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Question 1
Incorrect
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A 4-year-old boy is presented to the GP by his father. He has developed a rash around his mouth and nose over the past few days. It started as a flat red patch at the corner of his mouth but quickly progressed to a blistering rash that oozes fluid. During today's examination, the rash appears to have a crusty, golden appearance on the surface. The child is healthy otherwise and has no prior history of skin problems. Based on this history and examination, what is the most probable diagnosis?
Your Answer: Guttate psoriasis
Correct Answer: Impetigo
Explanation:The most likely diagnosis based on the history and examination is impetigo or eczema herpeticum, which can have similar presentations and are difficult to differentiate clinically. However, since the child has no prior history of skin conditions, eczema herpeticum is less probable. Therefore, option 2 is the correct answer.
Option 1: Atopic eczema would not manifest with a yellowish crust.
Option 3: Chickenpox would not exhibit this particular progression.
Understanding Impetigo: Causes, Symptoms, and Management
Impetigo is a common bacterial skin infection that is caused by either Staphylococcus aureus or Streptococcus pyogenes. It can occur as a primary infection or as a complication of an existing skin condition such as eczema. Impetigo is most common in children, especially during warm weather. The infection can develop anywhere on the body, but it tends to occur on the face, flexures, and limbs not covered by clothing.
The infection spreads through direct contact with discharges from the scabs of an infected person. The bacteria invade the skin through minor abrasions and then spread to other sites by scratching. Infection is spread mainly by the hands, but indirect spread via toys, clothing, equipment, and the environment may occur. The incubation period is between 4 to 10 days.
Symptoms of impetigo include ‘golden’, crusted skin lesions typically found around the mouth. It is highly contagious, and children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment.
Management of impetigo depends on the extent of the disease. Limited, localized disease can be treated with hydrogen peroxide 1% cream or topical antibiotic creams such as fusidic acid or mupirocin. MRSA is not susceptible to either fusidic acid or retapamulin, so topical mupirocin should be used in this situation. Extensive disease may require oral flucloxacillin or oral erythromycin if penicillin-allergic. The use of hydrogen peroxide 1% cream was recommended by NICE and Public Health England in 2020 to cut antibiotic resistance. The evidence base shows it is just as effective at treating non-bullous impetigo as a topical antibiotic.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 2
Incorrect
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A 25-year-old woman visits the clinic with a rash on her right ankle. She suspects it was triggered by a new anklet gifted by her friend. What category of hypersensitivity response does this fall under?
Your Answer: Type 2
Correct Answer: Type 4
Explanation:The Gell and Coombs classification divides hypersensitivity reactions into four types. Type 1 is immediate and IgE mediated, type 2 is mediated by IgG and IgM causing cell death, type 3 is mediated by immune complexes, and type 4 is delayed and mediated by T lymphocytes causing contact dermatitis. Examples of each type include allergic rhinitis, Goodpasture syndrome, and rheumatoid arthritis. Nickel is a common cause of contact dermatitis.
Understanding Contact Dermatitis
Contact dermatitis is a skin condition that can be caused by two main types of reactions. The first type is irritant contact dermatitis, which is a non-allergic reaction that occurs due to exposure to weak acids or alkalis, such as detergents. This type of dermatitis is commonly seen on the hands and is characterized by erythema, but crusting and vesicles are rare.
The second type of contact dermatitis is allergic contact dermatitis, which is a type IV hypersensitivity reaction. This type of dermatitis is uncommon and is often seen on the head following hair dyes. It presents as an acute weeping eczema that predominantly affects the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent steroid is indicated for this type of dermatitis.
Cement is a frequent cause of contact dermatitis. The alkaline nature of cement may cause an irritant contact dermatitis, while the dichromates in cement can also cause an allergic contact dermatitis. It is important to understand the different types of contact dermatitis and their causes to effectively manage and treat this condition.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 3
Correct
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Which one of the following is not a pathological response to extensive burns in elderly patients?
Your Answer: Absolute polycythaemia
Explanation:The primary pathological response is haemolysis.
Pathology of Burns
Extensive burns can cause various pathological changes in the body. The heat and microangiopathy can damage erythrocytes, leading to haemolysis. The loss of capillary membrane integrity can cause plasma leakage into the interstitial space, resulting in hypovolaemic shock. This shock can occur up to 48 hours after the injury and can cause a decrease in blood volume and an increase in haematocrit. Additionally, protein loss and secondary infections, such as Staphylococcus aureus, can occur. There is also a risk of acute peptic stress ulcers, known as Curling’s ulcers. Furthermore, full-thickness circumferential burns in an extremity can lead to compartment syndrome.
The healing process of burns depends on the severity of the burn. Superficial burns can heal through the migration of keratinocytes to form a new layer over the burn site. However, full-thickness burns can result in dermal scarring, which may require skin grafts to provide optimal coverage. It is important to understand the pathology of burns to provide appropriate treatment and prevent further complications.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 4
Correct
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Which one of the following structures does not pass anterior to the lateral malleolus?
Your Answer: Peroneus brevis
Explanation:The lateral malleolus is located posterior to the path of the peroneus brevis.
Anatomy of the Lateral Malleolus
The lateral malleolus is a bony prominence on the outer side of the ankle joint. Posterior to the lateral malleolus and superficial to the superior peroneal retinaculum are the sural nerve and short saphenous vein. These structures are important for sensation and blood flow to the lower leg and foot.
On the other hand, posterior to the lateral malleolus and deep to the superior peroneal retinaculum are the peroneus longus and peroneus brevis tendons. These tendons are responsible for ankle stability and movement.
Additionally, the calcaneofibular ligament is attached at the lateral malleolus. This ligament is important for maintaining the stability of the ankle joint and preventing excessive lateral movement.
Understanding the anatomy of the lateral malleolus is crucial for diagnosing and treating ankle injuries and conditions. Proper care and management of these structures can help prevent long-term complications and improve overall ankle function.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 5
Incorrect
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In a confrontation, a 35-year-old woman was stabbed in the medial aspect of her left thigh. Upon examination, there is a noticeable decrease in knee extension. Additionally, there is a reduction in sensation over the anterior thigh.
Which anatomical structure has been affected by the stabbing?Your Answer: Superior gluteal nerve
Correct Answer: Femoral nerve
Explanation:The femoral nerve is responsible for loss of knee extension and sensory loss to the anterior and medial aspect of the thigh following a stab injury. The muscles innervated by the femoral nerve are responsible for hip flexion and knee extension, while the nerve is responsible for sensation over the anterior thigh. Injury to the inferior gluteal nerve would result in loss of hip extension, while injury to the obturator nerve would result in a loss of sensation to the medial thigh and impaired hip adduction. Although the quadriceps tendon is vital to knee extension, it would not explain the sensory deficit and the location of the injury.
Lower limb anatomy is an important topic that often appears in examinations. One aspect of this topic is the nerves that control motor and sensory functions in the lower limb. The femoral nerve controls knee extension and thigh flexion, and provides sensation to the anterior and medial aspect of the thigh and lower leg. It is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds. The obturator nerve controls thigh adduction and provides sensation to the medial thigh. It can be injured in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh provides sensory function to the lateral and posterior surfaces of the thigh, and can be compressed near the ASIS, resulting in a condition called meralgia paraesthetica. The tibial nerve controls foot plantarflexion and inversion, and provides sensation to the sole of the foot. It is not commonly injured as it is deep and well protected, but can be affected by popliteral lacerations or posterior knee dislocation. The common peroneal nerve controls foot dorsiflexion and eversion, and can be injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and can be injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve can result in a positive Trendelenburg sign. The inferior gluteal nerve controls hip extension and lateral rotation, and is generally injured in association with the sciatic nerve. Injury to this nerve can result in difficulty rising from a seated position, as well as difficulty jumping or climbing stairs.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 6
Incorrect
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A 16-year-old soccer player injures her ankle while playing a game. She reports that her ankle turned inward, causing her foot to roll inward, and she experienced immediate pain and swelling.
What ligament is the most probable to have been sprained in this scenario?Your Answer: Calcaneonavicular ligament
Correct Answer: Anterior talofibular ligament
Explanation:The most frequently sprained ligament in ankle inversion injuries is the anterior talofibular ligament, which runs from the talus to the fibula and restricts inversion in plantar flexion. The calcaneonavicular ligament, located between the calcaneus and navicular bones, stabilizes the medial longitudinal arch and is not involved in resisting inversion or eversion, making it unlikely to be injured. The deltoid ligament, found on the medial side of the ankle, resists eversion and is therefore not typically affected in inversion injuries. The interosseous ligament, located between the tibia and fibula above the ankle joint, is only impacted if there is trauma to the lower leg. The Lisfranc ligament, which connects the second metatarsal to the medial cuneiform, is more commonly disrupted by direct blows or axial loads on a plantarflexed foot with rotation, whereas a simple sprain to the anterior talofibular ligament is more common in inversion injuries.
Ankle Sprains: Types, Presentation, Investigation, and Treatment
Ankle sprains occur when ligaments in the ankle are stretched or torn. The ankle joint is composed of the distal tibia and fibula and the superior aspect of the talus, which form a mortise secured by ligamentous structures. Low ankle sprains involve the lateral collateral ligaments, with the anterior inferior tibiofibular ligament being the most commonly injured. Inversion injury is the most common mechanism, causing pain, swelling, tenderness, and sometimes bruising. Low ankle sprains are classified into three grades based on the extent of ligament disruption, bruising and swelling, and pain on weight-bearing. Radiographs should be done to rule out associated fractures, and MRI may be useful for evaluating perineal tendons. Treatment for low ankle sprains involves rest, ice, compression, and elevation, with occasional use of a removable orthosis, cast, or crutches. Surgical intervention is rare.
High ankle sprains involve the syndesmosis, which is rare and severe. The mechanism of injury is usually external rotation of the foot, causing the talus to push the fibula laterally. Patients experience more pain when weight-bearing than with low ankle sprains. Radiographs may show widening of the tibiofibular joint or ankle mortise, and MRI may be necessary for high suspicion of syndesmotic injury. Treatment for high ankle sprains involves non-weight-bearing orthosis or cast until pain subsides, or operative fixation if there is diastasis or failed non-operative management.
Isolated injuries to the deltoid ligament are rare and frequently associated with a fracture, such as Maisonneuve fracture of the proximal fibula. Treatment for deltoid ligament injuries is similar to that for low ankle sprains, provided the ankle mortise is anatomically reduced. If not, reduction and fixation may be necessary.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 7
Incorrect
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From which of the following structures does the long head of the triceps muscle arise?
Your Answer: Coracoid process
Correct Answer: Infraglenoid tubercle
Explanation:The infraglenoid tubercle is the origin of the long head, while the lateral and medial heads are connected to the back of the humerus, specifically between the teres minor insertion and the olecranon fossa.
Anatomy of the Triceps Muscle
The triceps muscle is a large muscle located on the back of the upper arm. It is composed of three heads: the long head, lateral head, and medial head. The long head originates from the infraglenoid tubercle of the scapula, while the lateral head originates from the dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve. The medial head originates from the posterior surface of the humerus on the inferomedial side of the radial groove and both of the intermuscular septae.
All three heads of the triceps muscle insert into the olecranon process of the ulna, with some fibers inserting into the deep fascia of the forearm and the posterior capsule of the elbow. The triceps muscle is innervated by the radial nerve and supplied with blood by the profunda brachii artery.
The primary action of the triceps muscle is elbow extension. The long head can also adduct the humerus and extend it from a flexed position. The radial nerve and profunda brachii vessels lie between the lateral and medial heads of the triceps muscle. Understanding the anatomy of the triceps muscle is important for proper diagnosis and treatment of injuries or conditions affecting this muscle.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 8
Correct
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A 28-year-old female patient presents to a rheumatology clinic with complaints of pain and stiffness in the small joints of her hands. After diagnosis, she is prescribed methotrexate for her rheumatoid arthritis. How does the addition of a folate supplement reduce the risk of which side effect?
Your Answer: Myelosuppression
Explanation:The risk of myelosuppression can be reduced by prescribing folate along with methotrexate, as folate supplements can counteract the inhibition of folate caused by methotrexate. This is important because methotrexate targets fast-dividing cells by preventing DNA, RNA, and protein synthesis, and the cells in the bone marrow are heavily reliant on folate due to their rapid division.
Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.
Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5 mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.
It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 9
Incorrect
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A 35-year-old female presents to a clinic with worsening joint pains, low-grade fever and tiredness for the past 6 months. She also has chest pain that increases when breathing in. On examination, there are painless ulcers in her oral cavity. There is a reddish butterfly-patterned rash on her cheeks. She mentions that the rash worsens when she goes out into the sun. Her blood tests show:
Hb 98 g/L Male: (135-180)
Female: (115 - 160)
Platelets 95 * 109/L (150 - 400)
WBC 3.2 * 109/L (4.0 - 11.0)
ESR 90 mm/hr (0 - 20)
Urinalysis reveals proteinuria and red cell casts. Investigations for autoantibodies are sent for the patient.
What is the most sensitive test for the condition that this 35-year-old female patient is likely to have?Your Answer: Anti-Smith antibodies
Correct Answer: Antinuclear antibodies (ANA)
Explanation:Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive and 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 has a lower sensitivity (30%). Other antibody tests that can be used 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, and 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. Overall, these investigations can help diagnose and monitor SLE, allowing for appropriate management and treatment.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 10
Incorrect
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A 23-year-old man is stabbed in the chest at the level of the junction between the sternum and manubrium. What is the structure that is most vulnerable?
Your Answer: Inferior vena cava
Correct Answer: Aortic arch
Explanation:The aortic arch can be located at the Angle of Louis (Manubriosternal angle) on the surface. The oesophagus is situated at the back and is less susceptible to damage.
The sternal angle is a significant anatomical landmark located at the level of the upper sternum and manubrium. It is characterized by several structures, including the upper part of the manubrium, left brachiocephalic vein, brachiocephalic artery, left common carotid, left subclavian artery, lower part of the manubrium, and costal cartilages of the 2nd ribs. Additionally, the sternal angle marks the transition point between the superior and inferior mediastinum, and is also associated with the arch of the aorta, tracheal bifurcation, union of the azygos vein and superior vena cava, and the crossing of the thoracic duct to the midline. Overall, the sternal angle is a crucial anatomical structure that serves as a reference point for various medical procedures and diagnoses.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 11
Incorrect
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A 70-year-old man is recuperating from a fall that resulted in a fracture of his left fibular neck. He has observed that his left foot drags on the ground when he attempts to walk. Which nerve is the most probable to have been affected?
Your Answer: Tibial nerve
Correct Answer: Common peroneal nerve
Explanation:The patient is likely to have suffered damage to their common peroneal nerve, resulting in foot drop, following a fibular neck fracture. This is a common occurrence in such cases.
It is important to note that damage to the lateral cutaneous nerve of the thigh, obturator nerve, or pudendal nerve is unlikely to cause foot drop. These nerves are associated with different symptoms and conditions.
Lower limb anatomy is an important topic that often appears in examinations. One aspect of this topic is the nerves that control motor and sensory functions in the lower limb. The femoral nerve controls knee extension and thigh flexion, and provides sensation to the anterior and medial aspect of the thigh and lower leg. It is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds. The obturator nerve controls thigh adduction and provides sensation to the medial thigh. It can be injured in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh provides sensory function to the lateral and posterior surfaces of the thigh, and can be compressed near the ASIS, resulting in a condition called meralgia paraesthetica. The tibial nerve controls foot plantarflexion and inversion, and provides sensation to the sole of the foot. It is not commonly injured as it is deep and well protected, but can be affected by popliteral lacerations or posterior knee dislocation. The common peroneal nerve controls foot dorsiflexion and eversion, and can be injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and can be injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve can result in a positive Trendelenburg sign. The inferior gluteal nerve controls hip extension and lateral rotation, and is generally injured in association with the sciatic nerve. Injury to this nerve can result in difficulty rising from a seated position, as well as difficulty jumping or climbing stairs.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 12
Correct
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A 50-year-old man presents to the emergency department with a 24-hour history of left knee pain and swelling. He has difficulty bearing weight on the left leg and reports no recent trauma, fevers, or chills. The patient has also been experiencing constipation, excessive urination, and fatigue for several months. He has a history of passing a kidney stone with hydration. He does not take prescription medications or use tobacco, alcohol, or illicit drugs.
During examination, the patient's temperature is 37.2 ºC (98.9ºF) and blood pressure is 130/76 mmHg. The right knee is tender, erythematous, and swollen. Arthrocentesis reveals a white blood cell count of 30,000/mm3, with a predominance of neutrophils and numerous rhomboid-shaped crystals.
What substance is most likely the composition of the crystals?Your Answer: Calcium pyrophosphate
Explanation:The patient is experiencing acute inflammatory arthritis, which is likely caused by pseudogout. This condition occurs when calcium pyrophosphate dihydrate crystals are deposited in the synovial fluid, and it is often associated with chronic hypercalcemia resulting from primary hyperparathyroidism. Pseudogout typically affects the knee joint, and the presence of rhomboid-shaped calcium pyrophosphate crystals in the synovial fluid is diagnostic. Calcium hydroxyapatite crystals are typically found in tendons, while calcium oxalate is the most common component of renal calculi. Xanthomas refer to the deposition of cholesterol and other lipids in soft tissues, while gout is characterized by the deposition of monosodium urate in joints and soft tissues.
Understanding 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 commonly associated with increasing age, but younger patients who develop pseudogout usually have an underlying risk factor 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 in pseudogout. Diagnosis is made through joint aspiration, which reveals weakly-positively birefringent rhomboid-shaped crystals, and x-rays, which show chondrocalcinosis. In the knee, linear calcifications of the meniscus and articular cartilage can be seen.
Management of pseudogout involves joint fluid aspiration to rule out septic arthritis, followed by treatment with NSAIDs or intra-articular, intra-muscular, or oral steroids, similar to the treatment for gout. Understanding the risk factors and symptoms of pseudogout can help with early diagnosis and effective management of this condition.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 13
Incorrect
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A 67-year-old retired firefighter visits the clinic complaining of recurring burning chest pain. He reports that the pain worsens after consuming take-away food and alcohol, and he experiences increased belching. The patient has a medical history of high cholesterol, type two diabetes, and osteoarthritis. He is currently taking atorvastatin, metformin, gliclazide, naproxen, and omeprazole, which he frequently forgets to take. Which medication is the probable cause of his symptoms?
Your Answer: Atorvastatin
Correct Answer: Naproxen
Explanation:Peptic ulcers can be caused by the use of NSAIDs as a medication. Symptoms of peptic ulcer disease include a burning pain in the chest, which may be accompanied by belching, alcohol consumption, and high-fat foods. However, it is important to rule out any cardiac causes of the pain, especially in patients with a medical history of high cholesterol and type two diabetes.
Other medications that can cause peptic ulcer disease include aspirin and corticosteroids. Each medication has its own specific side effects, such as myalgia with atorvastatin, hypoglycemia with gliclazide, abdominal pain with metformin, and bradycardia with propranolol.
Understanding Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and COX-2 Selective NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) are medications that work by inhibiting the activity of cyclooxygenase enzymes, which are responsible for producing key mediators involved in inflammation such as prostaglandins. By reducing the production of these mediators, NSAIDs can help alleviate pain and reduce inflammation. Examples of NSAIDs include ibuprofen, diclofenac, naproxen, and aspirin.
However, NSAIDs can also have important and common side-effects, such as peptic ulceration and exacerbation of asthma. To address these concerns, COX-2 selective NSAIDs were developed. These medications were designed to reduce the incidence of side-effects seen with traditional NSAIDs, particularly peptic ulceration. Examples of COX-2 selective NSAIDs include celecoxib and etoricoxib.
Despite their potential benefits, COX-2 selective NSAIDs are not widely used due to ongoing concerns about cardiovascular safety. This led to the withdrawal of rofecoxib (‘Vioxx’) in 2004. As with any medication, it is important to discuss the potential risks and benefits of NSAIDs and COX-2 selective NSAIDs with a healthcare provider before use.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 14
Incorrect
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Mary, an 80-year-old female, presents to the emergency department after a low impact fall. She complains of pain in her right leg.
Mary is neurovascularly intact upon examination and an X-ray reveals an intracapsular neck of femur fracture on the right leg (hip fracture). As a result, Mary is scheduled for a hemiarthroplasty.
What is the usual indication observed during the examination of Mary's leg?Your Answer: Leg is shortened and internally rotated
Correct Answer: Leg is shortened and externally rotated
Explanation:In cases of hip fracture, the affected leg is typically shortened and externally rotated. This is due to the muscles pulling on the fractured femur, causing it to become misaligned and overlap. The short external rotators, such as piriformis, gemellus superior, obturator internus, and psoas muscle, contribute to the external rotation of the leg. It may also be abducted. It’s important to note that internal rotation is more commonly associated with a posterior hip dislocation, not a hip fracture.
Hip fractures are a common occurrence, particularly in elderly women with osteoporosis. The femoral head’s blood supply runs up the neck, making avascular necrosis a risk in displaced fractures. Symptoms include pain and a shortened and externally rotated leg. Patients with non-displaced or incomplete neck of femur fractures may still be able to bear weight. Hip fractures are classified based on their location, either intracapsular or extracapsular. The Garden system is a commonly used classification system that categorizes fractures into four types based on stability and displacement. Blood supply disruption is most common in Types III and IV.
Undisplaced intracapsular fractures can be treated with internal fixation or hemiarthroplasty if the patient is unfit. Displaced fractures require replacement arthroplasty, with total hip replacement being preferred over hemiarthroplasty if the patient was able to walk independently outdoors with no more than a stick, is not cognitively impaired, and is medically fit for anesthesia and the procedure. Extracapsular fractures are managed with a dynamic hip screw for stable intertrochanteric fractures and an intramedullary device for reverse oblique, transverse, or subtrochanteric fractures.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 15
Incorrect
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A 50-year-old woman presents to the clinic with complaints of muscle aches that have been ongoing for more than a year. She reports that her chest and back are more affected than her limbs. She also mentions experiencing shortness of breath every 3 months. The patient leads a healthy lifestyle and does not drink or smoke.
During the physical examination, the doctor observes a flat erythematous rash on the patient's torso and purple discoloration around her eyelids, which she has had for a long time. What is the antibody associated with this patient's condition?Your Answer:
Correct Answer: Anti-Jo-1
Explanation:Dermatomyositis is characterized by muscle weakness, muscle pain, and a skin rash, and is often associated with the anti-Jo-1 antibody. The weakness typically affects proximal muscles and can even impact breathing, while systemic symptoms may include dysphagia, arrhythmias, and joint calcifications. One key feature to look out for is the heliotrope rash, which is a purple discoloration often seen in dermatomyositis cases.
There are several other antibodies that can be associated with dermatomyositis, such as ANA, anti M2, and anti-Jo1. However, anti-Jo-1 is more commonly found in polymyositis, although it can also be present in dermatomyositis cases.
Other antibodies that are associated with different autoimmune conditions include anti-smooth muscle antibody (autoimmune hepatitis), anti-histone (drug-induced lupus), and anti Scl-70 (scleroderma).
Understanding Dermatomyositis
Dermatomyositis is a condition that causes inflammation and weakness in the muscles, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying malignancies. Patients with dermatomyositis may experience symmetrical, proximal muscle weakness, and photosensitive skin rashes. The skin lesions may include a macular rash over the back and shoulders, a heliotrope rash in the periorbital region, Gottron’s papules, and mechanic’s hands. Other symptoms may include Raynaud’s, respiratory muscle weakness, interstitial lung disease, dysphagia, and dysphonia.
To diagnose dermatomyositis, doctors may perform various tests, including screening for underlying malignancies. The majority of patients with dermatomyositis are ANA positive, and around 30% have antibodies to aminoacyl-tRNA synthetases, such as anti-synthetase antibodies, antibodies against histidine-tRNA ligase (Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.
In summary, dermatomyositis is a condition that affects both the muscles and skin. It can be associated with other disorders or malignancies, and patients may experience a range of symptoms. Proper diagnosis and management are essential for improving outcomes and quality of life for those with dermatomyositis.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 16
Incorrect
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A 70-year-old man is being examined on the geriatric ward during the morning ward round. He reports feeling fine this morning. He has a medical history of atrial fibrillation, recurrent falls, severe asthma and diverticulosis.
During the examination, the doctor notices twitching of the facial muscles when tapping his face. Other than that, no abnormalities are found.
What could be causing the facial muscle twitching in this patient?Your Answer:
Correct Answer: Denosumab
Explanation:Denosumab has been known to cause hypocalcaemia, which can be identified through the examination finding of facial twitching upon tapping of the face, also known as Chvostek’s sign. This is due to the drug’s ability to inhibit the formation, function, and survival of osteoclasts, which are responsible for releasing calcium into the blood through bone resorption.
On the other hand, lithium is a mood stabilizer that can cause hypercalcaemia by resetting the setpoint for PTH. However, since there is no mention of the patient being on lithium in their medical history, this is unlikely to be the cause of their condition.
Rhabdomyolysis, which can result in hypercalcaemia, is often seen in patients who have experienced falls or prolonged bed rest, particularly in geriatric wards where patients may be less mobile.
Thiazide-like diuretics, such as indapamide, can also cause hypercalcaemia by increasing urinary calcium resorption. However, this usually resolves once the diuretic is discontinued.
Finally, milk-alkali syndrome is a condition characterized by high blood calcium levels caused by excessive intake of calcium and absorbable alkali, often through dietary supplements or antacids taken to prevent osteoporosis.
Denosumab for Osteoporosis: Uses, Side Effects, and Safety Concerns
Denosumab is a human monoclonal antibody that inhibits the development of osteoclasts, the cells that break down bone tissue. It is given as a subcutaneous injection every six months to treat osteoporosis. For patients with bone metastases from solid tumors, a larger dose of 120mg may be given every four weeks to prevent skeletal-related events. While oral bisphosphonates are still the first-line treatment for osteoporosis, denosumab may be used as a next-line drug if certain criteria are met.
The most common side effects of denosumab are dyspnea and diarrhea, occurring in about 1 in 10 patients. Other less common side effects include hypocalcemia and upper respiratory tract infections. However, doctors should be aware of the potential for atypical femoral fractures in patients taking denosumab and should monitor for unusual thigh, hip, or groin pain.
Overall, denosumab is generally well-tolerated and may have an increasing role in the management of osteoporosis, particularly in light of recent safety concerns regarding other next-line drugs. However, as with any medication, doctors should carefully consider the risks and benefits for each individual patient.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 17
Incorrect
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A 29-year-old rugby player comes to your clinic with a painful shoulder. The discomfort began three weeks ago after a rugby match. Although he has experienced aches and pains after rugby before, this has been more persistent and limiting. He has been painting a room in his house and finds that the pain worsens when he reaches upward. He has been unable to participate in rugby or go to the gym. During the examination, there is tenderness on the tip of the shoulder. Both the empty can test is positive. You suspect that the patient may have a partial articular supraspinatus tendon avulsion (PASTA) lesion. Where does the supraspinatus tendon insert on the humerus?
Your Answer:
Correct Answer: Greater tubercle of the humerus
Explanation:The greater tubercle of the humerus is the correct answer. It is the insertion site for the supraspinatus muscle, which is one of three rotator cuff muscles that insert onto the greater tubercle. The infraspinatus muscle inserts onto the middle facet of the greater tubercle, while the teres minor muscle inserts onto the inferior facet.
The lesser tubercle of the humerus is located on the anteromedial aspect of the bone and is the insertion site for the subscapularis muscle, which is the remaining rotator cuff muscle.
The deltoid tuberosity is found on the lateral surface of the humeral shaft and is the insertion site for the deltoid muscle.
The intertubercular sulcus is a groove in the humerus that houses the tendon of the long head of biceps brachii. The floor of the intertubercular sulcus is the insertion site for the latissimus dorsi muscle.
The capitulum of the humerus is located at the distal end of the bone and articulates with the head of the radius.
PASTA lesions are partial tears of the supraspinatus tendon where it inserts into the humerus. They typically occur in athletes after a pulling or twisting injury.
The empty can test, also known as Jobe’s test, is used to test the supraspinatus tendon. It involves slight abduction of the arm, rotating the arm so the thumbs point downwards (as though holding two empty cans), and resisting downward pressure from the examiner. A positive test result indicates a PASTA lesion.
Understanding the Rotator Cuff Muscles
The rotator cuff muscles are a group of four muscles that are responsible for the movement and stability of the shoulder joint. These muscles are known as the SItS muscles, which stands for Supraspinatus, Infraspinatus, teres minor, and Subscapularis. Each of these muscles has a specific function in the movement of the shoulder joint.
The Supraspinatus muscle is responsible for abducting the arm before the deltoid muscle. It is the most commonly injured muscle in the rotator cuff. The Infraspinatus muscle rotates the arm laterally, while the teres minor muscle adducts and rotates the arm laterally. Lastly, the Subscapularis muscle adducts and rotates the arm medially.
Understanding the functions of each of these muscles is important in diagnosing and treating rotator cuff injuries. By identifying which muscle is injured, healthcare professionals can develop a treatment plan that targets the specific muscle and promotes healing. Overall, the rotator cuff muscles play a crucial role in the movement and stability of the shoulder joint.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 18
Incorrect
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A 2nd-year medical student is tasked with placing a cannula in the cubital fossa of the patient.
What anatomical structure can be found in the cubital fossa?Your Answer:
Correct Answer: Median nerve
Explanation:The only content of the cubital fossa is the median nerve, while the ulnar nerve passes posterior to the medial epicondyle to enter the forearm. The femoral nerve and artery are located in the femoral canal, and the tricep tendon is situated on the posterior aspect of the arm.
The Antecubital Fossa: Anatomy and Clinical Significance
The antecubital fossa is a depression located on the anterior aspect of the arm, between the arm and forearm. It is an important area for medical professionals as it is where venous blood samples are typically taken from. The borders of the antecubital fossa are the brachioradialis muscle laterally, the pronator teres medially, and a line between the medial and lateral epicondyles superiorly.
There are both deep and superficial structures found in the antecubital fossa. Deep structures include the radial nerve, tendon of the biceps muscle, brachial artery, and medial nerve. Superficial structures consist of a network of veins, including the cephalic vein and basilic vein, which come together as the median cubital vein.
The main clinical relevance of the antecubital fossa is its use for blood sampling and cannulation. However, it is also important to have a working knowledge of the anatomy as structures can become damaged. Excessive straining of the biceps tendon can cause it to rupture, leading to a ‘Popeye sign’. Damage to the medial nerve can also occur, resulting in muscle paralysis in the forearm and hand. Overall, understanding the anatomy and clinical significance of the antecubital fossa is crucial for medical professionals.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 19
Incorrect
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A 58-year-old man presents to his GP with difficulty ascending stairs and transitioning from sitting to standing. He reports experiencing relief from buttock pain with ibuprofen. He has no prior medical or surgical history, but has a 20-pack year smoking habit and works in finance for a large multinational corporation, requiring him to sit for extended periods during meetings. Upon examination, there is limited hip extension and lateral rotation. During gait analysis, he exhibits a backward trunk lurch. The GP refers him for further physiotherapy evaluation, suspecting nerve entrapment from prolonged sitting.
Which nerve is likely to be entrapped in this patient's presentation?Your Answer:
Correct Answer: Inferior gluteal nerve
Explanation:The patient in the vignette is experiencing impaired hip extension and lateral rotation, making it difficult for them to rise from a seat and climb stairs. These symptoms are consistent with inferior gluteal nerve palsy, which can be caused by nerve entrapment or compression. The inferior gluteal nerve runs anterior to the piriformis and can be damaged during hip replacement surgery or by sitting for prolonged periods with a wallet in a rear pocket.
Other nerves that can be affected in the lower limb include the femoral nerve, which supplies the lower limb extensively and can be injured by direct trauma or compression. Lateral femoral cutaneous nerve compression can cause meralgia paresthetica, which leads to burning, tingling, and numbness in the front and lateral aspect of the thigh. The obturator nerve is rarely injured but can cause medial thigh sensory changes, weak hip adduction, and a wide-based gait if damaged. The superior gluteal nerve innervates the gluteus medius and minimus and can be assessed with tests that assess hip abductor and stabilizer function.
Overall, understanding the anatomy and function of these nerves can help diagnose and manage lower limb nerve injuries.
Lower limb anatomy is an important topic that often appears in examinations. One aspect of this topic is the nerves that control motor and sensory functions in the lower limb. The femoral nerve controls knee extension and thigh flexion, and provides sensation to the anterior and medial aspect of the thigh and lower leg. It is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds. The obturator nerve controls thigh adduction and provides sensation to the medial thigh. It can be injured in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh provides sensory function to the lateral and posterior surfaces of the thigh, and can be compressed near the ASIS, resulting in a condition called meralgia paraesthetica. The tibial nerve controls foot plantarflexion and inversion, and provides sensation to the sole of the foot. It is not commonly injured as it is deep and well protected, but can be affected by popliteral lacerations or posterior knee dislocation. The common peroneal nerve controls foot dorsiflexion and eversion, and can be injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and can be injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve can result in a positive Trendelenburg sign. The inferior gluteal nerve controls hip extension and lateral rotation, and is generally injured in association with the sciatic nerve. Injury to this nerve can result in difficulty rising from a seated position, as well as difficulty jumping or climbing stairs.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 20
Incorrect
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Mr. Johnson is a 65-year-old man who has had rheumatoid arthritis for 20 years. During his yearly check-up, he mentions experiencing difficulty while eating as his food feels very dry. Additionally, he has received comments about his cheeks appearing larger. Mr. Johnson has also developed a dry cough and a CT scan of his chest reveals early signs of bronchiectasis.
What could be the possible reason for these new symptoms?Your Answer:
Correct Answer: Sjogren's syndrome
Explanation:Sjogren’s syndrome is the most appropriate answer as it can affect multiple systems of the body, including the lacrimal and salivary glands, which can lead to xerophthalmia and xerostomia. Additionally, it can predispose individuals to conditions such as COPD and bronchiectasis due to mucosal dryness. Early stages of bronchiectasis, early COPD, and parotitis are not the most appropriate answers as they do not fully explain the oral symptoms and other systemic manifestations associated with Sjogren’s syndrome.
Understanding Sjogren’s Syndrome
Sjogren’s syndrome is a medical condition that affects the exocrine glands, leading to dry mucosal surfaces. It can either be primary or secondary to other connective tissue disorders, such as rheumatoid arthritis. The condition is more common in females, with a ratio of 9:1. Patients with Sjogren’s syndrome have a higher risk of developing lymphoid malignancy, which is 40-60 times more likely than the general population.
The symptoms of Sjogren’s syndrome include dry eyes, dry mouth, vaginal dryness, arthralgia, Raynaud’s, myalgia, sensory polyneuropathy, recurrent episodes of parotitis, and subclinical renal tubular acidosis. To diagnose the condition, doctors may perform a Schirmer’s test to measure tear formation, as well as check for the presence of rheumatoid factor, ANA, anti-Ro (SSA) antibodies, and anti-La (SSB) antibodies.
Management of Sjogren’s syndrome involves the use of artificial saliva and tears, as well as medications like pilocarpine to stimulate saliva production. It is important for patients with Sjogren’s syndrome to receive regular medical care and monitoring to manage their symptoms and reduce the risk of complications.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 21
Incorrect
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A young woman presents with the inability to extend her wrist. Examination confirms this and is consistent with a 'wrist drop'. Which nerve has most likely been affected?
Your Answer:
Correct Answer: Radial nerve
Explanation:If the radial nerve is damaged, it can lead to wrist drop because it is responsible for innervating the extensor muscles that help extend the hand against gravity. This symptom is unique to radial nerve damage and is not seen with any of the other nerves listed.
Damage to the axillary nerve would affect the deltoid muscle and cause problems with arm abduction.
Impaired biceps brachii muscle function and arm flexion would result from damage to the musculocutaneous nerve.
Damage to the ulnar nerve would cause weakness in the lateral two fingers, resulting in a claw-like appearance.
Paralysis of the thenar muscles due to damage to the median nerve would lead to an inability to abduct and oppose the thumb.
Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 22
Incorrect
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Which one of the following is not a content of the posterior triangle of the neck?
Your Answer:
Correct Answer: Phrenic nerve
Explanation:The contents of the posterior triangle include the phrenic nerve, while the carotid sheath and its contents are found in the anterior triangle.
The Anterior Triangle of the Neck: Boundaries and Contents
The anterior triangle of the neck is a region that is bounded by the anterior border of the sternocleidomastoid muscle, the lower border of the mandible, and the anterior midline. It is further divided into three sub-triangles by the digastric muscle and the omohyoid muscle. The muscular triangle contains the neck strap muscles, while the carotid triangle contains the carotid sheath, which houses the common carotid artery, the vagus nerve, and the internal jugular vein. The submandibular triangle, located below the digastric muscle, contains the submandibular gland, submandibular nodes, facial vessels, hypoglossal nerve, and other structures.
The digastric muscle, which separates the submandibular triangle from the muscular triangle, is innervated by two different nerves. The anterior belly of the digastric muscle is supplied by the mylohyoid nerve, while the posterior belly is supplied by the facial nerve.
Overall, the anterior triangle of the neck is an important anatomical region that contains many vital structures, including blood vessels, nerves, and glands. Understanding the boundaries and contents of this region is essential for medical professionals who work in this area.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 23
Incorrect
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Which muscle is not a part of the rotator cuff?
Your Answer:
Correct Answer: Deltoid
Explanation:Understanding the Rotator Cuff Muscles
The rotator cuff muscles are a group of four muscles that are responsible for the movement and stability of the shoulder joint. These muscles are known as the SItS muscles, which stands for Supraspinatus, Infraspinatus, teres minor, and Subscapularis. Each of these muscles has a specific function in the movement of the shoulder joint.
The Supraspinatus muscle is responsible for abducting the arm before the deltoid muscle. It is the most commonly injured muscle in the rotator cuff. The Infraspinatus muscle rotates the arm laterally, while the teres minor muscle adducts and rotates the arm laterally. Lastly, the Subscapularis muscle adducts and rotates the arm medially.
Understanding the functions of each of these muscles is important in diagnosing and treating rotator cuff injuries. By identifying which muscle is injured, healthcare professionals can develop a treatment plan that targets the specific muscle and promotes healing. Overall, the rotator cuff muscles play a crucial role in the movement and stability of the shoulder joint.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 24
Incorrect
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A 65-year-old man presents with a cough, headache, and fever. He has a medical history of hypertension and dyslipidemia and has taken ibuprofen for symptom relief. What is the mechanism of action for the antipyretic effect of the medication he took?
Your Answer:
Correct Answer: Reduction of prostaglandin E2
Explanation:Non-steroidal anti-inflammatory drugs (NSAIDs) reduce the production of prostaglandin E2 (PGE2), which is responsible for their antipyretic effect. NSAIDs inhibit the enzyme cyclooxygenase (COX), which is required for the production of thromboxanes, prostaglandins, and prostacyclins. By reducing the production of PGE2, NSAIDs decrease fever by acting on the thermoregulation centre in the hypothalamus. However, NSAIDs can have side effects such as gastric ulcer, acute kidney injury, indigestion, and an increased risk of heart failure. It is important to note that insulin-like growth factor 1 (IGF-1) is not affected by NSAIDs, as it is stimulated by growth hormones.
Understanding Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and COX-2 Selective NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) are medications that work by inhibiting the activity of cyclooxygenase enzymes, which are responsible for producing key mediators involved in inflammation such as prostaglandins. By reducing the production of these mediators, NSAIDs can help alleviate pain and reduce inflammation. Examples of NSAIDs include ibuprofen, diclofenac, naproxen, and aspirin.
However, NSAIDs can also have important and common side-effects, such as peptic ulceration and exacerbation of asthma. To address these concerns, COX-2 selective NSAIDs were developed. These medications were designed to reduce the incidence of side-effects seen with traditional NSAIDs, particularly peptic ulceration. Examples of COX-2 selective NSAIDs include celecoxib and etoricoxib.
Despite their potential benefits, COX-2 selective NSAIDs are not widely used due to ongoing concerns about cardiovascular safety. This led to the withdrawal of rofecoxib (‘Vioxx’) in 2004. As with any medication, it is important to discuss the potential risks and benefits of NSAIDs and COX-2 selective NSAIDs with a healthcare provider before use.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 25
Incorrect
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A 28-year-old man presents to the emergency department with a wrist injury sustained from a fall. Upon examination, the physician notes tenderness in the anatomical snuffbox, as well as localized swelling and bruising. The physician suspects a fracture in one of the carpal bones and orders a series of plain x-rays to confirm the diagnosis. The physician is concerned about the potential consequences of leaving this fracture untreated due to its precarious blood supply.
Which blood supply could be compromised as a result of this injury?Your Answer:
Correct Answer: Retrograde blood supply to the scaphoid through the tubercle
Explanation:Fractures to the scaphoid bone can result in avascular necrosis due to its sole blood supply through the tubercle. The healing process may be complicated by non-union as well. It is important to note that blood supply to the scaphoid is not anterograde and pain in the anatomical snuffbox is indicative of a scaphoid fracture, not a trapezium fracture. Additionally, the scaphoid bone receives blood supply through the tubercle, not the lunate surface.
The scaphoid bone has various articular surfaces for different bones in the wrist. It has a concave surface for the head of the capitate and a crescentic surface for the lunate. The proximal end has a wide convex surface for the radius, while the distal end has a tubercle that can be felt. The remaining articular surface faces laterally and is associated with the trapezium and trapezoid bones. The narrow strip between the radial and trapezial surfaces and the tubercle gives rise to the radial collateral carpal ligament. The tubercle also receives part of the flexor retinaculum and is the only part of the scaphoid bone that allows for the entry of blood vessels. However, this area is commonly fractured and can lead to avascular necrosis.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 26
Incorrect
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A patient with a history of multiple deep vein thromboses presents with pain around the medial side of their leg. On examination, venous eczema, lipodermatosclerosis, and overlying erythema are noted around the medial malleolus.
What is the most appropriate first-line treatment for this condition in a slightly older patient?Your Answer:
Correct Answer: Four-layer compression bandaging
Explanation:Venous ulcers typically develop in the gaiter region, specifically around the medial malleolus. The ankle-brachial pressure index and venous duplex ultrasound are diagnostic tools used to investigate ulcers, not treat them. The primary conservative treatment for venous ulcers is four-layer compression bandaging. If conservative measures fail, surgical debridgement may be considered. There is limited evidence supporting the use of intermittent pneumatic compression devices for venous ulcers.
Venous ulceration is a type of ulcer that is commonly found above the medial malleolus. To determine the cause of non-healing ulcers, it is important to conduct an ankle-brachial pressure index (ABPI) test. A normal ABPI value is between 0.9 to 1.2, while values below 0.9 indicate arterial disease. However, values above 1.3 may also indicate arterial disease due to arterial calcification, especially in diabetic patients.
The most effective treatment for venous ulceration is compression bandaging, specifically four-layer bandaging. Oral pentoxifylline, a peripheral vasodilator, can also improve the healing rate of venous ulcers. While there is some evidence supporting the use of flavonoids, there is little evidence to suggest the benefit of hydrocolloid dressings, topical growth factors, ultrasound therapy, and intermittent pneumatic compression.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 27
Incorrect
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A 36-year-old woman has a thyroidectomy for Graves disease and subsequently develops a tense hematoma in her neck. Which fascial plane will contain the hematoma?
Your Answer:
Correct Answer: Pretracheal fascia
Explanation:Tense haematomas can develop due to the unyielding nature of the pretracheal fascia that encloses the thyroid.
Anatomy of the Thyroid Gland
The thyroid gland is a butterfly-shaped gland located in the neck, consisting of two lobes connected by an isthmus. It is surrounded by a sheath from the pretracheal layer of deep fascia and is situated between the base of the tongue and the fourth and fifth tracheal rings. The apex of the thyroid gland is located at the lamina of the thyroid cartilage, while the base is situated at the fourth and fifth tracheal rings. In some individuals, a pyramidal lobe may extend from the isthmus and attach to the foramen caecum at the base of the tongue.
The thyroid gland is surrounded by various structures, including the sternothyroid, superior belly of omohyoid, sternohyoid, and anterior aspect of sternocleidomastoid muscles. It is also related to the carotid sheath, larynx, trachea, pharynx, oesophagus, cricothyroid muscle, and parathyroid glands. The superior and inferior thyroid arteries supply the thyroid gland with blood, while the superior and middle thyroid veins drain into the internal jugular vein, and the inferior thyroid vein drains into the brachiocephalic veins.
In summary, the thyroid gland is a vital gland located in the neck, responsible for producing hormones that regulate metabolism. Its anatomy is complex, and it is surrounded by various structures that are essential for its function. Understanding the anatomy of the thyroid gland is crucial for the diagnosis and treatment of thyroid disorders.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 28
Incorrect
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A 40-year-old man with a diagnosis of chronic fatigue syndrome visits his GP reporting a recent worsening of his symptoms following a strenuous workout. The GP decides to conduct routine blood tests.
What are the most probable results that the GP will discover assuming that the patient's current condition is the cause of the exacerbation?Your Answer:
Correct Answer: Normal ESR, normal haemoglobin
Explanation:Graded exercise therapy is often recommended for chronic fatigue syndrome as symptoms can worsen after over-exercising. Routine blood tests are used to rule out other potential causes of the symptoms, such as anaemia or underlying inflammatory diseases, as chronic fatigue syndrome is a diagnosis of exclusion.
Understanding Chronic Fatigue Syndrome
Chronic fatigue syndrome is a condition that is diagnosed after at least four months of disabling fatigue that affects mental and physical function more than 50% of the time, in the absence of other diseases that may explain the symptoms. It is more common in females, and past psychiatric history has not been shown to be a risk factor. Fatigue is the central feature of this condition, and other recognized features include sleep problems, muscle and/or joint pains, headaches, painful lymph nodes without enlargement, sore throat, cognitive dysfunction, physical or mental exertion that makes symptoms worse, general malaise or ‘flu-like’ symptoms, dizziness, nausea, and palpitations.
To diagnose chronic fatigue syndrome, a large number of screening blood tests are carried out to exclude other pathology, such as FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin*, coeliac screening, and urinalysis. The management of chronic fatigue syndrome includes cognitive behavior therapy, which is very effective, with a number needed to treat of 2. Graded exercise therapy is also recommended, which is a formal supervised program, not advice to go to the gym. ‘Pacing’ is another management technique, which involves organizing activities to avoid tiring. Low-dose amitriptyline may be useful for poor sleep, and referral to a pain management clinic is recommended if pain is a predominant feature. Children and young people have a better prognosis than adults.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 29
Incorrect
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A 43-year-old man comes to the clinic complaining of a painful rash on his left anterior chest wall that extends to his back and under his armpit, but does not cross the midline. The rash has been present for one day, and he has been feeling lethargic for three days. Based on these symptoms, what virus do you suspect is causing his condition?
Your Answer:
Correct Answer: Varicella zoster virus
Explanation:The Varicella zoster virus (VZV) is the correct answer. Shingles is a painful rash that typically appears in a dermatomal distribution and does not usually cross the mid-line. VZV is the virus responsible for causing chickenpox, and after the initial infection, it can remain dormant in nerve cells for many years. Shingles occurs when VZV reactivates. Additional information on shingles can be found below.
Epstein-Barr virus is primarily linked to infectious mononucleosis (glandular fever).
Human papillomavirus (HPV) is associated with viral warts, and some strains are linked to gynecological malignancies. Due to their potential to cause cancer, some types of HPV are now vaccinated against.
Herpes simplex virus is associated with oral or genital herpes infections.
Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The diagnosis is usually clinical and management includes analgesia, antivirals, and reminding patients they are potentially infectious. Complications include post-herpetic neuralgia, herpes zoster ophthalmicus, and herpes zoster oticus. Antivirals should be used within 72 hours to reduce the incidence of post-herpetic neuralgia.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 30
Incorrect
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Which one of the following is a content of the adductor canal?
Your Answer:
Correct Answer: Saphenous nerve
Explanation:The saphenous nerve and the superficial branch of the femoral artery are both present in this area.
The Adductor Canal: Anatomy and Contents
The adductor canal, also known as Hunter’s or the subsartorial canal, is a structure located in the middle third of the thigh, immediately distal to the apex of the femoral triangle. It is bordered laterally by the vastus medialis muscle and posteriorly by the adductor longus and adductor magnus muscles. The roof of the canal is formed by the sartorius muscle. The canal terminates at the adductor hiatus.
The adductor canal contains three important structures: the saphenous nerve, the superficial femoral artery, and the superficial femoral vein. The saphenous nerve is a sensory nerve that supplies the skin of the medial leg and foot. The superficial femoral artery is a major artery that supplies blood to the lower limb. The superficial femoral vein is a large vein that drains blood from the lower limb.
In order to expose the contents of the adductor canal, the sartorius muscle must be removed. Understanding the anatomy and contents of the adductor canal is important for medical professionals who perform procedures in this area, such as nerve blocks or vascular surgeries.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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