MSS Important Questions Flashcards by 888 😉

[Old PP]
In diagnosis of tuberculous spondylitis, which investigation is MOST USEFUL clinically?

A. Biopsy of bone
B. Blood culture for acid-fast bacilli
C. Sputum for acid-fast bacilli
D. Tuberculin skin test
E. X-ray of spine

B, D: not specific to TB of bone
C: pulmonary TB
E: radiological diagnosis of spondylitis only, X microbiological diagnosis

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[Old PP]
A cirrhotic patient develops symptoms of necrotising fasciitis. What is the most common causative agent?
A. Bacteroides
B. Klebsiella pneumoniae
C. Staphylococcus aureus
D. Vibrio cholerae
E. Vibrio vulnificus

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[Old PP]
Which of the following is the earliest sign of necrotising fasciitis?
A. Blue discolouration
B. Blister formation
C. Local numbness
D. Local tenderness
E. Fever

Spreading edge: tender
Centre: anaesthetic later

Late: septic shock

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[Old PP]
Which of the following is the most common cause of necrotising fasciitis?
A. Streptococcus agalactiae
B. Streptococcus dysgalactiae
C. Streptococcus iniae
D. Streptococcus pyogenes
E. Streptococcus bovis

Most common cause (type II - monomicrobial, streptococcal):
- GAS (most common) OR beta-hemolytic streptococci +/- others (e.g. S. aureus)

GBS: S. agalactiae
Group C/G: S. dysgalactiae
GDS: S. bovis, Enterococci (formerly) => rarely cause Type II necrotising fasciitis

Beta-hemolytic: GAS, GBS, Group C/G, S. iniae
Gamma-hemolytic: GDS

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[Self-assessment]
Which layer of skin does impetigo involve?

Upper epidermis

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[Self-assessment]
Which layers are involved in cellulitis?

Skin and subcutaneous tissue

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[PP]
What is the most common pathogen involved in necrotising fasciitis following exposure to seawater?

Vibrio vulnificus

Type III necrotising fasciitis (monomicrobial)
1. Vibrio vulnificus
2. Aeromonas hydrophila (fresh / brackish water)

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[PP]
Which of the following skin and soft tissue infections is characterised by a diffuse inflammation of the soft tissue without pus collections?
A. Carbuncle
B. Cellulitis
C. Furuncle
D. Impetigo

Lower extremities most involved

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[PP]
A 57-year-old woman developed a rapidly progressive cellulitis of the thigh after a minor injury by a lobster at the fish market. What is the most likely pathogen(s) involved?

Vibrio vulnificus

Clues: seawater, raw or undercooked seafood e.g. shellfish

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[PP]
Necrotising fasciitis of the trunk in a child following a recent episode of chickenpox. What is the most likely pathogen(s) involved?

Streptococcus pyogenes

Children who had chickenpox (varicella) are more likely to develop serious GAS infections, though uncommon.

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[PP]
Dermatophytes are fungi that require keratin for growth and hence causes infection of skin and skin appendages. Which of the following fungi is a dermatophyte?

A. Aspergillus
B. Cryptococcus
C. Histoplasma
D. Trichophyton

Dermatophytosis / Ringworm / Tinea
1. Skin (stratum corneum) e.g. tinea pedis (athletes’s foot), tinea faciei, tinea corporis
2. Hair e.g. tinea capitis
3. Nail e.g. tinea unguium

Dermatophytes:
1. Epidermophyton floccosum
2. Trichophyton
3. Microsporum

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[PP]
What is the most common pathogen involved in furuncle?

S. aureus

Other causative agents: Pseudomonas aeruginosa

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[PP]
What is the most common pathogen involved in onychomycosis?

Dermatophytes (e.g. Trichophyton rubrum)

Non-dermatophyte moulds
Yeasts
(fungi)

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[PP]
What is the most common pathogen involved in diaper rash?

Candida albicans

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[PP]
Until a few years ago the inflammation in gout was thought to be due to mechanical damage by neutrophils. In recent years this view has changed. Outline the role of cathepsins (3 marks) and the inflammasome (2 marks) in the pathogenesis of gout.

Monosodium urate crystals are phagocytosed by neutrophils.
They are incorporated into phagosomes where they combine with cathepsins.
Rupture of the membrane leads to cathepsin release.
& ROS production from mitochondria
=> dissociation of TXNIP from TRX-TXNIP complex
=> TXNIP activates NLRP3 inflammasome
The inflammasome is formed and activated.
This leads to caspase activation and secretion of proinflammatory IL-1.

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[PP]
Which of the following joint conditions has the greatest disease burden in the Hong Kong population?
A. Ankylosing spondylitis
B. Gout
C. Osteoarthritis
D. Rheumatoid arthritis

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[PP]
A synovial biopsy from a 35-year-old lady shows a papillary architecture with increased lymphocytes and plasma cells in the stroma. What is the most likely diagnosis?
A. Ankylosing spondylitis
B. Gout
C. Osteoarthritis
D. Rheumatoid arthritis

Histology;
Papillary synovium with cell hyperplasia
Neovascularisation
Fibrin
Edema
Nodules of lymphocytes, plasma cells, mast cells

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[PP]
A 55-year-old Chinese man presents with a well demarcated erythematous patch below his umbilicus. You suspect contact dermatitis to nickel. What type of hypersensitivity reaction does allergic contact dermatitis belong to?

Type 4 hypersensitivity reaction

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[Old PP]
Joints can be classified according to the type of binding tissues that connect bones to each other. Which type of joint is pubic symphysis?

Secondary cartilaginous joint (immovable)

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[Old PP]
Axis of femoral neck is at an angle of 8-14° with reference to transcondylar axis. What is the name of this angle which is important in maintaining hip stability and normal walking?

Angle of anteversion / femoral torsion

(inferior view) between line joining 2 femoral condyle & line along femoral neck

Measured by surgical transepicondylar axis

Too large
-> intoeing (excessive hip internal rotation)

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[Old PP]
A patient had a deformity of hip where angle between neck and shaft of femur in frontal plane is decreased. Name this angle.

Angle of inclination

Between line along shaft & line along neck

Too large (>125°): coxa valga
Too small (<125°): coxa vara

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[Old PP]
A school teacher has torn his medial meniscus in a skiing accident. What structure does medial meniscus bind to which makes it more prone to damage than lateral meniscus?

Tibial / Medial collateral ligament

Unhappy triad:
valgus (lateral) force injures
- ACL
- Medial meniscus
- MCL / tibial collateral ligament Unhappy triad

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[Old PP]
Head and shaft of femur made an angle of 125°. What is the name of this angle?

Angle of inclination

Angle of anteversion / femoral torsion: 8-14°

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[Old PP]
Which of the following statements most appropriately describes ligaments of knee joint?

A. ACL prevents posterior displacement of femur in relation to tibia.
B. ACL & PCL act synergistic to each other
C. LCL tear will most likely be associated with a tear in lateral meniscus.
D. Sudden change in direction at high speeds will likely cause PCL injury.
E. MCL resists force pushing from medial side.

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[Old PP] Which of the following statements regarding acetabulum is correct? A. Entire acetabular surface articulates with head of femur. B. Acetabulum is shallower than glenoid fossa. C. Acetabulum is a common site for avascular necrosis. D. Acetabular surface forms an ellipsoid joint with head of femur. E. Acetabulum is contributed by all 3 bones of pelvis.

E Acetabular fossa is non-articular

[Old PP] Which of the following statements about knee joint is correct? A. Knee joint is a typical synovial hinge joint B. Medial meniscus is attached to joint capsule C. Flexion of knee is limited by tension in collateral ligaments D. Popliteus unlocks joint by rotating femur medially on tibia E. Suprapatellar bursa is separate from synovial cavity of joint

B Modified synovial hinge joint Popliteus unlocks joint by rotating tibia medially on femur

[Old PP] Which of the following ligaments resists hyperextension and medial rotation of hip joint? A. Iliofemoral ligament B. Ischiofemoral ligament C. Ligament of head of femur D. Pubofemoral ligament E. Transverse acetabular ligament

[Old PP] A 25-year-old footballer is struck on thigh one Saturday afternoon when playing soccer at Causeway Bay. Bone that would most likely be broken is: A. Femur B. Fibula C. Ilium D. Ischium E. Tibia

[PP] A patient arrived at the Accident and Emergency Department suffering from a blow on the lateral side of the left knee. Which ligament was most likely torn if the anterior drawer sign was positive and excessive displacement of the tibia anteriorly was observed?

ACL

[PP] Anterior displacement of which bone indicates a positive anterior drawer test?

Tibia

[PP] What ligament is tested by the ‘anterior drawer test’?

Anterior cruciate ligament

[PP] A football player was tackled by an opponent, hitting her left leg. Her knee joint experienced a significant inward angulation and rotation, causing severe pain. Anterior drawer test was positive. The orthopaedist suspected a damage to the ‘unhappy triad’ structures. List the three ‘unhappy triad’ structures. (3 marks)

ACL MCL Medial meniscus

[PP] The greater sciatic foramen is an opening in the pelvis bound by the greater sciatic notch and ligaments. Which muscle passes through this foramen?

Piriformis

[Old PP] Which of the following is NOT a lateral rotator of hip? A. Obturator internus B. Piriformis C. Quadratus femoris D. Superior gemellus E. Tensor fascia latae

[Old PP] Name the major function of gluteus medius.

Abduction of hip Also gluteus minimus

[Self-assessment] Which muscle winds over the lesser sciatic notch?

Obturator internus Enters gluteal region through lesser sciatic foramen

[Self-assessment] Which of the following muscles is attached to the axial skeleton? A. Gluteus medius B. Piriformis C. Obturator internus

[Old PP] Which of the following passes through lesser sciatic foramen? A. Inferior gemellus B. Obturator extrenus C. Obturator internus D. Piriformis E. Superior gemellus

[Old PP] In treating vaginal prolapse, a nerve that innervates a muscles passing through the lesser sciatic foramen is injured. What is this muscle?

Obturator internus

[PP] What is the most anterior muscle amongst the three tendons that form the pes anserinus on the anteromedial surface of proximal tibia?

Sartorius

[PP] A patient with a large sarcoma in the adductor component of the thigh was admitted to the hospital for muscle group resection. Which muscle in this group is inserted on the tibia?

Gracilis

[PP] Which muscle inverts and dorsiflexes the foot?

tibialis anterior

[PP] Which muscles extend the thigh, and flex and medially rotate the leg?

Semitendinosus & semimembranosus

[PP] Which muscles flex the knee joint and plantarflex the foot?

Gastrocnemius & Plantaris

[PP] Tonic contraction of leg muscles with tendons that extend into the foot helps maintaining the foot arches. Which muscle tendon winds around the lateral border of the foot and passes below the cuboid bone to support the lateral longitudinal arch?

Peroneus longus

[PP, Formative] Ankle sprains can result in an avulsion fracture of the 5th metatarsal. Which muscle is attached to the base of the 5th metatarsal?

Fibularis brevis

[PP, Formative] A 5-year-old child is brought to the emergency department, holding her right elbow and crying in pain. There is tenderness over the lateral aspect of the elbow. Which ligament is likely involved in the injury described in this child? A. Acromioclavicular ligament B. Annular ligament C. Medial collateral ligament D. Triangular ligament

[PP, Formative] A 55-year-old man developed an erythematous scaly rash over the right groin. Which of the following may be a useful test for diagnosis? A. Blood culture B. Gram stain of wound swab C. KOH smear of skin scraping D. Mantoux test

C Dermatophytosis / Ringworm / Tinea -> Annular scaling patches & plaques with advancing border +/- fissures (Non-dermatophyte: Candida, Fusarium)

[PP, Formative] A 67-year-old woman is admitted with severe pain over her left arm. She reported a cut on her left index finger three days ago when handling shrimp. Necrotising fasciitis is suspected. What is the MOST LIKELY microorganism?

Vibrio vulnificus

[PP, Formative] Fungal infection of nails is called …

onychomytosis

[PP, Formative] Inflammation of the hair follicles that can be due to infectious or non-infectious causes is called …

folliculitis

[PP, Formative] Infection of the knee joint is most likely …

septic arthritis

[PP, Formative] Infection that spreads across the deep subcutaneous tissue plan is called …

necrotising fasciitis

[PP] Which muscle laterally rotates the thigh at the knee joint at the beginning of flexion?

Popliteus

[PP, Formative] The tarsal tunnel transmits structures from the posterior leg to the plantar aspect of the foot. Which tendon in the tarsal tunnel runs to the navicular bone?

Tibialis posterior

[PP] Which muscle arises from the anterior surface of sacrum?

piriformis

[PP] Which muscle(s) can behave as antagonist(s) of pronator teres during movement of the forearm?

Biceps brachii & Supinator

[PP] A 55-year-old female has red swollen and painful joints due to gouty attack. Which of the following is the MOST appropriate drug for relieving her symptoms? A. Aspirin B. Betamethasone C. Colchicine D. Denosumab

[Old PP] Allopurinol is used to treat gout. Describe its mechanism.

Xanthine oxidase inhibitor (allopurinol, febuxostat) Allopurinol: - converted by xanthine oxidase to alloxanthine => (-) xanthine oxidase from converting hypoxanthine to xanthine to uric acid => (-) plasma uric acid Febuxostat: - non-competitive inhibitor of xanthine oxidase

[Old PP] A 65-year-old lady experienced an acute gout attack. Which drug is best to reduce inflammatory response? A. Allopurinol B. Aspirin C. Ibuprofen D. Paracetamol E. Probecenid

C NSAIDS (e.g. indomethacin, ibuprofen) - For acute gout - Inhibjt prostanoid production (by inhibiting cyclooxygenase) & urate phagocytosis - X salicylates (e.g. aspirin) as they decrease uric acid excretion => further aspirin is not given to children <16, pregnant women & elderly

[Self-assessment] Uricosuric agents reduce the plasma level of uric acid by: A. inhibiting urate transporter-1 B. inhibiting xanthine oxidase C. inhibiting urate oxidase

A MOA of uricosuric agents: - inhibit URAT-1 in luminal side of renal proximal tubule => reduce uric acid reabsorption => increase excretion MOA of uricolytic agents (e.g. rasburicase): - catalyse oxidation of uric acid to allantoin (more soluble)

[Self-assessment] Which one of the following approaches helps to prevent the occurrence of gout flare associated with urate-lowering therapy? A. Concomitant intake of anti-inflammatory drugs B. Increasing the dose of urate-lowering drugs C. Intake of large amount of water

A Gout flare (inflammatory response due to urate crystals in the joint) Sudden reduction in plasma uric acid => mobilisation of urate from tissue deposit - avoided by anti-inflammatory therapy during the initiation of therapy - risk reduced with reduced tissue urate deposit Drinking large amount of water: - precaution of xanthine oxidase inhibitor & uricosuric agents - prevent renal stones (more xanthine / uric acid in urine) => need to increase urine volume / urine pH to >6.0

[Self-assessment] Which one of the following statements describes the mechanism of action of colchicine? A. It inhibits the binding of interlukin-1 to the receptor B. It inhibits the activity of cyclooxygenase C. It inhibits the polymerisation of tubulin

C MOA of colchicine: - decrease inflammatory response by 1. inhibit tubulin polymerisation -> microtubules => (-) leukocyte migration to urate crystals 2. (-) leukotriene B4 formation by PMNs

[Self-assessment] Which one of the following drugs should be avoided during acute gouty attack? A. Indomethacin B. Allopurinol C. Colchicine

[Self-assessment] Estrogen replacement therapy, when used in the management of osteoporosis in post-menopausal women, increases the risk of: A. osteosarcoma B. vasomotor symptoms C. breast cancer

C Estrogen or hormone replacement (estrogen + progestin) - act on estrogen receptor on bone => (-) bone resorption - adverse effects: breast cancer, heart disease, uterus cancer => for women with ongoing postmenopausal vasomotor symptoms (also relieved by the therapy) but no risk of CVS disease Analogs of PTH / PTH-related protein (e.g. Teriparatide, abaloparatide) - Activate PTHR in bone => (+) bone formation (anabolic effects) - adverse effects: osteosarcoma, various pain & cramps

[Self-assessment] Which one of the following drugs is considered to be an anabolic agent? A. Teriparatide B. Alendronate C. Denosumab

A Bisphosphonate (e.g. Alendronate, Clodronate, Risendronate, Pamidronate) - Antiresorptive: bind to bone matrix => (+) osteoclast apoptosis & (-) osteoclastic f(x) Denosumab: - Antiresorptive: inhibit RANKL & bind to RANK on the surface of precursor & mature osteoclasts => block osteoclast formation & activation

[PP] Different processes enable bone growth, remodelling and repair. Through what process does the shaft of long bone grow thicker during childhood? A. Appositional growth B. Endochondral ossification C. Interstitial growth D. Intramembranous ossification

A Bone: appositional growth only (as calcified matrix is inexpandible) - from periosteum & endosteum - layer + layer Interstitial growth - possible in cartilage, though usually appositional growth - grow within the centre

[Self-assessment] Which type of bone cells is responsible for bone resorption? A. Osteocytes B. Osteoblasts C. Osteoclasts

C Osteoblasts: bone formation - line all bone surfaces Osteocytes: Maintenance of bone - in matrix, X surface Osteoclasts: bone resorption (digest -> absorb -> transport Ca & collagen to blood) - in depressions of bone surfaces (Howship’s lacunae)

[Old PP] Osteoclasts are cells responsible for bone resorption. What is the cell type that gives rise to osteoclasts?

Monocytes (mononuclear phagocyte system) Formed by fusion to form large, multinucleated, mobile cells

[Old PP] Which of the following about osteoclasts is incorrect? A. They are derived from circulating monocytes. B. They are located in Howship’s lacunae. C. They are large and acidophilic D. They contain many mitochondria. E. They secrete bone matrix.

E B: Howship’s lacunae = bony depressions (due to resorption by Oc)

[PP] Vitamin C deficiency causes scurvy with symptoms including easy bruising, bleeding and joint pains, due to defective production of specific extracellular matrix (ECM) proteins. Synthesis of which class of ECM protein is required? A. Collagens B. Fatty acids C. Glycoproteins D. Proteoglycans

A Vitamin C = cofactor for hydroxylation of proline residues important for the stability and secretion of newly synthesised molecules to the extracellular space

[PP] Osteogenesis imperfecta due to mutations of type I collagen genes are often treated with bisphosphonate influencing the bone remodelling process. What would be the outcome for such treatment? A. Less bone is degraded by osteoclasts B. More bone is produced by osteoblasts C. More collagen fibrils are produced during remodelling D. More minerals are deposited during remodelling

[PP] Achondroplasia, a dwarfism condition caused by gain-of-function mutations in FGFR3 gene which affects bone growth, now has potential pharmacological treatment. (a) Define “gain-of-function” in the context of these mutations. (2 marks) (b) Define the cellular impact of these mutations in the cartilage growth plates leading to dwarfism. (2 marks) (c) At which cell cycle checkpoint will a pharmacological treatment be effective? (1 mark)

(a) Mutations enhance the normal function of the gene. FGFR3 can be activated for a prolonged period of time or even in the absence of ligand. (b) Chondrocyte proliferation would be suppressed, leading to retardation of growth of long bone. (c) G to S checkpoint. Activation of FGFR3 prevents the progression across this checkpoint as a negative regulator of chondrocyte proliferation.

[PP] Duchenne muscular dystrophy (DMD) is caused by loss-of-function mutation in the dystrophin gene, which encodes the dystrophin protein. What is the function of the dystrophin protein? A. It cross-links the extracellular matrix B. It links the cytoskeleton to extracellular matrix C. It links the endoplasmic reticulum to the nuclear membrane D. It regulates the contraction of skeletal muscle

B Dystrophin f(x): maintain shape & structure of muscle fibre - brown protein surrounding plasma membrane on staining Dystrophin-glycoprotein complex: - dystrophin links to F-actin (actin filament) in cytoplasm - the complex (including DG and SG complexes on sarcolemma) links to merosin subunit of laminin in ECM DMD gene: point mutation / deletion => DMD / BMD / outlier

[PP] Duchenne Muscular Dystrophy (DMD) is caused by mutations in the dystrophin gene. Multiple diagnosis methods are used clinically. Which of the following tests can give a specific diagnosis of DMD? A. Creatine kinase test B. Electromyography C. H&E staining D. Immunostaining

D Non-specific: - CK test (blood test) 10-100X normal amount due to leakage - EMG - Muscle biopsy Specific: - Immunostaining - Western blot - Detection at DNA level: DNA blood test for X chromosome analysis / PCR / Southern Blot / DNA sequencing

[PP] Give one possible mutation in dystrophin gene that may cause DMD and one that may cause BMD.

BMD: point mutation in Xp21 DMD: deletion in Xp21 Xp21: a locus in short arm (p arm) of X chromosome

[PP] Which method can provide a definitive diagnosis of Duchenne Muscular Dystrophy (DMD) and rule out other causes? A. Creatine kinase (CK) test B. Electromyography (EMG) C. Immunostaining with anti-dystrophin antibody D. Western blot with anti-myosin antibody

[PP] Duchenne Muscular Dystrophy (DMD) is caused by mutations in the dystrophin gene. It is proposed that induced pluripotent stem cells (iPSCs) can be a potential treatment for DMD. (a) List the essential steps of iPSC-based therapy for DMD. (4 marks) (b) List one technical difficulty in applying iPSCs treatment for DMD. (1 mark)

(a) 1. Collect somatic cells e.g. skin cells 2. Reprogram into iPSCs (+reprogramming factors e.g. Oct4, Sox2, Klf4, c-Myc, viruses) => divide to form genetically identical colonies 3. Correct mutation e.g. CRISPR-Cas9 4. Differentiation into skeletal muscle progenitor cells / myogenic cells 5. Transplant (b) Immune response => rejection

[PP] The dystrophin protein expressed in skeletal muscle can be detected by immunostaining. What is the function of the secondary antibody used in the immunostaining? A. It specifically recognises the color developing enzyme. B. It specifically recognises the dystrophin heavy chain. C. It specifically recognises the dystrophin light chain. D. It specifically recognises the myosin protein. E. It specifically recognises the primary antibody.

[Old PP] Mutations in dystrophin gene leads to DMD. Dystrophin is a linker protein. Which one of the following interactions is directly affected in DMD? A. Actin filaments and microtubules B. Actin and actin C. Membrane glycoprotein complex and actin D. Microtubules and microtubules E. Myosin and kinesis

[Old PP] Compare the levels of dystrophin protein in DMD, BMD, BMD/DMD outlier.

BMD > Outlier > DMD

[Old PP] DMD is caused by genetic mutations in dystrophin gene. From patient muscle biopsies, which of the following abnormalities can be detected using a Western blot? A. A small deletion in DMD gene B. Abnormal DMD gene size C. Abnormal dystrophin mRNA size D. Abnormal dystrophin protein size E. Absence of dystrophin mRNA

D Western blot: protein Southern blot: DNA Northern blot: RNA Eastern blot: post-translational modification of protein

Name the type of soft tissue infection that involves the epidermis and upper dermis with prominent lymphatic involvement.

Erysipelas

[PP] Necrotising fasciitis can be classified according to the pathogens involved. Which of the following conditions is a type I necrotising fasciitis? A. Carbuncle B. Erysipelas C. Fournier’s gangrene D. Gas gangrene

C Type I necrotising fasciitis (polymicrobial): - Anaerobes (e.g. Bacteroides), facultative anaerobes (e.g. Streptococci, Enterpbacterales) E.g. Fournier’s gangrene (external genitalia, perineum) & Ludwig angina (floor of the mouth)

[PP] A 32-year-old mountain biker crashed his vehicle while performing a dangerous stunt and landed on his right side. He is unable to move all five fingers afterwards. He also has complete loss of sensation distal to the elbow. What is the MOST LIKELY site injured? A. Injury to the brachial plexus B. Injury to the cervical spinal cord C. Injury to the median nerve D. Injury to the musculocutaneous nerve

[PP] In a patient who presents with joint pain, it may be difficult to distinguish rheumatoid arthritis from osteoarthritis. Which of the following radiological features is MORE LIKELY to be seen in osteoarthritis than rheumatoid arthritis? A. Bilateral wrist deformity with subluxation B. Calcification of menisci C. Fusing of bones in spine giving a ‘bamboo spine’ D. Subchondral bone cyst formation

D A: RA B: CPPD C: Ankylosing spondylitis D: OA

[PP] A female patient with rheumatoid arthritis is prescribed with methotrexate, a disease modifying anti-rheumatic drug (DMARD) to retard the progress of bone and cartilage damage. Which one of the following is the adverse effect that she should be cautious of? A. Cataracts B. Hepatotoxicity C. Hypertension D. Muscle wasting

[PP] Striated muscle is made up of long, multinucleated cells called muscle fibres. Which of the following structures, comprising thick filaments of myosin protein, appear as dark bands under light microscopy in striated muscle? A. A bands B. H zones C. I bands D. Z lines

Which nerve transmits the sensory signals in Golgi tendon reflex?

Group Ib afferent nerve

Which nerve transmits the sensory signals of pupillary light reflex?

optic nerve

Which nerve transmits the sensory signals of stretch reflex?

Group Ia afferent nerve

A 45-year-old woman presented to the hospital with progressive blurring of vision in the left eye for 10 days. She had pain and reduced colour vision in the left eye. On examination, relative afferent pupillary defect on the left eye was revealed. The right eye was normal. (a) Which cranial nerve was abnormal in this patient? (2 marks) (b) Which reflex was tested in this patient? (1 mark) (c) What would be observed in the left eye when light is moved from the right eye to the left eye in this patient? (1 mark) (d) What would be observed in the left eye when light is moved from the right eye to the left eye in a normal person? (1 mark)

(a) Left optic nerve (b) Pupillary light reflex (c) Pupillary dilation / reduced pupillary constriction (d) No change in pupil size (keep constricting)

[PP] Which muscle forms the medial boundary of the cubital fossa?

Lateral border of pronator teres Boundaries of cubital fossa: Superior - imaginary line between two epicondyles of humerus Lateral - Brachioradialis Medial - Pronator teres Roof - skin, fascia, bicipital aponeurosis Floor - Brachialis, supinator

[PP] List three main superficial veins that are found in the cubital fossa. (3 marks)

Cephalic vein Basilic vein Median cubital vein

[PP] What is the position of the brachial artery relative to the median nerve in the cubital fossa?

Lateral to median nerve

[PP, Formative] Clinical assessment of stretch reflexes helps with localisation of neural lesion or neuropathy. Which stretch reflexes helps can be diminished in C7 radiculopathy? A. Biceps reflex B. Patellar reflex C. Scapulohumeral reflex D. Triceps reflex

D Biceps: C5 Brachioradialis: C6 Triceps: C7 Knee jerk / Patellar: L4 Ankle jerk: S1

[PP] A man slammed his fist against a wall in frustration after learning that he had failed his driving test. The impact along the axis of the 4th and 5th metacarpals caused the hamate and the adjacent carpal bone on its radial side to be fractured. What is the name of this adjacent carpal bone? A. Capitate B. Lunate C. Scaphoid D. Triquetral

A From radial side: Proximal row: Scaphoid Lunate Triquetrum Pisiform Distal row: Trapezium Trapezoid Capitate Hamate Some Lovers Try Positions That They Can’t Handle 3 Ts: Triquetrum Trapezoid (rhymes with Capitate) Trapezium (rhymes with Thumb)

[PP] An ice hockey player dislocated his left acromioclavicular joint during practice. Which extrinsic ligament is the MOST IMPORTANT in maintaining the stability of this joint? A. Acromioclavicular ligament B. Coracoacromial ligament C. Coracoclavicular ligament D. Costoclavicular ligament

C Intrinsic ligament (part of joint capsule): - acromioclavicular ligament (weak & lax) Extrinsic ligament: - coracoclavicular ligament (strong) = trapezoid + conoid ligaments Coracoacromial ligament - connect 2 parts of scapula Costoclavicular ligament - stabilise sternoclavicular joint (synovial saddle joint / double plane joint)

[PP] A burglar injured his right ankle after jumping from the 1st floor of a building to the ground. A ligament that normally supports the head of the talus was ruptured. What is the name of this ligament? A. Deltoid ligament B. Long plantar ligament C. Short plantar ligament D. Spring ligament

D Spring ligament (plantar calcanonavicular ligament) - bridges the gap between navicular & sustentaculum tali (shelf-like) of calcaneus on plantar side => support talus - support medial longitudinal arch of foot Ligaments supporting foot arches 1. Long plantar ligament 2. Short plantar ligament (plantar calcaneocuboid ligament) 3. Spring ligament Collateral ligaments 1. Medial - Deltoid ligament 2. Lateral - Ant. / Post. talofibular ligament - Calcaneofibular ligament

[PP] A woman over-inverted her foot and injured her ankle while running down the stairs. Which of the following ligaments is MOST likely to be sprained? A. Anterior talofibular ligament B. Deltoid ligament C. Long plantar ligament D. Spring ligament

A Over-inversion: - rupture / sprain injury of calcaneofibular ligament (lateral) - avulsion of lateral malleolus - push fracture of medial malleolus Over-eversion: - rupture / sprain injury of deltoid ligament (medial) - avulsion of medial malleolus - push fracture of lateral malleolus

[PP] Avascular necrosis of the femoral head is a serious complication of fractures of the femoral neck in the elderly. Damage to which blood vessel(s) is MOST LIKELY the cause of this condition? A. Artery of the ligamentum teres B. Inferior gluteal artery C. Nutrient artery of the femur D. Reticular arteries

D Blood supply to femoral head 1. Reticular arteries - major supply 2. Artery of ligamentum teres - important in childhood (obliterates with age) - torn ligamentum teres => avascular necrosis 3. Nutrient artery of femur - insignificant

[PP, Formative] What is the MOST COMMON Gram-positive pathogen causing acute septic arthritis?

Staphylococcus aureus

[PP, Formative] A 55-year-old man with good past health presented to the emergency department with high fever, malaise and severe pain of the right leg. He was found to be hypertensive on arrival. The right lower limb was swollen, red and tender even to light touch. The erythema was progressing from lower shin to above the knee within hours. What severe infective condition needs to be ruled out?

Necrotising fasciitis

[PP, Formative] Name TWO COMMON organisms that can cause the monomicrobial form of necrotising fasciitis.

Streptococcus pyogenes (GAS) / Vibrio / Aeromonas Polymicrobial (Type I); - Anaerobe (e.g. Bacteroides) + Facultative anaerobes (e.g. streptococci, Enterobacterales) e.g. Fournier gangrene, Ludwig angina

[PP, Formative] Name TWO IMPORTANT management measures of necrotising fasciitis.

Surgical debridement / Antibiotics / Resuscitation

[PP, Formative] A 25-year-old man presented with fever, swelling, and pain of the right knee for 2 days. There was no prior injury. He enjoyed good past health. What is the MOST LIKELY clinical diagnosis?

Acute septic arthritis of the right knee

[PP, Formative] Apart from blood culture, what is the MOST IMPORTANT clinical specimen for microbiological testing of septic arthritis?

Joint fluid aspirate

[PP, Formative] A Gram-negative diplococcus was isolated from the blood culture of a patient with suspected septic arthritis, what is the MOST LIKELY organism?

Neisseria gonorrhoeae

[PP, Formative] Name one important treatment for a patient with acute septic arthritis of right knee.

Antibiotics / Drainage / Debridement

[PP] A 46-year-old man who was an intravenous drug user was admitted for a 5-day history of progressive left knee pain and swelling, together with a fever up to 38°C. List two essential clinical specimens that should be collected for microbiological investigations in this patient.

Blood culture Joint / Synovial fluid aspirate

[PP] A 46-year-old man who was an intravenous drug user was admitted for a 5-day history of progressive left knee pain and swelling, together with a fever up to 38°C. Name one microorganism that is most commonly associated with this infection in this clinical setting.

Staphylococcus aureus

[PP] A 46-year-old man who was an intravenous drug user was admitted for a 5-day history of progressive left knee pain and swelling, together with a fever up to 38°C. Name one beta-lactase antibiotic that can be used for empirical treatment of this patient.

Amoxicillin

[PP] A 45-year-old lady presents with a 6-month history of bilateral pain in the wrists with swelling. On examination there is bilateral flexion deformities. X-ray shows swelling of the joints with no osteophyte formation. Biopsy of the joint is performed and this shows a papillary synovial with increased cellularity in the stroma. List two types of inflammatory cells that are typically seen in the stroma.

1. Lymphocytes 2. Plasma cells

[PP] A 45-year-old lady presents with a 6-month history of bilateral pain in the wrists with swelling. On examination there is bilateral flexion deformities. X-ray shows swelling of the joints with no osteophyte formation. Biopsy of the joint is performed and this shows a papillary synovial with increased cellularity in the stroma. What changes would you expect to see in the synovial cells?

Hyperplasia

Rheumatoid arthritis

[PP] A 45-year-old lady presents with a 6-month history of bilateral pain in the wrists with swelling. On examination there is bilateral flexion deformities. X-ray shows swelling of the joints with no osteophyte formation. Biopsy of the joint is performed and this shows a papillary synovial with increased cellularity in the stroma. What is the post-translational modification which results in antibodies in this condition?

Citrullination

[PP] Except rituximab, name two other classes of biologic or targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) in RA.

Biologic: TNF inhibitors, anti-IL6, CTLA4-Ig, rituximab (B-cell cytotoxic agent) Targeted synthetic: JAK inhibitors

[PP] A 69-year-old man developed a sudden onset of fever, pain and swelling in the right knee. The right knee is inflamed. Aspiration of synovial fluid is taken from the knee. Culture shows numerous leukocytes and clusters of Gram-positive cocci. The crystals are needle-shaped and negative birefringent. What is the bacteria?

Staphylococcus aureus

Intravenous antibiotics (penicillin e.g. cloxacillin, ampicillin, amoxicillin, vancomycin if suspect MRSA) + surgical drainage / debridement 3rd generation cephalosporins (e.g. ceftriaxone) for N. gonorrhoeae, H. influenzae

Monosodium urate (MSU)

[PP] Name the specific nerve type in grey rami communicans.

Unmyelinated postsynaptic / postganglionic sympathetic nerve fibres VS White rami communicans - myelinated presynaptic / preganglionic sympathetic nerve fibres

[PP] What is the origin and destination of fibres of grey rami communicans?

- Origin: sympathetic chain ganglion / trunk - Destination: spinal nerve VS White rami communicans - Origin: Lateral horn - Destination: sympathetic chain ganglion / trunk

[PP] Trace the visceral afferent pathway from hindgut to CNS.

1. Inferior mesenteric ganglion and plexus 2. Lumbar splanchnic nerve 3. Sympathetic trunk 4. White rami communicans 5. Dorsal root ganglion

[PP] Name one possible extra-articular feature associated with RA.

Lung fibrosis Haematological involvement (Felty’s syndrome) Ocular involvement (episcleritis, scleritis) Vasculitis Rheumatoid nodules Amyloidosis Lungs Have Overactive Vessels, Rheumatoid Aftermath

[PP] A 50-year-old woman with longstanding seropositive rheumatoid arthritis (RA) presents with recurrent infections after Rituximab treatment. Name two chronic deformities of small hand joints in established rheumatoid arthritis.

Boutonniere Ulnar deviation Swan neck Z-shaped thumb MCP subluxation BUS’Z

Osteoarthritis

[PP] A 60-year-old retired delivery man presented to his local doctor with complaints of a 6-month history of stiffness and pain in the right knee. He reported difficulty in walking. There were no other joints involved and no systemic symptoms. On physical examination he was obese. There was swelling and deformity of the right knee joint. List three changes that may be present on plain radiography of the right knee joint.

Loss of joint space (erosion of cartilage) Osteophyte formation Subchondral cyst Subchondral sclerosis LOSS

[PP] The JSC-EAP recommends that the COVID-19 mRNA vaccines be administered intramuscularly into the thigh for adolescents aged 12 to 17 years, especially males. Which part of the quadriceps femoris muscle is the preferred injection site to avoid accidentally hitting major blood vessels or nerves? A. Rectus femoris B. Vastus intermedius C. Vastus lateralis D. Vastus medialis

[PP] Bisphosphonate is used to treat patients with OI that alters the balance of cell activities in bone remodelling. Which cell type does it affect and what is its mode of action?

Osteoclasts Increase bone content by reducing activity of osteoclasts (inhibition + apoptosis) (for bone resorption) -> balance osteoblast & osteoclast activities

[PP] Type I collagen is a trimer containing two alpha1(I) and one alpha2(I) chains encoded by the COL1A1 and COL1A2 genes, respectively. Osteogenesis imperfecta (OI) can be caused by mutations in these two genes. If there is a mutation affecting one allele of the COL1A1 gene, what proportion of the type I collagen molecules would contain only normal type I collagen chains?

1/4

[PP] From the perspective of bone density and quality, why is bisphosphonate treatment benefit for OI patients?

Bone density: - reduce bone resorption by osteoclasts - bone formation by osteoblasts is unchanged - bone remodelling activities by osteoblasts & osteoclasts is balanced - increase bone density Bone quality: - having more inferior bone can be more beneficial than not enough though quality is unchanged

[PP] Major forms of osteogenesis imperfecta (OI) are related to mutations in type I collagen genes (COL1A1 & COL1A2), affecting the integrity of bone. Glycine mutations in the alpha1(I) chain of the type I collagen gene (COL1A1) exert a dominant-negative effect, contributing to the severity of the phenotype. In relation to the function of type I collagen in bone, give two properties of bone that will be affected by the presence of the abdominal collagen molecules. (2 marks)

1. Bone mineral density 2. Bone tensile strength Type II OI

[Old PP] Osteogenesis imperfecta (OI) is a genetic disorder of bones, causing deformities and recurrent fractures. Many forms of OI are caused by mutations in COL1A1 and COL1A2 genes of type I collagen. If a mutation results in loss-of-function of COL1A2 gene, how will this affect the quality and quantity of type I collagen molecules being produced by bone cells?

Quality: unchanged Quantity: reduced Loss-of-function mutations - haploinsufficiency (one allele affected -> reduction in quantity by half) e.g. nonsense mutations (premature termination) -> nonsense-mediated mRNA decay OR -> non-functional, truncated chains => bone resorption by osteoclast

[Old PP] For a heterozygous mutation in the helical domain of COL1A1, explain how and to what degree this can affect the amount of normal type I collagen molecules produced.

Type I collagen triple helix = 2 alpha-1 + 1 alpha-2 chains 1/4 normal collagen 3/4 abnormal collagen Dominant-negative effects: one mutant chain already leads to impaired secretion of molecules

[Old PP] Will loss-of-function mutations of COL1A2 gene result in a mild or severe condition in spectrum of OI?

Mild No dominant-negative effect Remaining collagen chains can function normally Type I OI

[Old PP] Osteogenesis imperfecta (brittle bone disease) can be caused by single nucleotide substitutions in genes (COL1A1 and COL1A2) coding for type I collagen, resulting in a disease of varying degree of severity from mild to lethal conditions. What are possible changes in the gene, mRNA or protein that could result from such mutations? Give three possibilities?

Gene: - null allele (loss-of-function mutation) - altered promoter / enhancer sequences -> change gene expression level mRNA: nonsense mutation -> mutant mRNA -> nonsense-mediated mRNA decay Protein: - nonsense mutation -> truncated, non-functional collagen - missense mutation -> glycine substitution in triple helix -> abnormal type I collagen

[Old PP] Marfan syndrome, Fibrillin 1 mutation, which one affected? A. TGF-beta B. FGF

[Old PP] Fibrillins are structural protein in ECM of many connective tissues. They also regulate presentation of a specific class of signalling molecules to cells. Which of the following is signalling molecule? A. Fibroblast growth factor B. Hedgehog protein C. Parathyroid hormone related protein D. Transforming growth factor beta D. Vascular endothelial growth factor

[Old PP] Osteogenesis imperfecta (brittle bone disease) is caused mainly by A. A reduction in bone mineral B. A reduction in collagen content of bones C. Abnormal differentiation of bone forming cells D. An imbalanced hormonal control E. An increase in bone resorption activity

[Old PP] According to “Sillence classification”, osteogenesis imperfecta could be classified into different types. However, osteogenesis imperfecta type I will have little or no deformity, while osteogenesis imperfecta type II would be lethal at perinatal stage, though they are both resulted from collagen mutations in heterozygous condition. What is the nature of mutation, type I VS type II, that causes the symptoms we see? A. Dominant negative VS loss of function B. Loss of function VS haploinsufficiency C. Haploinsufficiency VS loss of function D. Haploinsufficiency VS Dominant negative E. Loss of function VS Gain of function

[Self-assessment] Osteogenesis imperfecta patients often have a blue sclera. Why is this the case? A. The sclera is too thin B. The sclera turns blue C. The sclera is too thick

A OI -> reduced type I collagen in sclera -> thin sclera -> visualisation of densely vascular choroid behind sclera

[Self-assessment] In genetic counselling of families, blood from mother, father and the affected child for a “Trio” testing is necessary for which of the following reasons? A. Mode of inheritance B. Validation of the mutation C. To assess the molecular consequence of the mutation

A Recessive / dominant / sporadic

[Self-assessment] Which of the following genetic mutations in the type I collagen gene, COL1A1, can lead to a loss-of-function outcome causing osteogenesis imperfecta? A. Missense mutation B. Gene duplication C. Nonsense mutation

[Self-assessment] A loss-of-function mutation in type I collagen genes (COL1A1 or COL1A2) in a heterozygous individual would give rise to which form of osteogenesis imperfecta? A. Severe B. Mild C. Moderate

B Remaining collagen chains can function normally

[Self-assessment] Which of the following genetic mutation in the type I collagen gene, COL1A1, can lead to a dominant-negative outcome causing osteogenesis imperfecta? A. Gene deletion B. Gene duplication C. Missense mutation

C Change amino acid residue -> abnormal chain Whole triple helix molecule affected even if just a single chain is abnormal (dominant-negative) Gene deletion -> haploinsufficiency Gene duplication -> gain-of-function

[Self-assessment] A treatment for osteogenesis imperfecta is to use bisphosphonate. Which of the following is the cell target? A. Osteoclasts B. Osteoblasts C. Osteocytes

[Self-assessment] What would be the outcome of bisphosphonate as a form of treatment for osteogenesis imperfecta? A. Bone with higher organic content B. No change in bone quality C. Bone with higher mineral content

[Self-assessment] Type II collagen is a homotrimer of three identical alpha-chains encoded by the COL2A1 gene. Missense mutation will lead to a dominant-negative effect. What fraction of the molecules produced will consist of only normal chains? A. 1/8 B. 7/8 C. 1/3

A 7/8: abnormal

[Self-assessment] Why Losartan (an angiotensin II type 1 receptor blocker) can be used to treat patients with the Marfan syndrome from mutations in an extracellular matrix protein, Fibrillin-1? A. Counteract excessive TGF-beta signalling in aneurysm tissue B. Corrects the skeletal abnormalities C. Improves tensile strength of elastic fibres

A Fibrillin-1 containing ECM binds TGF-beta and regulates its level, defective in Marfan patients -> excessive TGF-beta signalling Fibrillin collagen fibres are still defective -> no change in tensile strength of elastic fibres Skeletal abnormalities (e.g. scoliosis) are developmental, once formed, cannot be corrected

[PP] The atlas articulates with the axis at three atlanto-axial articulations. What type of joint is the median atlanto-axial joint? A. Condyloid joint B. Hinge joint C. Pivot joint D. Plane joint

C Median atlanto-axial: pivot 2 lateral atlanto-axial: plane

[PP] Muscles attached to the vertebrae are necessary to support and move the spine. Because of these muscles, a person could do various exercises, for example, the sit-up. Which muscle contributes to the head-to-knee forward fold during sit-up? A. Erector spinae B. Psoas major C. Splenius muscles D. Transversospinalis

B Flexion of trunk: - rectus abdominis - psoas major - gravity Flexion of head and neck - prevertebral muscles - scalene muscles

[PP] Sciatica may be caused by intervertebral disc herniation. Which direction does the intervertebral disc MOST COMMONLY herniate towards? A. Anterior-central B. Anterolateral C. Lateral D. Posterolateral

D Posterolateral protrusion of nucleus pulposus

[PP] A 25-year-old female felt a sharp pain in her lower back while moving heavy furniture. Examinations revealed a compression of the left L3 spinal nerve by lumbar vertebrae. Where is the compression MOST LIKELY located? A. Between laminae of L2 and L3 B. Between laminae of L3 and L4 C. Between pedicles of L2 and L3 D. Between pedicles of L3 and L4

A Most intervertebral disc herniations occur posterolaterally

[PP] The “Scottie dog” sign refers to the normal appearance of the lumbar spine when seen on oblique radiographic project. Fracture (spondylolysis) of which structure is seen as a collar of the “Scottie” dog? A. Pars interarticularis B. Pedicle C. Superior articular process D. Transverse process

A Weakest point Nose: transverse process Eye: pedicle Ear: superior articular process Neck: pars interarticularis Body: lamina (anterior) and spinous process (posterior) Forelimb: inferior articular process Hindlimb: contralateral inferior articular process Tail: contralateral superior articular process

[PP] An experienced house officer performed lumbar puncture on a patient. He asked the patient to flex her spine to open the space between the laminae. As the needle was entering between two adjacent laminae, what ligament was it going through? A. Anterior longitudinal ligament B. Interspinous ligament C. Ligamentum flavum D. Posterior longitudinal ligament E. Supraspinous ligament

C Lumbar puncture: supraspinous -> interspinous -> ligamentum flavum (yellow due to elastin)

[Old PP] Name the joints of the vertebral arch articulating superior and inferior articular facets of adjacent vertebrae.

Zygapophyseal joints - plane / facet / synovial joints

[Old PP] What structures form the anterior wall of intervertebral foramen?

IV disc Vertebral body Posterior longitudinal ligament

[Old PP] What is the orientation of the joint surfaces at the region of lumbar vertebrae?

In sagittal plane Cervical: horizontal plane Thoracic: coronal / frontal plane Lumbar: sagittal plane

[Old PP] Name one type of movement allowed at zygapophyseal joints in lumbar region.

Flexion, extension Cervical: most directions Thoracic: rotation, limited extension and (lateral) flexion

[Old PP] At which spinal level does the subarachnoid space end inferiority in adults?

[Old PP] Name two structures found in the subarachnoid space below the termination of the spinal cord.

Filum terminale (internum) Cauda equina Conus medullaris terminates at L1

[Old PP] Name three distinguishing characteristics of a normal lumbar spine.

1. Body: - Large, kidney-shaped -> carry most body weight 2. Articular facets: - nearly vertically oriented (superior faces medially, inferior faces laterally) (parasagittal) -> prevent rotation - pars interarticularis in between 3. Transverse processes: - long, slender 4. Spinous processes: - short, blunt -> for attachment of back muscles 5. Vertebral canal - small -> most nerves have already left spinal cord

[Old PP] Individuals with osteoporosis have greater incidence of anterior compression fracture of the vertebrae. Explain.

Decrease in bone density -> higher risk of fracture of weight-bearing bones like vertebrae

[Old PP] Name two characteristic features of a typical osteoporotic vertebra.

1. Compression fracture 2. Collapse of central endplate -> biconcave body 3. Expanded disc spaces

[Old PP] A lumbar puncture, also known as a spinal tap, is a diagnostic and/or therapeutic procedure performed by inserting a hollow needle into the subarachnoid space in the lumbar region of the vertebral column. Name the seven structures pierced by the needle during lumbar puncture.

Skin -> subcutaneous tissue -> supraspinous ligament -> interspinous ligament -> ligamentum flavum -> epidural space -> dura mater -> subdural space -> arachnoid mater -> subarachnoid space

[PP] A. Calcaneofibular ligament B. Deltoid ligament C. Iliofemoral ligament D. Sacrotuberous ligament E. Patellar ligament F. Spring ligament G. Sacrospinous ligament H. Long plantar ligament I. Tibial collateral ligament J. Fibular collateral ligament Which ligament is Y-shaped (inverted)?

F Sustentaculum tali of calcaneus -> navicular => support head of talus

[Old PP] A basketball player twisted his ankle and it was over-everted. Which of the following ligaments is sprained? A. Anterior talofibular ligament B. Calcaneofibular ligament C. Deltoid ligament D. Long plantar ligament E. Posterior talofibular ligament

[Old PP] Which of the following joints corresponds with each other? A. Ankle joint: Hinge joint B. Hip joint: ellipsoid joint C. Intertarsal joint: pivot joint D. Pubic symphysis: ball-and-socket joint

A Hip joint: ball-and-socket Transverse tarsal joints (calcaneocuboid, talonavicular, tarsometatarsal): plane Pubic symphysis: secondary cartilaginous

[Old PP] Which of the following bones does tibia and fibula articulate with? A. Talus B. Calcaneus C. Cuboid D. Navicular E. Cuneiform

A Ankle joint = talus + tibia + fibula

[Old PP] Which of the following joints is least stable? A. Sacroiliac joint B. Knee joint C. 1st carpometacarpal joint D. Shoulder joint E. Facet joint

D Sacroiliac joint: plane CMC: plane (1st: saddle)

[Old PP] Ankle joint is a A. Synovial condyloid joint B. Synovial ellipsoid joint C. Synovial hinge joint D. Synovial pivot joint E. Synovial plane joint

[PP] Both aspirin and celecoxib are non-steroidal anti-inflammatory drugs (NSAIDS). Describe one major difference between the mechanisms of action of aspirin and celecoxib. (1 mark)

Aspirin is a non-selective COX inhibitor Celecoxib is a selective COX-2 inhibitor

[PP] Both aspirin and celecoxib are non-steroidal anti-inflammatory drugs (NSAIDS). Which one of them is associated with cardiovascular risk? (1 mark) Explain how the drug increases the risk of cardiovascular diseases. (3 marks)

Celecoxib Celecoxib increases risk of cardiovascular thrombotic events - inhibit COX-2 in endothelial cells => less PGI2 (prostacyclin 2), (PGE2) secretion => lose inhibition on platelet adhesion, activation and aggregation + lack effects on platelet COX-1 => does not inhibit thromboxane A2

[PP] Pathophysiology of diseases A. Carnitine uptake deficiency B. Clotting factor deficiency C. Glucose-6-phosphatase deficiency D. Glucose-6-dehydrogenase deficiency E. Hepcidin deficiency F. Hepcidin in excess G. Inhibition of angiotensin converting enzyme H. Inhibition of cyclooxygenase-2 I. Non-specific inhibition of cyclooxygenases J. Venous thromboembolism A 65-year-old woman had been taking an anti-inflammatory drug for treating arthritis. Today she is admitted following an ischaemic stroke. Select the MOST PROBABLE pathological cause.

[PP] A patient has rheumatoid arthritis and the symptoms cannot be effectively managed by non-steroidal anti-inflammatory drugs. Which of the following medications can be prescribed to relieve the arthritic symptoms? A. Aspirin B. Colchicine C. Paracetamol D. Prednisolone

D Synthetic glucocorticoid

[PP] A 5-year-old girl has high fever, a runny nose and a sore throat. She is diagnosed to have influenza. Which anti-pyretic medication is contraindicated for her condition? A. Aspirin B. Diclofenac C. Ibuprofen D. Indomethacin E. Paracetamol

A Children with fever due to viral illnesses + salicylates -> Reye’s syndromes (brain swelling) Children with asthma that show allergic reaction to aspirin -> replace with ibuprofen

[PP] A patient has rheumatoid arthritis and is prescribed with disease-modifying anti-rheumatic drugs (DMARDS) to retard the progress of bone and cartilage damage. Which of the following medications is used as a DMARD? A. Betamethasone B. Celecoxib C. Hydroxychloroquine D. Indomethacin

C Betamethasone: glucocorticoid Celecoxib, indomethacin: NSAIDS Hydroxychloroquine: DMARD (anti-malarial drug)

[Old PP] Packet labels of four drugs used in management of joint disorder include sulfasalazine, methotrexate, hydrochloroquine and tofacitinib. Which class are these four drugs grouped into?

Disease-modifying anti-rheumatic drugs (DMARDs)

[Old PP] Packet labels of four drugs used in management of joint disorder include sulfasalazine, methotrexate, hydrochloroquine and tofacitinib. Which one of them is considered first-line treatment?

Methotrexate (conventional synthetic DMARD, cytotoxic agent)

[Old PP] Packet labels of four drugs used in management of joint disorder include sulfasalazine, methotrexate, hydrochloroquine and tofacitinib. One of them is more recently approved and known to have a specific management of joint disorders. Name targeted synthetic molecule in this group.

Janus-activated kinase 1 and 3 (Tofacitinib)

[Old PP] Name one adverse effect associated with the use of targeted synthetic DMARDs. What investigation is necessary to assess patient’s suitability for this medication?

1. Increase risk of infection esp. herpes virus 2. Increase risk of non-melanoma skin cancer 3. Increase plasma level of liver enzymes => regular LFT 4. Increase plasma lipoproteins (LDL, HDL) 5. GI perforation 6. Anaemia, leukopenia, neutropenia, lymphopenia, thrombocytopenia Screen for latent or active TB (by tuberculin skin test) (and viral hepatitis) before initiation

[Old PP] Packet labels of four drugs used in the management of joint disorder include methotrexate, hydroxychloroquine, sulfasalazine and abatacept. One of them is a biological. Name the biologic in this group.

Abatacept (T-cell co-stimulation modulator / CTLA4-Ig)

[Old PP] List two major differences, in terms of structures and/or mechanisms of actions, between non-biological and biologics.

Structure: - Biologics are larger and more complex, e.g. antibodies and binding proteins MOA: - Biologics are more specific, e.g. block TNF-alpha

[Old PP] Name two adverse effectives associated with the use of biologics in the management of joint disorders. What investigation is necessary to assess suitability of biologics for treatment of patients?

1. Increase risk of infections esp. TNF-alpha blockers 2. Allergic / hypersensitivity / infusion reactions 3. Injection site irritation Screen for latent or active TB by tuberculin skin test (and viral hepatitis) before initiation

[Old PP] 5-year-old boy with fever and pain and is suspected to have influenza infection. Which of the following is the most suitable drug to use? A. Aspirin B. Ibuprofen C. Indomethacin D. Colchicine

[Old PP] A 65-year-old female patient has rheumatoid arthritis. She is obese and is taking statins to lower her cholesterol level. She also has gastric ulcer and osteoporosis. She is prescribed with celecoxib, a selective cyclooxygenase-2 inhibitor, to relieve her inflammatory symptoms due to rheumatoid arthritis. Which of the following is an adverse effect that she should be cautious of? A. Hypoglycaemia B. Infection C. Liver damage D. Metabolic acidosis E. Thrombosis

[Old PP] Patient with RA, given celecoxib (COX-2 inhibitor). What is the most likely adverse effect? A. Bleeding B. Hypoglycaemia C. Liver damage D. Peptic ulcer E. Renal insufficiency

[Old PP] A 65-year-old man is diagnosed as OA with knee pain. He is otherwise healthy except occasional stomachache. What is the most suitable drug for his knee pain? A. Allopurinol B. Aspirin C. Hydrocortisone D. Indomethacin E. Paracetamol

E Aspirin, indomethacin, hydrocortisone are contraindicated in peptic ulcer Hydrocortisone: short-acting

[Old PP] Name two differences between paracetamol and NSAIDS.

1. Paracetamol lacks anti-inflammatory effect (only analgesic and antipyretic) 2. Paracetamol does not cause GI bleeding

[Old PP] Sandra Walker is a 65-year-old lady from Armidale. She presents to her general practitioner with a 6-month history of painful hands, wrists and feet. You think this could be due to either osteoarthritis or rheumatoid arthritis. Mrs Walker begins treatment with naproxen. This drug would be expected to A. Selectively inhibit cyclooxygenase isoenzyme 2 B. Reduce potentiation of primary inflammatory mediators by prostaglandins C. Have no effect on platelet function D. Inhibit lipoxygenase pathway

[Old PP] Pain can be suppressed by A. Decreasing concentration of opioids at wound site B. Decreasing concentration of prostaglandins at wound site C. Increasing concentration of histamine at wound site D. Increasing concentration of substance P at wound site E. None of above

[PP] Tetanus is a potentially-life threatening infection in non-immune individuals. Name the organism causing tetanus. (2 marks)

Clostridium tetani Spore-forming anaerobic Gram-positive bacilli In soil & GI tract Entry through wounds

[PP] Name the main virulence factor of the organism causing tetanus. (1 mark)

Tetanospasmin (tetanus toxin) Also tetanolysin Other toxin-mediated infections - botulism (Clostridium botulinum) - diphtheria

[PP] What is the nature of the vaccine against tetanus? (1 mark)

Toxoid After recovery => must receive full vaccination

[PP] In non-immune individuals presenting with high risk tetanus-prone wounds, name one essential preventive measure in addition to local wound treatment, antibiotics, and vaccination. (1 mark)

Human tetanus immunoglobulin (TIG): antitoxin Antibiotics: metronidazole, penicillin Wound care, treat concomitant infections Antitoxin: human TIG Supportive care: muscle relaxants, cardiovascular and respiratory support

[PP] A patient complained of a painful mass in her right popliteal fossa. What are the superomedial, superolateral, inferomedial and inferolateral boundaries of the popliteal fossa, respectively? (4 marks)

Superomedial - semimembranosus (0.5 mark) and semitendinosus (0.5 mark) Superolateral - biceps femoris (1 mark) Inferomedial - medial head of gastrocnemius (1 mark) Inferolateral - lateral head of gastrocnemius (1 mark) Roof - skin, fascia Floor - popliteus, popliteal surface of femur, capsule of knee joint Content: AVN2 (medial to lateral) 1. Popliteal artery 2. Popliteal vein 3. Tibial nerve 4. Common fibular nerve

[PP] Which muscle forms part of the floor of the popliteal fossa? (1 mark)

Popliteus

[PP] What is the name of the fascial layer (indicated by X in the diagram) through which the cephalic vein pierces to join with a deep vein?

Clavipectoral fascia OR coracoclavicular fascia OR costocoracoid membrane

[PP] Which deep vein receives the cephalic vein?

Axillary vein

[PP] Name the artery (1 mark) and nerve (1 mark) that pierce the clavipectoral fascia.

Thoracoacromial artery Lateral pectoral nerve Cephalic vein Lymphatics / Lateral pectoral nerve Acromiothoracic / Thoracoacromial artery Pectoral nerve (lateral)

[PP] What is the name of the triangular depression/groove which contains the cephalic vein?

Deltopectoral triangle / Clavipectoral groove / Infraclavicular fossa Boundaries Superior: clavicle Lateral: deltoid Medial: pectoralis major

[PP] At which joint does inversion and eversion take place at?

Subtalar joint VS dorsiflexion / plantarflexion: ankle joint

[PP] Knowledge of the anatomy of tendons and neurovascular structures around the ankle region is important in positioning the portals during ankle arthroscopy. Which blood vessel (1 mark) and cutaneous nerve (1 mark) may be at risk if an anteromedial portal is used?

Great saphenous vein Saphenous nerve

[PP] Knowledge of the anatomy of tendons and neurovascular structures around the ankle region is important in positioning the portals during ankle arthroscopy. Which cutaneous nerve may be at risk if an anterolateral portal is used? (1 mark)

Superficial peroneal / fibular nerve

[PP] Give the action of tibialis anterior at ankle joint.

Dorsiflexion X inversion (at subtalar joint)

[PP] When asked to stand on his left foot, a patient showed a positive Trendelenburg sign with the pelvis dropping significantly toward the unsupported (right) side as shown in the figure. Damage to which nerve can lead to a positive Trendelenburg sign? (1 mark)

Superior gluteal nerve

[PP] When asked to stand on his left foot, a patient showed a positive Trendelenburg sign with the pelvis dropping significantly toward the unsupported (right) side as shown in the figure. Specify the muscle group and the side which is weakened or paralysed in this patient. (2 marks)

Hip / thigh abductors Left / Supported side

[PP] When asked to stand on his left foot, a patient showed a positive Trendelenburg sign with the pelvis dropping significantly toward the unsupported (right) side as shown in the figure. List the two muscles that are MOST LIKELY involved. (2 marks)

Left gluteus medius Left gluteus minimus

[PP] What is the relationship between the ulnar nerve and the pisiform bone at the wrist? (1 mark)

Ulnar nerve is lateral to pisiform

[PP] A cyclist consulted his doctor for tingling and increasing weakness in his right hand. After initial examination, the doctor suspected that the patient's complaints were due to compression of the ulnar nerve as it passes into the wrist. List four muscles that move the little finger which might be affected. (4 marks)

Abductor digiti minimi Flexor digiti minimi Opponens digiti minimi Lumbricals Palmar interosseous Palmar interossei: II, IV, V Dorsal interossei: II, III, IV

[PP] The sympathetic nervous system has a two-neuron efferent pathway. Through which structure do the presynaptic fibres enter the sympathetic chain from a spinal nerve? (1 mark)

White ramus communicans

[PP] Name any two destinations of the presynaptic fibres after they enter the sympathetic chain. (4 marks)

1. Prevertebral ganglion, e.g. celiac / superior mesenteric / inferior mesenteric ganglion, via splanchnic nerves 2. Paravertebral (sympathetic) ganglion at the level above or below

[PP] A patient came to the Accident and Emergency Department with dull abdominal pain. Through which pathway do preganglionic sympathetic fibres innervate the jejunum? A. They enter the sympathetic chain through the gray rami communicantes B. They exit the sympathetic chain through the gray rami communicantes C. They synapse in the superior mesenteric ganglia D. They synapse in the T10 paravertebral ganglia

[PP] The efferent pathways of the autonomic nervous system consist of two neurons. Where do the postsynaptic neurons of the secretomotor innervation of the floor of the oral cavity locate? A. C1 dorsal root ganglion B. Submandibular ganglion C. Superior mesenteric ganglion D. Trigeminal ganglion

B Parasympathetic secretomotor A, D: sensory C: sympathetic

[PP] A patient is diagnosed with osteoporosis, which is caused by the imbalance between bone resorption and bone formation. Which bone cell plays the role of bone formation? (1 mark)

Osteoblast

[PP] List four histological features of the bone cell responsible for bone resorption. (4 marks)

1. Large, multinucleated, mobile cells 2. Acidophilic cytoplasm 3. Ruffled border -> increase SA of bone resorption 4. Clear space -> region of cytoplasm that surrounds the ruffled border to isolate the region of osteolytic activity

[PP] A 77-year-old woman suffered from a mildly displaced oblique fracture of the distal radius and is being treated with a plaster cast. What is the expected mode of fracture healing for her?

Secondary bone healing For displaced fractures with any gap

[PP] A 77-year-old woman suffered from a mildly displaced oblique fracture of the distal radius and is being treated with a plaster cast. Please outline events in different stages and the time frame involved. (4 marks)

1. Bleeding / hematoma / hemostasis in hours 2. Inflammatory / exudate / resorptive / granulation phase in days 3. Proliferative phase / soft callus / hard callus formation in weeks (with collagen deposition, woven non-organised bone) 4. Remodelling phase in months (with reabsorption, rearrangement, replacement of collagen / mechanical adaptation to stress / formation of strong compact bone)

[PP] SKIN AND SOFT TISSUE INFECTIONS A. Aspergillus fumigatus B. Candida albicans C. Salmonella enterica D. Staphylococcus aureus E. Staphylococcus epidermidis F. Streptococcus pneumoniae G. Streptococcus pyogenes H. Trichophyton rubrum I. Vibrio cholerae J. Vibrio vulnificus For each of the following soft tissue infections, what is the MOST COMMON pathogen involved? Each option may be used once, more than once, or not at all. Cellulitis

[PP] Which of the following treatment modalities is the MOST IMPORTANT for chronic osteomyelitis? A. Adequate antibiotic coverage against anaerobic bacteria B. Combination of multiple antibiotics C. Hyperbaric oxygen D. Modulation of immune system by corticosteroids E. Surgical debridement of sequestrum

E Chronic osteomyelitis: - Surgical debridement of dead bone (sequestrum) - Prolonged antibiotics

[PP] A 52-year-old housewife developed rapidly progressive cellulitis of the left hand and forearm after sustaining a puncture wound of the index finger by a marine fish. Which of the following microbes is the MOST LIKELY cause of her cellulitis? A. Candida albicans B. Legionella pneumophila C. Staphylococcus aureus D. Streptococcus pneumoniae E. Vibrio vulnificus

[PP] Which of the following is the MOST COMMON cause of osteomyelitis in an otherwise healthy adult? A. Klebsiella pneumoniae B. Neisseria meningitidis C. Staphylococcus aureus D. Streptococcus pneumoniae

[PP] A 20-year-old lady presented with an acute onset of some lesions (photo below showing golden yellow crusty lesions) over the chin area for 2 days. Which of the following skin and soft tissue anatomical structures are affected in this disease? A. Epidermis B. Hair follicles C. Sebaceous glands D. Skin lymphatics

A Impetigo - S. aureus, GAS - Upper epidermis Erysipelas - beta-hemolytic Streptococci - Upper dermis with prominent lymphatic involvement

[PP] A 5-year-old child presents with honeycomb crusted plaques over the upper lip and philtrum. What is the LIKELY causative organism? A. Herpes simplex virus B. Staphylococcus epidermidis C. Streptococcus pyogenes D. Varicella zoster virus

C Impetigo HSV: vesicles -> shallow erosions VZV: scattered vesicles and erosions -> reactivation as herpes zoster

[ALW] In the flexion of elbow, name the agonist / prime mover, antagonist, synergist and fixator.

Agonist / prime mover: biceps brachii, brachialis Antagonist: triceps brachii Synergist: brachioradialis Fixator: deltoid (stabilise the arm)

[ALW] State the changes in muscle length and compare tension & opposing force in concentric, isometric and eccentric muscle contractions.

1. Concentric (isotonic) - Shortens - Tension > opposing force 2. Isometric - Remains unchanged - Tension = opposing force 3. Eccentric (isotonic) - Lengthens - Tension < opposing force

[PP] A 70-year-old man presented with a hard nodule on the extensor surface of the elbow. Excision performed and histology showed large eosinophilic acellular areas surrounded by macrophages and multinucleated giant cells. No bacteria are identified. What is the MOST LIKELY diagnosis? A. Abscess B. Chondrocalcinosis C. Gouty tophus D. Rheumatoid arthritis E. Tuberculosis granuloma

C Chalky white gouty tophus -> bone erosion Needle-shaped sodium urate crystals -> foreign body giant cell granulomatous reaction

[PP] A 75-year-old man presents with a 1-week history of acute pain in the right knee without fever. He does not improve with antibiotics and biopsy with aspiration of fluid from the joint is performed. The biopsy shows a purple area of granularity in the meniscus without giant cells or macrophages identified. What is the MOST LIKELY diagnosis? A. Gout B. Osteoarthritis C. Pseudogout D. Rheumatoid arthritis

C Calcification of meniscus Joint fluid aspirate -> rhomboid calcium pyrophosphate crystals

[PP] What is the name given for the inflamed granulation tissue arising from damaged synovium which can erode cartilage and bone in rheumatoid arthritis? A. Bone cyst B. Osteophyte C. Pannus D. Tophus

[PP] A 25-year-old lady presented to the rheumatology clinic with joint pain, hair loss, malar rash and oral ulcers for 1 year. She was positive for antinuclear antibodies. Physical examination showed no joint swelling but swan-neck deformity of her fingers was observed. Which condition best describes her joint problem? A. Gouty arthritis B. Jaccoud arthropathy C. Psoriatic arthritis D. Rheumatoid arthritis

B Juvenile onset arthropathy with positive ANA (anti-nuclear antibodies)

[PP] A 32-year-old lady presented to the rheumatology clinic with chronic back pain for 3 months. The pain worsened at night and was relieved by diclofenac. There was an episode of diarrhoea 3 weeks before the onset of back pain. Which condition BEST describes her joint problem? A. Ankylosing spondyloarthritis B. Infective spondylitis C. Prolapsed intervertebral disc D. Reactive arthritis

D Chronic inflammatory back pain with preceding dysentery -> reactive arthritis Diclofenac: NSAID

[PP] A 22-year-old gentleman is recently diagnosed to have axial spondyloarthritis. What is the associated eye problem? A. Anterior uveitis B. Cataract C. Glaucoma D. Keratoconjunctivitis sicca

[PP] Which of the following options is a major pre-requisite for primary bone healing to occur? A. There is an intact periosteum. B. There is formation of hard callus. C. There is laying down of woven bone. D. There is no fracture gap.

D Primary bone healing: - perfectly opposed fracture with no gap for hematoma Secondary bone healing - fracture gap for hematoma and then callus formation and remodelling of woven bone into compact bone Intact periosteum - provides nutrients which facilitates both types of bone healing

[PP] A 32-year-old pedestrian got hit by a passenger vehicle at 40 km/hour when crossing the road and was thrown off 5 metres. Which fracture pattern is MOST LIKELY to happen? A. Long wedge fracture of the tibia B. Oblique fracture of the tibia C. Spiral fracture of the femur D. Transverse fracture of the femur

D High energy injuries (acute bending at high velocity / direct impact to shaft of long bones) -> Transverse and highly comminuted fracture Low energy injuries (lower velocity / indirect bending or torsion) - Spiral, long oblique and wedge patterns are caused by lower level of energies with lower velocity indirect bending or torsion.

[PP] A 30-year-old arm wrestler suffered a spiral fracture of the distal humerus shaft. What is the MOST COMMON type of associated injury? A. Axonotmesis of the median nerve B. Contusion of the musculocutaneous nerve C. Laceration of the ulnar nerve D. Neuropraxia of the radial nerve

[Self-assessment] Patient A, a 20-year-old male, presents with fluctuating muscle weakness that worsens with activity and improves with rest. He complains of drooping eyelids and double vision, especially after prolonged reading or watching television. On examination, there is no sensory deficit, but fatigable weakness is noted in his ocular muscles. Which of the following is the most likely diagnosis for Patient A? A. Myasthenia Gravis B. Muscular Dystrophy C. Lambert-Eaton Syndrome D. Multiple Sclerosis

A Autoantibodies that attack and block acetylcholine receptors on muscle cells, leading to muscle weakness and fatigue

[Self-assessment] Which of the following best describes the pathogenesis of Myasthenia Gravis? A. Dysfunction of the neuromuscular junction due to acetylcholine receptor gene mutations B. Autoimmune attack on postsynaptic acetylcholine receptors by IgG antibodies C. Overexpression of muscle-specific kinase protein causing muscle weakness D. Deficiency of acetylcholinesterase leading to impaired neurotransmission

[PP] Sharon presents with a three month history of muscle weakness and fatigue. She initially noticed weakness in her eyelids, leading to drooping, and difficulty in maintaining eye contact. Over time, the weakness has spread to her face, making it difficult for her to smile or chew food properly. Which of the following is a characteristic feature of Myasthenia Gravis? A. Fasciculations B. Hemiparesis C. Bulbar muscle involvement D. Proximal muscle weakness

C dysphagia, speech difficulties, and facial weakness.

[PP] A 56-year-old female patient presents with a long history of pain in hands and wrists bilaterally. Examination reveals mildly swollen wrist and finger joints, slightly warm to touch. You want to further investigate if the patient may have rheumatoid arthritis. What is the BEST initial imaging test? A. MRI of the hands B. Ultrasound of the hands C. Whole body PET-CT scan D. X-ray of both hands

D Good bone and joint details Readily available

[PP] In suspected infective spondylodiscitis, what is the MOST sensitive and specific imaging modality? A. Computed tomography B. Magnetic resonance imaging C. Radiograph D. Radionuclide scan

B MRI: best soft tissue details of spine CT, radiography: bony pathology e.g. fractures (CT: more sensitive; Radiography: more cost-effective, first-line) Radionuclide scan (e.g. bone scan): functional information on bone remodelling -> bone metastases, osteomyelitis

[PP] Magnetic resonance imaging (MRI) is a “quantitative” assessment of intervertebral disc degeneration. Which of the following outcomes of intervertebral disc degeneration can be measured by MRI? A. Elasticity and the level of elastin B. Hydration and the amount of glycosaminoglycans C. Innervation and back pain D. Level of osteocalcin and the degree of mineralisation E. Tensile strength and the organisation of collagen fibres

B Signal intensity correlates with hydration

[PP] A 45-year-old male sustained an ankle injury whilst playing football. He attended Accident and Emergency Department. You are his attending physician. On examination, the left ankle is swollen, and tender on weight bearing. You suspect a fracture. What is the best initial imaging test to try to establish a diagnosis? A. CT scan of the ankle B. MRI of the ankle C. Ultrasound of the ankle D. X-ray of the ankle (AP and lateral views)

D Good bone and joint details Readily available

[PP] A 55-year-old male developed acute low back pain after lifting heavy objects. Thereafter, he developed persistent pain radiating down the right leg, associated with numbness in the right foot. As an attending doctor, you suspect a prolapsed intervertebral disc with nerve root compression in the lumbar spine region. What is the BEST imaging modality to help you make the diagnosis? A. Bone scan on the axial skeletons B. CT scan of the lumbar spine (with thin cuts) C. MRI of the lumbar spine D. XR lumbar spine (AP and Lateral Views)

C Best for spinal pathology

[PP] A 75-year-old male fell from height and hit his knee. He was admitted to the A&E. You are asked to examine the patient. You noticed red and swollen knee with minor abrasion and no open wound. There is severe tenderness around the joint line with joint effusion clinically. Which of the followings is the best for initial investigation? A. CT scan of knee B. MRI scan of knee C. Plain radiograph of knee D. Ultrasound

[Old PP] Mr Chan is a 30-year-old male presenting with superficial soft tissue mass in left shoulder that he has noted for 2 years. Lesion is soft and mobile on clinical examination. Which of following is BEST imaging modality as initial assessment? A. Bone scan B. Computed tomography C. Magnetic resonance imaging D. Positron emission tomography-computed tomography E. Ultrasonography

[Old PP] A 65-year-old man complain of lower back pain. Pain radiates to buttock and posterior thigh. He is suspected of sciatica due to S5/L1 dermatome numbness. Lumbar spine X-ray reveals normal bone structure. Which of following is best imaging method? A. Bone scan B. CT of spine C. MRI of spine D. Plain radiograph of pelvis E. Ultrasound

[Old PP] Septic arthritis A. Bone ankylosis is commonly seen. B. Joint space narrowing in acute phase on radiograph C. Radiograph is good for diagnosis. D. Bone sclerosis in acute phase on radiograph E. Ultrasound is good for diagnosis.

E Bone ankylosis (bone fusion) is only occasionally seen in subacute septic arthritis Joint space narrowing, reactive bone sclerosis only occurs in subacute septic arthritis In acute septic arthritis, initial radiographs are frequently normal Ultrasound can assist in guiding aspiration of effusion for microbiological analysis, it is good for visualising superficial soft tissue details

[Old PP] Which of following statements best describes Hill-Sachs lesion? A. A radiological defect shown as a tear on inferior aspect of acetabulum B. A radiological defect shown as a tear on inferior aspect of glenoid labrum C. A radiological defect shown as an indentation fracture of posterior aspect of humeral head D. A radiological defect shown as an indentation fracture of posterior aspect of glenoid labrum E. A lesion that is never associated with Bankart lesion

C Anterior shoulder dislocation -> posterolateral humeral head fracture Bankart lesion: tear in lower rim of labrum

[Self-assessment] Sarah, a fitness enthusiast, incorporates bicep curls into her routine. During this exercise, she focuses on the concentric contraction phase, where the muscle shortens as it generates force. By lifting a challenging weight, she feels her bicep muscles working hard with each curl. Sarah emphasizes control and form to maximize the benefits of concentric contraction. She values the effectiveness of this phase in building muscle strength and endurance, and looks forward to progressing in her strength training program. In the case study of Sarah's strength training program, what happens during eccentric contraction? A. The muscle does not generate any force B. The muscle lengthens while generating force C. The muscle shortens while generating force D. The muscle remains at a constant length while generating force

B The muscle is actively resisting a force that is trying to lengthen it E.g. lowering a weight in strength training Isometric contraction (tension = opposing force) - muscle generates tension but no change in length - because tension generated < force required to move the load Isotonic contraction: - changing length, constant tension / force that is enough to move the load 1. Concentric contraction (tension > opposing force): muscle shortens (weight attached is less than its peak tension capabilities) 2. Eccentric contraction (tension < opposing force): muscle elongates (when it ends, unopposed load stretches the muscle -> muscle / tendon tear OR elastic recoil of skeletal muscle to oppose the load again)

[PP] The nervous system communicates with skeletal muscles at the neuromuscular junction. How does the membrane permeability change when acetylcholine binds to receptors in muscle fibres? A. Decreased membrane permeability to calcium ions B. Decreased membrane permeability to sodium ions C. Increased membrane permeability to calcium ions D. Increased membrane permeability to sodium ions

D ACh binding -> Sodium influx -> membrane depolarisation

[PP] Recent research studies have indicated that intravenous immunoglobulin is an effective treatment for many patients with autoimmune myasthenia gravis. What is the possible action of intravenous immunoglobulin? A. Inhibiting acetylcholine degradation B. Inhibiting acetylcholine reuptake C. Neutralising the antibodies against acetylcholine receptors D. Promoting the synthesis of acetylcholine receptors

[PP] Pyridostigmine has been used as a treatment for myasthenia gravis. What is the action of pyridostigmine? A. Inhibition of acetylcholine degradation B. Inhibition of acetylcholine receptor endocytosis C. Inhibition of acetylcholine reuptake D. Inhibition of acetylcholine synthesis

A AChE inhibitor - reduce degradation of ACh -> more ACh in NMJ -> strengthen neuromuscular transmission Disadvantage: effect starts to wear off after a few hours

[PP] Motor unit recruitment refers to the spatial and/or temporal summation of forces generated by voluntary muscle contraction. What explains the temporal recruitment of motor units to produce a greater force? A. Activating more muscle fibres in a motor unit B. Activating more motor units in muscle contraction C. Increasing the amplitude of action potentials in motor neurons D. Increasing the frequency of action potentials in motor neurons

D Spatial recruitment (B): increasing no. of active motor units Temporal recruitment (D): increase firing frequency of motor neurons -> increase strength of voluntary muscle contraction

[PP] Excitation-contraction coupling is the link between the generation of an action potential in the sarcolemma and the start of a muscle contraction. Describe how the action potential in the sarcolemma is initiated? (2 marks)

Somatic motor neuron releases ACh into NMJ -> ACh binds to nicotinic ACh receptors -> Opening of Na+ channels -> Na+ influx -> Sarcolemma depolarisation

[PP] Excitation-contraction coupling is the link between the generation of an action potential in the sarcolemma and the start of a muscle contraction. Describe the source and role of calcium ions in the contraction cycle. (3 marks)

Source: sarcoplasmic reticulum (major), extracellular Ca2+ (minor) Role: Upon depolarisation, action potential travels down -> Ca2+ release from sarcoplasmic reticulum -> Ca2+ binds to troponin -> Positional change in tropomyosin -> Expose actin binding sites for myosin -> Cross-bridge formation (binding of actin with myosin) -> start of contraction cycle

[PP] What is seropositive MG?

MG with detectable autoantibodies in blood against postsynaptic AChR

[PP] Name the well-characterized autoantibody in MG pathogenesis.

Anti-AChR antibodies Also Anti-MuSK (muscle-specific kinase)

[PP] Name three different serological tests for MG diagnosis.

1. Enzyme-linked immunosorbent assay (ELISA) - Sensitive, quantitative assay to detect and measure circulating IgG autoantibodies in serum - Colour detection 2. Radioimmunoprecipitation (RIPA) assay / Radioimmunoassay (RIA) - Radioactive alpha-bungarotoxin to detect pathogenic autoantibodies against AChR in a test tube - Radioactive signal 3. Cell-based assay (CBA) - Postsynaptic protein (AChR / MuSK) expressed in heterologous cells to detect the binding of pathogenic autoantibodies - Fluorescence signal

[PP] The latissimus dorsi muscle is often harvested for use in reconstructive surgery. Which of the following movements can be affected by the loss of this muscle? A. Abduction of the arm B. Extension of the arm C. Lateral rotation of the arm D. Rotation of the scapula

B Adduction, extension, medial rotation (Latissimus dorsi, teres major)

[PP] The radiograph of a 30-year-old woman showed an isolated avulsion fracture of the lesser tubercle of her right humerus. Which muscle is inserted at this bony prominence? A. Pectoralis major B. Subscapularis C. Supraspinatus D. Teres major

B Rotator cuff muscles Subscapularis -> lesser tubercle: medial rotation Suprascapularis (first 15° of abduction), infrascapularis, teres minor (lateral rotation) -> greater tubercle Pectoralis major -> lateral lip of intertubercular groove Teres major -> medial lip of intertubercular groove

[PP] A construction worker fell from an elevated work platform and fractured the coracoid process of his left scapula. Which muscle is inserted on this bony process? A. Coracobrachialis B. Long head of the biceps brachii C. Pectoralis major D. Pectoralis minor E. Short head of biceps brachii

D Origin: 3rd to 5th ribs Insertion: coracoid process A, E: originate from coracoid process

[PP] A 23-year-old man who was stabbed in the area of the posterior axillary fold during a gang fight complained of weakness in extending and adducting his left arm. Which muscle is likely to be involved? A. Infraspinatus B. Latissimus dorsi C. Pectoralis major D. Serratus anterior E. Trapezius

[PP] A medical student slipped on his way to class. He had his hand outstretched to break the fall and as a result fractured a carpal bone deep to the anatomical snuff box. Which carpal bone is this? A. Capitate B. Hamate C. Lunate D. Pisiform E. Scaphoid

[PP] An elderly woman presented with a painful and deformed wrist after falling in the bathroom. X-ray showed a transverse fracture of her right radius, about 2 cm proximal to the wrist joint. Which of the following muscles is inserted on the distal fragment? A. Brachioradialis B. Extensor carpi radialis brevis C. Flexor carpi radialis D. Pronator teres

A Brachioradialis -> distal end of radius (base of styloid process): flex elbow in mid-prone position Extensor carpi radialis longus (superficial) -> base of 2nd metacarpal Extensor carpi radialis brevis (superficial) -> base of 3rd metacarpal Flexor carpi radialis -> base of 2nd & 3rd metacarpals Pronator teres -> mid-shaft of radius

[PP] A doctor performed the Modified Allen Test on a patient, which involves compressing the patient's radial and ulnar arteries at the wrist, to assess the collateral circulation in the hands. The radial artery is lateral to which tendon at the wrist level? (1 mark)

Flexor carpi radialis

[PP] A doctor performed the Modified Allen Test on a patient, which involves compressing the patient's radial and ulnar arteries at the wrist, to assess the collateral circulation in the hands. The ulnar artery is lateral to which tendon at the wrist level? (1 mark)

Flexor carpi ulnaris

[PP] A doctor performed the Modified Allen Test on a patient, which involves compressing the patient's radial and ulnar arteries at the wrist, to assess the collateral circulation in the hands. At the level of the flexor retinaculum, which bony landmark can be used to locate the ulnar artery, and what is its relation to the artery? (2 marks)

Pisiform Medial to ulnar artery

[PP] A doctor performed the Modified Allen Test on a patient, which involves compressing the patient's radial and ulnar arteries at the wrist, to assess the collateral circulation in the hands. Name the vascular structure that is the direct continuation of the ulnar artery in the hand. (1 mark)

Superficial palmar arch

[PP, formative] The bone tissue plays important roles in electrolyte balance. The activity of which type of cells in bone tissue will increase to maintain calcium balance when blood calcium level is high? A. Fibroblast B. Megakaryocyte C. Osteoblast D. Osteoclast

[PP] A 62-year-old diabetic man was seen in the clinic for itchy and scaly lesions over the groins for 4 weeks. The lesions were spreading to the lower abdominal wall. What is the MOST LIKELY clinical diagnosis? (2 marks)

Tinea / Ringworm

[PP] Name one organism that is commonly associated with tinea in Hong Kong. (2 marks)

Trichophyton rubrum

[PP] Name one drug that can be used for systemic treatment of tinea. (1 mark)

Fluconazole Itraconazole Terbinafine

[ALW] A family had their first child with bilateral polydactyly affecting both hands and feet. Is this a genetic condition?

Yes Because it is bilateral

[ALW] A family had their first child with bilateral polydactyly affecting both hands and feet. Which genetic test should the geneticist recommend? Rank from the most suitable to the least suitable.

Selected panel of genes Exome sequencing Whole genome sequencing Main consideration: cost Second consideration: identification of novel mutations in normal genes

[ALW] Is testing only the affected child sufficient in the assessment of an unknown genetic condition?

No Could be sporadic / inherited mutation Need to determine inheritance pattern

[ALW] Bilateral polydactyly. Along which axis of limb development would the mutant gene have an impact? A. Proximal/distal B. Anterior/posterior C. Dorsal/ventral

B Anterior: radius Posterior: ulna

[ALW] Bilateral polydactyly. Propose the potential mutant gene.

Sonic hedgehog (Shh): Ligand for receptor Patched Patched (Ptc): receptor Smoothened (Smo): transducer Downstream partners in Gli complex

[ALW] A sporadic mutation in FGFR3 gene was detected. What phenotype would the child develop with postnatal growth?

Achondroplasia FGFR3 signalling affects chondrocyte proliferation in growth plate FGF = fibroblast growth factor

[ALW] Which zone of the growth plate is the action of FGFR3 signalling? A. Reserve zone B. Proliferative zone C. Hypertrophic zone

[ALW] If there is a pharmacological treatment for achondroplasia to inhibit FGFR3 signalling pathway, which period of patient growth will provide the golden window for pharmacological intervention? A. After infancy to adolescence B. Childhood to adulthood C. Adolescence to adulthood

A Maximal growth Treatment during adulthood has no effect as growth plate is close Prebirth treatment is avoided as it is unsafe

[PP] Achondroplasia is caused by gain-of-function mutations in the receptor, FGFR3, normally expressed in the cartilage growth plates of long bones. Which cellular process in the cartilage growth plate will be affected? A. Differentiation of chondrocytes to hypertrophic chondrocytes B. Differentiation of hypertrophic chondrocytes to osteoblasts C. Proliferation of chondrocytes D. Proliferation of hypertrophic chondrocytes E. Survival of chondrocytes

[PP] Patterning of the developing limb bones is controlled by defined molecular signals along the proximal-distal, anterior-posterior, and dorsal-ventral axes. Changes in which of the following molecular signals can alter the anterior-posterior axis affecting digit formation? A. Bone morphogenetic protein B. Fibroblast growth factor C. Hedgehog D. Transforming growth factor E. Wnt

C Anterior/posterior patterning, growth (e.g. identity, number of digits) - Shh signalling from Zone of Polarising Activity (ZPA) on posterior side - morphogens diffuse to anterior side to cause a gradient - cells in mesenchyme read the gradient to determine their fate

[PP] Gain-of-function mutations in the Fibroblast Growth Factor Receptor 3 (FGFR3) cause Achondroplasia, a form of dwarfism. (a) What is the definition of gain-of-function in the context of these mutations? (1 mark)

Activity of FGFR3 is enhanced either in the presence of in some instance the absence of ligands

[PP] Gain-of-function mutations in the Fibroblast Growth Factor Receptor 3 (FGFR3) cause Achondroplasia, a form of dwarfism. Which process of bone formation will be affected? (1 mark)

Endochondral ossification

[PP] Gain-of-function mutations in the Fibroblast Growth Factor Receptor 3 (FGFR3) cause Achondroplasia, a form of dwarfism. What cellular process is being affected? (1 mark)

Reduced chondrocyte proliferation

[PP] Gain-of-function mutations in the Fibroblast Growth Factor Receptor 3 (FGFR3) cause Achondroplasia, a form of dwarfism. If a drug can correct the action of the mutation, will this drug be useful throughout life? Explain. (2 marks)

No Of benefit only prior to puberty, when growth of long bones is still active

[PP] In the healing process of a bone fracture, membranous bone formation occurs with progenitor cells originating from the periosteum, while endochondral bone formation occurs with progenitor cells in the bony callus. Define the key initial cellular differentiation step in membranous bone formation.

Differentiation of progenitor cells directly into functional osteoblasts

[PP] In the healing process of a bone fracture, membranous bone formation occurs with progenitor cells originating from the periosteum, while endochondral bone formation occurs with progenitor cells in the bony callus. Which key transcription factor is involved in controlling this process? (1 mark)

RUNX2 / Osterix

[PP] In the healing process of a bone fracture, membranous bone formation occurs with progenitor cells originating from the periosteum, while endochondral bone formation occurs with progenitor cells in the bony callus. Define the key cellular differentiation processes in endochondral ossification.

Differentiation of progenitor cells into chondrocytes, forming a cartilage tissue Then undergo hypertrophy and then convert to bone

[PP] In the healing process of a bone fracture, membranous bone formation occurs with progenitor cells originating from the periosteum, while endochondral bone formation occurs with progenitor cells in the bony callus. Which key transcription factor is involved in initiating this process? (1 mark)

SOX9

[PP] A 23-year-old man was hit by a minibus and was admitted for a fractured tibia. List five reasons why this type of injury is potentially serious to the patient. (5 marks)

1. High-energy injury is associated with multiple fractures 2. Risk of associated life-threatening trauma to trunk / chest / abdomen / head 3. Risk of blood loss / hypovolaemic shock 4. Risk of damage of local soft tissues / skin 5. Injury to nerves 6. Blood vessels cause future complications 7. Open fractures have higher risk of infections / amputations 8. Younger patients are financially vulnerable to loss of income and job

[PP] GANGLIA IN THE PERIPHERAL NERVOUS SYSTEM A. Celiac ganglion B. Ciliary ganglion C. Geniculate ganglion D. Inferior mesenteric ganglion E. Otic ganglion F. Pterygopalatine ganglion G. Stellate ganglion H. Submandibular ganglion I. Superior mesenteric ganglion J. Trigeminal ganglion Match the ganglion to the description. The option may be used once, more than once, or not at all. Contains the postsynaptic neurones for the presynaptic parasympathetic fibres from CNVII, innervating the nasal cavity

[PP] GANGLIA IN THE PERIPHERAL NERVOUS SYSTEM A. Celiac ganglion B. Ciliary ganglion C. Geniculate ganglion D. Inferior mesenteric ganglion E. Otic ganglion F. Pterygopalatine ganglion G. Stellate ganglion H. Submandibular ganglion I. Superior mesenteric ganglion J. Trigeminal ganglion Match the ganglion to the description. The option may be used once, more than once, or not at all. Destination for presynaptic fibres of lesser splanchnic nerve

[PP) Mr. Lee, 53-year-old male, is suffering from a herniated disk in the lower back. Mr. Lee works as a construction worker and his job requires him to lift heavy objects and stand for a long period of time. What is the MOST EFFECTIVE way that the work environment can be modified to support Mr. Lee returning to work? A. Allowing to work from home B. Implementing a job rotation schedule C. Providing ergonomic chairs and standing desks D. Providing workplace education

[PP] Which of the following drug regimens is appropriate for the treatment of Mycobacterium marinum tenosynovitis? A. Isoniazid + rifampicin B. Isoniazid + rifampicin + pyrazinamide + ethambutol C. Rifampicin + ethambutol D. Streptomycin + pyrazinamide

[PP] A patient has Horner syndrome, with ptosis and miosis. The presynaptic sympathetic fibres that are affected MOST LIKELY travel through the white ramus of which spinal nerve? A. C2 B. L1 C. L5 D. T1

[PP] During the development of the limbs, three signalling centres coordinate the growth and patterning along three spatial axes. Which of the following is responsible for anteroposterior patterning? A. Apical ectodermal ridge (AER) B. Non-AER ectoderm C. Progress zone D. Zone of polarising activity

[PP] Reflex impairment can be caused by a damage to any part of the reflex arc, which typically consists of receptor, sensory neuron, integration centre, motor neuron, and effector. Which receptor detects the stimulus that triggers the flexor reflex? (1 mark)

Pain receptor / Nociceptor

[PP] Reflex impairment can be caused by a damage to any part of the reflex arc, which typically consists of receptor, sensory neuron, integration centre, motor neuron, and effector. What is the integration centre of the defecation reflex? (1 mark)

Spinal cord

[PP] Reflex impairment can be caused by a damage to any part of the reflex arc, which typically consists of receptor, sensory neuron, integration centre, motor neuron, and effector. Which muscle is the effector of the pupillary light reflex? (1 mark)

Pupillary constrictor muscle / Pupillary sphincter

[PP] Reflex impairment can be caused by a damage to any part of the reflex arc, which typically consists of receptor, sensory neuron, integration centre, motor neuron, and effector. Which nerve transmits both afferent and efferent signals of the baroreceptor reflex? (1 mark)

Vagus nerve

[PP] Reflex impairment can be caused by a damage to any part of the reflex arc, which typically consists of receptor, sensory neuron, integration centre, motor neuron, and effector. What is the response of the plantar reflex in normal adults? (1 mark)

Flexion of toes

[PP] Which NSAID is contraindicated with the use of allopurinol? (1 mark)

Aspirin (salicylate)

[PP] How does allopurinol treat gouty arthritis?

Xanthine oxidase inhibitor Xanthine oxidase converts allopurinol to alloxanthine -> inhibit xanthine oxidase from converting hypoxanthine -> xanthine -> uric acid -> decrease plasma uric acid Also febuxostat (non-competitive inhibitor of xanthine oxidase)

[PP] Precise cellular changes within the cartilage growth plates coordinate the linear growth of long bones through endochondral ossification. What is the sequence of events for this process? A. Chondrocyte hypertrophy, mineralisation of cartilage, proliferation of chondrocytes B. Chondrocyte hypertrophy, proliferation of chondrocytes, mineralisation of cartilage C. Chondrocyte proliferation, chondrocyte hypertrophy, mineralisation of cartilage D. Chondrocyte proliferation, mineralisation of cartilage, chondrocyte hypertrophy

[PP, formative] Name one muscle that is innervated by musculocutaneous nerve (C5-7).

Coracobrachialis Biceps brachii Brachialis

[PP, formative] List two muscles of the arm that are innervated by median nerve.

Muscles of anterior forearm (except FCU & medial half of FDP) Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, lateral half of flexor digitorum profundus, flexor pollicis longus, pronator quadratus

[PP, formative] Name two actions of tibialis anterior.

Dorsiflexion Inversion

[PP, formative] Which nerve innervates tibialis anterior?

Deep fibular / peroneal nerve Also fibularis tertius, extensor hallucis longus, extensor digitorum longus

[PP, formative] Which nerve innervates fibularis longus?

Superficial fibular / peroneal nerve Also fibularis brevis

[PP, formative] A. Biceps brachii B. Brachioradialis C. Coracobrachialis D. Deltoid E. Extensor carpi radialis F. Extensor carpi ulnaris G. Flexor carpi radialis H. Flexor carpi ulnaris I. Teres major J. Teres minor Link an appropriate option to each stem. The option may be used once, more than once, or not at all. Supinates the forearm.

[PP, formative] A 6-month-old infant presents with a congenital limb malformation characterised by the absence of the radius and a shortened forearm. Source: Chen H. Atlas of Genetic Diagnosis and Counseling. Springer 2017 Which of the following processes is MOST LIKELY disrupted during embryogenesis of this patient? A. Apoptosis of mesenchymal cells B. Formation of the Apical Ectodermal Ridge (AER) C. Migration of neural crest cells D. Secondary ossification

[PP] A patient has difficulty in abducting the arm, and extending the elbow and wrist joints. Which neural structure is MOST LIKELY damaged? A. Axillary nerve B. Lateral cord of the brachial plexus C. Posterior cord of the brachial plexus D. Radial nerve E. Suprascapular nerve

C Axillary nerve (C5-6) -> deltoid (first 45° abduction) Radial nerve (C5-T1) -> posterior (extensor) muscles of arm and forearm

[PP] MUSCLES OF THE UPPER LIMB AND THEIR INNERVATION A. Coracobrachialis B. Deltoid C. Infraspinatus D. Latissimus dorsi E. Pectoralis major F. Pectoralis minor G. Serratus anterior H. Teres major I. Teres minor J. Trapezius It is innervated exclusively by a branch of the lateral cord of the brachial plexus.

A Musculocutaneous nerve (C5-C7)

[PP] MUSCLES OF THE UPPER LIMB AND THEIR INNERVATION A. Coracobrachialis B. Deltoid C. Infraspinatus D. Latissimus dorsi E. Pectoralis major F. Pectoralis minor G. Serratus anterior H. Teres major I. Teres minor J. Trapezius It receives dual innervation from branches of the medial and lateral cords of the brachial plexus.

E Medial pectoral nerve (C8) + lateral pectoral nerve (C5-7)

[PP] MUSCLES OF THE UPPER LIMB AND THEIR INNERVATION A. Coracobrachialis B. Deltoid C. Infraspinatus D. Latissimus dorsi E. Pectoralis major F. Pectoralis minor G. Serratus anterior H. Teres major I. Teres minor J. Trapezius It is innervated by a branch from the C5, C6 and C7 roots of the brachial plexus.

G Long thoracic nerve (C5-C7) SALT

[PP] MUSCLES OF THE UPPER LIMB AND THEIR INNERVATION A. Coracobrachialis B. Deltoid C. Infraspinatus D. Latissimus dorsi E. Pectoralis major F. Pectoralis minor G. Serratus anterior H. Teres major I. Teres minor J. Trapezius It is supplied by a branch of the upper trunk of the brachial plexus.

C Upper trunk -> nerve to subclavius (C5-6), suprascapular nerve (C5-6) Suprascapular nerve -> supraspinatus, infraspinatus

H Posterior cord -> upper & lower subscapular nerves (C5-C6), thoracodorsal nerve (C6-8) Subscapularis: upper & lower subscapular nerves Teres major: lower subscapular nerve

[PP] An 18-year-old male student complained of numbness, tingling and pain in the thumb side half of the right hand. He also complained of the difficulties in opening a water bottle and moving the thumb across the palm. There was no numbness or weakness proximal to the right hand. Which nerve is MOST LIKELY damaged? A. Median nerve B. Musculocutaneous nerve C. Radial nerve D. Ulnar nerve

[PP] A 35-year-old man who recently had an appendectomy complains of pain in the right lower abdomen, scrotum and upper thigh. There was also sensory loss over the femoral triangle. You suspect that the neuralgia was associated with a nerve that pierces the anterior surface of the psoas major muscle. What is the name of this nerve? A. Femoral nerve B. Genitofemoral nerve C. Iliohypogastric nerve D. Obturator nerve

B Genitofemoral nerve: anterior to psoas major Femoral, iliohypogastric nerve: lateral to psoas major Obturator nerve: medial to psoas major

[PP] A nerve that runs along the medial border of the psoas major muscle at the pelvic brim was accidentally damaged during surgical drainage of a psoas abscess. Which of the following movements of the thigh is MOST LIKELY to be lost or weakened? A. Abduction B. Adduction C. Extension D. Flexion

[PP] MUSCLES THAT MOVE THE HIP JOINT A. Gluteus maximus B. Gluteus medius C. Gluteus minimus D. Inferior gemellus E. Obturator externus F. Obturator internus G. Piriformis H. Quadratus femoris I. Superior gemellus J. Tensor fascia lata It is innervated by the inferior gluteal nerve.

A Inferior gluteal nerve -> gluteus maximus Superior gluteal nerve -> gluteus medius, gluteus minimus, tensor fasciae latae

E Tendon is outside the hip joint capsule -> lubricated by bursa

E Obturator nerve (L2-L4) -> hip adductors, obturator externus

[PP] A 55-year-old woman has tortuous, dilated vessels visible on the posterior aspect of her leg (calf). Which vessels are these likely to be? A. Peroneal veins B. Posterior tibial veins C. Sural veins D. Tributaries of the great saphenous vein E. Tributaries of the small saphenous vein

[PP] A man came into the Emergency Room with profuse bleeding from the femoral vessels due to a penetrating wound in the mid-thigh level deep to the sartorius muscle. What is the name of the space in which the femoral vessels were perforated? A. Adductor canal B. Adductor hiatus C. Femoral canal D. Femoral triangle E. Popliteal fossa

A Femoral triangle -> adductor canal (subsartorial canal) -> adductor hiatus (in adductor magnus) -> popliteal fossa

D ZPA: anteroposterior / cranio-caudal patterning AER: proximal-distal patterning

[PP] A baby girl was born with a lobster claw hand deformity in which the middle finger was missing in both hands. Which embryonic structure was likely to be defective during limb development? A. Apical ectodermal ridge B. Progress zone C. Proliferative zone D. Zone of polarising activity

A Defect in central part of AER -> failure of metacarpal and phalanges of middle finger to develop Ectopic anterior ZPA -> duplicate thumb (polydactyly)

[PP] Clinical assessment of stretch reflexes helps with localisation of neural lesions or neuropathy. Which stretch reflex can be diminished in C7 radiculopathy? A. Achilles reflex B. Biceps reflex C. Patellar reflex D. Triceps reflex

D Biceps reflex: C5-C6 Brachioradialis reflex: C5-C6 Triceps reflex: C7-C8 Knee jerk / Patellar reflex: L4-L5 Ankle jerk / Achilles reflex: S1-S2

[PP] An interruption along a reflex pathway impairs the reflex. Damage to which of the following fibres would directly cause abnormal sensory signal in the stretch reflex? A. Alpha motor nerve fibres B. Extrafusal muscle fibres C. Group Ib fibres D. Intrafusal muscle fibres

D Extrafusal muscle fibres: alpha motor neurons Infrafusal muscle fibres: Ia sensory fibres, gamma motor neurons

[PP] In the withdrawal reflex, the flexor contracts whereas the extensor relaxes. What triggers relaxation of the quadriceps when a leg withdraws from a painful stimulus? A. Activation of alpha motor neurons in the spinal cord B. Activation of inhibitory interneurons in the spinal cord C. Inhibition of excitatory interneurons in the spinal cord D. Inhibition of inhibitory interneurons in the spinal cord

B Flexor: alpha motor neurons Extensor: inhibitory interneurons

[PP] The pupillary light reflex serves as a clinical indicator of visual function. What abnormality is observed in a patient with an efferent defect of the left eye? A. Impaired pupillary constriction of both eyes when the left eye is stimulated B. Impaired pupillary constriction of both eyes when the right eye is stimulated C. Impaired pupillary constriction of left eye when either eye is stimulated D. Impaired pupillary constriction of right eye when either eye is stimulated

[PP] ASSESSMENT OF HUMAN REFLEXES IN NEUROLOGICAL EXAMINATIONS A. Ankle eversion B. Ankle inversion C. Dorsiflexion D. Elbow extension E. Elbow flexion F. Knee extension G. Knee flexion H. Plantar flexion I. Shoulder extension J. Shoulder flexion For each of the following reflexes, select the normal motor response from the list of options above. Each option may be used once, more than once, or not at all. Ankle jerk reflex

[PP] Which is the pathway for sensory transmission of the following reflexes? Each option may be used once, more than once, or not at all. A. Optic nerve B. Ia afferent C. Ib afferent D. II afferent E. Oculomotor nerve F. Glossopharyngeal nerve G. Pain afferent Q29 H. Phrenic nerve I. Hypoglossal nerve J. Preganglionic fibres Q30 K. Post-ganglionic fibres Golgi tendon reflex

[PP] A. Celiac ganglion B. Superior mesenteric ganglion C. Inferior mesenteric ganglion D. Superior hypogastric plexus E. Inferior hypogastric plexus F. Vagus nerve G. Sacral splanchnic nerves H. Pelvic splanchnic nerves I. Thoracic splanchnic nerves Parasympathetic supply of stomach

F Foregut & midgut: vagus nerve Hindgut: pelvic splanchnic nerve

[PP] 80 y/o man, acute pain for 2 months. Afebrile, no response to antibiotics. Biopsy showed purple granulation without the presence of giant cells and macrophages. What is the most correct diagnosis? A. OA B. RA C. Gout D. Calcium pyrophosphate dihydrate deposition disease

[PP] What is the likely causative agent of osteomyelitis in an adult, otherwise healthy? A. Streptococcus pneumoniae B. Klebsiella pneumoniae C. Neissereia meningitidis D. Staphylococcus aureus

[PP] A woman excessively inverted her ankle when she was descending a flight of stairs. Which of the following ligament is the most likely to be sprained? A. Anterior talofibular ligament B. Long plantar ligament C. Spring ligament D. Talocalcaneal interosseous ligament

A Lateral: anterior / posterior talofibular ligament & calcaneofibular ligament Medial: deltoid ligament

[PP] Loss of latissimus dorsi, which movement will be affected? A. Abduction of arm B. Extension of arm C. Lateral rotation of arm D. Rotation of scapula

B Extension, adduction, medial rotation of arm

[PP] A patient suffered from a cut injury to the radial nerve at the level of the mid humerus. Which of the following is the MOST LIKELY clinical feature? A. Weakness in extending his elbow B. Weakness in opening up his palm C. Weakness in the abduction of the thumb D. Weakness in the flexion of the little finger

[PP] MUSCLES OF THE LEG A. Fibularis brevis B. Fibularis longus C. Fibularis tertius D. Flexor digitorum longus E. Flexor hallucis longus F. Gastrocnemius G. Popliteus H. Soleus I. Tibialis anterior J. Tibialis posterior For each of the following descriptions, select the MOST RELEVANT muscle from the list of options. The option may be used once, more than once, or not at all. It rotates the knee joint.

[PP] [PP] A patient's radiological examination showed a bony spur (osteophyte) narrowing the intervertebral foramen at level L1-L2. Which spinal nerve was impinged? A. L1 B. L2 C. L3 D. T12

Pupillary light reflex

[PP] A 30-year-old man presented with head injuries in a traffic accident. His vital signs were normal but he was unconscious. Physical examination of the pupillary responses to light was performed. How does a lesion in the following structures affect the reflexive responses on his left eye? (i) Right oculomotor nerve (2 marks) (ii) Left optic nerve (2 marks)

i. Normal direct and consensual responses ii. Impaired direct response, normal consensual response

[PP] A 60-year-old retired delivery man presented to his local doctor with complaints of a 6- month history of stiffness and pain in the right knee. He reported difficulty in walking. There were no other joints involved and no systemic symptoms. On physical examination he was obese. There was swelling and deformity of the right knee joint. (a) List three changes that may be present on plain radiography of the right knee joint. (3 marks) (b) Explain the pathological change for any one of these changes. (1 mark) (c) What is your most likely diagnosis? (1 mark)

(a) Loss of joint space (erosion of cartilage, eburnation) Osteophyte formation Subchondral cyst Subchondral sclerosis (b) Subchondral cyst: increased pressure -> synovial fluid is drawn from joint space into subchondral bone (lower pressure) Osteophyte formation: remodelling to adapt to abnormal weight distribution (c) Osteoarthritis

[PP] ECM of cartilage (a) What is the use of Type 2 collagen (1m) (b) What is the use of aggrecan? (1m) (c) How do these work together to give the structural property of cartilage? (2m) (d) Name of the class of enzymes that degrade collagen?

(a) Provide tensile strength (b) Retains water -> swelling pressure, compressive strength, shock absorption (c) Type 2 collagen provides tensile strength, aggrecan provides compressive strength -> structural support and shock absorption (d) Matrix metalloproteinases (MMP)

[Old PP] What is the most common relationship between the sciatic nerve and the piriformis muscle at the greater sciatic foramen? (1 mark)

Sciatic nerve is inferior to piriformis Superior gluteal VAN: superior to piriformis All others: inferior to piriformis

[Old PP] What is the main action of the piriformis muscle? (1 mark)

Lateral rotation of hip Piriformis Superior gemellus Obturator internus Inferior gemellus Quadratus femoris Obturator externus

[Old PP] Besides the sciatic nerve, name three other nerves / vessels that exit from the greater sciatic foramen. (6 marks)

Superior gluteal VAN (superior to piriformis) Inferior to piriformis: Inferior gluteal VAN Pudendal nerve Internal pudendal vessels Nerve to quadratus femoris Posterior femoral cutaneous nerve

[Old PP] A 35-year-old male with a history of trauma to his right buttock was diagnosed with piriformis syndrome, which is a condition in which the sciatic nerve is irritated or compressed by the piriformis muscle as it passes through the greater sciatic foramen. If, in addition to sciatica, the patient also complains of weakness in hip abduction, what other nerve is most likely to be compressed? (2 marks)

Superior gluteal nerve (compressed -> Trenbelenburg sign) Hip abductors: gluteus medius, gluteus minimus

[Old PP] Which areas of skin in the lower limb are innervated by sciatic nerve? (3 marks)

Posterior and lateral aspects of leg Dorsum and sole of foot

[Old PP] Where is the 'safe' area for intramuscular injections at the buttock? (2 marks)

Upper lateral quadrant of hip / anterior part of gluteus maximus Avoid triangular area formed by PSIS, ischial tuberosity, greater trochanter

[Old PP] Sciatic nerve may be damaged by a careless intramuscular injection at the gluteal region. Which muscle groups in the lower limb may be affected? (3 marks)

Knee flexors (hamstrings), plantarflexors Foot evertors Foot invertors, dorsiflexors Plantar muscles

[Old PP] Which nerve supplies the muscles in the anterior compartment of the leg? (2 marks)

Deep fibular / peroneal nerve

[Old PP] Name the muscles in the anterior compartment of the leg. (4 marks)

Fibularis (Peroneus) tertius Extensor hallucis longus Extensor digitorum longus Tibialis anterior

[Old PP] A sedentary 45-year-old man was diagnosed with 'compartment syndrome' which resulted from swelling of muscles in the anterior fascial compartment of his leg after running a marathon. Pain was felt on anterior aspect of the leg and there was decreased sensation in an area of his foot. The circulation of which artery was compromised in this patient? (1 mark)

Anterior tibial artery

[Old PP] A sedentary 45-year-old man was diagnosed with 'compartment syndrome' which resulted from swelling of muscles in the anterior fascial compartment of his leg after running a marathon. Pain was felt on anterior aspect of the leg and there was decreased sensation in an area of his foot. Which area of skin was likely reduced in sensation? (2 marks)

Deep peroneal / fibular nerve: foot (1st web space between 1st and 2nd toes) Superficial peroneal / fibular nerve: lateral side of leg + dorsum of foot (except lateral side of little toe supplied by sural branch of tibial nerve)

[Old PP] Name one fascial structure that separates the anterior compartment of the leg from adjacent compartments. (1 mark)

Anterior intermuscular septum Interosseous membrane between tibia and fibula Deep (crural) fascia

[Old PP] Which muscles are attached to Achilles tendon? (2 marks)

Gastrocnemius Soleus

[Old PP] Name in sequence (beginning with the one closest to Achilles tendon) three muscles that lie behind medial malleolus. (4 marks)

Tibialis posterior Flexor digitorum longus Flexor hallucis longus Tom Dick And Very Nervous Harry (tarsal tunnel) Tibialis posterior flexor Digitorum longus posterior tibial Artery posterior tibial Vein tibial Nerve flexor Hallucis longus

[Old PP] What is name of thick band of fascia between medial malleolus and heel that overlie tendons? (1 mark)

Flexor retinaculum

[Old PP] Name nerve in tarsal tunnel (1 mark), and briefly summarise its motor and sensory functions in foot. (2 marks)

Tibial nerve Motor: intrinsic plantar muscles Sensory: sole and lateral side of foot

[Old PP] Which muscle is responsible for ‘unlocking’ the knee during the initial phase of flexion? (2 marks)

Popliteus Unlock the knee from screw home position Swing phase of gait cycle (fixed femur): medially rotate tibia on femur Stance phase of gait cycle (fixed tibia): laterally rotate femur on tibia

[Old PP] What is the function of the anterior cruciate ligament? (2 marks)

To prevent anterior displacement of tibia relative to femur

[Old PP] What is the function of the tibial collateral ligament? (2 marks)

Maintain side-to-side stability of knee joint

[Old PP] Why is the medial meniscus more prone to injury than the lateral one? (2 marks)

Medial meniscus is firmly attached to medial (tibial) collateral ligament and joint capsule While lateral meniscus is not attached to lateral (fibular) collateral ligament or joint capsule => medial meniscus is less mobile -> more prone to injury

[Old PP] What passive movement normally occurs in the knee joint during the last phase of extension? (2 marks)

Medial rotation of femur relative to tibia

[Old PP] Which muscle is most important in maintaining the stability of the knee? (1 mark)

Quadriceps femoris

[Old PP] Name the boundaries of the quadrangular space.

Superior: teres minor, subscapularis Medial: long head of triceps brachii Lateral: surgical neck of humerus Inferior: teres major

[Old PP] A rugby player who complained of tenderness in posterior shoulder area and weakness of shoulder abduction. He was told by doctor that his condition was due to nerve entrapment in quadrangular space. Name nerve that is compressed. (1 mark) Which part of brachial plexus does it come from? (1 mark)

Axillary nerve Posterior cord

Deltoid Teres minor

[Old PP] A rugby player who complained of tenderness in posterior shoulder area and weakness of shoulder abduction. He was told by doctor that his condition was due to nerve entrapment in quadrangular space. Why is shoulder abduction not completely lost? (2 marks)

Initiation of first 15° of shoulder abduction is by supraspinatus Innervates by suprascapular nerve of upper trunk

[Old PP] What blood vessels pass through quadrangular space? (1 marks)

Posterior circumflex humeral artery (from Axillary artery)

[Old PP] A patient complaining of shoulder pain was diagnosed with a torn subscapularis tendon. Which PART of the brachial plexus gives off the nerve that supplies the subscapularis? (1 mark)

Posterior cord -> upper and lower subscapular nerve (C5-C6)

[Old PP] What muscles in hand are innervated by ulnar nerve? (8 marks)

Hypothenar muscle: abductor digiti minimi, flexor digiti minimi, opponens digiti minimi Thenar muscle: adductor pollicis Medial (3rd and 4th) lumbricals Interossei

[Old PP] Sensory supply of ulnar nerve

Medial part of hand, medial 1.5 fingers (dorsal + palmar)

[Old PP] Action of subscapularis

Medial rotation of arm

[Old PP] Insertion of subscapularis on humerus

Lesser tubercle

[Old PP] Main antagonists of subscapularis

Infraspinatus Teres minor -> lateral rotate

[Old PP] Two muscles that can compensate for loss of subscapularis

Pectoralis major Latissimus dorsi Teres major

[Old PP] Boundaries of carpal tunnel

Roof: flexor retinaculum Floor: carpal bones (trapezium, trapezoid, capitate, hamate) Lateral: tubercle of trapezoid, scaphoid, thenar muscles Medial: hook of hamate, pisiform, hypothenar muscles

[Old PP] Contents of carpal tunnel

Tendons of flexor digitorum superficialis (*4) Tendons of flexor digitorum profundus (*4) Tendon of flexor carpi radialis Median nerve

[Old PP] Which artery becomes femoral artery when it enters femoral triangle? (2 marks)

External iliac artery

[Old PP] Pulse of femoral artery can be felt below inguinal ligament midway between two anatomical landmarks. Name two landmarks. (4 marks)

Anterior superior iliac spine Pubic symphysis

[Old PP] Which important superficial vein drains into femoral vein within femoral triangle? (2 marks)

Great saphenous vein

[Old PP] What is relationship between femoral artery and femoral vein in femoral triangle? (2 marks)

Femoral vein is medial to femoral artery Lateral to medial: Femoral nerve Femoral artery Femoral vein Deep inguinal lymphatics (NAVY, Y = trunk)

[PP] A 36-year-old male factory worker was rushed to the hospital after an explosion. There were no witnesses to his injuries. The patient was semi-conscious and unable to respond to commands. On arrival, his blood pressure was 80/46 with pulse rate 120. There was a deformity at his right leg with an open wound. There was soot residual over his face and body. List five factors which make the management of this scenario challenging. (5 marks)

Multiple associated fractures Open fractures Traumatic head injury / intracranial bleeding Injury to visceral organs Neurovascular structures damage Profuse blood loss High-energy injury associated with extensive soft tissue trauma Inhalation burn Surface burn injuries Multiple victims involved

[PP] A volleyball player consulted his doctor for posterolateral shoulder pain, and weakness in shoulder abduction and lateral rotation. A diagnosis of nerve entrapment was made after physical examining and imaging. Which nerve was MOST LIKELY impaired? A. Axillary nerve B. Dorsal scapular nerve C. Subscapular nerve D. Suprascapular nerve

D Supraspinatus: initiate abduction (first 15°) Infraspinatus (together with teres minor): lateral rotation

[PP] Which of the following pathogens typically causes polyarthritis? A. Mycobacterium marinum B. Neisseria gonorrhoeae C. Pseudomonas aeruginosa D. Staphylococcus aureus

[Old PP] Upper extremities A. Axillary artery B. Brachial artery C. Dorsal scapular artery D. Lateral thoracic artery E. Profunda brachii artery F. Radial artery G. Subscapular artery H. Supreme thoracic artery I. Thoracoacromial artery J. Ulnar artery 1. Give rise to circumflex scapular artery 2. Along radial nerve 3. Give rise to common interosseous artery 4. Penetrate clavipectoral fascia 5. Branch of subclavian artery

G E J I C

[PP] Which of the following is a depolarising neuromuscular blocking agent? A. Cis-atracurium B. Mivacurium C. Rocuronium D. Suxamethonium

[PP] Which of the following will NOT AFFECT the effects of local anaesthetics? A. Adding glucose to local anaesthetic B. Adding sodium bicarbonate to local anaesthetic C. Concentration of local anaesthetic D. Total volume of local anaesthetic

[PP] A patient fractured his femur. During bone fracture healing, what was the initial structure formed to stabilise the fracture site? A. Haematoma B. Hard callus C. Soft callus D. Woven bone

[PP] Which process involves the replacement of a cartilage model with bone tissue? A. Bone resorption B. Endochondral ossification C. Interstitial growth D. Intramembranous ossification

[PP] Which cranial nerve is responsible for the majority of parasympathetic output? A. Facial nerve (VII) B. Glossopharyngeal nerve (IX) C. Oculomotor nerve (III) D. Vagus nerve (X)

[PP] A runner with pain and swelling on the lateral side of the back of his knee was diagnosed with tendinopathy. Which of the following muscles was MOST LIKELY involved? A. Biceps femoris B. Plantaris C. Semimembranosus D. Semitendinosus

[PP] Some limb muscles have dual innervation because they develop from different muscle compartments. Which of the following receives dual innervation from the obturator and sciatic nerves? A. Adductor brevis B. Adductor magnus C. Biceps femoris D. Pectineus

B Adductor part: obturator n. Hamstring part: sciatic n.

[PP] A 20-year-old patient used his wrists extensively playing a drumming video game over the summer holiday. He complained of numbness, tingling and pain in his left hand. Examination revealed that opposition of left thumb was impaired. Which nerve was MOST LIKELY damaged? A. Median nerve B. Musculocutaneous nerve C. Radial nerve D. Ulnar nerve

[PP] A patient complained of vertigo for 3 months. It occurred upon rotation of her head to the left side. CT scan revealed that the transverse foramen of C1 vertebra on the left side was partially occluded. Which structure was MOST LIKELY impaired in the transverse foramen? A. Ascending cervical artery B. Internal carotid artery C. Vagus nerve D. Vertebral artery

[PP] Molecular signals regulate patterning in limb development, controlling number and size of the skeletal elements. Sonic hedgehog (SHH) expressed in the zone of polarizing activity (ZPA) regulates patterning along the anterior/posterior axis. Abnormal SHH signalling will affect which of the following outcomes in hind limb development? A. Length of the femur B. Number of digits C. Position of the synovial joints D. Size of the tibia

[PP] John, a 22-year-old office worker presented to his family physician with pain in his lower back and pelvic region for 3 years. He denied any trauma to his back. He said the pain was sporadic in the beginning. But in the recent few months, it had gradually gotten worse. He complained of stiffness and also pain in his buttocks which were exacerbated with prolonged sitting at his desk. What is the MOST LIKELY diagnosis of John's condition? A. Ankylosing spondylitis B. Mechanical back pain C. Recurrent peri-arthritis D. Rheumatoid arthritis

[PP] Which of the following skin and soft tissue infections has the highest propensity to cause outbreaks in health care settings? A. Carbuncles B. Folliculitis C. Necrotizing fasciitis D. Scabies

[PP] Dermatophytes are fungi that require keratin for growth and hence causes infection of skin and skin appendages. Which of the following fungi is a dermatophyte? A. Aspergillus B. Cryptococcus C. Histoplasma D. Trichophyton

[PP] MUSCLES OF THE LOWER LIMB A. Biceps femoris B. Gracilis C. Peroneus brevis D. Plantaris E. Popliteus F. Sartorius G. Semimembranosus H. Soleus I. Tibialis anterior J. Tibialis posterior For each of the following descriptions, select the MOST RELEVANT muscle from the list of options above. Each option may be used once, more than once, or not at all. (i) It inverts and dorsiflexes the foot. (ii) It extends the thigh, and flexes and medially rotates the leg. (iii) It laterally rotates the thigh at the knee joint at the beginning of flexion. (iv) It flexes the knee joint and plantarflexes the foot.

I G E D

[PP] MUSCLES OF THE THIGH A. Adductor brevis B. Adductor longus C. Adductor magnus D. Biceps femoris E. Gracilis F. Pectineus G. Rectus femoris H. Sartorius I. Semimembranosus J. Semitendinosus For each of the following descriptions, select the MOST RELEVANT muscle from the list of options. The option may be used once, more than once, or not at all. (i) It is innervated by both the tibial and common fibular components of the sciatic nerve. (ii) It is the MOST ANTERIOR amongst the three tendons that form the pes anserinus on the anteromedial surface of proximal tibia. (iii) It forms the superolateral boundary of the popliteal fossa.

D H D

[PP] THE MOST LIKELY CAUSE OF SOFT TISSUE INFECTIONS CAN SOMETIMES BE PREDICTED BY THE CLINICAL MANIFESTATIONS AND EXPOSURE HISTORY. A. Clostridioides difficile B. Clostridium perfringens C. Cryptococcus neoformans D. Escherichia coli + Streptococcus anginosus + Bacteroides fragilis E. Mycobacterium marinum F. Pseudomonas aeruginosa + Streptococcus pyogenes G. Staphylococcus aureus, methicillin-resistant H. Staphylococcus aureus, methicillin-sensitive I. Streptococcus pyogenes J. Vibrio vulnificus For each of the following scenarios, what is/are the MOST LIKELY pathogen(s) involved? The option may be used once, more than once, or not at all. (i) A 57-year-old woman developed a rapidly progressive cellulitis of the thigh after a minor injury by a lobster at the fish market. (ii) Necrotizing fasciitis of the trunk in a child following a recent episode of chickenpox. (iii) A 69-year-old man with poorly controlled diabetes developed progressive swelling and inflammation of the scrotum and perineal soft tissues followed by areas of necrosis in the affected areas.

J I D

[PP, formative] Spasticity is a motor disorder characterised by hyperexcitability of stretch reflexes. What is the neural mechanism underlying hyperreflexia in patients with spinal cord injury? A. Decreased activity of alpha motor neurons B. Decreased activity of la sensory neurons C. Increased activity of gamma motor neurons D. Increased activity of inhibitory interneurons

[PP, formative] Pectoralis minor is an important landmark to identify structures in the axilla. Which structure normally lies deep to the pectoralis minor? A. Cephalic vein B. Lateral cord of brachial plexus C. Posterior circumflex humeral artery D. Suprascapular nerve

[PP, formative] Degradation of the articular cartilage is a hallmark of osteoarthritis. A degradative fragment of a cartilage extracellular matrix protein can be used as a biomarker. The fragment from which extracellular matrix protein can serve as a biomarker? A. Aggrecan B. Collagen type I C. Osteocalcin D. Tendomodulin

[PP, formative] Ultraviolet light plays an important role in photoaging, and malignancies. What absorb(s) photons in the dermis? A. Apocrine glands B. Langerhan cells C. Melanin D. Stratum lucidum

[PP] which HBD increases expression in psoriasis patients? A. HBD1 B. HBD2 C. HBD3 D. HBD4

B HBD = Human beta-defensin

[PP] 57 y/o male insurance broker, present to his family physician with acute pain at right first toe joint. yesterday hot pot with client, lots of beer, he claimed that he’s a little bit drunk. red, swelling, tenderness at the right first metatarsophalangeal joint. possible cause? a. acute gout b. acute septic arthritis c. hallux rigidus d. traumatic arthritis

A 1st MTP

[PP] Q31: 52M, spondylodiscitis, histopathology of vertebrae and IV disc shows granulomatous inflammation Q32: otherwise healthy housewife, tenderness & tenosynovitis in right hand over 1 month Options: - Candida albicans - Mycobacterium marinum - Mycobacterium tuberculosis - Neisseria gonorrhoea - Neisseria Meningitidis - Staphylococcus aureus - Streptococcus anginosus - Vibrio Cholera - Vibrio vulnificus

Mycobacterium tuberculosis Mycobacterium marinum

[PP] Which of the following extend the pharmacological effect of LA A. Injecting adrenaline to LA B. Diluting to make LA less concentrated C. Injection of LA away from the targeted nerve D. Reduced the inject volume of LA

Injecting adrenaline to LA Vasoconstriction -> slow down absorption into systemic circulation

[Self-assessment] Eccrine glands are found most densely populated in which area? Select one: Soles Groin Back

Soles Soles, palms and axilla

[Self-assessment] Mast cells have a high affinity for binding to which type of immunoglobulin? Select one: IgG IgE IgA

IgE

MSS Important Questions Flashcards

(438 cards)