-
Question 1
Incorrect
-
A 65-year-old woman presents with severe and continuous 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 causative organism for the underlying diagnosis?Your Answer: Escherichia coli
Correct 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 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)
-
-
Question 2
Incorrect
-
A 45-year-old man comes in with sudden onset of severe lower back pain. Upon evaluation, you determine that prescribing ibuprofen and codeine phosphate would be appropriate. The patient has a history of depression and is currently taking fluoxetine. In which ONE situation would you consider adding a PPI to provide gastro-protection?
Your Answer: BMI >35 kg/m2
Correct Answer: Co-prescription of fluoxetine
Explanation:According to the current recommendations by NICE, it is advised to consider gastro-protection for patients who meet more than one of the following criteria: using the highest recommended dose of an NSAID, being 65 years or older, having a history of peptic ulcer or gastrointestinal bleeding, taking medications that increase the risk, using low dose aspirin, anticoagulants, corticosteroids, or anti-depressants including SSRIs and SNRIs, requiring prolonged NSAID usage, having osteoarthritis or rheumatoid arthritis at any age, or experiencing long-term back pain if older than 45.
If gastro-protection is necessary, it is recommended to choose either omeprazole 20 mg daily or lansoprazole 15-30 mg daily as the preferred PPIs.
In the case of this patient, they are currently taking 400 mg of ibuprofen three times a day, which is within the maximum recommended dose of 2.4 g daily. Therefore, there is no need for gastro-protection based on the dosage of ibuprofen alone. Additionally, factors such as co-prescription of codeine, a raised BMI, and a family history of peptic ulceration would also not warrant the need for gastro-protection.
For more information, you can refer to the NICE Clinical Knowledge Summary on prescribing issues with NSAIDs.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 3
Incorrect
-
A 45-year-old construction worker comes in with intense lower back pain. He has experienced back pain on and off for several years, but it has recently worsened significantly. He is walking with a noticeable limp, and during the examination, you observe that he has weakness in knee extension. You decide to conduct a digital rectal examination and discover that his anal sphincter tone is unexpectedly loose.
What is the SINGLE most probable diagnosis?Your Answer: Reactive arthritis
Correct Answer: Cauda equina syndrome
Explanation:Cauda equina syndrome (CES) is a rare but serious complication that can occur when a disc in the spine ruptures. This happens when the material from the disc is pushed into the spinal canal and puts pressure on a bundle of nerves in the lower back and sacrum. When this happens, it can lead to problems with controlling the bladder and bowels.
There are certain signs that may indicate the presence of CES, which are known as red flags. These include experiencing sciatica on both sides of the body, having a severe or worsening neurological deficit in both legs, such as significant weakness in the muscles that extend the knee, turn the ankle outward, or lift the foot upward. Other red flags include difficulty starting to urinate or a decreased sensation of the flow of urine, a loss of feeling when the rectum is full, a loss of sensation in the perianal, perineal, or genital areas (also known as saddle anesthesia or paresthesia), and a looseness in the anal sphincter muscle.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 4
Incorrect
-
A 42-year-old carpenter presents with a sudden onset of severe pain in his left wrist. He recently started taking bendroflumethiazide to help with his ankle swelling. He is overweight with a BMI of 36 kg/m2 and admits to drinking a few beers most nights. He describes the pain as unbearable and it was at its worst in the first 8-10 hours. On examination, his left wrist is swollen, hot, and extremely tender. The skin over the area is red.
What is the most likely diagnosis for this patient?Your Answer: Reactive arthritis
Correct Answer: Gout
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)
-
-
Question 5
Correct
-
You request your colleague to assess a patient you have evaluated with wrist discomfort. After conducting a thorough history and examination, your colleague diagnoses the individual with de Quervain's tenosynovitis.
Which specific tendon is commonly impacted in cases of de Quervain's tenosynovitis?Your Answer: Extensor pollicis brevis
Explanation:De Quervain’s tenosynovitis is a condition characterized by inflammation and thickening of the sheath that contains the tendons of the extensor pollicis brevis and abductor pollicis longus. This leads to pain on the radial side of the wrist. The condition is more commonly observed in men than women, particularly in the age group of 30 to 50 years. It is often associated with repetitive activities that involve pinching and grasping.
During examination, swelling and tenderness along the tendon sheath may be observed. The tendon sheath itself may also appear thickened. The most pronounced tenderness is usually felt over the tip of the radial styloid. A positive Finkelstein’s test, which involves flexing the wrist and moving it towards the ulnar side while the thumb is flexed across the palm, can help confirm the diagnosis.
Treatment for De Quervain’s tenosynovitis involves avoiding movements that can trigger symptoms and using a thumb splint to immobilize the thumb. In cases where symptoms persist, a local corticosteroid injection or surgical decompression may be considered.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 6
Incorrect
-
A 35-year-old woman presents to the Emergency Department complaining of low back pain and numbness in both feet. Three days ago, she had felt a sharp, shooting pain in her back after lifting a heavy box at work. The pain had worsened over the past three days, and she has now developed weakness in her left leg. She is also complaining of some difficulty passing urine. Her past medical history includes a laminectomy for a herniated lumbar disc four years previously. Her examination revealed normal power in her right leg but reduced power in the left leg. Motor strength was 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. Her ankle and Achilles tendon reflexes were absent on the left-hand side. Sensory examination revealed reduced sensation in the left calf, left foot, vulva, and perianal area. Rectal examination revealed reduced sphincter tone.
What is the gold-standard investigation to confirm the diagnosis in this case?Your Answer: CT myelogram
Correct Answer: MRI scan of the spine
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)
-
-
Question 7
Incorrect
-
A 72-year-old woman presents with a painful swollen left big toe. The pain started this morning and is described as the most severe pain she has ever experienced. It has gradually worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in opened toe sandals. The overlying skin is red and shiny.
She has a history of hypertension, which has been difficult to control. She is currently taking amlodipine 10 mg and ramipril 10 mg per day for this and is awaiting a review of her antihypertensive medication. Her blood pressure today is 165/94 mmHg.
She has recently also been diagnosed with a myelodysplastic syndrome and has to have regular blood transfusions. She is being monitored in a local haematology clinic for a low white cell count and thrombocytopenia.
What is the SINGLE most appropriate next step in her management?Your Answer: Commence allopurinol
Correct Answer: Commence prednisolone
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 is not very beneficial 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 an 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. It’s important to note that colchicine can have effects on the bone marrow, leading to an increase in neutrophils and a decrease in platelets. Therefore, it should not be used in patients with blood disorders, as is the case with this patient.
Allopurinol should not be used during an acute gout attack as it can prolong the attack and even trigger another acute attack. If a patient is already taking allopurinol, it should be continued, and the acute attack should be treated with NSAIDs, colchicine, or corticosteroids as appropriate.
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. In this patient’s case, using corticosteroids would be the safest and most reasonable treatment option.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 8
Incorrect
-
A 35-year-old carpenter presents with shoulder pain that worsens during repetitive overhead work. The patient also reports experiencing nighttime pain and difficulty in raising the arm. There is no history of any injury.
What is the SINGLE most probable diagnosis?Your Answer: Subscapularis tear
Correct Answer: Subacromial impingement
Explanation:The supraspinatus tendon passes through a narrow space located between the underside of the acromion and acromioclavicular joint, as well as the head of the humerus. When the tendon becomes trapped in this space, it can cause pain and restrict movement, especially during overhead activities. This condition is known as subacromial impingement.
Impingement can occur due to various factors, such as thickening of the tendon caused by partial tears, inflammation, or degeneration. It can also be a result of the space narrowing due to osteoarthritis of the acromioclavicular joint or the presence of bone spurs. Some individuals may have a naturally downward sloping acromion, which makes them more susceptible to impingement.
Certain professions that involve a significant amount of overhead work, like plasterers, builders, and decorators, are particularly prone to developing subacromial impingement.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 9
Incorrect
-
A 30-year-old woman presents with a painful knee. She first noticed the pain a few days ago and is now experiencing general malaise and a fever. Upon examination, the joint appears swollen, hot, and red. The patient is hesitant to move the knee due to the intense pain. No other joints are affected.
What is the MOST LIKELY causative organism in this scenario?Your Answer: Streptococcus viridans
Correct Answer: Staphylococcus aureus
Explanation:Septic arthritis in adults is most commonly caused by Staphylococcus aureus. However, Streptococcus spp. is the most common group of bacteria responsible for this condition. In the past, Haemophilus influenzae used to be a significant cause of septic arthritis, but with the introduction of vaccination programs, its occurrence has significantly decreased. Other bacteria that can lead to septic arthritis include E. Coli, Salmonella, Neisseria gonorrhoea, and Mycobacterium.
It is important to note that viruses can also be a cause of septic arthritis. Examples of such viruses include hepatitis A, B, and C, coxsackie, adenovirus, and parvovirus. Additionally, fungi can also be responsible for septic arthritis, with Histoplasmosa and Blastomyces being notable examples.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 10
Correct
-
A 45-year-old patient presents with a painful, swollen left knee. His symptoms started three days ago. He has no history of injury, and a joint aspirate is sent for laboratory testing. The aspirate reveals pus cells, negatively birefringent crystals, and no presence of organisms.
What is the SINGLE most probable diagnosis?Your Answer: Gout
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)
-
-
Question 11
Incorrect
-
You evaluate a child with a limp and complaints of hip discomfort. An X-ray is conducted, and the diagnosis of Perthes' disease is confirmed.
Which ONE statement about this condition is accurate?Your Answer: Treatment is always surgical
Correct Answer: A positive family history is present in 10-15% of cases
Explanation:Perthes’ disease is a hip disorder that occurs in childhood due to a disruption in the blood supply to the femoral head. This leads to a lack of blood flow, causing the bone to die. The condition typically affects children between the ages of 4 and 10, with boys being more commonly affected than girls. In about 10-15% of cases, there is a family history of the disease, and approximately 15% of patients have the condition in both hips.
The progression of Perthes’ disease can be seen through characteristic changes on X-rays, which can take between 2 and 4 years to fully heal. The earliest sign is an increased density of the epiphysis (the end of the bone) and widening of the medial joint space. As the disease progresses, the epiphysis may fragment and the head of the femur may flatten. Over time, the bone gradually heals, with the dense bone being reabsorbed and replaced by new bone. This process continues until growth stops, and the bone is remodeled.
Children with Perthes’ disease typically present with hip pain and a limp. The pain can vary in severity, and clinical signs may be minor, with only a slight restriction in hip joint movement.
The treatment of Perthes’ disease is a topic of debate. Around 50% of patients can achieve good results with conservative management alone, without the need for surgery. Surgical intervention, such as osteotomy (reshaping the bone), is usually reserved for cases where the disease progresses unfavorably or when conservative treatment fails. Potential complications of Perthes’ disease include permanent hip deformity and secondary arthritis.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 12
Incorrect
-
A 60-year-old individual presents with an arthropathy affecting their right knee. A diagnosis of pseudogout is made based on the findings of a joint aspirate that has been sent for laboratory analysis.
What type of crystals are deposited in the joints in pseudogout?Your Answer: Urate crystals
Correct Answer: Calcium pyrophosphate 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)
-
-
Question 13
Incorrect
-
A 52-year-old man comes in with an acute episode of gout.
Which SINGLE statement regarding the management of acute gout is accurate?Your Answer: Colchicine is contraindicated in heart failure
Correct Answer: A common first-line treatment is Naproxen as a stat dose of 750 mg followed by 250 mg TDS
Explanation:In cases where there are no contraindications, high-dose NSAIDs are the recommended initial treatment for acute gout. A commonly used and effective regimen is to administer a stat dose of Naproxen 750 mg, followed by 250 mg three times a day. It is important to note that Aspirin should not be used in gout as it hinders the urinary clearance of urate and interferes with the action of uricosuric agents. Instead, more appropriate choices include Naproxen, diclofenac, or indomethacin.
Allopurinol is typically used as a prophylactic measure to prevent future gout attacks by reducing serum uric acid levels. However, it should not be initiated during the acute phase of an attack as it can worsen the severity and duration of symptoms.
Colchicine works by binding to tubulin and preventing neutrophil migration into the joint. It is just as effective as NSAIDs in relieving acute gout attacks. Additionally, it has a role in prophylactic treatment if a patient cannot tolerate Allopurinol.
It is important to note that NSAIDs are contraindicated 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 for patients with heart failure or those who cannot tolerate NSAIDs.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 14
Correct
-
A 45-year-old office worker presents with a few weeks history of lower back pain. He is experiencing significant pain and has difficulty moving. You discuss the available treatment options.
According to the current NICE guidelines, which of the following pharmacological treatments is recommended? Choose ONE option only.Your Answer: Ibuprofen alone
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)
-
-
Question 15
Incorrect
-
A 40-year-old carpenter comes in with a few weeks of persistent lower back pain. Despite taking the maximum dose of ibuprofen, the pain continues to be significant. What would be the most suitable course of treatment? Choose only ONE option.
Your Answer: Low-dose diazepam
Correct Answer: 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)
-
-
Question 16
Correct
-
You evaluate a 62-year-old woman with a painful swollen left big toe. The pain began this morning and is described as the most severe pain she has ever experienced. It has progressively worsened over the past 8 hours. She is unable to wear socks or shoes and had to attend the appointment wearing open-toe sandals. The skin over the affected area appears red and shiny.
What is the most probable diagnosis in this scenario?Your 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, accompanied by acute pain that intensifies over a period of 6-12 hours, it is highly likely to be a crystal arthropathy. While pseudogout is also a possibility, it is much less probable, with gout being the most likely diagnosis in such cases.
In cases of acute gout, the joint most commonly affected is the first metatarsal-phalangeal joint, accounting for 50-75% of cases. The underlying 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, the usual approach involves the use of either NSAIDs or colchicine.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 17
Incorrect
-
A 32-year-old man recently suffered a fracture in his right wrist. His cast has been taken off, and he visits you with worries about his right hand. Since the fracture, he has experienced tingling sensations in his thumb and has accidentally dropped items from his right hand a few times. These symptoms have not shown any improvement after the removal of the cast.
What is the MOST probable diagnosis?Your Answer: De Quervain’s tenosynovitis
Correct Answer: Ulnar neuritis
Explanation:Ulnar neuritis is characterized by hand clumsiness and can progress to muscle weakness and wasting in the ulnar nerve-supplied muscles. It may also cause numbness or tingling in the little finger and medial half of the ring finger. This condition is caused by the narrowing of the ulnar groove at the elbow and is associated with risk factors such as osteoarthritis, trauma, and rheumatoid arthritis. Nerve conduction studies and surgical decompression may be necessary for diagnosis and treatment.
De Quervain’s tenosynovitis occurs when there is inflammation of the thumb extensor and abductor tendon sheaths. This leads to pain over the radial styloid, which worsens with forced adduction and flexion of the thumb. Treatment options include anti-inflammatory medications, thumb splints, and steroid injections.
Dupuytren’s contracture occurs when the palmar fascia contracts, preventing finger extension. It commonly affects the fifth finger on the right hand and is more prevalent in men over the age of 65. Risk factors for this condition include male sex, family history, alcohol use, diabetes, smoking, trauma, and manual labor. Surgical release is necessary if the contracture affects daily activities or work.
Trigger finger occurs when a nodule becomes stuck in the tendon sheath, causing the affected finger to remain in a fixed flexed position. The ring and middle fingers are most commonly affected, and risk factors include rheumatoid arthritis and diabetes. Steroid injections or surgical removal can be used to treat this condition.
Carpal tunnel syndrome occurs when the median nerve is compressed under the flexor retinaculum, resulting in numbness, pain, and wasting of the thenar eminence in the lateral three and a half digits. Symptoms are often worse at night. While most cases are idiopathic, risk factors include obesity, oral contraceptive use, hypothyroidism, rheumatoid arthritis, pregnancy, diabetes, amyloidosis, acromegaly, tumors compressing the carpal tunnel, and previous wrist fractures. Tinel’s test and Phalen’s test can help diagnose carpal tunnel syndrome, and nerve conduction studies may be requested for further evaluation. Treatment options include splints, steroid injections, and surgical release if symptoms persist.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 18
Incorrect
-
A 60-year-old individual comes in with an arthropathy impacting the metatarsophalangeal joint on their left foot. Gout is suspected, and a joint aspirate is sent for laboratory analysis.
What type of crystals would be anticipated in the presence of gout?Your Answer: Amorphous crystals
Correct Answer: Negatively birefringent needle-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)
-
-
Question 19
Incorrect
-
You assess a limping adolescent with hip discomfort. An X-ray is conducted, and a diagnosis of Slipped upper femoral epiphysis (SUFE) is confirmed.
Which ONE statement about this condition is NOT true?Your Answer: It is bilateral in approximately 20% of cases
Correct Answer: It typically presents later in girls
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)
-
-
Question 20
Incorrect
-
You evaluate a 72-year-old woman with a painful swollen left big toe. The pain started this morning and is described as the most severe pain she has ever experienced. It has gradually worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in open-toe sandals. The overlying skin is red and shiny.
She has a history of hypertension, which has been challenging to control. She is currently taking amlodipine 10 mg and ramipril 10 mg per day for this and is awaiting a review of her antihypertensive medication. Her blood pressure today is 165/94 mmHg.
She has recently also been diagnosed with a myelodysplastic syndrome and requires regular blood transfusions. She is being monitored in a local hematology clinic for a low white cell count and thrombocytopenia.
What is the most appropriate next step in management for this patient?Your Answer: Commence colchicine
Correct Answer: Commence prednisolone
Explanation:The diagnosis in this case is clearly gout. According to the European League Against Rheumatism (EULAR) guidelines, 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 is not very beneficial 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 an 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. It’s important to note that colchicine can also affect the bone marrow, leading to an increase in white blood cells and a decrease in platelets. Therefore, it should not be used in patients with blood disorders, as in this case.
During an acute gout attack, allopurinol should not be used as it can prolong the attack and even trigger another acute attack. If a patient is already taking allopurinol, it should be continued, and the acute attack should be treated with NSAIDs, colchicine, or corticosteroids as appropriate.
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. In this patient’s case, using corticosteroids would be the safest and most reasonable treatment option.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 21
Correct
-
You assess a patient in a clinic who has been diagnosed with a neuropathy affecting the muscles around her shoulder joint. During the examination, you observe that she has significant restriction in the abduction of her arm. Your consultant examines the patient and instructs her to raise her arms parallel to the ground in the scapular plane. When rotating the arm internally with the thumbs pointing downwards, she is unable to sustain the position with her left arm when pressure is applied.
Which nerve is most likely to have been affected in this scenario?Your Answer: Suprascapular nerve
Explanation:The supraspinatus muscle is a small muscle located in the upper back. It extends from the supraspinatus fossa of the scapula to the greater tubercle of the humerus. This muscle is part of the rotator cuff, along with three other muscles. The supraspinatus muscle is innervated by the suprascapular nerve, which also innervates the infraspinatus muscle. The suprascapular nerve originates from the upper trunk of the brachial plexus.
The main function of the supraspinatus muscle is to assist the deltoid muscle in abducting the arm at the shoulder joint. Specifically, it is responsible for the initial 15 degrees of arm abduction. Beyond this range, the deltoid muscle takes over as the primary abductor.
In addition to its role in arm movement, the supraspinatus muscle works together with the other rotator cuff muscles to stabilize the shoulder joint. It helps keep the humeral head in the glenoid fossa and counteracts the downward gravitational forces exerted on the shoulder joint by the weight of the arm.
One common test used to assess the supraspinatus muscle is called the empty can test. During this test, the patient is positioned either standing or sitting, with their arms raised parallel to the ground in the scapular plane. The arm is then internally rotated fully, with the thumb facing downward. The clinician applies downward pressure on either the wrists or the elbow, while the patient resists this pressure. If the patient experiences weakness, pain, or both during this resistance, it indicates a possible tear in the supraspinatus tendon or muscle, or a suprascapular nerve neuropathy.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 22
Incorrect
-
A 55-year-old woman presents with a swollen, red, and painful right knee. Septic arthritis is suspected, and a joint aspirate is sent for laboratory testing. The patient's medical history reveals that she is a known carrier of MRSA, raising concerns of an MRSA infection.
What is the recommended first-line antibiotic for septic arthritis when MRSA is suspected?Your Answer: Flucloxacillin
Correct Answer: Vancomycin
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)
-
-
Question 23
Incorrect
-
You evaluate a 52-year-old man with a painful swollen left big toe. He has a known history of gout and states that this pain is similar to previous flare-ups. He is currently on a daily dose of allopurinol 200 mg and has been taking it for the past year. This is his second episode of acute gout during this time period. He has no significant medical history and is not taking any other medications. He has no known allergies.
What is the MOST suitable next step in management?Your Answer: Increase the dose of allopurinol to 300 mg per day
Correct 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)
-
-
Question 24
Correct
-
You ask your consultant to review a patient you have seen with knee pain. Following a history and examination, the consultant makes a diagnosis of patellofemoral pain syndrome.
Which SINGLE statement is correct regarding this diagnosis?Your Answer: It affects more than one tendon
Explanation:De Quervain’s tenosynovitis is a condition characterized by inflammation and thickening of the sheath that contains the tendons of the extensor pollicis brevis and abductor pollicis longus. This leads to pain on the radial side of the wrist. It is more commonly observed in women, particularly those aged between 30 and 50 years. The condition is often associated with repetitive activities that involve pinching and grasping.
During examination, swelling and tenderness along the tendon sheath may be observed. The tendon sheath itself may also appear thickened. The most pronounced tenderness is usually felt over the tip of the radial styloid. A positive Finkelstein’s test, which involves flexing the wrist and moving it towards the ulnar side while the thumb is flexed across the palm, can help confirm the diagnosis.
Treatment for De Quervain’s tenosynovitis involves avoiding movements that can trigger symptoms and using a thumb splint to immobilize the thumb. In cases where symptoms persist, a local corticosteroid injection or surgical decompression may be considered.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 25
Incorrect
-
A middle-aged homeless individual with a history of intravenous drug use complains of extremely intense back pain, accompanied by a fever and weakness in the left leg. The pain has been disrupting his sleep and hindering his ability to walk. During the examination, tenderness is observed in the lower lumbar spine, along with weakness in left knee extension and foot dorsiflexion.
What is the MOST probable diagnosis in this case?Your Answer: Non-Hodgkin lymphoma
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 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)
-
-
Question 26
Incorrect
-
A 25-year-old woman comes to the clinic with a swollen and red right knee. She recently returned from a trip to Bangkok. During the examination, her temperature is 38.6°C and she has a rash with small blisters on her trunk. The knee feels warm to touch and is immobile. Attempts to flex or extend the knee are unsuccessful. A joint aspiration is done, and Gram-negative diplococci are observed.
Which of the following antibiotics would be the most suitable to prescribe for this patient?Your Answer: Gentamicin
Correct Answer: Cefotaxime
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 upset.
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 (methicillin-resistant Staphylococcus aureus), vancomycin should be used. For suspected 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)
-
-
Question 27
Correct
-
A 45-year-old office worker comes in with a few weeks of persistent lower back pain. The pain is severe and has greatly affected their ability to move. You discuss the available treatment options.
Which of the following medication treatments is NOT recommended according to the current NICE guidelines? Choose ONE option.Your Answer: Paracetamol alone
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)
-
-
Question 28
Incorrect
-
A 32-year-old individual comes in with a recent onset of low back pain that has been getting worse over the past few days. They have been experiencing chills today and their temperature is elevated at 38°C.
Which of the following is a warning sign that suggests an infectious origin for their back pain?Your Answer: Severe central pain in the spine which is relieved by lying down
Correct Answer: Use of immunosuppressant drugs
Explanation:Infectious factors that can lead to back pain consist of discitis, vertebral osteomyelitis, and spinal epidural abscess. There are certain warning signs, known as red flags, that indicate the presence of an infectious cause for back pain. These red flags include experiencing a fever, having tuberculosis, being diabetic, having recently had a bacterial infection such as a urinary tract infection, engaging in intravenous drug use, and having a weakened immune system due to conditions like HIV or the use of immunosuppressant drugs.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 29
Incorrect
-
A 50-year-old carpenter comes in with a chief complaint of shoulder pain that worsens with repetitive overhead tasks. Additionally, he reports experiencing nighttime pain and difficulty in raising his arm. There is no history of any injuries.
Which muscle is most likely to be affected in this scenario?Your Answer: Teres minor
Correct Answer: Supraspinatus
Explanation:The supraspinatus tendon passes through a narrow space located between the underside of the acromion and acromioclavicular joint, as well as the head of the humerus. When the tendon becomes trapped in this space, it can cause pain and restrict movement, especially during overhead activities. This condition is known as subacromial impingement.
Impingement can occur due to various factors, such as thickening of the tendon caused by partial tears, inflammation, or degeneration. It can also be a result of the space narrowing due to osteoarthritis of the acromioclavicular joint or the presence of bone spurs. Some individuals may have a naturally downward sloping acromion, which makes them more susceptible to impingement.
Certain professions that involve a significant amount of overhead work, like plasterers, builders, and decorators, are particularly prone to developing subacromial impingement.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 30
Incorrect
-
A 32-year-old construction worker complains of lower back pain and stiffness. He experiences the most discomfort while sitting at his desk and also feels very stiff in the mornings. You decide to evaluate him using a widely recognized risk stratification tool for back pain.
Which risk stratification tool does the current NICE guidance support?Your Answer:
Correct Answer: Keele STarT Back risk assessment tool
Explanation:NICE recommends the use of a risk stratification tool at the first point of contact with a healthcare professional for new episodes of low back pain, whether with or without sciatica. The specific tool mentioned in the current NICE guidelines is the Keele STarT Back risk assessment tool.
The Keele STarT Back Screening Tool (SBST) is a short questionnaire designed to guide initial treatment for low back pain in primary care. It consists of nine items that assess both physical (such as leg pain, comorbid pain, and disability) and psychosocial factors (such as bothersomeness, catastrophising, fear, anxiety, and depression) that have been identified as strong indicators of poor prognosis.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
00
Correct
00
Incorrect
00
:
00
:
0
00
Session Time
00
:
00
Average Question Time (
Mins)