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Stem
A 70-year-old retired woman presents with a 5-year history of gradually worsening pain in both knees, the right worse than the left. The pain is worse on walking, climbing stairs and towards the end of the day, and eases with rest. She has about 15 minutes of morning stiffness. On examination there is bony swelling of both knees, crepitus on active flexion, joint-line tenderness, reduced flexion and a mild genu varus (bow-leg) deformity of the right knee. She is obese (BMI 34). She also has bony swellings over several distal interphalangeal joints of her hands. She is systemically well with no synovitis at the metacarpophalangeal joints.
Questions
a) What is the most likely diagnosis, and which four features in the history and examination support a mechanical rather than an inflammatory arthritis? (3 marks)
b) Name the typical joint distribution of this condition in the hands, and identify the nodal swellings she has. Which hand joints are characteristically spared? (2 marks)
c) List the four radiographic hallmarks (the LOSS mnemonic). Why should imaging severity not be the main guide to treatment? (3 marks)
d) Outline the first-line management, stating clearly which intervention is disease-modifying in this obese patient. Name one indication for joint replacement. (2 marks)