-
Question 1
Correct
-
A 60-year-old female underwent a surgery involving the posterior triangle of the neck. After the surgery, she had difficulty when moving her right shoulder joint. Which of the following nerves is most probably involved?
Your Answer: Accessory nerve
Explanation:The accessory nerve innervates the trapezius muscle which is involved in shoulder movements. Any injury to this nerve will result in the difficulty of movements around the shoulder.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 2
Correct
-
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 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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 3
Correct
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 4
Incorrect
-
A 68-year-old male presented with right sided hip pain and was found to have a fracture of right hip. On examination he had bilateral pedal oedema and was also found to be deaf. Which of the following is the most probable diagnosis?
Your Answer: Spondylosis
Correct Answer: Paget's disease
Explanation:Paget disease is a localized disorder of bone remodelling . Hip pain is most common when the acetabulum and proximal femur are involved. The most common neurologic complication is deafness as a result of involvement of the petrous temporal bone. Bilateral pedal oedema is due to associated heart failure.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 5
Correct
-
Presence of which of the following indicates a worse prognosis in rheumatoid arthritis?
Your Answer: Anti-CCP antibodies
Explanation:Rheumatoid arthritis is both common and chronic, with significant consequences for multiple organ systems. Anti-cyclic citrullinated peptide (anti-CCP) antibody testing is particularly useful in the diagnosis of rheumatoid arthritis, with high specificity, presence early in the disease process, and ability to identify patients who are likely to have severe disease and irreversible damage. However, its sensitivity is low, and a negative result does not exclude disease. Anti-CCP antibodies have not been found at a significant frequency in other diseases to date, and are more specific than rheumatoid factor for detecting rheumatoid arthritis. The other factors that are mentioned do not play a key prognostic role.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 6
Incorrect
-
A 32-year-old woman presents with a painful elbow which she has been feeling for the past two weeks. Which of the following will be consistent with a diagnosis of tennis elbow?
Your Answer: Pain on pressure over the medial epicondyle
Correct Answer: Pain on wrist extension against resistance
Explanation:Lateral epicondylitis (tennis elbow) is an overuse injury of the hand and finger extensor tendons that originate in the lateral humeral epicondyle that occurs following repeated or excessive pronation/supination and extension of the wrist (e.g., in racquet sports). Clinical features include pain and tenderness over the lateral epicondyle and along extensor muscles and thickening of the tendons. The examiner holds the patient’s hand with the thumb placed over the lateral epicondyle – The patient makes a fist, supinates the forearm, deviates radially, and extends the fist against the examiner’s resistance which will result in pain over the lateral epicondyle. Conservative treatment includes rest, physiotherapy and orthotic braces. If this fails corticosteroids and lidocaine injections are employed. Surgery is indicated in patients with persistent symptoms despite 6 months of conservative treatment. Excision of abnormal tendon tissue; longitudinal incisions (tenotomies) in scarred and fibrotic areas to promote healing.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 7
Correct
-
A 68-year-old man presents with acute symptoms of gout on his first metatarsophalangeal joint. Which option best explains the underlying mechanism of gout?
Your Answer: Decreased renal excretion of uric acid
Explanation:Primary gout is related more often to underexcretion of uric acid or overproduction.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 8
Correct
-
A 43-year-old female presents with an array of symptoms including weakness, lethargy, dysphagia, dry mouth, gritty sensation in her eyes and increased photosensitivity. In order to confirm the suspected diagnosis, which of the following tests should be performed?
Your Answer: Labial gland biopsy
Explanation:To confirm the diagnosis, especially in patients with negative anti-Ro or anti-La antibodies, labial gland biopsy is done. In performing a labial biopsy, the surgeon typically makes a shallow 1/2 inch wide incision on either side of the inner lip after numbing the area with a local anaesthetic. Schirmer’s test determines whether the eye produces enough tears to keep it moist. This test can be done for ocular symptoms of Sjogren syndrome but is of no diagnostic importance as it can be positive with many other diseases.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 9
Correct
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 10
Incorrect
-
A 39-year-old woman with a history of rheumatoid arthritis has recently been switched from methotrexate to leflunomide. Monitoring of full blood count and LFTs has been carried out. Which of the following parameters should also be monitored in this case?
Your Answer: Peak expiratory flow rate
Correct Answer: Blood pressure
Explanation:Blood pressure should be routinely measured as leflunomide may cause hypertension and thus an increase in BP. It doesn’t cause changes in blood sugar levels, peak expiratory flow rate or haematuria.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 11
Correct
-
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: 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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 12
Correct
-
A 16-year-old patient was admitted with walking difficulties and knee pain. Upon examination, his leg is externally rotated and is 2 cm shorter. His ability to flex, abduct and medially rotate his leg is limited and when he flexes his hip, external rotation is increased. What is the most probable diagnosis?
Your Answer: Slipped femoral epiphysis
Explanation:The clinical presentation is typical of a slipped femoral epiphysis, which refers to a fracture through the growth plate (physis), resulting in slippage of the overlying end of the femur. It is the most common hip disorder in adolescence. SCFEs usually cause groin pain on the affected side, but sometimes cause knee or thigh pain. The range of motion in the hip is restricted in internal (medial) rotation, abduction, and flexion.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 13
Correct
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 14
Incorrect
-
A 72-year-old man presents with sudden and severe pain on the medial aspect of his right calf while walking uphill. Foot extension is normal and there is no associated ankle swelling. Which of the following is the most likely diagnosis?
Your Answer: Acute limb ischemia
Correct Answer: Popliteal cyst
Explanation:A popliteal cyst, also known as a Baker’s cyst, is a fluid-filled swelling that causes a lump at the back of the knee, leading to tightness and restricted movement. The cyst can be painful when you bend or extend your knee.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 15
Correct
-
A 68-year-old male patient presents with central chest pain and associated flushing. He claims the pain is crushing in character. ECG reveals T wave inversion in II, III and AVF. Blood exams are as follows: Troponin T = 0.9 ng/ml. Which substance does troponin bind to?
Your Answer: Tropomyosin
Explanation:Troponin T is a 37 ku protein that binds to tropomyosin, thereby attaching the troponin complex to the thin filament.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 16
Correct
-
An 18-year-old girl presents with short history of marked, right hip pain and an associated limp. She has a history of acute lymphoblastic leukaemia for which she completed treatment for last six months.
Your Answer: Avascular necrosis of the femoral head
Explanation:Avascular necrosis (AVN) of the femoral head is a pathological process that results from disruption of the blood supply to the bone and occurs most commonly in the femoral epiphysis. Patients usually present with pain and limited joint motion. The mechanism involves impaired circulation to a specific area that ultimately becomes necrotic. AVN is most frequently associated with high doses of oral and intravenous corticosteroids and prolonged duration of therapy. Cancer patients receiving chemotherapy are usually also treated with corticosteroids.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 17
Correct
-
A 20-year-old male student presents to the clinic with swelling of his face, hands and feet along with diffuse abdominal pain. He has a history of similar recurrent episodes since he was 10 years old, with each episode lasting 2-3 days. Examination reveals swelling on face, hands, feet but no sign of urticaria. Family history is significant for similar episodes in the mother who experienced these since childhood, and a brother who passed away following respiratory distress at age of 8 during one such episode. Which of the following tests would be the most helpful in reaching the diagnosis?
Your Answer: C1 esterase inhibitor
Explanation:Hereditary C1 inhibitor deficiency leads to recurrent angioedema without urticaria or pruritus. Physical triggers include dental work, surgery or intubation. Medical triggers include angiotensin-converting enzyme (ACE) inhibitor, tamoxifen, oestrogen-containing medications (e.g., hormone replacement therapy and oral contraceptives). It is diagnosed on the basis of low levels of C1 esterase inhibitor or elevated levels of dysfunctional C1 esterase inhibitor. C4 levels are low between attacks. IgE levels, eosinophils, skin prick tests and RASTs are helpful in other allergic conditions and asthma but not of use in this case.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 18
Incorrect
-
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: Systemic lupus erythematosus
Correct 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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 19
Incorrect
-
High titre of which of the following antibodies is not considered diagnostic for the mentioned disease?
Your Answer: Ads-DNA antibodies in systemic lupus erythematosus (SLE)
Correct Answer: Rheumatoid factor in rheumatoid arthritis (RA)
Explanation:Diagnosis of RA is mainly based on clinical features (e.g., morning stiffness, symmetrical joint swelling) and laboratory tests (e.g., anti-CCP). Rheumatoid factor is not very specific for this disease and hence has low reliability. X-ray findings (e.g., soft tissue swelling or joint space narrowing) occur late in the disease and are therefore not typically used for diagnosis.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 20
Incorrect
-
A 45-year-old female was diagnosed with a benign ovarian mass on her right side. She complained of inner thigh pain on her right side. Which of the following nerves is responsible for her inner thigh pain?
Your Answer: Pudendal nerve
Correct Answer: Obturator nerve
Explanation:The obturator nerve is compressed due to the ovarian mass, this causes pain in the inner thigh because it innervates this area.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 21
Correct
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 22
Incorrect
-
A 68-year-old female is on long term prednisolone therapy for polymyalgia rheumatica. Which of the following would be the most suitable protection against osteoporosis?
Your Answer: Calcium and vitamin D
Correct Answer: Oral bisphosphonate
Explanation:Prevention of osteoporosis associated with chronic glucocorticoid therapy is done by administrating bisphosphonates. Oral bisphosphonates are indicated for patients aged above 65 who have been on steroid therapy for over 3 months, so as to reduce the risk of steroid induced osteoporosis. HRT is usually done in post menopausal women who have oestrogen related bone resorption.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 23
Correct
-
Which of the following cancers is responsible in producing osteoblastic bone metastases instead of osteolytic?
Your Answer: Prostate adenocarcinoma
Explanation:Osteoblastic (or sclerotic) bone metastases, characterized by deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 24
Incorrect
-
A 43-year-old man with hemochromatosis presents with a painful and swollen right knee. X-ray shows extensive chondrocalcinosis but no fracture. Given the most likely diagnosis, which of the following would be present in the joint fluid aspirate?
Your Answer: Monosodium urate crystals
Correct Answer: Positively birefringent rhomboid-shaped crystals
Explanation:Pseudogout is a paroxysmal joint inflammation due to calcium pyrophosphate crystal deposition (calcium pyrophosphate dihydrate). Arthrocentesis should be performed, especially in acute cases.
Polarized light microscopy: detection of rhomboid-shaped, positively birefringent CPPD crystals.
Synovial fluid findings: 10,000-50,000 WBCs/μL with > 90% neutrophils.
X-ray findings: cartilage calcification of the affected joint (chondrocalcinosis).
Fibrocartilage (meniscus, annulus fibrosus of intervertebral disc) and hyaline cartilage (joint cartilage) may be affected. -
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 25
Correct
-
A 45-year-old male presents with lower backache and pain in his hips. Blood tests are normal except for elevated serum alkaline phosphatase which is 1200 IU/l (45-105). Radiological examination shows combined osteolytic and osteosclerotic lesions. What is the most common site of occurrence of this disease?
Your Answer: Pelvis
Explanation:The patient most likely suffers from Paget’s disease of the bone as his radiological examination shows both osteolytic and osteosclerotic lesions. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the pelvis > lumbar spine > femur > thoracic spine > sacrum > skull > tibia.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 26
Correct
-
Drug-induced lupus erythematosus most often occurs after taking which of the following drugs?
Your Answer: Procainamide
Explanation:Many drugs are responsible for causing drug induced lupus. However, it is most commonly associated with hydralazine, procainamide and quinidine.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 27
Incorrect
-
A 67-year-old man reports weight loss. Labs show a raised alkaline phosphatase at 290 U/L (normal range 35-120). Plain radiographs reveal sclerotic lesions of the bone. Which of the following is the most likely cause of these findings?
Your Answer: Osteomalacia
Correct Answer: Prostate cancer
Explanation:Osteoblastic (or sclerotic) bony metastases, characterized by deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma. The other cancers listed in the options are osteolytic.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 28
Incorrect
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 29
Incorrect
-
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: Life-long warfarin, target INR 2 - 3
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 30
Incorrect
-
A 75-year-old male patient with a three weeks history of recurrent epistaxis and haemoptysis presents with acute kidney injury. Which antibody would you expect positive?
Your Answer: P ANCA
Correct Answer: C ANCA
Explanation:Pulmonary renal syndrome is most commonly due to an ANCA positive vasculitis. The history of recurrent epistaxis makes Wegener’s granulomatosis the most probable diagnosis. It presents with pulmonary haemorrhage producing haemoptysis, rapidly progressive glomerulonephritis and anti-glomerular basement membrane antibodies. Recurrent epistaxis favours the diagnosis. In this patient we suspect C ANCA to be positive.
-
This question is part of the following fields:
- Musculoskeletal System
-
SESSION STATS - PERFORMANCE PER SPECIALTY
