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Question 1
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A 28-year-old woman presents with painful genital ulceration. She reports that these attacks have been recurrent over the past 4 years. She has been treated previously with oral acyclovir but this has had little effect on the duration of her symptoms. Over the past year, she has noticed almost weekly attacks of mouth ulcers that heal slowly. Past medical history is significant for treatment of thrombophlebitis two years ago. Which of the following is the most likely diagnosis?
Your Answer: Behcet's syndrome
Explanation:Behçet disease is a rare vasculitic disorder that is characterized by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis. The systemic manifestations can be variable. Ocular disease has the greatest morbidity, followed by vascular disease generally from active vasculitis. Cutaneous manifestations can occur in up 75% of patients with Behcet disease and can range from acneiform lesions, to nodules and erythema nodosum. GI manifestations can be severe. Differentiating Behçet disease from active inflammatory bowel disease can be clinically difficult. Herpes would have ideally responded to acyclovir. Sarcoidosis does not have genital and oral ulcerations.
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This question is part of the following fields:
- Musculoskeletal System
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Question 2
Correct
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A 22-year-old man who has recently returned from a trip to Far East presents with sore eyes and symmetrical joint pain in his knees, ankles and feet. Labs reveal an elevated ESR. The synovial fluid aspirate is sterile and has a high neutrophil count. What is the most likely diagnosis?
Your Answer: Reactive arthropathy
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 3
Correct
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An 18-year-old boy, thin with a tall stature, and a high arched palate arrives at the hospital with a spontaneous pneumothorax. He is accompanied by his brother who has a similar appearance. You suspect Marfan's Syndrome.
The gene encoding which of the following proteins is defective in this condition?Your Answer: Fibrillin-1
Explanation:A variety of proteins compose the structure of microfibrils, the most prominent of which are the two fibrillins. Fibrillin-1 a scaffolding protein is encoded by FBN1 on human chromosome 15q21 and fibrillin-2 is encoded by FBN2 on 5q23. Mutations in FBN1 produce Marfan syndrome, a pleiotropic autosomal dominant connective tissue disorder with prominent manifestations in the skeleton, eye and cardiovascular system. A number of conditions related to Marfan syndrome are also due to FBN1 mutations.
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This question is part of the following fields:
- Musculoskeletal System
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Question 4
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A 32-year-old female is diagnosed with SLE based on her complaints of polyarthralgia, mouth ulcers and ANA positivity. Labs reveal normal urinalysis, urea and electrolytes. ESR is 90mm in the first hour. How will you manage this patient?
Your Answer: Hydroxychloroquine 200 mg/day
Explanation:Hydroxychloroquine is used in the management of SLE as it prevents disease progression and has relatively mild side effects, for instance headache, nausea etc. Its use reduces the usage of corticosteroids. It is particularly effective when the disease is less severe and there is no organ involvement. Cyclophosphamide and prednisolone are indicated in cases of renal, neurological and lung involvement.
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This question is part of the following fields:
- Musculoskeletal System
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Question 5
Correct
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A 42-year-old female presents with a funny bone sensation in her right elbow that is accompanied by numbness and tingling in the 4th and 5th digits. The symptoms are aggravated when the elbow is bent for a prolonged period. Which of the following explains the most likely diagnosis?
Your Answer: Cubital tunnel syndrome
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 6
Incorrect
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A 60-year-old diabetic female patient presented with spasmodic pain in her left thigh and calf muscle. During examination the doctor noticed that the femoral and popliteal pulses were absent on the left side. Which of the following vessels is most probably occluded?
Your Answer: Aorto-Iliac
Correct Answer: External Iliac Artery
Explanation:The external iliac artery supplies both the thigh and calf muscles. The absence of pulses in femoral and popliteal vessels indicates the obstruction of the external iliac artery.
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This question is part of the following fields:
- Musculoskeletal System
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Question 7
Incorrect
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Which of the following statements is incorrect regarding etanercept?
Your Answer: Is an inhibitor of TNF-alpha
Correct Answer: Must be given intravenously
Explanation:Etanercept is a TNF receptor fused with human immunoglobulin. It binds to TNF-alpha preventing it from binding to its normal receptor. Thus, inhibiting it competitively. It is used for treatment of rheumatoid arthritis in adults when traditional treatments fail. When injected subcutaneously, it is accompanied with skin reactions and urticaria. It should be given intravenously. Serious blood disorders and demyelination have also been associated.
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This question is part of the following fields:
- Musculoskeletal System
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Question 8
Incorrect
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A 35-year-old female, known case of antiphospholipid syndrome, arrives at the clinic due to a swollen and painful left leg. Doppler ultrasonography confirms the diagnosis of a deep vein thrombosis. She was previously diagnosed with DVT 4 months back and was on warfarin therapy (target INR 2-3) when it occurred. How should her anticoagulation be managed?
Your Answer: Add in life-long low-dose aspirin
Correct Answer: Life-long warfarin, increase target INR to 3 - 4
Explanation:If the INR in the range of 2-3 has still resulted in thrombosis, the target INR is increased to 3-4. However, because the risk of bleeding increases as the INR rises, the INR is closely monitored and adjustments are made as needed to maintain the INR within the target range.
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This question is part of the following fields:
- Musculoskeletal System
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Question 9
Incorrect
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A 55-year-old male presented with a mass in his right groin. On examination there was a pulsatile mass just below the midpoint of the inguinal ligament. Which of the following is the most probable diagnosis?
Your Answer: Femoral aneurysm
Correct Answer: Femoral hernia
Explanation:Midpoint of the inguinal ligament is halfway between the pubic tubercle and the anterior superior iliac spine (the two attachments of the inguinal ligament). The opening to the inguinal canal is located just above this point. The femoral artery is at the mid-inguinal point which is halfway between the pubic symphysis and the anterior superior iliac spine. As the mass is at the midpoint of the inguinal ligament, the most probable answer is a femoral hernia. A femoral aneurysm is also a possibility.
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This question is part of the following fields:
- Musculoskeletal System
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Question 10
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A 32-year-old complains of pain in her hands bilaterally. Which of the following symptoms would point towards an inflammatory joint disease such as rheumatoid arthritis?
Your Answer: Marked stiffness for more than an hour in the mornings
Explanation:In rheumatoid arthritis (RA), clinical symptoms of joint stiffness, pain, and functional disability are commonly most severe in the early morning. These symptoms closely follow the circadian rhythm of the pro-inflammatory cytokine, interleukin (IL)-6. In RA, the increase in nocturnal anti-inflammatory cortisol secretion is insufficient to suppress ongoing inflammation, resulting in the morning symptoms characteristic of RA. Established diagnostic criteria for RA include prolonged morning stiffness that could last up to an hour. Loss of joint mobility, pain, malaise and swelling of finger joints are features that are not specific to rheumatoid arthritis, and are found in many other conditions.
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This question is part of the following fields:
- Musculoskeletal System
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Question 11
Incorrect
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A 23-year-old male presents with a history of lower back pain for the last one year. Presence of which of the following features most likely points towards ankylosing spondylitis?
Your Answer: Limited lumbar spine motion on physical examination
Correct Answer: Bilateral erosion of sacroiliac joints on X-ray
Explanation:Bilateral erosions of the sacroiliac joints on pelvic radiographs of patients with ankylosing spondylitis are an important feature of the modified New York classification criteria. Although HLA-B27 is commonly associated with AS, it can also be found in normal individuals. Back stiffness is worse in the morning and gets better as the day progresses. Tenderness and limited lumbar motion can be associated with other spine problems as well and is not characteristic of rheumatoid arthritis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 12
Correct
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Psoriatic arthropathy most commonly presents with which of the following types of arthritis?
Your Answer: Peripheral asymmetric oligoarthropathy
Explanation:Most patients with psoriatic arthritis present with monoarthritis or asymmetric oligoarthritis. The most common form of the disease is the one involving a few joints of the peripheral skeleton with a distinct asymmetry of symptoms. Involvement of the smaller joints of the hands and feet, especially distal interphalangeal joints, seems to be a characteristic feature. Arthritis mutilans is a rare and severe complication of psoriatic arthritis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 13
Incorrect
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In the case of absent tibial and popliteal pulses, which artery is most likely injured?
Your Answer: Dorsalis pedis
Correct Answer: Femero-popliteal
Explanation:The popliteal artery is the continuation of the femoral artery. It passes deeply, through the adductor hiatus and continues through the popliteal fossa to reach the lower border of the popliteus muscle, where it branches into the anterior and posterior tibial arteries.
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This question is part of the following fields:
- Musculoskeletal System
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Question 14
Correct
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An 81-year-old woman had fallen down in her house. She is now unable to walk. An x-ray was done on her left hip joint, which showed a fracture in the neck of the femur. Which nerve is most likely to be injured?
Your Answer: Sciatic nerve
Explanation:Femoral neck fractures are common injuries that most often result from low-energy falls in the elderly; however, they also can occur in young patients as a result of high-energy mechanisms
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This question is part of the following fields:
- Musculoskeletal System
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Question 15
Incorrect
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A 26-year-old male presents with right sided elbow and wrist pain and left sided knee and ankle pain that has persisted for about two weeks. He recently returned from a trip to Thailand that last for two weeks. The patient admits to having unprotected sex while on holiday. Examination reveals swelling and tenderness of tendons around joints but no inflammation of the joints. A vesiculopustular skin rash is also observed. What is the most likely cause?
Your Answer: Reactive arthritis
Correct Answer: Gonococcal arthritis
Explanation:Patients with disseminated gonococcal arthritis may present with dermatitis-arthritis syndrome (60%) of with localized septic arthritis. (40%). Arthritis-dermatitis syndrome includes the classic triad of dermatitis, tenosynovitis, and migratory polyarthritis. Gout usually involves a singe joint and does not cause vesicopustular skin rash. Reactive arthritis has ocular symptoms (conjunctivitis), urethritis, and arthritis. Fungal arthritis occurs rarely and it may occur after a surgical infection or fungal spread hematogenously. it presents with tender, red, hot and swollen joint with loss of range of motion.
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This question is part of the following fields:
- Musculoskeletal System
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Question 16
Incorrect
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A 33-year-old male presented with complaints of arthritis involving the knee joint. O/E the overlying joint was red, swollen and tender. The patient also gave a history of constipation and noting a change in his shoe size. The most likely diagnosis in this patient would be?
Your Answer: Ankylosing spondylitis
Correct Answer: Pseudogout
Explanation:Pseudogout is caused by the deposition of calcium pyrophosphate crystals and effects the large joints, as compared to gout where the small joints are usually involved. The joint tends to be tender, swollen and warm, giving a picture of cellulitis. Pseudogout has an association with hypothyroidism, therefore symptoms of dry skin and constipation can also be present.
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This question is part of the following fields:
- Musculoskeletal System
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Question 17
Incorrect
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A 22-year-old man is being evaluated for chronic lower backache. Which of the following would most strongly point towards the diagnosis of ankylosing spondylitis?
Your Answer: Loss of thoracic kyphosis
Correct Answer: Reduced lateral flexion of the lumbar spine
Explanation:Ankylosing spondylitis (spondylarthritis) is a chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine. Males are disproportionately affected and upwards of 90% of patients are positive for the HLA-B27 genotype, which predisposes to the disease. The most characteristic early finding is pain and stiffness in the neck and lower back, caused by inflammation of the vertebral column and the sacroiliac joints. The pain typically improves with activity and is especially prominent at night. Other articular findings include tenderness to percussion and displacement of the sacroiliac joints (Mennell’s sign), as well as limited spine mobility, which can progress to restrictive pulmonary disease.
The most common extra-articular manifestation is acute, unilateral anterior uveitis. Diagnosis is primarily based on symptoms and x-ray of the sacroiliac joints, with HLA-B27 testing and MRI reserved for inconclusive cases. There is no curative treatment, but regular physiotherapy can slow progression of the disease. Additionally, NSAIDs and/or tumour necrosis factor-? inhibitors may improve symptoms. In severe cases, surgery may be considered to improve quality of life. The spine adopts a bamboo shape, not lordosis. The pain usually improves as the day progresses. leg raise test causes pain in cases of meningitis etc not in this case. -
This question is part of the following fields:
- Musculoskeletal System
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Question 18
Correct
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A 28-year-old female with a history of psoriatic arthritis would most likely have which of the following hand conditions?
Your Answer: Nail dystrophy
Explanation:Nail dystrophy (pitting of nails, onycholysis, subungual hyperkeratosis), dactylitis, sausage shaped fingers are most commonly seen with psoriatic arthropathy. There is asymmetric joint involvement most commonly distal interphalangeal joints. Uveitis and sacroiliitis may also occur. Arthritis mutilans may occur but is very rare. Cutaneous lesions may or may not develop. When they do, its usually much after the symptoms of arthritis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 19
Correct
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A 75-year-old gentleman sustained an injury to his arm after falling on outstretched hands. An X-ray confirms the fracture of the distal radius with backward shift of the distal fragment. The name given to this kind of deformity is?
Your Answer: Dinner fork deformity
Explanation:Dinner fork deformity is the name given to the fracture of distal radius, in which the distal fragment is dorsally angulated, displaced and sometimes impacted. Coxa vara is the hip deformity when angle between the head and shaft of the femur is reduced to more than 120 degree. A garden fork deformity is a reversed Colles fracture.
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This question is part of the following fields:
- Musculoskeletal System
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Question 20
Incorrect
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A 28-year-old male arrives at the clinic complaining of fever, arthralgia and urethritis. On examination, the ankle is swollen and there is a pustular rash on the dorsal foot. What is the most likely diagnosis?
Your Answer: Reactive arthritis
Correct Answer: Disseminated gonorrhoea
Explanation:DGI presents as two syndromes: 1) a bacteremic form that includes a triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis and 2) a septic arthritis form characterized as a purulent arthritis without associated skin lesions. Many patients will have overlapping features of both syndromes. Time from infection to clinical manifestations may range from 1 day to 3 months. There is no travel history and the rash of Lyme disease is not purulent. Reactive arthritis presents with conjunctivitis, urethritis and arthritis usually with a red hot tender and swollen joint.
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This question is part of the following fields:
- Musculoskeletal System
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Question 21
Correct
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A 55-year-old woman presents with drooping on the left side of her mouth, hearing defect, and partial in-coordination of movements and loss of sensation over her entire face. She is diagnosed with multiple sclerosis. What is the most likely anatomical site affected?
Your Answer: Brain stem
Explanation:Cranial nerve 5, 7, and 8 involvement suggest a lesion in the brainstem.
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This question is part of the following fields:
- Musculoskeletal System
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Question 22
Correct
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A 31-year-old female complains of bilateral proximal muscle weakness. There is marked blanching of fingers especially in response to cold weather. Lab results are as follows:
Anti Jo-1: positive
ANA: positive
CK: 2000 U/L
ESR: 60mm/hr
EMG: myopathic changes
Presence of which of the following signifies the worst prognosis?Your Answer: Interstitial lung disease
Explanation:Polymyositis is an inflammatory disorder causing symmetrical, proximal muscle weakness. It is thought to be a T-cell mediated cytotoxic process directed against muscle fibres. It may be idiopathic or associated with connective tissue disorders. It may also be associated with malignancy for example small cell lung carcinoma.
Dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids.
It typically affects middle-aged, female: male 3:1. Features include proximal muscle weakness +/- tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia, dysphagia, dysphonia. Investigations: elevated creatine kinase, other muscle enzymes (lactate dehydrogenase (LD), aldolase, AST and ALT) are also elevated in 85-95% of patients, EMG, muscle biopsy. Anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever. Interstitial lung disease plays a major role in morbidity and mortality in patients with polymyositis and is considered a major risk factor for premature death in patients with myositis. -
This question is part of the following fields:
- Musculoskeletal System
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Question 23
Incorrect
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A 26-year-old male presents with a history of fever and pain in the right lower thigh for one month. On examination the lower one third of the thigh is red, hot and tender. Radiological examination reveals new bone formation. What is the most likely diagnosis?
Your Answer: Exostosis
Correct Answer: Osteomyelitis
Explanation:Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children, while the feet, spine, and hips are most commonly involved in adults. Diagnosis of osteomyelitis is often based on radiologic results showing a lytic centre with a ring of sclerosis. Osteomyelitis, a bone infection, may leave the adjacent bone with exostosis formation. An exostosis, also known as bone spur, is the formation of new bone on the surface of a bone.[
Malignant bone tumours can be classified as primary (arising from abnormal bone or cartilage cells) or secondary (bone metastases of other tumours). The most common primary bone tumours are osteosarcomas, Ewing sarcomas, and chondrosarcomas. These tumours differ with regard to primary localization, radiographic characteristics, and the patient age at which they usually develop.
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This question is part of the following fields:
- Musculoskeletal System
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Question 24
Incorrect
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An 82-year-old man arrives at the clinic with painful right upper arm that he has been experiencing for the last few months. The pain is gradually worsening and often wakes him up at night. He is a known case of Paget's disease involving his lumbar spine and pelvis and is currently taking oral bisphosphonates. On examination, shoulder movements are intact. Which of the following is the most likely cause of his arm pain?
Your Answer: Osteonecrosis
Correct Answer: Osteosarcoma
Explanation:Paget’s accelerates the remodelling process with old bone breaking down more quickly which disrupts the normal growth process. New bone development eventually adjusts to the faster pace and speeds up on its own. The pace is too fast for healthy bone growth, and the regrowth ends up softer and weaker than normal. The effect of this accelerated process causes bone pain, fractures, and deformities. Since osteosarcoma is a type of bone cancer linked to abnormal bone growth, this makes it a rare but possible complication of Paget’s disease although the chances of developing osteosarcoma are minimal. Fractures are painful and restrict movement whereas this patients pain is gradually developing. Pain associated with osteoarthritis is usually mild to moderate and worsens as the day progresses.
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This question is part of the following fields:
- Musculoskeletal System
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Question 25
Incorrect
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Which of the following statements is the most characteristic of primary Raynaud's phenomenon?
Your Answer: Nail fold capillary scope shows dilated vessels
Correct Answer: Fingers are symmetrically involved during an attack
Explanation:A typical attack may last less than an hour but can also persist for longer. In primary Raynaud’s, attacks are more likely symmetric, episodic, and without evidence of peripheral vascular disease. Patients more commonly have a negative ANA and normal inflammatory markers. There should be no evidence of tissue gangrene, digital pitting, or tissue injury in primary Raynaud’s. In contrast, patients with secondary Raynaud’s will describe attacks that are more frequent, painful, often asymmetric and may lead to digital ulcerations.
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This question is part of the following fields:
- Musculoskeletal System
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Question 26
Incorrect
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A 46-year-old male, known with Rheumatoid Arthritis presents with a swollen and painful right ankle. No drug allergies are reported. On examination, the vitals are as follows:
Temp: 38.8
BP: 90/60 mmHg
Pulse: 110/min.
Right ankle examination reveals tenderness, warmth, erythema and tense joint effusion. Blood samples including blood cultures are collected and fluid resuscitation is initiated. Which of the following interventions would be most appropriate for this man?Your Answer: Urgently arrange ankle aspiration
Correct Answer: Administer i.v. flucloxacillin, and arrange joint aspiration urgently
Explanation:Although microscopic analysis of joint fluid aspirate and culture is the basis of septic arthritis diagnosis and should usually be collected before the administration of antibiotics, the patient is showing signs of septic shock. A delay in antibiotics might lead to worsening of symptoms so they are administered first.
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This question is part of the following fields:
- Musculoskeletal System
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Question 27
Incorrect
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A 78-year-old woman presents to the clinic complaining of left sided temporal headaches and jaw claudication that has been going on for a month. A left temporal artery biopsy is negative. Results show:
Hb: 130g/l
Platelets: 359*109/l
WBC: 10*109/l
CRP: 89 mg/l
Which of the following options would be the next best step in the management of this patient?Your Answer: Biopsy the right temporal artery
Correct Answer: Commence prednisolone
Explanation:Temporal arteritis is a chronic large- and medium-sized vessel vasculitis that typically involves the temporal arteries. Classical symptoms include temporal headaches, jaw claudication, amaurosis fugax. Physical exam shows scalp tenderness, palpation of the temporal area may demonstrate an absent pulse, knot-like swelling and vision loss. Lab results reveal an increased erythematous sedimentation rate and C-reactive protein. Temporal artery biopsy confirms the diagnosis. Management approach: high-dose systemic corticosteroids should be promptly administered even before the diagnosis is established. Temporal artery biopsy confirms the diagnosis. Inability to manage this or administer glucocorticoids might lead to development of blindness.
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This question is part of the following fields:
- Musculoskeletal System
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Question 28
Correct
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A 56-year-old obese female presents due to moderate pain in her finger joints which occurs mostly at the end of the day which gets better with rest. There is also some associated swelling. On examination, there is enlargement of her distal interphalangeal joints and tenderness to palpation. Which of the following is the most likely diagnosis?
Your Answer: Osteoarthritis
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 29
Incorrect
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A 23-year-old male patient presents with urethritis for the last 2 weeks that has not responded to antibiotics. Lately he has developed an onset of new range of symptoms that are linked to his HLA B27 positivity. Which of the following signs is not related to Reiter's syndrome?
Your Answer: A well demarcated rash on the penis with serpiginous edges
Correct Answer: A mild fever with a generalised macular rash
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 30
Correct
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A 41-year-old woman who has a history of SLE presents with a dry cough, dyspnoea and fever. She is being treated with a monthly dose of IV cyclophosphamide for Grade IV nephropathy. The last cyclophosphamide dose was 10 years ago. Lab investigations are as follows:
WCC: 2.3 (lymphocyte count 0.7)
Platelets: 81
Hb: 10.5
ESR: 56
CRP: 43
PO2: 7.2 kPa, PCO2: 3.6 kPa after walking out to the toilet.
Chest X ray was unremarkable apart from some patchy pulmonary infiltration.
What is the likely diagnosis?Your Answer: Pneumocystis carinii pneumonia (PCP)
Explanation:Pneumocystis carinii pneumonia, is an opportunistic fungal lung infection occurring almost exclusively in immunocompromised individuals. In 50% of cases, PCP is the first manifestation of AIDS (acquired immune deficiency syndrome), but it may be caused by other immunodeficiency disorders. PCP should be suspected in patients with a history of progressive dyspnoea and a dry cough with resistance to standard antibiotic treatment. Signs that support this diagnosis include a CD4 count < 200/μL, an increased beta-D-glucan level, and diffuse bilateral infiltrates on chest x-ray. Management of PCP includes high-dose trimethoprim/sulfamethoxazole (TMP/SMX), treatment of the underlying immunodeficiency disorder, and steroids in the case of severe respiratory insufficiency. TB is less likely to be present in this case as ESR is relatively low and chest x-ray appeared normal.
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This question is part of the following fields:
- Musculoskeletal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
