-
Question 1
Correct
-
A 34-year-old female presents to the clinic with skin tightness. On examination she has sclerodactyly, thickened skin of the shoulders and bi-basal crepitations. Her HRCT chest shows ground glass changes. Raynaud phenomenon is suspected and she is started on a monthly dose of IV cyclophosphamide (1 gm/month) for 6 months and a daily dose of 10 mg of oral prednisolone. However, she returned over a period of few weeks after developing exertional dyspnoea, pedal oedema and feeling unwell. On examination, JVP is raised, there is marked pedal oedema and bi basal crepitations on chest auscultation. Urine dipstick shows haematuria (++) and proteinuria (++). What in your opinion is the most likely cause of her deteriorating renal function?
Your Answer: Scleroderma renal crisis
Explanation:Scleroderma renal crisis (SRC) is a rare but severe complication in patients with systemic sclerosis (SSc). It is characterized by malignant hypertension, microangiopathic haemolytic anaemia with schistocytes and oligo/anuric acute renal failure. SRC occurs in 5% of patients with systemic scleroderma, particularly in the first years of disease evolution and in the diffuse form. Patients may develop symptoms of fluid overload.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 2
Correct
-
Which of the following drugs would be the safest to prescribe in a 22-year-old man with seropositive rheumatoid arthritis who is planning to start a family?
Your Answer: Prednisolone
Explanation:Prednisolone although has many undesirable side effects it may be considered relatively safe compared to the drugs that are provided here. Prolonged treatment with sulphasalazine may depress semen quality and cause irreversible infertility. Methotrexate and leflunomide both inhibit purine/pyrimidine synthesis (the former by inhibiting folate metabolism) and are contraindicated in pregnancy or while trying to conceive. In males, a temporary or permanent decrease in sperm count may occur with cyclophosphamide. Because the recovery of fertility after cyclophosphamide therapy is variable, sperm banking should be considered before treatment is begun.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 3
Correct
-
A 75-year-old woman presented with difficulty in climbing the stairs and difficulty in holding her head up, for the past 6 months. She didn't have any significant joint pain. Her creatinine phosphokinase level was very high and ESR was normal. Which of the following is the most probable diagnosis?
Your Answer: Polymyositis
Explanation:Polymyositis is an idiopathic inflammatory myopathy characterized by symmetrical, proximal muscle weakness, elevated skeletal muscle enzyme levels and characteristic electromyography (EMG) and muscle biopsy findings. Weak neck extensors cause difficulty holding the head up. Pain is not a significant symptom, which differentiates it from arthritic conditions. ESR is elevated in only 50% of patients with polymyositis.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 4
Incorrect
-
A 35-year-old female patient presents with butterfly rash, haematuria and photosensitivity. She is currently on TB treatment. Which antibody would you expect positive?
Your Answer: Anti-Ds DNA
Correct Answer: Anti-Histone
Explanation:This patient is probably suffering from a drug-induced lupus. There’s a 95% chance that anti-histone antibodies are positive. Drug-induced lupus is a lupus-like disease caused by certain prescription drugs. The drugs most commonly connected with drug-induced lupus are: hydralazine (used to treat high blood pressure or hypertension), procainamide (used to treat irregular heart rhythms) and isoniazid (used to treat tuberculosis).
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 5
Correct
-
A 56-year-old woman taking procainamide develops drug induced erythematosus. Which of the following features is the most characteristic of this condition?
Your Answer: It may occur with chlorpromazine
Explanation:Drug induced lupus is usually positive for antinuclear and antihistone antibodies, typically without renal or neurologic involvement. However, pulmonary involvement is common. Drugs that can induce lupus include isoniazid, hydralazine, procainamide, chlorpromazine, and other anticonvulsants.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 6
Correct
-
A 72-year-old woman presents with left side groin pain. She says she suddenly collapsed and was not able to lift her leg anymore. She is on calcium supplements and alendronate. What is the best diagnosis?
Your Answer: Fracture of neck of femur
Explanation:Fracture of the neck of femur is characterised by inability to lift the affected limb. This is relatively common in osteoporotic patients.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 7
Correct
-
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: 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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 8
Correct
-
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
-
-
Question 9
Incorrect
-
A 56-year-old woman presents to the clinic complaining of shoulder pain that she has been experiencing for the last 4 weeks. She does not remember getting injured previously. The pain worsens on movement especially when she is moving the arm quickly. At night, lying on the affected side is painful. Examination reveals no erythema or swelling. However, pain is felt on passive abduction between 60 to 120 degrees and she is unable to abduct the arm past 70-80 degrees. Flexion and extension are intact. What is the most likely diagnosis?
Your Answer: Adhesive capsulitis (frozen shoulder)
Correct Answer: Supraspinatus tendonitis
Explanation:Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse. This patient has the classic painful arc that is a sign of shoulder impingement characteristic of supraspinatus tendonitis.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 10
Incorrect
-
A 45-year-old man presents with fever, malaise, weight loss and myalgias that have been occurring for a month. You suspect polyarteritis nodosa and arrange for some lab investigations. Which of the following abnormality would most likely be present?
Your Answer: Positive ANCA
Correct Answer: Elevated creatinine
Explanation:People with polyarteritis nodosa often exhibit anaemia of chronic disease. Leucocytosis and eosinophilia may also be present. ANCA is only rarely positive. As polyarteritis nodosa affects the kidneys as well, the creatinine is elevated in most cases.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 11
Correct
-
A 72-year-old female, known with rheumatoid arthritis for last 17 years, presents with recurrent attacks of red eyes with a sensation of grittiness. Which of the following is most likely cause of the red eyes?
Your Answer: keratoconjunctivitis sicca
Explanation:Rheumatoid arthritis is an inflammatory systemic disease associated with some extraarticular manifestations. Keratoconjunctivitis sicca, episcleritis, scleritis, corneal changes, and retinal vasculitis are the most common ocular complications among extraarticular manifestations of RA. The overall prevalence of keratoconjunctivitis sicca also known as dry eye syndrome among patients of RA is 21.2% and is the most common with sense of grittiness in the eyes.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 12
Correct
-
A 31-year-old female with systemic lupus erythematosus wants to know if she has any predisposing factors for the disease. Which of the following carries the greatest risk of developing SLE?
Your Answer: Monozygotic twin
Explanation:An overall concordance rate in monozygotic twins was documented to be 25% as compared to dizygotic twins with 3%. First degree relatives have a chance of around 3% of developing the disease. Caucasians show an increase frequency of HLA-B8. The Japanese lupus patients had a stronger association with HLA-DR2.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 13
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 14
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 15
Incorrect
-
A 60-year-old male presents with thickened patches of skin over his knuckles and extensor surfaces that are consistent with Gottron's papules. Results reveal an elevated creatine kinase. Diagnosis of dermatomyositis is suspected. Which of the following autoantibody is most specific for this condition?
Your Answer: Anti-Jo-1 antibodies
Correct Answer: Anti-Mi-2 antibodies
Explanation:Anti-Mi-2 antibodies are highly specific for dermatomyositis, but sensitivity is low; only 25% of patients with dermatomyositis demonstrate these antibodies. A positive antinuclear antibody (ANA) finding is common in patients with dermatomyositis, but is not necessary for diagnosis. Anti-Jo-1 antibodies are mostly associated with polymyositis. Anti Scl-70 antibodies and anti centromere antibodies are most commonly found in systemic scleroderma.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 16
Correct
-
A 53-year-old female, longstanding case of rheumatoid arthritis comes for a review. Which of the following features are commonly associated with her condition?
Your Answer: Proximal interphalangeal joint involvement in the hands
Explanation:Rheumatoid arthritis is a polyarthritis that results in symmetrical pain and swelling of the affected joints (also at rest). It particularly affects the metacarpophalangeal joints (MCPJs) and proximal interphalangeal joints (PIPJs), not the distal interphalangeal joints (DIPs).
Ulcerative colitis and IBD are associated with seronegative arthritides, not RA. The condition can also cause various extra-articular manifestations such as ocular symptoms, rheumatoid nodules and pulmonary fibrosis. Scleritis, episcleritis and keratoconjunctivitis sicca are more common than uveitis. Early intervention with disease-modifying antirheumatic drugs (DMARDs) plays a decisive role in successful treatment. -
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 17
Correct
-
After examination, a 50-year-old woman was found to have fissuring of the skin of her hands. She has been complaining of fatigue and difficulty in climbing stairs for a couple of months. CXR shows pulmonary fibrosis. Which antibody would you expect to be positive?
Your Answer: Anti Scl 70
Explanation:Anti-Scl-70 antibodies are associated with pulmonary fibrosis and indicate a poor prognosis when positive. Also, they are a specific marker for the diffuse type of systemic sclerosis. Systemic scleroderma, also called diffuse scleroderma or systemic sclerosis, is an autoimmune disease of the connective tissue. It is characterized by thickening of the skin caused by accumulation of collagen, and by injuries to small arteries.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 18
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 19
Correct
-
A 22-year-old nulliparous female presents with shortness of breath. She has a history of recurrent deep vein thrombosis. Complete blood count and clotting screen reveals the following results:
Hb: 12.4 g/dl
Plt: 137
WBC: 7.5*109/l
PT: 14 secs
APTT: 46 secs
Which of the following would be the most likely diagnosis?Your Answer: Antiphospholipid syndrome
Explanation:The combination of APTT and low platelets with recurrent DVTs make antiphospholipid syndrome the most likely diagnosis.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 20
Correct
-
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
-
-
Question 21
Correct
-
High titre of which of the following antibodies is not considered diagnostic for the mentioned disease?
Your 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 22
Correct
-
Which of the following treatments would you advise for a young, 21-year-old student who has ankylosing spondylitis and complains of worsening back pain and morning stiffness?
Your Answer: Oral NSAIDs
Explanation:NSAIDs are considered as the first line of treatment for managing pain and stiffness associated with ankylosing spondylitis. Other useful medications include TNF-alpha inhibitors. Other drugs like paracetamol, colchicine, and steroids are not routinely used. Bilateral total hip replacement might be indicated in advanced disease contrary to complicated spinal surgery.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 23
Incorrect
-
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: Paget's disease
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 24
Incorrect
-
A 34-year-old woman presents to the emergency department due to right sided weakness. Past history reveals a DVT following the birth of her daughter, and two miscarriages. Head CT confirms an ischaemic stroke in the territory of left middle cerebral artery. What would be the most likely finding on echocardiography?
Your Answer: Dilated cardiomyopathy
Correct Answer: Normal
Explanation:The patient most likely suffers from antiphospholipid syndrome. The clinical criteria consist of vascular thrombosis and pregnancy morbidity. Vascular thrombosis is defined as one or more clinical episodes of arterial, venous, or small-vessel thrombosis in any tissue or organ confirmed by findings from imaging studies, Doppler studies, or histopathology. ASD, VSDs would cause paradoxical emboli and stroke, however the recurrent pregnancy loss in this case is strongly suggestive of antiphospholipid syndrome. The ECG would be normal in most cases associated with anti phospholipid syndrome.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 25
Incorrect
-
A 32-year-old male presents following a car accident. He has a swollen foot, with loss of sensation in the space between the 3rd metatarsal and big toe and foot tenderness. In addition, his dorsalis pedis is not palpable. Which is the most probable diagnosis?
Your Answer: DVT
Correct Answer: Compartment syndrome
Explanation:Acute compartment syndrome results from severe high pressure in the compartment with concomitant insufficient blood supply to the tissue involved. Acute compartment syndrome is a surgical emergency that can lead to severe impairment of the function of the affected limb, if left untreated.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 26
Incorrect
-
A 33-year-old female presents with dyspnoea, myalgia, arthralgia and a skin rash. The presence of which of the following antibodies would be the most specific for SLE?
Your Answer: Anti-Ro
Correct Answer: Anti-Sm
Explanation:Anti-Sm antibodies are essential for diagnosis of SLE, especially in anti-dsDNA-negative patients. ANA are also found in 95% of the patients with SLE but they may also occur with other conditions like Juvenile inflammatory arthritis, chronic activity hepatitis, and Sjogren’s syndrome. Anti-Ro, although also found with SLE are more characteristic of Sjogren Syndrome. RF is usually associated with rheumatoid arthritis and cANCA with Wegener’s granulomatosis, Churg Strauss, and microscopic polyangiitis.
-
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 36-year-old man presents with severe pain in his right big toe which is erythematous and swollen. He recently had an appendicectomy. Personal history reveals that he consumes 30 units of alcohol per week. Choose the most likely diagnosis.
Your Answer: Pseudogout
Correct Answer: Gout
Explanation:Chronic alcoholism leads to increased levels of uric acid in the blood. Gout is caused by high levels of uric acid.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 29
Incorrect
-
A 28-year-old woman is involved in a cycling accident. She has severe pain and swelling of her right upper leg. An x-ray confirms a fracture of neck of fibula. What is the most common associated nerve injury?
Your Answer: Tibial nerve
Correct Answer: Lateral peroneal nerve
Explanation:Lateral peroneal nerve, also known as the superficial peroneal nerve.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 30
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 31
Incorrect
-
Which of the following statements is the most characteristic of primary Raynaud's phenomenon?
Your Answer: Anti-nuclear antibody is positive in 70% of cases
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 32
Incorrect
-
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: Lumbar spine
Correct 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 33
Incorrect
-
A 35-year-old sales representative presents with severe pain going down her neck and right arm. She admits that this pain is worse on sitting and driving for long periods. Past history is significant for two previous road traffic accidents. Examination reveals weakness and sensory loss over C5/C6 nerve distribution. There is pain with neck movement and particularly extension. Which of the following investigations would be the most helpful in this case?
Your Answer: Nerve conduction studies
Correct Answer: MRI scan of the cervical spinal cord
Explanation:Cervical radiculopathy is usually due to compression or injury to a nerve root by a herniated disc or degenerative changes. Levels C5 to T1 are the most commonly affected. It is usually, but not always, accompanied by cervical radicular pain, a sharp and shooting pain that travels from the neck and down the upper limb and may be severe. This needs to be differentiated from pain referred from the musculoskeletal (somatic) structures in the neck, which may be aching rather than sharp, and is more severe in the neck than in the upper limb. The neurological signs of cervical radiculopathy depend on the site of the lesion. The patient may have motor dysfunction, sensory deficits or alteration in tendon reflexes. While pain is a common presenting symptom, not all radiculopathies are painful (i.e. only motor deficits may be obvious). CT scanning cannot accurately demonstrate the commonest cause for cervical radiculopathy (disc herniation) without myelography, which requires hospital admission, lumbar puncture and the use of contrast. In patients with cervical radiculopathy, MRI is the imaging technique of choice for the detection of root compression by disc herniation and osteophytes. MRI allows the nerve roots to be directly visualised. Nerve conduction studies are also useful in determining the nerve roots that are involved.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 34
Correct
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 35
Incorrect
-
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: Vestibulocochlear nerve
Correct 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 36
Correct
-
A 68-year-old male presents with muscle weakness - he is unable to go up the stairs and has complained of mild breathlessness. He has said that he finds it difficult to swallow food sometimes. Lab tests are conducted and the reports show the following results: alkaline phosphatase 216 U/L; aspartate aminotransferase 49 U/L; alanine transaminase 43 U/L; creatine kinase 417; erythrocyte sedimentation rate 16 mm/h. From the list of options, choose the most likely diagnosis.
Your Answer: Polymyositis
Explanation:Muscle weakness and the inability to climb the stairs are consistent with a diagnosis of polymyositis. The condition usually affects those between 30-50 years of age and individuals present with stiffness in the muscles closest to the trunk which gradually worsens over time. Difficulty swallowing may be experienced if the muscle in the oesophagus is affected.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 37
Incorrect
-
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: Swelling of the finger joints
Correct 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 38
Incorrect
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 39
Correct
-
A 74-year-old man presents with 12 kg weight loss and persistent back pain that is unrelated to activity for the past several months. Laboratory findings show :
WCC: 6.7 x 109/l (5.4 neutrophils, 1.2 lymphocytes and 0.2 monocytes)
Haemoglobin: 11.2 g/dl
haematocrit: 33.3%
MCV: 88 fl
Platelet count: 89 x 109/l.
The biochemistry shows:
sodium 144 mmol/l
potassium 4.5 mmol/l
chloride 100 mmol/l
bicarbonate 26 mmol/l
urea 14 mmol/l
creatinine 90 μmol/l
a glucose of 5.4 mmol/l.
A CT scan of the spine reveals scattered 0.4 to 1.2 cm bright lesions in the vertebral bodies.
Which of the following additional laboratory test findings is he most likely to have?Your Answer: Serum prostate specific antigen of 35 microgram/l
Explanation:Old age, persistent backache, weight loss, and osteosclerotic lesions make prostatic adenocarcinoma the most likely diagnosis. The sequelae include severe pain, pathological fractures, hypercalcemia and cord compression. Prostatic adenocarcinoma is detected by elevated levels of prostate specific antigen. Positive serology for borrelia burgdorferi would hint at Lyme disease which does not cause osteosclerotic bone lesions, neither would Neisseria gonorrhoeae have such a presentation.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 40
Incorrect
-
A 23-year-old student presented with swelling and tenderness near the Lister tubercle of the radius. Passive extension of thumb and index finger further increases the pain. X-ray was normal. What will be the next step in the management of this case?
Your Answer: Magnetic resonance imaging (MRI)
Correct Answer: Immobilization with a cast
Explanation:This patient most likely has distal intersection syndrome, which occurs in the proximal forearm due to the tenosynovitis of extensor pollicis longus muscle tendons.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 41
Incorrect
-
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: Pain on straight leg raising
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
-
-
Question 42
Incorrect
-
In the case of absent tibial and popliteal pulses, which artery is most likely injured?
Your Answer: Aorto-iliac
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 43
Incorrect
-
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: Lateral peroneal nerve
Correct 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
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 44
Correct
-
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 mild fever with a generalised macular rash
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 45
Incorrect
-
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 46
Incorrect
-
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: Radioallergosorbent test (RAST)
Correct 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 47
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: Tendon Achilles rupture
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 48
Incorrect
-
Which of the following would be the most appropriate treatment (leaving out the current NICE guidelines) for a 29-year-old man with erythrodermic psoriasis and arthritis mutilans involving several digits of both hands?
Your Answer: Sulfasalazine
Correct Answer: Etanercept
Explanation:TNF-alpha inhibitors are known to ameliorate the symptoms and disease activity of Arthritis mutilans (a rare and severe form of psoriatic arthritis), by disabling the cytokines that are involved in inflammation and joint destruction. From the mentioned choices, this would be the most effective option. Methotrexate is the most commonly used DMARD, followed by sulfasalazine used in mild to moderate forms of psoriatic arthritis but has not shown much efficacy in arthritis mutilans. Phototherapy, narrowband UVB light therapy can be very effective in clearing skin lesions.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 49
Incorrect
-
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: Gout
Correct 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 50
Correct
-
A 35-year-old female complains of headache at the back of her head that has been occurring for several days and pain on neck flexion. She works as a housemaid. Which of the following is the most likely cause of her presentation?
Your Answer: Cervical spondylosis
Explanation:Cervical spondylosis is a general term for age-related wear and tear affecting the spinal disks in your neck. As the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projections along the edges of bones (bone spurs). Cervical spondylosis is very common and worsens with age.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 51
Correct
-
Which of the following features occurs very less frequently with drug induced lupus?
Your Answer: Glomerulonephritis
Explanation:Drug induced lupus typically presents with pulmonary involvement and no renal or neurological involvement. Hence glomerulonephritis would be highly unlikely in this case. Rash and arthralgias are classic presentations. Pleurisy can be present as pulmonary involvement may occur with DILE.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 52
Incorrect
-
A 52-year-old shopkeeper presents with pain in her hands. Examination reveals plaques on the extensor surfaces of her upper limbs and a telescoping deformity of both index fingers. Nails show pitting and horizontal ridging. The patient is most likely suffering from which of the following?
Your Answer: Rheumatoid arthritis
Correct Answer: Arthritis mutilans
Explanation:Arthritis mutilans is a rare (occurs in only 5% of the patients) and extremely severe form psoriatic arthritis characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers.’ The associated nail changes are also characteristic of arthritis.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 53
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 54
Correct
-
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: 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 55
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: Femoral 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 56
Correct
-
A 20-year-old male, who was otherwise completely healthy, has developed severe and sudden pain in his lower back. It started after getting up from his bed. What is the most probable diagnosis in this case?
Your Answer: PID
Explanation:Sudden onset of severe lower back pain whilst is felt more when bending (such as getting up from a bed) is consistent with a diagnosis of a prolapsed intervertebral disc.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 57
Incorrect
-
Which of the following statements is incorrect regarding etanercept?
Your Answer: Has been associated with demyelination
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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 58
Incorrect
-
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: Nystatin drops
Correct 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.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 59
Incorrect
-
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: Osgood-Schlatter disease
Correct 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 60
Incorrect
-
An 80-year-old female, previously diagnosed with polymyalgia rheumatica 18 months back, presents to the outpatient clinic with bilateral shoulder stiffness and generalized myalgia. The ESR was found to be 60 mm/1st hour at the time of presentation. Prednisolone therapy was initiated at a daily dose of 15 mg along with Calcium and Vitamin supplementation. She reported resolution of her symptoms in one week. However the symptoms relapsed when the prednisolone dose was reduced below the current dose of 12.5 mg daily. How should she be ideally managed?
Your Answer:
Correct Answer: Continue the current dose of prednisolone and start methotrexate
Explanation:Polymyalgia rheumatica, a syndrome characterized by proximal muscle pain and stiffness in older persons, generally is treated with prednisone. Dosages of 15 to 25 mg of prednisone per day can reduce inflammation considerably, although many patients relapse when therapy is tapered. Long-term (18 to 36 months) steroid treatment has been recommended by several studies, but this can result in multiple side effects, including osteoporosis, hypertension, cataracts, and hyperglycaemia. Methotrexate has been used to reduce inflammation in rheumatoid arthritis, systemic vasculitis, and giant cell arteritis, and in some studies has been combined with prednisone to treat polymyalgia rheumatica, decreasing the duration of treatment.
-
This question is part of the following fields:
- Musculoskeletal System
-
SESSION STATS - PERFORMANCE PER SPECIALTY
