Block 2 Practice Questions Flashcards

1
Q

Which one of the following statements about septic (bacterial) arthritis is true?

A

The clinical features can be similar to gout

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2
Q

Which of the following risk factors is most likely to contribute to osteoporosis?

A

Inactivity

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3
Q

Which of the following is true regarding non-steroidal anti-inflammatory drugs?

A

They may cause renal impairment

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4
Q

With reference to the image of the leg and foot (anterior view) below, the tendon that is indicated by X belongs to which of the following?

A

Tibialis anterior

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5
Q

With reference to the image below of two articulated vertebrae (lateral view), which part of the vertebral column do these vertebrae belong?

A

Lumbar

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6
Q

A 75 year old woman with osteoarthritis is prescribed diclofenac.

Which one of the following statements about diclofenac sodium is correct?

A

It inhibits both Cox I and Cox II isoenzymes

Diclofenac is a non-specific COX inhibitor. The anti-inflammatory properties of these drugs relate to their ability to inhibit COX 2. Platelets contain the constitutively expressed COX1. COX1 in the kidney is responsible for the local production of prostaglandins which have vasodilator properties. COX1 in the stomach is responsible for the local production for prostaglandins (PGE1) which stimulate mucosal blood flow and bicarbonate mucus secretion.

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7
Q

The characteristic that is common to almost all forms of arthritis is which of the following?

A

Pain

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8
Q

A 69 year old man presents to his doctor with an acutely swollen painful right knee. He has had previous episodes of acute pain and swelling affecting his big toes and ankles over the last 10 years.

What is the most likely diagnosis?

A

Acute gout

With the past history of similar episodes in typical areas (podagra and knees), gout is the most likely explanation. Infection needs to be excluded in this clinical setting. Acute pseudogout, psoriatic and rheumatoid arthritis are possible but less likely.

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9
Q

A 28 year old man is involved in a head-on vehicle collision. He had allegedly been drinking at a pub with friends and left after a dispute. He was initially trapped in the car with the major impact on his right thigh. He is brought into the Emergency Department conscious, but pale with a pulse of 135bpm and blood pressure of 90/60mmHg. He has deformity of his mid thigh with visible bone protruding from an anterior wound.

Which of the following is the most likely early complication?

A

Femoral artery injury

Femoral fractures can shear the femoral artery, causing massive blood loss into the femoral compartment. S1 and L5 nerve roots are not located near the femur. A ruptured bladder can occur independently, but is not directly related to the fracture. A pulmonary embolus is a systemic complication, and occurs usually several days after the precipitating event.

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10
Q

Which of the following accelerates the natural process of fracture healing?

A

Restoring anatomical continuity of the bones

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11
Q

Many nerve fibres are coated with layers of condensed cell membrane (myelin).

What role does this play in the conduction of action potentials?

A

Increases the velocity of nerve conduction

Myelin lowers the capacitance of the axon where it covers it. This enables action potentials to jump from one internode (Node of Ranvier) to the next (saltatory conduction). This increases the velocity of conduction roughly 40 fold. It reduces the ion flows associated with action potential propagation.

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12
Q

With regard to the pathology of rheumatoid arthritis, which of the following statements is correct?

A

Pannus destroys articular cartilage and underlying bone

Rheumatoid arthritis involves synovial joints. The erosions are mainly articular. The nodules are associated with more severe disease, and consist of connective tissue with areas of fibrinoid necrosis with a mixed inflammatory infiltrate. It is associated with periarticular osteopenia.

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13
Q

A patient is found to have very low levels of Vitamin D.

Which of the following would you expect to find?

A

Muscle weakness

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14
Q

Which of the following does the median nerve innervate?

A

Opponens pollicis

The thumb muscles are also innervated by the radial and ulna nerves. The ulna nerve innervates adductor pollicis, the medial lumbricals, and the skin on the dorsum of the 5th digit.

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15
Q

Adenosine Tri-Phosphate (ATP) is the immediate source of energy within muscles.

With regard to ATP, which of the following statements is true?

A

One molecule of ATP is consumed per cross bridge cycle

A. Anaerobic ATP production can also occur
B. Correct
C. ATP is consumed rapidly but it is regenerated almost equally rapidly. Rigor only occurs on death.
D. ATP is synthesised in all cells by oxidative or anaerobic pathway and is not necessary in the diet.
E. The sodium pump does consume ATP but only a small fraction of the total. Crossbridge cycling consumes most ATP.

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16
Q

A 69 year old man presents to the doctor with an acutely swollen right knee. He has had previous episodes of acute pain and swelling in his big toes and ankles over the last 10 years.

What is the most appropriate initial investigation to determine the diagnosis?

A

Microscopy of synovial fluid

Although the most likely diagnosis is gout, this patient needs a knee aspiration and microscopy to exclude septic arthritis, and to diagnose gout. The other tests may aid the diagnosis, but they do not make the diagnosis.

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17
Q

Which of the following is true regarding gouty arthritis?

A

It is caused by precipitation of urate crystals in joints

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18
Q

What is the most important direct action of the vitamin D hormone, 1,25 dihydroxyvitamin D?

A

Increase gut calcium absorption

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19
Q

A 46 year old woman presents with a three-month history of pain and stiffness in multiple joints. It takes her two hours in the morning before her joints “loosen up”.

What distribution of involvement would suggest that this is due to rheumatoid arthritis?

A

Proximal interphalangeal and metacarpophalangeal joints

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20
Q

A 75 year old woman presents with a 6 month history of pain in her right knee, which is worse with prolonged walking. She has no relevant past history. Physical examination reveals a small effusion and crepitus on movement. Her BMI is 32kg/m2.

Which statement is true regarding the diagnostic workup of this patient?

A

Aspiration of the fluid is likely to reveal a white cell count < 200 x 106/L

This lady’s history, which contains the typical features of osteoarthritis of the knee, is the most important diagnostic tool. CRP is not usually elevated in osteoarthritis. XRay can be normal in osteoarthritis. The effussion associated with osteoarthritis is typically low in white cells and clear in appearance. Rheumatoid factor is present in 10% of the normal population.

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21
Q

A 46 year old woman presents with a 12 month history of pain and stiffness in multiple joints. She is most troubled in the morning and it takes her two hours in the morning before her joints “loosen up”. She is investigated and found to have antibodies to cyclic citrullinated peptide.

Which of the following pathological features would you most likely see?

A

Synovial hyperplasia

Various phases of joint destruction are seen in RA: early RA, erosion formation, pseudocyst formation, and advanced RA.

In early RA, inflammation leads to synovial hyperemia and swelling (pannus formation). Synovial processes adhere to cartilage surfaces at joint periphery.

In the stage of erosion formation, marginal destruction of cartilage, granulation tissue formation, and osteoclastic resorption of nearby bone leads to tissue loss, which is radiologically depicted as erosion.

With pseudocyst formation, granulation tissue formed in continuity with the inflamed synovial membrane continues to replace bone and cartilage at circumference of articular surfaces. This tissue extends through the surfaces to form radiolucent zones called pseudocysts.

In advanced RA, the extent of synovitis and fasciitis, tendonitis, and cellulitis becomes greater than before. Adhesions between joint surfaces cause ligament and capsule laxity. This, in addition to muscle atrophy and tendonitis, allows joint subluxation to occur. Little normal articular cartilage remains. Secondary osteoarthritis develops with osteoporosis. Fibrous ankylosis is likely with joint shortening and destruction.

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22
Q

A 53 year old man has had frequent attacks of gout. He has developed nodules over his elbows one of which breaks down to ooze white paste.

What is the principle component of this paste?

A

Sodium urate

Gout is caused by the saturation, and deposition of insoluble monosodium urate crystals within joints. It is characterised by elevated levels of uric acid in body fluids.

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23
Q

A 17 year old student fell off his skateboard 2 days ago. He presents to the Emergency Department with pain over the base of his thumb and tenderness over the region of the anatomical snuffbox. There is also a small amount of swelling over the same region with no other deformity.

What is the most likely diagnosis?

A

Scaphoid fracture

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24
Q

A patient undergoing halothane anaesthesia develops muscular rigidity, rapidly increasing body temperature and cyanosis.

What mechanism underlies this reaction?

A

Release of calcium from the sarcoplasmic reticulum

A. A distractor
B. This is wrong, the problem is within the muscle.
C. Correct
D. Neuromuscular blocking drugs do not stop the contractures.
E. Mutations in the Na channel can cause depolarisation at the end of long tetani leading to slower relaxation (myotonia).

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25
Q

A 75 year old woman presents with a six-month history of pain in her right knee, which is worse with prolonged walking. She has no relevant past history. Physical examination reveals a small effusion and crepitus on movement. Her body mass index is 32. You make a diagnosis of osteoarthritis

Which of the following is the most important initial aspect of treatment?

A

Weight loss

The symptoms and function of patients with early osteoarthritis are best improved by lifestyle measures. This includes weight loss, activity modification, physiotherapy exercises, mobility aids. Paracetamol is the pharmacological agent of first choice for pain relief. NSAIDs commonly cause peptic ulcer disease in the elderly. Surgical options are best reserve for late, debilitating osteoarthritis.

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26
Q

Why is a cohort study a good source of evidence to answer questions about aetiology?

A

Exposure data are collected before disease status is known

27
Q

A 45 year old man presents with a painful, swollen, red knee.

Which of the following is the most important initial investigation to perform to help with the diagnosis?

A

Joint aspirate

28
Q

A 56 year old man with a past history of recurrent episodes of pain and swelling of the left 1st metatarsophalangeal joint, presents with a further episode coming on rapidly over a few hours. He cannot walk and the joint is red, swollen and tender.

What is the most likely diagnosis?

A

Gout

29
Q

What do features of lumbar vertebrae include?

A

Large kidney-shaped body

30
Q

Which of the following is the best marker of active inflammatory disease in rheumatoid arthritis?

A

C-Reactive protein

31
Q

Osteoarthritis is the most common form of arthritis in the community. There are many risk factors for the development of osteoarthritis.

What is a modifiable risk factor for osteoarthritis?

A

Obesity

32
Q

How is an “open” fracture defined?

A

Associated with a breach in the overlying skin

33
Q

Which of the following joints are affected most commonly by osteoarthritis?

A

Distal interphalangeal joint

34
Q

The semispinalis capitis muscle attaches to which of the following structures

A

Occipital bone

35
Q

A 28 year old man is involved in a head-on vehicle collision. He had allegedly been drinking at a pub with friends and left after a dispute. He was initially trapped in the car with the major impact on his right thigh. He is brought into the Emergency Department conscious, but pale with a pulse of 135bpm and blood pressure of 90/60mmHg. He has deformity of his mid thigh with visible bone protruding from a wound.

What is the correct terminology to describe his fracture?

A

Compound fracture

Open fractures occur when a broken bone protrudes to the exterior of the body giving rise to soft tissue injuries of the muscles, tendons and ligaments. There is a high risk of injection to the internal tissues

A greenstick fracture is an incomplete fracture in which only one side of the bone has been broken. The bone usually is “bent” and only broken of the outside of the bend. It is mostly seen in children and is considered a stable fracture due to the fact that the whole bone has not been broken.

A pathological fracture is one which would not have occurred in normal bone. It is usually secondary to osteoporosis.

An impacted fracture occurs where the ends of the broken bones are wedged together

36
Q

A 35 year old man presents with an acutely painful swollen right knee. His temperature is 38.2ºC and he cannot bear weight. On examination his knee is tender, swollen and erythematous.

What is the single most important investigation in this setting?

A

Aspiration of synovial fluid for culture

Septic arthritis must be excluded in this patient. This is done most reliably by aspirating the affected joint.

37
Q

Which of the following is the defining clinical characteristic of Polymyalgia Rheumatica?

A

Pain and stiffness of the shoulder and the pelvic girdle muscles

38
Q

What are the meninges of the spinal cord comprised of?

A

Dura mater, arachnoid mater and pia mater

39
Q

What is the most important direct action of the hormone 1,25 Dihydroxyvitamin D?

A

Increase gut calcium absorption

Vitamin D increases bone resorption to some extent. Its direct actions to modulate urine calcium and phosphate losses are marginal. The most important action is to stimulate small intestinal calcium absorption. PTH actually increases the conversion of Vitamin D to its more active form in the kidney.

40
Q

Regarding bone remodelling, which of the following statements is correct?

A

The hormone calcitonin acts directly on mature osteoclasts to inhibit bone resorption

41
Q

A probable explanation for the increased risk of cardiovascular adverse events with COX-2 inhibitors is which of the following?

A

Inhibition of prostacyclin (PGI2) synthesis by inflammatory monocytes in atheromatous plaques

42
Q

A 45 year old woman presents with a 3 month history of arthritis. Physical examination reveals tender swollen metacarpo-phalangeal joints in a symmetrical pattern.

What is the most likely diagnosis?

A

Rheumatoid arthritis

43
Q

Which of these features is the earliest change in cartilage with osteoarthritis?

A

Increased hydration of cartilage

Pannus formation is typical of the inflammatory process in rheumatoid arthritis.

In osteoarthritis, there is an initial increase in water content of the matrix, followed by chondrocyte proliferation, as they group in clusters. As superficial articular cartilage is mechanically degraded, there is fibrillation and cracking of the collagen matrix framework. Eventually, all the cartilage is sloughed, leaving subchondral bone exposed as the new articular surface.

44
Q

For a patient recovering from a hip fracture, and with reference to the International Classification of Functioning (ICF), a relevant “activity” is defined as which of the following?

A

Ability to walk to the toilet

45
Q

Which molecules interact and activate the CD4 T lymphocytes which mediate rheumatoid arthritis?

A

HLA class II molecules

Antigen-specific receptors on CD4 T cells recognise and bind to HLA class II-peptide complexes on the antigen presenting cells. the efficiency of binding is increased by the CD4 molecules that binds to non-polymorphic regions of HLA-class II. CD8 T cells bind HLA class I-peptide complexes. B7 on antigen-presenting cells binds CD28 on T cells. This interaction does not involve the foreign peptide. CD3 is associated with T cells receptors and transmits signals from the TCR to the nucleus.

46
Q

A 60 year old woman is noted to have painless swollen hard nodules around her distal inter-phalangeal joints.

A

Osteoarthritis

47
Q

A 72 year-old man has increasing tremor and difficulty with movement for the past 6 years. He is diagnosed with Parkinson’s disease.

A case-control study compares a history of use of aluminium containing deodorants between men with and without Parkinson’s disease.

Which of the following is a common major weakness in a study such as this?

A

Measurement bias due to exposure data being collected retrospectively

In case-control studies exposure (deodorant) is measured retrospectively after the outcome (Parkingson’s disease) is already known.

48
Q

The seronegative spondyloarthropathies are a group of connective tissue disorders.

Which of the following findings is characteristic of this group?

A

Associated with sacro-iliitis

49
Q

Regarding calcium metabolism, which of the following statements is correct?

A

Intestinal calcium absorption is regulated by 1,25 dihydroxyvitamin D (calcitriol)

50
Q

A 78 year old woman slips and falls in her bathroom at home. She is unable to walk due to pain in her right hip. She is brought to the Emergency Department and a presumptive diagnosis of a fractured right neck of femur is made.

What is the typical position the affected leg is in?

A

Shortened and externally rotated

51
Q

A 75 year old woman is brought into the Emergency Department by ambulance after a fall at home. She is unable to walk and complains of severe groin pain when she moves her left leg. On examination she is lying in bed with her left leg externally rotated. The left leg is 3 cm shorter than the right leg. She is usually well and takes no medications.

What is the most appropriate investigation?

A

Plain X-ray of the hip

The clinical presentation is that of a fractured neck of femur: plain radiology of the hip is the appropriate initial investigation

52
Q

With respect to normal bone, which of the following is correct?

A

Osteoclasts are responsible for bone resorption

53
Q

Which of the following investigations is useful in the monitoring of rheumatoid arthritis?

A

C- reactive protein

54
Q

Which of the following is a “red flag” in a patient presenting with back pain?

A

Pain that persists during the night

55
Q

A 25 year old male falls onto his outstretched hand. Upon examination, he is tender in the anatomical snuffbox.

Which carpal bone is he most likely to have fractured?

A

Scaphoid

56
Q

With regard to muscle glycogen, which of the following statements is true?

A

Glycogen stores contribute to muscular endurance

A. No, glycogen consists only of carbohydrate.
B. No, glycogen can be broken down anaerobically in which case the end product is lactic acid.
C. No. Optimal glycogen storage occurs with a carbohydrate-rich diet..
D. Yes. Hence carbohydrate-loading diets before a marathon
E. No. The main roles of insulin are increase glucose entry into muscle and increased synthesis of glycogen.

57
Q

The ligament in the vertebral column with a high proportion of elastic fibres that prevents buckling into the vertebral canal is:

A

ligamentum flavum

58
Q

For the lower limb structures listed below select the nerve from that options list that has the close topographical relationship.

Inguinal ligament

A

Femoral nerve

59
Q

For the lower limb structures listed below select the nerve from that options list that has the close topographical relationship.

Superior margin of piriformis

A

Superior gluteal nerve

60
Q

For the lower limb structures listed below select the nerve from that options list that has the close topographical relationship.

Distal tendon of biceps femoris

A

Common peroneal nerve

61
Q

For the lower limb structures listed below select the nerve from that options list that has the close topographical relationship.

Tarsal tunnel

A

Tibial nerve

62
Q

Choose the most appropriate shoulder muscles for each of the scenarios below.

The long thoracic nerve innervates

A

Serratus anterior

63
Q

Choose the most appropriate shoulder muscles for each of the scenarios below.

The muscle that attaches to the clavicle

A

Subclavius

64
Q

Choose the most appropriate shoulder muscles for each of the scenarios below.

The muscle that initiates abduction of the shoulder joint

A

Supraspinatus