Illness Scripts
36F with 8 months of hand pain. 90 minutes of morning stiffness, ROS (-). Swelling of the bilateral MCPs, PIPs, and wrists. DIPs are normal. RF (-).
1. What diagnosis is most likely?
2. What antibody would you order next?
Rheumatoid arthritis; anti-CCP
45M with known gout, presents with hot swollen knee, fever. Next best test?
Arthrocentesis; send for culture (with Gram stain), crystals, and cell count
67M with RA scheduled for urgent surgery who has neck pain and hand paresthesias.
Atlanto-axial instability; cervical myelopathy
This Grammy Award-winning singer developed chronic widespread pain, fatigue, poor sleep, and cognitive dysfunction, forcing her to postpone tours. She has spoken extensively about living with this condition and raising awareness.
Lady Gaga; Fibromyalgia
True or false: A positive ANA means lupus.
False. ANA is a screening test, not a diagnostic test. Up to 15–20% of healthy adults have a positive ANA. Always interpret ANA in the context of the clinical picture.
24F presents with polyarthritis, photosensitivity, oral ulcers, and new proteinuria. CBC - lymphopenia.
1. Most likely diagnosis?
2. Organ system most concerning today?
3. What investigation should not be delayed?
SLE; Lupus nephritis; Kidney biopsy
Proximal muscle weakness and CK 5000.
Possible next steps?
MRI, EMG/NCS, myositis antibody panel, muscle biopsy
43F with RF/CCP+ RA, thrombocytopenia, neutropenia, and splenomegaly. Diagnosis?
Felty's syndrome; at risk for LGL-leukemia
This professional tennis player was diagnosed with a SARD after years of profound fatigue, dry eyes, dry mouth, and declining athletic performance, eventually forcing her to withdraw from major tournaments.
Venus Williams; Sjogren disease
True or false: A normal serum uric acid excludes gout.
False. Serum uric acid may be normal during an acute flare. Arthrocentesis with crystal identification remains the gold standard.
48F with 5-years of Raynaud's. She now has puffy fingers, progressive dysphagia, worsening reflux, and exertional dyspnea.
1. What diagnosis fits best?
2. What two diagnoses should be screened for in every patient?
3. Autoantibody associated with severe renal disease?
Systemic sclerosis; ILD and pulmonary hypertension; RNA polymerase III
A 32-year-old woman presents with inflammatory arthritis, photosensitivity, oral ulcers, and a positive ANA (1:640).
What single investigation would most change your management today?
Urinalysis/urine protein/creatinine ratio
A 28F with SLE presents with persistent fever (39.5°C), fatigue, confusion, and diffuse arthralgias. Laboratory investigations demonstrate:
Hemoglobin 72, Platelets 48, WBC 1.9, CRP 253, Ferritin 18,500, ALT 320, Triglycerides 5.8 (H). Fibrinogen 1.1 (L), Blood cultures negative after 48 hours.
Macrophage activation syndrome (MAS); Hemophagocytic lymphohistiocytosis (HLH)
This actress and singer was diagnosed with SLE, underwent chemotherapy for severe disease, and ultimately required a kidney transplant due to lupus nephritis.
Selena Gomez
True or false: You can start urate lowering therapy during an active gout flare.
True. Current guidelines support starting ULT during an acute flare, provided effective anti-inflammatory therapy has been initiated. Starting allopurinol during a flare does not prolong or worsen the flare when appropriate flare treatment is given.
66M with difficulty climbing stairs and getting out of a chair over three months. Examination: Gottron papules and proximal muscle weakness. CK is 4800.
1. Diagnosis?
2. One life-threatening complication?
3. One antibody associated with malignancy?
Dermatomyositis
ILD and dysphagia/respiratory muscle involvement
Anti-TIF1γ
61F with 15 years of Raynaud's, puffy fingers, reflux, and mild exertional dyspnea. Lung examination is normal. Anti-centromere B positive.
What single investigation is most likely to detect early organ involvement?
Pulmonary function tests (with DLCO)
52F with diffuse skin thickening, GERD, positive ANA, creatinine 200, hemoglobin 72, platelets 54, schistocytes, LDH 430, haptoglobin <0.1, bilirubin 87.
Scleroderma renal crisis (SRC)
This actor revealed that he developed a rare systemic vasculitis causing hearing loss, vestibular dysfunction, and peripheral neuropathy, leaving him temporarily unable to hear, see, or walk normally.
Ashton Kutcher; ?Cogan's
True or false: A normal CK essentially excludes clinically important inflammatory myopathy.
False. Anti-MDA5 dermatomyositis is often clinically amyopathic despite severe cutaneous disease and life-threatening rapidly progressive ILD.
58F with dry eyes and dry mouth over several years. Fatigue, intermittent parotid swelling, and numbness in both feet. Examination: Palpable purpura.
1. What illness script fits best?
2. Which antibody is most likely positive?
3. Serious long-term complication?
Primary Sjögren disease
SSA-60/Ro
Lymphoma
63F with systemic sclerosis presents with rapidly worsening hypertension and AKI.
Which investigation should not delay treatment?
None - start an ACE inhibitor (i.e. captopril) immediately.
A pregnant patient with SLE is positive for anti-Ro (SSA) antibodies. What fetal complication requires surveillance?
Congenital heart block (neonatal lupus). Serial fetal echocardiography from approximately 16–26 weeks.
This professional golfer developed psoriatic arthritis affecting his joints and performance but returned to elite competition after starting biologic therapy.
Phil Mickelson
True or false: Methotrexate should be stopped in RA-ILD.
False. Methotrexate does not appear to increase the risk of developing RA-ILD or accelerate its progression. Methotrexate pneumonitis is a distinct, uncommon, idiosyncratic hypersensitivity reaction (typically acute/subacute with fever, cough, dyspnea, and diffuse infiltrates) and is an indication to stop methotrexate permanently.