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  • Question 1 - You evaluate a 62-year-old man with a painful swollen left big toe. The...

    Incorrect

    • You evaluate a 62-year-old man with a painful swollen left big toe. The pain began this morning and is described as the most severe pain he has ever experienced. It has gradually worsened over the past 8 hours. He is unable to wear socks or shoes and had to come to the appointment in open-toe sandals. The skin over the affected area appears red and shiny.

      His only significant medical history is hypertension, which has been challenging to control. He is currently taking amlodipine 10 mg and ramipril 10 mg daily for this condition and is awaiting a medication review for his antihypertensive treatment. His blood pressure today measures 165/94 mmHg.
      What is the SINGLE most appropriate next step in management?

      Your Answer: Check serum urate levels to confirm diagnosis

      Correct Answer: Commence colchicine

      Explanation:

      The diagnosis in this case is clearly gout. According to the guidelines from the European League Against Rheumatism (EULAR), the symptoms of acute pain, joint swelling, tenderness, and redness that worsen over a 6-12 hour period strongly suggest crystal arthropathy.

      Checking serum urate levels to confirm hyperuricemia before starting treatment for acute gout attacks has little benefit and should not delay treatment. While these levels can be useful for monitoring treatment response, they often decrease during an acute attack and can even be normal. If levels are checked and found to be normal during the attack, they should be rechecked once the attack has resolved.

      The first-line treatment for acute gout attacks is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. However, caution should be exercised when using NSAIDs in patients with a history of hypertension. Since this patient has had difficulty controlling their blood pressure and remains hypertensive, it would be wise to avoid NSAIDs in this case.

      Colchicine is an effective alternative for treating gout, although it may take longer to take effect. It is often used in patients who cannot take NSAIDs due to contraindications such as hypertension or a history of peptic ulcer disease. Therefore, it is the most suitable choice for this patient.

      During an acute gout attack, allopurinol should not be used as it can prolong the attack and even trigger another acute episode. However, in patients already taking allopurinol, it should be continued, and the acute attack should be treated with NSAIDs or colchicine as appropriate.

      Febuxostat (Uloric) is another option for managing chronic gout, but like allopurinol, it should not be used for acute episodes.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      142.2
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  • Question 2 - A 45-year-old woman presents with a swollen, red, and painful left knee. The...

    Correct

    • A 45-year-old woman presents with a swollen, red, and painful left knee. The doctor suspects septic arthritis and sends a joint aspirate to the lab for diagnosis. The patient has a known allergy to penicillin.
      Which antibiotic would be the most suitable choice for this patient?

      Your Answer: Clindamycin

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      27.6
      Seconds
  • Question 3 - A 12-year-old girl presents with her father. She is very active and enjoys...

    Incorrect

    • A 12-year-old girl presents with her father. She is very active and enjoys participating in various sports at a high level. Lately, she has been worried about experiencing pain in her right ankle. There is no history of injury, instability, or swelling. She is in good overall health. She can walk and run without discomfort, and the pain does not worsen after prolonged periods of rest. During the examination of her ankle, you observe tenderness and slight swelling around the lateral malleolus.

      What is the SINGLE most likely diagnosis?

      Your Answer: Still’s disease

      Correct Answer: Osgood-Schlatter disease

      Explanation:

      Osgood-Schlatter disease is commonly observed in active teenagers and is characterized by pain and tenderness in the tibial tuberosity. Rest is typically recommended as part of the treatment plan, and the diagnosis is made based on clinical evaluation.

      Chondromalacia patella is most prevalent in teenage girls and is often accompanied by knee pain while going up and downstairs. Discomfort tends to worsen after prolonged periods of sitting. Treatment options include pain relief medication and physiotherapy.

      Prepatellar bursitis, also known as housemaid’s knee, is linked to excessive kneeling.

      Pseudogout is an inflammatory arthritis caused by the accumulation of pyrophosphate crystals. While the knees are frequently affected, it is unlikely to occur in this age group.

      Still’s disease accounts for approximately 10% of cases of juvenile chronic arthritis. It typically involves multiple systems in the body and is often characterized by fever, rash, swollen lymph nodes, and joint pain.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 4 - A 45-year-old woman comes in with a swollen, red, and painful left knee....

    Correct

    • A 45-year-old woman comes in with a swollen, red, and painful left knee. The doctor suspects septic arthritis and sends a joint aspirate to the lab.
      What is the most common organism that causes septic arthritis?

      Your Answer: Staphylococcus aureus

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      14.9
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  • Question 5 - A 35-year-old woman presents with a swollen, red, and warm right knee. She...

    Incorrect

    • A 35-year-old woman presents with a swollen, red, and warm right knee. She has recently returned from a trip to Tokyo. During examination, her temperature is 38.6°C, and she has a rash with small blisters on her chest. The knee feels warm to touch and is immobile. Attempts to bend or straighten the knee are unsuccessful. A joint fluid sample is taken, revealing the presence of Gram-negative diplococci.
      What is the most likely organism responsible for this condition?

      Your Answer: Staphylococcus aureus

      Correct Answer: Neisseria gonorrhoea

      Explanation:

      The most probable diagnosis in this case is septic arthritis, which occurs when an infectious agent invades a joint and causes pus formation. The patient’s recent travel to Bangkok, presence of a vesicular rash on the trunk, and the identification of Gram-negative diplococci support this diagnosis.

      Septic arthritis is characterized by several clinical features. These include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty in moving the joint. Patients may also experience fever and systemic symptoms.

      The most common cause of septic arthritis is Staphylococcus aureus. Other bacteria that can lead to this condition include Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea (typically seen in sexually active young adults with macules or vesicles on the trunk), and Escherichia coli (common in intravenous drug users, the elderly, and seriously ill individuals).

      According to the current recommendations by NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary), the treatment for septic arthritis involves the following approaches. Flucloxacillin is the first-line antibiotic. In cases of penicillin allergy, clindamycin is recommended. If there is suspicion of MRSA infection, vancomycin should be used. For gonococcal arthritis or Gram-negative infection, cefotaxime is the preferred choice. The suggested duration of treatment is 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      96.5
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  • Question 6 - A 60-year-old individual presents with an arthropathy affecting the metatarsophalangeal joint on their...

    Correct

    • A 60-year-old individual presents with an arthropathy affecting the metatarsophalangeal joint on their left foot. Gout is suspected, and a joint aspirate is sent to the lab for analysis.
      What type of crystals are deposited in the joints during gout?

      Your Answer: Urate crystals

      Explanation:

      Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.

      Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      20.4
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  • Question 7 - You evaluate a child with a limp and hip discomfort. An X-ray is...

    Correct

    • You evaluate a child with a limp and hip discomfort. An X-ray is conducted, and a diagnosis of Slipped upper femoral epiphysis (SUFE) is established.
      Which ONE statement about this condition is accurate?

      Your Answer: Trethowan’s sign may be present in the early stages

      Explanation:

      Slipped upper femoral epiphysis (SUFE), also referred to as slipped capital femoral epiphysis, is a rare but significant hip disorder that primarily affects children. It occurs when the growth plate slips at the epiphysis, causing the head of the femur to shift from its normal position on the femoral neck. Specifically, the femoral epiphysis remains in the acetabulum while the metaphysis moves forward and externally rotates.

      SUFE typically presents later in boys, usually between the ages of 10 and 17, compared to girls who typically experience it between 8 and 15 years of age. Several risk factors contribute to its development, including being male, being overweight, having immature skeletal maturity, having a positive family history, being of Pacific Island or African origin, having hypothyroidism, growth hormone deficiency, or hypogonadism.

      Patients with SUFE commonly experience hip pain and a limp. In severe cases, a leg length discrepancy may be noticeable. While the condition may not be immediately apparent on an anteroposterior (AP) film, it is usually detectable on a frog-leg lateral film. A diagnostic sign is the failure of a line drawn up the lateral edge of the femoral neck (known as the line of Klein) to intersect the epiphysis during the acute stage, also known as Trethowan’s sign.

      Surgical pinning is the most common treatment for SUFE. In approximately 20% of cases, bilateral SUFE occurs, prompting some surgeons to recommend prophylactic pinning of the unaffected hip. If a significant deformity is present, osteotomies or even arthroplasty may be necessary.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      67.8
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  • Question 8 - A patient has been diagnosed with septic arthritis in their left knee. The...

    Incorrect

    • A patient has been diagnosed with septic arthritis in their left knee. The joint aspirate reveals the presence of Escherichia coli.

      Which of the following patient populations is at the highest risk for developing septic arthritis caused by Escherichia coli?

      Your Answer: Young, sexually active adults

      Correct Answer: Intravenous drug users

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      71.5
      Seconds
  • Question 9 - A 35-year-old man with a known history of lumbar radiculopathy causing neuropathic pain...

    Incorrect

    • A 35-year-old man with a known history of lumbar radiculopathy causing neuropathic pain presents with an increase in his symptoms. He describes the pain as a severe burning sensation on the right side of his lower back and leg. You discuss his treatment options.
      Which of the following pharmacological therapies is recommended by the current NICE guidelines for the management of neuropathic pain? Select ONE option only.

      Your Answer: Co-dydramol

      Correct Answer: Duloxetine

      Explanation:

      The first line of treatment for neuropathic pain includes options such as amitriptyline, duloxetine, gabapentin, or pregabalin. The dosage should be adjusted based on how the individual responds to the medication and their ability to tolerate it. If the initial treatment does not provide relief or is not well tolerated, one of the remaining three medications can be considered as an alternative option.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      53.5
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  • Question 10 - A 70-year-old woman presents with an acute episode of gout. She has a...

    Incorrect

    • A 70-year-old woman presents with an acute episode of gout. She has a history of chronic heart failure and hypertension. Her current medications include lisinopril and hydrochlorothiazide.

      Which SINGLE statement regarding the treatment of gout is true?

      Your Answer: NSAIDs are the treatment of choice for patients with a history of heart failure

      Correct Answer: Colchicine has a role in prophylactic treatment

      Explanation:

      In cases where there are no reasons to avoid them, high-dose NSAIDs are the first choice for treating acute gout. A commonly used and effective regimen is to take Naproxen 750 mg as a single dose, followed by 250 mg three times a day. Aspirin should not be used for gout because it reduces the clearance of urate in the urine and interferes with the action of uricosuric agents. Instead, Naproxen, diclofenac, or indomethacin are more suitable options.

      Allopurinol is used as a preventive measure to reduce future gout attacks by lowering the levels of uric acid in the blood. However, it should not be started during an acute gout episode as it can worsen the severity and duration of symptoms. Colchicine works by affecting neutrophils, binding to tubulin to prevent their migration into the affected joint. It is equally effective as NSAIDs in relieving acute gout attacks and can also be used for prophylactic treatment if a patient cannot tolerate allopurinol.

      NSAIDs should not be used in patients with heart failure as they can lead to fluid retention and congestive cardiac failure. In such cases, colchicine is the preferred treatment option. Colchicine is also recommended for patients who cannot tolerate NSAIDs. Febuxostat (Uloric) is an alternative to allopurinol and is used for managing chronic gout.

      Corticosteroids are an effective alternative for managing acute gout in patients who cannot take NSAIDs or colchicine. They can be administered orally, intramuscularly, intravenously, or directly into the affected joint.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      46.6
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  • Question 11 - A 35-year-old woman comes to the clinic with a red, warm, swollen left...

    Incorrect

    • A 35-year-old woman comes to the clinic with a red, warm, swollen left knee a few days after returning from a vacation in Thailand. She also reports feeling generally sick and has a rash on her trunk. The doctor decides to send a sample of the knee fluid to the lab for testing. What is the most likely finding on Gram-stain testing?

      Your Answer: Branching Gram-positive rods

      Correct Answer: Gram-negative pairs of cocci

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      12.8
      Seconds
  • Question 12 - A 40-year-old construction worker comes in with a few weeks of lower back...

    Correct

    • A 40-year-old construction worker comes in with a few weeks of lower back pain. He is currently experiencing discomfort and wants to know which pain medication would be most effective. You give him a self-help guide and discuss his treatment choices.
      According to the latest NICE guidelines, what is the recommended initial pharmacological treatment for lower back pain? Choose ONE option.

      Your Answer: Ibuprofen

      Explanation:

      The current guidelines from NICE provide recommendations for managing low back pain. It is suggested to consider using oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, while taking into account the potential risks of gastrointestinal, liver, and cardio-renal toxicity, as well as the person’s individual risk factors and age. When prescribing oral NSAIDs, it is important to conduct appropriate clinical assessments, monitor risk factors regularly, and consider the use of gastroprotective treatment. It is advised to prescribe the lowest effective dose of oral NSAIDs for the shortest duration possible. In cases where NSAIDs are contraindicated, not tolerated, or ineffective, weak opioids (with or without paracetamol) may be considered for managing acute low back pain. However, NICE does not recommend the use of paracetamol alone, opioids for chronic low back pain, serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants for non-neuropathic pain, anticonvulsants, or benzodiazepines for muscle spasm associated with acute low back pain. For more information, you can refer to the NICE guidance on low back pain and sciatica in individuals over 16 years old, as well as the NICE Clinical Knowledge Summary on low back pain without radiculopathy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      91.8
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  • Question 13 - A 42-year-old woman presents with a painful swollen left big toe. The pain...

    Incorrect

    • A 42-year-old woman presents with a painful swollen left big toe. The pain began this morning and is described as the most severe pain she has ever felt. It has progressively worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in open-toed sandals. The skin over the affected area appears red and shiny.

      What is the MOST likely diagnosis?

      Your Answer: Septic joint

      Correct Answer: Gout

      Explanation:

      The guidelines from the European League Against Rheumatism (EULAR) regarding the diagnosis of gout state that if a joint becomes swollen, tender, and red, and if acute pain develops in that joint over a period of 6-12 hours, it is highly likely to be a crystal arthropathy. Pseudogout is also a possibility, but it is much less likely. In this case, gout is the most probable diagnosis.

      The joint that is most commonly affected in acute gout is the first metatarsal-phalangeal joint, which accounts for 50-75% of cases.

      The main cause of gout is hyperuricaemia, and the clinical diagnosis can be confirmed by the presence of negatively birefringent crystals in the synovial fluid aspirate.

      For the treatment of acute gout attacks, NSAIDs or colchicine are generally used.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 14 - Gout is becoming more prevalent in Western societies due to various factors, including...

    Incorrect

    • Gout is becoming more prevalent in Western societies due to various factors, including longer lifespans, high protein diets, and an increasing occurrence of metabolic syndrome.

      Which of the following conditions is not typically associated with metabolic syndrome?

      Your Answer: Hyperlipidaemia

      Correct Answer: Hyperthyroidism

      Explanation:

      Gout is a form of arthritis that causes a swollen, tender, red, and hot joint. Initially, it was believed to primarily affect wealthy individuals due to dietary connections, but it is now becoming more prevalent and is estimated to impact around 1-2% of the Western population. This increase may be attributed to longer lifespans and changes in our eating habits. Additionally, there is a positive correlation between the rising rates of metabolic disease and gout.

      While gout commonly affects the metatarsal-phalangeal joint of the big toe (approximately 50% of cases), it can also impact other joints such as the fingers, wrists, knees, and ankles. The pain experienced during an episode is often excruciating, and these episodes typically last about a week. Approximately half of the patients experience a recurrence within a year.

      Hyperuricemia is the underlying cause of gout. Uric acid, a byproduct of purine metabolism, is typically eliminated through the kidneys. However, in about 90% of cases, hyperuricemia occurs due to the under-excretion of urate, while the remaining 10% is caused by overproduction. Elevated urate levels increase the likelihood of crystal formation. Measuring uric acid levels in the blood can be misleading, as some individuals with high levels do not develop gout, and levels can be normal during an attack. The crystallization process is complex and more likely to occur in cooler temperatures (which is why the feet are often affected, and symptoms worsen at night), during acidosis, and when there are rapid fluctuations in uric acid levels.

      Diagnosing gout is primarily based on clinical evaluation. If there is a rapid onset of severe pain, swelling, and tenderness that reaches its peak within 6-12 hours, accompanied by redness, it strongly suggests crystal inflammation. The presence of monosodium urate crystals in synovial fluid or tophi confirms the diagnosis. When these crystals are examined under polarized light, they exhibit negative birefringence. Since gout symptoms can be mistaken for septic arthritis, if there is uncertainty in the diagnosis and the joint has been aspirated, it should also be sent for gram-staining.

      Tophi are painless, hard lumps that develop when hyperuricemia persists for an extended period. They often appear on the elbows and ears.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      93.5
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  • Question 15 - You evaluate a 62-year-old man with a painful swollen left big toe. The...

    Correct

    • You evaluate a 62-year-old man with a painful swollen left big toe. The pain began this morning and is described as the most severe pain he has ever experienced. It has progressively worsened over the past 8 hours. He is unable to wear socks or shoes and had to come to the appointment in open-toe sandals. The skin over the affected area appears red and shiny.

      His only significant medical history is hypertension, which has been challenging to control. He is currently prescribed amlodipine 10 mg and ramipril 10 mg daily for this condition and is awaiting a medication review for his antihypertensive treatment. His blood pressure reading today is 165/94 mmHg.

      What is the MOST appropriate next step in managing his condition?

      Your Answer: Commence colchicine

      Explanation:

      The diagnosis in this case is clearly gout. According to the guidelines from the European League Against Rheumatism (EULAR), the development of sudden joint pain accompanied by swelling, tenderness, and redness, which worsens over a period of 6-12 hours, strongly suggests crystal arthropathy.

      Checking serum urate levels to confirm high levels of uric acid before starting treatment for acute gout attacks has little benefit and should not delay treatment. While these levels can be useful for monitoring treatment response, they often decrease during an acute attack and can even be within the normal range. If levels are checked and found to be normal during the attack, they should be rechecked once the attack has resolved.

      The first-line treatment for acute gout attacks is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. However, caution should be exercised when using NSAIDs in patients with a history of hypertension. Since this patient has had difficulty controlling their blood pressure and remains hypertensive, it would be wise to avoid NSAIDs in this case.

      Colchicine is an effective alternative for treating gout, although it may take longer to take effect. It is often used in patients who cannot take NSAIDs due to contraindications such as hypertension or a history of peptic ulcer disease. Therefore, it is the most suitable choice for this patient.

      During an acute gout attack, allopurinol should not be used as it can prolong the attack and even trigger another acute episode. However, if a patient is already taking allopurinol for chronic gout management, it should be continued, and the acute attack should be treated with NSAIDs or colchicine as appropriate.

      Febuxostat (Uloric) is an alternative to allopurinol for managing chronic gout. Like allopurinol, it should not be used for treating acute gout episodes.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      74.4
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  • Question 16 - A middle-aged individual with a history of intravenous drug use and unstable housing...

    Incorrect

    • A middle-aged individual with a history of intravenous drug use and unstable housing presents with extremely intense back pain, elevated body temperature, and weakness in the left leg. The patient has experienced multiple episodes of nighttime pain and is struggling to walk. During the examination, tenderness is noted in the lower lumbar spine, along with weakness in left knee extension and foot dorsiflexion.

      What is the preferred diagnostic test to definitively confirm the diagnosis?

      Your Answer: CT scan spine

      Correct Answer: MRI scan spine

      Explanation:

      Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in intravenous drug users and those with weakened immune systems. Gram-negative organisms such as Escherichia coli and Mycobacterium tuberculosis can also cause discitis.

      There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in 1-2% of cases post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.

      The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, refusal to walk may also be a symptom.

      When diagnosing discitis, MRI is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. CT scanning is also not very sensitive in detecting discitis.

      Treatment for discitis involves admission to the hospital for intravenous antibiotics. Before starting the antibiotics, it is important to send three sets of blood cultures and a full set of blood tests, including a CRP, to the lab. The choice of antibiotics depends on the specific situation. A typical antibiotic regimen for discitis may include IV flucloxacillin as the first-line treatment if there is no penicillin allergy, IV vancomycin if the infection was acquired in the hospital or there is a high risk of MRSA, and possibly IV gentamicin if there is a possibility of a Gram-negative infection. In cases where there is acute kidney injury and Gram-negative cover is required, IV piperacillin-tazobactam alone may be used.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 17 - A 45-year-old individual presents with a swollen and painful left knee. The symptoms...

    Incorrect

    • A 45-year-old individual presents with a swollen and painful left knee. The symptoms started three days ago. There is no history of any injury, and a joint aspirate is sent for laboratory analysis. The aspirate reveals the presence of pus cells, positively birefringent crystals, and no organisms.
      What is the SINGLE most probable diagnosis?

      Your Answer: Septic arthritis

      Correct Answer: Pseudogout

      Explanation:

      Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.

      Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      97.4
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  • Question 18 - A 45-year-old woman comes in with a swollen, red, and hot left knee....

    Incorrect

    • A 45-year-old woman comes in with a swollen, red, and hot left knee. During the examination, her temperature is recorded as 38.6°C. The knee feels warm to touch and is stiff, making it impossible for the patient to move it.

      Which of the following antibiotics would be the most suitable to prescribe for this situation?

      Your Answer: Gentamicin

      Correct Answer: Flucloxacillin

      Explanation:

      The most probable diagnosis in this case is septic arthritis, which occurs when an infectious agent invades a joint and causes pus formation. The clinical features of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty in moving the joint. Patients may also experience fever and overall feeling of being unwell.

      The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria can also be responsible. These include Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea (typically seen in sexually active young adults with macules or vesicles on the trunk), and Escherichia coli (common in intravenous drug users, the elderly, and seriously ill individuals).

      According to the current recommendations by NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary), the treatment for septic arthritis involves using specific antibiotics. Flucloxacillin is the first-line choice, but if a patient is allergic to penicillin, clindamycin can be used instead. If there is suspicion of MRSA (Methicillin-resistant Staphylococcus aureus), vancomycin is recommended. In cases where gonococcal arthritis or Gram-negative infection is suspected, cefotaxime is the preferred antibiotic.

      The suggested duration of treatment for septic arthritis is 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 19 - A 52-year-old man presents with a swollen and painful right big toe. He...

    Correct

    • A 52-year-old man presents with a swollen and painful right big toe. He has a history of gout and states that this pain is similar to previous flare-ups. He has been taking allopurinol 200 mg daily for the past year and this is his second episode of acute gout during that time. He has no significant medical history and is not on any other medications. He has no known allergies.
      What is the MOST appropriate next step in managing his condition?

      Your Answer: Continue with the allopurinol and commence naproxen

      Explanation:

      Allopurinol should not be started during an acute gout attack as it can make the attack last longer and even trigger another one. However, if a patient is already taking allopurinol, they should continue taking it and treat the acute attack with NSAIDs or colchicine as usual.

      The first choice for treating acute gout attacks is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. Colchicine can be used if NSAIDs are not suitable, for example, in patients with high blood pressure or a history of peptic ulcer disease. In this case, the patient has no reason to avoid NSAIDs, so naproxen would still be the preferred option.

      Once the acute attack has subsided, it would be reasonable to gradually increase the dose of allopurinol, aiming for urate levels in the blood of less than 6 mg/dl (<360 µmol/l). Febuxostat (Uloric) is an alternative to allopurinol that can be used for long-term management of gout.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 20 - A 35-year-old woman presents to the Emergency Department complaining of lower back pain...

    Incorrect

    • A 35-year-old woman presents to the Emergency Department complaining of lower back pain and numbness in both feet. Three days ago, she experienced a sharp, shooting pain in her back after lifting a heavy object at work. The pain has worsened over the past three days, and she has now developed weakness in her right leg. She is also experiencing difficulty with urination. Her medical history includes a previous laminectomy for a herniated lumbar disc four years ago. During the examination, normal power is observed in her left leg, but reduced power is noted in the right leg. Motor strength is reduced to 3 out of 5 in the hamstrings, 2 out of 5 in the ankle and toe plantar flexors, and 0 out of 5 in the ankle dorsiflexors and extensor hallucis longus. The right ankle and Achilles tendon reflexes are absent. Sensory examination reveals reduced sensation in the right calf, right foot, labia, and perianal area. Rectal examination reveals reduced sphincter tone.

      What is the SINGLE most likely diagnosis?

      Your Answer: Peripheral neuropathy

      Correct Answer: Cauda equina syndrome

      Explanation:

      Cauda equina syndrome (CES) is a rare but serious complication that can occur when a disc ruptures. This happens when the material from the disc is pushed into the spinal canal and puts pressure on the bundle of nerves in the lower back and sacrum. As a result, individuals may experience loss of control over their bladder and bowel functions.

      There are certain red flags that may indicate the presence of CES. These include experiencing sciatica on both sides of the body, having severe or worsening neurological issues in both legs (such as significant weakness in knee extension, ankle eversion, or foot dorsiflexion), difficulty starting urination or a decreased sensation of urinary flow, loss of sensation in the rectum, experiencing numbness or tingling in the perianal, perineal, or genital areas (also known as saddle anesthesia or paresthesia), and having a lax anal sphincter.

      Conus medullaris syndrome (CMS) is a condition that affects the conus medullaris, which is located above the cauda equina at the T12-L2 level. Unlike CES, CMS primarily causes back pain and may have less noticeable nerve root pain. The main symptoms of CMS are urinary retention and constipation.

      To confirm a diagnosis of CES and determine the level of compression and any underlying causes, an MRI scan is considered the gold-standard investigation. In cases where an MRI is not possible or contraindicated, a CT myelogram or standard CT scans can be helpful. However, plain radiographs have limited value and may only show significant degenerative or traumatic bone diseases.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 21 - A 45-year-old woman presents with a red, hot, swollen right knee. On examination,...

    Correct

    • A 45-year-old woman presents with a red, hot, swollen right knee. On examination, her temperature is 38.6°C. The knee is warm to touch and is held rigid by the patient. You are unable to flex or extend the knee.
      Which of the following is the most likely causative organism?

      Your Answer: Staphylococcus aureus

      Explanation:

      The most probable diagnosis in this case is septic arthritis, which occurs when an infectious agent invades a joint and causes pus formation. The clinical features of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty in moving the joint. Patients may also experience fever and overall feeling of being unwell.

      The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria can also be responsible. These include Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea (typically seen in sexually active young adults with macules or vesicles on the trunk), and Escherichia coli (common in intravenous drug users, the elderly, and seriously ill individuals).

      According to the current recommendations by NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary), the treatment for septic arthritis involves using specific antibiotics. Flucloxacillin is the first-line choice, but if a patient is allergic to penicillin, clindamycin can be used instead. If there is suspicion of MRSA (Methicillin-resistant Staphylococcus aureus), vancomycin is recommended. In cases where gonococcal arthritis or Gram-negative infection is suspected, cefotaxime is the preferred antibiotic.

      The suggested duration of treatment for septic arthritis is 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 22 - A 65-year-old woman presents with severe and persistent back pain a few days...

    Incorrect

    • A 65-year-old woman presents with severe and persistent back pain a few days after spinal surgery. She has a temperature of 38.4°C and is highly sensitive over the area where the surgery was performed. On examination, she has weakness of left knee extension and foot dorsiflexion.

      What is the SINGLE most probable diagnosis?

      Your Answer: Spinal stenosis

      Correct Answer: Discitis

      Explanation:

      Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in certain cases, especially in immunocompromised individuals and intravenous drug users. Gram-negative organisms like Escherichia coli and Mycobacterium tuberculosis can also cause discitis, particularly in cases of Pott’s disease.

      There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in about 1-2% of patients post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.

      The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, a refusal to walk may also be a symptom.

      When diagnosing discitis, magnetic resonance imaging (MRI) is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. Computed tomography (CT) scanning is also not very sensitive in detecting discitis.

      Treatment for discitis involves hospital admission for intravenous antibiotics. Before starting the antibiotics, it is recommended to send three sets of blood cultures and a full set of blood tests, including a C-reactive protein (CRP) test, to the laboratory.

      A typical antibiotic regimen for discitis would include intravenous flucloxacillin 2 g every 6 hours as the first-line treatment if there is no penicillin allergy. Intravenous vancomycin may be used if the infection was acquired in the hospital, if there is a high risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, or if there is a documented penicillin allergy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 23 - A middle-aged intravenous drug user with an unstable living situation complains of intense...

    Correct

    • A middle-aged intravenous drug user with an unstable living situation complains of intense back pain, fever, and weakness in the left leg. The pain has been disrupting his sleep and making it hard for him to walk. During the examination, tenderness is observed in the lower lumbar spine, and there is weakness in left knee extension and foot dorsiflexion.
      What is the probable organism responsible for these symptoms in this individual?

      Your Answer: Staphylococcus aureus

      Explanation:

      Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in intravenous drug users and those with weakened immune systems. Gram-negative organisms such as Escherichia coli and Mycobacterium tuberculosis can also cause discitis.

      There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in 1-2% of cases post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.

      The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, refusal to walk may also be a symptom.

      When diagnosing discitis, MRI is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. CT scanning is also not very sensitive in detecting discitis.

      Treatment for discitis involves admission to the hospital for intravenous antibiotics. Before starting the antibiotics, it is important to send three sets of blood cultures and a full set of blood tests, including a CRP, to the lab. The choice of antibiotics depends on the specific situation. A typical antibiotic regimen for discitis may include IV flucloxacillin as the first-line treatment if there is no penicillin allergy, IV vancomycin if the infection was acquired in the hospital or there is a high risk of MRSA, and possibly IV gentamicin if there is a possibility of a Gram-negative infection. In cases where there is acute kidney injury and Gram-negative cover is required, IV piperacillin-tazobactam alone may be used.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 24 - A 32-year-old individual comes in with a recent onset of low back pain...

    Incorrect

    • A 32-year-old individual comes in with a recent onset of low back pain that is more severe in the mornings. They mention that their mother has ankylosing spondylitis and are concerned about the possibility of having the same condition.
      What is a red flag symptom that suggests spondyloarthritis as the underlying cause of back pain?

      Your Answer: Recent onset of faecal incontinence

      Correct Answer: Buttock pain

      Explanation:

      Spondyloarthritis is a term that encompasses various inflammatory conditions affecting both the joints and the entheses, which are the attachment sites of ligaments and tendons to the bones. The primary cause of spondyloarthritis is ankylosing spondylitis, but it can also be triggered by reactive arthritis, psoriatic arthritis, and enteropathic arthropathies.

      If individuals below the age of 45 experience four or more of the following symptoms, they should be referred for a potential diagnosis of spondyloarthritis:

      – Presence of low back pain and being younger than 35 years old
      – Waking up in the second half of the night due to pain
      – Buttock pain
      – Pain that improves with movement or within 48 hours of using nonsteroidal anti-inflammatory drugs (NSAIDs)
      – Having a first-degree relative with spondyloarthritis
      – History of current or past arthritis, psoriasis, or enthesitis.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      8
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  • Question 25 - A 35-year-old woman comes in with a red, hot, swollen left knee a...

    Incorrect

    • A 35-year-old woman comes in with a red, hot, swollen left knee a few days after returning from a vacation in Thailand. She also reports feeling generally unwell and has a rash on her trunk. Which antibiotic would be the most suitable for this patient?

      Your Answer: Clindamycin

      Correct Answer: Cefotaxime

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      91.8
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  • Question 26 - A 40-year-old construction worker comes in with a few weeks of persistent lower...

    Incorrect

    • A 40-year-old construction worker comes in with a few weeks of persistent lower back pain. Despite taking the maximum dose of ibuprofen, he is still experiencing discomfort and is seeking additional pain relief. What would be the most suitable next course of treatment? Choose only ONE option.

      Your Answer: Switch to diclofenac sodium

      Correct Answer: Add low-dose codeine phosphate

      Explanation:

      The current guidelines from NICE provide recommendations for managing low back pain. It is suggested to consider using oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, while taking into account the potential risks of gastrointestinal, liver, and cardio-renal toxicity, as well as the person’s individual risk factors and age. When prescribing oral NSAIDs, it is important to conduct appropriate clinical assessments, monitor risk factors regularly, and consider the use of gastroprotective treatment. It is advised to prescribe the lowest effective dose of oral NSAIDs for the shortest duration possible. In cases where NSAIDs are contraindicated, not tolerated, or ineffective, weak opioids (with or without paracetamol) may be considered for managing acute low back pain. However, NICE does not recommend the use of paracetamol alone, opioids for chronic low back pain, serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants for non-neuropathic pain, anticonvulsants, or benzodiazepines for muscle spasm associated with acute low back pain. For more information, you can refer to the NICE guidance on low back pain and sciatica in individuals over 16 years old, as well as the NICE Clinical Knowledge Summary on low back pain without radiculopathy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 27 - A 32-year-old individual comes in with a history of recent onset morning lower...

    Incorrect

    • A 32-year-old individual comes in with a history of recent onset morning lower back pain. After being referred and assessed by a specialist, they are diagnosed with spondyloarthritis as the underlying cause of their back pain. Which of the following is the most likely underlying diagnosis?

      Your Answer: Reactive arthritis

      Correct Answer: Ankylosing spondylitis

      Explanation:

      Spondyloarthritis is a term that encompasses various inflammatory conditions affecting both the joints and the entheses, which are the attachment sites of ligaments and tendons to the bones. The primary cause of spondyloarthritis is ankylosing spondylitis, but it can also be triggered by reactive arthritis, psoriatic arthritis, and enteropathic arthropathies.

      If individuals below the age of 45 experience four or more of the following symptoms, they should be referred for a potential diagnosis of spondyloarthritis:

      – Presence of low back pain and being younger than 35 years old
      – Waking up in the second half of the night due to pain
      – Buttock pain
      – Pain that improves with movement or within 48 hours of using nonsteroidal anti-inflammatory drugs (NSAIDs)
      – Having a first-degree relative with spondyloarthritis
      – History of current or past arthritis, psoriasis, or enthesitis.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      20.8
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  • Question 28 - A 60-year-old patient comes in with an arthropathy affecting his right knee. After...

    Correct

    • A 60-year-old patient comes in with an arthropathy affecting his right knee. After sending a joint aspirate to the laboratory, a diagnosis of pseudogout is made. What type of crystals would you anticipate observing in the presence of pseudogout?

      Your Answer: Positively birefringent brick-shaped crystals

      Explanation:

      Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.

      Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 29 - A patient comes in with a history of back pain and neurological symptoms...

    Incorrect

    • A patient comes in with a history of back pain and neurological symptoms in the lower limbs. He has experienced back issues intermittently for a few years and has previously been diagnosed with spondylolysis.
      Which specific part of the vertebra is typically affected by spondylolysis?

      Your Answer: Superior vertebral notch

      Correct Answer: Pars interarticularis

      Explanation:

      Spondylolysis refers to a flaw or fracture caused by stress in the pars interarticularis of the vertebral arch. While it can occur in the cervical vertebrae, it is most commonly found in the lower lumbar vertebrae, specifically L5. This injury is frequently seen in children and adolescents who engage in sports activities that place repetitive strain on the lower back, such as gymnastics, football, and weightlifting.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 30 - A 32-year-old individual comes in with a recent onset of low back pain...

    Incorrect

    • A 32-year-old individual comes in with a recent onset of low back pain that is more severe in the mornings. They mention that their mother has ankylosing spondylitis and express concern about the possibility of having the same condition.
      Which of the following is NOT a red flag characteristic that suggests spondyloarthritis as the underlying cause of back pain?

      Your Answer: Buttock pain

      Correct Answer: Progressive neurological deficit

      Explanation:

      Spondyloarthritis is a term that encompasses various inflammatory conditions affecting both the joints and the sites where ligaments and tendons attach to the bones, known as entheses. The primary cause of spondyloarthritis is ankylosing spondylitis, but it can also be caused by reactive arthritis, psoriatic arthritis, and enteropathic arthropathies.

      If individuals under the age of 45 exhibit four or more of the following symptoms, they should be referred for a potential diagnosis of spondyloarthritis:
      – Presence of low back pain and being younger than 35 years old
      – Waking up in the second half of the night due to pain
      – Experiencing buttock pain
      – Pain that improves with movement or within 48 hours of using nonsteroidal anti-inflammatory drugs (NSAIDs)
      – Having a first-degree relative with spondyloarthritis
      – History of current or past arthritis, psoriasis, or enthesitis

      It is important to note that a progressive neurological deficit would be an atypical presentation for spondyloarthritis and may instead indicate cauda equina syndrome (CES).

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      13.3
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SESSION STATS - PERFORMANCE PER SPECIALTY

Musculoskeletal (non-traumatic) (10/30) 33%
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