Rheumatology & Musculoskeletal

A 32-year-old woman has 6 months of morning stiffness >1 hour, symmetric pain and swelling of MCP and PIP joints, and fatigue. Exam: synovitis in both hands and wrists. ESR/CRP elevated; RF positive; anti-CCP high; hand X-ray: periarticular osteopenia, no erosions.

A 58-year-old man with chronic tophi over elbows and ears presents with acute first MTP pain after a big meal. Joint aspirate: needle-shaped, strongly negatively birefringent crystals; WBC 25,000. Uric acid 9.6 mg/dL; CKD stage 3.

A 24-year-old man with chronic low back pain improved by exercise and worse at night, limited chest expansion, and alternating buttock pain. HLA-B27 positive; sacroiliac MRI shows bone marrow edema.

A 49-year-old woman with dry eyes and dry mouth has parotid enlargement, rampant dental caries, and arthralgias. Schirmer test low; anti-Ro/SSA positive.

A 35-year-old woman presents with malar rash sparing nasolabial folds, photosensitivity, oral ulcers, and arthralgia. Labs: ANA 1:640 homogeneous, anti-dsDNA positive, low C3/C4, proteinuria 1.5 g/day.

A 67-year-old woman has bilateral shoulder and hip girdle aching with morning stiffness 2 hours, difficulty rising from a chair, and elevated ESR. No true weakness; CK normal.

A 42-year-old man with psoriasis has DIP arthritis, dactylitis of the 3rd toe, and nail pitting. X-ray: pencil-in-cup changes.

A 61-year-old woman with long-standing RA on methotrexate develops progressive dyspnea and dry cough; HRCT shows basilar reticulation and honeycombing.

A 28-year-old man develops asymmetric oligoarthritis of knees and ankles 3 weeks after Shigella diarrhea; has enthesitis at Achilles and painless shallow oral ulcers.

A 55-year-old woman with diffuse cutaneous systemic sclerosis has new abrupt hypertension, headache, and rising creatinine; urinalysis: mild proteinuria; she’s on high-dose steroids.

A 70-year-old man has chronic knee pain worse with activity and relieved by rest; brief stiffness (<15 min). X-ray: joint space narrowing, osteophytes. BMI 33.

A 38-year-old woman has widespread pain, nonrestorative sleep, fatigue, and “fibro fog”; tender points present; labs normal.

A 47-year-old man with alcohol use presents with acute monoarthritis of the knee; arthrocentesis: positively birefringent rhomboid crystals; X-ray: chondrocalcinosis.

A 33-year-old woman has recurrent miscarriages and a DVT at age 30; lupus anticoagulant and anticardiolipin IgG positive twice 12 weeks apart.

A 26-year-old man with recurrent oral and genital ulcers, erythema nodosum, and uveitis; pathergy positive.

A 59-year-old man with nasal crusting, epistaxis, migratory arthralgia, hematuria, and pulmonary nodules; c-ANCA/PR3 positive.

A 46-year-old woman has Raynaud phenomenon, sclerodactyly, telangiectasia, and pulmonary hypertension; anti-centromere positive.

A 34-year-old woman has proximal muscle weakness climbing stairs; CK 2,500 U/L; EMG myopathic; anti–Jo-1 positive; bibasilar crackles on exam.

A 71-year-old man has atraumatic swollen calf; ultrasound shows popliteal Baker cyst with fluid tracking into calf; knee OA present.

A 29-year-old postpartum woman has wrist/thumb pain with positive Finkelstein test after carrying newborn.

A 45-year-old carpenter has nocturnal hand numbness in thumb, index, and middle fingers; thenar atrophy; positive Phalen and Tinel.

A 35-year-old runner has heel pain worst with first steps in the morning; point tenderness at medial calcaneal tubercle.

A 62-year-old man with chronic steroid use presents with groin pain and limited hip ROM; X-ray normal; MRI shows femoral head signal changes.

A 29-year-old man has recurrent shoulder dislocations while throwing; positive apprehension and relocation tests.

A 54-year-old woman with hypothyroidism has diffuse myalgias and proximal pain but normal CK and normal joint exam; widespread tender points.

A 66-year-old man with hemochromatosis has recurrent wrist and knee flares; X-ray shows hook-like osteophytes at MCP; aspirate: CPPD crystals.

A 41-year-old woman on isoniazid for LTBI develops symmetric small-joint pain and stiffness; exam: synovitis; serologies negative; symptoms resolve after stopping INH and pyridoxine replacement.

A 63-year-old man with long-standing gout has erosive changes on X-ray (rat-bite lesions), multiple tophi, and urate 8.9 mg/dL on allopurinol 200 mg/day and adherent to colchicine prophylaxis. eGFR 48.

A 52-year-old woman with photosensitive rash and arthralgia started minocycline for acne; now has fever, serositis, ANA+, antihistone antibodies.

A 38-year-old man with IBD has back pain and morning stiffness; sacroiliitis on imaging.

A 44-year-old woman has fever, weight loss, livedo reticularis, mononeuritis multiplex, and abdominal pain; HBV positive; ANCA negative.

A 59-year-old man has chronic low back pain with red flags: weight loss, night pain, and history of prostate cancer. Neurologic exam normal.

A 27-year-old woman has acute swollen, warm knee after a twisting injury; joint aspirate WBC 3,000, no crystals; MRI shows medial meniscal tear.

A 50-year-old man with chronic elbow pain; tenderness over lateral epicondyle; pain with resisted wrist extension.

A 36-year-old woman with hypermobility, frequent sprains, easy bruising, atrophic scars; Beighton score 6/9.

A 60-year-old woman with OA knee has persistent pain despite NSAIDs and PT; desires injection before an event.

A 41-year-old man with chronic tophaceous gout starts pegloticase; after third infusion he develops infusion reaction and rising urate.

A 48-year-old smoker with digital ulcers and severe Raynaud has positive anti–RNA polymerase III antibodies; skin thickening proximal to elbows.

A 52-year-old woman with symmetric hand arthritis and sicca symptoms; RF negative, anti-CCP positive; ultrasound shows synovial power Doppler signal.

A 63-year-old man with diabetes has a red, warm, swollen midfoot but minimal pain due to neuropathy; X-ray: midfoot collapse and fragmentation.

A 56-year-old man with gout develops a swollen, fluctuant, erythematous swelling over the posterior elbow; he is afebrile and ROM is preserved.

A 49-year-old woman with gradual shoulder stiffness and pain, especially with external rotation; both active and passive ROM are limited. Diabetes present.

A 62-year-old man with traumatic shoulder injury cannot abduct above 60°; positive drop-arm and external rotation weakness; night pain.

A 45-year-old man felt a “pop” in the posterior ankle while sprinting after a week of ciprofloxacin; unable to plantarflex; positive Thompson test.

A 58-year-old woman 6 weeks after distal radius fracture has severe burning pain, allodynia, edema, and shiny skin in the hand; x-ray shows patchy demineralization.

A 67-year-old man has painless progressive flexion contracture of the ring finger with palmar nodules and cords; cannot place hand flat on table.

A 41-year-old desk worker has numbness/tingling in the 4th–5th fingers, intrinsic hand weakness, and positive Tinel at the elbow; symptoms worse with elbow flexion.

A 52-year-old woman has painful catching/locking of the right ring finger on flexion; palpable nodule at A1 pulley.

A 60-year-old woman with long-standing seropositive RA develops neutropenia, splenomegaly, and recurrent leg ulcers/infections.

A 55-year-old man on methotrexate for RA presents with subacute dyspnea, dry cough, fever; CXR: diffuse interstitial pattern; eosinophilia; infectious workup negative.

A 63-year-old Han Chinese man with CKD starts allopurinol 300 mg/day for gout; 2 weeks later he develops fever, diffuse rash, eosinophilia, and AKI.

A 71-year-old woman with gout and CKD is treated with colchicine and clarithromycin for pneumonia; now has profound weakness and elevated CK.

A 48-year-old man with kidney transplant on azathioprine has recurrent gout; clinician considers allopurinol.

A 59-year-old man starts allopurinol for tophaceous gout; within 2 weeks he has increased flare frequency.

A 70-year-old woman has hand pain at DIP and first CMC joints with bony enlargement (Heberden/Bouchard nodes); minimal morning stiffness.

A 74-year-old woman with sudden severe midline back pain after lifting a box; focal vertebral tenderness; height loss; X-ray shows wedge compression fracture.

A 68-year-old man with bone pain and hearing loss has elevated ALP with normal calcium/phosphate; skull x-ray shows thickened bone with cotton-wool appearance.

A 28-year-old man after tibial shaft fracture fixation has escalating pain out of proportion, tense compartments, and severe pain with passive toe extension; pulses present.

A 23-year-old soccer player hears a “pop” during pivoting; immediate swelling and instability; positive Lachman and anterior drawer.

A 72-year-old man has bilateral buttock and posterior thigh pain after walking 50–100 meters; relief when leaning forward on a shopping cart; neuro exam normal.