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  • Question 1 - A 65-year-old woman came to see her GP due to severe fatigue and...

    Incorrect

    • A 65-year-old woman came to see her GP due to severe fatigue and muscle pain in her shoulders and hips. The symptoms began three weeks ago and have progressively worsened. Although she can still climb stairs, it causes her pain. She also experiences stiffness, particularly in the morning, which improves throughout the day. She denies any joint swelling or rash and shows no signs of muscle wasting upon examination. What findings suggest a diagnosis of polymyalgia rheumatica?

      Your Answer:

      Correct Answer: Normal power on resisted movements of shoulder and hip

      Explanation:

      On examination, there is no actual weakness of limb girdles in polymyalgia rheumatica. Any perceived weakness of muscles is a result of myalgia-induced pain inhibition. PMR patients typically exhibit elevated ESR levels, but normal CK levels (indicating no true myositis). It is important to note that photophobia is not a symptom of PMR.

      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.

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  • Question 2 - A 7-year-old girl with sickle cell disease arrives at the emergency department. She...

    Incorrect

    • A 7-year-old girl with sickle cell disease arrives at the emergency department. She has been running a fever for a week and complains of nausea and loss of appetite. In the past 24 hours, she has been experiencing intense pain in her left leg. The initial treatment for a sickle crisis is administered, including oxygen, fluids, morphine, and antibiotics. However, an X-ray reveals osteomyelitis in her leg.
      What is the probable causative organism for her osteomyelitis?

      Your Answer:

      Correct Answer: Salmonella enteritidis

      Explanation:

      Salmonella osteomyelitis is a common occurrence in sickle cell patients.

      Among sickle cell patients, Salmonella is the leading cause of osteomyelitis. In contrast, Staphylococcus aureus is the most frequent cause in children. Haemophilus, Group A streptococcus, and Enterococcus are all less prevalent causes of osteomyelitis.

      Understanding Osteomyelitis: Types, Causes, and Treatment

      Osteomyelitis is a bone infection that can be classified into two types: haematogenous and non-haematogenous. Haematogenous osteomyelitis is caused by bacteria that enter the bloodstream and is usually monomicrobial. It is more common in children, with vertebral osteomyelitis being the most common form in adults. Risk factors include sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis. On the other hand, non-haematogenous osteomyelitis results from the spread of infection from adjacent soft tissues or direct injury to the bone. It is often polymicrobial and more common in adults, with risk factors such as diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.

      Staphylococcus aureus is the most common cause of osteomyelitis, except in patients with sickle-cell anaemia where Salmonella species predominate. To diagnose osteomyelitis, MRI is the imaging modality of choice, with a sensitivity of 90-100%. Treatment for osteomyelitis involves a six-week course of flucloxacillin. Clindamycin is an alternative for patients who are allergic to penicillin.

      In summary, osteomyelitis is a bone infection that can be caused by bacteria entering the bloodstream or spreading from adjacent soft tissues or direct injury to the bone. It is more common in children and adults with certain risk factors. Staphylococcus aureus is the most common cause, and MRI is the preferred imaging modality for diagnosis. Treatment involves a six-week course of flucloxacillin or clindamycin for penicillin-allergic patients.

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  • Question 3 - A 60-year-old African American male presents with widespread bone pain and muscle weakness....

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    • A 60-year-old African American male presents with widespread bone pain and muscle weakness. Upon conducting investigations, the following results were obtained:
      Calcium 2.05 mmol/l
      Phosphate 0.68 mmol/l
      ALP 270 U/l
      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Osteomalacia

      Explanation:

      Osteomalacia may be indicated by bone pain, tenderness, and proximal myopathy (resulting in a waddling gait), as well as low levels of calcium and phosphate and elevated alkaline phosphatase.

      Understanding Osteomalacia

      Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.

      The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.

      The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.

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  • Question 4 - 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:

      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.

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  • Question 5 - A 26-year-old male has been admitted to the gastroenterology ward with a three-day...

    Incorrect

    • A 26-year-old male has been admitted to the gastroenterology ward with a three-day history of severe bloody diarrhoea, passing 6-7 stools a day, with abdominal pain and poor oral intake. Colonoscopy shows inflammation throughout the colon and biopsies confirm Crohn's disease. He has no significant past medical history and takes no regular medication.
      Before starting azathioprine for inducing remission and long-term maintenance, which of the following blood tests must be carried out?

      Your Answer:

      Correct Answer: Thiopurine methyltransferase

      Explanation:

      Before starting treatment with azathioprine, it is crucial to check for thiopurine methyltransferase deficiency (TPMT) as this enzyme metabolizes thiopurine drugs like azathioprine and mercaptopurine. TPMT deficiency can cause myelosuppression, and if the levels are reduced or absent, an alternative medication should be considered. While anti-nuclear antibody is commonly positive in patients with autoimmune diseases, it is not relevant to the management of Crohn’s disease. Although CRP and LFTs may be important for disease monitoring and identifying underlying inflammation or hepatic dysfunction, they are not the most important blood tests to perform before starting azathioprine.

      Azathioprine is a medication that is broken down into mercaptopurine, which is an active compound that inhibits the production of purine. To determine if someone is at risk for azathioprine toxicity, a test for thiopurine methyltransferase (TPMT) may be necessary. Adverse effects of this medication include bone marrow depression, which can be detected through a full blood count if there are signs of infection or bleeding, as well as nausea, vomiting, pancreatitis, and an increased risk of non-melanoma skin cancer. It is important to note that there is a significant interaction between azathioprine and allopurinol, so lower doses of azathioprine should be used in conjunction with allopurinol. Despite these potential side effects, azathioprine is generally considered safe to use during pregnancy.

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      • Musculoskeletal
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  • Question 6 - A 25-year-old female soccer player presents to the clinic with intense left knee...

    Incorrect

    • A 25-year-old female soccer player presents to the clinic with intense left knee discomfort. She reports that she landed awkwardly on her knee while playing soccer and heard a 'snapping sound' followed by significant swelling around the left knee joint. During the physical examination, there was an increase in laxity on anterior drawer of the left tibia compared to the femur. What is the most suitable test to confirm the diagnosis?

      Your Answer:

      Correct Answer: Left knee magnetic resonance imaging (MRI)

      Explanation:

      The anterior cruciate ligament (ACL) is a knee ligament that is frequently injured, with non-contact injuries being the most common cause. However, a lateral blow to the knee or skiing can also cause ACL injuries. Symptoms of an ACL injury include a sudden popping sound, knee swelling, and a feeling of instability or that the knee may give way. To diagnose an ACL injury, doctors may perform an anterior draw test or a Lachman’s test. During the anterior draw test, the patient lies on their back with their knee at a 90-degree angle, and the examiner pulls the tibia forward to assess the amount of anterior motion in comparison to the femur. An intact ACL should prevent forward translational movement. Lachman’s test is a variant of the anterior draw test, but the knee is at a 20-30 degree angle, and it is considered more reliable than the anterior draw test.

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      • Musculoskeletal
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  • Question 7 - A 62-year-old man visits the outpatient department for a review of his osteoporosis,...

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    • A 62-year-old man visits the outpatient department for a review of his osteoporosis, where he is booked in for a DEXA scan. His T-score from his scan is recorded as -2.0, indicating decreased bone mineral density. What patient factors are necessary to calculate his Z-score?

      Your Answer:

      Correct Answer: Age, gender, ethnicity

      Explanation:

      When interpreting DEXA scan results, it is important to consider the patient’s age, gender, and ethnicity. The Z-score is adjusted for these factors and provides a comparison of the patient’s bone density to that of an average person of the same age, sex, and race. Meanwhile, the T-score compares the patient’s bone density to that of a healthy 30-year-old of the same sex. It is worth noting that ethnicity can impact bone mineral density, with some studies indicating that Black individuals tend to have higher BMD than White and Hispanic individuals.

      Osteoporosis is a condition that affects bone density and can lead to fractures. To diagnose osteoporosis, doctors use a DEXA scan, which measures bone mass. The results are compared to a young reference population, and a T score is calculated. A T score of -1.0 or higher is considered normal, while a score between -1.0 and -2.5 indicates osteopaenia, and a score below -2.5 indicates osteoporosis. The Z score is also calculated, taking into account age, gender, and ethnicity.

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  • Question 8 - A 26-year-old man presents to the emergency department after injuring his knee while...

    Incorrect

    • A 26-year-old man presents to the emergency department after injuring his knee while playing basketball. He reports hearing a loud 'pop' and experiencing severe pain in his right knee, causing him to fall to the ground. He is unable to bear weight on the affected knee and feels like it may give out. Upon examination, the knee is visibly swollen. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Ruptured anterior cruciate ligament

      Explanation:

      The sudden popping sound that occurred during athletic activity followed by knee pain, swelling, and instability is indicative of an ACL injury. This is the most likely answer based on the given information. A ruptured patella tendon would result in a high riding patella, while a ruptured medial meniscus would cause catching or locking of the knee. A ruptured posterior cruciate ligament is less common and would require further testing to differentiate from an ACL injury. However, based on the scenario described, an ACL injury is the most probable cause.

      The anterior cruciate ligament (ACL) is a knee ligament that is frequently injured, with non-contact injuries being the most common cause. However, a lateral blow to the knee or skiing can also cause ACL injuries. Symptoms of an ACL injury include a sudden popping sound, knee swelling, and a feeling of instability or that the knee may give way. To diagnose an ACL injury, doctors may perform an anterior draw test or a Lachman’s test. During the anterior draw test, the patient lies on their back with their knee at a 90-degree angle, and the examiner pulls the tibia forward to assess the amount of anterior motion in comparison to the femur. An intact ACL should prevent forward translational movement. Lachman’s test is a variant of the anterior draw test, but the knee is at a 20-30 degree angle, and it is considered more reliable than the anterior draw test.

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  • Question 9 - A 30-year-old woman presents with a swollen second toe and wrist pain associated...

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    • A 30-year-old woman presents with a swollen second toe and wrist pain associated with a 5 month history of generalised fatigue. She has no other symptoms including no skin changes, and no previous medical history. Her mother suffers from psoriasis. She had the following blood tests as part of her investigations.

      Hb 125 g/l

      Platelets 390 * 109/l

      WBC 6.5 * 109/l

      ESR 78 mm/h

      Rheumatoid Factor Negative

      Antinuclear Antibody Negative

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Psoriatic arthritis

      Explanation:

      Although females in this age group can be affected by SLE and rheumatoid arthritis, the most probable diagnosis for this patient is psoriatic arthritis due to the presence of dactylitis and a first-degree relative with psoriasis. Furthermore, rheumatoid factor and antinuclear antibody are typically positive in rheumatoid arthritis, while antinuclear antibody is mainly positive in SLE. Gout usually targets the first metatarsophalangeal joint of the first toe.

      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 10 - A young child develops an eczematous, weeping rash on their wrist after receiving...

    Incorrect

    • A young child develops an eczematous, weeping rash on their wrist after receiving a new bracelet. In the Gell and Coombs classification of hypersensitivity reactions, what type of reaction is this an example of?

      Your Answer:

      Correct Answer: Type IV reaction

      Explanation:

      Allergic contact dermatitis, which is often caused by nickel, is the type IV hypersensitivity reaction observed in this patient.

      Classification of Hypersensitivity Reactions

      Hypersensitivity reactions are classified into four types according to the Gell and Coombs classification. Type I, also known as anaphylactic hypersensitivity, occurs when an antigen reacts with IgE bound to mast cells. This type of reaction is responsible for anaphylaxis and atopy, such as asthma, eczema, and hay fever. Type II, or cytotoxic hypersensitivity, happens when cell-bound IgG or IgM binds to an antigen on the cell surface. This type of reaction is associated with autoimmune hemolytic anemia, ITP, Goodpasture’s syndrome, and other conditions. Type III, or immune complex hypersensitivity, occurs when free antigen and antibody (IgG, IgA) combine to form immune complexes. This type of reaction is responsible for serum sickness, systemic lupus erythematosus, post-streptococcal glomerulonephritis, and extrinsic allergic alveolitis. Type IV, or delayed hypersensitivity, is T-cell mediated and is responsible for tuberculosis, graft versus host disease, allergic contact dermatitis, and other conditions.

      In recent times, a fifth category has been added to the classification of hypersensitivity reactions. Type V hypersensitivity occurs when antibodies recognize and bind to cell surface receptors, either stimulating them or blocking ligand binding. This type of reaction is associated with Graves’ disease and myasthenia gravis. Understanding the different types of hypersensitivity reactions is important in diagnosing and treating various conditions. Proper identification of the type of reaction can help healthcare professionals provide appropriate treatment and management strategies.

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  • Question 11 - A 27-year-old male patient arrives at the emergency department complaining of fever, chills,...

    Incorrect

    • A 27-year-old male patient arrives at the emergency department complaining of fever, chills, and excruciating joint pain that has been ongoing for a day. Upon examination, the patient seems to be in distress, and the joint is warm and erythematosus to the touch. Additionally, there is a skin abscess located beneath the left axilla. To aid in further diagnosis, a synovial fluid aspiration is performed. Based on this presentation, which joint is most likely affected?

      Your Answer:

      Correct Answer: Knee

      Explanation:

      Septic arthritis is most frequently observed in the knees of adults.

      The patient is exhibiting symptoms of septic arthritis, such as a painful, warm, and red joint, as well as chills and a fever. The primary cause of septic arthritis is the spread of infection from a distant site through the bloodstream. In this case, the patient’s axillary abscess is likely the source of his septic arthritis.

      The correct answer is knee. Among adults, septic arthritis most commonly affects the knee joint, making it the appropriate choice in this situation.

      Hip is not the correct answer. Although the hip joint is also frequently affected by septic arthritis, it is less common than the knee, making it an incorrect option for this patient.

      Ankles, shoulders, and elbows are also incorrect answers. While these joints can be affected by septic arthritis, they are less commonly affected than the knee, making them inappropriate choices for this patient.

      Septic Arthritis in Adults: Causes, Symptoms, and Treatment

      Septic arthritis is a condition that occurs when bacteria infect a joint, leading to inflammation and pain. The most common organism that causes septic arthritis in adults is Staphylococcus aureus, but in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism. The infection usually spreads through the bloodstream from a distant bacterial infection, such as an abscess. The knee is the most common location for septic arthritis in adults. Symptoms include an acute, swollen joint, restricted movement, warmth to the touch, and fever.

      To diagnose septic arthritis, synovial fluid sampling is necessary and should be done before administering antibiotics if necessary. Blood cultures may also be taken to identify the cause of the infection. Joint imaging may also be used to confirm the diagnosis.

      Treatment for septic arthritis involves intravenous antibiotics that cover Gram-positive cocci. Flucloxacillin or clindamycin is recommended if the patient is allergic to penicillin. Antibiotic treatment is typically given for several weeks, and patients are usually switched to oral antibiotics after two weeks. Needle aspiration may be used to decompress the joint, and arthroscopic lavage may be required in some cases.

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  • Question 12 - Which of the following characteristics is not typically associated with Marfan's syndrome? ...

    Incorrect

    • Which of the following characteristics is not typically associated with Marfan's syndrome?

      Your Answer:

      Correct Answer: Learning difficulties

      Explanation:

      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 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 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 syndrome.

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  • Question 13 - Sarah is a 19-year-old woman who visits her GP complaining of myalgia and...

    Incorrect

    • Sarah is a 19-year-old woman who visits her GP complaining of myalgia and fatigue. She has no significant medical history. In the past, she had a rash on her cheeks that did not improve with anti-fungal cream.
      During the examination, her vital signs are normal, and there is no joint swelling or redness. However, she experiences tenderness when her hands are squeezed. Sarah's muscle strength is 5/5 in all groups.
      Sarah's maternal aunt has been diagnosed with systemic lupus erythematosus (SLE), and she is worried that she might have it too.
      Which of the following blood tests, if negative, can be a useful test to rule out SLE?

      Your Answer:

      Correct Answer: ANA

      Explanation:

      A useful test to rule out SLE is ANA positivity, as the majority of patients with SLE are ANA positive. While CRP and ESR may rise during an acute flare of SLE, they are not specific to autoimmune conditions. ANCA is an antibody found in patients with autoimmune vasculitis.

      Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive, making it useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%), but less sensitive (70%). Anti-Smith testing is also highly specific (>99%), but only 30% of SLE patients test positive. Other antibody tests include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

      Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, but a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Proper monitoring of SLE is crucial for effective management of the disease.

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  • Question 14 - A 35-year-old intravenous drug user has been diagnosed with osteomyelitis of the right...

    Incorrect

    • A 35-year-old intravenous drug user has been diagnosed with osteomyelitis of the right tibia. What organism is most likely responsible for this infection?

      Your Answer:

      Correct Answer: Staphylococcus aureus

      Explanation:

      Understanding Osteomyelitis: Types, Causes, and Treatment

      Osteomyelitis is a bone infection that can be classified into two types: haematogenous and non-haematogenous. Haematogenous osteomyelitis is caused by bacteria that enter the bloodstream and is usually monomicrobial. It is more common in children, with vertebral osteomyelitis being the most common form in adults. Risk factors include sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis. On the other hand, non-haematogenous osteomyelitis results from the spread of infection from adjacent soft tissues or direct injury to the bone. It is often polymicrobial and more common in adults, with risk factors such as diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.

      Staphylococcus aureus is the most common cause of osteomyelitis, except in patients with sickle-cell anaemia where Salmonella species predominate. To diagnose osteomyelitis, MRI is the imaging modality of choice, with a sensitivity of 90-100%. Treatment for osteomyelitis involves a six-week course of flucloxacillin. Clindamycin is an alternative for patients who are allergic to penicillin.

      In summary, osteomyelitis is a bone infection that can be caused by bacteria entering the bloodstream or spreading from adjacent soft tissues or direct injury to the bone. It is more common in children and adults with certain risk factors. Staphylococcus aureus is the most common cause, and MRI is the preferred imaging modality for diagnosis. Treatment involves a six-week course of flucloxacillin or clindamycin for penicillin-allergic patients.

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  • Question 15 - A 28-year-old female patient complains of abdominal pain, weight loss, and bloody diarrhea...

    Incorrect

    • A 28-year-old female patient complains of abdominal pain, weight loss, and bloody diarrhea for the past month. After being referred for colonoscopy and biopsy, it was discovered that she has continuous inflammation in the mucosa and crypt abscesses. What is the most specific antibody associated with her probable diagnosis?

      Your Answer:

      Correct Answer: pANCA

      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.

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  • Question 16 - A 50-year-old man presents to the hospital with acute knee pain, swelling, and...

    Incorrect

    • A 50-year-old man presents to the hospital with acute knee pain, swelling, and stiffness that started last night. He is experiencing systemic symptoms with a temperature of 39.2ºC and is unable to bear weight. A joint aspiration is performed to confirm the diagnosis.
      What is the recommended duration of antibiotic treatment for this patient's most likely diagnosis?

      Your Answer:

      Correct Answer: 4-6 weeks

      Explanation:

      Septic arthritis necessitates a prolonged antibiotic treatment of at least 4-6 weeks. The most probable diagnosis in this scenario is septic arthritis, as the patient is experiencing acute joint swelling and pain, along with systemic distress and a high fever. Joint aspiration is a crucial diagnostic tool that is likely to reveal purulent synovial fluid, which may test positive for the causative organism. Patients with septic arthritis should receive joint aspiration and an initial 2 weeks of intravenous antibiotics, followed by 2-4 weeks of oral antibiotics. Antibiotics are necessary for treating septic arthritis, and joint aspiration alone is insufficient and may lead to joint destruction and sepsis. Current British Society of Rheumatology guidelines (2006) recommend against antibiotic courses of 7 days and 2 weeks, as they are inadequate. However, some evidence suggests that 1 week of intravenous antibiotics followed by oral antibiotics may be as effective as longer intravenous courses in some patients. A lifelong course of antibiotics is not necessary in this case, although it may be used under expert supervision in patients with recurrent septic arthritis.

      Septic Arthritis in Adults: Causes, Symptoms, and Treatment

      Septic arthritis is a condition that occurs when bacteria infect a joint, leading to inflammation and pain. The most common organism that causes septic arthritis in adults is Staphylococcus aureus, but in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism. The infection usually spreads through the bloodstream from a distant bacterial infection, such as an abscess. The knee is the most common location for septic arthritis in adults. Symptoms include an acute, swollen joint, restricted movement, warmth to the touch, and fever.

      To diagnose septic arthritis, synovial fluid sampling is necessary and should be done before administering antibiotics if necessary. Blood cultures may also be taken to identify the cause of the infection. Joint imaging may also be used to confirm the diagnosis.

      Treatment for septic arthritis involves intravenous antibiotics that cover Gram-positive cocci. Flucloxacillin or clindamycin is recommended if the patient is allergic to penicillin. Antibiotic treatment is typically given for several weeks, and patients are usually switched to oral antibiotics after two weeks. Needle aspiration may be used to decompress the joint, and arthroscopic lavage may be required in some cases.

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      • Musculoskeletal
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  • Question 17 - A 38-year-old woman comes to her GP with a few months of gradual...

    Incorrect

    • A 38-year-old woman comes to her GP with a few months of gradual symmetrical swelling and stiffness in her fingers. She experiences more discomfort in cold weather. Additionally, she reports having more frequent episodes of 'heartburn' lately. During the examination, the doctor observes three spider naevi on her face, and her fingers appear red, slightly swollen, and shiny. The examination of her heart and lungs reveals no abnormalities. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Limited systemic sclerosis

      Explanation:

      The most likely diagnosis for this patient is limited systemic sclerosis, also known as CREST syndrome. This subtype includes Raynaud’s phenomenon, oesophageal dysmotility, sclerodactyly, and telangiectasia, although calcinosis may not always be present. There is no evidence of systemic fibrosis, which rules out diffuse systemic sclerosis. Rheumatoid arthritis is a possible differential diagnosis, but the systemic features are more indicative of systemic sclerosis. Primary Raynaud’s phenomenon is unlikely given the suggestive symptoms of sclerotic disease.

      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.

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  • Question 18 - A 65-year-old woman visits her GP complaining of a persistent headache that has...

    Incorrect

    • A 65-year-old woman visits her GP complaining of a persistent headache that has been bothering her for two weeks. The pain is more intense on the right side and is aggravated when she combs her hair. She also experiences discomfort in her jaw when eating. Her neurological and fundoscopy examinations reveal no abnormalities, and she is referred to the emergency department.

      Upon admission, the patient is prescribed high-dose oral prednisolone and undergoes a temporal artery biopsy, which yields normal results. What is the next most appropriate course of action for her treatment?

      Your Answer:

      Correct Answer: Continue high-dose prednisolone and repeat biopsy

      Explanation:

      Performing an emergency computed tomography (CT) of the brain is not necessary for this patient. Emergency CT head scans are typically reserved for cases of head injury with symptoms such as reduced GCS, repeated vomiting, skull base fracture signs, post-traumatic seizures, or focal neurological deficits. Elderly patients may require a CT scan if they have experienced a fall with head injury or confusion.

      Stopping high-dose prednisolone and referring the patient to a neurology clinic is not recommended. With a high suspicion of GCA, it is crucial to continue corticosteroid treatment to prevent inflammation from spreading to the eye. Any vision changes caused by GCA are typically irreversible, making it an acute problem that cannot wait for a referral to a neurology clinic.

      Switching the patient to a lower dose of oral prednisolone is not advised. There is no evidence to suggest that reducing the dose of prednisolone is beneficial for GCA if the biopsy is negative. It is important to remember that a negative biopsy result may be due to skip lesions and not because the diagnosis is less likely.

      Temporal arthritis, also known as giant cell arthritis, is a condition that affects medium and large-sized arteries and is of unknown cause. It typically occurs in individuals over the age of 50, with the highest incidence in those in their 70s. Early recognition and treatment are crucial to minimize the risk of complications, such as permanent loss of vision. Therefore, when temporal arthritis is suspected, urgent referral for assessment by a specialist and prompt treatment with high-dose prednisolone is necessary.

      Temporal arthritis often overlaps with polymyalgia rheumatica, with around 50% of patients exhibiting features of both conditions. Symptoms of temporal arthritis include headache, jaw claudication, and tender, palpable temporal artery. Vision testing is a key investigation in all patients, as anterior ischemic optic neuropathy is the most common ocular complication. This results from occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins. Other symptoms may include aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.

      Investigations for temporal arthritis include raised inflammatory markers, such as an ESR greater than 50 mm/hr and elevated CRP. A temporal artery biopsy may also be performed, and skip lesions may be present. Treatment for temporal arthritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is used. If there is evolving visual loss, IV methylprednisolone is usually given prior to starting high-dose prednisolone. Urgent ophthalmology review is necessary, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin.

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  • Question 19 - A 35-year-old businesswoman comes to the GP complaining of persistent pain and swelling...

    Incorrect

    • A 35-year-old businesswoman comes to the GP complaining of persistent pain and swelling in her forefoot. She reports that she recently relocated to London for a new job and spends a lot of time on her feet, often wearing high heels. The pain is exacerbated when she bears weight on her foot, and squeezing the area reproduces the discomfort. Based on these symptoms, which bone is most likely affected by a stress fracture?

      Your Answer:

      Correct Answer: 2nd metatarsal

      Explanation:

      Metatarsal fractures are a common occurrence, with the potential to affect one or multiple metatarsals. These fractures can result from direct trauma or repeated mechanical stress, known as stress fractures. The metatarsals are particularly susceptible to stress fractures, with the second metatarsal shaft being the most common site. The proximal 5th metatarsal is the most commonly fractured metatarsal, while the 1st metatarsal is the least commonly fractured.

      Fractures of the proximal 5th metatarsal can be classified as either proximal avulsion fractures or Jones fractures. Proximal avulsion fractures occur at the proximal tuberosity and are often associated with lateral ankle sprains. Jones fractures, on the other hand, are transverse fractures at the metaphyseal-diaphyseal junction and are much less common.

      Symptoms of metatarsal fractures include pain, bony tenderness, swelling, and an antalgic gait. X-rays are typically used to distinguish between displaced and non-displaced fractures, which guides subsequent management options. However, stress fractures may not appear on X-rays and may require an isotope bone scan or MRI to establish their presence. Overall, metatarsal fractures are a common injury that can result from a variety of causes and require prompt diagnosis and management.

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  • Question 20 - A 54-year-old woman presents to her GP complaining of fatigue and difficulty sleeping....

    Incorrect

    • A 54-year-old woman presents to her GP complaining of fatigue and difficulty sleeping. She also experiences weakness in her limbs, making it hard to complete household tasks. She has a history of bipolar disorder, which has been well-controlled with lithium carbonate for many years. The following blood tests were taken:

      - Hb: 113 g/L (normal range: 115 - 160)
      - Platelets: 201 * 109/L (normal range: 150 - 400)
      - WBC: 10.2 * 109/L (normal range: 4.0 - 11.0)
      - Calcium: 2.81 mmol/L (normal range: 2.1-2.6)
      - Phosphate: 0.55 mmol/L (normal range: 0.8-1.4)
      - Parathyroid hormone: 17.1 pmol/L (normal range: 2.0-8.5)
      - ALP: 207 u/L (normal range: 30 - 100)
      - Serum lithium: 0.67 mmol/L (normal range: 0.4 - 1.0)

      What is the most appropriate definitive management for this patient, given the likely diagnosis?

      Your Answer:

      Correct Answer: Parathyroidectomy

      Explanation:

      The patient’s elevated serum calcium, raised ALP, and raised PTH levels, along with low serum phosphate, indicate a diagnosis of primary hyperparathyroidism.

      Lab Values for Bone Disorders

      When it comes to bone disorders, certain lab values can provide important information for diagnosis and treatment. In cases of osteoporosis, calcium, phosphate, alkaline phosphatase (ALP), and parathyroid hormone (PTH) levels are typically within normal ranges. However, in osteomalacia, there is a decrease in calcium and phosphate levels, an increase in ALP levels, and an increase in PTH levels.

      Primary hyperparathyroidism, which can lead to osteitis fibrosa cystica, is characterized by increased calcium and PTH levels, but decreased phosphate levels. Chronic kidney disease can also lead to secondary hyperparathyroidism, with decreased calcium levels and increased phosphate and PTH levels.

      Paget’s disease, which causes abnormal bone growth, typically shows normal calcium and phosphate levels, but an increase in ALP levels. Osteopetrosis, a rare genetic disorder that causes bones to become dense and brittle, typically shows normal lab values for calcium, phosphate, ALP, and PTH.

      Overall, understanding these lab values can help healthcare professionals diagnose and treat various bone disorders.

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  • Question 21 - A 28-year-old woman contacts her GP via telephone to discuss her back pain...

    Incorrect

    • A 28-year-old woman contacts her GP via telephone to discuss her back pain that has been ongoing for three months. She reports that the pain is most severe in the morning and is accompanied by stiffness, which gradually improves throughout the day with physical activity. The pain is primarily located in her lumbar spine, and she has been struggling to complete her daily tasks. Despite not having examined the patient, the GP suspects an inflammatory cause, specifically ankylosing spondylitis. What aspect of this history would raise the GP's suspicion the most?

      Your Answer:

      Correct Answer: Pain improves with exercise

      Explanation:

      Exercise is known to improve inflammatory back pain, such as that seen in ankylosing spondylitis. This type of pain is typically worse in the morning or with rest, but eases with physical activity. Other causes of inflammatory back pain include rheumatoid arthritis. Difficulty with activities of daily living and insidious onset are non-specific and may be seen in other types of back pain. Ankylosing spondylitis is more common in men, but can still occur in women.

      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 22 - A 50-year-old male patient complains of a painful swelling at the back of...

    Incorrect

    • A 50-year-old male patient complains of a painful swelling at the back of his elbow, without any history of injury. Upon examination, an erythematosus and tender swelling is observed. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Olecranon bursitis

      Explanation:

      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 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:

      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.

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  • Question 24 - A 70-year-old man with a recent chest infection arrives at the Emergency Department...

    Incorrect

    • A 70-year-old man with a recent chest infection arrives at the Emergency Department complaining of severe pain in his right knee. Upon conducting a joint aspirate, analysis of the synovial fluid reveals the presence of positively birefringent crystals. The patient is currently undergoing treatment with desferrioxamine for his iron overload. What would be the most suitable initial management for his musculoskeletal symptoms?

      Your Answer:

      Correct Answer: Ibuprofen

      Explanation:

      Pseudogout, which is caused by an excess of calcium pyrophosphate levels in the body, has several risk factors including haemochromatosis, hyperparathyroidism, hypophosphataemia, hypothyroidism, hypomagnesemia, and old age. This patient, who has haemochromatosis, is currently taking iron chelating agents to manage their iron overload. The recommended first line treatment for pseudogout is NSAIDs and colchicine. Allopurinol is not effective for pseudogout as it is not caused by uric acid overload. Methotrexate may be used for chronic pseudogout, but it is not typically the first line treatment. Sulfasalazine is not indicated for pseudogout.

      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.

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  • Question 25 - 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:

      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.

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  • Question 26 - As an orthopaedic ward doctor, you are examining a 24-year-old man who was...

    Incorrect

    • As an orthopaedic ward doctor, you are examining a 24-year-old man who was brought in by ambulance after falling from a tree branch. He reports dislocating his left hip after landing on it while flexed and abducted. The dislocation was reduced under general anaesthetic. During the current assessment, the patient reports experiencing pain primarily in the posterior area of his left thigh, which radiates down to the posterior and lateral regions of his leg. Upon gait assessment, a left foot drop was observed. Which nerve is most likely affected due to this injury?

      Your Answer:

      Correct Answer: Sciatic nerve

      Explanation:

      The patient’s symptoms are indicative of a hip dislocation, which is consistent with their reported injury. It is common for the sciatic nerve to be damaged or stretched during a posterior hip dislocation, as it runs behind the femur. The pain experienced by the patient follows the path of the sciatic nerve, and the foot drop is a result of damage to the common peroneal nerve, which is supplied by the sciatic nerve. While femoral nerve injury is also possible with a posterior hip dislocation, it would result in different symptoms such as loss of sensation in the front and inside of the thigh and weakness in hip flexion and knee extension. The obturator nerve and pudendal nerve are unlikely to be affected in this case, as they would cause different symptoms such as weakness in thigh abduction or sensory impairment to the external genitalia and bladder/bowel dysfunction, respectively.

      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, without 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 27 - A 45-year-old woman with a history of rheumatoid arthritis visits her GP with...

    Incorrect

    • 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:

      Correct 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.

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  • Question 28 - A 65-year-old woman comes to the clinic complaining of gradual onset discomfort on...

    Incorrect

    • A 65-year-old woman comes to the clinic complaining of gradual onset discomfort on her right lateral hip for the past two weeks. She denies any history of trauma and is able to bear weight fully. However, she experiences the worst discomfort at night, which sometimes wakes her up when lying on her right side. What is the probable underlying diagnosis?

      Your Answer:

      Correct Answer: Greater trochanteric pain syndrome

      Explanation:

      Trochanteric bursitis is characterized by pain in the lateral hip/thigh area, accompanied by tenderness over the greater trochanter. This condition, also known as greater trochanteric pain syndrome, is likely the cause of the patient’s symptoms, as there are no other systemic issues present. Iliotibial band syndrome typically affects the knee and does not usually cause nighttime symptoms, making it an unlikely diagnosis in this age group. Meralgia paresthetica, which results from compression of the lateral femoral cutaneous nerve, typically presents with numbness or tingling rather than pain. Osteoarthritis is unlikely to cause pain upon direct pressure over the greater trochanter.

      Understanding Greater Trochanteric Pain Syndrome

      Greater trochanteric pain syndrome, also known as trochanteric bursitis, is a condition that results from the repetitive movement of the fibroelastic iliotibial band. This condition is most commonly observed in women aged between 50 and 70 years. The primary symptom of this condition is pain experienced over the lateral side of the hip and thigh. Additionally, tenderness is observed upon palpation of the greater trochanter.

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  • Question 29 - What factors are linked to a favorable outcome in rheumatoid arthritis prognosis, particularly...

    Incorrect

    • What factors are linked to a favorable outcome in rheumatoid arthritis prognosis, particularly in younger patients?

      Your Answer:

      Correct Answer: Rheumatoid factor negative

      Explanation:

      Prognostic Features of Rheumatoid Arthritis

      A number of factors have been identified as predictors of a poor prognosis in patients with rheumatoid arthritis. These include being rheumatoid factor positive, having anti-CCP antibodies, presenting with poor functional status, showing early erosions on X-rays, having extra-articular features such as nodules, possessing the HLA DR4 gene, and experiencing an insidious onset. While there is some discrepancy regarding the association between gender and prognosis, both the American College of Rheumatology and the recent NICE guidelines suggest that female gender is linked to a poorer prognosis. It is important for healthcare professionals to be aware of these prognostic features in order to provide appropriate management and support for patients with rheumatoid arthritis.

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  • Question 30 - A 67-year-old woman visits her doctor with complaints of sudden onset of paraesthesia...

    Incorrect

    • A 67-year-old woman visits her doctor with complaints of sudden onset of paraesthesia and pain in her right leg. Upon further inquiry, she describes the pain spreading along the back of her thigh and the posterolateral region of her leg, reaching the top of her foot and her big toe. During the examination, you notice a loss of sensation in the top of her right foot and weakened strength when attempting to dorsiflex her right ankle. Her reflexes are intact, and she has a positive right-sided straight leg raise test. What is the most probable cause of her symptoms?

      Your Answer:

      Correct Answer: L5 radiculopathy

      Explanation:

      The patient is experiencing weakness in hip abduction and foot drop, which are indicative of an L5 radiculopathy. This condition is often caused by a herniated disc that is putting pressure on the nerve root. Unlike other nerve issues, L5 radiculopathy does not result in the loss of any specific reflexes. A positive SLR test is typically used to diagnose this condition. It is important to differentiate L5 radiculopathy from sciatic neuropathy, which can cause a loss of ankle jerk and plantar response, as well as knee flexion and power below the knee. The femoral nerve is responsible for the anterior thigh, not the posterior thigh. L4 radiculopathy can cause a reduction in knee jerk, while S1 can affect the ankle jerk.

      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.

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