MSK

Question 1

pain in right shoulder and upper arm for 6 weeks. worsens when elevating arm above head

no deformity, tenderness or reduced range of movement. pain on abduction of right shoulder that is worse with the arm in internal rotation and when abduction is resisted. he is treated with ibuprofen

next step in management?

Answer 1

Refer for physiotherapy.

diagnosis = right supraspinatus tendinopathy. no further inestigations required to confirm. can be managed in primary care. general advise and home exercises or physio

Question 2

A 48 year old man has 8 months of a painful, stiff left shoulder. The pain is dull and worse at night. There is no history of trauma. He has type 1 diabetes mellitus.He has reduced passive and active range of movement in the left shoulder with pain at extremes of range of motion. Neck movements are normal. Power and sensation are normal.Investigations:CRP 6
Which is the most likely diagnosis?
A. Adhesive capsulitis
B. Glenohumeral osteoarthritis
C. Polymyalgia rheumatica
D. Rotator cuff tear
E. Subacromial bursitis

UKMLA PPQ

Answer 2

Adhesive capsulitis (frozen shoulder) presents with dull shoulder pain, that often disturbs sleep, followed by stiffness and loss of shoulder mobility. Adhesive capsulitis is unlikely in patients younger than 40 years of age, and patients older than 70 are more likely to have rotator cuff tears or glenohumeral osteoarthritis. Patients with subacromial pathology often give an occupational or athletic history of heavy lifting or repetitive movements, especially above shoulder level. Patients with rotator cuff tendinopathy and subacromial bursitis often complain of activity-related pain and problems performing usual activities. Adhesive capsulitis is more common In diabetics

Question 3

A 40 year old woman has 1 day of a painful, swollen left elbow and fever. She has rheumatoid arthritis and takes methotrexate and infliximab.Her temperature is 38.2°C, pulse rate 100 bpm and BP 119/83 mmHg. The left elbow is swollen and erythematous.Investigations:White cell count 16.4 × 109/L (3.8–10.0)Urea 6.7 mmol/L (2.5–7.8)
Creatinine 98 μmol/L (60–120)
CRP 171 mg/L (<5)Joint aspiration: no organisms on Gram stain, white cell count 2043/μL (<200), mostly neutrophils, no crystals.She is advised to take oral paracetamol.
Which is the most appropriate additional management?

UKMLA ppq

Answer 3

IV flucloxacillin

Question 4

A 24 year old man develops low back pain the day after falling while playing tennis . He is usually well and takes no regular medication. He is a laboratory technician.
Which is the most appropriate advice?

Answer 4

Continue usual activity!,,

Notttt referral for physio.

Short duration acute low back pain in fit person. Therefore most appropriate response would be to continue usual activity and to provide appropriate safety netting advice

Question 5

Acute Gout. patient has chronic kidney disease stage 4. first line management?

Answer 5

oral prednisolone!!

nsaids would be option but CKD

acute gout treatment: oral steroids, NSAIDS and colchicine

Question 6

classic polymyalgia rhuematica symptoms. management?

Answer 6

oral prednisolone!

Question 7

Acute Gout first line treatment

Answer 7

Start naproxen/colchicine - colchicine preferred

Question 8

70 yo. 6 months increasing pain at base of left thumb. No other joint painful. 1st carpometacarpal joint swollen and tender with reduced opposition of thumb. Most likely diagnosis?

Answer 8

Osteoarthritis!!!

6 months not acute so less likely to be gout.

OA fits with joint affected. Not multiple joints so RA unlikely

Question 9

A 73 year old man has 3 months of increasing weakness of his right hand with
reduced sensation of the forearm.
There is wasting of all the intrinsic muscles of the right hand. There is
weakness of finger abduction and adduction, and thumb adduction. Finger
flexion is normal. There is mild altered light touch sensation along the ulnar
aspect of the forearm. The biceps, supinator and triceps reflexes are normal.
The lower limbs and the left arm are normal

where is the most likely site of the lesion causing his symptoms?

Answer 9

T1 nerve root

The intrinsic hand muscle wasting suggests
T1. The normal reflexes and normal other arm are against a cord lesion. The
sensory loss on the forearm excludes median and ulnar nerve lesions. T1
dermatome is often thought to be higher in the arm medially.

Question 10

A 44 year old dentist complains of right elbow pain. He has tenderness over the right lateral epicondyle. You suspect lateral elbow tendinopathy (tennis elbow)./ lateral epicondylytis Which clinical test is likely to reproduce pain?

Answer 10

resisted wrist EXTENSION. and SUPINATION

resisted wrist flexion = for medial epicondyle/golfers elbow

(try moves out on your hand)

empty can test = supraspinatus tendinopathy

Finklestein’s test is a test for tenosynovitis of the 1st extensor compartment at the wrist (De Quervain’s tenosynovitis).

Question 11

polmyositis = weakness rather than pain/muscle aches in polymyalgia rheumatica.

polymyositis = raised CK

Question 12

A 42 year old man comes to see you with swelling at his right elbow. He has a long history of episodes of arthritis affecting his 1st MTP joint, with pain and swelling lasting ~5 days and responding to ibuprofen. More recent episodes have affected his ankles and right knee. Which is the most likely diagnosis?

Answer 12

gout

Gout reflect inflammation caused by deposition of sodium urate crystals, usually within joints but also with in bursae (fluid sacs). It typically first presents at the 1st MTP joint. Crystal formation is favoured by degenerate cartilage and this may be one reason for early involvement of the 1st MTP joint. This patient may have developed an olecranon bursitis explaining the swelling at the right elbow. The transient episodes of inflammation are typical for a crystal arthritis. ‘Flares’ of arthritis in other forms of inflammatory arthritis typically last longer than this.

Question 13

A 65 year old woman has a bone density scan. This shows T scores of -1.8 at the neck of femur, -1.6 at the total hip and -2.3 at the lumbar spine. What is the diagnosis?

Answer 13

osteopenia!!!

A T score above -1.0 is defined as ‘normal bone density’, a T score between -1.0 and -2.5 is defined as ‘osteopenia’ and a T score of -2.5 and below is defined as osteoporosis.

Question 14

fibromyalgia presentation?

Answer 14

widespread pain and on the experience of fatigue/waking unrefreshed/cognitive symptoms/headaches, abdominal pain or depression. These are set out in the 2016 diagnostic criteria. Blood tests and imaging studies will be normal.

Question 15

A 65 year old woman has a bone density scan. This shows T scores of -1.8 at the neck of femur, -1.6 at the total hip and -2.3 at the lumbar spine, with readings of -2.1, -2.1, -2.4 and -2.6 at L1-4 respectively. Which reading do you enter into the WHO FRAX calculator in order to obtain an estimate of fracture risk?

Answer 15

Neck of femur reading (-1.8)

The FRAX calculator uses the neck of femur reading to calculate fracture risk. Readings at the lumbar spine and total hip can be falsely elevated in the presence of degenerative change and so are less reliable as a predictor of fracture.

Question 16

An HLA B27+ve reactive arthritis may follow infection with which three of the following organisms?

Answer 16

chlamydia

Question 17

A 45 year old woman experiences dryness of her eyes. She has aching of her joints and prominent fatigue. Blood tests show that she is positive for anti-nuclear antibody and the ENA screen shows that she is positive for anti-Ro and anti-La antibodies. Which is the most likely diagnosis?

Answer 17

primary sjogrens!!

you would expect +ve dsdna in sle

Question 18

A 23 year old woman is experiencing aching of small joints of her hands, oral ulceration, hair fall and has a facial rash. Which is the most likely diagnosis?

Answer 18

SLE

Question 19

complete week 2 rheum questions medlearn

Answer 19

https://medlearn.imperial.ac.uk/rheumatology-2425/learning-material/practice-questions/week-2/

Question 20

suspected scaphoid fracture, normal imaging management

Answer 20

Wrist splinting and review in 7 days

Question 21

The most common site of metatarsal stress fractures i

Answer 21

2nd metatarsals

Question 22

Investigation most sensitive for lupus

Answer 22

ANA - used as the rule out test as over 99% of people with sle are positive

Dsdna = most specific

Question 23

osgood shlatter disease presentation?

Answer 23

Unilateral (but may be bilateral in up to 30% of people).
Gradual in onset and initially mild and intermittent, but may progress to become severe and continuous.
Relieved by rest and made worse by kneeling and activity, such as running or jumping.

Question 24

xray finding that helps point to psuedogout and not gout?

Answer 24

x-ray: chondrocalcinosis
in the knee this can be seen as linear calcifications of the meniscus and articular cartilage

Question 25

A 45-year-old man presents with a painful swelling on the posterior aspect of his elbow. There is no history of trauma. On examination an erythematous tender swelling is noted. What is the most likely diagnosis?

Answer 25

olecranon bursitis

Question 26

In young adults with septic arthritis, what is the most common organism found?

Answer 26

gonorrhea

Question 27

methotrexate carries a risk of bone marrow suppression. name two drugs that can interact with methotrexate and worsen this

Answer 27

co-trimoxazole

trimethoprim

Question 28

A 45-year-old Afro-Caribbean lady presents to the dermatology department with several painful raised lesions on her shins. The only past medical history of note is asthma. She uses a salbutamol inhaler as required and takes the oral contraceptive pill.

raised serum calcium

diagnosis?

Answer 28

sarcoidosis

patient has erythema nodosum

Question 29

name and describe each point on the salter harris system

Answer 29

Type Injury pattern
I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphysis to include the joint
IV Fracture involving the physis, metaphysis and epiphysis
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)

bone from top down = (epiphysis), physis or growth plate, metaphysis, diaphysis

Question 29

A 53-year-old man presents to the ED with a three-week history of right foot pain and swelling. He stepped on a nail at his construction site a month ago but did not seek medical attention initially as he cleaned the wound at home.

On examination, there is redness and localised swelling of the right foot, worse over the plantar surface. There is tenderness on palpation and severe pain upon movement. The wound at the site of injury appears to be well-healed. Blood test show high white cell count

Ix to confirm the diagnosis?

Answer 29

MRI

wound has healed but still pain and inlammation -> Worried about osteomyelitis!!!

Question 30

pseudogout risk factors?

Answer 30

haemochromatosis!!!
hyperparathyroidism!!!= hypercalcemia!!!
low magnesium, low phosphate
acromegaly, Wilson’s disease

Question 31

Joint aspirate in rheumatoid arthritis shows a high WBC count, predominantly PMNs. Appearance is typically yellow and cloudy with absence of crystals

Septic arthritis would have similar joint aspirate but the patient would be systemically unwell and it would likely have been precipitated by trauma.

Question 32

A 64-year-old patient with psoriasis, hypothyroidism and psychotic depression presents to you with painful aphthous-like ulcers for the past 3 weeks since starting a new medication.

Which medication is most likely to be causing their symptom?

Answer 32

methotrexate!!! = mucositis

indicated for psoriasis

Question 33

Local muscle strengthening exercises and general aerobic fitness is an important component of knee and hip osteoarthritis

Question 34

ankylosing spondylitis first line treatment? note it can also present with periperal joint treatment

ankylosing spondylitis clinical exam findings

other features of this condition?

Answer 34

NSAIDs

schobers test <5cm

reduced lateral flexion
reduced forward flexion
reduced chest expansion!!!

the ‘A’s
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
peripheral arthritis

Question 35

A 26-year-old woman has 3 weeks of shortness of breath and fatigue on exertion and a new skin rash over her face and nose. During this time, she has felt generally unwell and has had a dry cough and malaise. She has never smoked.

She has cervical and submandibular lymphadenopathy and dark indurated plaques are noted around the eyes, nose, and cheeks.

Blood tests show:

Hb 110 g/L (115 - 160)
Platelets 260 * 109/L (150 - 400)
WBC 5.3 * 109/L (4.0 - 11.0)
Na+ 141 mmol/L (135 - 145)
K+ 4.5 mmol/L (3.5 - 5.0)
Calcium 2.8 mmol/L (2.1 - 2.6)
Urea 5.6 mmol/L (2.0 - 7.0)
Creatinine 180 µmol/L (55 - 120)
Creatine kinase 105 IU/L (25-200)
ESR 45 mm/hr (< 18)

What is the most likely diagnosis?

Answer 35

sarcoidosis!!!

• the facial rash is lupus pernio, also hypercalcemia

sle rash is malar and butterfly shaped and spares nasolabial folds

Question 36

sarcoidosis management?

Answer 36

oral prednisolone
is first-line in patients with stage 2/3 sarcoidosis who are also symptomatic, in patients with hypercalcaemia, or in patients with eye, heart, or neuro involvement.

none of these symptoms/asymptomatic = no

Question 37

trauma

On examination, there is some bruising to the lateral aspect of his right forearm, with no obvious deformities and good tone, power and range of movement and in the fingers, wrist and elbow joints. Sensation is in-tact throughout the limb, although he reports pins and needles in his fingers. When assessing tone, the patient is in visible discomfort, which is not reproduced to the same extent as when assessing power.

An x-ray of his right arm is clear

next step in management?

Answer 37

refer to orthopaedic surgeons

compartment syndrome!!!

pain out of proportion, paraesthesia. may also cause pulselessness

Question 38

most common reason total hip replacements need to be revised?

other complications of hip replacements?

Answer 38

aseptic loosening (most common reason for revision )

leg length discrepancy!!!
posterior dislocation!!!!
may occur during extremes of hip flexion
typically presents acutely with a ‘clunk’, pain and inability to weight bear
on examination there is internal rotation and shortening of the affected leg

perioperative”
venous thromboembolism
intraoperative fracture
nerve injury
surgical site infection

Aseptic loosening

Question 39

A 50-year-old woman with chronic kidney disease presents with an acutely painful joint. On examination, the joint is red and swollen. The patient describes waking up with the pain, and it worsens to 9/10 severity over the course of the day. Despite simple analgesia, the pain has not improved.

temperature is 39 degrees

given the likely diagnosis, what joint is most likely affected?

Answer 39

knee!!! = septic arthritis

Question 40

first-line investigation for a suspected osteoporotic vertebral fracture

Answer 40

xray spine

Question 41

patient presents with signs of septic arthritis, next step in management?

Answer 41

synovial fluid sampling!!!!
(also blood cultures, and joint imaging but above is most important)

oral flucloxacillin is later

Question 42

A 32-year-old mother of three-month-old infant presents to the outpatient clinic with a complaint of pain on her right wrist for one week. The pain is on the radial side of the wrist, and there is tenderness over the radial styloid process.

What is the most likely diagnosis?

Answer 42

De Quervain’s tenosynovitis

Finkelstein’s test is positive (on grasping the patient’s thumb and abducting the hand to the ulnar side, there is pain over the radial styloid process).

meanwhile scaphoid fracture Symptoms includes pain at the base of the thumb,

Question 43

scaphoid fracture management?

Answer 43

non-displaced fractures of the scaphoid and distal pole fractures can be managed conservatively with a cast for 6 weeks.

Displaced scaphoid fractures generally require surgical fixation, and

all proximal pole fractures require surgical fixation due to the risk of the development of avascular necrosis.

In instances where clinical suspicion for a scaphoid fracture exists but no abnormality is evident on imaging, immobilisation using a Futuro splint and orthopaedic review in 7 days

Question 44

achilles tendon rupture imaging?

Answer 44

ankle ultrasound!!!

Question 45

A 28-year-old man has 3 days of severe right knee pain. He has rheumatoid arthritis and has had urethral discharge over the last week since having unprotected sexual intercourse.

He appears diaphoretic, with a temperature of 38.6ºC, pulse of 95 bpm, and a blood pressure of 120/74 mmHg. He cannot weightbear on the right side. The right knee is swollen, erythematous, warm, and tender on palpation.

Synovial fluid aspiration results:

Appearance yellow and cloudy
Gram stain negative
Crystals none
WBC 58,000 /mm³, predominantly neutrophils (< 200)

Which diagnosis is most likely?

Answer 45

septic arthritis!!!!!

gram staining is negative in 30-50% of cases of septic arthritis!!!!

reactive athritis would not have fever!!!!! and would present several days to weeks after an infection!!! you would also have eye symptoms

Question 46

ulcer with surrounding erythema

was treated with oral flucloxacillin and the cellulitis improved but after a week of treatment the ulcer was still discharging and on examination there was a tender area of swelling over the ulcer.

What is the most likely explanation?

Answer 46

The patient has a collection of pus which requires surgical drainage

Question 47

TNF alpha inhibitors are about to be commenced for rheumatoid arthritis

Which investigation would you perform before the commencement of treatment?

Answer 47

chest x ray - risk of TB reactivation

Question 48

plantar fasciitis management

Answer 48

initially with rest, stretching and weight loss if overweight

Question 49

acute flares of rheumatoid arthritis are managed with?

Answer 49

Oral or IM methylprednisolone

Question 50

what is an earlier and more common sign on X-ray if ankylosing spondylitis?

Answer 50

Syndesmophytes!!

bamboo spine is late and uncommon

Question 51

most common mechanism of ankle sprain? (pain, swelling, difficulty weight bearing)

Answer 51

inversion of foot

Question 52

An 82-year-old woman with long-standing rheumatoid arthritis presents with a history of recurrent chest infections over the past 6 months. On examination she is found to have splenomegaly. Her current medications include methotrexate and sulphasalazine. Blood results demonstrate:

Hb 96 g/l
WBC 3.6 * 109/l
Neuts 0.8 * 109/l
Lymphs 1.6 * 109/l
Eosin 0.6 * 109/l

What is the most likely cause of the neutropenia?

Answer 52

feltys syndrome!!!

methotrexate would not cause splenomegaly

Question 53

when suspecting osteoporosis in a man, what is a key hormone to check?

Answer 53

testosterone - Hypogonadism is a common cause of osteoporosis

Question 54

An 82-year-old female is brought to the emergency department with an extremely painful right thigh. She also has an indwelling catheter and has recently attended her GP due to suffering from recurrent urinary tract infections (UTIs). On examination, she is febrile, with extreme tenderness over the right thigh and is unable to move the right knee due to pain. Blood and bone cultures both return a positive finding and a diagnosis of osteomyelitis is made.

What is the likely causative organism?

Answer 54

s aureaus from skin affecting catheter

Question 55

In polymylagia rheumatica, there is Normal power on resisted movements of shoulder and hip!!! - There is no true weakness of limb girdles in polymyalgia rheumatica on examination. Any weakness of muscles is due to myalgia (pain inhibition)

Question 56

osteoarthritis first line treatment? eg for knee

Answer 56

Topical ibuprofen!!!

oral is second line

help with weight loss, given advice about local muscle strengthening exercises

intra-articular steroid injections may be tried if standard pharmacological treatment is ineffective
patients should be aware that they only provide short-term relief (2-10 weeks)
if conservative methods fail then refer for consideration of joint replacement

Question 57

undisplaced fracture of patella management?

Answer 57

Conservative management with knee immobilisation!!!

meanwhile Arthroscopy is useful for recurrent patella dislocations and meniscal/ligamentous damage

ORIF is indicated when there is failure of the extensor mechanism, open fractures or fracture displacement.

Question 58

which antibiotic has a risk a risk of achilles tendon rupture?

Answer 58

Ciprofloxacin. Fluoroquinolone antibiotics,

Question 59

how often is methotrexate given for RA?

Answer 59

WEEKLY!!!

not daily

Question 60

There is a fracture of the distal radius involving the growth plate and the distal portion of the diaphysis. There is no involvement of the distal epiphysis.

What type of Salter-Harris fracture does this describe?

Answer 60

2

Question 61

He experienced his first gout attack five weeks ago in his right big toe, which was treated successfully with colchicine. Currently, he is asymptomatic. His regular medications are lisinopril and metformin and he is no longer taking colchicine. Investigations show:

Uric acid 0.84 mmol/L (0.18 - 0.48)

What is the most appropriate management?

Answer 61

Initiate allopurinol with colchicine immediately -NSAID or colchicine ‘cover’ should be used when starting allopurinol

Question 62

The best way to remove a tick is using fine-tipped tweezers, grasping the tick as close to the skin as possible and pulling upwards firmly

Question 63

what are the x ray findings in rheumatoid arthritis?

Answer 63

loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation

Question 64

A 14-year-old boy jumps off a 10 foot wall and lands on both feet. An x-ray shows a bimalleolar fracture of the right ankle

diagnosis?

Answer 64

potts

Question 65

A 22-year-old drunk man is involved in a fight. He hurts his thumb when he punches his opponent.

Answer 65

Bennett’s -Intra-articular fracture of the first carpometacarpal joint

Question 66

Galeazzi fracture?

Answer 66

Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow

Question 67

Monteggia’s fracture?

Answer 67

Dislocation of the proximal radioULNAR joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability

Question 68

Barton’s fracture?

Answer 68

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist

Question 69

Achilles tendonitis management: rest, NSAIDs, and physio if symptoms persist beyond 7 days

Question 70

A 68-year-old woman presents to the GP with severe back pain after a minor fall. Imaging studies have confirmed a vertebral fracture. She has never undergone bone density testing but reports a family history of osteoporosis.

What is the most appropriate next step in management?

A 67-year-old woman is seen in clinic for a health check. Her history includes a wrist fracture 6 years ago and hypertension. Her BMI is 18.3 kg/m², she experienced menopause at 51 years old, and she smokes 15 cigarettes daily.

On examination, her vital signs are normal and she currently feels well. A FRAX score is calculated and returns as 12%.

Which option is the best next step?

Answer 70

Initiate bisphosphonate therapy immediately

A postmenopausal woman who’s had an osteoporotic vertebral fracture should be started on a bisphosphonate straight away - don’t wait for a DEXA scan

If a patient is deemed high-risk based on a QFracture or FRAX score they should have a DEXA scan to assess bone mineral density (BMD)

Question 71

Undisplaced fractures of the scaphoid waist are typically managed with?

Answer 71

Cast for 6-8 weeks

Question 72

criteria used to assess the probability of septic arthritis in children?

Answer 72

kocher criteria

Child-Pugh score, meanwhile, is utilised to ascertain the severity of cirrhosis

Question 73

lyme disease investigation?

Answer 73

Antibody titres for Borrelia burgdorferi

aka ELISA

Question 74

He landed awkwardly on his arm and was found to have a fracture. This was reduced but the patient is still experiencing extreme pain, particularly on passive stretching. His arm appears swollen and he is complaining of tingling in his hand and forearm.

Which fracture is most commonly associated with the condition he is experiencing?

Answer 74

Supracondylar fracture

Compartment syndrome is most commonly associated with supracondylar and tibial shaft fractures

Question 75

x-ray performed which reveals a transverse fracture of the radius 1.5cm proximal to the radio-carpal joint as well as posterior displacement of the distal fragment. Examination of the elbow joint reveals no significant signs.

What type of fracture has this patient sustained?

Answer 75

COLLES FRACTURE

as radiocarpal joint not radioulnar joint

Question 76

A 4-year-old girl presented with a painful left little finger after a door was closed on it. A resulting radiograph shows a fracture line that passes through the metaphysis, growth plate, and epiphysis. What type of fracture is this?

Answer 76

SH 4

Question 77

A 34-year-old woman to the emergency department with left flank pain and haematuria as well as deep pain in her knees and hips. She reports feeling generally unwell over the past 2 months, with increasing shortness of breath, a non-productive cough and constipation. Although she hasn’t weighed herself, she feels her clothes hang looser and she has regularly felt feverish over the same period. Her family also states she has had periods of confusion.

A chest x-ray is performed and bilateral hilar shadowing is observed, the rest of the lung fields appear normal.

What is the most likely diagnosis?

Answer 77

sarcoidosis!!

The patient has presented with clinical features that are suggestive of hypercalcaemia. The abdominal pain and haematuria could indicate the presence of a renal calculus, while the deep-seated pain she is experiencing is likely to be bone pain. She is also experiencing constipation and confusion, further symptoms of hypercalcaemia.

can also cause weight loss

Question 78

A diagnosis of polymyalgia rheumatica is suspected and the patient is started on prednisolone. After 3 weeks, her symptoms have not improved.

What is the most appropriate next step?

Answer 78

Patients with polymyalgia rheumatica typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis

Question 79

A 35-year-old runner presents with heel pain. On examination, there is diffuse tenderness which is worse on the medial aspect of the heel bed. Although the patient has stopped running for the past week, the pain is aggravated by being on their feet at work all day. Pain is worse when you ask them to walk on their toes. What is the most likely diagnosis?

Answer 79

plantar fasciitis
. Pain in Achilles tendonitis is at the calcaneal insertion of the tendon or further up the tendon depending on the area affected

Question 80

A 24-year-old man attends the emergency department following a knee injury. He explains he was playing a basketball match when he heard a loud ‘popping’ sound and fell to the floor in extreme pain from his right knee. He could not continue playing. The knee felt like it would ‘give way’ with any weight-bearing.

On inspection, the knee appears swollen.

What is the most likely diagnosis?

Answer 80

ACL injury - loud pop

Question 81

anagement for intertrochanteric (extracapsular) proximal femoral fracture?

Answer 81

dynamic hip screw

if reverse oblique, transverse or subtrochanteric fractures: intramedullary device

Question 82

Most patients with sarcoidosis get better even without treatment

Question 83

A 45-year-old lady, with a past medical history of rheumatoid arthritis, is scheduled to have a laparoscopic cholecystectomy. What imaging should be performed pre-operatively?

Answer 83

Anteroposterior and lateral cervical spine radiographs

subluxation is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression. Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication, ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation.

Question 84

She has been on oral alendronate for five years after being diagnosed with osteoporosis following a fragility fracture of her left wrist. She has had no further fractures since starting alendronate. Her clinician is considering her ongoing management based on the latest guidelines.

She has a past medical history of deep venous thrombosis (DVT) 15 years ago. Alongside her alendronate, she also takes vitamin D and calcium supplements.

Which management option is the most appropriate next step?

Answer 84

Reassess her using frax tool

In osteoporosis, 10 year fracture risk should be reassessed after 5 years of treatment with alendronate

Question 85

In children the most common site where osteomyelitis occurs in a long bone is the?

Answer 85

Metaphysis!

Question 86

Lupus 1st line treatment?

Answer 86

Hydroxychloroquine

Question 87

A 40-year-old woman complains of a permanent ‘funny-bone’ sensation in her right elbow. This is accompanied by tingling in the little and ring finger. Her symptoms are worse when the elbow is bent for prolonged periods. What is the most likely diagnosis?

Answer 87

Cubital tunnel syndrome!- compression of ulnar nerve

Lateral and medial epicondilytis do not present with tingling in fingers

Radial tunnel syndrome =
compression of the posterior interosseous branch of the radial nerve.symptoms are similar to lateral epicondylitis making it difficult to diagnose
however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
symptoms may be worsened by extending the elbow and PRONATING the forearm

Median nerve entrapment syndrome refers to compression or irritation of the median nerve, often at the level of carpal tunnel in the wrist. Symptoms include numbness, tingling, and pain primarily affecting the thumb, index finger, middle finger and half of ring finger.

Question 88

Region T-score
Lumbar spine -0.7
Femoral neck -1.2

What is the most accurate interpretation of these results?

Answer 88

Osteopenia as T score less than -1

Question 89

patient with pain swelling and erythema of knee joint. Knee X-ray given and shows white deposits in the joint space between the bones. Most likely diagnosis?

Answer 89

Pseudo gout!!!

Question 90

meniscal tear is typically caused by twisting or pivoting. Meniscal tears result in a variety of symptoms including pain (which is often intermittent), locking, catching, and the knee giving way. Swelling usually occurs but develops several hours after the injury. On examination, there is well-localised pain over the joint line (anteromedial or anterolateral), along with varying levels of swelling and reduced mobility.

Whilst the anterior cruciate ligament (ACL) may also be injured by sudden twisting movements, an injury of the ACL typically results in a popping noise/popping sensation and is followed by RAPID swelling of the knee and an inability to return to full activity. On examination, there is lateral knee and joint line tenderness.

Question 91

A 54-year-old woman presents to her GP with 3 weeks of lethargy and painful finger. She has also found a soft lump at the base of her right calf and asks for this to be reviewed. She denies any trauma, fever, or weight loss. She has a past medical history of systemic lupus erythematosus.

On examination, the right index finger proximal interphalangeal joint is erythematous and swollen. She can move the joint independently, but range of motion is limited by pain.

Arthrocentesis shows:

Appearance yellow fluid
Crystal formation negative
Gram stain negative
Leucocytes 40,000/µL
Cytology polymorphonuclear neutrophil predominance

What is the likely diagnosis?

Answer 91

Despite this not being a typical history of rheumatoid arthritis, the arthrocentesis findings and the patient’s history of constitutional symptoms, an Achilles tendon nodule and past medical history of systemic lupus erythematosus (SLE) all support the diagnosis of rheumatoid arthritis.

Question 92

Scaphoid fracture physical signs

Answer 92

Point of maximal tenderness over the anatomical snuffbox
2. Wrist joint effusion
3. Pain elicited by telescoping of the thumb (pain on longitudinal compression)!!!
4. Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
5. Pain on ULNAR deviation of the wrist!

Question 93

How many different non-steroidal anti-inflammatory drugs must this patient have failed to respond to before he can be started on anti-TNF alpha inhibitors, in someone with predominantly axial disease in ankylosing spondilitis?

Answer 93

2

Question 94

CKD is a risk factor for osteoporosis!!! name some others

Answer 94

history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking

Question 95

Which of the following neurovascular structures is most likely to be compromised by a scaphoid fracture?

Answer 95

Dorsal carpal arch of the radial artery

Question 96

in septic arthritis how long should patients recieve antibiotics?

Answer 96

4-6 weeks

Question 97

what can be monitored in Rhuematoid arthritis?

Answer 97

Complement levels are useful for monitoring her SLE flare - the levels are usually low during active disease

ESR is generally used
during active disease the CRP may be normal - a raised CRP may indicate underlying infection

Question 98

what is the marker of the worst/ poor prognosis in rhuematoid arthritis?

Answer 98

Anti-CCP antibodies
49%

Question 99

in lyme disease, if doxycyline is contraindicated, what do you give?

Answer 99

Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)

ceftriaxone if disseminated disease -> cardiovascular, neurological

Question 100

methotrexate toxictiy treatment?

Answer 100

folinic acid

Question 101

Indications for corticosteroid treatment for sarcoidosis are?

Answer 101

hypercalcemia!!! uveitis
parenchymal lung disease, and neurological or cardiac involvement

Question 102

methotrexate is administered weekly not daily

Question 103

A hand X-ray reveals a fracture of the proximal pole of a carpal bone.

What is the most appropriate next step in her management?

Answer 103

Refer for urgent surgical screw fixation

Question 104

A 46-year-old man is seen in clinic following treatment for a hip fracture after a fall from standing. He has rheumatoid arthritis and chronic gastrointestinal problems, including diarrhoea, bloating, and weight loss.

He appears pale and thin, with a BMI of 18.0 kg/m². A dual-energy x-ray absorptiometry (DEXA) scan of the hip reveals a T-score of -3.0.

Which option is the best next step?

Answer 104

Perform blood tests to exclude secondary causes!!!

Since the patient already has a confirmed osteoporosis diagnosis via DEXA scan, calculating the FRAX score is not necessary at this stage.

Prescribing denosumab is premature without first evaluating secondary causes of osteoporosis.

Question 105

Felty’s syndrome is defined as RA, splenomegaly and?

Answer 105

low wcc!!!