00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A 15-year-old boy complains of dull, throbbing pain and swelling in his left...

    Incorrect

    • A 15-year-old boy complains of dull, throbbing pain and swelling in his left knee that is aggravated by his routine basketball practices. The boy also experiences a sensation of the left knee joint getting stuck and a painful 'click' when bending or straightening the left knee. Physical examination of the knee joint reveals a slight accumulation of fluid and a detectable loose body. Furthermore, tenderness is noticeable upon palpating the femoral condyles while the knee is flexed. What is the most appropriate diagnosis for this condition?

      Your Answer: Osgood-Schlatter disease

      Correct Answer: Osteochondritis dissecans

      Explanation:

      Osteochondritis dissecans is commonly seen in the knee joint and is characterized by knee pain after exercise, locking, and ‘clunking’. This condition is often caused by overuse of joints due to sports activities and can lead to secondary effects on joint cartilage, including pain, swelling, and possible formation of free bodies. Baker’s cyst, Osgood-Schlatter disease, and osteoarthritis are not the correct diagnoses as they present with different symptoms and causes.

      Understanding Osteochondritis Dissecans

      Osteochondritis dissecans (OCD) is a condition that affects the subchondral bone, usually in the knee joint, and can lead to secondary effects on the joint cartilage. It is most commonly seen in children and young adults and can progress to degenerative changes if left untreated. Symptoms of OCD include knee pain and swelling, catching, locking, and giving way, as well as a painful clunk when flexing or extending the knee. Signs of the condition include joint effusion and tenderness on palpation of the articular cartilage of the medial femoral condyle when the knee is flexed.

      To diagnose OCD, X-rays and MRI scans are often used. X-rays may show the subchondral crescent sign or loose bodies, while MRI scans can evaluate cartilage, visualize loose bodies, stage the condition, and assess the stability of the lesion. Early diagnosis is crucial, as clinical signs may be subtle in the early stages. Therefore, there should be a low threshold for imaging and/or orthopedic opinion.

      Overall, understanding OCD is important for recognizing its symptoms and seeking appropriate medical attention. With early diagnosis and management, patients can prevent the progression of the condition and maintain joint health.

    • This question is part of the following fields:

      • Musculoskeletal
      32.4
      Seconds
  • Question 2 - Mrs. Jane is a 55-year-old woman who visits her GP with a complaint...

    Incorrect

    • Mrs. Jane is a 55-year-old woman who visits her GP with a complaint of frank haematuria that has been present for a week. She also reports a persistent dry cough and dyspnoea that has been bothering her for the past 3 months, along with a long-standing history of sinusitis and nosebleeds. During the examination, the patient is found to have a saddle-shaped nasal deformity and bilateral crepitations on auscultation. What is the specific antibody that is most closely associated with this patient's condition?

      Your Answer: Anti-glomerular basement membrane antibody (anti-GBM)

      Correct Answer: Cytoplasmic antineutrophil cytoplasmic antibodies (cANCA)

      Explanation:

      ANCA Associated Vasculitis: Common Findings and Management

      Anti-neutrophil cytoplasmic antibodies (ANCA) are associated with small-vessel vasculitides such as granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and microscopic polyangiitis. ANCA associated vasculitis is more common in older individuals and presents with renal impairment, respiratory symptoms, systemic symptoms, and sometimes a vasculitic rash or ear, nose, and throat symptoms. First-line investigations include urinalysis, blood tests for renal function and inflammation, ANCA testing, and chest x-ray. There are two main types of ANCA – cytoplasmic (cANCA) and perinuclear (pANCA) – with varying levels found in different conditions. ANCA associated vasculitis should be managed by specialist teams and the mainstay of treatment is immunosuppressive therapy.

      ANCA associated vasculitis is a group of small-vessel vasculitides that are associated with ANCA. These conditions are more common in older individuals and present with renal impairment, respiratory symptoms, systemic symptoms, and sometimes a vasculitic rash or ear, nose, and throat symptoms. To diagnose ANCA associated vasculitis, first-line investigations include urinalysis, blood tests for renal function and inflammation, ANCA testing, and chest x-ray. There are two main types of ANCA – cytoplasmic (cANCA) and perinuclear (pANCA) – with varying levels found in different conditions. ANCA associated vasculitis should be managed by specialist teams and the mainstay of treatment is immunosuppressive therapy.

    • This question is part of the following fields:

      • Musculoskeletal
      26.9
      Seconds
  • Question 3 - A 15-year-old patient presents to the emergency department after a football injury resulting...

    Correct

    • A 15-year-old patient presents to the emergency department after a football injury resulting in a fracture. Despite reduction, the patient is experiencing severe pain, especially during passive stretching. The affected arm is visibly swollen, and the patient reports tingling sensations in their hand and forearm. What type of fracture is commonly associated with these symptoms?

      Your Answer: Supracondylar fracture

      Explanation:

      Compartment syndrome is often linked to fractures in the supracondylar region of the arm and the tibial shaft in the lower leg. Symptoms include excessive pain, especially during passive stretching, as well as swelling and paraesthesia in the affected limb. Late signs may include numbness and paralysis.

      Compartment syndrome is a complication that can occur after fractures or vascular injuries. It is characterized by increased pressure within a closed anatomical space, which can lead to tissue death. Supracondylar fractures and tibial shaft injuries are the most common fractures associated with compartment syndrome. Symptoms include pain, numbness, paleness, and possible paralysis of the affected muscle group. Diagnosis is made by measuring intracompartmental pressure, with pressures over 20 mmHg being abnormal and over 40 mmHg being diagnostic. X-rays typically do not show any pathology. Treatment involves prompt and extensive fasciotomies, with careful attention to decompressing deep muscles in the lower limb. Patients may develop myoglobinuria and require aggressive IV fluids. In severe cases, debridement and amputation may be necessary, as muscle death can occur within 4-6 hours.

    • This question is part of the following fields:

      • Musculoskeletal
      19.7
      Seconds
  • Question 4 - A 75-year-old male presents to his primary care physician and is screened for...

    Incorrect

    • A 75-year-old male presents to his primary care physician and is screened for osteoporosis using the QFracture risk assessment tool. The tool indicates that his risk of experiencing a fragility fracture is over 10%, leading to a referral for a DEXA scan. The results of the scan show a T-score of -2.9.
      What abnormalities might be observed in this patient's blood work?

      Your Answer: Raised ALP and PTH and decreased calcium and phosphate

      Correct Answer: Normal ALP, calcium, phosphate and PTH

      Explanation:

      Osteoporosis is typically not diagnosed through blood tests, as they usually show normal values for ALP, calcium, phosphate, and PTH. Instead, a DEXA scan is used to confirm the diagnosis, with a T-score below -2.5 indicating osteoporosis. Treatment for osteoporosis typically involves oral bisphosphonates like alendronate. Blood test results showing increased ALP and calcium but normal PTH and phosphate may indicate osteolytic metastatic disease, while increased calcium, ALP, and PTH but decreased phosphate may suggest primary or tertiary hyperparathyroidism. Conversely, increased phosphate, ALP, and PTH but decreased calcium may indicate secondary hyperparathyroidism, which is often associated with chronic kidney disease.

      Understanding Osteoporosis

      Osteoporosis is a condition that affects the skeletal system, causing a loss of bone mass. As people age, their bone mineral density decreases, but osteoporosis is defined by the World Health Organisation as having a bone mineral density of less than 2.5 standard deviations below the young adult mean density. This condition is significant because it increases the risk of fragility fractures, which can lead to significant morbidity and mortality. In fact, around 50% of postmenopausal women will experience an osteoporotic fracture at some point.

      The primary risk factors for osteoporosis are age and female gender, but other factors include corticosteroid use, smoking, alcohol consumption, low body mass index, and family history. To assess a patient’s risk of developing a fragility fracture, healthcare providers may use screening tools such as FRAX or QFracture. Additionally, patients who have sustained a fragility fracture should be evaluated for osteoporosis.

      To determine a patient’s bone mineral density, a dual-energy X-ray absorptiometry (DEXA) scan is used to examine the hip and lumbar spine. If either of these areas has a T score of less than -2.5, treatment is recommended. The first-line treatment for osteoporosis is typically an oral bisphosphonate such as alendronate, although other treatments are available. Overall, osteoporosis is a significant condition that requires careful evaluation and management to prevent fragility fractures and their associated complications.

    • This question is part of the following fields:

      • Musculoskeletal
      31.4
      Seconds
  • Question 5 - A 72-year-old woman presents to the emergency department with a painful swollen ankle....

    Incorrect

    • A 72-year-old woman presents to the emergency department with a painful swollen ankle. She is currently on oral antibiotics for a respiratory infection. She has a past medical history of rheumatoid arthritis.

      Observations:
      Heart rate 90 beats per minute
      Blood pressure 150/80 mmHg
      Respiratory rate 20/minute
      Oxygen saturations 95% on room air
      Temperature 37.2C

      On examination, the left ankle is erythematosus, tender and swollen with a restricted range of motion.

      Plain radiography of the left ankle reveals erosion of the joint space.

      What is the most likely diagnosis?

      Your Answer: Septic arthritis

      Correct Answer: Pseudogout

      Explanation:

      Gout is not the correct diagnosis in this case. While it is a possible cause of monoarthritis, the radiological findings and the affected joint suggest pseudogout as a more likely cause. Psoriatic arthritis is also an unlikely diagnosis, as this type of inflammatory arthritis typically presents in multiple joints and may be associated with a family history or psoriatic rash. Similarly, while rheumatoid arthritis can present as monoarthritis, it is more commonly seen as small joint polyarthritis with erosions and osteopenia visible on x-ray. It is important not to miss the correct diagnosis in cases of monoarthritis.

      Pseudogout, also known as acute calcium pyrophosphate crystal deposition disease, is a type of microcrystal synovitis that occurs when calcium pyrophosphate dihydrate crystals are deposited in the synovium. This condition is more common in older individuals, but those under 60 years of age may develop it if they have underlying risk factors such as haemochromatosis, hyperparathyroidism, low magnesium or phosphate levels, acromegaly, or Wilson’s disease. The knee, wrist, and shoulders are the most commonly affected joints, and joint aspiration may reveal weakly-positively birefringent rhomboid-shaped crystals. X-rays may show chondrocalcinosis, which appears as linear calcifications of the meniscus and articular cartilage in the knee. Treatment involves joint fluid aspiration to rule out septic arthritis, as well as the use of NSAIDs or steroids, as with gout.

    • This question is part of the following fields:

      • Musculoskeletal
      52.5
      Seconds
  • Question 6 - John is an 80-year-old man who has come in with stiffness and pain...

    Incorrect

    • John is an 80-year-old man who has come in with stiffness and pain in both shoulders. His doctor suspects PMR and orders some blood tests.
      ESR - erythrocyte sedimentation rate
      CRP - C-reactive protein
      Anti-ccp - anti-cyclic citrullinated peptide
      CK - creatine kinase
      Which of the following results would be most indicative of PMR in John?

      Your Answer: ESR normal , CRP normal, anti-CCP normal, CK ↑

      Correct Answer: ESR ↑ , CRP ↑, anti-CCP normal, CK normal

      Explanation:

      Polymyalgia rheumatica typically presents with normal levels of creatine kinase, while patients are likely to have elevated ESR and CRP at the time of diagnosis. Unlike polymyositis, which is more commonly associated with muscle weakness, PMR does not cause an increase in CK levels. Additionally, a raised anti-CCP is typically indicative of rheumatoid arthritis.

      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 arthritis, 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 15 mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.

    • This question is part of the following fields:

      • Musculoskeletal
      27.7
      Seconds
  • Question 7 - A 58-year-old woman has presented to the hospital with a five-hour history of...

    Incorrect

    • A 58-year-old woman has presented to the hospital with a five-hour history of intermittent retrosternal chest pain radiating into the shoulder and jaw with associated diaphoresis, dyspnoea, and dizziness.

      She has a past medical history of Crohn's disease and takes azathioprine 150 mg daily. She was previously started on sulfasalazine but developed facial swelling.

      ECG shows normal sinus rhythm at 78 bpm but demonstrates 3mm of ST depression in leads II, III, and aVF.

      Blood results are:
      Urea 5.6 mmol/L (2.0 - 7.0)
      Creatinine 132 µmol/L (55 - 120)
      Initial Troponin T 17 ng/L (5-14)
      5 hour Troponin T 326 ng/L (5-14)

      A diagnosis of an inferior non-ST elevation myocardial infarction is made.

      Which medication should be avoided?

      Your Answer: Ticagrelor

      Correct Answer: Aspirin

      Explanation:

      There is a risk of allergy to sulfasalazine for patients who are allergic to aspirin.

      The correct answer is aspirin. Evidence suggests that there is cross-sensitivity between aspirin and sulfasalazine, so if a patient is allergic to one, they may also be allergic to the other. Bisoprolol is safe to administer as there are no known contraindications, allergies, or intolerances. Clopidogrel is also safe to administer in the current situation, but its use should be reviewed if the patient is experiencing an acute flare of Crohn’s with excessive rectal bleeding. Ramipril is safe to administer.

      Sulfasalazine: A DMARD for Inflammatory Arthritis and Bowel Disease

      Sulfasalazine is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage inflammatory arthritis, particularly rheumatoid arthritis, as well as inflammatory bowel disease. This medication is a prodrug for 5-ASA, which works by reducing neutrophil chemotaxis and suppressing the proliferation of lymphocytes and pro-inflammatory cytokines.

      However, caution should be exercised when using sulfasalazine in patients with G6PD deficiency or those who are allergic to aspirin or sulphonamides due to the risk of cross-sensitivity. Adverse effects of sulfasalazine may include oligospermia, Stevens-Johnson syndrome, pneumonitis/lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, and the potential to color tears and stain contact lenses.

      Despite these potential side effects, sulfasalazine is considered safe to use during pregnancy and breastfeeding, making it a viable option for women who require treatment for inflammatory arthritis or bowel disease. Overall, sulfasalazine is an effective DMARD that can help manage the symptoms of these conditions and improve patients’ quality of life.

    • This question is part of the following fields:

      • Musculoskeletal
      54.1
      Seconds
  • Question 8 - A 28-year-old woman of Afro-Caribbean descent visits her doctor with complaints of fatigue,...

    Incorrect

    • A 28-year-old woman of Afro-Caribbean descent visits her doctor with complaints of fatigue, widespread musculoskeletal pain, low mood, and swollen lumps in her neck and armpit. Her blood test results are as follows:
      - Hemoglobin (Hb): 107g/L (Male: 135-180, Female: 115-160)
      - Platelets: 140* 109/L (150-400)
      - White blood cells (WBC): 3.2* 109/L (4.0-11.0)
      - Sodium (Na+): 138 mmol/L (135-145)
      - Potassium (K+): 4.0mmol/L (3.5-5.0)
      - Urea: 12.5mmol/L (2.0-7.0)
      - Creatinine: 165µmol/L (55-120)
      - C-reactive protein (CRP): 115mg/L (<5)
      - Antinuclear antibodies: Positive
      - Anti-double-stranded DNA: Positive

      As a result of her abnormal renal function results, a renal biopsy is conducted and examined under electron microscopy, revealing no mesangial deposits. Based on her likely diagnosis, what medication should be prescribed to this patient?

      Your Answer: Prednisolone

      Correct Answer: Hydroxychloroquine

      Explanation:

      The recommended treatment for systemic lupus erythematosus (SLE) is hydroxychloroquine, which is a disease-modifying anti-rheumatic drug (DMARD). A patient presenting with symptoms such as fatigue, musculoskeletal pain, low mood, and lymphadenopathy, along with positive results for antinuclear antibodies and double-stranded DNA antibodies, may be diagnosed with SLE. Hydroxychloroquine works by increasing lysosomal pH in antigen-presenting cells, which interferes with activity and downregulates the inappropriate autoimmune response. Cyclophosphamide, an alkylating agent used in cancer treatment, is not appropriate for SLE management unless there is renal involvement. Methotrexate, another DMARD, can be used as a steroid-sparing agent in conjunction with prednisolone if the patient’s symptoms are not controlled by NSAIDs and hydroxychloroquine. Prednisolone, a corticosteroid, is typically reserved for patients with internal organ involvement or if their symptoms are not controlled by other medications due to the long-term risks associated with steroid use.

      Managing Systemic Lupus Erythematosus

      Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects various organs and tissues in the body. To manage SLE, several treatment options are available. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help relieve joint pain and inflammation. It is also important to use sunblock to prevent skin damage and flare-ups triggered by sun exposure.

      Hydroxychloroquine is considered the treatment of choice for SLE. It can help reduce disease activity and prevent flares. However, if SLE affects internal organs such as the kidneys, nervous system, or eyes, additional treatment may be necessary. In such cases, prednisolone and cyclophosphamide may be prescribed to manage inflammation and prevent organ damage.

      To summarize, managing SLE involves a combination of medication and lifestyle changes. NSAIDs and sunblock can help manage symptoms, while hydroxychloroquine is the preferred treatment for reducing disease activity. If SLE affects internal organs, additional medication may be necessary to prevent organ damage.

    • This question is part of the following fields:

      • Musculoskeletal
      37.2
      Seconds
  • Question 9 - Sophie is a 16-year-old who has been brought to the emergency department by...

    Correct

    • Sophie is a 16-year-old who has been brought to the emergency department by her father after a fall. An X-ray of her left ankle shows a Weber A fracture. What is the most suitable course of action for treating this injury?

      Your Answer: Remain weight bearing as tolerated in a CAM boot for 6 weeks

      Explanation:

      Patients with minimally displaced and stable Weber A fractures may bear weight as tolerated while wearing a CAM boot. These fractures occur below the ankle syndesmosis and are considered stable, requiring immobilization in a CAM boot for six weeks. Pain relief is necessary but not the primary management for this injury. A below-knee cast is not required as the fracture is stable. Open reduction and external fixation are only necessary for unstable injuries such as Weber C fractures.

      Ankle Fractures and their Classification

      Ankle fractures are a common reason for emergency department visits. To minimize the unnecessary use of x-rays, the Ottawa ankle rules are used to aid in clinical examination. These rules state that x-rays are only necessary if there is pain in the malleolar zone and an inability to weight bear for four steps, tenderness over the distal tibia, or bone tenderness over the distal fibula. There are several classification systems for describing ankle fractures, including the Potts, Weber, and AO systems. The Weber system is the simplest and is based on the level of the fibular fracture. Type A is below the syndesmosis, type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis, and type C is above the syndesmosis, which may itself be damaged. A subtype known as a Maisonneuve fracture may occur with a spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, requiring surgery.

      Management of Ankle Fractures

      The management of ankle fractures depends on the stability of the ankle joint and patient co-morbidities. Prompt reduction of all ankle fractures is necessary to relieve pressure on the overlying skin and prevent necrosis. Young patients with unstable, high velocity, or proximal injuries will usually require surgical repair, often using a compression plate. Elderly patients, even with potentially unstable injuries, usually fare better with attempts at conservative management as their thin bone does not hold metalwork well. It is important to consider the patient’s overall health and any other medical conditions when deciding on the best course of treatment.

    • This question is part of the following fields:

      • Musculoskeletal
      29.2
      Seconds
  • Question 10 - A 45-year-old woman with a history of rheumatoid arthritis visits her GP with...

    Correct

    • A 45-year-old woman with a history of rheumatoid arthritis visits her GP with complaints of heightened pain and stiffness in her wrists and fatigue for the past week. Upon examination, there is slight swelling and tenderness in both wrists. The patient has been taking sulfasalazine for the past 5 years without any issues. What is the best course of action for management?

      Your Answer: Methylprednisolone IM

      Explanation:

      Methylprednisolone, an intramuscular steroid, is commonly used to manage acute flares of rheumatoid arthritis. The bilateral swelling and tenderness in the wrists presented by the patient is a typical symptom of an acute flare of rheumatoid arthritis. According to NICE guidelines, oral or intramuscular steroids are recommended for the treatment of such flares. Methylprednisolone is the most appropriate choice as it primarily inhibits proinflammatory cytokine production, providing rapid relief from pain and discomfort by reducing inflammation.

      In addition to steroids, the patient’s sulfasalazine dose may be increased or changed to another DMARD. Steroids can be used as a bridging treatment to control inflammation while the DMARD takes effect. Leflunomide would be prescribed if sulfasalazine is not managing the rheumatoid arthritis effectively. TNF inhibitors such as etanercept or infliximab are indicated only after an inadequate response to at least two DMARDs, including methotrexate.

      Although paracetamol can be useful for baseline pain management, it is not the most appropriate treatment for this flare of rheumatoid arthritis. Steroids are required to reduce inflammation and form a crucial part of the patient’s management.

      Managing Rheumatoid Arthritis with Disease-Modifying Therapies

      The management of rheumatoid arthritis (RA) has significantly improved with the introduction of disease-modifying therapies (DMARDs) in the past decade. Patients with joint inflammation should start a combination of DMARDs as soon as possible, along with analgesia, physiotherapy, and surgery. In 2018, NICE updated their guidelines for RA management, recommending DMARD monotherapy with a short course of bridging prednisolone as the initial step. Monitoring response to treatment is crucial, and NICE suggests using a combination of CRP and disease activity to assess it. Flares of RA are often managed with corticosteroids, while methotrexate is the most widely used DMARD. Other DMARDs include sulfasalazine, leflunomide, and hydroxychloroquine. TNF-inhibitors are indicated for patients with an inadequate response to at least two DMARDs, including methotrexate. Etanercept, infliximab, and adalimumab are some of the TNF-inhibitors available, each with their own risks and administration methods. Rituximab and Abatacept are other DMARDs that can be used, but the latter is not currently recommended by NICE.

    • This question is part of the following fields:

      • Musculoskeletal
      29.7
      Seconds
  • Question 11 - A 54-year-old woman presents with thickened skin on her face and below her...

    Correct

    • A 54-year-old woman presents with thickened skin on her face and below her elbows, while the skin above her elbows appears normal. She has a known history of Raynaud's phenomenon. What is the probable diagnosis?

      Your Answer: Limited cutaneous systemic sclerosis

      Explanation:

      Limited cutaneous systemic sclerosis is a form of systemic sclerosis where the skin hardening is limited to the face and distal limbs, below the elbows. In contrast, diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs. Sclerodactyly specifically refers to skin hardening of the fingers or toes. Dermatomyositis and systemic lupus erythematosus are inflammatory conditions that do not typically cause skin hardening. Psoriasis is a skin condition characterized by red, scaly patches of skin covered with silvery scales.

      Understanding Systemic Sclerosis

      Systemic sclerosis is a condition that affects the skin and other connective tissues, but its cause is unknown. It is more common in females, with three patterns of the disease. Limited cutaneous systemic sclerosis is characterised by Raynaud’s as the first sign, affecting the face and distal limbs, and associated with anti-centromere antibodies. CREST syndrome is a subtype of limited systemic sclerosis that includes Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, and Telangiectasia. Diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs, associated with scl-70 antibodies, and has a poor prognosis. Respiratory involvement is the most common cause of death, with interstitial lung disease and pulmonary arterial hypertension being the primary complications. Renal disease and hypertension are also possible complications, and patients with renal disease should be started on an ACE inhibitor. Scleroderma without internal organ involvement is characterised by tightening and fibrosis of the skin, manifesting as plaques or linear. Antibodies such as ANA, RF, anti-scl-70, and anti-centromere are associated with different types of systemic sclerosis.

    • This question is part of the following fields:

      • Musculoskeletal
      38.1
      Seconds
  • Question 12 - A 38-year-old teacher presents to your clinic with complaints of painful and stiff...

    Incorrect

    • A 38-year-old teacher presents to your clinic with complaints of painful and stiff joints. The stiffness is more pronounced in the mornings and lasts for over an hour, but improves as the day progresses. The patient reports feeling fatigued but denies any other symptoms. Upon examination, synovitis is observed in two interphalangeal joints of the left hand, left wrist, and a single distal interphalangeal joint in the right foot. The patient is referred to a rheumatologist who diagnoses psoriatic arthritis. What is the most distinguishing feature between psoriatic arthritis and rheumatoid arthritis?

      Your Answer: Subcutaneous nodules

      Correct Answer: Asymmetrical joint pains

      Explanation:

      Psoriatic arthritis patients may experience a symmetrical polyarthritis similar to rheumatoid arthritis. Fatigue is a common symptom in inflammatory arthritides, including psoriatic arthritis, but it is not specific to this condition. Joint pain caused by mechanical factors like osteoarthritis and fibromyalgia can also lead to fatigue. Prolonged morning stiffness is a sign of inflammatory arthritis, such as psoriatic arthritis or rheumatoid arthritis, but it can also occur in other inflammatory arthritides. In contrast, morning stiffness in osteoarthritis is usually shorter in duration, lasting less than an hour. Improvement in stiffness with use is a distinguishing feature of inflammatory arthritis, such as psoriatic and rheumatoid arthritis, while physical activity in osteoarthritis tends to worsen symptoms.

      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.

    • This question is part of the following fields:

      • Musculoskeletal
      37
      Seconds
  • Question 13 - A 50-year-old man with a history of haemochromatosis complains of a painful and...

    Correct

    • A 50-year-old man with a history of haemochromatosis complains of a painful and swollen right knee. An x-ray reveals no fracture but significant chondrocalcinosis. Assuming the diagnosis is pseudogout, what is the most probable finding in the joint fluid?

      Your Answer: Positively birefringent rhomboid shaped crystals

      Explanation:

      Pseudogout is characterized by rhomboid-shaped crystals that exhibit weakly positive birefringence.

      Pseudogout, also known as acute calcium pyrophosphate crystal deposition disease, is a type of microcrystal synovitis that occurs when calcium pyrophosphate dihydrate crystals are deposited in the synovium. This condition is more common in older individuals, but those under 60 years of age may develop it if they have underlying risk factors such as haemochromatosis, hyperparathyroidism, low magnesium or phosphate levels, acromegaly, or Wilson’s disease. The knee, wrist, and shoulders are the most commonly affected joints, and joint aspiration may reveal weakly-positively birefringent rhomboid-shaped crystals. X-rays may show chondrocalcinosis, which appears as linear calcifications of the meniscus and articular cartilage in the knee. Treatment involves joint fluid aspiration to rule out septic arthritis, as well as the use of NSAIDs or steroids, as with gout.

    • This question is part of the following fields:

      • Musculoskeletal
      16.8
      Seconds
  • Question 14 - A 29-year-old man is brought to the emergency department following a head-on collision...

    Incorrect

    • A 29-year-old man is brought to the emergency department following a head-on collision with his motorcycle. He is conscious and responsive, but he reports severe agony in his right leg. Upon examination, there is an exposed break in the right tibia with significant damage to the surrounding soft tissue and contamination. The medical team has administered intravenous antibiotics. What is the primary treatment for his fracture?

      Your Answer: Urgent intravenous antibiotics and fracture irrigation in the emergency department

      Correct Answer: Urgent intravenous antibiotics and debridement in theatre

      Explanation:

      Immediate administration of intravenous antibiotics and debridement is necessary for the management of open fractures, and definitive management should be delayed until soft tissues have recovered. A combined orthoplastic approach is recommended for achieving debridement, fixation, and soft tissue cover. If suitable, fixation and definitive soft tissue cover can be done immediately after debridement. However, if this is not possible, cover should be carried out within 72 hours to minimize the risk of infection. It is important to note that external fixation, fracture irrigation, and internal fixation should not be done before operative debridement, and free flap surgery should only be done after debridement.

      Fracture Management: Understanding Types and Treatment

      Fractures can occur due to trauma, stress, or pathological reasons. Diagnosis involves evaluating the site and type of injury, as well as associated injuries and neurovascular deficits. X-rays are important in assessing changes in bone length, distal bone angulation, rotational effects, and foreign material. Fracture types include oblique, comminuted, segmental, transverse, and spiral. It is also important to distinguish open from closed injuries, with the Gustilo and Anderson classification system being the most common for open fractures. Management involves immobilizing the fracture, monitoring neurovascular status, managing infection, and debriding open fractures within 6 hours of injury.

      To ensure proper fracture management, it is crucial to understand the different types of fractures and their causes. Diagnosis involves not only evaluating the fracture itself, but also any associated injuries and neurovascular deficits. X-rays are an important tool in assessing the extent of the injury. It is also important to distinguish between open and closed fractures, with open fractures requiring immediate attention and debridement. Proper management involves immobilizing the fracture, monitoring neurovascular status, and managing infection. By understanding the different types of fractures and their treatment, healthcare professionals can provide effective care for patients with fractures.

    • This question is part of the following fields:

      • Musculoskeletal
      75.4
      Seconds
  • Question 15 - A 50-year-old man presents to the rheumatology clinic after experiencing an acute monoarthropathy...

    Incorrect

    • A 50-year-old man presents to the rheumatology clinic after experiencing an acute monoarthropathy in his left big toe's metatarsophalangeal joint. The synovial fluid analysis revealed the presence of negatively birefringent crystals under polarised light. After resolving the inflammation with acute treatment, the rheumatologist decides to start prophylactic treatment with allopurinol to prevent future occurrences. What is the most suitable medication to begin with allopurinol?

      Your Answer: Hydroxychloroquine

      Correct Answer: Diclofenac

      Explanation:

      When starting allopurinol for prophylactic treatment of gout, it is important to use NSAID or colchicine ‘cover’ to prevent an acute flare up of gout. This is because starting allopurinol can trigger an acute flare up of gout. In this case, diclofenac, an NSAID, should be given alongside allopurinol initially. Azathioprine use is contraindicated alongside allopurinol due to the risk of toxicity. Febuxostat is an alternative to allopurinol but should not be used alongside it. Hydroxychloroquine and methotrexate are not used in the treatment of gout but have a role in maintenance treatment for other rheumatological diseases.

      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.

    • This question is part of the following fields:

      • Musculoskeletal
      32.1
      Seconds
  • Question 16 - A 61-year-old man arrives at the Emergency Department complaining of intense pain in...

    Incorrect

    • A 61-year-old man arrives at the Emergency Department complaining of intense pain in his right ankle and 1st metatarsophalangeal joint. The pain started overnight and has worsened since he took his furosemide in the morning. He is also taking omeprazole for a recent peptic ulcer. What medication should be prescribed to alleviate his symptoms?

      Your Answer: Allopurinol

      Correct Answer: Colchicine

      Explanation:

      If a patient has a peptic ulcer and cannot take NSAIDs for acute gout treatment, colchicine is a suitable alternative.

      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.

    • This question is part of the following fields:

      • Musculoskeletal
      26.1
      Seconds
  • Question 17 - A 55-year-old woman presents at the one-stop breast clinic for triple assessment following...

    Incorrect

    • A 55-year-old woman presents at the one-stop breast clinic for triple assessment following a suspicious lesion detected on a screening mammogram. You review recent blood tests from her GP and are asked to identify the most probable underlying cause of the abnormal result.

      Hb 121 g/L Male: (135-180)
      Female: (115 - 160)

      Platelets 242 * 109/L (150 - 400)

      WBC 10.0 * 109/L (4.0 - 11.0)

      Calcium 2.6 mmol/L (2.1-2.6)

      Phosphate 1.1 mmol/L (0.8-1.4)

      Magnesium 0.8 mmol/L (0.7-1.0)

      Thyroid stimulating hormone (TSH) 4.5 mU/L (0.5-5.5)

      Free thyroxine (T4) 12 pmol/L (9.0 - 18)

      Amylase 203 U/L (70 - 300)

      Uric acid 0.46 mmol/L (0.18 - 0.48)

      Creatine kinase 1200 U/L (35 - 250)

      Your Answer: Rhabdomyolysis

      Correct Answer: Polymyositis

      Explanation:

      The patient is suspected to have breast cancer based on her age and abnormal mammogram results. Additionally, her blood tests show an elevated creatinine kinase (CK) level. This combination of malignancy and raised CK suggests the possibility of polymyositis, a condition that is often associated with cancer. However, a thorough medical history should be obtained before making any definitive diagnosis. The patient may report experiencing muscle weakness and tenderness, particularly in the proximal areas such as the shoulders. It is unlikely that drug-induced factors are causing the raised CK, as there is no indication of this in the patient’s case. Myocardial infarction (MI) is another potential cause of elevated CK, but there is no evidence to suggest that this is the case here. Polymyalgia rheumatica may present with similar symptoms to polymyositis, but it does not typically cause a raised CK. Instead, it is associated with elevated inflammatory markers such as ESR and CRP. Therefore, CK levels can be a useful tool in distinguishing between polymyalgia rheumatica and polymyositis.

      Polymyositis: An Inflammatory Disorder Causing Muscle Weakness

      Polymyositis is an inflammatory disorder that causes symmetrical, proximal muscle weakness. It is believed to be a T-cell mediated cytotoxic process directed against muscle fibers and can be idiopathic or associated with connective tissue disorders. This condition is often associated with malignancy and typically affects middle-aged women more than men.

      One variant of the disease is dermatomyositis, which is characterized by prominent skin manifestations such as a purple (heliotrope) rash on the cheeks and eyelids. Other features of polymyositis include Raynaud’s, respiratory muscle weakness, dysphagia, and dysphonia. Interstitial lung disease, such as fibrosing alveolitis or organizing pneumonia, is seen in around 20% of patients and indicates a poor prognosis.

      To diagnose polymyositis, doctors may perform various tests, including an elevated creatine kinase, EMG, muscle biopsy, and anti-synthetase antibodies. Anti-Jo-1 antibodies are seen in a pattern of disease associated with lung involvement, Raynaud’s, and fever.

      The management of polymyositis involves high-dose corticosteroids tapered as symptoms improve. Azathioprine may also be used as a steroid-sparing agent. Overall, polymyositis is a challenging condition that requires careful management and monitoring.

    • This question is part of the following fields:

      • Musculoskeletal
      83.8
      Seconds
  • Question 18 - A 45-year-old patient presents with an upper limb nerve injury. The patient reports...

    Correct

    • A 45-year-old patient presents with an upper limb nerve injury. The patient reports weak finger abduction and adduction with reduced sensation over the ulnar border of the hand. Clawing of the 4th and 5th digits is observed during examination. The patient experiences worsening of this deformity during recovery before eventually resolving. What is the most probable diagnosis?

      Your Answer: Damage to ulnar nerve at the elbow

      Explanation:

      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.

    • This question is part of the following fields:

      • Musculoskeletal
      42.9
      Seconds
  • Question 19 - A 5-year-old girl is brought to the hospital with a suspected fracture of...

    Correct

    • A 5-year-old girl is brought to the hospital with a suspected fracture of her left femur. Her parents are unsure how this happened and deny any injury. During the examination, you observe extensive dental decay, a bluish hue to the whites of her eyes, and on X-ray, multiple fractures at different stages of healing are noted.

      What is the probable diagnosis in this scenario?

      Your Answer: Osteogenesis imperfecta

      Explanation:

      Osteogenesis imperfecta is a collagen disorder that is identified by blue sclera, multiple fractures during childhood, dental caries, and deafness due to otosclerosis. It is often mistaken for child abuse or neglect, but the presence of blue sclera is a crucial indicator of osteogenesis imperfecta. In contrast, rickets is more likely to cause growth stunting and deformities rather than multiple fractures.

      Osteogenesis imperfecta, also known as brittle bone disease, is a group of disorders that affect collagen metabolism, leading to bone fragility and fractures. The most common type of osteogenesis imperfecta is type 1, which is inherited in an autosomal dominant manner and is caused by a decrease in the synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides. This condition typically presents in childhood and is characterized by fractures that occur following minor trauma, as well as blue sclera, dental imperfections, and deafness due to otosclerosis.

      When investigating osteogenesis imperfecta, it is important to note that adjusted calcium, phosphate, parathyroid hormone, and ALP results are usually normal. This condition can have a significant impact on a person’s quality of life, as it can lead to frequent fractures and other complications. However, with proper management and support, individuals with osteogenesis imperfecta can lead fulfilling lives.

    • This question is part of the following fields:

      • Musculoskeletal
      39.9
      Seconds
  • Question 20 - A 57-year-old motorcyclist is involved in a road traffic accident and suffers a...

    Correct

    • A 57-year-old motorcyclist is involved in a road traffic accident and suffers a displaced femoral shaft fracture. No other injuries are found during the primary or secondary surveys. The fracture is treated with closed, antegrade intramedullary nailing. The next day, the patient becomes increasingly confused and agitated. Upon examination, he is pyrexial, hypoxic with SaO2 at 90% on 6 litres O2, tachycardic, and normotensive. A non-blanching petechial rash is observed over the torso during systemic examination. What is the most probable explanation for this?

      Your Answer: Fat embolism

      Explanation:

      This individual displays physical indications and a recent injury that are consistent with fat embolism syndrome. In the early stages, meningococcal sepsis is not commonly linked to hypoxia. Likewise, pyrexia is not typically associated with pulmonary emboli.

      Understanding Fat Embolism: Diagnosis, Clinical Features, and Treatment

      Fat embolism is a medical condition that occurs when fat globules enter the bloodstream and obstruct blood vessels. This condition is commonly seen in patients with long bone fractures, particularly in the femur and tibia. The diagnosis of fat embolism is based on clinical features, including respiratory symptoms such as tachypnea, dyspnea, and hypoxia, as well as dermatological symptoms such as a red or brown petechial rash. CNS symptoms such as confusion and agitation may also be present. Imaging may not always show vascular occlusion, but a ground glass appearance may be seen at the periphery.

      Prompt fixation of long bone fractures is crucial in the treatment of fat embolism. However, there is some debate regarding the benefit versus risk of medullary reaming in femoral shaft or tibial fractures in terms of increasing the risk of fat embolism. DVT prophylaxis and general supportive care are also important in the management of this condition. While fat embolism can be a serious and potentially life-threatening condition, prompt diagnosis and treatment can improve outcomes for patients.

    • This question is part of the following fields:

      • Musculoskeletal
      28.8
      Seconds
  • Question 21 - A 39-year-old woman experiences lower back pain that travels down her left leg...

    Incorrect

    • A 39-year-old woman experiences lower back pain that travels down her left leg while doing DIY work. She reports a severe, sharp, stabbing pain that worsens with movement. During the clinical examination, a positive straight leg raise test is observed on the left side, but there are no other notable findings. The patient is given appropriate pain relief. What is the most appropriate next step in managing this condition?

      Your Answer: Lumbar spine x-ray

      Correct Answer: Arrange physiotherapy

      Explanation:

      A prolapsed disc is suspected based on the patient’s symptoms. However, even if an MRI scan confirms this diagnosis, the initial management would remain the same as most patients respond well to conservative treatment like physiotherapy.

      Understanding Prolapsed Disc and its Features

      A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.

      The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Musculoskeletal
      75.8
      Seconds
  • Question 22 - A 40-year-old woman with a 2 year history of rheumatoid arthritis presents to...

    Correct

    • A 40-year-old woman with a 2 year history of rheumatoid arthritis presents to your clinic with an acute flare up of her symptoms. The patient reports increased pain in her joints, general fatigue, and difficulty performing her usual daily activities due to swelling and stiffness in her hands. She mentions experiencing high levels of stress at work and concerns about her financial stability. However, she is otherwise healthy and has normal physical observations. Currently, she is receiving methotrexate 7.5mg intramuscularly weekly. What is the most effective treatment option for managing this presentation?

      Your Answer: Intramuscular methylprednisolone acetate

      Explanation:

      Methylprednisolone, an intramuscular steroid, is commonly used to manage acute flares of rheumatoid arthritis. Glucocorticoids, such as methylprednisolone acetate and triamcinolone acetonide, are effective short-term treatment options that can be administered via intra-articular injection, intramuscular injection, or orally. Disease modifying anti-rheumatic drugs (DMARDs) like methotrexate may take several months to become effective, so they are not suitable for treating acute flare-ups. Non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen can be used for a short period to reduce pain and inflammation, but their potential side effects and risks must be considered. Paracetamol can help with pain relief, but it does not address the inflammation associated with rheumatoid arthritis and is therefore not the most effective treatment option.

      Managing Rheumatoid Arthritis with Disease-Modifying Therapies

      The management of rheumatoid arthritis (RA) has significantly improved with the introduction of disease-modifying therapies (DMARDs) in the past decade. Patients with joint inflammation should start a combination of DMARDs as soon as possible, along with analgesia, physiotherapy, and surgery. In 2018, NICE updated their guidelines for RA management, recommending DMARD monotherapy with a short course of bridging prednisolone as the initial step. Monitoring response to treatment is crucial, and NICE suggests using a combination of CRP and disease activity to assess it. Flares of RA are often managed with corticosteroids, while methotrexate is the most widely used DMARD. Other DMARDs include sulfasalazine, leflunomide, and hydroxychloroquine. TNF-inhibitors are indicated for patients with an inadequate response to at least two DMARDs, including methotrexate. Etanercept, infliximab, and adalimumab are some of the TNF-inhibitors available, each with their own risks and administration methods. Rituximab and Abatacept are other DMARDs that can be used, but the latter is not currently recommended by NICE.

    • This question is part of the following fields:

      • Musculoskeletal
      82.1
      Seconds
  • Question 23 - A 35-year-old female accountant presents to her local urgent care centre with a...

    Incorrect

    • A 35-year-old female accountant presents to her local urgent care centre with a 4 day history of right side thumb and wrist pain. She complains of pain down the dorsal aspect of her thumb towards the radial aspect of her wrist which occurs when she is at work and using her computer mouse for extended periods of time. She reports the pain is not present at rest.

      During examination, you are able to reproduce the pain when she abducts her thumb against resistance. The patient also reports pain when you palpate over her radial styloid process. There is no other sensory or motor deficits in the remainder of your examination. There does not appear to be any erythema or swelling that you note.

      What is the likely diagnosis based on these findings?

      Your Answer: Superficial radial neuritis

      Correct Answer: De Quervain's tenosynovitis

      Explanation:

      De Quervain’s tenosynovitis is a condition characterized by inflammation of the tendons surrounding the extensor pollicis brevis and abductor pollicis longus, resulting in pain on the radial side of the wrist and tenderness over the radial styloid process. This condition is often referred to as texter’s thumb due to its association with repetitive texting motions. Carpal tunnel syndrome, on the other hand, is caused by compression of the median nerve in the carpal tunnel, resulting in tingling, weakness, and clumsiness in the thumb, forefinger, and middle finger. Carpal tunnel syndrome is typically worse at night and can be diagnosed through a positive Tinel’s sign. Carpal metacarpal osteoarthritis may cause pain at the base of the thumb that progresses over time and may be accompanied by Heberden’s nodes. Intercarpal instability, which involves a loss of alignment between the carpal bones or radioulnar joint, is an unlikely diagnosis in the absence of trauma and requires radiological evidence for diagnosis.

      De Quervain’s Tenosynovitis: Symptoms, Diagnosis, and Treatment

      De Quervain’s tenosynovitis is a condition that commonly affects women between the ages of 30 and 50. It occurs when the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons becomes inflamed. The condition is characterized by pain on the radial side of the wrist, tenderness over the radial styloid process, and pain when the thumb is abducted against resistance. A positive Finkelstein’s test, in which the thumb is pulled in ulnar deviation and longitudinal traction, can also indicate the presence of tenosynovitis.

      Treatment for De Quervain’s tenosynovitis typically involves analgesia, steroid injections, and immobilization with a thumb splint (spica). In some cases, surgical treatment may be necessary. With proper diagnosis and treatment, most patients are able to recover from this condition and resume their normal activities.

    • This question is part of the following fields:

      • Musculoskeletal
      47.5
      Seconds
  • Question 24 - A 55-year-old woman visits her doctor complaining of fatigue and weakness. She has...

    Correct

    • A 55-year-old woman visits her doctor complaining of fatigue and weakness. She has been experiencing difficulty getting up from chairs, lifting objects, and climbing stairs for the past 2 months. However, she has no issues with other movements like knitting or writing. Upon examination, she has bilateral hip and shoulder weakness. Blood tests reveal the following results: calcium 2.4 mmol/L (2.1-2.6), thyroid stimulating hormone (TSH) 4.5 mU/L (0.5-5.5), free thyroxine (T4) 12.4 pmol/L (9.0 - 18), creatine kinase (CK) 1752 U/L (35 - 250), and ESR 62 mm/hr (< 40). What is the most probable diagnosis?

      Your Answer: Polymyositis

      Explanation:

      Polymyositis: An Inflammatory Disorder Causing Muscle Weakness

      Polymyositis is an inflammatory disorder that causes symmetrical, proximal muscle weakness. It is believed to be a T-cell mediated cytotoxic process directed against muscle fibers and can be idiopathic or associated with connective tissue disorders. This condition is often associated with malignancy and typically affects middle-aged women more than men.

      One variant of the disease is dermatomyositis, which is characterized by prominent skin manifestations such as a purple (heliotrope) rash on the cheeks and eyelids. Other features of polymyositis include Raynaud’s, respiratory muscle weakness, dysphagia, and dysphonia. Interstitial lung disease, such as fibrosing alveolitis or organizing pneumonia, is seen in around 20% of patients and indicates a poor prognosis.

      To diagnose polymyositis, doctors may perform various tests, including an elevated creatine kinase, EMG, muscle biopsy, and anti-synthetase antibodies. Anti-Jo-1 antibodies are seen in a pattern of disease associated with lung involvement, Raynaud’s, and fever.

      The management of polymyositis involves high-dose corticosteroids tapered as symptoms improve. Azathioprine may also be used as a steroid-sparing agent. Overall, polymyositis is a challenging condition that requires careful management and monitoring.

    • This question is part of the following fields:

      • Musculoskeletal
      78.5
      Seconds
  • Question 25 - A 57-year-old woman presents to her GP with pain in her left hand....

    Incorrect

    • A 57-year-old woman presents to her GP with pain in her left hand. She reports that the pain is located at the base of her left thumb and is a constant ache that worsens with movement. The patient states that the pain has been progressively worsening over the past year. She has a medical history of gout in her big toe, which is managed with allopurinol. Her mother was diagnosed with rheumatoid arthritis five years ago, and she is concerned that she may also have this condition. On examination, there is tenderness on palpation of the left thumb base, and unilateral squaring of the left thumb is observed. What is the most likely diagnosis based on this history and clinical examination?

      Your Answer: De Quervain's tendinosis

      Correct Answer: Osteoarthritis

      Explanation:

      Hand osteoarthritis is characterized by squaring of the thumbs. This is due to bony outgrowths at the basilar joint of the thumb. Additionally, the pain experienced is typically unilateral and worsens with movement. De Quervain’s tendinosis may cause pain at the base of the thumb but does not result in thumb squaring. Gout is unlikely to present with thumb squaring and typically affects joints in the lower limb. Psoriatic arthritis typically affects distal joints and may present with skin and nail signs. Rheumatoid arthritis, despite a positive family history and similar pain history, does not explain the squaring of the thumb.

      Understanding Osteoarthritis of the Hand

      Osteoarthritis of the hand, also known as nodal arthritis, is a condition that occurs when the cartilage at synovial joints is lost, leading to the degeneration of underlying bone. It is more common in women, usually presenting after the age of 55, and may have a genetic component. Risk factors include previous joint trauma, obesity, hypermobility, and certain occupations. Interestingly, osteoporosis may actually reduce the risk of developing hand OA.

      Symptoms of hand OA include episodic joint pain, stiffness that worsens after periods of inactivity, and the development of painless bony swellings known as Heberden’s and Bouchard’s nodes. These nodes are the result of osteophyte formation and are typically found at the distal and proximal interphalangeal joints, respectively. In severe cases, there may be reduced grip strength and deformity of the carpometacarpal joint of the thumb, resulting in fixed adduction.

      Diagnosis is typically made through X-ray, which may show signs of osteophyte formation and joint space narrowing before symptoms develop. While hand OA may not significantly impact a patient’s daily function, it is important to manage symptoms through pain relief and joint protection strategies. Additionally, the presence of hand OA may increase the risk of future hip and knee OA, particularly for hip OA.

    • This question is part of the following fields:

      • Musculoskeletal
      23.3
      Seconds
  • Question 26 - A 46-year-old man visits his GP complaining of back pain that extends to...

    Incorrect

    • A 46-year-old man visits his GP complaining of back pain that extends to his right leg. He has no medical history and is not on any medications. During the examination, the doctor observes sensory loss on the posterolateral part of the right leg and the lateral aspect of the foot. The patient also exhibits weakness in plantar flexion and a decreased ankle reflex. Which nerve root is the most probable cause of these symptoms?

      Your Answer: L4

      Correct Answer: S1

      Explanation:

      The patient’s symptoms suggest an S1 lesion, as evidenced by sensory loss in the posterolateral aspect of the leg and lateral aspect of the foot, weakness in plantar flexion of the foot, reduced ankle reflex, and a positive sciatic nerve stretch test. L3, L4, and L5 are not the correct answer as their respective nerve root involvement would cause different symptoms.

      Understanding Prolapsed Disc and its Features

      A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.

      The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Musculoskeletal
      19.3
      Seconds
  • Question 27 - Which one of the following is not related to carpal tunnel syndrome? ...

    Incorrect

    • Which one of the following is not related to carpal tunnel syndrome?

      Your Answer: Weakness of thumb abduction

      Correct Answer: Wasting of the hypothenar eminence

      Explanation:

      Understanding Carpal Tunnel Syndrome

      Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. Patients with this condition typically experience pain or pins and needles in their thumb, index, and middle fingers. In some cases, the symptoms may even ascend proximally. Patients often shake their hand to obtain relief, especially at night.

      During an examination, doctors may observe weakness of thumb abduction and wasting of the thenar eminence (not the hypothenar). Tapping on the affected area may cause paraesthesia, which is known as Tinel’s sign. Flexion of the wrist may also cause symptoms, which is known as Phalen’s sign.

      Carpal tunnel syndrome can be caused by a variety of factors, including idiopathic reasons, pregnancy, oedema (such as heart failure), lunate fracture, and rheumatoid arthritis. Electrophysiology tests may show prolongation of the action potential in both motor and sensory nerves.

      Treatment for carpal tunnel syndrome may include a 6-week trial of conservative treatments, such as corticosteroid injections and wrist splints at night. If symptoms persist or are severe, surgical decompression (flexor retinaculum division) may be necessary.

    • This question is part of the following fields:

      • Musculoskeletal
      39.8
      Seconds
  • Question 28 - A 55-year-old woman comes to her doctor complaining of persistent stiffness and pain...

    Incorrect

    • A 55-year-old woman comes to her doctor complaining of persistent stiffness and pain in the distal interphalangeal (DIP) joints of her left hand. She reports that her symptoms are more severe in the morning and improve with activity.

      What is the probable diagnosis?

      Your Answer: Rheumatoid arthritis

      Correct Answer: Psoriatic arthritis

      Explanation:

      Psoriatic arthritis is suggested by an asymmetrical presentation, as it typically involves inflammation of distal and proximal interphalangeal joints in an asymmetric manner. In contrast, rheumatoid arthritis tends to affect symmetrical joints and may also have extra-articular manifestations such as atlantoaxial subluxation, rheumatoid nodules, and episcleritis. Osteoarthritis typically affects the distal interphalangeal joints and is characterized by pain and stiffness that worsens with activity and improves with rest. Gout, on the other hand, is characterized by acute attacks that commonly affect a single joint, such as the MTP joint, and can be triggered by consuming purine-rich foods or alcohol. Synovial fluid analysis can differentiate gout from pseudogout, which is characterized by calcium pyrophosphate deposition.

      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.

    • This question is part of the following fields:

      • Musculoskeletal
      10.5
      Seconds
  • Question 29 - A 63-year-old woman comes to her doctor complaining of pain and swelling in...

    Incorrect

    • A 63-year-old woman comes to her doctor complaining of pain and swelling in the small joints of her hands that have been present for about eight weeks. She has no significant medical history and is not taking any regular medications. Upon examination, the doctor finds that the 2nd and 3rd proximal interphalangeal joints on both hands are swollen and tender. The doctor orders a plain radiography of the hands, which shows juxta-articular osteopenia. What is the most probable diagnosis?

      Your Answer: Gout

      Correct Answer: Rheumatoid arthritis

      Explanation:

      Early signs of rheumatoid arthritis can be observed through x-rays, specifically the presence of juxta-articular osteoporosis/osteopenia.

      X-Ray Changes in Rheumatoid Arthritis

      Rheumatoid arthritis is a chronic autoimmune disease that affects the joints, causing pain, stiffness, and swelling. X-ray imaging is often used to diagnose and monitor the progression of the disease. Early x-ray findings in rheumatoid arthritis include a loss of joint space, juxta-articular osteoporosis, and soft-tissue swelling. These changes indicate that the joint is being damaged and that the bones are losing density.

      As the disease progresses, late x-ray findings may include periarticular erosions and subluxation. Periarticular erosions are areas of bone loss around the joint, while subluxation refers to the partial dislocation of the joint. These changes can lead to deformities and functional impairment.

      It is important to note that x-ray findings may not always correlate with the severity of symptoms in rheumatoid arthritis. Some patients may have significant joint damage on x-ray but experience minimal pain, while others may have severe pain despite minimal x-ray changes. Therefore, x-ray imaging should be used in conjunction with other clinical assessments to determine the best course of treatment for each individual patient.

    • This question is part of the following fields:

      • Musculoskeletal
      52.8
      Seconds
  • Question 30 - A 54-year-old woman presents to the rheumatology clinic with a history of her...

    Correct

    • A 54-year-old woman presents to the rheumatology clinic with a history of her fingers turning white, blue, and red intermittently for the past four months. She also reports tightness of the skin on her fingers, hands, and face, without involvement of the skin on her upper arm or chest. Additionally, she experiences troubling reflux symptoms. On examination, there is fibrotic skin overlying the hands and face with telangiectasia. Which autoantibody is most likely to be positive in this patient, given the probable diagnosis?

      Your Answer: Anti-centromere antibodies

      Explanation:

      The presence of skin tightening, Raynaud’s phenomenon, and telangiectasia in this patient suggests a diagnosis of systemic sclerosis. The limited subtype is most likely as there is no involvement of the upper arm and chest. Anti-centromere antibodies are commonly associated with this subtype. Anti-RNA polymerase III and anti-Scl-70 antibodies are more commonly associated with diffuse systemic sclerosis, which involves the chest and upper arms and more severe internal organ involvement. Anti-Ro antibodies are typically associated with Sjögren’s syndrome, which is unlikely in this patient. Anti-dsDNA antibodies are commonly associated with systemic lupus erythematosus (SLE), but systemic sclerosis is more likely given the absence of a butterfly rash and the presence of oesophageal dysmotility.

      Understanding Systemic Sclerosis

      Systemic sclerosis is a condition that affects the skin and other connective tissues, but its cause is unknown. It is more common in females, with three patterns of the disease. Limited cutaneous systemic sclerosis is characterised by Raynaud’s as the first sign, affecting the face and distal limbs, and associated with anti-centromere antibodies. CREST syndrome is a subtype of limited systemic sclerosis that includes Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, and Telangiectasia. Diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs, associated with scl-70 antibodies, and has a poor prognosis. Respiratory involvement is the most common cause of death, with interstitial lung disease and pulmonary arterial hypertension being the primary complications. Renal disease and hypertension are also possible complications, and patients with renal disease should be started on an ACE inhibitor. Scleroderma without internal organ involvement is characterised by tightening and fibrosis of the skin, manifesting as plaques or linear. Antibodies such as ANA, RF, anti-scl-70, and anti-centromere are associated with different types of systemic sclerosis.

    • This question is part of the following fields:

      • Musculoskeletal
      24.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Musculoskeletal (11/30) 37%
Passmed