Crash course rheum and ortho SBA questions Flashcards
1
Q
1a. A 55-year-old woman develops tingling and numbness in the radial 3.5 fingers of her right hand. Which is the most relevant part of her medical history to be considered in the diagnosis?
A:A family history of hypertension.
B:A drug history including nonsteroidal use.
C:A medical history of underactive thyroid.
D:A social history of working as an accountant.
E:A systemic enquiry revealing marked fatigue.
A
C:A medical history of underactive thyroid.
- commonly associated with carpal tunnel syndrome
2
Q
1b.A 55-year-old woman presents with a fragility fracture. She undergoes a dual-energy X-ray absorptiometry (DEXA) scan revealing osteoporosis. Which of the following is the most important in terms of her medical history?
A.A family history of traumatic hip fracture.
B.Prednisolone 10mg daily for several years for poorly controlled asthma.
C.Menopause aged 53 years.
D.Living in South America for several years.
E.A personal history of type 2 diabetes mellitus.
A
B: Prednisolone 10mg daily for several years for poorly controlled asthma.
- corticosteroids are risk factor for osteoporosis
3
Q
1c.A 64-year-old man presents with severe pain in his fingertips and skin colour changes (see image). What in his history would help differentiate between primary and secondary Raynaud disease?
A.A recent history of difficulty in swallowing.
B.A social history of alcohol misuse.
C.A family history of osteoarthritis.
D.A drug history of nifedipine use.
E.A medical history of chronic obstructive pulmonary disease (COPD).
A
A: A recent history of difficulty in swallowing.
- dysphagia is feature of CREST syndrome (systemic sclerosis)
4
Q
1d.A 44-year-old normally fit and well woman presents with bilateral swollen ankles and knee joints, which occurred a few weeks after a chest infection. The joints are warm and stiff for 2 hours upon waking. She has not been experiencing fever. She feels tired but is otherwise well. Her family history includes a brother with ankylosing spondylitis. What is the likely diagnosis based on the history?
A.Gout.
B.Rheumatoid arthritis.
C.Ankylosing spondylitis.
D.Reactive arthritis.
E.Septic arthritis.
A
D.Reactive arthritis.
- condition can occur after bacterial infections (such as mycoplasma pneumoniae in lower respiratory tract infections) and favours the larger joints of the lower limbs
5
Q
2a. A 38-year-old electrician presents with a painful swollen right knee. His knee has become progressively more painful and swollen over a week. On examination, there is a large erythematous swelling anterior to the patella, which is tender to palpate. The skin appears thickened. There is no effusion in the knee joint. He is able to flex his knee to 45 degrees before he is limited by a combination of pain and tightness.
What is the likely diagnosis?
A.Osteoarthritis.
B.Septic arthritis.
C.Baker cyst.
D.Patellar fracture.
E.Prepatellar bursitis.
A
E.Prepatellar bursitis.
- common in patients who work a lot on their knees
6
Q
2b. What causes a locked knee?
A.Anterior cruciate ligament tear.
B.Radial medical tear.
C.Medial collateral ligament tear.
D.Bucket-handle meniscal tear.
E.Tibial plateau fracture.
A
D.Bucket-handle meniscal tear.
- The handle segment flips over and becomes trapped in the joint resulting in the knee locking. The patient is unable to extend the knee fully.
7
Q
2c. A patient with an acquired foot drop will most likely present with which type of gait?
A.Trendelenburg.
B.Antalgic.
C.Circumduction.
D.Waddling
E.High-stepping
A
E.High-stepping
- the leg must be lifted higher to clear the ground
8
Q
2d. A young man experiences a wrist fracture while skiing. Afterwards, he is unable to lift his thumb off a table when the hand is placed flat. The tendon of which muscle has likely been damaged?
A.Adductor pollicis.
B.Extensor pollicis longus (EPL).
C.Abductor pollicis brevis.
D.Opponens pollicis.
E.Extensor digitorum.
A
B.Extensor pollicis longus (EPL)
- The tendon of EPL runs over the radial side of the wrist joint and is commonly affected by displaced wrist fractures. It controls thumb extension
9
Q
2e. 5.A patient with a severe burning sensation in her hands presents with bilateral thenar and hypothenar wasting. The pain occurs over her thumb, index finger and middle finger. She has a history of hypothyroidism. What is the most likely cause of her symptoms and signs?
A.Carpal tunnel syndrome.
B.Hypothyroid-related peripheral neuropathy.
C.Peripheral vascular disease.
D.C8 radiculopathy.
E.Golfer’s elbow.
A
A.Carpal tunnel syndrome.
- Her hypothyroidism is a risk factor for the condition. The classic presentation is of pain occurring in the thumb, index and middle finger and the thumb side of the ring finger.
10
Q
3a.A 33-year-old Asian woman presents to her physician complaining of fatigue, myalgia and weight loss. She finds it more painful to bear weight compared with 6 months ago. She is losing her hair and there is a non-itchy rash over her nose and cheeks.
Which test is most likely to confirm the diagnosis?
A.Anti-double stranded DNA antibodies.
B.Eerythrocyte sedimentation rate (ESR).
C.Skin biopsy of the rash.
D.Thyroid function tests.
E.MRI of her hips.
A
A.Anti-double stranded DNA antibodies.
- highly specific for systemic lupus erythematosus (SLE)
11
Q
3b.A 68-year-old woman presents to her GP with fatigue. She has a history of rheumatoid arthritis and has recently had several flares requiring her medication to be increased. The GP performs some blood tests:
Liver function:
- Alkaline phosphatase: 78 (range 44–147)
- Aspartate aminotransferase (AST): 138 (range 10–40)
- Alanine aminotransferase (ALT): 179 (range 10–56)
- γ-glutamyl transpeptidase (GGT): 36 (range 3–48)
- Bilirubin: 17 (range 0–22)
What is the likely cause of the above results?
A.Primary biliary cirrhosis.
B.Methotrexate hepatotoxicity.
C.Acute viral hepatitis due to immunocompromised state.
D.Gallstones.
E.Alcohol.
A
B.Methotrexate hepatotoxicity.
- important that a patient’s blood is closely monitored when increasing doses of methotrexate. Signs of toxicity include flu-like symptoms, nausea, diarrhoea, fatigue and recurrent mouth ulcers.
12
Q
3c.A 28-year-old woman presents with Raynaud phenomenon, which ulcerated last winter, progressive tightness in her hands and small red dots on her chest that branch out like spiders.
Which antibody is she likely to have?
A.Jo-1.
B.Anti-dsDNA.
C.Anti-SCL-70.
D.p-ANCA.
E.Histone.
A
C.Anti-SCL-70.
- This woman has systemic sclerosis with secondary Raynaud phenomenon, sclerodactyly and telangiectasia
13
Q
3d.A 45-year-old man is getting out of a car when he twists his leg and feels a pop in his knee. He is immediately unable to bear his weight and the joint proceeds to swell.
Which investigation will be most helpful in arriving at a diagnosis?
A.Joint aspiration.
B.X-ray knee.
C.Ultrasound scan (USS).
D.MRI.
E.Erythrocyte sedimentation rate (ESR).
A
D.MRI.
- The twisting mechanism with a popping sensation suggests a meniscal tear for which MRI is the best investigative procedure
14
Q
4a.A 68-year-old woman presents with a history of lower back pain and fatigue.
Which of the following additional findings with regard to back pain would warrant urgent investigations?
A.A history of urinary incontinence.
B.A raised erythrocyte sedimentation rate (ESR).
C.A family history of psoriasis.
D.Abnormal thyroid function tests (TFTs).
E.A positive antinuclear antibody (ANA; 1:40).
A
A.A history of urinary incontinence.
- red flag feature of back pain and an urgent MRI should be carried out to exclude cord compression
15
Q
4b.A young woman presents to A&E after playing sports. She twisted and felt a pop in her knee and now the joint is swollen, tense and tender.
Joint aspiration is undertaken: the fluid is bloodied with white/yellow globules mixed in.
What does the aspirate imply?
A.A rheumatoid knee.
B.Ruptured anterior cruciate ligament (ACL).
C.Septic arthritis.
D.Patellar dislocation.
E.Pseudo gout.
A
B.Ruptured anterior cruciate ligament (ACL).
- The fluid description of blood with fat globules suggests lipohaemarthrosis, which usually indicates a fracture or ruptured ACL
16
Q
4c.A 61-year-old retired bricklayer presents with chronic back pain. His pain is exacerbated by walking, particularly downhill, and radiates into his buttocks, thighs and calves bilaterally. Examination shows a stooped gait with reduced motion in the lumbar spine. His symptoms are worsened by extension of the spine.
What is the diagnosis?
A.Prolapsed intervertebral disc.
B.Mechanical back pain.
C.Spinal stenosis.
D.Spondylolisthesis.
E.Spinal malignancy.
A
C.Spinal stenosis.
- The pain is bilateral, radiates and is relieved by flexing the spine (hence the patient’s stooped gait). Extension aggravates his symptoms
17
Q
4d.A 77-year-old man has bilateral shoulder pain, which is aching in nature, stiffness and difficulty in dressing. He is also fatigued, more so over the past 3 months.
Which test is the most useful in establishing the diagnosis?
A.Nerve conducting studies.
B.Bilateral shoulder X-ray image.
C.Urinary Bence Jones protein.
D.Erythrocyte sedimentation rate (ESR).
E.MRI of the neck.
A
D.Erythrocyte sedimentation rate (ESR).
- This gentleman has polymyalgia rheumatica, a common cause of bilateral shoulder pain, fatigue and stiffness in the elderly. Treatment is with steroids
18
Q
4e.Following a stroke, a patient develops severe hand pain, with skin changes, hypersensitivity and arm swelling.
What is the diagnosis?
A.Arterial insufficiency.
B.Upper limb deep vein thrombosis (DVT).
C.Factitious pain.
D.Phantom-limb pain.
E.Complex regional pain syndrome.
A
E.Complex regional pain syndrome.
- characterized by severe pain after an injury, skin changes, hypersensitivity and occasional swelling. Arterial insufficiency causes claudication and ulceration. Upper limb DVT would not normally cause hypersensitivity.
19
Q
5a.A 68-year-old woman presents with bilateral hip and shoulder pain. She has an elevated erythrocyte sedimentation rate (ESR; 68). She is prescribed steroids and a provisional diagnosis of polymyalgia rheumatic (PMR) is reached.
Two months later she is seen in clinic and despite the steroids she is still symptomatic, has developed synovitis and has lost 2 stone in weight.
What is the next investigation to consider?
A.CT thorax, abdomen and pelvis.
B.Vitamin D.
C.Muscle biopsy.
D.Check rheumatoid factor.
E.Skeletal survey.
A
A.CT thorax, abdomen and pelvis.
- This woman has an atypical presentation of PMR with overlapping inflammatory joint disease; the possibility of a paraneoplastic rheumatic syndrome must be considered. A CT scan of the thorax, abdomen and pelvis is the first-line test when considering an occult malignancy
20
Q
5b.A 35-year-old Asian woman presents with widespread pain, fatigue, dry eyes and a rash over her nose and cheeks.
Which is the best test to confirm the diagnosis?
A.Erythrocyte sedimentation rate (ESR).
B.Anti-dsDNA antibodies.
C.Schirmer test.
D.Rheumatoid factor.
E.Urine dip.
A
B.Anti-dsDNA antibodies.
- highly specific for systemic lupus erythematosus. ESR is nonspecifically elevated in a variety of inflammatory conditions
21
Q
5c.A 38-year-old woman presents with pain throughout the shoulders, arms and hip girdle. She has intermittent loose stools/constipation, low mood and severe fatigue.
Investigations show the following:
Erythrocyte sedimentation rate: 9mm/h (normal 0–29mm/h)
Calcium: 2.27mmol/L (normal 2.20–2.70mmol/L)
Vitamin D: 78nmol/L (normal 70–100nmol/L)
Which of the following drugs would you consider using in treating her condition?
A.Naproxen.
B.Adalimumab.
C.Pregabalin.
D.Methotrexate.
E.Oxycodone.
A
C.Pregabalin.
- This woman has fibromyalgia. A multitherapy approach to treatment is required involving physiotherapy/graded exercise, addressing trigger stressors and analgesia (anticonvulsants are often used). Naproxen is a nonsteroidal antiinflammatory drug and therefore useful
22
Q
5d.A 42-year-old woman is unable to walk. She has focal neurological findings indicative of a specific neurological lesion but is tender over her greater trochanters, lower back and quadriceps. She is tearful and discloses a history of insomnia and intermittent paraesthesia. She has pain in 14/18 trigger points.
Her initial blood tests are normal. Her chest X-ray and EKG are similarly unremarkable.
What is the next best step?
A.MRI of the spine.
B.Autoimmune profile.
C.Electromyography.
D.Reassurance.
E.Intravenous immunoglobulins.
A
D.Reassurance.
- This woman has fibromyalgia.
23
Q
5e.Which of the following are not typical features of fibromyalgia?
A.Altered sleeping pattern.
B.Pain in multiple tender points.
C.Altered bowel habit.
D.Headache.
E.Foot drop.
A
E.Foot drop.
- This usually indicates an L5/S1 nerve root lesion
24
Q
6a.A 62-year-old diabetic woman presents with an acutely hot swollen right knee. She has recently been treated for a foot ulcer. She is febrile.
Her bloods show a white cell count of 15.5 and a C-reactive protein of 113.
What will her joint aspirate most likely show?
A.Gram-positive cocci.
B.Gram-negative bacilli.
C.Needle-shaped negatively birefringent crystals.
D.Rod-shaped positively birefringent crystals.
E.Blood.
A
A.Gram-positive cocci.
- This woman has septic arthritis and the most common organism is Staphylococcus aureus, a common skin bacterium. Gram-negative bacilli tend to inhabit the GI tract.
25
**6b.** A 25-year-old man presents with acute monoarthritis of the left knee. He has a history of an itchy, flaky rash affecting the knees and his lower back. He has had painful distal finger joints in the past.
How would you start to treat his condition?
A. Antibiotics.
B. Disease-modifying antirheumatic drugs (DMARDs).
C. Paracetamol.
D. High dose steroids.
E. Topical emollients.
**B. Disease-modifying antirheumatic drugs (DMARDs).**
- This man has psoriatic arthritis, a common cause of acute inflammatory monoarthritis in young men
26
**6c.** 3. A 48-year-old man presents with acute arthritis of the right ankle. The joint is red and inflamed and he has difficulty bearing weight on it.
Which of the following features would favour gout rather than septic arthritis?
A. A low-grade fever.
B. A high C-reactive protein (CRP).
C. A previous history of right ankle swelling and pain.
D. A history of immunosuppression.
E. A family history of rheumatoid arthritis.
**C. A previous history of right ankle swelling and pain.**
- This suggests recurrence of a gout flare
27
**7a.** Which of the following is not a risk factor in the development of Perthes disease?
A. Delayed bone age.
B. Hypothyroidism.
C. Low socioeconomic group.
D. Low-birthweight children.
E. Family history.
**B. Hypothyroidism.**
- Delayed bone age, low socioeconomic group, low birth weight and a family history are all risk factors of developing Perthes disease
28
**7b.** A 13-year-old overweight boy presents with severe right hip pain, with a background of 2 weeks of groin pain. There is no history of trauma and he is otherwise well. He is unable to bear his weight, holds his hip in external rotation and flexion and has a decreased range of motion in all axes because of pain. Inflammatory markers are normal. What is the likely diagnosis?
A. Perthes disease.
B. Septic arthritis.
C. Neck of femur fracture.
D. Osteoarthritis.
E. Slipped upper femoral epiphysis.
**E. Slipped upper femoral epiphysis.**
- This condition occurs in adolescents aged 11–14 years and is more common in boys than girls
29
**7c.** A 3-year-old girl is brought to A&E by her mother with a 24-hour history of a left leg limp. Her mother states there is no history of trauma. The child localizes the pain to her groin. The patient has an unremarkable medical history, although her mother notes she had a cold last week. On examination, the child is apyrexial and is systemically well. She is refusing to bear her weight fully and has a decreased range of motion in all axes secondary to pain. X-ray examination shows no abnormality and her blood tests are normal.
What is the likely diagnosis?
A. Transient synovitis.
B. Septic arthritis.
C. Slipped upper femoral epiphysis.
D. Perthes disease.
E. Malignancy.
**A. Transient synovitis.**
- history of a recent viral illness and normal radiology and inflammatory markers, transient synovitis is most likely.
30
**7d. **A 7-year-old boy is brought to A&E by his father having been in pain for 6 hours and with reduced range of motion in his hip. He was recently admitted with pneumonia. He appears unwell and is febrile. His pulse is elevated and he is clammy to the touch.
What is the most appropriate next step?
A. Aspiration of the painful joint.
B. Await blood tests and await culture results to direct treatment.
C. Ultrasound scan hip.
D. Immediate resuscitation and IV antibiotics.
E. X-ray examination of both hips.
**D. Immediate resuscitation and IV antibiotics.**
- Whilst the other steps may be important in the management of the patient, they should not delay resuscitation
31
**8a.** A normally fit and well 45-year-old woman presents to her GP with a lump on her wrist. She describes a 1-year history of a marble-sized lump on the volar aspect of her wrist. She states the lump comes and goes and is not painful. On examination, there is a 1 × 1 cm fluctuant lesion on the volar aspect of her left wrist. It is fixed to underlying tissues.
What is the most likely diagnosis?
A. Soft-tissue sarcoma.
B. Lipoma.
C. Ganglion.
D. Osteophyte.
E. Rheumatoid nodule.
**C. Ganglion.**
- The history of a small fluctuant lesion surrounding a joint with an intermittent history is that of a ganglion
32
**8b.** A 73-year-old lady reports symptoms of pain and a large lump in her thigh. She is kept awake at night by this and has been struggling to bear her weight. She reports weight loss and informs you she was diagnosed with Paget disease several years ago.
What is the most likely diagnosis?
A. Osteosarcoma.
B. Lipoma.
C. Osteophyte.
D. Ewing sarcoma.
E. Deep vein thrombosis.
**A. Osteosarcoma.**
- rare but most commonly occurs in adolescents and elderly patients with Paget bone disease. It is a highly malignant tumour and requires urgent investigation
33
**8c.** A 44-year-old lady presents with a complaint of a lump on the back of her leg behind the knee. She reports it is painless and has been there for several months not changing in size. She is walking normally and does not report night pain. On examination, it is soft, immobile and transilluminates.
What is the most likely diagnosis?
A. Popliteal aneurysm.
B. Osteochondroma.
C. Lipoma.
D. Baker cyst.
E. Sebaceous cyst.
**D. Baker cyst.**
- common benign mass on the back of the knee; it is thought to be a sack of joint fluid pushed posterior in the knee. It should be carefully felt for pulsatility to rule out an aneurysm.
34
**9a.** In the case of a prolapsed vertebral disc, pain is caused when the nerve root is compressed by:
A. Annulus fibrosis.
B. Posterior longitudinal ligament.
C. Ligamentum flavum.
D. Nucleus pulposus.
E. Interspinous ligament.
**D. Nucleus pulposus.**
- disc prolapse occurs when part of the nucleus pulposus herniates through the annulus fibrosus and presses on a spinal nerve root
35
**9b.** Which of the following is a sign of impending cauda equina syndrome?
A. Severe unilateral sciatic-type pain.
B. Bilateral sciatic-type pain.
C. Prolonged duration of symptoms.
D. Leg pain and altered sensation.
E. Muscle weakness.
**B. Bilateral sciatic-type pain.**
-
36
**9c.** Which is the most important investigation in diagnosing impending cauda equina syndrome?
A. Blood test including urea and electrolytes, C-reactive protein and white cell count.
B. MRI scan.
C. CT scan.
D. X-ray examination.
E. White cell count scan.
**B. MRI scan.**
37
**9d.** A 61-year-old retired bricklayer presents with chronic back pain. He describes his pain as exacerbated by walking, particularly downhill, and radiating into his buttocks, thighs and calves bilaterally. Examination reveals a stooped gait and a reduced range of motion in the lumbar spine. His symptoms are exacerbated by extension of the spine.
What is the diagnosis?
A. Prolapsed intervertebral disc.
B. Mechanical back pain.
C. Spinal stenosis.
D. Spondylolisthesis.
E. Spinal malignancy.
**C. Spinal stenosis.**
- The pain in his buttocks, thighs and calves is spinal claudication. Patients walk with a stooped gait to flex the lumbar spine and alleviate their symptoms.
38
**9e.** A 72-year-old male presents with back pain and mild weakness in both legs. An X-ray examination is performed and shows a sclerotic lesion in the L5 vertebrae. What is the most likely underlying diagnosis causing this man’s problem?
A. Multiple myeloma.
B. Malignant sarcoma.
C. Metastatic prostate cancer.
D. Metastatic lung cancer.
E. Paget disease
**C. Metastatic prostate cancer.**
- the spread of tumour into the spine is thought to made more likely by back flow through the venous complex
39
**10a.** A distal radius fracture with significant dorsal angulation is most likely to cause altered sensation in the distribution of which nerve:
A. Ulnar nerve.
B. Superficial radial nerve.
C. Medial cutaneous nerve of the forearm.
D. Median nerve.
E. Axillary nerve.
**D. Median nerve.**
- A dorsally angulated distal radius fracture can cause compression of the median nerve
40
**10b.** A 56-year-old woman with rheumatoid arthritis presents to her GP with a 6-month history of altered sensation and pain in both her hands, the right worse than the left. She describes pins and needle in her index, middle and ring fingers and pain at night, which frequently wakens her from sleep. She also describes decreased grip strength. On examination, there is wasting of the thenar eminences and percussion at the wrist crease exacerbates her symptoms.
A. Cervical radiculopathy.
B. Cubital tunnel syndrome.
C. Peripheral neuropathy.
D. Carpal tunnel syndrome.
E. Transient ischaemic attacks.
What is the diagnosis?
**D. Carpal tunnel syndrome.**
- Percussion at the wrist crease is Tinel sign.
41
**10c. **A patient presents with numbness in the hand, worse at night, in the radial three digits. It passes off rapidly, but she has begun to notice loss of fine movements in the hand. Which of these tests will be most helpful in confirming the diagnosis?
A. Blood tests including urea and electrolytes, C-reactive protein and full blood count.
B. MRI cervical spine.
C. Nerve conduction studies.
D. X-ray examination of the wrist.
E. CT of the brain.
**C. Nerve conduction studies.**
- will give a grading from 1 to 4 as to how severe it is. Ultimately, the decision to decompress is still made clinically.
42
**10d.** A 67-year-old lady with a previous history of myocardial infarction presents with numbness and tingling in her left arm of only 6 hours’ duration. She is mildly confused and has 60% power in the left arm with numbness throughout. What is the likely diagnosis?
A. Transient ischaemic attack (TIA).
B. Carpal tunnel syndrome.
C. Brachial plexus injury.
D. Prolapsed cervical disc.
E. Ulnar nerve entrapment.
**A. Transient ischaemic attack (TIA).**
- This story is much more acute and concerning than that of a simple nerve entrapment and should be investigated for stroke or TIA with a central cause far more likely then a peripheral cause.
43
**11a.** Which of the following is not a typical finding from an X-ray examination in osteoarthritis?
A. Lytic bone lesions.
B. Joint space narrowing.
C. Sclerosis.
D. Cyst formation.
E. Osteophytes.
**A. Lytic bone lesions.**
- This suggests malignant infiltration of the bone. The other four findings are all classic signs of osteoarthritis.
44
**11b.** A 77-year-old man sees his GP for left knee pain, gradually worsening over a month. He is now struggling to bear weight on it and the joint appears slightly swollen. The pain is achy and is affecting his ability to walk. He has now started to experience pain at night.
What would an X-ray examination reveal?
A. Erosions.
B. Osteophytes.
C. Hairline fracture.
D. Osteopenia.
E. Soft tissue swelling.
**B. Osteophytes.**
- This gentleman is suffering from osteoarthritis
45
**11c. **An 80-year-old woman complains of worsening stiffness in her hands for 6 months. She finds it difficult to button up her clothes and her hands ache after gardening and doing household chores.
What might you expect to find on clinical examination?
A. Ulnar deviation.
B. Boutonniere deformity.
C. Heberden nodes.
D. Dupuytren contracture.
E. Metacarpophalangeal (MCP) swelling.
**C. Heberden nodes.**
- The patient’s clinical history and age are suggestive of osteoarthritis.
46
**11d. **A 65-year-old former factory worker presents to his physician with pain in his hips. He has trouble sitting and standing. The pain increases after walking and radiates to his knees. Resting makes it better.
What is the next most appropriate step in his management?
A. Glucosamine.
B. Joint replacement.
C. Trial of steroids.
D. Physiotherapy.
E. Joint injection.
**D. Physiotherapy.**
- This man has osteoarthritis (OA).
47
**12a. **A 65-year-old woman with stable rheumatoid arthritis (RA) notices loss of sensation in the lateral 3.5 fingers, palmar aspect.
Which is the most appropriate therapy for this more recent condition?
A. Splinting.
B. Oral steroids.
C. Methotrexate.
D. Physiotherapy.
E. Intramuscular gold injections.
**A. Splinting.**
- The patient is developing carpal tunnel syndrome, a recognized complication of RA.
48
**12b.** An 80-year-old man presents to his GP with pain in his fingers and joints for 6–12 months. He is struggling to work in his garden and is finding dressing himself difficult. He has flattened knuckles, swan-neck deformity of his fingers and z-thumb deformity of the thumbs. There is slight ulnar deviation.
Which might you not expect to see on an X-ray image of his hands?
A. Juxtaarticular erosions.
B. Joint effusion.
C. Narrowed joint space.
D. Osteopenia.
E. Soft tissue swelling.
**B. Joint effusion.**
- Hand joints are very small and therefore detecting an effusion on X-ray images is particularly challenging.
49
**12c.** A 48-year-old woman presents with 8-week onset of bilateral stiffness and intermittent swelling of the metacarpophalangeal joints. She is otherwise fit and well. On further questioning, she admits to similar episodes over the previous 2 years.
She is anti-CCP and rheumatoid factor positive, with high erythrocyte sedimentation rate and C-reactive protein. X-ray images show erosive arthropathy.
What is the next most appropriate management step?
A. Physiotherapy.
B. MRI of the hands.
C. Start disease-modifying antirheumatic drugs (DMARDs).
D. Hydrotherapy.
E. Start nonsteroidal antiinflammatory drugs (NSAIDs).
**C. Start disease-modifying antirheumatic drugs (DMARDs).**
- methotrexate would be the drug of choice. Physiotherapy has a role to play in the management of rheumatoid arthritis but will not quickly alleviate the synovitis
50
**12d. **An 86-year-old woman goes to her GP with pain in her fingers and toes for 6 months. It is intermittent and her fingers feel stiff and tender. Stiffness is greatest when she wakes and eases as the day goes by. She has also noticed firm subcutaneous lumps forming on the extensor side of her elbow. Her medical history states she has had bleeding from a duodenal ulcer.
Which of the following would be best avoided in this woman?
A. Hydroxychloroquine.
B. Methotrexate.
C. Paracetamol.
D. Naproxen.
E. Sulfasalazine.
**D. Naproxen.**
- associated risk of gastrointestinal bleeding
51
**12e.** A 58-year-old woman with longstanding rheumatoid arthritis and secondary osteoporosis presents with progressive worsening breathlessness. She has been on methotrexate and sulfasalazine for many years and has had considerably long courses of steroids.
Which is the least likely cause for her breathlessness?
A. Rheumatoid lung disease.
B. Anaemia.
C. Methotrexate-induced lung fibrosis.
D. Acquired kyphosis.
E. Constrictive pericarditis.
**E. Constrictive pericarditis.**
- This is a very rare complication of longstanding pericardial inflammation, which is no longer seen as common in rheumatoid arthritis (RA) due to improvements in treatment
52
**13a.** A 22-year-old man develops an acute swelling of his left knee and ankle with painful heels. There was no trauma.
A week previously he had conjunctivitis and a fever.
Blood and urine samples are taken for culture.
Which of the following is NOT the likely pathogen?
A. Haemophilus influenzae.
B. Chlamydia trachomatis.
C. Salmonella typhi.
D. Neisseria gonorrhoeae.
E. Escherichia coli.
**A. Haemophilus influenzae.**
- This is a respiratory pathogen. The man has Reiter syndrome, which is associated with gut infections and sexually transmitted infections.
53
**13b.** A 53-year-old woman complains of bloody diarrhoea and abdominal pain. She experiences low-grade fever, nausea and weight loss. A colonoscopy is conducted, which shows ulcerative lesions in her rectum.
During this period her shoulders becomes progressively stiffer and she develops pain and swelling in her right knee. The intensity of the pain has worsened with her bowel symptoms.
What is the most appropriate immediate management for this woman?
A. Nonsteroidal antiinflammatory drugs (NSAIDs).
B. Corticosteroids.
C. Panproctocolectomy.
D. Biologic therapy.
E. Sulfasalazine.
**B. Corticosteroids.**
- These will act fast to settle both the bowel and joint symptoms.
54
**13c. **A 45-year-old man presents to his GP with joint pain and stiffness in both wrists, knuckles and distal interphalangeal joints. There is a slight degree of swelling in the right and left middle fingers, giving them a sausage-like appearance. The GP notices dry skin around his hairline and back of his ears.
Which of the following nail changes is he most likely to have?
A. Keratoderma blennorrhagica.
B. Koilonychia.
C. Subungal hyperkeratosis.
D. Leuconychia.
E. Paronychia.
**C. Subungal hyperkeratosis.**
- This occurs in psoriatic arthritis.
55
**13d.** Which of the following is not associated with ankylosing spondylitis?
A. Amyloidosis.
B. Apical lung fibrosis.
C. Aortic incompetence.
D. Anticardiolipin antibody.
E. Acute anterior uveitis.
**D. Anticardiolipin antibody.**
- This is associated with connective tissue disease and antiphospholipid syndrome. AS is a seronegative spondyloarthropathy. The other four are the four As associated with ankylosing spondylitis.
56
**13e.** Which of the following types of spondyloarthropathy is most closely associated with HLA B27 positivity?
A. Psoriatic arthritis.
B. Enteropathic arthritis.
C. Reactive arthritis.
D. Undifferentiated spondyloarthritis.
E. Ankylosing spondylitis.
**E. Ankylosing spondylitis.**
- 90% of patients are HLA B27 positive.
57
**14a.** A 63-year-old man presents with a headache for 3 days. It is severe and unilateral, only affecting the left side of his head. It radiates to his scalp.
He has no visual disturbance or pain in his jaw on eating, but feels sore when he brushes his hair. The pain is constant, with only temporary relief from analgesia.
What investigation is most useful in confirming the diagnosis?
A. Temporal artery biopsy.
B. Erythrocyte sedimentation rate (ESR).
C. Antineutrophil cytoplasmic antibody (ANCA) screening.
D. Lumbar puncture.
E. MRI of the aortic arch.
**A. Temporal artery biopsy.**
- This is the gold standard test for giant cell arteritis. ESR should be elevated but this is nonspecific.
58
**14b.** A 58-year-old man presents to the respiratory clinic with breathlessness. He is found to have a raised pulmonary artery pressure. High-resolution CT of the chest shows pulmonary fibrosis.
He also complains of painful discolouration of his fingers when outdoors, has evidence of skin thickening in the fingers and hands with hard deposits under the skin, and small red spider-like lesions on the chest and face.
What is the most likely explanation for the findings.
A. Systemic lupus erythematosus (SLE).
B. Systemic sclerosis.
C. Linear scleroderma.
D. Paraneoplastic syndrome.
E. Multiple sclerosis.
**B. Systemic sclerosis.**
- This patient has evidence of widespread multisystem sclerosis and fibrosis with pulmonary hypertension, pulmonary fibrosis, Raynaud phenomenon, scleroderma and calcinosis in the hands and telangiectasia.
59
**14c.** A 48-year-old woman complains of dry eyes, dry mouth and lethargy. There is evidence of oral candidiasis and dental caries. She also complains of pains in multiple joints. Her GP questions what her diagnosis may be.
Which is the most likely test to confirm the diagnosis?
A. HIV test.
B. Schober test.
C. Schirmer test.
D. Transoesophageal echocardiogram.
E. Trendelenburg test.
**C. Schirmer test.**
- This test is used in the diagnosis of Sjögren syndrome
60
**14d. **A 60-year-old woman comes to the GP with stiffness, fatigue and muscle pains affecting her shoulder and hips. The onset was over several days. On examination, she is slow to rise from a chair, has difficulty in raising her arms and cannot undo her bra-strap. She also complains of a right sided headache, which isn’t made better by simple analgesia and which is progressively worsening.
What should you do immediately?
A. Check erythrocyte sedimentation rate (ESR).
B. Refer for temporal artery biopsy.
C. Refer for muscle biopsy.
D. Administer prednisolone.
E. Administer a nonsteroidal anti-inflammatory drug.
**D. Administer prednisolone.**
- This woman has polymyalgia rheumatica with features of giant cell arteritis. It requires urgent treatment to preserve vision and reduce the risk of stroke.
61
**14e.** A 67-year old man presents to the GP complaining of difficulty in rising from a chair. He has also noticed the development of erythematous plaques over his knuckles and a lilac discolouration of his eyelids. The GP decides to order some tests to confirm the diagnosis.
Which test has the highest diagnostic yield?
A. Erythrocyte sedimentation rate (ESR).
B. Antinuclear antibodies.
C. Chest X-ray.
D. X-ray of the affected joints.
E. Serum creatine kinase levels.
**E. Serum creatine kinase levels.**
- Dermatomyositis will produce inflamed muscles, which leak enzymes due to oedema in the cells.
62
**14f. **A 35-year-old woman is admitted as an emergency to A&E with breathlessness, haemoptysis, chest pain and signs of shock. She receives thrombolysis and is seen to improve. Contrast CT of the pulmonary arteries confirms bilateral pulmonary emboli.
She gives a history of stillbirth in the past and a retinal vein occlusion.
What is the most appropriate next investigation for this woman?
A. Antiphospholipid antibody.
B. Anti-double-stranded DNA antibody.
C. Antineutrophil cytoplasmic antibody (ANCA).
D. Prothrombin time.
E. Syphilis serology.
**A. Antiphospholipid antibody.**
- A stillbirth and two vascular events suggest antiphospholipid syndrome, which is also associated with levido, migraines, low platelets and systemic lupus erythematosus.
63
**15a.** An 85-year-old presents to his GP with lower back pain for 2 days. Over the previous 3 years he has noticed his shirts seem to be getting longer but not looser. He had a rib fracture a year ago after slipping off a chair.
Blood tests are performed, which show the following:
Calcium: 2.38 mmol/L (normal 2.12–2.65 mmol/L)
Phosphate: 1.1 mmol/L (normal 0.8–1.4 mmol/L)
Alkaline phosphatase: 98 U/L (normal 30–150 U/L)
What is the most likely diagnosis?
A. Osteoporosis.
B. Myeloma.
C. Osteomalacia.
D. Paget disease.
E. Potts disease (spinal tuberculosis).
**A. Osteoporosis.**
- Vertebral height loss, back pain from a probable vertebral fracture and previous history of low-energy fracture all suggest osteoporosis.
64
**15b.** A 58-year-old woman presents to her GP with hip pain for 3 weeks. On examination, she has bowing of her tibias. She seems to be having difficulty hearing and the doctor has to keep repeating himself. Her father had a similar issue with bowing of the tibias.
What would be the next most appropriate step in diagnosis?
A. Coeliac serology.
B. Bone biochemistry.
C. Dual-energy X-ray absorptiometry (DEXA) scan.
D. MRI of the tibias.
E. Test for rheumatoid factor.
**B. Bone biochemistry.**
- The patient has Paget disease of bone and this simple blood test will show an elevated alkaline phosphatase level. Coeliac serology should be tested if vitamin D deficiency is thought to be the cause.
65
**15c.** An 80-year-old man who has chronic renal failure starts developing bony tenderness and muscle weakness. He even finds walking with a zimmer frame difficult due to pain. Blood tests are performed:
Calcium: 1.56 mmol/L (normal 2.12–2.65 mmol/L)
Phosphate: 0.62 mmol/L (normal 0.8–1.4 mmol/L)
Alkaline phosphatase: 198 U/L (normal 30–150 U/L)
What is not a possible consequence of his condition?
A. Skeletal deformity.
B. Tetany.
C. Polydipsia.
D. Convulsions.
E. Arrhythmias.
**C. Polydipsia.**
- polydipsia = extreme thirstiness
- The patient has renal osteomalacia where vitamin D fails to be metabolized into the active form by chronically failing kidneys. Polydipsia is a commonly seen symptom in hypercalcaemia but is not associated with low calcium or low phosphate levels.
66
**15d. **A 56-year-old woman presents to her physician with pain shooting down her right leg from her back and also with sore knees. They feel warm to touch. She also has pain when walking. Bone biochemistry is checked and the results are as follows:
Calcium: 2.38 mmol/L (normal 2.1–2.65 mmol/L)
Phosphate: 1.1 mmol/L (normal 0.8–1.4 mmol/L)
Alkaline phosphatase (ALP): 220 U/L (normal 30–150 U/L)
What is the likely diagnosis?
A. Osteoarthritis.
B. Prolapsed vertebral disc.
C. Septic arthritis.
D. Paget disease.
E. Gout.
**D. Paget disease.**
- Back pain, knee pain with increased blood flow and high levels of alkaline phosphatase suggest this
67
**15e.** A 68-year-old woman presents to her GP feeling tired, with myalgia and bone pain. The GP does a broad battery of blood tests and these are her results:
Calcium: 1.87 mmol/L (normal 2.12–2.65 mmol/L)
Phosphate: 0.58 mmol/L (normal 0.8–1.4 mmol/L)
Alkaline phosphatase: 202 U/L (normal 30–150 U/L)
Haemoglobin: 10.3 g/dL (normal 11.5–16.0 g/dL)
Mean cell volume: 101 fL (normal 76–96 fL)
Iron: 9 μmol/L (normal 11–30 μmol/L)
Folate: 1.9 μg/L (normal 2.1 μg/L)
Which investigation would be most useful to confirm the diagnosis?
A. Anti-double-stranded DNA antibody.
B. Antiphospholipid antibody.
C. Anti-smooth muscle antibody.
D. Anti-vitamin D3 antibody.
E. Anti-tissue transglutaminase antibody.
**E. Anti-tissue transglutaminase antibody.**
- Coeliac disease is a common malabsorptive cause of osteomalacia causing low levels of iron, folate, vitamin D and other essential vitamins and minerals
68
**16a. **A 75-year-old man develops pain in his right wrist and right third metacarpophalangeal joint. The joints are red, warm, swollen and tender. He cannot do his usual activities due to pain. Aspiration of his wrist shows rhomboid calcium pyrophosphate crystals. An X-ray examination of the joint reveals chondrocalcinosis, subchondral sclerosis and osteophytes. He is given co-codamol for pain relief.
What is the next most effective step in his management?
A. Antibiotics.
B. Disease-modifying antirheumatic drugs.
C. Joint replacement.
D. Physiotherapy.
E. Splinting.
**E. Splinting.**
- This will allow the joint time to rest and pain relief to be given
69
**16b.** A 59-year-old obese man presents to his physician with acute onset of pain and swelling in his left first metatarsophalangeal joint. It is red, swollen, tender and warm. He is unable to bear weight on it. The physician also finds unusual white lumps on his fingers. The joint is aspirated.
What will the fluid microscopy probably show?
A. Gram-positive bacteria.
B. Calcium pyrophosphate.
C. Pus.
D. Monosodium urate crystals.
E. Clear synovial fluid.
**D. Monosodium urate crystals.**
- These are found in acute gout. The white lumps are tophi. Bacteria need to be excluded from an acute hot joint but the presence of tophi make septic arthritis less likely
70
**16c. **A 55-year-old woman comes to her doctor with an excruciatingly painful right first metatarsophalangeal joint for 24 hours. The overlying skin is warm, shiny and the joint is swollen and immobile. She has a history of chronic kidney disease. Last year she had a similar short-lived episode that resolved and left her symptomless.
What is the most likely explanation for her condition?
A. This is an autoimmune condition where T-lymphocytes attack the synovial lining of joints, eventually causing erosion of the cartilage and underlying bone.
B. There is an ongoing chronic infection in the joint.
C. Chronic hyperuricemia leading to the formation of sodium urate crystals that get deposited in the synovium, causing inflammation.
D. Calcium pyrophosphate crystals have deposited in the joint space.
E. Degeneration of the weight-bearing cartilage and subsequent eburnation of subchondral bone.
**C. Chronic hyperuricemia leading to the formation of sodium urate crystals that get deposited in the synovium, causing inflammation.**
- This is the underlying process in gout.
71
**16d. **A 72-year-old man presents with a 24-hour history of a painful swollen knee. There is no history of trauma. He is otherwise well. He is apyrexial. His knee is mildly erythematous and is tender on palpation with decreased range of motion. An X-ray examination is performed (see image). Erythrocyte sedimentation rate and C-reactive protein are mildly elevated, but the white cell count is normal.
What is the most likely diagnosis?
A. Gout.
B. Pseudogout.
C. Septic arthritis.
D. Rheumatoid arthritis.
E. Haemarthrosis.
**B. Pseudogout.**
- Both gout and pseudogout would occur without trauma, but given the finding of chondrocalcinosis from the X-ray examination, the joint involved and age, pseudogout is most likely.
72
**16e.** A 65-year-old man presents with a warm, hot, swollen and tender right ankle. He has a history of gout and has had recurrent flares of his disease. He currently takes 200 mg of allopurinol daily. His GP treats acutely with colchicine and his symptoms settle. Sometime later, his uric acid level is checked and is found to be 460 μg/mL. His other blood tests are normal, including renal function.
What is the next appropriate step in managing this man’s gout?
A. Increase allopurinol to 300 mg daily.
B. Add febuxostat 120 mg daily.
C. Start long-term prednisolone 10 mg daily.
D. Add colchicine 500 μg twice daily.
E. Start ibuprofen 400 mg three times daily.
**A. Increase allopurinol to 300 mg daily.**
- The patient’s blood should be rechecked within 12 weeks and the dose increased as required to maintain serum uric acid below 360 μg/ml
73
**17a. **The majority of the blood supply to the femoral head in adults arises from:
A. Artery of ligamentum teres.
B. Lateral femoral circumflex artery.
C. Obturator artery.
D. Medial femoral circumflex artery.
E. Profunda femoris artery.
**D. Medial femoral circumflex artery.**
- The majority of the blood supply to the femoral head in adults arises from the medial femoral circumflex artery
74
**17b.** A 12-year-old boy attends the hospital with a new onset of pain in his left hip. He is overweight and has not started puberty. He is unable to bear weight on this leg and on examination all movements are generally painful. An X-ray examination reveals that he has an abnormality of the femoral neck in keeping with a SUFE. In what position is his leg most likely to lie?
A. Internal rotation.
B. External rotation.
C. Flexion.
D. Abduction.
E. Adduction.
**B. External rotation.**
- The classic position for a leg to lie after SUFE is in external rotation and shortened
75
**17c.** A baby is assessed in the birthing room after delivery at term. An abnormality is noted involving an inward-pointing foot and calf wasting. The father tells you he had the same thing as a child. What is the most likely diagnosis?
A. Talipes equinovarus.
B. Normal variant.
C. Cerebral palsy.
D. Pes planus.
E. Spina bifida.
**A. Talipes equinovarus.**
- This baby has a deformity that is commonly called a clubfoot.
76
**17d.** A 6-year-old boy attends the fracture clinic with a fracture of his wrist, which has been treated in a cast and seems to be healing. His mother tells you he also recently broke his other wrist and had a supra-condylar fracture 1 year ago, all with low-energy trauma. He seems happy and well-dressed but is small in stature and on examination has a subtle scoliosis. What is the most likely underlying diagnosis here?
A. Marfan syndrome.
B. Idiopathic scoliosis.
C. Nonaccidental injury.
D. Osteoporosis.
E. Osteogenesis imperfecta.
**E. Osteogenesis imperfecta.**
- There is a chance that this child is the victim of NAI and this should be explored. However, given the scoliosis, short stature and multiple low-energy fractures, a diagnosis of osteogenesis imperfecta should be considered and investigated.
77
**17e.** A patient is admitted to an orthopaedic ward with a proximal tibia fracture whilst awaiting surgery. During the night the patient experiences a severe increase in pain. This is initially settled with opiate analgesia but rapidly returns and eventually opiate analgesia is no longer effective.
What are you primarily concerned about?
A. Further displacement of the fracture.
B. Deep vein thrombosis.
C. Compartment syndrome.
D. Embolic arterial occlusion.
E. Nerve injury following the fracture.
**C. Compartment syndrome.**
- Any patient who has a severe increase in pain following a fracture should be assessed for compartment syndrome. Proximal tibial fractures are at increased risk of developing compartment syndrome.
78
**17f.** A 68-year-old woman is seen 3 days after a total hip replacement. Initially progressing well, she suddenly develops sharp left-sided chest pain and shortness of breath. On examination, she has slight pyrexia (37.5°C) and is hypoxic on room air (SpO2 91%) and tachycardic (heart rate 110 bpm).
What is the cause of her symptoms?
A. Pulmonary thromboembolism.
B. Myocardial infarction.
C. Basal atelectasis.
D. Fat embolism.
E. Pneumothorax.
**A. Pulmonary thromboembolism.**
- Although rare, pulmonary thromboembolism is a recognized complication of arthroplasty surgery. The onset and nature of the patient’s symptoms are highly suggestive of this condition.
79
**17g.** What is the main principle when choosing internal fixation over casting of fractures?
A. Lower complication rate.
B. Cheaper.
C. Early mobilization.
D. Ensure union of fracture.
E. Less pain.
**C. Early mobilization.**
- The main principle of internal fixation is to allow early mobilization.
80
**17h.** A young man is involved in an road traffic accident and is brought into A&E with a collar in situ. He has a Glasgow Coma Scale of 15, but after completing an ABCDE survey he is found to be unstable due to a suspected unstable pelvic fracture. What is the first step to take in dealing with this?
A. Place an external fixator while in A&E.
B. Urgent angiogram.
C. Apply a pelvic binder.
D. Laparotomy and pelvic packing.
E. Anteroposterior X-ray examination of the pelvis.
**C. Apply a pelvic binder.**
81
**17i.** A 92-year-old lady who is normally fit and well presents to A&E with a painful hip and not able to bear weight. She is normally mobile in the home but has chronic obstructive pulmonary disorder and a poor maximum walking distance. She is examined and her hip is found to be in external rotation and shortened. She is seen to have an intracapsular neck of femur fracture on X-ray examination. What is the best treatment for her?
A. Hemiarthroplasty.
B. Dynamic hip screw (DHS).
C. Total hip replacement.
D. Girdlestone procedure.
E. Conservative management.
**A. Hemiarthroplasty.**
- Fixation with DHS is not an option because the blood supply to the femoral head will be compromised. The patient is not fit enough for total hip replacement. Girdlestone is a complete disarticulation of the hip and is a last resort if all other options have failed. Conservative treatment in a previously mobile patient would be a poor option, committing her to several months of pain and immobility.
82
**19a.** A man arrives in A&E following a car accident, with a suspected pelvic fracture. He is unresponsive, hypotensive and tachycardic. Which is the first step in the management of this patient?
A. Obtain intravenous access and commence fluid resuscitation.
B. Apply a pelvic binder.
C. Get an anteroposterior pelvis X-ray examination.
D. Crossmatch the patient for type-matched blood.
E. Assess the airway whilst stabilizing the cervical spine.
**E. Assess the airway whilst stabilizing the cervical spine.**
- follow the ABCDE pathway and assess systems in order of importance. Do not become distracted by the perceived main issue. All patients should be assumed to have a cervical spine injury until proven otherwise.
83
**19b.** A 20-year-old patient is involved in a road traffic accident, fracturing their femur. They are brought into the A&E and assessed using an ABCDE approach. Their blood pressure is noted to be 100/60 and their pulse is 110. What is their likely percentage blood loss?
A. 0%–15%
B. 15%–30%
C. 30%–40%
D. > 40%
**B. 15%–30%**
- Their blood pressure has fallen in response to volume depletion and their pulse rate has gone up in order to attempt to maintain perfusion of end organs.
84
**19c.** An 80-year-old patient trips in her bathroom and hits her head on a toilet seat. She is admitted to A&E D and undergoes evaluation using an ABCDE approach. She is found to have a bruise on the back of her head and complains of neck pain. She has a GCS of 14 and no neurological abnormalities. She is on warfarin with an INR of 3. Which is the next best investigation?
A. MRI head and C-spine.
B. X-ray examination of C-spine.
C. CT angiogram.
D. CT head and C-spine.
E. Bone scan.
**D. CT head and C-spine.**
- It is likely this patient also has an intracranial abnormality. If the patient already needs to undergo a CT scan and has symptoms, C-spine X-ray examination will be an extra, unhelpful step. Whilst an MRI is informative, it is difficult to obtain in an emergency situation, unlike a CT scan.
85
**20a.** Which is the most common pathogen in septic arthritis in adults?
A. Streptococcus sp.
B. Mycobacterium tuberculosis.
C. Staphylococcus aureus.
D. Haemophilus influenzae.
E. Enterobacter sp.
**C. Staphylococcus aureus.**
- most common pathogen in septic arthritis in adults, followed by Streptococcus and Enterobacter. S. aureus is the most common pathogen in all ages.
86
**20b.** A 64-year-old man with a background of diabetes presents with a 24-hour history of progressive atraumatic left knee pain. He is unable to bend his knee and unable to bear weight. On examination, he is pyrexial and his left knee is hot and erythematous. He has a large effusion, virtually no range of movement and global tenderness around the knee.
What is the most important step in this man's management?
A. Anteroposterior and lateral X-ray examination of the knee.
B. Commence intravenous antibiotics.
C. Aspiration of the knee.
D. Bloods for inflammatory markers.
E. Ultrasound scan of the knee.
**C. Aspiration of the knee.**
- This man has septic arthritis until proven otherwise
87
**20c.** A 38-year-old electrician presents with a painful swollen right knee. He states that over the past week his knee has become increasing swollen and red and he now has a decreased range of motion. On examination, there is a large erythematous swelling anterior to the patella, which is tender to palpate. There is thickened skin over the anterior of the knee. There is no effusion in the knee. He is able to flex his knee to 45 degrees before he is limited by a combination of pain and tightness in the knee.
What is the likely diagnosis?
A. Osteoarthritis.
B. Septic arthritis.
C. Baker cyst.
D. Patellar fracture.
E. Prepatellar bursitis.
**E. Prepatellar bursitis.**
- common in patients who kneel when working (e.g., electricians, plumbers)
88
**20d.** In the case of septic arthritis in intravenous drug abusers, which of the following pathogens is most likely?
A. Staphylococcus aureus.
B. Pseudomonas.
C. Fungal infections.
D. Streptococcus sp.
E. All of the above.
**E. All of the above.**
- IV drug abusers inject themselves with potentially contaminated drugs through a dirty needle. They are also frequently immunosuppressed and undernourished; consequently, they are at risk of a wide range of infections. As a result, they will require a broad range of antibiotics to cover potential pathogens.
89
**21a.** A 30-year-old man presents with an intensely painful right proximal tibia with no history of trauma. He experiences pain during the day and night. Of note, he states that aspirin relieves his pain significantly. On examination, there is significant tenderness over the proximal tibial metaphysis. X-ray examination shows a small lucent area in the tibial metaphysis with dense sclerosis surrounding it.
What is the most likely diagnosis?
A. Enchondroma.
B. Osteoid osteoma.
C. Chondrosarcoma.
D. Osteochondroma.
E. Lymphoma.
**B. Osteoid osteoma.**
- Osteoid osteoma presents insidiously, giving rise to intense pain and tenderness over the affected area, sometimes with a history of night pain. A central lucent nidus surrounded by a dense area of reactive bone will be seen on X-ray image.
90
**21b.** A 24-year-old, normally fit and healthy woman presents with a 4-month history of gradually increasing pain in her left knee. There was no history of trauma. She is now having difficulty bearing weight and is frequently woken at night with pain. She also notes weight loss in the same timeframe. X-ray examination of her knee demonstrates an expansile and lytic lesion in her distal femur, with cortical destruction and significant periosteal reaction.
What is the most likely diagnosis?
A. Tuberculosis.
B. Osteosarcoma.
C. Enchondroma.
D. Osteomyelitis.
E. Stress fracture.
**B. Osteosarcoma.**
- Osteosarcoma is most common between the ages of 10 and 40 years and frequently occurs around the knee. The symptoms of night pain and weight loss are suspicious of malignancy. The X-ray findings are typical of osteosarcoma.
91
**21c.** An 89-year-old man presents with a painful lumbar spine and difficulty mobilizing. He tells you this has only been present for 6 weeks but that he has noticed some weight loss and feels generally unwell. He undergoes an X-ray examination of the spine, which shows sclerotic change through L5 and S1.
What is the most likely underlying diagnosis?
A. Prostate cancer.
B. Renal cancer.
C. Lung cancer.
D. Thyroid cancer.
E. Bowel cancer.
**A. Prostate cancer.**
- The finding of a sclerotic lesion makes prostate cancer the most likely cause for this metastatic deposit. Prostate cancer often metastasizes to the spine due to the venous drainage connection.
92
**21d.** Which of these common bony structures visible on X-ray images might be an indication of malignancy?
A. Looser zones.
B. Periarticular erosions.
C. Osteophytes.
D. Periosteal reaction.
E. Vertebral trabecular thickening.
**D. Periosteal reaction.**
- This is the Codman triangle appearance on an X-ray image whereby, in aggressive lesions, the cortex does not have time to remodel and there is a raised multilayered edge of periosteum. Looser zones are present in osteomalacia, vertebral trabecular thickening is seen in Paget disease and the other changes are in keeping with osteoarthritis.
93
**22a.** What causes a locked knee?
A. Anterior cruciate ligament tear.
B. Radial meniscal tear.
C. Medial collateral ligament tear.
D. Bucket handle meniscal tear.
E. Tibial plateau fracture.
**D. Bucket handle meniscal tear.**
- The handle part of a bucket handle tear flips over, becoming trapped in the joint and preventing full extension.
94
**22b.** An 18-year-old football player presents to A&E with a knee injury. He describes turning quickly and twisting his right knee, precipitating immediate pain. He states his knee was grossly swollen before he left the pitch. On examination, there is a tense effusion, no joint line tenderness and a poor range of motion. Lachman test is positive, but otherwise the knee is stable.
What is the diagnosis?
A. Medial meniscal tear.
B. Posterior cruciate ligament tear.
C. Medial collateral ligament tear.
D. Patellar dislocation.
E. Anterior cruciate ligament tear.
**E. Anterior cruciate ligament tear.**
- An ACL tear is normally caused by a twisting injury to the knee. Patients will describe immediate pain and rapid swelling. Examination will reveal a large effusion, due to the haemarthrosis, and laxity in the AP axis. Lachman test and anterior drawer test are used for diagnosis.
95
**22c.** A 23-year-old man walks into A&E reporting pain in his left shoulder. He has an obvious deformity and is unable to move the shoulder. A dislocation is diagnosed. What is the most likely position for the humerus to lie, in relation to the glenoid?
A. Anterior, medial.
B. Posterior.
C. Anterior superior.
D. Anterior inferior.
E. Superior.
**D. Anterior inferior.**
- The majority of dislocations come out anterior inferior due to the weakness of the muscle cover in this position.
96
**22d.** Which of the following conditions make a patellar dislocation more likely?
A. Patella fracture.
B. Cerebral palsy.
C. Anterior cruciate ligament injury.
D. Hypoplastic trochlea.
E. Osteoarthritis.
**D. Hypoplastic trochlea.**
- A shallow trochlea will increase the risk of patellar dislocation, which is particularly common in young women and can be difficult to treat.
97
**23a. **De Quervain tenosynovitis involves inflammation of which tendon sheath?
A. Extensor pollicis longus.
B. Abductor pollicis longus.
C. Extensor indicis.
D. Flexor pollicis longus.
E. Extensor carpi radialis longus.
**B. Abductor pollicis longus.**
- De Quervain tenosynovitis is inflammation of the tendon sheaths of abductor pollicis longus and extensor pollicis brevis.
98
**23b.** A 55-year-old man presents with pain and swelling over his left elbow. He has an obvious swelling but not much redness at the olecranon and a normal range of motion. His C-reactive protein is 6 and his white cells 7.3. What is the first line treatment for this condition?
A. Nonsteroidal antiinflammatory drugs (NSAIDs) and rest.
B. Aspiration and culture.
C. Intravenous antibiotics.
D. Open washout.
E. Bursectomy.
**A. Nonsteroidal antiinflammatory drugs (NSAIDs) and rest.**
- this is olecranon bursitis
99
**23c.** Which tissue is primarily involved in the development of Dupuytren contracture?
A. Flexor tendons.
B. Palmar fascia.
C. Metacarpophalangeal joint capsule.
D. Flexor tendon sheaths.
E. Skin.
**B. Palmar fascia.**
- Dupuytren contracture is a disease in which palmar fascia undergoes fibrosis and contracture.
100
**24a.** An 82-year-old female undergoes hemiarthroplasty after fracture of her left hip. Six hours after the operation, her pulse is 70 bpm and her blood pressure is 80/40. She is not confused but is not producing any urine. Which is the most likely cause for her condition?
A. Cardiogenic shock.
B. Hypovolaemia.
C. Anaphylaxis.
D. Sepsis.
E. Neurogenic shock.
**B. Hypovolaemia.**
- Hypovolaemia = loss of fluid
- The patient is likely to be still very hypovolaemic postoperatively. This should be corrected but not too aggressively in an older patient.
101
**24b.** A 79-year-old male presents to A&E with pain in his right hip. He is unable to move and reports that he simply bent over to do up his shoe lace and felt a severe pain in his hip. Of note in his history, he had a total hip replacement on the right side 9 years previously but had been functioning well. What is the most likely cause for his pain?
A. Hip dislocation.
B. Periprosthetic fracture.
C. Implant loosening.
D. Deep infection.
E. Implant failure and breakage.
**A. Hip dislocation.**
- Given the patient’s history, he is most likely to have suffered a dislocation of his hip replacement. This normally happens with a low impact mechanism; a periprosthetic fracture would usually require more force.
102
**24c.** A 55-year-old female had a total hip replacement carried out 6 months previously. She has constantly struggled with pain and has leakage through the wound. She has a C-reactive protein of 110 and white cell count 12.0. She has attended the A&E today but remains haemodynamically stable. What is the best treatment?
A. Immediate intravenous antibiotics and admission.
B. Admission, observation and aspiration in theatre.
C. Single stage revision total hip replacement.
D. Admission and bone scan.
E. Discharge and review in clinic.
**B. Admission, observation and aspiration in theatre.**
- This is a problem frequently encountered on the orthopaedic ward. If the patient is well, antibiotics should be withheld until samples have been taken. Immediate single stage revision would be unwise in the presence of likely infection. A bone scan would add little as infection is extremely likely with this history. This patient clearly requires investigation and should not be discharged.
