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Question 1
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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 2
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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 3
Correct
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A 42-year-old female with a history of SLE presents with an exacerbation of wrist pain. Which of the following markers would be the most suitable for monitoring disease activity?
Your Answer: Anti-dsDNA titres
Explanation:A high level of anti-dsDNA in the blood is strongly associated with lupus and is often significantly increased during or just prior to a flare-up. When the anti-dsDNA is positive and the person tested has other clinical signs and symptoms associated with lupus, it means that the person tested likely has lupus. This is especially true if an anti-Sm test is also positive.
In the evaluation of someone with lupus nephritis, a high level (titre) of anti-dsDNA is generally associated with ongoing inflammation and damage to the kidneys.
A very low level of anti-dsDNA is considered negative but does not exclude a diagnosis of lupus. Only about 65-85% of those with lupus will have anti-dsDNA.
Low to moderate levels of the autoantibody may be seen with other autoimmune disorders, such as Sjögren syndrome and mixed connective tissue disease (MCTD).
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This question is part of the following fields:
- Musculoskeletal System
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Question 4
Incorrect
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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).
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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 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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 6
Incorrect
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Which of the following cancers is responsible in producing osteoblastic bone metastases instead of osteolytic?
Your Answer: Choriocarcinoma in either gender
Correct 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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 7
Correct
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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.
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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 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: Ewing's Sarcoma
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 9
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: Accentuated lumbar lordosis
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 10
Correct
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A 34-year-old lady presented with complaints of generalised body ache, arthritis, dryness of eyes and mouth. The most likely diagnosis would be?
Your Answer: Primary Sjögren's syndrome
Explanation:Sjogren syndrome is characterised by keratoconjunctivitis sicca, dry mouth and generalised body aches. It is one of the connective tissue diseases and has positive auto Ro and La antibodies.
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This question is part of the following fields:
- Musculoskeletal System
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Question 11
Correct
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A 70-year-old woman accidentally fell and was brought to the orthopaedics department. Investigations reveal a fracture of the neck of the humerus. Which artery may most likely be injured?
Your Answer: Circumferential artery
Explanation:Circumferential artery provides the blood supply to the neck of the femur. Damage to the artery may lead to avascular necrosis of the femoral neck or head.
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This question is part of the following fields:
- Musculoskeletal System
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Question 12
Incorrect
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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.
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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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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 14
Incorrect
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A 49-year-old female presents to the clinic complaining of pain in her left elbow that is localized to the left lateral epicondyle. She has spent the weekend painting her house. A diagnosis of lateral epicondylitis is suspected. The pain would characteristically worsen on which of the following movements?
Your Answer: Pronation of the forearm with the elbow flexed
Correct Answer: Resisted wrist extension with the elbow extended
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, 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 results 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.
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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 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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 16
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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 17
Incorrect
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Drug-induced lupus erythematosus most often occurs after taking which of the following drugs?
Your Answer: Isoniazid
Correct Answer: Procainamide
Explanation:Many drugs are responsible for causing drug induced lupus. However, it is most commonly associated with hydralazine, procainamide and quinidine.
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This question is part of the following fields:
- Musculoskeletal System
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Question 18
Correct
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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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 19
Incorrect
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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: Herpes simplex virus type 2
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.
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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 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.
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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 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 22
Correct
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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: 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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 23
Incorrect
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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: Spondylosis
Correct 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.
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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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A 27-year-old female diagnosed with rheumatoid arthritis has failed to respond to methotrexate and sulfasalazine. Her GP decides to start her on etanercept injections. Which one among the following is an adverse effect associated with the use of etanercept?
Your Answer: Thrombocytosis
Correct Answer: Reactivation of tuberculosis
Explanation:Among the give options, reactivation of tuberculosis may occur in a patient under treatment with etanercept.
Etanercept is a biological TNF inhibit commonly used to control ankylosing spondylitis, juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, and rheumatoid arthritis.
Etanercept is a soluble receptor that binds both TNF-alpha and TNF-beta to inhibit the inflammatory response in joints and skin that is characteristic of these autoimmune disorders.
The most common adverse effects include infections (viral, bacterial, and fungal – mostly upper respiratory tract infections) and injection site reaction (erythema, itching, pain, swelling, bleeding, bruising).
Rarely it can also cause, reactivation of hepatitis B and TB, pneumocystis pneumonia, congestive cardiac failure, Steven-Johnson syndrome, toxic epidermal necrolysis, etc. -
This question is part of the following fields:
- Musculoskeletal System
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Question 25
Incorrect
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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: Polymyalgia rheumatica
Correct 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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 26
Correct
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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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 27
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 28
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 29
Correct
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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.
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This question is part of the following fields:
- Musculoskeletal System
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Question 30
Correct
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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 mild fever with a generalised macular rash
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
