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Question 1
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A 28-year-old administrative assistant complains of pain on the thumb side of her left wrist, persisting for the past week. She also notices that her left wrist seems more swollen than her right. During the examination, she experiences discomfort over her radial styloid when her thumb is forcefully flexed.
What is the probable diagnosis?Your Answer: Tenosynovitis
Explanation:The patient is positive for Finkelstein test, indicating De Quervain’s tenosynovitis. This condition causes pain over the radial styloid when the thumb is forcefully abducted or flexed. Unlike De Quervain’s tenosynovitis, rheumatoid arthritis affects both sides of the body. Mallet thumb is an injury that causes the thumb to bend towards the palm. Carpal tunnel syndrome is caused by compression of the median nerve and results in numbness and tingling in the thumb, index, and middle fingers. Osteoarthritis is a degenerative condition that primarily affects the elderly due to mechanical wear and tear.
De Quervain’s Tenosynovitis: Symptoms, Diagnosis, and Treatment
De Quervain’s tenosynovitis is a condition that commonly affects women between the ages of 30 and 50. It occurs when the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons becomes inflamed. The condition is characterized by pain on the radial side of the wrist, tenderness over the radial styloid process, and pain when the thumb is abducted against resistance. A positive Finkelstein’s test, in which the thumb is pulled in ulnar deviation and longitudinal traction, can also indicate the presence of tenosynovitis.
Treatment for De Quervain’s tenosynovitis typically involves analgesia, steroid injections, and immobilization with a thumb splint (spica). In some cases, surgical treatment may be necessary. With proper diagnosis and treatment, most patients are able to recover from this condition and resume their normal activities.
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This question is part of the following fields:
- Musculoskeletal
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Question 2
Correct
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A 67-year-old woman presents to General Practitioner with a 2-day history of fever and pain in her right shin.
On examination, she was found to have a tender erythematous skin swelling in the anterior aspect of her right shin. This measured around 10 cm × 4 cm. Her temperature was 38.2°C and the rest of her parameters included a heart rate of 120 bpm, respiratory rate of 21 bpm and oxygen saturation of 99%.
What is the most appropriate next investigation?
Select the SINGLE best option from the list below.
Select ONE option only.Your Answer: Full blood count, urea and electrolytes and C-reactive protein (CRP)/erythrocyte sedimentation rate (ESR)
Explanation:Diagnostic Tests for Cellulitis: Which Ones are Necessary?
Cellulitis is a clinical diagnosis, but certain tests may be necessary in patients with a systemic response. A full blood count, urea and electrolytes, and CRP/ESR are recommended to assess the severity of the infection. A wound swab and blood cultures may also be considered. An ABPI measurement is indicated in patients with suspected lower-limb arterial disease. A chest X-ray is not necessary unless co-existing lung pathology is suspected. In stable patients with no systemic upset, no further investigations are needed. A punch biopsy is not necessary for diagnosis but may be considered in other skin conditions.
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This question is part of the following fields:
- Dermatology
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Question 3
Incorrect
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Which one of the following pathological changes favours ulcerative colitis (UC) over Crohn disease in elderly patients?
Your Answer: Transmural involvement
Correct Answer: Crypt abscesses
Explanation:Differences between Crohn’s Disease and Ulcerative Colitis
Crohn’s disease and ulcerative colitis are both types of inflammatory bowel disease, but they differ in several aspects. One of the main differences is the presence of granulomas. While a lack of granulomas does not rule out Crohn’s disease, it is a far more likely option if they are present. Granulomas are not present in ulcerative colitis.
Another difference is the layers of the bowel affected. Crohn’s disease affects all layers of the bowel, known as transmural disease, whereas ulcerative colitis is confined to the mucosa with occasional submucosa inflammation. Only Crohn’s disease has muscularis and serosa involvement. Additionally, Crohn’s disease can affect anything from the mouth to the anus, whereas ulcerative colitis is limited to colonic lesions.
Skip lesions, or areas of discontinuity of the inflammatory process, are characteristic of Crohn’s disease. When skip lesions are present, this is suggestive of Crohn’s disease. Ulcerative colitis is a continuous disease, whereas Crohn’s disease can be present in multiple areas of the bowel with sharply demarcated areas.
In terms of histology, both diseases show intense infiltration of the mucosa and submucosa with neutrophils and lymphoid aggregates. However, in fulminant cases of ulcerative colitis, the muscularis propria may be affected. On the other hand, the histologic characteristic pattern of inflammation in Crohn’s disease is transmural involvement of the bowel wall by lymphoid infiltrates that contain non-caseating granulomas.
Therefore, it is important to differentiate between Crohn’s disease and ulcerative colitis to provide appropriate treatment. Endoscopy must be performed if ulcerative colitis is suspected.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 4
Incorrect
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A 40-year-old man comes to his General Practitioner with a painless neck lump. He has a history of hyperparathyroidism in the past. During the examination, the lump is found to be irregular and fixed at his thyroid. The patient is worried about cancer, as his father died in his 50s due to a phaeochromocytoma. What type of thyroid cancer is most probable in this case?
Your Answer: Anaplastic
Correct Answer: Medullary
Explanation:Thyroid Cancer Types and their Association with Multiple Endocrine Neoplasia Type 2 (MEN2)
Thyroid cancer can be classified into different types based on their histology and clinical features. Among these types, medullary thyroid cancer is associated with multiple endocrine neoplasia type 2 (MEN2), a genetic disorder that predisposes individuals to develop tumors in various endocrine glands. MEN2 has three subtypes, and medullary thyroid cancer is a hallmark feature of MEN2a and MEN2b. Other associated neoplasms include phaeochromocytoma and parathyroid tumors in MEN2a, and marfanoid habitus/mucosal neuromas in MEN2b.
Anaplastic thyroid cancer, on the other hand, is not associated with MEN2 and has a poor prognosis. It is more common in older women and is characterized by rapid growth and aggressiveness. Follicular thyroid cancer is also not associated with MEN2 and is more prevalent in women over 50 years old. Lymphoma and papillary thyroid cancer are also not associated with MEN2, with the latter having an excellent prognosis and primarily affecting young women.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 5
Correct
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A 29-year-old woman comes to the clinic to discuss contraception. She has recently given birth to a healthy baby girl and is currently breastfeeding. After discussing various options, she has decided to start taking progesterone-only pills. When would be the appropriate time to advise her to begin taking them?
Your Answer: Can start immediately
Explanation:Women who have recently given birth, whether they are breastfeeding or not, can begin taking the progesterone-only pill at any time postpartum.
It is safe to use progesterone-only pills while breastfeeding, and there is no need to wait for a specific amount of time before starting them. If the pills are started after 21 days, it is recommended to use additional protection for the first 2 days. However, if the woman starts taking the pills immediately, there is no need for extra protection.
Delaying the start of progesterone-only pills can increase the risk of unwanted pregnancy. Therefore, it is important to begin taking them as soon as possible, regardless of whether the woman is breastfeeding or not.
In summary, there is no contraindication to starting progesterone-only pills during the first 21 days postpartum, and breastfeeding does not affect the decision to start them. Women can continue breastfeeding while taking these pills.
After giving birth, women need to use contraception after 21 days. The progestogen-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progestogen enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.
The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.
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This question is part of the following fields:
- Reproductive Medicine
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Question 6
Incorrect
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A 25-year-old male with a history of ankylosing spondylitis presents to the emergency department with a painful red eye, photophobia, lacrimation, and reduced visual acuity. On examination, an irregularly shaped pupil is noted. What is the most suitable approach to manage this patient's current condition?
Your Answer: Oral steroids and pilocarpine eye drops
Correct Answer: Steroid and cycloplegic (mydriatic) eye drops
Explanation:Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Correct
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A social worker in their 40s has been diagnosed with hepatitis C infection.
Which test will conclusively establish the presence of this infection?Your Answer: HCV RNA
Explanation:Hepatitis C Testing Methods
Hepatitis C is a viral infection that affects the liver. There are several testing methods available to diagnose and monitor hepatitis C infection.
Quantitative HCV RNA tests measure the amount of hepatitis C virus in the blood, which is also known as the viral load. This test is the most sensitive and accurate way to confirm a hepatitis C diagnosis, especially when viral loads are low.
Screening tests for co-infection with other viruses, such as hepatitis B or HIV, may be done but do not assist in the diagnosis of hepatitis C infection itself.
Anti-hepatitis C virus (HCV) serologic screening involves an enzyme immunoassay (EIA) that can detect antibodies to the virus. However, this test cannot distinguish between acute and chronic infection and may yield false-positive results.
HCV genotyping is a helpful tool for predicting the likelihood of response and duration of treatment. It is used in adult, non-immunocompromised patients with known chronic HCV infection.
Immunoglobulin M (IgM) anti-HAV screening tests for co-infection with hepatitis A virus may be done but do not assist in the diagnosis of hepatitis C infection itself.
Hepatitis C Testing Methods
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This question is part of the following fields:
- Immunology/Allergy
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Question 8
Incorrect
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The Medicines and Healthcare products Regulatory Agency has cautioned that which category of medication may be linked to a higher incidence of venous thromboembolism in older individuals?
Your Answer: Tricyclic antidepressants
Correct Answer: Atypical antipsychotics
Explanation:Elderly individuals taking antipsychotics are at a higher risk of experiencing stroke and VTE.
Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.
Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.
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This question is part of the following fields:
- Psychiatry
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Question 9
Correct
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A 50-year-old woman presented with worsening pains in the small joints of both her feet with swelling and redness. She experienced stiffness which was worse in the morning. She was initially started on oral prednisolone with a proton-pump inhibitor whilst awaiting a specialist review from a rheumatologist. After seeing the specialist who performed blood tests and x-rays on her feet she was started on a new medication called hydroxychloroquine.
What serious side effects does the specialist need to counsel the patient on when starting this new medication?Your Answer: Retinopathy
Explanation:Hydroxychloroquine, a drug used to prevent and treat malaria, is now commonly included in treatment guidelines for conditions such as rheumatoid arthritis, SLE, and porphyria cutanea tarda. However, it is important for patients to be aware of the potential severe and permanent retinopathy that can result from chronic use of the drug. The mechanism behind this adverse effect is uncertain, but it can lead to permanent visual loss. To prevent eye toxicity, the daily safe maximum dose of hydroxychloroquine can be estimated based on the patient’s height and weight.
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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This question is part of the following fields:
- Musculoskeletal
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Question 10
Correct
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A 28-year-old woman visits her GP complaining of joint pain. She has previously sought medical attention for this issue, but her high BMI of 30 kg/m² was deemed to be the cause and weight loss was recommended. Upon examination, the doctor notes a significant effusion in her left knee and limited range of motion. The metacarpophalangeal joints in her right hand appear swollen and her fingers have a sausage-like appearance. Her left hand does not show any obvious deformities. The patient has tested positive for HLA-B27 and has a blood pressure of 138/87 mmHg and a temperature of 36.7ºC. Based on this information, what is the most probable diagnosis?
Your Answer: Psoriatic arthritis
Explanation:Psoriatic arthritis is a type of arthritis that can occur without prior psoriatic skin lesions and is often associated with dactylitis, also known as ‘sausage fingers’. HLA-B27 is commonly found in patients with psoriatic arthritis. Gout is unlikely in a woman under 60 and typically affects the big toe joint. Rheumatoid arthritis is also unlikely as it causes symmetrical polyarthritis and is associated with HLA-DRB1 rather than HLA-B27. Therefore, given the patient’s age, sex, dactylitis, and nail changes, psoriatic arthritis is a more likely diagnosis.
Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is known to have a poor correlation with cutaneous psoriasis. In fact, it often precedes the development of skin lesions. This condition affects both males and females equally, with around 10-20% of patients with skin lesions developing an arthropathy.
The presentation of psoriatic arthropathy can vary, with different patterns of joint involvement. The most common type is symmetric polyarthritis, which is very similar to rheumatoid arthritis and affects around 30-40% of cases. Asymmetrical oligoarthritis is another type, which typically affects the hands and feet and accounts for 20-30% of cases. Sacroiliitis, DIP joint disease, and arthritis mutilans (severe deformity of fingers/hand) are other patterns of joint involvement. Other signs of psoriatic arthropathy include psoriatic skin lesions, periarticular disease, enthesitis, tenosynovitis, dactylitis, and nail changes.
To diagnose psoriatic arthropathy, X-rays are often used. These can reveal erosive changes and new bone formation, as well as periostitis and a pencil-in-cup appearance. Management of this condition should be done by a rheumatologist, and treatment is similar to that of rheumatoid arthritis. However, there are some differences, such as the use of monoclonal antibodies like ustekinumab and secukinumab. Mild peripheral arthritis or mild axial disease may be treated with NSAIDs alone, rather than all patients being on disease-modifying therapy as with RA. Overall, psoriatic arthropathy has a better prognosis than RA.
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This question is part of the following fields:
- Musculoskeletal
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