MSK

A 58-year-old man presents to the emergency department with a 12-hour history of severe pain, swelling and redness of his right first metatarsophalangeal joint. He describes waking from sleep with excruciating pain, unable to tolerate the weight of a bedsheet on his foot. He has a history of hypertension treated with hydrochlorothiazide and admits to a heavy alcohol intake over the preceding weekend. He has had two similar episodes in the past two years that settled without specific treatment. On examination he is afebrile, with heart rate 92/min and blood pressure 148/88 mmHg. The right first MTP joint is exquisitely tender, warm, erythematous and swollen, with no overlying skin breach. Arthrocentesis is performed, and synovial fluid microscopy under polarised light reveals needle-shaped crystals that are negatively birefringent, with a white cell count of 18,000/µL and no organisms on Gram stain. He has never taken urate-lowering therapy. What is the most appropriate acute management?

A 70-year-old woman presents to the emergency department after a mechanical fall from standing height, complaining of sudden-onset mid-thoracic back pain. She denies any high-energy trauma. She is otherwise well, has been postmenopausal since age 50, and has never taken hormone therapy or bone-protective medication. She does not smoke and drinks alcohol rarely. Observations are within normal limits. Examination reveals localised tenderness over T8 with no neurological deficit and normal power, sensation and reflexes in both lower limbs. Plain radiographs confirm an acute wedge compression fracture of T8 with no retropulsion. Bone mineral density (DEXA) performed during her admission shows a lumbar spine T-score of -3.0. Serum calcium, phosphate, renal function and vitamin D are normal. What is the most appropriate next step in her long-term management?

A 30-year-old woman presents to the emergency department with a two-day history of left calf pain and swelling. She has a background of two first-trimester miscarriages and one prior unprovoked deep vein thrombosis six years ago. On examination she is afebrile, haemodynamically stable, with a swollen, tender, warm left calf measuring 4 cm greater in circumference than the right; Homans sign is positive. Duplex ultrasound confirms an acute occlusive thrombus in the left femoral vein. Serology drawn on this presentation and repeated 12 weeks later both demonstrate a positive lupus anticoagulant, fulfilling the laboratory criteria for antiphospholipid syndrome when combined with her thrombotic and obstetric history. She is currently not pregnant and has no contraindication to anticoagulation. What is the most appropriate long-term management plan?

A 4-year-old girl is brought to the emergency department by her parents with a 3-month history of intermittent swelling of both knees and ankles. Her mother reports that the girl limps and appears stiff for over an hour after waking each morning, with gradual improvement as the day progresses. There is no history of preceding illness, rash, diarrhoea or trauma, and she has been afebrile throughout. On examination she is well-looking and afebrile, with bilateral knee effusions, reduced range of motion, and mild warmth but no erythema or exquisite tenderness. She is able to weight-bear, though with a limp. Blood tests show a mildly elevated ESR, negative rheumatoid factor, and a positive antinuclear antibody (ANA) titre of 1:320. Plain radiographs show soft tissue swelling only, with no fracture or bony destruction. Which of the following is the most likely diagnosis?

A 50-year-old woman presents to the emergency department with a two-week history of worsening bilateral hand pain. She has a known history of seropositive rheumatoid arthritis (anti-CCP and rheumatoid factor positive) diagnosed nine months ago, for which she was commenced on oral methotrexate 15 mg weekly with folic acid six months ago. She reports morning stiffness lasting over an hour, and on examination there is symmetrical synovitis with tenderness and swelling of the metacarpophalangeal and proximal interphalangeal joints of both hands, with reduced grip strength. Vital signs are normal and there are no extra-articular features. Inflammatory markers remain elevated (CRP 42 mg/L, ESR 38 mm/hr), unchanged from three months ago, and she has not missed any doses of methotrexate. Which of the following is the most appropriate next step in management of her rheumatoid arthritis?

A 50-year-old woman presents to the emergency department with an exacerbation of her longstanding mechanical low back pain. She has no red flag features - no fever, no trauma, no saddle anaesthesia, no bowel or bladder disturbance and no leg weakness - and her observations and neurological examination are unremarkable. Her regular medications include sustained-release oxycodone 20 mg twice daily, which she has been prescribed continuously for the past three years by various providers after an initial disc injury. She reports her pain score remains 7/10 despite this dose, she has stopped attending physiotherapy, and she has become increasingly sedentary and socially withdrawn. She requests a script increase before she is due to see her general practitioner next week. Which of the following represents the most appropriate approach to her opioid therapy?