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  • Question 1 - A 38-year-old woman with systemic lupus erythematosus presents to her General Practitioner with...

    Incorrect

    • A 38-year-old woman with systemic lupus erythematosus presents to her General Practitioner with concerns about her current medication. She is currently taking azathioprine 130 mg/day, in divided doses. Yesterday she took a home pregnancy test which was positive.
      What is the best course of management for her medication?

      Your Answer: Stop azathioprine and start infliximab

      Correct Answer: Continue azathioprine

      Explanation:

      Managing Treatment for Pregnant Patients with Autoimmune Diseases

      When treating pregnant patients with autoimmune diseases, it is important to consider the potential risks and benefits of different medications. In the case of a patient already on an established dose of azathioprine, it is generally recommended to continue this medication during pregnancy, as stopping or reducing the dose could put the patient at risk of disease progression. Methotrexate should never be used during pregnancy due to its teratogenic effects. High-dose corticosteroids may also pose risks to the developing fetus if used for prolonged periods. Stopping all treatment could trigger disease worsening, so it is important to carefully weigh the risks and benefits of any changes to medication. In some cases, infliximab may be necessary during pregnancy, but this should be carefully considered and discussed with a specialist. Overall, managing treatment for pregnant patients with autoimmune diseases requires careful consideration of the potential risks and benefits of different medications.

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      • Musculoskeletal
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  • Question 2 - A 32-year-old female patient complains of gradual tingling and numbness in her right...

    Incorrect

    • A 32-year-old female patient complains of gradual tingling and numbness in her right hand's 4th and 5th fingers. The symptoms were occasional at first, but now they are persistent. She observes that the discomfort intensifies when she rests her right elbow on a surface. She remembers hitting her elbow against a door a while back. What is the probable diagnosis?

      Your Answer: Medial epicondylitis

      Correct Answer: Cubital tunnel syndrome

      Explanation:

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed, resulting in tingling and numbness in the fourth and fifth fingers.

      The correct answer is cubital tunnel syndrome. The ulnar nerve passes through the cubital tunnel, and when it is compressed, it can cause the symptoms described, such as tingling and numbness in the fourth and fifth fingers. Treatment for this condition may involve conservative measures, but surgery may be necessary in some cases.

      Carpal tunnel syndrome, on the other hand, is caused by compression of the median nerve at the wrist, leading to pain and tingling in the hand and wrist, rather than specific fingers.

      De Quervain’s tenosynovitis presents differently, with pain occurring during movement of the thumb and wrist, and the radial styloid may become thickened and hardened.

      Medial epicondylitis, or golfer’s elbow, causes pain in the medial elbow area, near the cubital tunnel, but it is a tendinopathy rather than nerve compression. The pain is localized to the affected area.

      Understanding Cubital Tunnel Syndrome

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed as it passes through the cubital tunnel. This can cause a range of symptoms, including tingling and numbness in the fourth and fifth fingers, which may start off intermittent but eventually become constant. Over time, patients may also experience weakness and muscle wasting. Pain is often worse when leaning on the affected elbow, and there may be a history of osteoarthritis or prior trauma to the area.

      Diagnosis of cubital tunnel syndrome is usually made based on clinical features, although nerve conduction studies may be used in selected cases. Management of the condition typically involves avoiding aggravating activities, undergoing physiotherapy, and receiving steroid injections. In cases where these measures are not effective, surgery may be necessary. By understanding the symptoms and treatment options for cubital tunnel syndrome, patients can take steps to manage their condition and improve their quality of life.

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  • Question 3 - A 45-year-old woman complains of right elbow pain that has been persistent for...

    Correct

    • A 45-year-old woman complains of right elbow pain that has been persistent for the last month without any apparent cause. During examination, she experiences pain when resisting wrist extension while the elbow is extended. What is the probable diagnosis?

      Your Answer: Lateral epicondylitis

      Explanation:

      Understanding Lateral Epicondylitis

      Lateral epicondylitis, commonly known as tennis elbow, is a condition that often occurs after engaging in activities that the body is not accustomed to, such as painting or playing tennis. It is most prevalent in individuals aged 45-55 years and typically affects the dominant arm. The primary symptom of this condition is pain and tenderness localized to the lateral epicondyle. The pain is often exacerbated by wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. Episodes of lateral epicondylitis can last between 6 months and 2 years, with patients experiencing acute pain for 6-12 weeks.

      To manage lateral epicondylitis, it is essential to avoid muscle overload and engage in simple analgesia. Steroid injections and physiotherapy are also viable options for managing the condition. By understanding the symptoms and management options for lateral epicondylitis, individuals can take the necessary steps to alleviate pain and discomfort associated with this condition.

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  • Question 4 - A 28-year-old presents to his General Practitioner with a 2-month history of pain...

    Correct

    • A 28-year-old presents to his General Practitioner with a 2-month history of pain in his right elbow. His GP suspects that the patient has lateral epicondylitis.
      What examination findings would confirm the diagnosis?

      Your Answer: Pain worse on resisted wrist extension with the elbow extended

      Explanation:

      Common Elbow Pain Symptoms and Their Features

      Elbow pain can be caused by various conditions, each with its own set of symptoms. Here are some common elbow pain symptoms and their features:

      1. Lateral Epicondylitis (Tennis Elbow)
      – Pain and tenderness localized to the lateral epicondyle
      – Pain worsens on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
      – Episodes typically last between six months and two years; patients tend to have acute pain for 6-12 weeks
      – Pain aggravated by wrist flexion and pronation

      2. Medial Epicondylitis (Golfer’s Elbow)
      – Pain and tenderness localized to the medial epicondyle
      – Pain aggravated by wrist flexion and pronation
      – Symptoms may be accompanied by numbness/tingling in the fourth and fifth fingers due to ulnar-nerve involvement

      3. Cubital Tunnel Syndrome
      – Initially intermittent tingling in the fourth and fifth fingers
      – Pain worsens when the elbow is resting on a firm surface or flexed for extended periods
      – Later numbness in the fourth and fifth fingers with associated weakness

      4. Carpal Tunnel Syndrome
      – Pain worsens when the wrists are in complete flexion for at least 30 seconds
      – The Phalen test is done to investigate its presence

      5. Olecranon Bursitis
      – Swelling over the posterior aspect of the elbow with associated pain, warmth, and erythema
      – Typically affects middle-aged male patients

      Understanding Common Symptoms of Elbow Pain

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  • Question 5 - A 4-year-old boy is brought to the Paediatric Emergency Department with a fever...

    Correct

    • A 4-year-old boy is brought to the Paediatric Emergency Department with a fever of one week. On evaluation, the child appears unwell, erythema of the palms and soles are noted, along with bilateral conjunctivitis. Examination of the oral cavity reveals cracked lips.
      In addition to the above findings, which one of the following features would prompt an urgent referral for echocardiography?

      Your Answer: Rash on the trunk and extremities

      Explanation:

      Clinical Features and Differential Diagnoses of Kawasaki Disease

      Kawasaki disease is a rare but serious condition that primarily affects children under the age of five. To diagnose Kawasaki disease, a patient must have a fever for at least five days and four out of five classical features: bilateral, non-exudative conjunctival injection, changes in lips and oral cavity, oedema and erythema in the hands and feet, polymorphous rash, and cervical lymphadenopathy. However, tonsillar exudate, leukopenia, neck stiffness, and small submental lymph nodes are not classical features of Kawasaki disease and should prompt consideration of other differential diagnoses. Patients with confirmed Kawasaki disease should undergo echocardiographic examination to detect potential coronary artery aneurysms. Early diagnosis and treatment are crucial to prevent serious complications.

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  • Question 6 - A woman in her early 50s with a history of rheumatoid arthritis presents...

    Correct

    • A woman in her early 50s with a history of rheumatoid arthritis presents with right foot drop and numbness in her right hand, with thenar eminence wasting and sensory loss over the radial half of her hand.
      Which of the following is the most likely cause for her symptoms?
      Select the SINGLE most appropriate cause from the list below.

      Your Answer: Mononeuritis multiplex

      Explanation:

      Neuropathies: Causes and Symptoms

      Neuropathies are a group of disorders that affect the peripheral nervous system. Here are some common causes and symptoms of different types of neuropathies:

      Mononeuritis Multiplex:
      This neuropathy affects two or more non-anatomically related peripheral nerves. It is caused by vasculopathy of the vasa nervorum or infiltration of the nerves. Common causes include diabetes mellitus, leprosy, polyarteritis nodosa, and rheumatoid arthritis. Symptoms include multiple concurrent peripheral nerve lesions without pain or paraesthesiae.

      Peripheral Sensory Neuropathy:
      This neuropathy is most commonly caused by diabetes mellitus (types 1 and 2) in the United Kingdom. It affects the sensory nerves and does not involve motor functions. Symptoms include aching pain, paraesthesiae, sensory loss, and muscle wasting.

      Entrapment Neuropathy:
      This neuropathy is caused by compression of peripheral nerves due to hypertrophied synovium or joint subluxation. It usually affects only one part of the body. The most common nerve compressions are cubital tunnel and carpal tunnel syndromes. Symptoms include aching pain, paraesthesiae, sensory loss, and muscle wasting.

      Myasthenia Gravis (MG):
      This autoimmune disorder affects the neuromuscular junction and causes fatigability of the muscle. It commonly affects the extraocular, bulbar, face, and neck muscles. Symptoms do not include pain or sensory loss, and wasting is only seen very late in the disease.

      Multiple Sclerosis:
      This autoimmune disorder affects the central nervous system and causes spasticity, ataxia, and paraesthesiae in the affected limbs. It commonly affects the optic nerve, causing optic neuritis. Peripheral nerve involvement is not seen.

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  • Question 7 - A 29-year-old male complains of experiencing low back pain and stiffness for a...

    Correct

    • A 29-year-old male complains of experiencing low back pain and stiffness for a few months now, with the worst symptoms occurring in the mornings. He reports that exercise helps alleviate the pain, but prolonged sitting at his desk exacerbates it. During the examination, there is limited lumbar flexion, and a pelvic X-ray reveals sacroiliitis. What is the best initial approach to managing this condition?

      Your Answer: Ibuprofen

      Explanation:

      Ankylosing spondylitis, a spondyloarthropathy associated with HLA-B27 and commonly seen in men aged 20-30, can be managed with exercise regimes and NSAIDs as the first line of treatment. Pelvic X-rays are helpful in identifying subchondral erosions and sclerosis in the commonly affected sacroiliac joints. Physiotherapy and NSAIDs like ibuprofen are recommended as the initial management. Intra-articular corticosteroid injections are useful for unilateral joint symptoms, while methotrexate may be considered for peripheral joint involvement. Paracetamol can be used in conjunction with NSAIDs if needed, but ibuprofen should be the first-line option.

      Investigating and Managing Ankylosing Spondylitis

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are usually elevated, but normal levels do not necessarily rule out ankylosing spondylitis. HLA-B27 is not a reliable diagnostic tool as it can also be positive in normal individuals. The most effective way to diagnose ankylosing spondylitis is through a plain x-ray of the sacroiliac joints. However, if the x-ray is negative but suspicion for AS remains high, an MRI can be obtained to confirm the diagnosis.

      Management of ankylosing spondylitis involves regular exercise, such as swimming, and the use of NSAIDs as the first-line treatment. Physiotherapy can also be helpful. Disease-modifying drugs used for rheumatoid arthritis, such as sulphasalazine, are only useful if there is peripheral joint involvement. Anti-TNF therapy, such as etanercept and adalimumab, should be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Ongoing research is being conducted to determine whether anti-TNF therapies should be used earlier in the course of the disease. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

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  • Question 8 - You assess a 23-year-old man who has recently been released from the local...

    Correct

    • You assess a 23-year-old man who has recently been released from the local hospital after having a pneumothorax drained. This is his second admission in two years for the same issue. Upon examination today, his chest is clear with good air entry in all fields. However, you observe that he has pectus excavatum. He is 1.83m tall and weighs 72 kg. The only other relevant medical history is joint hypermobility, for which he was referred to a physiotherapist last year. What is the most probable underlying diagnosis?

      Your Answer: Marfan's syndrome

      Explanation:

      The presence of recurrent pneumothoraces and joint hypermobility suggests the possibility of Marfan’s syndrome.

      Understanding Marfan’s Syndrome

      Marfan’s syndrome is a genetic disorder that affects the connective tissue in the body. It is caused by a defect in the FBN1 gene on chromosome 15, which codes for the protein fibrillin-1. This disorder is inherited in an autosomal dominant pattern, meaning that a person only needs to inherit one copy of the defective gene from one parent to develop the condition. Marfan’s syndrome affects approximately 1 in 3,000 people.

      The features of Marfan’s syndrome include a tall stature with an arm span to height ratio greater than 1.05, a high-arched palate, arachnodactyly (long, slender fingers), pectus excavatum (sunken chest), pes planus (flat feet), and scoliosis (curvature of the spine). In addition, individuals with Marfan’s syndrome may experience cardiovascular problems such as dilation of the aortic sinuses, mitral valve prolapse, and aortic aneurysm. They may also have lung issues such as repeated pneumothoraces. Eye problems are also common, including upwards lens dislocation, blue sclera, and myopia. Finally, dural ectasia, or ballooning of the dural sac at the lumbosacral level, may also occur.

      In the past, the life expectancy of individuals with Marfan’s syndrome was around 40-50 years. However, with regular echocardiography monitoring and the use of beta-blockers and ACE inhibitors, this has improved significantly in recent years. Despite these improvements, aortic dissection and other cardiovascular problems remain the leading cause of death in individuals with Marfan’s syndrome.

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  • Question 9 - A 30-year-old man presents to the emergency department following a motor vehicle collision...

    Incorrect

    • A 30-year-old man presents to the emergency department following a motor vehicle collision where he was the driver. A lorry in front lost control and caused significant damage to his car, resulting in the dashboard and footwell being pushed forward. The patient is currently stable but complains of severe pain in his right leg. Upon examination, his right leg is internally rotated, slightly flexed, adducted, and shortened compared to the left. What is the likely diagnosis?

      Your Answer: Anterior hip dislocation

      Correct Answer: Posterior hip dislocation

      Explanation:

      When a person has a posterior hip dislocation, their leg will appear shortened and internally rotated. This type of injury often occurs during car accidents, especially when the driver slams on the brakes to avoid a collision. The impact from the front of the car is then transferred through the leg to the hip joint, causing the femoral head to move behind the acetabulum. Pelvic fractures, on the other hand, typically cause pain when walking or touching the area, as well as instability, nerve or blood vessel damage in the leg, and signs of injury to pelvic organs such as bleeding from the rectum or blood in the urine. Anterior hip dislocations are less common than posterior ones, but they can cause the leg to appear abducted and externally rotated, with a noticeable bulge in the femoral head. These types of dislocations are often associated with hip prostheses. Finally, femoral shaft fractures can cause swelling, deformity, and shortening of the leg. Because such fractures require a significant amount of force to occur, there is usually also damage to the surrounding soft tissues and bleeding.

      Understanding Hip Dislocation: Types, Management, and Complications

      Hip dislocation is a painful condition that occurs when the ball and socket joint of the hip are separated. This is usually caused by direct trauma, such as road traffic accidents or falls from a significant height. The force required to cause hip dislocation can also result in other fractures and life-threatening injuries. Therefore, prompt diagnosis and appropriate management are crucial to reduce morbidity.

      There are three types of hip dislocation: posterior, anterior, and central. Posterior dislocation is the most common, accounting for 90% of cases. It causes the affected leg to be shortened, adducted, and internally rotated. On the other hand, anterior dislocation results in abduction and external rotation of the affected leg, with no leg shortening. Central dislocation is rare and occurs when the femoral head is displaced in all directions.

      The management of hip dislocation follows the ABCDE approach, which includes ensuring airway, breathing, circulation, disability, and exposure. Analgesia is also given to manage the pain. A reduction under general anaesthetic is performed within four hours to reduce the risk of avascular necrosis. Long-term management involves physiotherapy to strengthen the surrounding muscles.

      Complications of hip dislocation include nerve injury, avascular necrosis, osteoarthritis, and recurrent dislocation due to damage to supporting ligaments. The prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint. It takes about two to three months for the hip to heal after a traumatic dislocation.

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  • Question 10 - A 25-year-old man presents with sudden onset of pain in his right elbow...

    Correct

    • A 25-year-old man presents with sudden onset of pain in his right elbow and left Achilles tendon. He reports dysuria, conjunctivitis, and fever, and recently returned from a trip to the Far East where he had unprotected sex. He has also developed macules and pustules on his hands. What is the most likely diagnosis?

      Your Answer: Reactive arthritis

      Explanation:

      Reactive arthritis is a type of arthritis that occurs after an infection, typically dysentery or a sexually transmitted disease. It affects 1-2% of patients who have had these infections, with Salmonella, Shigella, and Yersinia causing diarrheal illness that can lead to reactive arthritis, and Chlamydia trichomonas and Ureaplasma urealyticum causing STDs. Those who are HLA-B27-positive are at a higher risk of developing reactive arthritis. Symptoms include acute, asymmetrical lower limb arthritis, enthesitis causing plantar fasciitis or Achilles tendinosis, and back pain from sacroiliitis and spondylosis. Other symptoms may include acute anterior uveitis, circinate balanitis, keratoderma blenorrhagia, nail dystrophy, mouth ulcers, and bilateral conjunctivitis. The classic triad of conjunctivitis, urethritis, and arthritis may also be present. In this scenario, the patient’s symptoms and history of unprotected sexual intercourse suggest reactive arthritis as the correct diagnosis. Other potential diagnoses, such as UTI, HIV, psoriatic arthritis, and syphilitic arthritis, can be ruled out based on the patient’s symptoms and history.

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  • Question 11 - A 48-year-old man presents to the clinic in the morning with a deformity...

    Correct

    • A 48-year-old man presents to the clinic in the morning with a deformity in his right hand. He denies any tingling or numbness but mentions experiencing slight difficulty in using his hand, particularly when writing. The little and ring fingers appear to be slightly flexed, with no observable weakness. What could be the probable cause of his symptoms?

      Your Answer: Dupuytren's contracture

      Explanation:

      Dupuytren’s contracture is characterized by the thickening of the palmar aponeurosis, resulting in the inward bending of the medial digits. This can severely affect hand function, but does not involve any sensory issues, making nerve palsy unlikely. Ganglions typically appear as cystic swellings on the back of the hand, while trigger finger is associated with a digit catching or snapping during flexion.

      Understanding Dupuytren’s Contracture

      Dupuytren’s contracture is a condition that affects about 5% of the population. It is more common in older men and those with a family history of the condition. The causes of Dupuytren’s contracture include manual labor, phenytoin treatment, alcoholic liver disease, diabetes mellitus, and trauma to the hand.

      The condition typically affects the ring finger and little finger, causing them to become bent and difficult to straighten. In severe cases, the hand may not be able to be placed flat on a table.

      Surgical treatment may be necessary when the metacarpophalangeal joints cannot be straightened.

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  • Question 12 - A 42-year-old woman is seen in the rheumatology clinic after being diagnosed with...

    Incorrect

    • A 42-year-old woman is seen in the rheumatology clinic after being diagnosed with rheumatoid arthritis 6 months ago. She was initially started on methotrexate, however, was unable to tolerate its side effects. The consultant is considering starting the patient on hydroxychloroquine.
      What should happen before the patient begins treatment?

      Your Answer: Chest X-ray

      Correct Answer: Examination by an ophthalmologist

      Explanation:

      Patients who will be on long-term hydroxychloroquine treatment must now undergo an initial ophthalmologic examination. Recent studies indicate that hydroxychloroquine-induced retinopathy is more prevalent than previously believed. The latest guidelines from RCOphth (March 2018) recommend color retinal photography and spectral domain optical coherence tomography scanning of the macula for patients who are expected to take the medication for more than five years. While it is recommended to conduct a complete blood count and assess renal and liver function when starting hydroxychloroquine, other options are unnecessary.

      Hydroxychloroquine: Uses and Adverse Effects

      Hydroxychloroquine is a medication commonly used in the treatment of rheumatoid arthritis and systemic/discoid lupus erythematosus. It is similar to chloroquine, which is used to treat certain types of malaria. However, hydroxychloroquine has been found to cause bull’s eye retinopathy, which can result in severe and permanent visual loss. Recent data suggests that this adverse effect is more common than previously thought, and the most recent guidelines recommend baseline ophthalmological examination and annual screening, including colour retinal photography and spectral domain optical coherence tomography scanning of the macula. Despite this risk, hydroxychloroquine may still be used in pregnant women if needed. Patients taking this medication should be asked about visual symptoms and have their visual acuity monitored annually using a standard reading chart.

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  • Question 13 - A 72-year-old male presents to the emergency department with wrist pain after slipping...

    Correct

    • A 72-year-old male presents to the emergency department with wrist pain after slipping in ill-fitting shoes. He reports having experienced progressive lumbar and hip pain over the past few years, which he attributed to old age. However, he denies any weight loss, night sweats, and feels otherwise well. A hand and wrist x-ray shows a hairline radial fracture. The patient's blood tests reveal Hb of 144 g/L, platelets of 340 * 109/L, WBC of 9.0 * 109/L, bilirubin of 14 µmol/L, ALP of 240 u/L, ALT of 30 u/L, ÎłGT of 20 u/L, and albumin of 48 g/L. What is the most appropriate next step in management for this patient, given the likely diagnosis?

      Your Answer: Alendronate

      Explanation:

      Bisphosphonates are the preferred treatment for Paget’s disease of the bone, as illustrated by the case of an elderly man presenting with bone pain, isolated elevated ALP, and a fragility fracture. While calcitonin may be used in some cases, it is less effective and has a shorter duration of action. Calcium supplementation is not indicated unless the patient is experiencing hypocalcemia. DEXA scans are not necessary for diagnosis in this case, as the patient will already be started on bisphosphonates. While orthotics may be helpful for ill-fitting footwear, they do not address the underlying issue of Paget’s disease and the fragility fracture.

      Understanding Paget’s Disease of the Bone

      Paget’s disease of the bone is a condition characterized by increased and uncontrolled bone turnover. It is believed to be caused by excessive osteoclastic resorption followed by increased osteoblastic activity. Although it is a common condition, affecting 5% of the UK population, only 1 in 20 patients experience symptoms. The most commonly affected areas are the skull, spine/pelvis, and long bones of the lower extremities. Predisposing factors include increasing age, male sex, northern latitude, and family history.

      Symptoms of Paget’s disease include bone pain, particularly in the pelvis, lumbar spine, and femur. The stereotypical presentation is an older male with bone pain and an isolated raised alkaline phosphatase (ALP). Classical, untreated features include bowing of the tibia and bossing of the skull. Diagnosis is made through blood tests, which show raised ALP, and x-rays, which reveal osteolysis in early disease and mixed lytic/sclerotic lesions later.

      Treatment is indicated for patients experiencing bone pain, skull or long bone deformity, fracture, or periarticular Paget’s. Bisphosphonates, either oral risedronate or IV zoledronate, are the preferred treatment. Calcitonin is less commonly used now. Complications of Paget’s disease include deafness, bone sarcoma (1% if affected for > 10 years), fractures, skull thickening, and high-output cardiac failure.

      Overall, understanding Paget’s disease of the bone is important for early diagnosis and management of symptoms and complications.

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  • Question 14 - A 26-year-old man is being examined for persistent back pain. What symptom would...

    Incorrect

    • A 26-year-old man is being examined for persistent back pain. What symptom would strongly indicate a diagnosis of ankylosing spondylitis?

      Your Answer: Accentuated lumbar lordosis

      Correct Answer: Reduced lateral flexion of the lumbar spine

      Explanation:

      Ankylosing spondylitis is characterized by an early reduction in lateral flexion of the lumbar spine. Patients with this condition often experience a decrease in lumbar lordosis and an increase in thoracic kyphosis.

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in young males, with a sex ratio of 3:1, and typically presents with lower back pain and stiffness that develops gradually. The stiffness is usually worse in the morning and improves with exercise, while pain at night may improve upon getting up. Clinical examination may reveal reduced lateral and forward flexion, as well as reduced chest expansion. Other features associated with ankylosing spondylitis include apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, amyloidosis, cauda equina syndrome, and peripheral arthritis (more common in females).

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  • Question 15 - A 32-year-old woman arrives at the Emergency Department complaining of feeling unwell for...

    Incorrect

    • A 32-year-old woman arrives at the Emergency Department complaining of feeling unwell for the past 2 days. She reports weakness in her legs and increasing shortness of breath. The patient has a history of rheumatoid arthritis and hypothyroidism and is currently taking methotrexate and levothyroxine. She recently received treatment for a urinary tract infection from her GP. The patient's blood results are as follows: Hb 108 g/L (female normal range: 115-160 g/L), platelets 97 * 109/L (normal range: 150-400 * 109/L), WBC 1.9 * 109/L (normal range: 4.0-11.0 * 109/L), Na+ 139 mmol/L (normal range: 135-145 mmol/L), K+ 4.1 mmol/L (normal range: 3.5-5.0 mmol/L), urea 5.9 mmol/L (normal range: 2.0-7.0 mmol/L), and creatinine 87 µmol/L (normal range: 55-120 µmol/L). What is the most likely cause of the patient's symptoms?

      Your Answer: Nitrofurantoin

      Correct Answer: Trimethoprim

      Explanation:

      If methotrexate and trimethoprim-containing antibiotics are used together, it may lead to severe or fatal pancytopenia and bone marrow suppression. This patient, who takes methotrexate for rheumatoid arthritis, has presented with pancytopenia and feeling unwell. Myelosuppression is a known adverse effect of methotrexate, which can be exacerbated by renal impairment and certain medications.

      Methotrexate: An Antimetabolite with Potentially Life-Threatening Side Effects

      Methotrexate is an antimetabolite drug that inhibits the enzyme dihydrofolate reductase, which is essential for the synthesis of purines and pyrimidines. It is commonly used to treat inflammatory arthritis, psoriasis, and some types of leukemia. However, it is considered an important drug due to its potential for life-threatening side effects. Careful prescribing and close monitoring are essential to ensure patient safety.

      The adverse effects of methotrexate include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis. The most common pulmonary manifestation is pneumonitis, which typically develops within a year of starting treatment and presents with non-productive cough, dyspnea, malaise, and fever. Women should avoid pregnancy for at least 6 months after treatment has stopped, and men using methotrexate need to use effective contraception for at least 6 months after treatment.

      When prescribing methotrexate, it is important to follow guidelines and monitor patients regularly. Methotrexate is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. The starting dose is 7.5 mg weekly, and folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after the methotrexate dose. Only one strength of methotrexate tablet should be prescribed, usually 2.5 mg. It is also important to avoid prescribing trimethoprim or co-trimoxazole concurrently, as it increases the risk of marrow aplasia, and high-dose aspirin increases the risk of methotrexate toxicity.

      In case of methotrexate toxicity, the treatment of choice is folinic acid. Methotrexate is a drug with a high potential for patient harm, and it is crucial to be familiar with guidelines relating to its use to ensure patient safety.

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  • Question 16 - A 13-year-old girl comes to her doctor with a 5-month history of aching...

    Incorrect

    • A 13-year-old girl comes to her doctor with a 5-month history of aching pain and swelling in the distal part of her left thigh. She has a family history of retinoblastoma and is in good health otherwise. A radiograph of her knee reveals a sunburst pattern and a triangular area of new subperiosteal bone in the metaphyseal region of the femur. What is the most probable diagnosis?

      Your Answer: Ewing's sarcoma

      Correct Answer: Osteosarcoma

      Explanation:

      Types of Bone Tumours

      Bone tumours can be classified into two categories: benign and malignant. Benign tumours are non-cancerous and do not spread to other parts of the body. Osteoma is a common benign tumour that occurs on the skull and is associated with Gardner’s syndrome. Osteochondroma, on the other hand, is the most common benign bone tumour and is usually diagnosed in patients aged less than 20 years. It is characterized by a cartilage-capped bony projection on the external surface of a bone. Giant cell tumour is a tumour of multinucleated giant cells within a fibrous stroma and is most commonly seen in the epiphyses of long bones.

      Malignant tumours, on the other hand, are cancerous and can spread to other parts of the body. Osteosarcoma is the most common primary malignant bone tumour and is mainly seen in children and adolescents. It occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure. Ewing’s sarcoma is a small round blue cell tumour that is also seen mainly in children and adolescents. It occurs most frequently in the pelvis and long bones and tends to cause severe pain. Chondrosarcoma is a malignant tumour of cartilage that most commonly affects the axial skeleton and is more common in middle-age. It is important to diagnose and treat bone tumours early to prevent complications and improve outcomes.

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  • Question 17 - A 38-year-old woman presents to you with complaints of persistent fatigue that has...

    Incorrect

    • A 38-year-old woman presents to you with complaints of persistent fatigue that has been ongoing for years. She reports that her fatigue has worsened in the past month and has prevented her from going to work. Despite conducting a thorough tiredness screen, all results have come back negative. The patient has been researching online and asks if you think she may have fibromyalgia or chronic fatigue syndrome. What is the minimum duration of symptoms required for a diagnosis of chronic fatigue syndrome?

      Your Answer: 1 month

      Correct Answer: 4 months

      Explanation:

      Before diagnosing chronic fatigue syndrome, other potential causes of fatigue must be ruled out through a comprehensive tiredness screen. This should include blood tests such as FBC, ESR/CRP, U&E, Cr, and eGFR, LFTs and Ca2+, TFTs, random blood glucose, anti-endomysial antibody test (to exclude coeliac disease), CK, and ferritin.

      Understanding Chronic Fatigue Syndrome

      Chronic fatigue syndrome is a condition that is diagnosed after at least four months of disabling fatigue that affects mental and physical function more than 50% of the time, in the absence of other diseases that may explain the symptoms. It is more common in females, and past psychiatric history has not been shown to be a risk factor. The central feature of chronic fatigue syndrome is fatigue, but other recognized features include sleep problems, muscle and joint pains, headaches, painful lymph nodes without enlargement, sore throat, cognitive dysfunction, physical or mental exertion that makes symptoms worse, general malaise or ‘flu-like’ symptoms, dizziness, nausea, and palpitations.

      To diagnose chronic fatigue syndrome, a large number of screening blood tests are carried out to exclude other pathology, such as FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening, and urinalysis. The management of chronic fatigue syndrome includes cognitive behavior therapy, graded exercise therapy, pacing, low-dose amitriptyline for poor sleep, and referral to a pain management clinic if pain is a predominant feature. Cognitive behavior therapy is very effective, with a number needed to treat of 2. Graded exercise therapy is a formal supervised program, not advice to go to the gym. Pacing involves organizing activities to avoid tiring. Children and young people have a better prognosis than adults.

      In summary, chronic fatigue syndrome is a debilitating condition that affects both mental and physical function. It is more common in females and is diagnosed after at least four months of disabling fatigue. The management of chronic fatigue syndrome includes cognitive behavior therapy, graded exercise therapy, pacing, low-dose amitriptyline for poor sleep, and referral to a pain management clinic if pain is a predominant feature. Children and young people have a better prognosis than adults.

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  • Question 18 - A 60-year-old man complains of worsening pain and swelling in both knees with...

    Incorrect

    • A 60-year-old man complains of worsening pain and swelling in both knees with stiffness and decreased mobility over the past eight months. He also has painful wrist joints with nodules at the proximal and distal interphalangeal joints which have developed slowly over the past two years.
      Which of the following is the most likely diagnosis?

      Your Answer: Rheumatoid arthritis (RA)

      Correct Answer: Osteoarthritis (OA)

      Explanation:

      Differentiating between types of arthritis: A case study

      In this case study, a patient presents with bony swelling at the DIP and PIP joints of the hands. It is important to differentiate between various types of arthritis to make an accurate diagnosis and provide appropriate treatment.

      Osteoarthritis (OA) is characterized by loss of articular cartilage and overgrowth of underlying bone, commonly affecting the hips, knees, and small hand joints. Pain and swelling are common presenting features, along with crepitus on examination. Heberden’s and Bouchard’s nodes may also be present.

      Osteoporosis, on the other hand, is a condition of reduced bone density and increased fragility, often diagnosed following a low-impact fracture or screening of high-risk patients. Pain and bony swelling are not typical features of osteoporosis.

      Psoriatic arthritis is an inflammatory seronegative spondyloarthropathy associated with psoriasis, commonly affecting the hands but not causing the changes described in this case. Dactylitis is a usual examination finding with psoriatic arthritis.

      Reactive arthritis is characterized by a triad of urethritis, conjunctivitis, and arthritis following an infection. It typically presents as an acute, asymmetrical lower-limb arthritis, occurring a few days to weeks after the initial infection.

      Rheumatoid arthritis (RA) presents most often in women between the ages of 35 and 55 with symmetrical polyarticular arthritis, most often in the small joints of the hands or feet. Swelling is present at the metacarpophalangeal and PIP joints of the hands, along with other signs such as swan neck and Boutonnière deformities of the fingers, ulnar deviation of fingers, and Z deformity of the thumb.

      In conclusion, careful examination and consideration of various types of arthritis are necessary for an accurate diagnosis and appropriate treatment plan.

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  • Question 19 - A 30-year-old runner complains of anterior groin pain accompanied by hip snapping. The...

    Incorrect

    • A 30-year-old runner complains of anterior groin pain accompanied by hip snapping. The pain is described as sharp and aggravated after prolonged sitting. During the examination, the patient displays limited range of motion and experiences pain when the hip is adducted and internally rotated while flexed to 90 degrees. What is the probable diagnosis?

      Your Answer: Osteonecrosis of the femoral head

      Correct Answer: Femoroacetabular impingement

      Explanation:

      Anterior groin pain in active young adults is often caused by femoroacetabular impingement (FAI), which is a common condition that can lead to persistent hip pain. Symptoms include hip/groin pain that worsens with prolonged sitting and is often accompanied by snapping, clicking, or locking of the hip. FAI is typically associated with prior hip pathology, such as Perthes disease in childhood, and is caused by an abnormality in hip anatomy that results in abnormal contact between the femur and acetabulum rim. Over time, this can cause soft tissue damage, including labral tears. Snapping hip syndrome, on the other hand, is characterized by a snapping or clunking sound as tendons move over the hip bones during flexion and extension. This condition is usually painless unless there is an associated labral tear. Stress fractures, in contrast, typically improve with rest rather than worsening. Osteonecrosis of the femoral head is usually associated with other risk factors, such as steroid use, alcohol consumption, or autoimmune conditions. Initially, pain occurs during activity, but it can become constant as the condition progresses.

      Causes of Hip Pain in Adults

      Hip pain in adults can be caused by a variety of conditions. Osteoarthritis is a common cause, with pain that worsens with exercise and improves with rest. Reduced internal rotation is often the first sign, and risk factors include age, obesity, and previous joint problems. Inflammatory arthritis can also cause hip pain, with pain typically worse in the morning and accompanied by systemic features and raised inflammatory markers. Referred lumbar spine pain may be caused by femoral nerve compression, which can be tested with a positive femoral nerve stretch test. Greater trochanteric pain syndrome, or trochanteric bursitis, is caused by repeated movement of the iliotibial band and is most common in women aged 50-70 years. Meralgia paraesthetica is caused by compression of the lateral cutaneous nerve of the thigh and typically presents as a burning sensation over the antero-lateral aspect of the thigh. Avascular necrosis may have gradual or sudden onset and may follow high dose steroid therapy or previous hip fracture or dislocation. Pubic symphysis dysfunction is common in pregnancy and presents with pain over the pubic symphysis with radiation to the groins and medial aspects of the thighs, often with a waddling gait. Transient idiopathic osteoporosis is an uncommon condition sometimes seen in the third trimester of pregnancy, with groin pain and limited range of movement in the hip, and patients may be unable to weight bear. ESR may be elevated in this condition.

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  • Question 20 - A 50-year-old woman presents to you with a 3-week history of shoulder pain...

    Correct

    • A 50-year-old woman presents to you with a 3-week history of shoulder pain in both shoulders. A shoulder X-ray taken 2 weeks ago did not reveal any signs of osteoarthritis. Her blood tests show an elevated ESR of 50mm/hour. What is the most appropriate course of action for this probable diagnosis?

      Your Answer: Prescribe a trial of oral prednisolone 15mg daily and arrange follow up after 1 week to assess clinical response

      Explanation:

      The symptoms exhibited by this patient strongly indicate the presence of polymyalgia rheumatica, and thus, a one-week course of steroids should be administered to produce a significant improvement. Prescribing paracetamol for a month is unlikely to yield any noticeable relief. An MRI scan is not likely to aid in the diagnosis. Administering a prolonged course of steroids without periodic review is not recommended.

      Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People

      Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arteritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.

      To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.

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  • Question 21 - A 30-year-old woman attends a routine cervical smear test and is noted to...

    Incorrect

    • A 30-year-old woman attends a routine cervical smear test and is noted to have extensive scarring of her vulva. On further questioning, she reports several visits to the Sexual Health Clinic for recurrent episodes of painful vulval ulceration.
      She has had several attendances at the dentist and General Practitioner with recurrent painful mouth ulcers. She has been referred to a dermatologist to investigate a painful nodular rash which developed on her shins several weeks ago but has since resolved. She was recently discharged from the Eye Clinic following treatment for an acutely painful red eye.
      Which of the following is the most likely diagnosis?
      Select ONE option only.

      Your Answer: Coeliac disease

      Correct Answer: Behçet’s disease

      Explanation:

      Behçet’s disease is a rare autoimmune condition that causes painful recurrent mouth and genital ulcers leading to scarring. Diagnosis is often delayed due to the absence of a definitive diagnostic test. This patient has had a rash associated with Behçet’s disease and an episode of acute red eye, which may have been anterior uveitis, another symptom of the condition. Herpes simplex infection, Crohn’s disease, coeliac disease, and lichen planus are all conditions that can cause similar symptoms but can be ruled out based on the patient’s medical history and physical examination.

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  • Question 22 - A 35-year-old male presents with inner elbow and forearm pain that started after...

    Correct

    • A 35-year-old male presents with inner elbow and forearm pain that started after building a bookcase at home three days ago. He has no regular medication and is generally healthy. During the examination, you notice tenderness in the medial elbow joint and the patient reports discomfort when resisting wrist pronation. What is the probable diagnosis?

      Your Answer: Golfer's elbow

      Explanation:

      Epicondylitis results from repetitive stress that leads to inflammation of the common extensor tendon located at the epicondyle. Medial epicondylitis, also known as golfer’s elbow, causes tenderness at the medial epicondyle and results in wrist pain on resisted pronation. Lateral epicondylitis, or tennis elbow, causes tenderness at the lateral epicondyle and results in elbow pain on resisted extension of the wrist.

      Common Causes of Elbow Pain

      Elbow pain can be caused by a variety of conditions, each with their own characteristic features. Lateral epicondylitis, also known as tennis elbow, is characterized by pain and tenderness localized to the lateral epicondyle. Pain is worsened by resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended. Episodes typically last between 6 months and 2 years, with acute pain lasting for 6-12 weeks.

      Medial epicondylitis, or golfer’s elbow, is characterized by pain and tenderness localized to the medial epicondyle. Pain is aggravated by wrist flexion and pronation, and symptoms may be accompanied by numbness or tingling in the 4th and 5th finger due to ulnar nerve involvement.

      Radial tunnel syndrome is most commonly due to compression of the posterior interosseous branch of the radial nerve, and is thought to be a result of overuse. Symptoms are similar to lateral epicondylitis, but the pain tends to be around 4-5 cm distal to the lateral epicondyle. Symptoms may be worsened by extending the elbow and pronating the forearm.

      Cubital tunnel syndrome is due to the compression of the ulnar nerve. Initially, patients may experience intermittent tingling in the 4th and 5th finger, which may be worse when the elbow is resting on a firm surface or flexed for extended periods. Later, numbness in the 4th and 5th finger with associated weakness may occur.

      Olecranon bursitis is characterized by swelling over the posterior aspect of the elbow, with associated pain, warmth, and erythema. It typically affects middle-aged male patients. Understanding the characteristic features of these conditions can aid in their diagnosis and treatment.

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  • Question 23 - A 55-year-old diabetic right-handed woman complains of left shoulder discomfort. She reports a...

    Incorrect

    • A 55-year-old diabetic right-handed woman complains of left shoulder discomfort. She reports a rigid shoulder that is frequently more painful at night and struggles with dressing or fastening her bra. Upon examination, there is no pinpoint tenderness, but you observe weakness in external rotation.
      What could be the probable reason for her shoulder pain?

      Your Answer: Calcific tendinopathy

      Correct Answer: Adhesive capsulitis

      Explanation:

      Adhesive capsulitis typically results in a reduction of external rotation, both in active and passive movements.

      Understanding Adhesive Capsulitis (Frozen Shoulder)

      Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.

      Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.

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  • Question 24 - A 28-year-old woman visits her GP complaining of joint pain. She has previously...

    Incorrect

    • A 28-year-old woman visits her GP complaining of joint pain. She has previously sought medical attention for this issue, but her high BMI of 30 kg/m² was deemed to be the cause and weight loss was recommended. Upon examination, the doctor notes a significant effusion in her left knee and limited range of motion. The metacarpophalangeal joints in her right hand appear swollen and her fingers have a sausage-like appearance. Her left hand does not show any obvious deformities. The patient has tested positive for HLA-B27 and has a blood pressure of 138/87 mmHg and a temperature of 36.7ÂşC. Based on this information, what is the most probable diagnosis?

      Your Answer: Rheumatoid arthritis

      Correct Answer: Psoriatic arthritis

      Explanation:

      Psoriatic arthritis is a type of arthritis that can occur without prior psoriatic skin lesions and is often associated with dactylitis, also known as ‘sausage fingers’. HLA-B27 is commonly found in patients with psoriatic arthritis. Gout is unlikely in a woman under 60 and typically affects the big toe joint. Rheumatoid arthritis is also unlikely as it causes symmetrical polyarthritis and is associated with HLA-DRB1 rather than HLA-B27. Therefore, given the patient’s age, sex, dactylitis, and nail changes, psoriatic arthritis is a more likely diagnosis.

      Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is known to have a poor correlation with cutaneous psoriasis. In fact, it often precedes the development of skin lesions. This condition affects both males and females equally, with around 10-20% of patients with skin lesions developing an arthropathy.

      The presentation of psoriatic arthropathy can vary, with different patterns of joint involvement. The most common type is symmetric polyarthritis, which is very similar to rheumatoid arthritis and affects around 30-40% of cases. Asymmetrical oligoarthritis is another type, which typically affects the hands and feet and accounts for 20-30% of cases. Sacroiliitis, DIP joint disease, and arthritis mutilans (severe deformity of fingers/hand) are other patterns of joint involvement. Other signs of psoriatic arthropathy include psoriatic skin lesions, periarticular disease, enthesitis, tenosynovitis, dactylitis, and nail changes.

      To diagnose psoriatic arthropathy, X-rays are often used. These can reveal erosive changes and new bone formation, as well as periostitis and a pencil-in-cup appearance. Management of this condition should be done by a rheumatologist, and treatment is similar to that of rheumatoid arthritis. However, there are some differences, such as the use of monoclonal antibodies like ustekinumab and secukinumab. Mild peripheral arthritis or mild axial disease may be treated with NSAIDs alone, rather than all patients being on disease-modifying therapy as with RA. Overall, psoriatic arthropathy has a better prognosis than RA.

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  • Question 25 - A 56-year-old man has been diagnosed with gout and you are discussing ways...

    Incorrect

    • A 56-year-old man has been diagnosed with gout and you are discussing ways to prevent future attacks. What is the most probable trigger for a gout attack?

      Your Answer: Smoking

      Correct Answer: Sardines

      Explanation:

      To prevent gout, it is recommended to steer clear of foods that are rich in purines such as liver, kidneys, seafood, oily fish like mackerel and sardines, and yeast-based products.

      Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

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  • Question 26 - A 49-year-old man presents to his GP complaining of difficulty walking. He describes...

    Correct

    • A 49-year-old man presents to his GP complaining of difficulty walking. He describes experiencing pain in both calves and feet after walking around 400m, which gradually worsens and eventually causes his legs to give out. The pain disappears completely after sitting and resting for a few minutes, and he has found that leaning forward helps him walk further before the pain returns. The patient has no prior medical history, and a physical examination of his lower limbs reveals no abnormalities. What is the probable diagnosis?

      Your Answer: Lumbar spinal stenosis

      Explanation:

      Lumbar spinal canal stenosis is often indicated by a history of progressive painful neurological deficit that improves when resting or leaning forward. This condition causes nerve root ischaemia due to inadequate microvascular blood flow to the spinal nerve roots, resulting in bilateral neuropathic pain and progressive deficit affecting the dermatomes and myotomes below the affected level. Leaning forward widens the canal, providing relief, while resting reduces the oxygen requirement of the nerve roots, allowing the ischaemia to slowly resolve. Neurological examination of the legs usually shows no abnormal findings as the symptoms are only brought on by consistent use of the nerve roots.

      Osteoarthritis, on the other hand, is a degenerative arthropathy that typically affects large weight-bearing joints in the lower limbs, causing pain that rarely improves with rest and is not associated with a neurological deficit. It is usually unilateral and does not cause symmetrical symptoms.

      Peripheral neuropathy can produce similar symptoms to spinal stenosis, but the pathology is not related to nerve use, and a deficit (usually sensory) would be detected on examination. The absence of such findings indicates that peripheral neuropathy is not the cause.

      Peripheral vascular disease is the most likely differential for patients with spinal stenosis and symptoms of progressive leg pain that is relieved by rest. However, evidence of vascular insufficiency, such as absent distal pulses, ulceration or skin changes, would be present on examination if the condition were severe enough to cause symptoms after relatively short distances of walking. Additionally, leaning forward does not improve symptoms in peripheral vascular disease, only rest does.

      Lumbar spinal stenosis is a condition where the central canal in the lower back is narrowed due to degenerative changes, such as a tumor or disk prolapse. Patients may experience back pain, neuropathic pain, and symptoms similar to claudication. However, one distinguishing factor is that the pain is positional, with sitting being more comfortable than standing, and walking uphill being easier than downhill. Degenerative disease is the most common cause, starting with changes in the intervertebral disk that lead to disk bulging and collapse. This puts stress on the facet joints, causing cartilage degeneration, hypertrophy, and osteophyte formation, which narrows the spinal canal and compresses the nerve roots of the cauda equina. MRI scanning is the best way to diagnose lumbar spinal stenosis, and treatment may involve a laminectomy.

      Overall, lumbar spinal stenosis is a condition that affects the lower back and can cause a range of symptoms, including pain and discomfort. It is often caused by degenerative changes in the intervertebral disk, which can lead to narrowing of the spinal canal and compression of the nerve roots. Diagnosis is typically done through MRI scanning, and treatment may involve a laminectomy. It is important to note that the pain associated with lumbar spinal stenosis is positional, with sitting being more comfortable than standing, and walking uphill being easier than downhill.

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  • Question 27 - A 56-year-old man with a history of type 2 diabetes mellitus complains of...

    Correct

    • A 56-year-old man with a history of type 2 diabetes mellitus complains of right shoulder pain and limited movement in all directions. What is the probable diagnosis?

      Your Answer: Adhesive capsulitis

      Explanation:

      The development of adhesive capsulitis is more likely in individuals with diabetes mellitus.

      Understanding Adhesive Capsulitis (Frozen Shoulder)

      Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.

      Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.

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  • Question 28 - As a foundation year two doctor in general practice, you encounter a thirty-four-year-old...

    Correct

    • As a foundation year two doctor in general practice, you encounter a thirty-four-year-old priest who reports knee pain without any history of trauma. Upon examination, you note stable observations and slight swelling with pain and tenderness overlying the knee. What is the probable diagnosis?

      Your Answer: Infrapatellar bursitis

      Explanation:

      The most probable diagnosis for this gentleman’s condition is infrapatellar bursitis, which is often associated with kneeling, particularly in clergymen. Although prepatellar bursitis may also be a possible cause, it is more commonly observed in housemaids who kneel in a more upright position. Osteoarthritis, which is characterized by knee pain and a feeling of instability, is more prevalent in individuals over the age of forty-five, making it less likely for this patient. Cruciate ligament damage, meniscal tear, and ruptured bursa are also potential causes, but they are typically associated with a history of trauma.

      Knee problems are common among older adults, and it is important to be aware of the key features of each condition. Osteoarthritis of the knee is often seen in patients over 50 years of age who are overweight. This condition can cause severe pain, intermittent swelling, crepitus, and limited movement. Infrapatellar bursitis, also known as Clergyman’s knee, is associated with kneeling, while prepatellar bursitis, or Housemaid’s knee, is associated with more upright kneeling. Anterior cruciate ligament injuries may be caused by twisting of the knee, and patients may have heard a popping noise. Rapid onset of knee effusion and a positive draw test are also common features. Posterior cruciate ligament injuries may be caused by anterior force applied to the proximal tibia, such as during a car accident. Collateral ligament injuries can cause tenderness over the affected ligament and knee effusion. Meniscal lesions may be caused by twisting of the knee and can cause locking and giving-way, as well as tenderness along the joint line.

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  • Question 29 - Which of the following is least likely to be associated with ankylosing spondylitis?...

    Incorrect

    • Which of the following is least likely to be associated with ankylosing spondylitis?

      Your Answer: Heart block

      Correct Answer: Achalasia

      Explanation:

      Ankylosing spondylitis is associated with several features that can be remembered using the acronym ‘A’s. These include apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, and amyloidosis. However, achalasia is not a known association with ankylosing spondylitis.

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in young males, with a sex ratio of 3:1, and typically presents with lower back pain and stiffness that develops gradually. The stiffness is usually worse in the morning and improves with exercise, while pain at night may improve upon getting up. Clinical examination may reveal reduced lateral and forward flexion, as well as reduced chest expansion. Other features associated with ankylosing spondylitis include apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, amyloidosis, cauda equina syndrome, and peripheral arthritis (more common in females).

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  • Question 30 - A 32-year-old woman reports experiencing discomfort in the plantar midfoot area between the...

    Incorrect

    • A 32-year-old woman reports experiencing discomfort in the plantar midfoot area between the third and fourth toes while wearing high heels.
      What is the most probable reason for her symptoms?

      Your Answer: Plantar fasciitis

      Correct Answer: Morton’s neuroma

      Explanation:

      Common Foot Conditions and Their Symptoms

      Morton’s Neuroma: This condition is characterized by perineural fibrosis and common digital nerve degeneration, resulting in neuropathic pain in the forefoot and interdigital space. The third web space is most commonly affected, and pain is aggravated by narrow, tight, high-heeled shoes. Treatment involves local steroid injections and footwear advice.

      Claw Toe: In this condition, there is MTP dorsiflexion with PIP and DIP flexion affecting any of the second to fifth toes. Patients often report pain at the PIP joint due to pressure from a shoe on the toe.

      Achilles Tendonitis: This results in activity-related pain and swelling of the Achilles tendon, felt at the lower calf. The toes are unaffected. Management includes rest, NSAIDs, heel padding, physiotherapy, and steroid injections.

      Hammer Toe: This is a deformity of the second, third, or fourth toe, characterized by progressive PIP flexion deformity and compensatory hyperextension of the MTP and DIP joints. The PIP joint becomes prominent dorsally, causing pain when rubbing against the shoe.

      Plantar Fasciitis: This is a pain in the inferior heel at the attachment of the medial band of the plantar fascia to the medial calcaneal tubercle. It is a chronic inflammatory process and an overuse injury, with pain worst in the morning. Treatment involves shoes with arch support, soft heels and heel padding, regular stretching exercises, NSAIDs, and local steroid injections.

      Understanding Common Foot Conditions and Their Symptoms

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