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  • Question 1 - 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: Carpal tunnel syndrome

      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 2 - You review the results of a DEXA scan for a 70-year-old man who...

    Incorrect

    • You review the results of a DEXA scan for a 70-year-old man who was referred due to a family history of femoral fracture. His past medical history includes type 2 diabetes, for which he takes metformin. He is a former smoker, quit 10 years ago, drinks 5 units of alcohol per week and follows a vegetarian diet. His T-score is -2.5. Blood results are shown below.

      Hb 140g/L 120-160g/L

      WCC 7.0x109/l 4.0-11x109/l

      Na+ 138 mmol/L 135-145 mmol/L

      K+ 4.2mmol/L 3.5-5.0mmol/L

      Ca2+ 2.3mmol/L 2.2-2.6mmol/L (adjusted)

      Vitamin D 60 nmol/L >50 nmol/L

      What is the most appropriate action?

      Your Answer: Calcium + vitamin D

      Correct Answer: Alendronate

      Explanation:

      The recommended prescription for this patient with osteoporosis is bisphosphonate therapy, specifically alendronate or risedronate. Before starting treatment, it is important to ensure that calcium and vitamin D levels are replete, but supplementation should only be prescribed if dietary intake is inadequate or if there is a risk of vitamin D deficiency due to lack of sunlight exposure. Continuous combined hormone replacement therapy is not recommended for older postmenopausal women with osteoporosis, as the risk vs benefit ratio is unfavourable.

      Bisphosphonates: Uses and Adverse Effects

      Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

      However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.

      To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.

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      • Musculoskeletal
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  • Question 3 - A 72-year-old woman presents to the emergency department with a painful swollen ankle....

    Correct

    • A 72-year-old woman presents to the emergency department with a painful swollen ankle. She is currently on oral antibiotics for a respiratory infection. She has a past medical history of rheumatoid arthritis.

      Observations:
      Heart rate 90 beats per minute
      Blood pressure 150/80 mmHg
      Respiratory rate 20/minute
      Oxygen saturations 95% on room air
      Temperature 37.2C

      On examination, the left ankle is erythematosus, tender and swollen with a restricted range of motion.

      Plain radiography of the left ankle reveals erosion of the joint space.

      What is the most likely diagnosis?

      Your Answer: Pseudogout

      Explanation:

      Gout is not the correct diagnosis in this case. While it is a possible cause of monoarthritis, the radiological findings and the affected joint suggest pseudogout as a more likely cause. Psoriatic arthritis is also an unlikely diagnosis, as this type of inflammatory arthritis typically presents in multiple joints and may be associated with a family history or psoriatic rash. Similarly, while rheumatoid arthritis can present as monoarthritis, it is more commonly seen as small joint polyarthritis with erosions and osteopenia visible on x-ray. It is important not to miss the correct diagnosis in cases of monoarthritis.

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

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      • Musculoskeletal
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  • Question 4 - A 15-year-old patient presents to the emergency department after a football injury resulting...

    Incorrect

    • A 15-year-old patient presents to the emergency department after a football injury resulting in a fracture. Despite reduction, the patient is experiencing severe pain, especially during passive stretching. The affected arm is visibly swollen, and the patient reports tingling sensations in their hand and forearm. What type of fracture is commonly associated with these symptoms?

      Your Answer: Radial head fracture

      Correct Answer: Supracondylar fracture

      Explanation:

      Compartment syndrome is often linked to fractures in the supracondylar region of the arm and the tibial shaft in the lower leg. Symptoms include excessive pain, especially during passive stretching, as well as swelling and paraesthesia in the affected limb. Late signs may include numbness and paralysis.

      Compartment syndrome is a complication that can occur after fractures or vascular injuries. It is characterized by increased pressure within a closed anatomical space, which can lead to tissue death. Supracondylar fractures and tibial shaft injuries are the most common fractures associated with compartment syndrome. Symptoms include pain, numbness, paleness, and possible paralysis of the affected muscle group. Diagnosis is made by measuring intracompartmental pressure, with pressures over 20 mmHg being abnormal and over 40 mmHg being diagnostic. X-rays typically do not show any pathology. Treatment involves prompt and extensive fasciotomies, with careful attention to decompressing deep muscles in the lower limb. Patients may develop myoglobinuria and require aggressive IV fluids. In severe cases, debridement and amputation may be necessary, as muscle death can occur within 4-6 hours.

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      • Musculoskeletal
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  • Question 5 - A 45-year-old individual complains of numbness and tingling along the ulnar border of...

    Incorrect

    • A 45-year-old individual complains of numbness and tingling along the ulnar border of their wrist and forearm. During examination, you observe weak flexion of all digits, including the thumb. What is the probable diagnosis?

      Your Answer: Carpal tunnel syndrome

      Correct Answer: C8 radiculopathy

      Explanation:

      Unlike named nerve pathology, radiculopathy follows a dermatomal distribution. This means that the pattern of sensory loss cannot be explained by a single named nerve. For example, while the ulnar nerve supplies the ulnar border of the hand and the medial antebrachial cutaneous nerve supplies the medial forearm, these areas are actually covered by the C8 dermatome.

      It’s important to note that thumb flexion would not be affected in ulnar nerve lesions, and carpal tunnel syndrome would only affect flexion of the thumb without producing this specific pattern of sensory loss. On the other hand, a cerebrovascular accident would likely result in complete upper limb weakness or numbness.

      Understanding Cervical Spondylosis

      Cervical spondylosis is a prevalent condition that arises from osteoarthritis. It is characterized by neck pain, which can be mistaken for headaches or other conditions. This condition is caused by the degeneration of the cervical spine, which is the part of the spine that is located in the neck. As the spine degenerates, it can cause the vertebrae to rub against each other, leading to pain and discomfort.

      Cervical spondylosis can also cause complications such as radiculopathy and myelopathy. Radiculopathy occurs when the nerves that run from the spinal cord to the arms and legs become compressed or damaged. This can cause pain, numbness, and weakness in the affected area. Myelopathy, on the other hand, occurs when the spinal cord itself becomes compressed or damaged. This can cause a range of symptoms, including difficulty walking, loss of bladder or bowel control, and even paralysis.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 6 - A 55-year-old female complains of dry eyes, dry mouth, arthralgia and fatigue for...

    Incorrect

    • A 55-year-old female complains of dry eyes, dry mouth, arthralgia and fatigue for the past 4 months. During examination, there is conjunctival injection, reduced salivary pool, dry mucous membranes and oral ulceration. The Schirmer's test is positive. Which of the following tests is the most suitable?

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

      Correct Answer: Anti-Ro / Anti-La antibodies

      Explanation:

      The symptoms observed and a positive Schirmer’s test indicate the possibility of Sjögren’s syndrome. The presence of anti-Ro and anti-La antibodies can aid in confirming the diagnosis.

      Understanding Sjogren’s Syndrome

      Sjogren’s syndrome is a medical condition that affects the exocrine glands, leading to dry mucosal surfaces. It is an autoimmune disorder that can either be primary or secondary to other connective tissue disorders, such as rheumatoid arthritis. The onset of the condition usually occurs around ten years after the initial onset of the primary disease. Sjogren’s syndrome is more common in females, with a ratio of 9:1. Patients with this condition have a higher risk of developing lymphoid malignancy, which is 40-60 times more likely.

      The symptoms of Sjogren’s syndrome include dry eyes, dry mouth, vaginal dryness, arthralgia, Raynaud’s, myalgia, sensory polyneuropathy, recurrent episodes of parotitis, and subclinical renal tubular acidosis. To diagnose the condition, doctors may perform a Schirmer’s test to measure tear formation, check for hypergammaglobulinaemia, and low C4. Nearly 50% of patients with Sjogren’s syndrome test positive for rheumatoid factor, while 70% test positive for ANA. Additionally, 70% of patients with primary Sjogren’s syndrome have anti-Ro (SSA) antibodies, and 30% have anti-La (SSB) antibodies.

      The management of Sjogren’s syndrome involves the use of artificial saliva and tears to alleviate dryness. Pilocarpine may also be used to stimulate saliva production. Understanding the symptoms and management of Sjogren’s syndrome is crucial for patients and healthcare providers to ensure proper treatment and care.

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      • Musculoskeletal
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  • Question 7 - A 25-year-old male is being evaluated by his GP due to gradually worsening...

    Correct

    • A 25-year-old male is being evaluated by his GP due to gradually worsening lower back pain. The pain is more severe in the morning and after prolonged periods of inactivity. He has also experienced increasing fatigue over the past 6 months. The GP prescribed regular NSAIDs, which resulted in significant symptom improvement. An x-ray of the lumbar spine was conducted, revealing indications of ankylosing spondylitis.
      What is the most probable finding on the patient's x-ray?

      Your Answer: Subchondral erosions

      Explanation:

      Ankylosing spondylitis can be identified through x-ray findings such as subchondral erosions, which are typically seen in the corners of vertebral bodies and on the iliac side of the sacroiliac joint. This is usually preceded by subchondral sclerosis, which can lead to squaring of the lumbar vertebrae and a characteristic bamboo spine appearance. It is important to note that juxta-articular osteoporosis, loss of vertebral height, and osteopenia are not typical x-ray findings for ankylosing spondylitis.

      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 8 - A 26-year-old man presents with a history of worsening low back pain over...

    Correct

    • A 26-year-old man presents with a history of worsening low back pain over the past year. He reports that the pain is more severe after prolonged periods of sitting and experiences stiffness in the morning lasting up to 30 minutes. Despite being an active footballer and gym-goer, he has been troubled by pain in his right Achilles tendon, limiting his physical activity. The GP has referred him to a rheumatologist and ordered lumbar spine and sacroiliac joint x-rays. What collection of findings is most likely to be observed?

      Your Answer: Subchondral erosions, sclerosis and squaring of vertebrae

      Explanation:

      Ankylosing spondylitis is a condition that typically affects males between the ages of 20-30 and is characterized by low back pain that worsens at rest and improves with activity, as well as early morning stiffness lasting more than 15 minutes. This condition is often associated with Achilles tendinopathy (enthesitis). Radiographic imaging commonly shows subchondral erosions and sclerosis in the sacroiliac joints (sacroiliitis), as well as vertebral body squaring, ligament calcification, and syndesmophytes in the lumbar spine. Over time, these changes can lead to the formation of a ‘bamboo spine’. Block vertebra is a different condition that involves a failure of separation of adjacent vertebral bodies and is not typically seen in ankylosing spondylitis. Osteoarthritis is characterized by joint space narrowing, osteophytes, and subchondral cysts, while rheumatoid arthritis is characterized by marginal erosions, soft tissue swelling, and periarticular osteoporosis. Gout is characterized by soft tissue swelling, punched-out bone lesions, and overhanging sclerotic margins.

      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 9 - A 30-year-old runner complains of heel pain. During examination, there is widespread tenderness...

    Incorrect

    • A 30-year-old runner complains of heel pain. During examination, there is widespread tenderness that is more severe on the medial side of the heel. Despite taking a break from running for the past week, the pain is exacerbated by standing on their feet all day at work. Walking on their toes intensifies the pain. What is the probable diagnosis?

      Your Answer: Achilles tendonitis

      Correct Answer: Plantar fasciitis

      Explanation:

      This presentation is typical of plantar fasciitis, which is the most common cause of heel pain in adults. Walking on tip toes exacerbates the pain, unlike subcalcaneal bursitis. Achilles tendonitis typically causes pain at the calcaneal insertion of the tendon or further up the tendon, depending on the affected area. Thompson’s test can rule out tendon rupture. S1 radiculopathy may cause sensory loss along the lateral aspect of the foot and reduced dorsiflexion of the foot. Morton’s neuroma is a thickening of the tissue around the nerve, usually between the 3rd and 4th toes, and pain is typically felt on the ball of the foot.

      Understanding Plantar Fasciitis

      Plantar fasciitis is a prevalent condition that causes heel pain in adults. The pain is typically concentrated around the medial calcaneal tuberosity, which is the bony bump on the inside of the heel. This condition occurs when the plantar fascia, a thick band of tissue that runs along the bottom of the foot, becomes inflamed or irritated.

      To manage plantar fasciitis, it is essential to rest the feet as much as possible. Wearing shoes with good arch support and cushioned heels can also help alleviate the pain. Insoles and heel pads may also be beneficial in providing additional support and cushioning. It is important to note that plantar fasciitis can take time to heal, and it is crucial to be patient and consistent with treatment. By taking these steps, individuals can effectively manage their plantar fasciitis and reduce their discomfort.

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      • Musculoskeletal
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  • Question 10 - A 25-year-old male presents to the emergency department complaining of pain in his...

    Incorrect

    • A 25-year-old male presents to the emergency department complaining of pain in his ankle. He reports that whilst playing basketball that evening he landed awkwardly on his left foot after jumping for a rebound. He felt a pop at the time of impact and his ankle immediately became swollen.

      On examination:

      Heart rate: 80/minute; Respiratory rate: 16/minute; Blood pressure: 120/80 mmHg; Oxygen saturations: 99%; Temperature: 36.8 ºC. Capillary refill time: 2 seconds.

      Left ankle: swollen, erythematosus and disaffirmed. Skin intact. Extremely tender upon palpation of the lateral malleolus. Difficulty weight-bearing and dorsiflexing the ankle. Sensation intact. Pulses present.

      Examination of the right ankle and lower limb is unremarkable.

      X-rays of the left ankle and foot are carried out which demonstrate a fractured lateral malleolus and associated dislocation of the ankle joint.

      What term is used to describe this pattern of injury?

      Your Answer: Colles’ fracture

      Correct Answer: Galeazzi fracture

      Explanation:

      The patient has a Galeazzi fracture, which involves a dislocation of the distal radioulnar joint and a fracture of the radius. It is important to differentiate this from a Monteggia fracture, which involves a fracture of the proximal ulna and a dislocation of the proximal radioulnar joint. To remember the difference, one can associate the name of the fracture with the bone that is broken: Monteggia ulna (Manchester United), Galeazzi radius (Galaxy rangers). Other types of fractures include Colles’ fracture, which involves a distal radius fracture with dorsal displacement, Smith’s fracture, which involves a distal radius fracture with volar displacement, and Boxer’s fracture, which involves a fracture of the neck of the fourth or fifth metacarpal with volar displacement of the metacarpal head.

      Upper limb fractures can occur due to various reasons, such as falls or impacts. One such fracture is Colles’ fracture, which is caused by a fall onto extended outstretched hands. This fracture is characterized by a dinner fork type deformity and has three features, including a transverse fracture of the radius, one inch proximal to the radiocarpal joint, and dorsal displacement and angulation. Another type of fracture is Smith’s fracture, which is a reverse Colles’ fracture and is caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed. This fracture results in volar angulation of the distal radius fragment, also known as the Garden spade deformity.

      Bennett’s fracture is an intra-articular fracture at the base of the thumb metacarpal, caused by an impact on a flexed metacarpal, such as in fist fights. On an X-ray, a triangular fragment can be seen at the base of the metacarpal. Monteggia’s fracture is a dislocation of the proximal radioulnar joint in association with an ulna fracture, caused by a fall on an outstretched hand with forced pronation. It requires prompt diagnosis to avoid disability. Galeazzi fracture is a radial shaft fracture with associated dislocation of the distal radioulnar joint, occurring after a fall on the hand with a rotational force superimposed on it. Barton’s fracture is a distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation, caused by a fall onto an extended and pronated wrist.

      Scaphoid fractures are the most common carpal fractures and occur due to a fall onto an outstretched hand, with the tubercle, waist, or proximal 1/3 being at risk. The surface of the scaphoid is covered by articular cartilage, with a small area available for blood vessels, increasing the risk of fracture. The main physical signs of scaphoid fractures are swelling and tenderness in the anatomical snuff box, pain on wrist movements, and longitudinal compression of the thumb. An ulnar deviation AP is needed for visualization of scaphoid, and immobilization of scaphoid fractures can be difficult. Finally, a radial head fracture is common in young adults and is usually caused by a fall on the outstretched hand. It is characterized by marked local tenderness over

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 11 - A 59 year old female visits her GP with complaints of fatigue and...

    Incorrect

    • A 59 year old female visits her GP with complaints of fatigue and body aches. Upon further inquiry, the patient reports feeling increasingly tired for the past several months and experiencing joint and muscle pains. Her medical history indicates chronic heart failure, which is being treated with isosorbide dinitrate and hydralazine. As hydralazine can lead to drug-induced lupus, what investigation would be most helpful in confirming this diagnosis?

      Your Answer: Alkaline phosphatase (ALP)

      Correct Answer: Anti-histone antibodies

      Explanation:

      ALP can be rewritten as alkaline phosphatase.

      Understanding Drug-Induced Lupus

      Drug-induced lupus is a condition that shares some similarities with systemic lupus erythematosus, but not all of its typical features are present. Unlike SLE, renal and nervous system involvement is rare in drug-induced lupus. The good news is that this condition usually resolves once the drug causing it is discontinued.

      The most common symptoms of drug-induced lupus include joint pain, muscle pain, skin rashes (such as the malar rash), and pulmonary issues like pleurisy. In terms of laboratory findings, patients with drug-induced lupus typically test positive for ANA (antinuclear antibodies) but negative for dsDNA (double-stranded DNA) antibodies. Anti-histone antibodies are found in 80-90% of cases, while anti-Ro and anti-Smith antibodies are only present in around 5% of cases.

      The most common drugs that can cause drug-induced lupus are procainamide and hydralazine. Other less common culprits include isoniazid, minocycline, and phenytoin.

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      • Musculoskeletal
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  • Question 12 - A 47-year-old woman comes to the rheumatology clinic for evaluation of her newly...

    Incorrect

    • A 47-year-old woman comes to the rheumatology clinic for evaluation of her newly diagnosed rheumatoid arthritis. The clinician employs a scoring system to assist in the patient's treatment plan.

      What is the probable scoring system utilized?

      Your Answer: ABCD2

      Correct Answer: DAS28

      Explanation:

      The measurement of disease activity in rheumatoid arthritis is done using the DAS28 score. This score evaluates the level of disease activity by assessing 28 joints, hence the name DAS28, where DAS stands for disease activity score.

      Managing Rheumatoid Arthritis with Disease-Modifying Therapies

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

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      • Musculoskeletal
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  • Question 13 - A 20-year-old basketball player arrives at the emergency department complaining of a sudden...

    Incorrect

    • A 20-year-old basketball player arrives at the emergency department complaining of a sudden popping sensation in his left heel. During the physical examination, a noticeable dip is palpable on the back of his ankle. The patient reports that he was prescribed ciprofloxacin for a chest infection while on a recent trip to Italy. What is the most suitable test to confirm the suspected diagnosis?

      Your Answer: Multiple views plain film radiographs (X Ray) ankle

      Correct Answer: Ultrasound ankle

      Explanation:

      Achilles tendon disorders are a common cause of pain in the back of the heel. These disorders can include tendinopathy, partial tears, and complete ruptures of the Achilles tendon. Certain factors, such as the use of quinolone antibiotics and high cholesterol levels, can increase the risk of developing these disorders. Symptoms of Achilles tendinopathy typically include gradual onset of pain that worsens with activity, as well as morning stiffness. Treatment for this condition usually involves pain relief, reducing activities that exacerbate the pain, and performing calf muscle eccentric exercises.

      In contrast, an Achilles tendon rupture is a more serious condition that requires immediate medical attention. This type of injury is often caused by sudden, forceful movements during sports or running. Symptoms of an Achilles tendon rupture include an audible popping sound, sudden and severe pain in the calf or ankle, and an inability to walk or continue the activity. To help diagnose an Achilles tendon rupture, doctors may use Simmond’s triad, which involves examining the foot for abnormal angles and feeling for a gap in the tendon. Ultrasound is typically the first imaging test used to confirm a diagnosis of Achilles tendon rupture. If a rupture is suspected, it is important to seek medical attention from an orthopaedic specialist as soon as possible.

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      • Musculoskeletal
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  • Question 14 - A 65-year-old male is receiving his last round of ICE chemotherapy for non-Hodgkin's...

    Incorrect

    • A 65-year-old male is receiving his last round of ICE chemotherapy for non-Hodgkin's lymphoma. What is the potential risk associated with his treatment that he may develop?

      Your Answer: Rheumatoid arthritis

      Correct Answer: Gout

      Explanation:

      Chemotherapy can lead to a higher risk of gout due to the increased production of uric acid from the breakdown of cells. However, it is not associated with an increased risk of pseudogout or rheumatoid arthritis, which are caused by different factors such as calcium pyrophosphate crystals and genetics, respectively.

      Understanding the Predisposing Factors of Gout

      Gout is a type of microcrystal synovitis that occurs when monosodium urate monohydrate is deposited in the synovium. This condition is caused by chronic hyperuricaemia, which is characterized by uric acid levels that exceed 0.45 mmol/l. There are two main factors that contribute to the development of hyperuricaemia: decreased excretion of uric acid and increased production of uric acid.

      One of the primary causes of decreased uric acid excretion is the use of diuretics. Chronic kidney disease and lead toxicity can also lead to decreased excretion of uric acid. On the other hand, increased production of uric acid can be caused by myeloproliferative/lymphoproliferative disorders, cytotoxic drugs, and severe psoriasis. Additionally, Lesch-Nyhan syndrome, which is an x-linked recessive disorder that is only seen in boys, can also lead to increased production of uric acid.

      It is important to note that aspirin in low doses is not thought to have a significant effect on plasma urate levels. Therefore, it is recommended that it should be continued if required for cardiovascular prophylaxis. Understanding the predisposing factors of gout can help individuals take preventative measures to reduce their risk of developing this painful condition.

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      • Musculoskeletal
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  • Question 15 - 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: Serum ESR levels

      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.

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      • Musculoskeletal
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  • Question 16 - A 51-year-old male presents with painful colour changes of his hands precipitated by...

    Incorrect

    • A 51-year-old male presents with painful colour changes of his hands precipitated by cold. He also reports difficulty swallowing and has noticed tightness of his skin especially on his face and his fingers.

      What is the most appropriate test from the options below?

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

      Correct Answer: Anti-centromere antibody

      Explanation:

      The symptoms indicate the possibility of scleroderma, and a detection of anti-centromere antibody can aid in confirming the diagnosis.

      Understanding Systemic Sclerosis

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

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  • Question 17 - 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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  • Question 18 - A 65-year-old woman presents with a 4-week history of widespread pain, stiffness, and...

    Correct

    • 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: 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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  • Question 19 - A 79-year-old female presents to the emergency department with severe right-sided hip pain...

    Incorrect

    • A 79-year-old female presents to the emergency department with severe right-sided hip pain following a car accident. She has a medical history of polymyalgia rheumatica and COPD and is currently taking prednisolone, alendronic acid, colecalciferol, and a salbutamol inhaler. Upon examination, she is visibly in pain and unable to bear weight on her right leg. Her right leg appears shortened and externally rotated compared to the left side. What is the probable diagnosis?

      Your Answer: Slipped capital femoral epiphysis

      Correct Answer: Hip fracture

      Explanation:

      The patient’s hip fracture is supported by several major risk factors, including being an elderly female, long-term steroid use, and a traumatic injury. A common finding in hip fractures is a shortened, externally rotated leg, which is also present in this case. Additionally, the patient is unable to bear weight on the affected leg.

      A is an incorrect answer as this condition typically occurs in obese teenagers and would not present in adult patients.

      B is the correct answer.

      C is an incorrect answer as while these fractures can occur in high-energy traumatic injuries, they are less common than hip fractures and would present with a visibly deformed thigh.

      D is an incorrect answer as this injury can occur in high-energy traumatic injuries, but it would result in a shortened, internally rotated leg.

      E is an incorrect answer as there is no evidence of prior hip pathology from the patient’s history, and the acute onset of symptoms does not support this diagnosis.

      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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  • Question 20 - A 67-year-old man presents to secondary care for a routine follow-up. He is...

    Correct

    • A 67-year-old man presents to secondary care for a routine follow-up. He is asymptomatic. Routine blood tests reveal the following:
      Calcium 3.1 mmol/L (2.1-2.6)
      Phosphate 0.3 mmol/L (0.8-1.4)
      Parathyroid hormone (PTH) 11.8 pmol/L (1.6 - 6.9)
      Magnesium 0.9 mmol/L (0.7-1.0)
      Thyroid stimulating hormone (TSH) 3.2 mU/L (0.5-5.5)
      Free thyroxine (T4) 17 pmol/L (9.0 - 18)
      What is the patient's most likely risk factor for developing a condition?

      Your Answer: Pseudogout

      Explanation:

      Primary hyperparathyroidism is often asymptomatic and can be detected through routine blood tests that show raised calcium, low phosphate, and raised parathyroid hormone levels. This condition is a known risk factor for the development of pseudogout or calcium pyrophosphate dihydrate deposition (CPPD) and chondrocalcinosis. However, there is no evidence to suggest an increased risk of gallstones. On the other hand, hyperparathyroidism can increase the risk of renal stones due to elevated serum and urinary calcium levels. Hypoparathyroidism, not hyperparathyroidism, is associated with ectopic soft tissue calcifications. Prolonged hypocalcaemia can increase the risk of cataracts, while hypercalcaemia can lead to corneal calcification. Primary hyperparathyroidism can also increase the risk of osteoporosis, osteitis fibrosa cystica, and pathological fractures, but it is not associated with osteopetrosis.

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

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  • Question 21 - A 50-year-old woman comes to see her GP for a follow-up on her...

    Incorrect

    • A 50-year-old woman comes to see her GP for a follow-up on her Dupuytren's contracture. She has been experiencing more difficulty lately with her job, which involves a lot of typing. Despite taking Naproxen, she has not found much relief. During the examination, the GP observes that the metacarpophalangeal joints on her right hand's little finger and ring finger are bent forward by 30 degrees, and she is unable to place her hand flat on the table. What should be the GP's next appropriate step in managing her condition?

      Your Answer: Corticosteroid injection

      Correct Answer: Make a routine referral to orthopaedics to be seen by a hand specialist

      Explanation:

      When a patient with Dupuytren’s contracture is unable to straighten their metacarpophalangeal joints and place their hand flat on a table, surgical treatment should be considered. This condition occurs when the palmar fascia becomes stiff and fibroses, causing the affected fingers to contract, typically the ring and little finger of the right hand.

      The severity of the condition will determine the appropriate management approach. In cases where the condition is severe and impacting the patient’s quality of life, referral to a hand specialist for secondary intervention is recommended. This may involve either surgical intervention or injectable enzyme therapy, which should only be initiated by a specialist.

      For minor cases where the condition is not significantly affecting the patient’s quality of life, primary care management may be appropriate. This will involve reassurance that the condition may improve over time, regular reviews, and advice on when to return for referral if necessary.

      It is important to note that corticosteroid injections are not effective in treating Dupuytren’s contracture. Additionally, as this is not an acute problem, patients should not be advised to attend the emergency department.

      Understanding Dupuytren’s Contracture

      Dupuytren’s contracture is a condition that affects about 5% of the population. It is more common in older men and those with a family history of the condition. The causes of Dupuytren’s contracture include manual labor, phenytoin treatment, alcoholic liver disease, diabetes mellitus, and trauma to the hand.

      The condition typically affects the ring finger and little finger, causing them to become bent and difficult to straighten. In severe cases, the hand may not be able to be placed flat on a table.

      Surgical treatment may be necessary when the metacarpophalangeal joints cannot be straightened.

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  • Question 22 - A 25-year-old patient visits the GP complaining of lower back pain and stiffness...

    Incorrect

    • A 25-year-old patient visits the GP complaining of lower back pain and stiffness that extends to the buttocks for the past 3 months. The pain is most severe upon waking up, but cycling seems to alleviate it. The patient denies any injury but is an avid cyclist. Additionally, the patient experiences fatigue. The patient had Chlamydia and was treated with doxycycline 8 months ago. The patient has a history of anxiety and does not take any regular medication, but ibuprofen helps alleviate the pain. What is the most probable diagnosis?

      Your Answer: Sciatica

      Correct Answer: Ankylosing spondylitis

      Explanation:

      Exercise is typically beneficial for patients with inflammatory back pain, such as those with ankylosing spondylitis. This condition is more common in males and presents with symptoms such as morning stiffness, back pain lasting over 3 months, and improvement with exercise. Inflammation can also affect the sacroiliac joints, causing buttock pain, and patients may experience fatigue. Lumbar spinal stenosis is an unlikely differential as it presents with back and buttock pain due to nerve compression, and patients may have leg weakness. Psoriatic arthritis can also cause spondyloarthritis, but it typically presents with peripheral arthritis and/or dactylitis, and patients may have a history of psoriasis. Reactive arthritis is also an unlikely differential as it typically presents 1-4 weeks after infection, and patients may have other symptoms such as enthesitis, peripheral arthritis, conjunctivitis, skin lesions, and urethritis.

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in young males, with a sex ratio of 3:1, and typically presents with lower back pain and stiffness that develops gradually. The stiffness is usually worse in the morning and improves with exercise, while pain at night may improve upon getting up. Clinical examination may reveal reduced lateral and forward flexion, as well as reduced chest expansion. Other features associated with ankylosing spondylitis include apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, amyloidosis, cauda equina syndrome, and peripheral arthritis (more common in females).

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  • Question 23 - A 70-year-old man presents to his GP with bone pain and muscle tenderness....

    Incorrect

    • A 70-year-old man presents to his GP with bone pain and muscle tenderness. He has a past medical history of stage 3 chronic kidney disease.
      The GP decides to take some blood, and the results are shown below.
      Calcium 2.1 mmol/L (2.2-2.7)
      Phosphate 0.72 mmol/L (0.8-1.4)
      Magnesium 0.9 mmol/L (0.7-1.0)
      Thyroid stimulating hormone (TSH) 4.8 mU/L (0.5-5.5)
      Free thyroxine (T4) 10.8 pmol/L (9.0 - 18)
      What is the most appropriate initial management?

      Your Answer: Intravenous fluids

      Correct Answer: Vitamin D supplements

      Explanation:

      The appropriate management for osteomalacia, which is likely caused by chronic kidney disease, involves vitamin D supplementation with an initial loading dose regime. Blood tests for osteomalacia typically reveal low levels of calcium and phosphate, as well as high levels of alkaline phosphatase. Calcium supplementation may also be prescribed if the patient’s dietary intake is insufficient. Intravenous fluids and bisphosphonates are not recommended for the treatment of hypocalcaemia, while levothyroxine is used to manage hypothyroidism and oral bisphosphonates are used for osteoporosis.

      Understanding Osteomalacia

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

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

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

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  • Question 24 - A 4-year-old is brought in with a fracture that affects the physis, metaphysis,...

    Correct

    • A 4-year-old is brought in with a fracture that affects the physis, metaphysis, and epiphysis of their left femur. What Salter-Harris classification does this fracture fall under?

      Your Answer: Salter-Harris IV

      Explanation:

      A Salter Harris 4 fracture is a type of fracture that occurs in children and involves damage to the growth plate, as well as the metaphysis and epiphysis of the bone. Unfortunately, this type of fracture is associated with a poor prognosis. The Salter-Harris classification system provides a more comprehensive breakdown of the different types of fractures that can occur in children.

      Paediatric Fractures and Pathological Conditions

      Paediatric fractures can be classified into different types based on the injury pattern. Complete fractures occur when both sides of the cortex are breached, while greenstick fractures only have a unilateral cortical breach. Buckle or torus fractures result in incomplete cortical disruption, leading to a periosteal haematoma. Growth plate fractures are also common in paediatric practice and are classified according to the Salter-Harris system. Injuries of Types III, IV, and V usually require surgery and may be associated with disruption to growth.

      Non-accidental injury is a concern in paediatric fractures, especially when there is a delay in presentation, lack of concordance between proposed and actual mechanism of injury, multiple injuries, injuries at sites not commonly exposed to trauma, or when children are on the at-risk register. Pathological fractures may also occur due to genetic conditions such as osteogenesis imperfecta, which is characterized by defective osteoid formation and failure of collagen maturation in all connective tissues. Osteopetrosis is another pathological condition where bones become harder and more dense, and radiology reveals a lack of differentiation between the cortex and the medulla, described as marble bone.

      Overall, paediatric fractures and pathological conditions require careful evaluation and management to ensure optimal outcomes for the child.

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  • Question 25 - A 35-year-old female patient visits your clinic with complaints of mouth and genital...

    Incorrect

    • A 35-year-old female patient visits your clinic with complaints of mouth and genital ulcers, accompanied by redness in her eyes. You suspect Behcet's syndrome as the possible diagnosis. What skin manifestation would provide the strongest evidence to support your diagnosis?

      Your Answer: Asteatotic eczema

      Correct Answer: Erythema nodosum

      Explanation:

      Behcet’s syndrome is linked to several skin symptoms, including genital ulcers, aphthous ulcers, acne-like lesions, and painful red lesions known as erythema nodosum. These lesions are caused by inflammation of the subcutaneous fat and are commonly found on the shins. In contrast, erythema marginatum is a rare rash characterized by pink rings on the extensor surfaces and is associated with rheumatic fever. Asteatotic eczema, also known as crazy paving eczema, has a unique appearance and is linked to hypothyroidism and lymphoma.

      Behcet’s syndrome is a complex disorder that affects multiple systems in the body. It is believed to be caused by inflammation of the arteries and veins due to an autoimmune response, although the exact cause is not yet fully understood. The condition is more common in the eastern Mediterranean, particularly in Turkey, and tends to affect young adults between the ages of 20 and 40. Men are more commonly affected than women, although this varies depending on the country. Behcet’s syndrome is associated with a positive family history in around 30% of cases and is linked to the HLA B51 antigen.

      The classic symptoms of Behcet’s syndrome include oral and genital ulcers, as well as anterior uveitis. Other features of the condition may include thrombophlebitis, deep vein thrombosis, arthritis, neurological symptoms such as aseptic meningitis, gastrointestinal problems like abdominal pain, diarrhea, and colitis, and erythema nodosum. Diagnosis of Behcet’s syndrome is based on clinical findings, as there is no definitive test for the condition. A positive pathergy test, where a small pustule forms at the site of a needle prick, can be suggestive of the condition. HLA B51 is also a split antigen that is associated with Behcet’s syndrome.

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  • Question 26 - A 33-year-old male arrives at the emergency department following a car accident. He...

    Correct

    • 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: 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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  • Question 27 - A young child develops an eczematous, weeping rash on their wrist after receiving...

    Incorrect

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

      Your Answer: Type II reaction

      Correct Answer: Type IV reaction

      Explanation:

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

      Classification of Hypersensitivity Reactions

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

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

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  • Question 28 - A 68-year-old male comes to the Emergency Department with lower back pain and...

    Correct

    • A 68-year-old male comes to the Emergency Department with lower back pain and difficulty standing without assistance. He has a history of metastatic lung cancer and is currently receiving palliative care. During examination, severe neurological deficits are observed in both legs. What would be a late sign in this patient, considering the probable diagnosis?

      Your Answer: Urinary incontinence

      Explanation:

      Cauda equina syndrome typically manifests as lower back pain, sciatica, and decreased perianal sensation. As the condition progresses, urinary incontinence may develop.

      The most likely diagnosis for this patient is cauda equina syndrome, which is characterized by compression of the lumbosacral nerve roots. This can be caused by metastatic spinal cord compression or spinal fractures that compromise spinal stability. It is important to note that CES can present in various ways, and there is no single symptom or sign that can definitively diagnose or rule out the condition. Symptoms may include lower back pain, bilateral sciatica, decreased perianal sensation, reduced anal tone, fecal incontinence, and urinary dysfunction such as incontinence, decreased awareness of bladder filling, and loss of urge to void.

      Cauda equina syndrome (CES) is a rare but serious condition that occurs when the nerve roots in the lower back are compressed. It is crucial to consider CES in patients who present with new or worsening lower back pain, as a late diagnosis can result in permanent nerve damage and long-term leg weakness and urinary/bowel incontinence. The most common cause of CES is a central disc prolapse, typically at L4/5 or L5/S1, but it can also be caused by tumors, infections, trauma, or hematomas. CES can present in various ways, and there is no single symptom or sign that can diagnose or exclude it. Possible features include low back pain, bilateral sciatica, reduced sensation in the perianal area, decreased anal tone, and urinary dysfunction. Urgent MRI is necessary for diagnosis, and surgical decompression is the recommended management.

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  • Question 29 - A 63-year-old man visits his doctor complaining of haemoptysis and symmetrical polyarthritis in...

    Incorrect

    • A 63-year-old man visits his doctor complaining of haemoptysis and symmetrical polyarthritis in his hands and feet for the past four weeks. He has also noticed blood in his urine recently. Upon conducting a urine dipstick test, the results show positive for blood and protein, but negative for nitrites, leucocytes, and ketones, with a pH of 7.5. The doctor orders various blood tests to aid in the diagnosis.
      What blood test is most likely to assist in the diagnosis?

      Your Answer: Rheumatoid factor

      Correct Answer: ANCA antibodies

      Explanation:

      If a patient presents with renal impairment, respiratory symptoms, joint pain, and systemic features, ANCA associated vasculitis should be considered. This is especially true if the patient has haematuria and proteinuria on dipstick, as well as haemoptysis and inflammatory arthritis. ANCA associated vasculitis can be diagnosed by testing for various serum ANCA antibodies. While a raised eosinophil count may suggest eosinophilic granulomatosis with polyangiitis, it is not specific enough to make a diagnosis. IgA levels can help diagnose IgA nephropathy, but this is not the most likely diagnosis in this case. Similarly, IgG is commonly raised in multiple myeloma, but this is not the diagnosis here.

      ANCA Associated Vasculitis: Common Findings and Management

      Anti-neutrophil cytoplasmic antibodies (ANCA) are associated with small-vessel vasculitis 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 30 - An 80-year-old woman complains of feeling generally fatigued and experiencing muscle aches. She...

    Incorrect

    • An 80-year-old woman complains of feeling generally fatigued and experiencing muscle aches. She reports stiffness and pain in her back, arms, and thighs, especially in the morning. These symptoms have persisted for the past two weeks, despite her previously being in good health. Upon examination, the only notable finding is tenderness in her deltoid and thigh muscles, with normal muscle strength. What is the probable diagnosis?

      Your Answer: Rheumatoid arthritis

      Correct Answer: Polymyalgia rheumatica

      Explanation:

      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 31 - A 63-year-old woman comes to her doctor complaining of pain and swelling in...

    Incorrect

    • A 63-year-old woman comes to her doctor complaining of pain and swelling in the small joints of her hands that have been present for about eight weeks. She has no significant medical history and is not taking any regular medications. Upon examination, the doctor finds that the 2nd and 3rd proximal interphalangeal joints on both hands are swollen and tender. The doctor orders a plain radiography of the hands, which shows juxta-articular osteopenia. What is the most probable diagnosis?

      Your Answer: Psoriatic arthritis

      Correct Answer: Rheumatoid arthritis

      Explanation:

      Early signs of rheumatoid arthritis can be observed through x-rays, specifically the presence of juxta-articular osteoporosis/osteopenia.

      X-Ray Changes in Rheumatoid Arthritis

      Rheumatoid arthritis is a chronic autoimmune disease that affects the joints, causing pain, stiffness, and swelling. X-ray imaging is often used to diagnose and monitor the progression of the disease. Early x-ray findings in rheumatoid arthritis include a loss of joint space, juxta-articular osteoporosis, and soft-tissue swelling. These changes indicate that the joint is being damaged and that the bones are losing density.

      As the disease progresses, late x-ray findings may include periarticular erosions and subluxation. Periarticular erosions are areas of bone loss around the joint, while subluxation refers to the partial dislocation of the joint. These changes can lead to deformities and functional impairment.

      It is important to note that x-ray findings may not always correlate with the severity of symptoms in rheumatoid arthritis. Some patients may have significant joint damage on x-ray but experience minimal pain, while others may have severe pain despite minimal x-ray changes. Therefore, x-ray imaging should be used in conjunction with other clinical assessments to determine the best course of treatment for each individual patient.

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  • Question 32 - A 54-year-old woman presents to the rheumatology clinic with a history of her...

    Correct

    • A 54-year-old woman presents to the rheumatology clinic with a history of her fingers turning white, blue, and red intermittently for the past four months. She also reports tightness of the skin on her fingers, hands, and face, without involvement of the skin on her upper arm or chest. Additionally, she experiences troubling reflux symptoms. On examination, there is fibrotic skin overlying the hands and face with telangiectasia. Which autoantibody is most likely to be positive in this patient, given the probable diagnosis?

      Your Answer: Anti-centromere antibodies

      Explanation:

      The presence of skin tightening, Raynaud’s phenomenon, and telangiectasia in this patient suggests a diagnosis of systemic sclerosis. The limited subtype is most likely as there is no involvement of the upper arm and chest. Anti-centromere antibodies are commonly associated with this subtype. Anti-RNA polymerase III and anti-Scl-70 antibodies are more commonly associated with diffuse systemic sclerosis, which involves the chest and upper arms and more severe internal organ involvement. Anti-Ro antibodies are typically associated with Sjögren’s syndrome, which is unlikely in this patient. Anti-dsDNA antibodies are commonly associated with systemic lupus erythematosus (SLE), but systemic sclerosis is more likely given the absence of a butterfly rash and the presence of oesophageal dysmotility.

      Understanding Systemic Sclerosis

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

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  • Question 33 - A 26-year-old male presents to the emergency department with feverish symptoms and a...

    Incorrect

    • A 26-year-old male presents to the emergency department with feverish symptoms and a painful right knee. He had a Chlamydia trachomatis infection two weeks ago. His vital signs are as follows:
      Respiratory rate 17 breath/min
      Heart rate 84 beats/min
      Blood pressure 122/76 mmHg
      Temperature 37.3ºC
      Oxygen saturations 97% on room air
      What is the most likely finding in a synovial fluid sample taken from this patient's knee?

      Your Answer: Positively birefringent crystals

      Correct Answer: Sterile synovial fluid with a high white blood cell count

      Explanation:

      The correct answer is synovial fluid that is sterile but has a high white blood cell count. The patient’s symptoms suggest reactive arthritis, which is a type of seronegative spondyloarthritis that typically affects the lower limbs and occurs after a gastrointestinal or urogenital infection. The condition is aseptic, meaning that no bacteria are present in the synovial fluid, but it can cause an increase in white blood cells, particularly polymorphonuclear leukocytes. Chlamydia trachomatis is an incorrect answer because while it may be the cause of reactive arthritis, the condition itself is aseptic. Staphylococcus aureus is also an incorrect answer because it is more commonly associated with septic arthritis, which is not suggested by the patient’s symptoms or test results. Negatively birefringent crystals are commonly seen in gout, while positively birefringent crystals are associated with calcium pyrophosphate deposition (pseudogout).

      Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, further studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA). Reactive arthritis is defined as arthritis that occurs after an infection where the organism cannot be found in the joint. The post-STI form is more common in men, while the post-dysenteric form has an equal incidence in both sexes. The most common organisms associated with reactive arthritis are listed in the table below.

      Management of reactive arthritis is mainly symptomatic, with analgesia, NSAIDs, and intra-articular steroids being used. Sulfasalazine and methotrexate may be used for persistent disease. Symptoms usually last for less than 12 months. It is worth noting that the term Reiter’s syndrome is no longer used due to the fact that Reiter was a member of the Nazi party.

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  • Question 34 - A 26-year-old male comes to the rheumatology clinic complaining of lower back pain...

    Incorrect

    • A 26-year-old male comes to the rheumatology clinic complaining of lower back pain that extends to his buttocks for the past 3 months. He experiences the most discomfort in the morning, but it gets better with physical activity. Sometimes, he wakes up in the early hours of the morning due to the pain. What is the most probable finding in this patient?

      Your Answer: Obstructive defect on spirometry

      Correct Answer: Syndesmophytes on plain x-ray

      Explanation:

      Syndesmophytes, which are ossifications of the outer fibers of the annulus fibrosus, are a common feature of ankylosing spondylitis. This patient is exhibiting symptoms of inflammatory joint pain, which is most likely caused by ankylosing spondylitis given his age, gender, and the nature of his pain. Plain x-rays can reveal the presence of ossifications within spinal ligaments or intervertebral discs’ annulus fibrosus. It is incorrect to assume that his symptoms would not improve with naproxen, as NSAIDs are commonly used to alleviate inflammatory joint pain. A bamboo spine on plain x-ray is a rare late sign that is not typically seen in clinical practice. While ankylosing spondylitis may be associated with apical lung fibrosis, this would present as a restrictive defect on spirometry, not an obstructive one.

      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 35 - A 67-year-old woman presents with a 6-week history of bilateral muscle weakness in...

    Incorrect

    • A 67-year-old woman presents with a 6-week history of bilateral muscle weakness in her shoulders and hips. She reports difficulty getting out of chairs without assistance and experiences breathlessness and fatigue. Her vital signs reveal a heart rate of 98 bpm and blood pressure of 130/75 mmHg. Proximal muscle strength is symmetrically 4/5, while distal strength is normal. No skin rashes or arthralgia are present. Laboratory results show Hb 116 g/L (115 - 160), WBC 7.5 * 109/L (4.0 - 11.0), Na+ 140 mmol/L (135 - 145), K+ 4.9 mmol/L (3.5 - 5.0), Creatine kinase 1250 U/L (35 - 250), Urea 6.7 mmol/L (2.0 - 7.0), Creatinine 115 µmol/L (55 - 120), and ESR 60 mm/hr (<40). What is the most likely diagnosis based on these features?

      Your Answer: Polymyalgia rheumatica

      Correct Answer: Polymyositis

      Explanation:

      The most likely diagnosis for the patient in the vignette is polymyositis, as she presents with true bilateral proximal muscle weakness, shortness of breath, and fatigue, along with elevated ESR and CK levels indicating muscle inflammation and injury. Dermatomyositis is less likely as no skin changes are mentioned. Motor neurone disease is also unlikely as it does not cause muscle tissue inflammation or elevated CK levels. Polymyalgia rheumatica is also unlikely as it does not present with true muscle weakness and is not associated with elevated CK levels.

      Polymyositis: An Inflammatory Disorder Causing Muscle Weakness

      Polymyositis is an inflammatory disorder that causes symmetrical, proximal muscle weakness. It is believed to be a T-cell mediated cytotoxic process directed against muscle fibers and can be idiopathic or associated with connective tissue disorders. This condition is often associated with malignancy and typically affects middle-aged women more than men.

      One variant of the disease is dermatomyositis, which is characterized by prominent skin manifestations such as a purple (heliotrope) rash on the cheeks and eyelids. Other features of polymyositis include Raynaud’s, respiratory muscle weakness, dysphagia, and dysphonia. Interstitial lung disease, such as fibrosing alveolitis or organizing pneumonia, is seen in around 20% of patients and indicates a poor prognosis.

      To diagnose polymyositis, doctors may perform various tests, including an elevated creatine kinase, EMG, muscle biopsy, and anti-synthetase antibodies. Anti-Jo-1 antibodies are seen in a pattern of disease associated with lung involvement, Raynaud’s, and fever.

      The management of polymyositis involves high-dose corticosteroids tapered as symptoms improve. Azathioprine may also be used as a steroid-sparing agent. Overall, polymyositis is a challenging condition that requires careful management and monitoring.

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  • Question 36 - A sixty-eight-year-old male arrived at the emergency department after tripping while getting out...

    Incorrect

    • A sixty-eight-year-old male arrived at the emergency department after tripping while getting out of his car and falling on his left side. He is experiencing pain in his groin and is unable to put weight on his left side. During the examination, it was observed that his left leg is externally rotated and shortened. What classification system should be utilized to categorize this patient's injury, given the most probable diagnosis?

      Your Answer: Weber

      Correct Answer: Garden

      Explanation:

      The Garden classification system is utilized for the classification of neck of femur fractures. In this case, the patient has experienced a fall on her left side resulting in a painful, shortened, and externally rotated leg, which is highly suggestive of a neck of femur fracture. The Garden classification system categorizes these fractures into four types based on their severity and displacement. On the other hand, Gartland classification is used for supracondylar fractures in children, Salter-Harris classification is used for fractures around the growth plate in children, and the Ottawa Rules are used to identify potential ankle fractures in patients.

      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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  • Question 37 - A 49-year-old female without significant medical history was diagnosed with deep vein thrombosis...

    Incorrect

    • A 49-year-old female without significant medical history was diagnosed with deep vein thrombosis without any known risk factors or precipitating events. The patient was successfully treated with dalteparin and subsequent thrombophilia screening revealed moderately elevated anticardiolipin antibodies on two separate occasions, twelve weeks apart. What is the most suitable long-term plan for managing this patient?

      Your Answer: Rivaroxaban

      Correct Answer: Warfarin

      Explanation:

      Patients diagnosed with antiphospholipid syndrome and a history of unprovoked thrombosis should receive lifelong warfarin as the preferred long-term anticoagulant. While unfractionated heparin or low molecular weight heparin may be used for acute episodes of thrombosis, they are not recommended for long-term anticoagulation in this condition. Failure to provide anticoagulation therapy to these patients is inappropriate due to their high risk of recurrent thrombosis. Additionally, the MHRA has advised against the use of direct-acting oral anticoagulants like rivaroxaban for long-term therapy in antiphospholipid syndrome patients due to an increased risk of thrombotic events compared to warfarin. Therefore, rivaroxaban is not a suitable management option.

      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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  • Question 38 - A 82-year-old woman arrives at the emergency department by ambulance after falling in...

    Incorrect

    • A 82-year-old woman arrives at the emergency department by ambulance after falling in her nursing home room. She is experiencing severe pain and is unable to bear weight on her leg, which appears shortened and externally rotated. An X-ray reveals a displaced intracapsular neck of femur fracture, and the orthopaedic team is contacted. The patient has a history of heart failure, mild Alzheimer's disease, and kidney stones. What is the most suitable form of pain relief for this patient?

      Your Answer: 1g oral paracetamol

      Correct Answer: Iliofascial nerve block

      Explanation:

      An iliofascial nerve block is a widely used and effective method of pain relief for patients with a fracture of the neck of the femur. By injecting local anaesthetic into the potential space between the fascia iliaca and the iliacus and psoas major muscles, the femoral, obturator, and lateral femoral cutaneous nerves can be affected, reducing the need for opioid analgesics like morphine. This is particularly beneficial for elderly patients who are more susceptible to the side effects of opioids. As most patients with neck of femur fractures are elderly, iliofascial nerve blocks are now the recommended first-line method of pain relief in many UK hospitals.

      While rectal diclofenac is an effective form of pain relief for kidney stones, it is not the preferred method for a fractured neck of femur. Oral paracetamol is unlikely to provide sufficient pain relief for this type of injury. Intravenous propofol is an anaesthetic agent and not appropriate for initial pain relief in the emergency department. Spinal anaesthesia is commonly used during surgery for neck of femur fractures, but it is less suitable than an iliofascial nerve block in the emergency department.

      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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  • Question 39 - A 30-year-old woman presents to the rheumatology clinic with a diagnosis of systemic...

    Incorrect

    • A 30-year-old woman presents to the rheumatology clinic with a diagnosis of systemic lupus erythematosus. You intend to initiate monotherapy with hydroxychloroquine. What particular monitoring should be considered before starting this medication?

      Your Answer: Liver function tests

      Correct Answer: Visual acuity and fundoscopy

      Explanation:

      Hydroxychloroquine can cause severe and permanent retinopathy, which can be detected through visual acuity and fundoscopy. It is recommended to conduct baseline screening and annual screening after 5 years of use. Echocardiography, liver function tests, pregnancy tests, and tuberculosis screening are not necessary for monitoring hydroxychloroquine use.

      Hydroxychloroquine: Uses and Adverse Effects

      Hydroxychloroquine is a medication commonly used in the treatment of rheumatoid arthritis and systemic/discoid lupus erythematosus. It is similar to chloroquine, which is used to treat certain types of malaria. However, hydroxychloroquine has been found to cause bull’s eye retinopathy, which can result in severe and permanent visual loss. Recent data suggests that this adverse effect is more common than previously thought, and the most recent guidelines recommend baseline ophthalmological examination and annual screening, including colour retinal photography and spectral domain optical coherence tomography scanning of the macula. Despite this risk, hydroxychloroquine may still be used in pregnant women if needed. Patients taking this medication should be asked about visual symptoms and have their visual acuity monitored annually using a standard reading chart.

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  • Question 40 - A 65-year-old patient visits her GP complaining of back pain that is relieved...

    Correct

    • A 65-year-old patient visits her GP complaining of back pain that is relieved by lying down. She has no history of trauma but had a hysterectomy at the age of 38 due to obstetric complications. Additionally, she has a history of poorly controlled asthma. Her FRAX® score indicates a 10-year fracture risk of 16%, prompting her GP to arrange a DEXA scan and relevant blood tests. The results show a calcium level of 1.8 mmol/L (2.1-2.6), vitamin D level of 17.2 ng/ml (≥20.0), phosphate level of 1.2 mmol/L (0.8-1.4), and a T-score of -3.2. What is the most appropriate next step in managing her condition?

      Your Answer: Vitamin D and calcium supplements

      Explanation:

      Before prescribing bisphosphonates for a patient with osteoporosis, it is important to correct any deficiencies in calcium and vitamin D. This is especially crucial for patients with hypocalcemia or vitamin D deficiency, as bisphosphonates can worsen these conditions by reducing calcium efflux from bones. In this case, the patient should receive calcium and vitamin D supplements before starting on alendronic acid. Hormone replacement therapy is not recommended for osteoporosis prevention, and vitamin D and alendronic acid should not be prescribed without also addressing calcium deficiencies.

      Bisphosphonates: Uses and Adverse Effects

      Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

      However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.

      To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.

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  • Question 41 - A 50-year-old woman with chronic back pain arrives at the emergency department after...

    Incorrect

    • A 50-year-old woman with chronic back pain arrives at the emergency department after experiencing a sudden exacerbation of her symptoms. She reports bilateral sciatica, left foot drop, perianal paraesthesia, and urinary incontinence over the past 24 hours. What imaging is necessary to confirm the suspected diagnosis?

      Your Answer: Pelvic x-ray

      Correct Answer: MRI spine

      Explanation:

      When a patient is suspected to have cauda equina syndrome, it is crucial to conduct an urgent MRI of the spine for investigation. This is the preferred method of investigation to determine the cause of the syndrome. The most common cause is a herniated intravertebral disc that compresses the cauda equina. Other possible causes include primary or metastatic spinal tumors, infections like epidural abscesses, or hematomas. Imaging is necessary to identify the specific pathology causing the syndrome, determine the level of pathology, and guide the appropriate intervention. The article Cauda equina syndrome by Lavy C and Wilson-MacDonald J in BMJ 2009;338:b936 provides further information on this topic.

      Cauda equina syndrome (CES) is a rare but serious condition that occurs when the nerve roots in the lower back are compressed. It is crucial to consider CES in patients who present with new or worsening lower back pain, as a late diagnosis can result in permanent nerve damage and long-term leg weakness and urinary/bowel incontinence. The most common cause of CES is a central disc prolapse, typically at L4/5 or L5/S1, but it can also be caused by tumors, infections, trauma, or hematomas. CES can present in various ways, and there is no single symptom or sign that can diagnose or exclude it. Possible features include low back pain, bilateral sciatica, reduced sensation in the perianal area, decreased anal tone, and urinary dysfunction. Urgent MRI is necessary for diagnosis, and surgical decompression is the recommended management.

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  • Question 42 - A 50-year-old man visits his GP complaining of increasing pain in one leg...

    Incorrect

    • A 50-year-old man visits his GP complaining of increasing pain in one leg over the past 6 months. He also reports mild weakness in the affected leg during any activity. The pain travels down the back of his left leg and worsens when walking, causing him to stop and rest frequently. However, the pain improves when he sits or crouches down. The patient has no history of smoking or cardiovascular issues and has a body mass index of 19.0 kg/m2. There are no abnormalities found during back and neurological examinations. What is the most probable diagnosis?

      Your Answer: Ankylosing spondylitis

      Correct Answer: Lumbar canal spinal stenosis

      Explanation:

      When a patient complains of claudication, spinal stenosis should be considered as a possible cause.

      If the patient experiences leg pain on one side that improves with rest, certain factors in their medical history may indicate spinal stenosis rather than peripheral arterial disease. These factors include pain relief when sitting or crouching, leg weakness, no history of smoking, and no cardiovascular issues. Ankylosing spondylitis, which primarily causes back pain, is more common in younger patients and is unlikely to cause leg pain. Conversion disorder, a psychiatric condition that presents with unexplained musculoskeletal symptoms, is typically diagnosed after ruling out physical causes, but the patient’s history suggests spinal stenosis rather than a psychiatric cause. While peripheral arterial disease is a possible differential diagnosis, the absence of cardiac risk factors and the pain-relieving factors suggest spinal stenosis. If the patient experiences claudication pain after walking 100 meters or more, peripheral arterial disease may be more likely.

      Lumbar spinal stenosis is a condition where the central canal in the lower back is narrowed due to degenerative changes, such as a tumor or disk prolapse. Patients may experience back pain, neuropathic pain, and symptoms similar to claudication. However, one distinguishing factor is that the pain is positional, with sitting being more comfortable than standing, and walking uphill being easier than downhill. Degenerative disease is the most common cause, starting with changes in the intervertebral disk that lead to disk bulging and collapse. This puts stress on the facet joints, causing cartilage degeneration, hypertrophy, and osteophyte formation, which narrows the spinal canal and compresses the nerve roots of the cauda equina. MRI scanning is the best way to diagnose lumbar spinal stenosis, and treatment may involve a laminectomy.

      Overall, lumbar spinal stenosis is a condition that affects the lower back and can cause a range of symptoms, including pain and discomfort. It is often caused by degenerative changes in the intervertebral disk, which can lead to narrowing of the spinal canal and compression of the nerve roots. Diagnosis is typically done through MRI scanning, and treatment may involve a laminectomy. It is important to note that the pain associated with lumbar spinal stenosis is positional, with sitting being more comfortable than standing, and walking uphill being easier than downhill.

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  • Question 43 - A 75-year-old male presents with bilateral buttock pain that radiates through his thighs...

    Incorrect

    • A 75-year-old male presents with bilateral buttock pain that radiates through his thighs and calves. The pain worsens with standing and walking, limiting his ability to walk for more than 10 minutes or 2 to 3 blocks. However, the pain is relieved by sitting or forward flexion of the spine. There is no history of bladder or bowel dysfunction, and motor and sensory neurological examination of the lower limbs is normal. What is the most probable cause of these symptoms?

      Your Answer: Ankylosing spondylitis (AS)

      Correct Answer: Lumbar spinal stenosis

      Explanation:

      AS, also known as ankylosing spondylitis, is a type of arthritis that primarily affects the spine. It causes inflammation and stiffness in the joints between the vertebrae, leading to fusion of the spine over time. AS can also affect other joints, such as the hips, shoulders, and knees, and can cause fatigue and eye inflammation. It is a chronic condition that typically develops in early adulthood and is more common in men than women. There is no cure for AS, but treatment options such as medication, exercise, and physical therapy can help manage symptoms and improve quality of life.

      Lumbar spinal stenosis is a condition where the central canal in the lower back is narrowed due to degenerative changes, such as a tumor or disk prolapse. Patients may experience back pain, neuropathic pain, and symptoms similar to claudication. However, one distinguishing factor is that the pain is positional, with sitting being more comfortable than standing, and walking uphill being easier than downhill. Degenerative disease is the most common cause, starting with changes in the intervertebral disk that lead to disk bulging and collapse. This puts stress on the facet joints, causing cartilage degeneration, hypertrophy, and osteophyte formation, which narrows the spinal canal and compresses the nerve roots of the cauda equina. MRI scanning is the best way to diagnose lumbar spinal stenosis, and treatment may involve a laminectomy.

      Overall, lumbar spinal stenosis is a condition that affects the lower back and can cause a range of symptoms, including pain and discomfort. It is often caused by degenerative changes in the intervertebral disk, which can lead to narrowing of the spinal canal and compression of the nerve roots. Diagnosis is typically done through MRI scanning, and treatment may involve a laminectomy. It is important to note that the pain associated with lumbar spinal stenosis is positional, with sitting being more comfortable than standing, and walking uphill being easier than downhill.

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      • Musculoskeletal
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  • Question 44 - Sophie is a 26-year-old woman who has come to you with a rash...

    Correct

    • Sophie is a 26-year-old woman who has come to you with a rash on her cheeks and bridge of her nose. She has also been experiencing non-specific muscle and joint aches and extreme fatigue. You want to run some blood tests to check for any systemic causes, specifically for systemic lupus erythematosus (SLE). Which of the following positive blood tests would strongly indicate a diagnosis of SLE?

      Out of the options below, which of the following blood tests if positive would be highly suggestive of this diagnosis?

      Your Answer: Anti-dsDNA

      Explanation:

      The anti-dsDNA test is highly specific for detecting lupus, making it useful in ruling out systemic lupus erythematosus if the results are negative. On the other hand, anti-CCP is utilized in diagnosing rheumatoid arthritis, while anti-La is primarily present in individuals with Sjogren’s syndrome. Although anti-La can also be found in those with lupus, it lacks specificity. Interestingly, infants born to mothers with anti-La and anti-Ro antibodies have an increased risk of developing neonatal lupus. ANCA is an antibody that targets neutrophils and is observed in patients with autoimmune vasculitis.

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

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

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      • Musculoskeletal
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  • Question 45 - A 38-year-old woman comes to the clinic with a chief complaint of swollen...

    Incorrect

    • A 38-year-old woman comes to the clinic with a chief complaint of swollen hands and feet for the past 3 months. She reports that the symptoms worsen in cold weather and her fingers frequently turn blue. She is now experiencing difficulty making a fist with both hands. Additionally, she has observed thickening of the skin spreading up her arms and thighs over the last month. She also reports a dry cough that started a month ago, accompanied by shortness of breath during physical activity. What is the probable diagnosis?

      Your Answer: Primary Raynaud's phenomenon

      Correct Answer: Diffuse systemic sclerosis

      Explanation:

      The patient is likely suffering from systemic sclerosis, which is characterized by the tightening and fibrosis of the skin, commonly known as scleroderma. The presence of a dry cough and involvement of the proximal limbs suggest diffuse systemic sclerosis, which has a poorer prognosis than limited systemic sclerosis (also known as CREST syndrome). Eosinophilic fasciitis, a rare form of systemic sclerosis, is unlikely as it spares the hands and does not present with Raynaud’s phenomenon. Primary Raynaud’s phenomenon, which is relatively common, does not typically present with sclerotic features and is likely part of the patient’s wider autoimmune disease.

      Understanding Systemic Sclerosis

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

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      • Musculoskeletal
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  • Question 46 - A 67-year-old man comes to the clinic complaining of sudden and severe pain...

    Incorrect

    • A 67-year-old man comes to the clinic complaining of sudden and severe pain in his right knee. He has never experienced this before. Upon examination, the joint fluid is extracted and sent to the lab for analysis. The rheumatology team suspects pseudogout. What characteristics can help differentiate this condition from gout?

      Your Answer: Warmth at the site of pain

      Correct Answer: Chondrocalcinosis

      Explanation:

      Chondrocalcinosis is a useful factor in distinguishing between pseudogout and gout. Linear calcifications of the meniscus and articular cartilage seen on a knee x-ray are indicative of pseudogout, but not particularly associated with gout. Therefore, the presence of chondrocalcinosis can be used to differentiate between the two conditions.

      Age is not a determining factor in the diagnosis of gout or pseudogout. In this case, the patient’s age of 64 years does not provide any significant information to sway the diagnosis in either direction.

      The presence of crystals is not a distinguishing factor between gout and pseudogout, as both conditions involve crystals. However, the type of crystals differs between the two. Pseudogout crystals are weakly-positively birefringent rhomboid-shaped, while gout crystals are negatively birefringent.

      Both gout and pseudogout typically respond well to colchicine for acute pain management, so this is not a useful factor in distinguishing between the two conditions.

      Increased warmth of the affected joint is not a reliable factor in distinguishing between gout and pseudogout, as it may be present in both conditions.

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

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      • Musculoskeletal
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  • Question 47 - A 12-year-old boy is admitted to the paediatric ward due to recurrent episodes...

    Incorrect

    • A 12-year-old boy is admitted to the paediatric ward due to recurrent episodes of arthralgia affecting multiple sites. During physical examination, swelling and tenderness are observed in the right ankle joint, while tenderness on motion and pain are present over the bilateral wrist and left sacroiliac joints. The patient had visited his GP two months ago with symptoms of vomiting, diarrhoea, and fever, for which he received supportive treatment. Synovial fluid analysis from the aspirated ankle joint reveals a high white cell count and no organisms present in the culture. What is the most likely diagnosis?

      Your Answer: Systemic lupus erythematosus

      Correct Answer: Reactive arthritis

      Explanation:

      The most likely diagnosis for this case is reactive arthritis, which is a type of arthritis that occurs after a distant infection in the gastrointestinal or urogenital area. It is characterized by joint pain, urethritis, and uveitis, and is more common in individuals who have the HLA-B27 gene. The infections that commonly trigger reactive arthritis are caused by Salmonella, Shigella, Yersinia, and Campylobacter organisms.

      Other possible diagnoses were ruled out based on the absence of certain symptoms. Behcet’s disease, which presents with oral and genital ulcers and uveitis, was unlikely due to the lack of ulcers or visual symptoms. Septic arthritis, which causes joint swelling and pain, was also considered but was less likely because it typically affects only one joint and is accompanied by fever and other signs. Systemic juvenile idiopathic arthritis and systemic lupus erythematosus were also considered but were ruled out due to the absence of their characteristic symptoms.

      Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, further studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA). Reactive arthritis is defined as arthritis that occurs after an infection where the organism cannot be found in the joint. The post-STI form is more common in men, while the post-dysenteric form has an equal incidence in both sexes. The most common organisms associated with reactive arthritis are listed in the table below.

      Management of reactive arthritis is mainly symptomatic, with analgesia, NSAIDs, and intra-articular steroids being used. Sulfasalazine and methotrexate may be used for persistent disease. Symptoms usually last for less than 12 months. It is worth noting that the term Reiter’s syndrome is no longer used due to the fact that Reiter was a member of the Nazi party.

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      • Musculoskeletal
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  • Question 48 - A 42-year-old Vietnamese man comes to the emergency department complaining of left-sided flank...

    Incorrect

    • A 42-year-old Vietnamese man comes to the emergency department complaining of left-sided flank pain that has been bothering him for the past 3 weeks. He denies experiencing any urinary symptoms and has already taken nitrofurantoin prescribed by his GP, but it did not alleviate his pain. During the physical examination, he has a fever of 38.4 °C, and his pain worsens when his left hip is extended. What is the probable diagnosis?

      Your Answer: Pott's disease of the spine

      Correct Answer: Iliopsoas abscess

      Explanation:

      The combination of fever, back pain, and pain when extending the hip suggests the presence of an iliopsoas abscess. The patient may also exhibit a limp while walking. Iliopsoas abscesses can be caused by primary or secondary factors. While Pott’s disease, a form of tuberculosis affecting the vertebrae, could explain the back pain and fever, the examination findings are more indicative of an iliopsoas abscess. Mechanical back pain would not typically produce constitutional symptoms like fever. Pyelonephritis is a potential differential diagnosis, but the examination findings are more consistent with an iliopsoas abscess. It may be helpful to rule out pyelonephritis with a urine dip and ultrasound. Although kidney stones can cause severe pain and fever if infected, the duration of the patient’s symptoms makes this possibility 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 49 - 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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      • Musculoskeletal
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  • Question 50 - A 53-year-old textiles worker is referred for nerve conduction studies after a trial...

    Incorrect

    • A 53-year-old textiles worker is referred for nerve conduction studies after a trial of conservative management fails to improve symptoms of sensory loss over the palmar aspect of her right thumb, index, middle and ring fingers. Examination reveals thenar wasting of the right hand.

      What would be the common findings in nerve conduction evaluation of this patient's symptoms?

      Your Answer:

      Correct Answer: Action potential prolongation in both sensory and motor axons

      Explanation:

      Both sensory and motor axons experience prolonged action potential in carpal tunnel syndrome, which is caused by compression of the median nerve. This physical compression affects the ability of all neurons to effectively conduct action potentials, resulting in symptoms that affect both sensory and motor pathways. No other combinations of axon functioning are linked to carpal tunnel syndrome.

      Understanding Carpal Tunnel Syndrome

      Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. Patients with this condition typically experience pain or pins and needles in their thumb, index, and middle fingers. In some cases, the symptoms may even ascend proximally. Patients often shake their hand to obtain relief, especially at night.

      During an examination, doctors may observe weakness of thumb abduction and wasting of the thenar eminence (not the hypothenar). Tapping on the affected area may cause paraesthesia, which is known as Tinel’s sign. Flexion of the wrist may also cause symptoms, which is known as Phalen’s sign.

      Carpal tunnel syndrome can be caused by a variety of factors, including idiopathic reasons, pregnancy, oedema (such as heart failure), lunate fracture, and rheumatoid arthritis. Electrophysiology tests may show prolongation of the action potential in both motor and sensory nerves.

      Treatment for carpal tunnel syndrome may include a 6-week trial of conservative treatments, such as corticosteroid injections and wrist splints at night. If symptoms persist or are severe, surgical decompression (flexor retinaculum division) may be necessary.

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      • Musculoskeletal
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