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  • Question 1 - A 35-year-old woman and her partner have come to seek advice from their...

    Incorrect

    • A 35-year-old woman and her partner have come to seek advice from their GP on how to conceive as they are planning to start a family. The woman has a medical history of asthma and obesity with a BMI of 32 kg/m², while her partner has Crohn's disease that is being managed with methotrexate. They have no significant family history and the woman hopes to have a vaginal birth. She has never been pregnant before. What is the primary advice that should be given?

      Your Answer: They should both take 5 milligrams of folic acid until the end of the first trimester

      Correct Answer: Her husband should use contraception and wait for 6 months after stopping treatment first

      Explanation:

      Patients who are using methotrexate must use effective contraception during treatment and for at least 6 months after treatment, whether they are male or female. In this case, the patient’s husband is taking methotrexate, which inhibits dihydrofolate reductase and folic acid metabolism. Therefore, both partners should stop taking methotrexate for 6 months and use effective contraception before attempting to conceive. Methotrexate can damage sperm in men and eggs in women, which can lead to severe complications such as neural tube defects in the fetus. Additional folic acid supplements will not significantly reduce the risk of complications associated with methotrexate. Therefore, both partners should use effective contraception during the time the husband is taking methotrexate. The advice to take 400 micrograms or 5 milligrams of folic acid until the end of the first trimester is incorrect in this case, as the couple should delay trying for a pregnancy for 6 months due to the husband’s methotrexate use.

      Methotrexate: An Antimetabolite with Potentially Life-Threatening Side Effects

      Methotrexate is an antimetabolite drug that inhibits the enzyme dihydrofolate reductase, which is essential for the synthesis of purines and pyrimidines. It is commonly used to treat inflammatory arthritis, psoriasis, and some types of leukemia. However, it is considered an important drug due to its potential for life-threatening side effects. Careful prescribing and close monitoring are essential to ensure patient safety.

      The adverse effects of methotrexate include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis. The most common pulmonary manifestation is pneumonitis, which typically develops within a year of starting treatment and presents with non-productive cough, dyspnea, malaise, and fever. Women should avoid pregnancy for at least 6 months after treatment has stopped, and men using methotrexate need to use effective contraception for at least 6 months after treatment.

      When prescribing methotrexate, it is important to follow guidelines and monitor patients regularly. Methotrexate is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. The starting dose is 7.5 mg weekly, and folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after the methotrexate dose. Only one strength of methotrexate tablet should be prescribed, usually 2.5 mg. It is also important to avoid prescribing trimethoprim or co-trimoxazole concurrently, as it increases the risk of marrow aplasia, and high-dose aspirin increases the risk of methotrexate toxicity.

      In case of methotrexate toxicity, the treatment of choice is folinic acid. Methotrexate is a drug with a high potential for patient harm, and it is crucial to be familiar with guidelines relating to its use to ensure patient safety.

    • This question is part of the following fields:

      • Musculoskeletal
      18.3
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  • Question 2 - A 35-year-old female accountant presents to her local urgent care centre with a...

    Incorrect

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

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

      What is the likely diagnosis based on these findings?

      Your Answer: Carpal tunnel syndrome

      Correct Answer: De Quervain's tenosynovitis

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 3 - A 28-year-old amateur football player arrives at the emergency department complaining of knee...

    Incorrect

    • A 28-year-old amateur football player arrives at the emergency department complaining of knee pain. During the game, she experienced a popping sensation in her left knee. Upon examination, her knee is swollen, and she cannot fully extend it. Which diagnostic test is most likely to reveal the underlying cause?

      Your Answer: Joint aspiration

      Correct Answer: Magnetic resonance imaging (MRI)

      Explanation:

      When it comes to detecting lateral and medial meniscal tears, an MRI is the most sensitive option available. It surpasses the other choices in terms of sensitivity and should be requested for all patients who are suspected of having a meniscal injury. Ultrasound may be challenging to perform due to the patient’s probable swelling and pain. An X-ray may be necessary for patients with arthritis or a history of repeated meniscal tears.

      Understanding Meniscal Tear and its Symptoms

      Meniscal tear is a common knee injury that usually occurs due to twisting injuries. Its symptoms include pain that worsens when the knee is straightened, a feeling that the knee may give way, tenderness along the joint line, and knee locking in cases where the tear is displaced. To diagnose a meniscal tear, doctors may perform Thessaly’s test, which involves weight-bearing at 20 degrees of knee flexion while the patient is supported by the doctor. If the patient experiences pain on twisting the knee, the test is considered positive.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 4 - A 28-year-old woman comes in with complaints of intermittent pain in her left...

    Incorrect

    • A 28-year-old woman comes in with complaints of intermittent pain in her left hand for several months, particularly when exposed to cold weather. She describes the pain as spasming and accompanied by numbness and a change in color in her hand. Upon examination, she appears to be in good health, and there are no visible signs or symptoms. However, a non-specific rash resembling eczema is present in the flexure creases. Blood tests are conducted, and the patient is referred for further specialized testing. What factors would suggest a primary disease rather than a secondary one?

      Your Answer: Presence of autoantibodies

      Correct Answer: Onset under 40 years

      Explanation:

      Raynaud’s disease, specifically primary Raynaud’s, is likely in a young woman experiencing bilateral symptoms. The spasming of hand vessels causing color changes, especially in cold weather, strongly suggests Raynaud’s. Onset under 40 years of age is a key feature of primary Raynaud’s, while onset over 40 years points more towards secondary Raynaud’s, which may be associated with a connective tissue disorder. Specialist testing, such as nail fold capillary microscopy, may be performed to rule out secondary Raynaud’s. Autoantibodies would indicate the possibility of a systemic disorder causing secondary Raynaud’s. The presence of a non-specific rash may also suggest secondary Raynaud’s, as many systemic conditions associated with Raynaud’s are also linked to rashes.

      Understanding Raynaud’s Phenomenon

      Raynaud’s phenomenon is a condition where the digital arteries and cutaneous arteriole overreact to cold or emotional stress, causing an exaggerated vasoconstrictive response. It can be classified as primary or secondary. Primary Raynaud’s disease is more common in young women and presents with bilateral symptoms. On the other hand, secondary Raynaud’s phenomenon is associated with underlying connective tissue disorders such as scleroderma, rheumatoid arthritis, and systemic lupus erythematosus, among others.

      Factors that suggest an underlying connective tissue disease include onset after 40 years, unilateral symptoms, rashes, presence of autoantibodies, and digital ulcers. Management of Raynaud’s phenomenon involves referral to secondary care for patients with suspected secondary Raynaud’s phenomenon. First-line treatment includes calcium channel blockers such as nifedipine. In severe cases, IV prostacyclin (epoprostenol) infusions may be used, and their effects may last for several weeks or months.

    • This question is part of the following fields:

      • Musculoskeletal
      12.9
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  • Question 5 - A 32-year-old woman comes to see her doctor complaining of a burning sensation...

    Correct

    • A 32-year-old woman comes to see her doctor complaining of a burning sensation on the outside of her left thigh. The pain is particularly bothersome when she moves, especially when she's standing at work. She reports no prior experience with this type of pain and has no significant medical history. Her records show a recent blood pressure reading of 130/90 mmHg and a BMI of 40 kg/m². What is the probable diagnosis in this scenario?

      Your Answer: Meralgia parasthetica

      Explanation:

      Pain in the distribution of the lateral cutaneous nerve of the thigh is a common symptom of Meralgia parasthetica. This pain is often worsened by standing and relieved by sitting, and is accompanied by altered sensation in the anterolateral aspect of the thigh. Meralgia parasthetica can be caused by pregnancy, obesity, tense ascites, trauma, or surgery, and is more prevalent in individuals with diabetes.

      In contrast, fibromyalgia typically presents with pain in the neck and shoulders, along with other symptoms such as fatigue, muscle stiffness, difficulty sleeping, and cognitive impairment. Fibromyalgia pain does not typically affect the lateral thigh.

      L3 lumbar radiculopathy, on the other hand, causes pain in the lower back and hip that radiates down into the leg, often accompanied by muscle weakness.

      Osteoarthritis is characterized by joint pain and stiffness in the hips or knees, and is more common in older individuals, females, and those who are overweight. It does not typically cause changes in sensation in the thigh.

      Understanding Meralgia Paraesthetica

      Meralgia paraesthetica is a condition characterized by paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN). It is caused by entrapment of the LFCN, which can be due to various factors such as trauma, iatrogenic causes, or neuroma. Although not rare, it is often underdiagnosed.

      The LFCN is a sensory nerve that originates from the L2/3 segments and runs beneath the iliac fascia before exiting through the lateral aspect of the inguinal ligament. Compression of the nerve can occur anywhere along its course, but it is most commonly affected as it curves around the anterior superior iliac spine. Meralgia paraesthetica is more common in men than women and is often seen in those aged between 30 and 40.

      Patients with meralgia paraesthetica typically experience burning, tingling, coldness, or shooting pain, as well as numbness and deep muscle ache in the upper lateral aspect of the thigh. Symptoms are usually aggravated by standing and relieved by sitting. The condition can be mild and resolve spontaneously or severely restrict the patient for many years.

      Diagnosis of meralgia paraesthetica can be made based on the pelvic compression test, which is highly sensitive. Injection of the nerve with local anaesthetic can also confirm the diagnosis and provide relief. Ultrasound is effective both for diagnosis and guiding injection therapy. Nerve conduction studies may also be useful. Overall, understanding meralgia paraesthetica is important for prompt diagnosis and management of this condition.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 6 - A 45-year-old woman with a history of rheumatoid arthritis visits her GP with...

    Incorrect

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

      Your Answer: Infliximab IV

      Correct Answer: Methylprednisolone IM

      Explanation:

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

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

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

      Managing Rheumatoid Arthritis with Disease-Modifying Therapies

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

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 7 - A 40-year-old man presents with a 3-day history of groin pain. He reports...

    Incorrect

    • A 40-year-old man presents with a 3-day history of groin pain. He reports feeling a snapping sensation in his hip accompanied by deep groin and hip pain. The patient participated in a football game over the weekend. He has no prior history of such symptoms and is not on any regular medication. Upon further inquiry, he admits to consuming alcohol regularly, with an average of 70 units per week.

      During the examination, the man's large body habitus is noted. He is able to bear weight and move around the room without difficulty. However, his range of motion is restricted due to pain, particularly during external rotation.

      What is the most probable diagnosis?

      Your Answer: Femoral neck fracture

      Correct Answer: Acetabular labral tear

      Explanation:

      Understanding Acetabular Labral Tears

      Acetabular labral tears are a common condition that can occur due to trauma or degenerative changes in the hip joint. Younger adults are more likely to experience this condition as a result of an injury, while older adults may develop it due to age-related wear and tear. The main symptoms of an acetabular labral tear include hip and groin pain, a snapping sensation around the hip, and occasional locking.
      Treatment options may include physical therapy, medication, or surgery, depending on the severity of the tear and your overall health. With proper care and management, most people with acetabular labral tears can find relief from their symptoms and return to their normal activities.

    • This question is part of the following fields:

      • Musculoskeletal
      10.1
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  • Question 8 - Which of the following characteristics is not typically associated with Marfan's syndrome? ...

    Incorrect

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

      Your Answer: Tall stature

      Correct Answer: Learning difficulties

      Explanation:

      Understanding Marfan’s Syndrome

      Marfan’s syndrome is a genetic disorder that affects the connective tissue in the body. It is caused by a defect in the FBN1 gene on chromosome 15, which codes for the protein fibrillin-1. This disorder is inherited in an autosomal dominant pattern, meaning that a person only needs to inherit one copy of the defective gene from one parent to develop the condition. Marfan’s syndrome affects approximately 1 in 3,000 people.

      The features of Marfan’s syndrome include a tall stature with an arm span to height ratio greater than 1.05, a high-arched palate, arachnodactyly (long, slender fingers), pectus excavatum (sunken chest), pes planus (flat feet), and scoliosis (curvature of the spine). In addition, individuals with Marfan syndrome may experience cardiovascular problems such as dilation of the aortic sinuses, mitral valve prolapse, and aortic aneurysm. They may also have lung issues such as repeated pneumothoraces. Eye problems are also common, including upwards lens dislocation, blue sclera, and myopia. Finally, dural ectasia, or ballooning of the dural sac at the lumbosacral level, may also occur.

      In the past, the life expectancy of individuals with Marfan syndrome was around 40-50 years. However, with regular echocardiography monitoring and the use of beta-blockers and ACE inhibitors, this has improved significantly in recent years. Despite these improvements, aortic dissection and other cardiovascular problems remain the leading cause of death in individuals with Marfan syndrome.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 9 - A 75-year-old patient arrives at the emergency department with a fractured neck of...

    Incorrect

    • A 75-year-old patient arrives at the emergency department with a fractured neck of femur. The patient has a medical history of polymyalgia rheumatica, ischaemic heart disease, and dyspepsia. Their current medications include bisoprolol, ramipril, simvastatin, aspirin, omeprazole, and prednisolone. A bone profile is ordered as part of the diagnostic workup.
      What would be the probable findings for this patient?

      Your Answer: PTH - high, calcium - normal, phosphate - low

      Correct Answer: PTH - normal, calcium - normal, phosphate - normal

      Explanation:

      Normal blood test values, including ALP, calcium, phosphate, and PTH, are commonly observed in patients with osteoporosis. However, in cases where osteoporosis is caused by chronic use of systemic steroids, the bone profile results may still appear normal. Other conditions, such as primary hyperparathyroidism, osteomalacia, CKD, and tertiary hyperparathyroidism, may present with abnormal blood test values, including high PTH, low calcium, and/or low phosphate.

      Understanding Osteoporosis

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

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

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

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 10 - A 46-year-old man visits his doctor complaining of joint pain and stiffness in...

    Incorrect

    • A 46-year-old man visits his doctor complaining of joint pain and stiffness in his fingers and wrists for the past 6 weeks. He is a pianist in a local orchestra and has noticed a decline in his performance due to his symptoms. On examination, there are visible deformities in his metacarpophalangeal joints with palpable tenderness, and his wrists are slightly swollen. He has a history of mild childhood asthma but has been otherwise healthy. There are no skin or nail changes. Based on the likely diagnosis, which of the following is associated with the poorest prognosis?

      Your Answer: Rheumatoid factor negative

      Correct Answer: Anti-CCP antibodies

      Explanation:

      Rheumatoid arthritis is a symmetrical, polyarthritis that is characterized by early morning joint pain and stiffness. A positive prognosis is associated with negative anti-CCP antibodies and negative rheumatoid factor. When anti-CCP antibodies are present, they are usually seen in conjunction with positive rheumatoid factor, which is a strong predictor of early transformation from transient to persistent synovitis. A gradual onset of symptoms is also linked to a poor prognosis for rheumatoid arthritis, rather than a sudden onset. Additionally, female gender is associated with a worse prognosis for rheumatoid arthritis, while male gender is not. Finally, HLA-B27 is not associated with rheumatoid arthritis, but rather with seronegative spondyloarthropathies like psoriatic and reactive arthritis.

      Prognostic Features of Rheumatoid Arthritis

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

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 11 - A 45-year-old patient presents with an upper limb nerve injury. The patient reports...

    Incorrect

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

      Your Answer: Damage to ulnar nerve at the wrist

      Correct Answer: Damage to ulnar nerve at the elbow

      Explanation:

      Understanding Cubital Tunnel Syndrome

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed as it passes through the cubital tunnel. This can cause a range of symptoms, including tingling and numbness in the fourth and fifth fingers, which may start off intermittent but eventually become constant. Over time, patients may also experience weakness and muscle wasting. Pain is often worse when leaning on the affected elbow, and there may be a history of osteoarthritis or prior trauma to the area.

      Diagnosis of cubital tunnel syndrome is usually made based on clinical features, although nerve conduction studies may be used in selected cases. Management of the condition typically involves avoiding aggravating activities, undergoing physiotherapy, and receiving steroid injections. In cases where these measures are not effective, surgery may be necessary. By understanding the symptoms and treatment options for cubital tunnel syndrome, patients can take steps to manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 12 - A 67-year-old man with a history of type 2 diabetes mellitus and peripheral...

    Correct

    • A 67-year-old man with a history of type 2 diabetes mellitus and peripheral arterial disease presents with fatigue and unexplained fever. He underwent a left toe amputation recently and is suspected to have osteomyelitis in the affected foot. What investigation would be most suitable for confirming the diagnosis?

      Your Answer: MRI

      Explanation:

      MRI is the preferred imaging technique for diagnosing osteomyelitis.

      Understanding Osteomyelitis: Types, Causes, and Treatment

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

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

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

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 13 - A 49-year-old man presents to the Emergency Department with right-sided flank pain radiating...

    Incorrect

    • A 49-year-old man presents to the Emergency Department with right-sided flank pain radiating to the back which had developed over the past 10 days. There is no history of trauma or injury to the area.

      He is a known intravenous drug user who has been commenced on a methadone rehabilitation programme around 2 weeks previously. He has no fixed abode and spends his night between various hostels.

      He has no significant past medical history. Although has previous admissions following various injuries such as stabbings.

      His observations are: heart rate 99/min, respiratory rate 16/min, blood pressure 98/75 mmHg, temperature 37.7º, Sats 99% on air.

      On examination, he appears to be in pain and is lying flat on his back with his knees flexed. He is very tender over his back at L1 and L2 levels. He actively resists passive movement from his position of comfort and is unable to weight bear due to pain.

      Blood tests show raised inflammatory markers, lumbar spine and pelvic x-ray show no abnormality.

      He is requesting analgesia for his pain.

      What is the most likely cause of this man's symptoms?

      Your Answer: Discitis

      Correct Answer: Psoas abscess

      Explanation:

      An iliopsoas abscess is a condition where pus accumulates in the iliopsoas compartment, which includes the iliacus and psoas muscles. There are two types of iliopsoas abscesses: primary and secondary. Primary abscesses occur due to the spread of bacteria through the bloodstream, with Staphylococcus aureus being the most common cause. Secondary abscesses are caused by underlying conditions such as Crohn’s disease, diverticulitis, colorectal cancer, UTIs, GU cancers, vertebral osteomyelitis, femoral catheterization, lithotripsy, endocarditis, and intravenous drug use. Secondary abscesses have a higher mortality rate compared to primary abscesses.

      The clinical features of an iliopsoas abscess include fever, back/flank pain, limp, and weight loss. During a clinical examination, the patient is positioned supine with the knee flexed and the hip mildly externally rotated. Specific tests are performed to diagnose iliopsoas inflammation, such as placing a hand proximal to the patient’s ipsilateral knee and asking the patient to lift their thigh against the hand, which causes pain due to contraction of the psoas muscle. Another test involves lying the patient on the normal side and hyperextending the affected hip, which should elicit pain as the psoas muscle is stretched.

      The investigation of choice for an iliopsoas abscess is a CT scan of the abdomen. Management involves antibiotics and percutaneous drainage, which is successful in around 90% of cases. Surgery is only indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 14 - A 70-year-old man with a recent chest infection arrives at the Emergency Department...

    Incorrect

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

      Your Answer: Methotrexate

      Correct Answer: Ibuprofen

      Explanation:

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

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

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 15 - A 35-year-old Afro-Caribbean woman presents with complaints of cold and painful hands during...

    Incorrect

    • A 35-year-old Afro-Caribbean woman presents with complaints of cold and painful hands during winter. She reports that her hands change color from pale to blue and red in the morning. Despite using gloves and hand warmers, her symptoms have only slightly improved. She is interested in trying medications to alleviate her symptoms. Based on the probable diagnosis, which medication should be prescribed?

      Your Answer: Ibuprofen

      Correct Answer: Nifedipine

      Explanation:

      Nifedipine is a recommended medication for treating Raynaud’s phenomenon. Patients with this condition should be advised to keep their hands warm and quit smoking. NICE suggests other treatments such as evening primrose oil, sildenafil, and prostacyclin for severe attacks or digital gangrene. Chemical or surgical sympathectomy may be helpful for those with severe disease. Propranolol, a beta-blocker, may worsen the condition as it commonly causes cold peripheries. Ibuprofen, an analgesic, may alleviate pain but not other symptoms. Amitriptyline, a tricyclic antidepressant, is also used for neuropathic pain but not specifically for Raynaud’s.

      Understanding Raynaud’s Phenomenon

      Raynaud’s phenomenon is a condition where the digital arteries and cutaneous arteriole overreact to cold or emotional stress, causing an exaggerated vasoconstrictive response. It can be classified as primary or secondary. Primary Raynaud’s disease is more common in young women and presents with bilateral symptoms. On the other hand, secondary Raynaud’s phenomenon is associated with underlying connective tissue disorders such as scleroderma, rheumatoid arthritis, and systemic lupus erythematosus, among others.

      Factors that suggest an underlying connective tissue disease include onset after 40 years, unilateral symptoms, rashes, presence of autoantibodies, and digital ulcers. Management of Raynaud’s phenomenon involves referral to secondary care for patients with suspected secondary Raynaud’s phenomenon. First-line treatment includes calcium channel blockers such as nifedipine. In severe cases, IV prostacyclin (epoprostenol) infusions may be used, and their effects may last for several weeks or months.

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      • Musculoskeletal
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  • Question 16 - A twenty-seven-year-old male presents to the emergency department with an ache-like pain in...

    Correct

    • A twenty-seven-year-old male presents to the emergency department with an ache-like pain in his back that radiates to his right groin. The pain started three days ago, has been progressively worsening, and is exacerbated by walking. He has attempted to alleviate the pain with paracetamol and ibuprofen, but to no avail. He also reports feeling feverish and experiencing chills for the past 24 hours.

      The patient has no significant medical history but is a heavy smoker, consuming 20 cigarettes a day, drinks 30 units of alcohol per week, and injects heroin daily. Upon examination, his heart rate is 96/minute, respiratory rate is 14/minute, blood pressure is 116/72 mmHg, and oxygen saturations are 98%. His temperature is 38.4 ºC.

      During examination of the spine and right hip, he experiences pain on movement of the hip joint, particularly flexion, but is not tender on palpation of the spine or hip joint. There is no evidence of swelling or erythema of the spine or hips, and no difference in temperature. Abdominal examination reveals a soft and non-tender abdomen, without organomegaly and present bowel sounds. The kidneys are non-ballotable.

      What is the most likely diagnosis?

      Your Answer: Iliopsoas abscess

      Explanation:

      When a patient presents with fever and back or flank pain, it is important to consider the possibility of an iliopsoas abscess. This condition is indicated by pain in the hip joint area, along with a fever and pain during movement. Iliopsoas abscess occurs when there is a collection of pus within the iliopsoas muscle, which extends from the T12 – L5 vertebrae to the femur’s lesser trochanter. Intravenous drug use is a risk factor for developing this condition.

      Vertebral osteomyelitis, on the other hand, usually presents with tenderness, swelling, and weakness of the surrounding muscles over the infected vertebrae. Avascular necrosis of the femoral head may cause groin pain, but given the patient’s fever and IVDU status, an iliopsoas abscess is more likely. Kidney stones can cause constant pain from the loin to the groin, while appendicitis usually presents with pain in the umbilical region or right iliac fossa. The patient’s normal abdominal exam also makes appendicitis less likely.

      An iliopsoas abscess is a condition where pus accumulates in the iliopsoas compartment, which includes the iliacus and psoas muscles. There are two types of iliopsoas abscesses: primary and secondary. Primary abscesses occur due to the spread of bacteria through the bloodstream, with Staphylococcus aureus being the most common cause. Secondary abscesses are caused by underlying conditions such as Crohn’s disease, diverticulitis, colorectal cancer, UTIs, GU cancers, vertebral osteomyelitis, femoral catheterization, lithotripsy, endocarditis, and intravenous drug use. Secondary abscesses have a higher mortality rate compared to primary abscesses.

      The clinical features of an iliopsoas abscess include fever, back/flank pain, limp, and weight loss. During a clinical examination, the patient is positioned supine with the knee flexed and the hip mildly externally rotated. Specific tests are performed to diagnose iliopsoas inflammation, such as placing a hand proximal to the patient’s ipsilateral knee and asking the patient to lift their thigh against the hand, which causes pain due to contraction of the psoas muscle. Another test involves lying the patient on the normal side and hyperextending the affected hip, which should elicit pain as the psoas muscle is stretched.

      The investigation of choice for an iliopsoas abscess is a CT scan of the abdomen. Management involves antibiotics and percutaneous drainage, which is successful in around 90% of cases. Surgery is only indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.

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      • Musculoskeletal
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  • Question 17 - A 68-year-old woman presents with acute lower back pain of one week duration....

    Incorrect

    • A 68-year-old woman presents with acute lower back pain of one week duration. The pain is localized to her lower back, rates 9/10 in severity, and has not improved with paracetamol and ibuprofen. She has a medical history significant for stage 3 chronic kidney disease, hypertension, osteoporosis, and hypercholesterolemia. The patient has a 30-pack-year smoking history and is currently taking bendroflumethiazide, amlodipine, alendronic acid, vitamin D supplements, calcium tablets, omeprazole, and atorvastatin. On physical examination, the patient has lumbar lordosis, decreased mobility, and spasm of the paravertebral muscles. Tenderness to palpation is noted at L4-L5. A previous DEXA scan taken 6 months ago shows a T-score of −3.0 in the lumbosacral spine and −3.2 in the left hip. What is the recommended first-line investigation?

      Your Answer: CT spine

      Correct Answer: X-ray spine

      Explanation:

      X-ray of the spine is the first-line investigation for a suspected osteoporotic vertebral fracture, while CT spine, MRI spine, repeat DEXA scan, and skeletal survey are not indicated or necessary.

      Understanding Osteoporotic Vertebral Fractures

      Osteoporotic vertebral fractures are a common consequence of osteoporosis, a condition where bones gradually decrease in bone mineral density, leading to an increased risk of fragility fractures. These fractures often present with acute onset back pain, but patients can also be asymptomatic. Osteoporosis is more prevalent in females than males, with a male-to-female ratio of 1:6. Advancing age is a major risk factor for osteoporotic fractures, with women over 65 and men over 75 being at increased risk. Other risk factors include a previous history of fragility fractures, frequent or prolonged use of glucocorticoids, history of falls, family history of hip fracture, alternative causes of secondary osteoporosis, low BMI, tobacco smoking, and high alcohol intake.

      Patients with osteoporotic vertebral fractures may present with acute back pain, breathing difficulties, gastrointestinal problems, loss of height, kyphosis, and localised tenderness on palpation of spinous processes at the fracture site. X-ray of the spine is the first investigation ordered, which may show wedging of the vertebra due to compression of the bone. Other investigations such as CT spine and MRI spine may be used to visualise the extent/features of the fracture more clearly and differentiate osteoporotic fractures from those caused by another pathology.

      To assess the likelihood of future fractures, risk factors are taken into account, and a dual-energy X-ray absorptiometry (DEXA) scan should be considered. The FRAX tool or QFracture tool can be used to estimate the 10-year risk of a fracture. These tools require the clinician to input patient information into a form, which is then used by the programme to calculate the risk. Understanding osteoporotic vertebral fractures and their risk factors is crucial in preventing and managing this condition.

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      • Musculoskeletal
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  • Question 18 - A 93-year-old man is brought into the emergency department after a car accident....

    Incorrect

    • A 93-year-old man is brought into the emergency department after a car accident. He was in the passenger seat and wearing a seatbelt at the time.
      His son, who was also in the car, reports hearing a loud 'thud' when his father's knees hit the dashboard. He had a right total hip replacement 12 years ago.
      A primary survey shows right-sided dislocation of the hip.
      What findings would be anticipated on examination, considering the probable type of dislocation?

      Your Answer: Hip adduction and external rotation

      Correct Answer: Leg shortening and internal rotation

      Explanation:

      A potential complication of total hip replacement is posterior dislocation, which can present with sudden leg shortening, internal rotation, and a clunk sound. This may occur due to direct impact on a flexed hip, such as when sitting in a car. The hip will be adducted, internally rotated, and flexed in a posterior dislocation. Therefore, options suggesting hip abduction, external rotation, or hyperextension are incorrect.

      Osteoarthritis (OA) of the hip is a prevalent condition, with the knee being the only joint more commonly affected. It is particularly prevalent in older individuals, and women are twice as likely to develop it. Obesity and developmental dysplasia of the hip are also risk factors. The condition is characterized by chronic groin pain that is exacerbated by exercise and relieved by rest. However, if the pain is present at rest, at night, or in the morning for more than two hours, it may indicate an alternative cause. The Oxford Hip Score is a widely used tool to assess the severity of the condition.

      If the symptoms are typical, a clinical diagnosis can be made. Otherwise, plain x-rays are the first-line investigation. Management of OA of the hip includes oral analgesia and intra-articular injections, which provide short-term relief. However, total hip replacement is the definitive treatment.

      Total hip replacement is a common operation in the developed world, but it is not without risks. Perioperative complications include venous thromboembolism, intraoperative fracture, nerve injury, surgical site infection, and leg length discrepancy. Postoperatively, posterior dislocation may occur during extremes of hip flexion, presenting with a clunk, pain, and inability to weight bear. Aseptic loosening is the most common reason for revision, and prosthetic joint infection is also a potential complication.

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      • Musculoskeletal
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  • Question 19 - A 65-year-old woman presents with a 4-week history of widespread pain, stiffness, and...

    Incorrect

    • A 65-year-old woman presents with a 4-week history of widespread pain, stiffness, and subjective weakness to her shoulders bilaterally. Getting dressed in the morning is taking longer, sometimes up to 45 minutes due to her symptoms. She denies any scalp tenderness or jaw claudication.

      Upon examination, there is no objective weakness identified in her upper and lower limbs. No erythema or swelling is visible in her shoulders. Passive motion of her shoulders bilaterally improves her pain.

      What is the most probable underlying diagnosis?

      Your Answer: Bilateral rotator cuff tendinopathy

      Correct Answer: Polymyalgia rheumatica

      Explanation:

      Upon examination, there is no actual weakness observed in the limb girdles of individuals with polymyalgia rheumatica. Any perceived weakness is likely due to myalgia, which is pain-induced inhibition.

      The most probable diagnosis for this case is polymyalgia rheumatica due to several factors. The patient’s gradual onset of symmetrical symptoms and demographic align with this condition. The subjective weakness reported is most likely due to pain rather than objective weakness, which is typical of polymyalgia rheumatica. If there were any visible deformities or true weakness, it would suggest a different diagnosis.

      Rotator cuff tendinopathy would not typically present with symmetrical features or significant morning stiffness. Cervical myelopathy would likely reveal objective weakness and other symptoms such as clumsiness, numbness, or paraesthesia. Fibromyalgia is an unlikely diagnosis as it does not usually present with morning stiffness and is less common as a first presentation in this age group.

      Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People

      Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arthritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.

      To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15 mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.

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      • Musculoskeletal
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  • Question 20 - A 50-year-old woman presents with a 1-month history of fatigue, aches, constipation, and...

    Correct

    • A 50-year-old woman presents with a 1-month history of fatigue, aches, constipation, and nausea. She reports increased thirst and waking at night to pass urine, and has been experiencing a low mood that has kept her from leaving the house frequently. The following investigations were performed:

      - Hb 140 g/L (115 - 160)
      - WBC 5.9 * 109/L (4.0 - 11.0)
      - Calcium 2.8 mmol/L (2.1-2.6)
      - PTH 75 pg/mL (10 - 55)
      - ALP 130 µmol/L (30 - 100)
      - Phosphate 0.4 mmol/L (0.8-1.4)
      - Urea 5.3 mmol/L (2.0 - 7.0)
      - Creatinine 68 µmol/L (55 - 120)
      - 25-hydroxycholecalciferol 48 nmol/L (>50)
      - eGFR 62 ml/min/1.73 m2

      What is the most likely underlying cause of her presentation?

      Your Answer: Parathyroid adenoma

      Explanation:

      The diagnosis of chronic kidney disease is incorrect in this case. An eGFR below 90 can still be considered normal if it is above 60 and there are no abnormalities in the U&Es. The patient’s eGFR is 62 and their urea and creatinine levels are within normal range, indicating that they do not have CKD. In cases of CKD, secondary hyperparathyroidism may occur, which would result in different blood test results. Since the kidneys are responsible for activating vitamin D, which is essential for the absorption of calcium in the intestines, low serum calcium levels would be expected in CKD. Additionally, due to kidney dysfunction, there would be inadequate excretion of phosphate, leading to increased serum phosphate levels. This increase in phosphate levels would cause calcium to be deposited in the insoluble calcium phosphate salt, further lowering calcium levels. Therefore, the symptoms of hypercalcemia that the patient is experiencing would not be present in secondary hyperparathyroidism caused by CKD. In summary, hyperparathyroidism secondary to CKD would result in low calcium and high phosphate levels, rather than high calcium and low phosphate levels.

      Lab Values for Bone Disorders

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

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

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

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

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      • Musculoskeletal
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  • Question 21 - A 45-year-old patient visits her primary care physician with a complaint of net-like...

    Incorrect

    • A 45-year-old patient visits her primary care physician with a complaint of net-like mottled skin on her hands, lower arms, feet, and calves that has persisted for 6 months. She reports no other symptoms. The physician orders routine blood tests, including FBC and coagulation screen, which reveal a haemoglobin level of 140 g/l, platelet count of 98 * 109/L, and white cell count of 8 * 109/L. The APTT is 45s, and the PT is 12s. An autoantibody screen is also performed, with the following significant results: positive for anti-cardiolipin antibodies and lupus anticoagulant, but negative for anti-dsDNA. What is the most appropriate treatment option for the likely diagnosis?

      Your Answer: Lifelong low-molecular weight heparin (LMWH)

      Correct Answer: Daily low-dose aspirin

      Explanation:

      Patients who have been diagnosed with antiphospholipid syndrome and have not had a history of thrombosis are typically prescribed low-dose aspirin. This condition is characterized by CLOTS, which stands for clots, livedo reticularis, obstetric complications, and thrombocytopenia. Diagnosis is confirmed through blood tests that show thrombocytopenia, a prolonged APTT, and positive antiphospholipid antibodies such as anti-cardiolipin, anti-beta-2-glycoprotein-1 antibodies, and lupus anticoagulant. Treatment for Raynaud’s phenomena, which causes painful and pale fingers and toes in cold temperatures, involves daily nifedipine. Lifelong LMWH is not recommended, but lifelong warfarin is recommended for patients with antiphospholipid syndrome who have experienced a previous thrombotic event. LMWH may be an option during pregnancy.

      Antiphospholipid syndrome is a condition that can be acquired and is characterized by a higher risk of both venous and arterial thrombosis, recurrent fetal loss, and thrombocytopenia. It can occur as a primary disorder or as a secondary condition to other diseases, with systemic lupus erythematosus being the most common. One important point to remember for exams is that antiphospholipid syndrome can cause a paradoxical increase in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade. Other features of this condition include livedo reticularis, pre-eclampsia, and pulmonary hypertension.

      Antiphospholipid syndrome can also be associated with other autoimmune disorders, lymphoproliferative disorders, and, rarely, phenothiazines. Management of this condition is based on EULAR guidelines. Primary thromboprophylaxis involves low-dose aspirin, while secondary thromboprophylaxis depends on the type of thromboembolic event. Initial venous thromboembolic events require lifelong warfarin with a target INR of 2-3, while recurrent venous thromboembolic events require lifelong warfarin and low-dose aspirin. Arterial thrombosis should be treated with lifelong warfarin with a target INR of 2-3.

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      • Musculoskeletal
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  • Question 22 - A 25-year-old Sri Lankan male comes to you with a complaint of low...

    Incorrect

    • A 25-year-old Sri Lankan male comes to you with a complaint of low back pain that has been gradually worsening over the past 6 months. He reports that the pain is particularly bad before he wakes up in the morning. Additionally, he has noticed increasing stiffness in his right wrist and left third metacarpal joints. Upon examination, you observe reduced spinal movements in lateral spinal flexion and rotation, as well as a positive Schober's test. The patient has not received any prior treatment for his back pain and has no other medical history. What would be the most appropriate initial course of action?

      Your Answer: No treatment

      Correct Answer: Physiotherapy and NSAIDs

      Explanation:

      Ankylosing spondylitis (AS) patients can often find relief from their symptoms through the use of nonsteroidal anti-inflammatory drugs (NSAIDs) alone, according to the most recent guidelines from the European League Against Rheumatism (EULAR). In fact, continuous NSAID therapy is recommended for those with active and persistent symptoms, as it has been shown to slow the progression of the disease. While systemic glucocorticoids are not effective for managing AS, intra-articular steroid injections may be helpful for peripheral joint or enthesitis issues. Of traditional disease-modifying antirheumatic drugs (DMARDs), only sulphasalazine has been found to be effective for peripheral joint involvement, but it does not work for those with axial joint involvement. For those with insufficiently controlled symptoms, TNF-alpha inhibitors such as etanercept, infliximab, or adalimumab are recommended, without significant difference in efficacy between the three.

      Investigating and Managing Ankylosing Spondylitis

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are usually elevated, but normal levels do not necessarily rule out ankylosing spondylitis. HLA-B27 is not a reliable diagnostic tool as it can also be positive in normal individuals. The most effective way to diagnose ankylosing spondylitis is through a plain x-ray of the sacroiliac joints. However, if the x-ray is negative but suspicion for AS remains high, an MRI can be obtained to confirm the diagnosis.

      Management of ankylosing spondylitis involves regular exercise, such as swimming, and the use of NSAIDs as the first-line treatment. Physiotherapy can also be helpful. Disease-modifying drugs used for rheumatoid arthritis, such as sulphasalazine, are only useful if there is peripheral joint involvement. Anti-TNF therapy, such as etanercept and adalimumab, should be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Ongoing research is being conducted to determine whether anti-TNF therapies should be used earlier in the course of the disease. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

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  • Question 23 - A 67-year-old man presents to the emergency department after a fall. He is...

    Incorrect

    • A 67-year-old man presents to the emergency department after a fall. He is orientated to person, place and time with a GCS of 15. He tripped whilst walking around the house, falling onto his back. He denies any paraesthesia, weakness or pain radiating down his leg, as well as any bowel or bladder dysfunction. There is no evidence head trauma. He also denies any history of fever or weight loss. The patient has longstanding dyspepsia, for which he has been taking omeprazole for 4 years.

      His observations are normal. On examination, there is marked spinal tenderness at the L2-L3 level. Neurological examination is unremarkable, with 5/5 power in both the upper and lower limbs.

      What is the most appropriate, first-line investigation?

      Your Answer: MRI of the whole spine

      Correct Answer: X-ray of the spine

      Explanation:

      Understanding Osteoporotic Vertebral Fractures

      Osteoporotic vertebral fractures are a common consequence of osteoporosis, a condition where bones gradually decrease in bone mineral density, leading to an increased risk of fragility fractures. These fractures often present with acute onset back pain, but patients can also be asymptomatic. Osteoporosis is more prevalent in females than males, with a male-to-female ratio of 1:6. Advancing age is a major risk factor for osteoporotic fractures, with women over 65 and men over 75 being at increased risk. Other risk factors include a previous history of fragility fractures, frequent or prolonged use of glucocorticoids, history of falls, family history of hip fracture, alternative causes of secondary osteoporosis, low BMI, tobacco smoking, and high alcohol intake.

      Patients with osteoporotic vertebral fractures may present with acute back pain, breathing difficulties, gastrointestinal problems, loss of height, kyphosis, and localised tenderness on palpation of spinous processes at the fracture site. X-ray of the spine is the first investigation ordered, which may show wedging of the vertebra due to compression of the bone. Other investigations such as CT spine and MRI spine may be used to visualise the extent/features of the fracture more clearly and differentiate osteoporotic fractures from those caused by another pathology.

      To assess the likelihood of future fractures, risk factors are taken into account, and a dual-energy X-ray absorptiometry (DEXA) scan should be considered. The FRAX tool or QFracture tool can be used to estimate the 10-year risk of a fracture. These tools require the clinician to input patient information into a form, which is then used by the programme to calculate the risk. Understanding osteoporotic vertebral fractures and their risk factors is crucial in preventing and managing this condition.

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      • Musculoskeletal
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  • Question 24 - A 55-year-old man visits his GP with complaints of numbness and tingling in...

    Incorrect

    • A 55-year-old man visits his GP with complaints of numbness and tingling in his right hand. He works as a computer programmer, is left-handed, and denies any recent injuries. He has never experienced these symptoms before.
      Upon further questioning, he reports that the numbness and tingling are most noticeable at night and affect his 1st and 2nd fingers. During the examination, no neurological deficits are observed, but Tinel's sign is positive.
      The GP suggests a splint and refers the patient to physiotherapy.
      What is the most probable diagnosis?

      Your Answer: Medial epicondyle fracture

      Correct Answer: Cubital tunnel syndrome

      Explanation:

      Cubital tunnel syndrome is the correct answer as it is caused by the compression of the ulnar nerve and can result in tingling or numbness in the 4th and 5th fingers. Tinel’s sign, which involves tapping on the affected nerve to reproduce symptoms, is positive in this condition. Brachial plexus injury is not the correct answer as the question specifies that the issue is atraumatic and the neurological examination is normal. Carpal tunnel syndrome affects the median nerve, which provides sensation to the first, second, and part of the third digit, but Tinel’s sign can also be used to check the ulnar nerve. While a medial epicondyle fracture may cause similar symptoms due to the path of the ulnar nerve, the absence of trauma makes this answer unlikely.

      Understanding Cubital Tunnel Syndrome

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed as it passes through the cubital tunnel. This can cause a range of symptoms, including tingling and numbness in the fourth and fifth fingers, which may start off intermittent but eventually become constant. Over time, patients may also experience weakness and muscle wasting. Pain is often worse when leaning on the affected elbow, and there may be a history of osteoarthritis or prior trauma to the area.

      Diagnosis of cubital tunnel syndrome is usually made based on clinical features, although nerve conduction studies may be used in selected cases. Management of the condition typically involves avoiding aggravating activities, undergoing physiotherapy, and receiving steroid injections. In cases where these measures are not effective, surgery may be necessary. By understanding the symptoms and treatment options for cubital tunnel syndrome, patients can take steps to manage their condition and improve their quality of life.

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      • Musculoskeletal
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  • Question 25 - A 33-year-old male arrives at the emergency department following a car accident. He...

    Incorrect

    • A 33-year-old male arrives at the emergency department following a car accident. He reports experiencing intense pain in his right ankle and is unable to put any weight on it. Upon examination, tenderness is noted over the distal tibia and there is an absence of the dorsalis pedis pulse on the right side. No neurological symptoms are observed. An X-ray confirms the presence of a displaced fracture in the ankle. What is the most appropriate initial course of action?

      Your Answer: Call the vascular surgeon

      Correct Answer: Reduce the fracture

      Explanation:

      Prompt reduction of an ankle fracture is crucial to avoid skin damage, as pressure on the skin can result in skin necrosis.

      Before contacting a vascular surgeon, it is essential to reduce the fracture to prevent bone displacement from compressing the artery. If the pulse remains absent after reduction, then it is appropriate to call a vascular surgeon.

      Ankle Fractures and their Classification

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

      Management of Ankle Fractures

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

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      • Musculoskeletal
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  • Question 26 - A 7-year-old boy is brought to the clinic by his mother for evaluation....

    Incorrect

    • A 7-year-old boy is brought to the clinic by his mother for evaluation. He has a history of multiple fractures, delayed dental development, hearing impairment, and abnormal bone growth. The healthcare provider suspects osteogenesis imperfecta. What laboratory findings are expected in this case?

      Your Answer: Low adjusted calcium, high PTH, normal ALP and low PO4

      Correct Answer: Normal adjusted calcium, normal PTH, normal ALP and normal PO4

      Explanation:

      Osteogenesis imperfecta, also known as brittle bone disease, typically presents with normal levels of adjusted calcium, PTH, ALP, and PO4. This group of disorders affects collagen metabolism, resulting in bone fragility and susceptibility to fractures. The mildest and most common form is type 1, which is usually diagnosed in childhood and may present with blue sclera, dental imperfections, and deafness due to otosclerosis.

      Primary hyperparathyroidism may present with raised adjusted calcium and PTH levels, normal or raised ALP levels, and low PO4 levels. Hypoparathyroidism may present with low adjusted calcium and PTH levels, normal ALP levels, and raised PO4 levels. Secondary hyperparathyroidism may present with low adjusted calcium, high PTH levels, normal ALP levels, and variable PO4 levels. Malignant PTH-related protein, which can occur in certain cancers such as squamous cell lung cancer, may present with raised adjusted calcium, low PTH levels, raised ALP levels, and raised PO4 levels, with normal ALP levels also possible.

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

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

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      • Musculoskeletal
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  • Question 27 - A 38-year-old man is seen for a follow-up appointment 3 weeks after sustaining...

    Incorrect

    • A 38-year-old man is seen for a follow-up appointment 3 weeks after sustaining a wrist injury from a fall onto outstretched hands. Imaging studies reveal a fracture of the scaphoid bone. What is the most common sign associated with this diagnosis?

      Your Answer: Weakened palmar extension of the thumb

      Correct Answer: Pain on longitudinal compression of the thumb

      Explanation:

      If you experience pain when compressing your thumb lengthwise, it could be a sign of a scaphoid fracture. These types of fractures can be challenging to detect on initial X-rays and are often only discovered on follow-up scans. Symptoms may include tenderness in the anatomical snuffbox or on the radial side of the wrist, pain when pressure is applied to the affected area, or weakened thumb opposition. Pain during thumb telescoping is a common indicator of a scaphoid fracture, as this movement puts direct pressure on the bone, which is located on the radial side of the carpal bones.

      It is incorrect to assume that a scaphoid fracture will cause reduced sensation over the anatomical snuffbox. While tenderness in this area may be present, any loss of sensation is unlikely. Similarly, weakened palmar extension of the thumb is an unlikely symptom of a scaphoid fracture, as this movement does not put any strain on the affected bone. Finally, a scaphoid fracture is unlikely to affect radial deviation of the wrist, as this range of motion is typically limited even in healthy individuals.

      Understanding Scaphoid Fractures

      A scaphoid fracture is a type of wrist fracture that typically occurs when a person falls onto an outstretched hand or during contact sports. It is important to recognize this type of fracture due to the unusual blood supply of the scaphoid bone. Interruption of the blood supply can lead to avascular necrosis, which is a serious complication. Patients with scaphoid fractures typically present with pain along the radial aspect of the wrist and loss of grip or pinch strength. Clinical examination is highly sensitive and specific when certain signs are present, such as tenderness over the anatomical snuffbox and pain on telescoping of the thumb.

      Plain film radiographs should be requested, including scaphoid views, but the sensitivity in the first week of injury is only 80%. A CT scan may be requested in the context of ongoing clinical suspicion or planning operative management, while MRI is considered the definite investigation to confirm or exclude a diagnosis. Initial management involves immobilization with a splint or backslab and referral to orthopaedics. Orthopaedic management depends on the patient and type of fracture, with undisplaced fractures of the scaphoid waist typically treated with a cast for 6-8 weeks. Displaced scaphoid waist fractures require surgical fixation, as do proximal scaphoid pole fractures. Complications of scaphoid fractures include non-union, which can lead to pain and early osteoarthritis, and avascular necrosis.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 28 - A 14-year-old boy comes to his doctor with a lump on the back...

    Correct

    • A 14-year-old boy comes to his doctor with a lump on the back of his right arm that has been getting bigger for the past three months. Recently, the lump has become very painful. The doctor orders a shoulder X-ray, which shows a lytic lesion in the diaphysis of the right humerus with an 'onion skin' appearance. What is the probable diagnosis?

      Your Answer: Ewing's sarcoma

      Explanation:

      The correct diagnosis is Ewing’s sarcoma, which is a malignant bone tumour that primarily affects children and adolescents. It is commonly found in the pelvis and long bones and can cause severe pain. X-rays may show an onion skin appearance. Fine-needle aspiration may be performed, and the presence of EWS-FLI1 protein is a key finding in cases of Ewing’s sarcoma.

      Chondrosarcoma is an incorrect diagnosis as it is a malignant tumour of cartilage that typically affects the axial skeleton and is more common in middle-aged individuals.

      Giant cell tumour is also an incorrect diagnosis as it is a benign tumour of multinucleated giant cells that is commonly found in the epiphysis of long bones and has a double-bubble or soap bubble appearance on x-ray. It is more commonly seen in patients aged 20-40 years old.

      Osteochondroma is another incorrect diagnosis as it is the most common benign bone tumour and typically presents as a cartilage-capped bony projection on the external surface of a bone. It is most commonly found in males under 20 years old and is therefore unlikely given the presentation.

      Types of Bone Tumours

      Bone tumours can be classified into two categories: benign and malignant. Benign tumours are non-cancerous and do not spread to other parts of the body. Osteoma is a common benign tumour that occurs on the skull and is associated with Gardner’s syndrome. Osteochondroma, on the other hand, is the most common benign bone tumour and is usually diagnosed in patients aged less than 20 years. It is characterized by a cartilage-capped bony projection on the external surface of a bone. Giant cell tumour is a tumour of multinucleated giant cells within a fibrous stroma and is most commonly seen in the epiphysis of long bones.

      Malignant tumours, on the other hand, are cancerous and can spread to other parts of the body. Osteosarcoma is the most common primary malignant bone tumour and is mainly seen in children and adolescents. It occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure. Ewing’s sarcoma is a small round blue cell tumour that is also seen mainly in children and adolescents. It occurs most frequently in the pelvis and long bones and tends to cause severe pain. Chondrosarcoma is a malignant tumour of cartilage that most commonly affects the axial skeleton and is more common in middle-age. It is important to diagnose and treat bone tumours early to prevent complications and improve outcomes.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 29 - A 13-year-old boy experiences facial swelling and a red, itchy rash shortly after...

    Incorrect

    • A 13-year-old boy experiences facial swelling and a red, itchy rash shortly after receiving his first dose of the HPV vaccine. Upon arrival, paramedics observe a bilateral expiratory wheeze and a blood pressure reading of 85/60 mmHg. According to the Gell and Coombs classification of hypersensitivity reactions, what type of reaction is this an example of?

      Your Answer: Type III reaction

      Correct Answer: Type I reaction

      Explanation:

      Classification of Hypersensitivity Reactions

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

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

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      • Musculoskeletal
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  • Question 30 - A 70-year-old man is currently in intensive care after experiencing a fall at...

    Incorrect

    • A 70-year-old man is currently in intensive care after experiencing a fall at home resulting in an open fracture of his right tibia/fibula and simple fractures in ribs 3-6. What steps can be taken to prevent the development of a chest infection in this patient?

      Your Answer: Prophylactic IV cefuroxime

      Correct Answer: Chest physiotherapy and adequate analgesia

      Explanation:

      Proper pain management is crucial in cases of rib fractures to ensure that breathing is not hindered by discomfort. Inadequate ventilation due to pain can increase the risk of chest infections. To prevent this, patients may benefit from chest physiotherapy and breathing exercises, along with appropriate pain relief. CPAP may be used at night to keep the airway open in patients with obstructive sleep apnoea. While prophylactic antibiotics have been shown to reduce the incidence of empyema and pneumonia in some studies of chest trauma, their routine use is controversial due to the risk of antibiotic resistance. High flow oxygen is not recommended in the absence of hypoxaemia as it does not improve the patient’s ability to take deep breaths and cough effectively.

      A rib fracture is a break in any of the bony segments of a rib. It is commonly caused by blunt trauma to the chest wall, but can also be due to underlying diseases that weaken the bone structure of the ribs. Rib fractures can occur singly or in multiple places along the length of a rib and may be associated with soft tissue injuries to the surrounding muscles or the underlying lung. Risk factors include chest injuries in major trauma, osteoporosis, steroid use, chronic obstructive pulmonary disease, and cancer metastases.

      The most common symptom of a rib fracture is severe, sharp chest wall pain, which is often more severe with deep breaths or coughing. Chest wall tenderness over the site of the fractures and visible bruising of the skin may also be present. Auscultation of the chest may reveal crackles or reduced breath sounds if there is an underlying lung injury. In some cases, pain and underlying lung injury can result in a reduction in ventilation, causing a drop in oxygen saturation. Pneumothorax, a serious complication of a rib fracture, can present with reduced chest expansion, reduced breath sounds, and hyper-resonant percussion on the affected side. Flail chest, a consequence of multiple rib fractures, can impair ventilation of the lung on the side of injury and may require treatment with invasive ventilation and surgical fixation to prevent complications.

      Diagnostic tests for rib fractures include a CT scan of the chest, which shows the fractures in 3D as well as the associated soft tissue injuries. Chest x-rays may provide suboptimal views and do not provide any information about the surrounding soft tissue injury. In cases of pathological fractures secondary to tumour metastases, a CT scan to look for a primary (if not already identified) is also required. Management of rib fractures involves conservative treatment with good analgesia to ensure breathing is not affected by pain. Inadequate ventilation may predispose to chest infections. Nerve blocks can be considered if the pain is not controlled by normal analgesia. Surgical fixation can be considered to manage pain if this is still an issue and the fractures have failed to heal following 12 weeks of conservative management. Flail chest segments are the only form of rib fractures that should be urgently discussed with cardiothoracic surgery as they can impair ventilation and result in significant lung trauma. Lung complications such as pneumothorax or haemothorax should be managed as necessary.

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      • Musculoskeletal
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  • Question 31 - A 7-year-old boy trips during recess and arrives at the Emergency Department with...

    Incorrect

    • A 7-year-old boy trips during recess and arrives at the Emergency Department with a severely painful left arm. X-rays reveal a distal humerus supracondylar fracture that is displaced posteriorly and closed. What signs would suggest an immediate requirement for surgery?

      Your Answer: Significant clinical deformity

      Correct Answer: Distal neurovascular deficit

      Explanation:

      Fractures in the region of the distal humerus pose a risk of injury to important structures in the arm, particularly the brachial artery. If the fractured end of the humerus shears the artery, it can result in distal neurovascular loss, which requires immediate exploration. While considering other options is important when managing such patients, they may occur without any neurovascular injury. Angulation is significant but not the most crucial factor, as it can occur without causing any distal deficits. Pain alone is not an indication for surgery, as many injuries can be painful without serious consequences. Although significant clinical deformity is highly suggestive of a severe injury, it can occur without limb-threatening consequences. Posterior displacement does not necessarily correlate with neurovascular injury, as bone fragments may miss important structures. Therefore, if there is any distal deficit, surgery is urgently required, regardless of the appearance of the arm or X-ray.

      Fracture Management: Understanding Types and Treatment

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

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

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      • Musculoskeletal
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  • Question 32 - A 54-year-old woman arrives at the emergency department complaining of headaches and oliguria....

    Incorrect

    • A 54-year-old woman arrives at the emergency department complaining of headaches and oliguria. Upon examination, she displays swollen, tight fingers and rough, thickened patches of skin on her neck and arms, as well as telangiectasia on her face. She also has bilateral lower limb pitting edema to the mid-tibia and is experiencing confusion. At triage, her blood pressure is measured at 223/125 mmHg. Her blood work reveals elevated levels of creatinine and urea compared to her results from one year ago. What treatment option is most likely to decrease the likelihood of her experiencing another renal crisis in the future?

      Your Answer: Bisoprolol

      Correct Answer: Ramipril

      Explanation:

      The patient appears to have diffuse cutaneous systemic sclerosis, a condition that causes widespread skin involvement and early organ fibrosis. One potential complication is scleroderma renal crisis, which can be fatal and presents with sudden onset hypertension and rapidly progressing renal failure. Treatment with ACE-inhibitors like ramipril can reduce mortality and risk of further crises, while calcium channel blockers may be added if necessary. IV cyclophosphamide is used for immunosuppression in organ or skin involvement, but not for renal crisis. Bisoprolol is not indicated for systemic sclerosis management.

      Understanding Systemic Sclerosis

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

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      • Musculoskeletal
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  • Question 33 - A 82-year-old man experiences a mechanical fall resulting in a pertrochanteric hip fracture....

    Incorrect

    • A 82-year-old man experiences a mechanical fall resulting in a pertrochanteric hip fracture. The fracture is treated with a dynamic hip screw (DHS). The physiotherapist on the ward asks for clarification on the patient's weight bearing status.

      What guidance would you provide?

      Your Answer: Full weight bearing after 24 hours

      Correct Answer: Full weight bearing immediately post-op

      Explanation:

      Hip fracture surgery aims to enable immediate weight bearing to reduce complications associated with immobility. The BOA recommends unrestricted weight bearing to shorten hospital stays and improve patient compliance. The dynamic hip screw requires weight bearing for proper compression of the fracture site.

      Hip fractures are a common occurrence, particularly in elderly women with osteoporosis. The femoral head’s blood supply runs up the neck, making avascular necrosis a potential risk in displaced fractures. Symptoms of a hip fracture include pain and a shortened and externally rotated leg. Patients with non-displaced or incomplete neck of femur fractures may still be able to bear weight. Hip fractures can be classified as intracapsular or extracapsular, with the Garden system being a commonly used classification system. Blood supply disruption is most common in Types III and IV fractures.

      Intracapsular hip fractures can be treated with internal fixation or hemiarthroplasty if the patient is unfit. Displaced fractures are recommended for replacement arthroplasty, such as total hip replacement or hemiarthroplasty, according to NICE guidelines. Total hip replacement is preferred over hemiarthroplasty if the patient was able to walk independently outdoors with the use of a stick, is not cognitively impaired, and is medically fit for anesthesia and the procedure. Extracapsular hip fractures can be managed with a dynamic hip screw for stable intertrochanteric fractures or an intramedullary device for reverse oblique, transverse, or subtrochanteric fractures.

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      • Musculoskeletal
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  • Question 34 - Emma is a 26-year-old patient who has been experiencing back pain for the...

    Incorrect

    • Emma is a 26-year-old patient who has been experiencing back pain for the past year. She describes the pain as a dull ache that is mostly located in her lower back and sometimes wakes her up in the early hours of the morning. Emma notes that she generally feels better when she is active throughout the day and is often worse when resting.

      What investigation would be most helpful in confirming Emma's diagnosis?

      Your Answer: Raised inflammatory markers

      Correct Answer: Pelvic X-ray

      Explanation:

      It is important to note that a negative HLA-B27 result should not be used to completely rule out a diagnosis of spondyloarthritis, as there are still cases of ankylosing spondylitis that do not show this genetic marker.

      Investigating and Managing Ankylosing Spondylitis

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are usually elevated, but normal levels do not necessarily rule out ankylosing spondylitis. HLA-B27 is not a reliable diagnostic tool as it can also be positive in normal individuals. The most effective way to diagnose ankylosing spondylitis is through a plain x-ray of the sacroiliac joints. However, if the x-ray is negative but suspicion for AS remains high, an MRI can be obtained to confirm the diagnosis.

      Management of ankylosing spondylitis involves regular exercise, such as swimming, and the use of NSAIDs as the first-line treatment. Physiotherapy can also be helpful. Disease-modifying drugs used for rheumatoid arthritis, such as sulphasalazine, are only useful if there is peripheral joint involvement. Anti-TNF therapy, such as etanercept and adalimumab, should be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Ongoing research is being conducted to determine whether anti-TNF therapies should be used earlier in the course of the disease. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

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      • Musculoskeletal
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  • Question 35 - A 25-year-old man presents to the emergency department with complaints of lower back...

    Incorrect

    • A 25-year-old man presents to the emergency department with complaints of lower back pain that has been ongoing for the past week. The pain has gradually worsened over the last few days, and he is now unable to change his posture due to the severity of the pain. The patient has a history of intravenous drug use and had visited his GP earlier in the month for shortness of breath and a low-grade fever. On examination, the patient has a temperature of 40ºC, needle track marks on his forearm, a systolic murmur in the tricuspid region, and severe restriction of movement in his back. A urine dip test reveals the presence of blood, but no other abnormalities are found. An MRI of the spine confirms a diagnosis of discitis. What other urgent investigations should be performed?

      Your Answer: MRI kidneys, ureters and bladder

      Correct Answer: Echocardiography

      Explanation:

      Patients who use intravenous drugs and have infective endocarditis may exhibit symptoms of discitis.

      The patient in question displays signs of infective endocarditis, including a mild fever, a systolic murmur in the tricuspid region (likely tricuspid regurgitation), and blood in their urine. Although these symptoms may seem unrelated, they are consistent with endocarditis. Septic emboli from the heart can travel to various parts of the body, causing inflammation and damage to tissues such as the intervertebral disc space and renal parenchyma. This can result in back pain and hematuria. It is important to rule out this condition by obtaining images of the heart.

      An MRI of the kidneys, ureters, and bladder would be an expensive way to diagnose kidney stones and would not provide any additional diagnostic benefit in this case. Surgical exploration is too invasive at this stage, and the issue lies with the heart rather than the kidneys. An X-ray of the kidneys would not be helpful in this situation.

      Understanding Discitis: Causes, Symptoms, Diagnosis, and Treatment

      Discitis is a condition characterized by an infection in the intervertebral disc space, which can lead to serious complications such as sepsis or an epidural abscess. The most common cause of discitis is bacterial, with Staphylococcus aureus being the most frequent culprit. However, it can also be caused by viral or aseptic factors. The symptoms of discitis include back pain, pyrexia, rigors, and sepsis. In some cases, neurological features such as changing lower limb neurology may occur if an epidural abscess develops.

      To diagnose discitis, imaging tests such as MRI are used due to their high sensitivity. A CT-guided biopsy may also be required to guide antimicrobial treatment. The standard therapy for discitis involves six to eight weeks of intravenous antibiotic therapy. The choice of antibiotic depends on various factors, with the most important being the identification of the organism through a positive culture, such as a blood culture or CT-guided biopsy.

      Complications of discitis include sepsis and epidural abscess. Therefore, it is essential to assess the patient for endocarditis, which can be done through transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae, which implies that the patient has had a bacteraemia, and seeding could have occurred elsewhere. Understanding the causes, symptoms, diagnosis, and treatment of discitis is crucial in managing this condition and preventing its complications.

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      • Musculoskeletal
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  • Question 36 - A 78-year-old female complains of stiffness and pain in her pelvic and shoulder...

    Incorrect

    • A 78-year-old female complains of stiffness and pain in her pelvic and shoulder girdle, along with painful mastication. She consumes around 12 units of alcohol per week and takes atorvastatin and amlodipine. Her ESR is found to be 90mm/hour. What is the probable diagnosis?

      Your Answer: Fibromyalgia

      Correct Answer: Polymyalgia rheumatica

      Explanation:

      The symptoms and high ESR levels suggest that the patient may have polymyalgia rheumatica, with the added indication of painful mastication pointing towards possible temporal arthritis. Immediate treatment with high doses of steroids is crucial. To distinguish between polymyalgia rheumatica and statin-induced myopathy, ESR levels are typically measured. A significantly elevated ESR level would indicate polymyalgia rheumatica, while a normal ESR level would suggest statin myopathy.

      Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People

      Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arthritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.

      To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15 mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.

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  • Question 37 - A 38-year-old man has been referred to the rheumatology clinic by his GP...

    Incorrect

    • A 38-year-old man has been referred to the rheumatology clinic by his GP due to suspicion of systemic lupus erythematosus (SLE). The patient complains of symmetrical arthralgia affecting the MCP and PIP joints for the past 3 months, along with mouth ulcers and photosensitivity. Which of the following medical histories would support a diagnosis of SLE?

      Your Answer: Type 1 diabetes

      Correct Answer: Pericarditis

      Explanation:

      The revised ARA criteria for the classification of lupus includes serositis (pleuritis or pericarditis) as a defining feature. Pericarditis is the most prevalent cardiac manifestation of SLE and is also included in the classification criteria of the British Society for Rheumatology 2018 guidelines for SLE. It is important to note that the other options are not part of these criteria, which are not comprehensive but are still considered a valuable diagnostic aid.

      Understanding Systemic Lupus Erythematosus

      Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple systems in the body. It is more common in women and people of Afro-Caribbean origin, and typically presents in early adulthood. The general features of SLE include fatigue, fever, mouth ulcers, and lymphadenopathy.

      SLE can also affect the skin, causing a malar (butterfly) rash that spares the nasolabial folds, discoid rash in sun-exposed areas, photosensitivity, Raynaud’s phenomenon, livedo reticularis, and non-scarring alopecia. Musculoskeletal symptoms include arthralgia and non-erosive arthritis.

      Cardiovascular manifestations of SLE include pericarditis and myocarditis, while respiratory symptoms may include pleurisy and fibrosing alveolitis. Renal involvement can lead to proteinuria and glomerulonephritis, with diffuse proliferative glomerulonephritis being the most common type.

      Finally, neuropsychiatric symptoms of SLE may include anxiety and depression, as well as more severe manifestations such as psychosis and seizures. Understanding the various features of SLE is important for early diagnosis and management of this complex autoimmune disorder.

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      • Musculoskeletal
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  • Question 38 - Mrs. Jane is a 55-year-old woman who visits her GP with a complaint...

    Incorrect

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

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

      Correct Answer: Cytoplasmic antineutrophil cytoplasmic antibodies (cANCA)

      Explanation:

      ANCA Associated Vasculitis: Common Findings and Management

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

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

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  • Question 39 - A 48-year-old male presents to the urology clinic with complaints of impotence. He...

    Incorrect

    • A 48-year-old male presents to the urology clinic with complaints of impotence. He has a history of hypertension and reports the absence of morning erections. Upon further inquiry, the patient describes experiencing pain in his buttocks that intensifies with movement. Physical examination reveals muscle atrophy, while the penis and scrotum appear normal. What is the probable diagnosis?

      Your Answer: Psychological impotence

      Correct Answer: Leriche syndrome

      Explanation:

      Leriche syndrome is a condition that typically affects men and is characterized by three main symptoms: claudication (painful cramping) in the buttocks and thighs, muscle wasting in the legs, and impotence caused by nerve paralysis in the L1 region. This condition is caused by atherosclerosis, which leads to blockages in the abdominal aorta and/or iliac arteries. Treatment involves addressing underlying risk factors such as high cholesterol and smoking cessation. Diagnosis is typically made through angiography.

      Understanding Leriche Syndrome

      Leriche syndrome is a condition that affects the iliac vessels, causing atheromatous disease that can compromise blood flow to the pelvic viscera. This can result in symptoms such as buttock claudication and impotence. To diagnose the condition, angiography is often used to identify any iliac occlusions. Treatment typically involves endovascular angioplasty and stent insertion to address the occlusions and improve blood flow.

      In summary, Leriche syndrome is a condition that can have significant impacts on a patient’s quality of life. By understanding the symptoms and diagnostic and treatment options available, healthcare providers can help patients manage this condition effectively.

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      • Musculoskeletal
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  • Question 40 - A 20-year-old male patient arrives at the emergency department following a fall from...

    Correct

    • A 20-year-old male patient arrives at the emergency department following a fall from his skateboard, where he landed on his outstretched right hand. On examination, the patient reports experiencing considerable pain and tenderness between the extensor pollicis longus and extensor pollicis brevis tendons of his right hand. An X-ray is conducted, but no abnormalities are detected.
      What is the best initial approach to managing this injury?

      Your Answer: Immobilise using Futuro splint or standard below-elbow backslab before specialist review

      Explanation:

      For non-displaced or minimally displaced scaphoid fractures (less than 0.5mm), immobilization for 6 weeks is sufficient for union. However, since these fractures can lead to avascular necrosis and other long-term complications, it is crucial to seek specialized medical attention. It is unnecessary to immobilize the elbow with a standard above-elbow backslab for suspected scaphoid fractures.

      Understanding Scaphoid Fractures

      A scaphoid fracture is a type of wrist fracture that typically occurs when a person falls onto an outstretched hand or during contact sports. It is important to recognize this type of fracture due to the unusual blood supply of the scaphoid bone. Interruption of the blood supply can lead to avascular necrosis, which is a serious complication. Patients with scaphoid fractures typically present with pain along the radial aspect of the wrist and loss of grip or pinch strength. Clinical examination is highly sensitive and specific when certain signs are present, such as tenderness over the anatomical snuffbox and pain on telescoping of the thumb.

      Plain film radiographs should be requested, including scaphoid views, but the sensitivity in the first week of injury is only 80%. A CT scan may be requested in the context of ongoing clinical suspicion or planning operative management, while MRI is considered the definite investigation to confirm or exclude a diagnosis. Initial management involves immobilization with a splint or backslab and referral to orthopaedics. Orthopaedic management depends on the patient and type of fracture, with undisplaced fractures of the scaphoid waist typically treated with a cast for 6-8 weeks. Displaced scaphoid waist fractures require surgical fixation, as do proximal scaphoid pole fractures. Complications of scaphoid fractures include non-union, which can lead to pain and early osteoarthritis, and avascular necrosis.

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  • Question 41 - A 65-year-old woman comes to her GP complaining of pain and stiffness in...

    Incorrect

    • A 65-year-old woman comes to her GP complaining of pain and stiffness in both knees and hands for a few months. She also reports swelling in her left index finger. Apart from hypertension, for which she takes amlodipine, and a cough that is currently being investigated, she is in good health and has no significant medical history. During the examination, the doctor notices dactylitis in her left index finger, as well as general pain and limited mobility in her fingers. X-rays of her hands reveal erosions in the distal interphalangeal (DIP) joint on both sides. What diagnosis is most consistent with these findings?

      Your Answer: Osteoarthritis

      Correct Answer: Psoriatic arthritis

      Explanation:

      The presence of DIP joint swelling and dactylitis in inflammatory arthritis suggests a diagnosis of psoriatic arthritis. Although there is not always a clear correlation between psoriatic arthritis and cutaneous psoriasis, arthritic symptoms often appear before skin lesions. While there may be some overlap with rheumatoid arthritis, the presence of DIP joint disease and dactylitis are more indicative of psoriatic arthritis. Gout is an unlikely diagnosis as it typically presents as acute and monoarticular or oligoarticular, without the other symptoms seen here. Osteoarthritis is also an unlikely diagnosis as it typically presents asymmetrically in larger joints and does not typically present with dactylitis or the findings seen on X-ray. Rheumatoid arthritis is a possibility, but a blood test for anti-cyclic citrullinated peptide antibodies (anti-CCP) should be performed to confirm the diagnosis, as these antibodies are highly specific to rheumatoid arthritis and are usually absent in psoriatic arthritis.

      Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is known to have a poor correlation with cutaneous psoriasis. In fact, it often precedes the development of skin lesions. This condition affects both males and females equally, with around 10-20% of patients with skin lesions developing an arthropathy.

      The presentation of psoriatic arthropathy can vary, with different patterns of joint involvement. The most common type is symmetric polyarthritis, which is very similar to rheumatoid arthritis and affects around 30-40% of cases. Asymmetrical oligoarthritis is another type, which typically affects the hands and feet and accounts for 20-30% of cases. Sacroiliitis, DIP joint disease, and arthritis mutilans (severe deformity of fingers/hand) are other patterns of joint involvement. Other signs of psoriatic arthropathy include psoriatic skin lesions, periarticular disease, enthesitis, tenosynovitis, dactylitis, and nail changes.

      To diagnose psoriatic arthropathy, X-rays are often used. These can reveal erosive changes and new bone formation, as well as periostitis and a pencil-in-cup appearance. Management of this condition should be done by a rheumatologist, and treatment is similar to that of rheumatoid arthritis. However, there are some differences, such as the use of monoclonal antibodies like ustekinumab and secukinumab. Mild peripheral arthritis or mild axial disease may be treated with NSAIDs alone, rather than all patients being on disease-modifying therapy as with RA. Overall, psoriatic arthropathy has a better prognosis than RA.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 42 - A 28-year-old male patient visits the rheumatology clinic with complaints of a dull...

    Incorrect

    • A 28-year-old male patient visits the rheumatology clinic with complaints of a dull ache in his lower back that typically starts in the morning and improves throughout the day. He also reports limited movement of his entire spine, particularly in the lumbar region. Additionally, he has been diagnosed with anterior uveitis. What test would be the most suitable to confirm the probable diagnosis?

      Your Answer: Lumbar x-ray to identify ‘bamboo spine’

      Correct Answer: Pelvic x-ray to identify sacroiliitis

      Explanation:

      The finding is not specific or sensitive as it pertains to the general population.

      Investigating and Managing Ankylosing Spondylitis

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are usually elevated, but normal levels do not necessarily rule out ankylosing spondylitis. HLA-B27 is not a reliable diagnostic tool as it can also be positive in normal individuals. The most effective way to diagnose ankylosing spondylitis is through a plain x-ray of the sacroiliac joints. However, if the x-ray is negative but suspicion for AS remains high, an MRI can be obtained to confirm the diagnosis.

      Management of ankylosing spondylitis involves regular exercise, such as swimming, and the use of NSAIDs as the first-line treatment. Physiotherapy can also be helpful. Disease-modifying drugs used for rheumatoid arthritis, such as sulphasalazine, are only useful if there is peripheral joint involvement. Anti-TNF therapy, such as etanercept and adalimumab, should be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Ongoing research is being conducted to determine whether anti-TNF therapies should be used earlier in the course of the disease. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 43 - A 29-year-old man is brought to the emergency department following a head-on collision...

    Incorrect

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

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

      Correct Answer: Urgent intravenous antibiotics and debridement in theatre

      Explanation:

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

      Fracture Management: Understanding Types and Treatment

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

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

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 44 - A 36-year-old teacher presents to the emergency department with a complaint of shin...

    Incorrect

    • A 36-year-old teacher presents to the emergency department with a complaint of shin pain that has been bothering her for the past 2 months. The pain is specifically located over the tibia and is relieved by rest. However, she is worried as she has a hiking trip planned for the weekend. She has not undergone any hospital investigations yet. On examination, there is diffuse tenderness over the tibia. She expresses her apologies for coming to the emergency department, stating that her GP could not offer an appointment for the next 2 weeks and she needs advice before the weekend.

      What is the next step in managing this patient?

      Your Answer: Perform a CT-scan of the legs

      Correct Answer: Undertake an x-ray of the legs

      Explanation:

      Tibial stress syndrome is the probable diagnosis, but it is important to rule out a stress fracture of the tibia before discharging the patient. An x-ray of the legs should be ordered as the initial investigation, even though symptoms may precede x-ray changes by a few weeks. The Ottawa ankle rules cannot be used to determine if an x-ray is necessary for a tibial stress fracture. While CT and MRI are more sensitive, an x-ray should be performed first, and further imaging may be required if there is no definitive answer. A plaster cast would not be appropriate at this stage, and an orthopaedic referral is not necessary. If the x-ray rules out a tibial stress fracture, an appropriate management plan would be to rest, elevate the leg, and repeatedly apply ice packs to the affected area.

      Stress fractures are small hairline fractures that can occur due to repetitive activity and loading of normal bone. Although they can be painful, they are typically not displaced and do not cause surrounding soft tissue injury. In some cases, stress fractures may present late, and callus formation may be visible on radiographs. Treatment for stress fractures may vary depending on the severity of the injury. In cases where the injury is associated with severe pain and presents at an earlier stage, immobilization may be necessary. However, injuries that present later may not require formal immobilization and can be treated with tailored immobilization specific to the site of injury.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 45 - A 32-year-old female presents with stiff and swollen joints. She reports that the...

    Incorrect

    • A 32-year-old female presents with stiff and swollen joints. She reports that the joints are especially stiff in the morning for the first few hours of the day. Her mother and sister have a history of rheumatoid arthritis (RA). On examination, she has symmetrical polyarthritis affecting the small joints of the hand. Rheumatoid factor antibody, anti-nuclear antibody, and anti-dsDNA are all negative.
      Which of the following tests is the most suitable?

      Your Answer: ANCA (anti-neutrophil cytoplasmic antibody)

      Correct Answer: Anti-CCP (cyclic citrullinated peptide) antibody

      Explanation:

      Rheumatoid arthritis can be diagnosed clinically, which is considered more important than using specific criteria such as those defined by the American College of Rheumatology. However, the college has established classification criteria for rheumatoid arthritis that require patients to have at least one joint with definite clinical synovitis that cannot be explained by another disease. The criteria also include scoring based on joint involvement, serology (RF and ACPA), acute-phase reactants (CRP and ESR), and duration of symptoms. A score of 6 out of 10 is needed for a definite diagnosis of rheumatoid arthritis.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 46 - A newly born infant is observed to have clubfoot on both feet. What...

    Incorrect

    • A newly born infant is observed to have clubfoot on both feet. What is the preferred treatment for this condition?

      Your Answer: Surgical correction at 6 months

      Correct Answer: Manipulation and progressive casting starting soon after birth

      Explanation:

      Talipes Equinovarus: A Common Foot Deformity in Newborns

      Talipes equinovarus, also known as club foot, is a foot deformity characterized by an inward turning and plantar flexed foot. It is a common condition that affects 1 in 1,000 newborns, with a higher incidence in males. In about 50% of cases, the deformity is present in both feet. While the cause of talipes equinovarus is often unknown, it can be associated with conditions such as spina bifida, cerebral palsy, and oligohydramnios.

      Diagnosis of talipes equinovarus is typically made during the newborn exam, and imaging is not usually necessary. The deformity is not passively correctable, and the diagnosis is based on clinical examination.

      In recent years, there has been a shift towards conservative management of talipes equinovarus, with the Ponseti method being the preferred approach. This method involves manipulation and progressive casting of the foot, starting soon after birth. The deformity is usually corrected within 6-10 weeks, and an Achilles tenotomy may be required in some cases. Night-time braces are then used until the child is 4 years old to prevent relapse, which occurs in about 15% of cases.

      Overall, talipes equinovarus is a common foot deformity in newborns that can be effectively managed with conservative methods such as the Ponseti method.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 47 - A 70-year-old woman visited her GP complaining of discomfort and pain in her...

    Correct

    • A 70-year-old woman visited her GP complaining of discomfort and pain in her shoulder. The doctor conducted a thorough examination of her shoulder and observed that she was unable to abduct her shoulder while standing with her arm flat against her body. However, the doctor was able to passively abduct her shoulder during the first 20 degrees, and she was able to fully abduct it. Which muscle is likely to be affected?

      Your Answer: Supraspinatus

      Explanation:

      The shoulder joint is stabilized by a group of muscles known as the rotator cuffs. To remember them, you can use the following order: Subscapularis, which is located on the front of your chest and assists with internal rotation of the shoulder; Supraspinatus, which runs parallel to your deltoid on top of your shoulder and is necessary for the first 20° of shoulder abduction before the deltoid takes over; and Infraspinatus, which is located on the upper back and helps with external rotation of the shoulder.

      Understanding the Rotator Cuff Muscles

      The rotator cuff muscles are a group of four muscles that are responsible for the movement and stability of the shoulder joint. These muscles include the supraspinatus, infraspinatus, teres minor, and subscapularis. Each muscle has a specific function that contributes to the overall movement of the shoulder.

      The supraspinatus muscle is responsible for abducting the arm before the deltoid muscle. It is also the most commonly injured muscle in the rotator cuff. The infraspinatus muscle rotates the arm laterally, while the teres minor muscle adducts and rotates the arm laterally. Lastly, the subscapularis muscle adducts and rotates the arm medially.

      Understanding the functions of each rotator cuff muscle is important in preventing injuries and maintaining shoulder health. By strengthening these muscles through targeted exercises, individuals can improve their shoulder stability and reduce the risk of injury.

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      • Musculoskeletal
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  • Question 48 - A 40-year-old woman presents with a 4-day history of left shoulder pain. The...

    Incorrect

    • A 40-year-old woman presents with a 4-day history of left shoulder pain. The pain is confined to the shoulder and has not spread to other areas. She reports injuring her shoulder while attempting shoulder exercises at the gym recently. The patient has a medical history of type 2 diabetes mellitus and hypercholesterolemia. Upon examination, the shoulder appears normal in temperature and color, without signs of swelling. Active and passive external rotation are significantly limited by pain. Flexion, extension, abduction, and adduction are also limited by pain, but to a lesser extent. What is the most probable diagnosis?

      Your Answer: Torn rotator cuff

      Correct Answer: Adhesive capsulitis

      Explanation:

      Adhesive capsulitis is the correct answer as it is commonly seen in middle-aged females, diabetic patients, and following trauma. The classic impairment in adhesive capsulitis is external rotation, both on active and passive movement. On the other hand, calcific tendonosis would present with bursitis, causing pain, restriction in movement, and a hot and swollen shoulder. Cervical nerve root entrapment would cause pain in the neck and/or shoulder, with possible radiation to the arm and impaired neck range of movement. Supraspinatus tendonosis and torn rotator cuff would primarily affect abduction, not external rotation.

      Understanding Adhesive Capsulitis (Frozen Shoulder)

      Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.

      Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 49 - A 20-year-old soldier has recently completed a long marching exercise and complains of...

    Incorrect

    • A 20-year-old soldier has recently completed a long marching exercise and complains of sudden and intense pain in the forefoot. Upon examination, there is tenderness along the second metatarsal. X-rays are taken and show callus formation around the shaft of the second metatarsal. What is the probable diagnosis?

      Your Answer: Mortons neuroma

      Correct Answer: Stress fracture

      Explanation:

      Based on the patient’s symptoms, physical examination, and radiological findings, it is likely that they are suffering from a stress fracture in their second metatarsal. The presence of callus indicates that immobilization may not be effective in treating the injury. Freiberg’s disease, which typically affects the head of the second metatarsal during puberty, is characterized by anterior metatarsalgia and is caused by stress microfractures at the growth plate. However, the key factor that distinguishes a stress fracture from Freiberg’s disease is the radiological evidence. In Freiberg’s disease, x-ray changes include joint space widening, bony spur formation, sclerosis, and flattening of the metatarsal head.

      Stress fractures are small hairline fractures that can occur due to repetitive activity and loading of normal bone. Although they can be painful, they are typically not displaced and do not cause surrounding soft tissue injury. In some cases, stress fractures may present late, and callus formation may be visible on radiographs. Treatment for stress fractures may vary depending on the severity of the injury. In cases where the injury is associated with severe pain and presents at an earlier stage, immobilization may be necessary. However, injuries that present later may not require formal immobilization and can be treated with tailored immobilization specific to the site of injury.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 50 - A 50-year-old woman comes to the rheumatology clinic with poorly controlled rheumatoid arthritis....

    Incorrect

    • A 50-year-old woman comes to the rheumatology clinic with poorly controlled rheumatoid arthritis. Her hands and feet have been swollen and painful for the past five years, particularly her metacarpophalangeal joints. The stiffness and pain are worse in the morning but improve with use throughout the day. Despite trying methotrexate and sulfasalazine, both treatments have been unsuccessful. The doctor decides to start her on a trial of TNF-inhibitors. What should be done before beginning treatment?

      Your Answer: Abdominal x-ray

      Correct Answer: Chest x-ray

      Explanation:

      Performing a chest X-ray before starting biologics for rheumatoid arthritis is crucial to check for TB as these medications can trigger reactivation of the disease. This is the correct answer. An abdominal X-ray is not necessary in this scenario as it is typically used for suspected abdominal perforation. While full blood count and liver function tests are essential monitoring tools for DMARDs, they are not required before initiating treatment due to the risk of myelosuppression and liver cirrhosis.

      Managing Rheumatoid Arthritis with Disease-Modifying Therapies

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

    • This question is part of the following fields:

      • Musculoskeletal
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