has a temperature of 38.6°C, and a grade II/VI systolic murmur is heard best at the apex. Blood tests reveal elevated ESR and a positive anti-streptolysin O (ASO) titre.

Which of the following is the most likely diagnosis?

A 52-year-old woman presents with a 3-month history of bilateral hand pain and stiffness. She reports difficulty turning doorknobs and fastening buttons. The stiffness lasts for over an hour in the morning and improves throughout the day. On examination, there is symmetrical swelling and tenderness at the second and third metacarpophalangeal and proximal interphalangeal joints.

Which of the following statements best describes the joint involvement pattern in rheumatoid arthritis?

A 54-year-old woman presents with progressive difficulty climbing stairs and rising from a chair over the past 3 months. She also reports increasing fatigue and has noticed a purplish rash on her eyelids and scaly red patches on the backs of her hands. She denies joint pain but mentions mild discomfort in her shoulders and thighs. On examination, there is proximal muscle weakness in both upper and lower limbs, and a violaceous rash over the upper eyelids.

Which of the following is the most likely diagnosis?

A 28-year-old woman of South Asian descent presents with a 3-month history of general fatigue, low-grade fever, and pain in her left arm during exertion. She has also noticed light-headedness when standing and occasional headaches. On examination, her left radial pulse is very weak, and there is a systolic bruit over her left subclavian area. Blood pressure is 150/85 mmHg on the right and unrecordable on the left. ESR is 78 mm/hr.

What is the most likely diagnosis?

A 56-year-old woman with a 10-year history of rheumatoid arthritis is scheduled for elective total hip replacement surgery. She has longstanding disease with joint deformities and is on methotrexate and low-dose prednisolone. On review, she denies dyspnoea or chest pain but has reduced neck movement. Her blood tests and chest X-ray are normal.

Which of the following preoperative investigations is most important from an anaesthetic perspective?

A 28-year-old man presents with a 9-month history of persistent lower back pain and stiffness. He reports that the pain improves with activity and worsens at night or during periods of rest. He has also noted some discomfort in his heels and reduced chest expansion. There is no significant past medical history. Examination reveals limited lumbar spine flexion and tenderness over the sacroiliac joints.
X-ray shows bilateral sacroiliitis.

What is the most appropriate initial management for this patient?

A 28-year-old man presents with a 2-week history of right knee swelling and pain. He reports a self-limiting episode of diarrhoea about 3 weeks ago after returning from a trip abroad. He also mentions some heel pain and mild redness in his left eye. On examination, the right knee is warm and swollen, and there is tenderness at the insertion of the Achilles tendon. His vision is intact, and he denies any urethral discharge or dysuria.

Which of the following is the most likely diagnosis?

A 42-year-old woman presents with a 6-month history of widespread musculoskeletal pain, severe fatigue, and non-restorative sleep. She describes difficulty concentrating and performing daily activities due to pain. There is no evidence of joint swelling or inflammation on examination, but she has multiple tender points on palpation. Basic blood tests including ESR, CRP, thyroid function, and vitamin D are within normal limits.

What is the most appropriate first-line pharmacological treatment to consider for this patient’s persistent pain affecting daily function?

A 65-year-old woman presents with a swollen, painful right knee of sudden onset. Examination reveals moderate effusion without redness. She is afebrile and systemically well. You decide to perform a diagnostic knee aspiration in the emergency department.

Which of the following best describes the correct technique for performing knee joint aspiration?

A 45-year-old male patient presents to your clinic with acute pain in his left ankle. The pain began suddenly last night and has progressively worsened. The ankle is swollen, red, and warm to the touch. He reports a similar episode a year ago that resolved on its own. He is asking about diagnostic tests to confirm whether this is another gout flare.

Which of the following statements is FALSE regarding gout?