passmed year 4

Question 1

A 19-year-old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination there is wasting of the quadriceps and pseudolocking of the knee.

how managed

Answer 1

A teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae (anterior knee pain). Most cases are managed with physiotherapy.

Question 2

A tall 18-year-old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination his knee is tense and swollen. X-ray shows no fractures.

Answer 2

A patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.

Question 3

An athletic 15-year-old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination there is tenderness overlying the tibial tuberosity and an associated swelling at this site.

Answer 3

osgood schlatters disease
Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.

Question 4

from what stage of classifciation in the garden criteria for NOF is classed as displaced

Answer 4

3 onwards

Question 5

ottowa ankle rules

Answer 5

An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:

bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)

bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)

inability to walk four weight bearing steps immediately after the injury and in the emergency department

Question 6

ed flags for back pain as non-mechanical back pain, past history of cancer/HIV, generally unwell, unexplained weight loss, widespread neurological symptoms, structural deformity and thoracic back pain. Thoracic back pain is more likely than neck or lower back pain to be caused by a serious underlying pathology and therefore requires prompt specialist review. For example, thoracic back pain may indicate the possibility of spinal cord compression, spinal osteomyelitis, or epidural abscess. The thoracic spine, being in the middle of the spine, is relatively stable and less prone to mechanical stress compared to the lumbar and cervical regions, making a mechanical cause less likely in the thoracic region.

list soem more causes

Answer 6

ank spond

spinal stenosis

PAD

Question 7

Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases

Answer 7

PAD

Question 8

does spinal stenosis reoslve when sits down

Answer 8

yes

Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis

Question 9

discitis linked with what and how long for abx

Answer 9

IE

6-8w

Question 10

L4 nerve compression

Answer 10

L4 nerve root compression would present with sensory loss over the anterior aspect of the knee, weakened quadriceps, and a reduced knee reflex.

Question 11

L5 radiculopathy

Answer 11

L5 radiculopathy: Weakness of hip abduction and foot drop, no specific reflex lost

Question 12

most common cause of OM in sickle cell people and in norm people

Answer 12

Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate

Question 13

tx for oM and how long

Answer 13

flucloxacillin for 6 weeks

Question 14

the definitive treatment for OA is hip replacement what are the complciations of this

Answer 14

venous thromboembolism
intraoperative fracture
nerve injury
surgical site infection
leg length discrepancy
posterior dislocation - (may occur during extremes of hip flexion, a ‘clunk’, pain and inability to weight bear, and on examination there is internal rotation and shortening of the affected leg)
- aseptic loosening (most common reason for revision )
prosthetic joint infection

Question 15

back pain with previous history of cancer is a red flag and prompts furher ix

Answer 15

true

Question 16

knee or distal thigh pain is common
loss of internal rotation of the leg in flexion

Answer 16

SUFE

Question 17

joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
limp
ANA may be positive in JIA - associated with anterior uveitis

Answer 17

JIA

Question 18

hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Answer 18

perthes

Question 19

mx of plantar fascitis
A 37-year-old gentleman presents to the general practitioner (GP) with a four month history of heel pain. He reports that the pain is worse when walking to and from work. The gentleman has a body mass index (BMI) of 29 kg/m² and is currently under investigation for diabetes mellitus. His past medical history includes: asthma, generalised anxiety disorder and Peyronie’s disease.

Answer 19

Plantar fasciitis is best managed initially with rest, stretching and weight loss if overweight

Question 20

A 42-year-old lady who has systemic lupus erythematosus presents to the clinic with a 5 day history of a painful purple lesion on her index finger. On examination she has a tender red lesion on the index finger.

Answer 20

osler nodes - seen. in SLE also

Question 21

herbedens nodes produce swelling wear

Answer 21

Heberdens nodes may produce swelling of the distal interphalangeal joint with deviation of the finger tip.

bouchard interphalangeal

Question 22

A 17-year-old male is brought to the clinic by his mother who is concerned about a lesion that has developed on the dorsal surface of his left hand. On examination he has a soft fluctuant swelling on the dorsal aspect of the hand, it is most obvious on making a fist.

Answer 22

Ganglions commonly occur in the hand and are usually associated with tendons. They are typically soft and fluctuant. They do not require removal unless they are atypical or causing symptoms.

Question 23

pain relieved when bending forward

Answer 23

spinal stenosis

Question 24

risk factor for adhesive capsulitis

Answer 24

DM

Question 25

In a child with an asymptomatic, fluctuant swelling behind the knee - It is approximately the size of a tennis ball. The swelling feels tense in full knee extension and soften again or disappear when the knee is flexed. Flexion is slightly reduced.

Answer 25

baker cyst

Question 26

when do you treat a baker cyst

Answer 26

normally only in adults

Question 27

can you reduce a dislocated shoulder without pain relief
and when might you need to give analgesia or sedation in the same type of injury

Answer 27

If the dislocation is recent then reduction may be attempted without any analgesia/sedation. However, other patients may require analgesia +/- sedation to ensure the rotator cuff muscles are relaxed

Question 28

5 signs of a scaphoid fracture

Answer 28

Point of maximal tenderness over the anatomical snuffbox
This is a highly sensitive (around 90-95%), but poorly specific test (<40%) in isolation
2. Wrist joint effusion
Hyperacute injuries (<4hrs old), and delayed presentations (>4days old) may not present with joint effusions.
3. Pain elicited by telescoping of the thumb (pain on longitudinal compression)
4. Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
5. Pain on ulnar deviation of the wrist

Question 29

management of a scaphoid fracture

Answer 29

immobilisation with a Futuro splint or standard below-elbow backslab
referral to orthopaedics
clinical review with further imaging should be arranged for7-10 days later when initial radiographs are inconclusive

Orthopaedic management wont know
undisplaced fractures of the scaphoid waist - cast for 6-8 weeks, union is achieved in > 95%
displaced scaphoid waist fractures
requires surgical fixation
proximal scaphoid pole fractures
require surgical fixation

Question 30

Squaring of the thumbs is a characteristic feature of hand

Answer 30

osteorthritis

Question 31

paraesthesia (an early sign), disproportionate pain on assessment of tone (passive rather than active movements) and normal x-ray findings should raise suspicion of

Answer 31

compartment syndrome

Question 32

A 44-year-old woman presents with pain in her right hand and forearm which has been getting worse for the past few weeks. There is no history of trauma. The pain is concentrated around the thumb and index finger and is often worse at night. Shaking her hand seems to provide some relief. On examination there is weakness of the abductor pollicis brevis and reduced sensation to fine touch at the index finger. What is the most likely diagnosis?

Answer 32

carpal tunnel syndrome

More proximal symptoms would be expected with a C6 entrapment neuropathy e.g. weakness of the biceps muscle or reduced biceps reflex.

Question 33

Meralgia parasthetica can be caused

Answer 33

sudden weight gain

Question 34

imaging modality of choice for suspected Achilles tendon rupture

Answer 34

USS

Question 35

The T2 weighted MRI spine in this scenario shows increased contrast enhancement of the disc and adjacent bone marrow. There is also a high signal intensity mass anterior to the thoracic vertebrae. These findings along with the infective clinical picture (evidenced by the low-grade fever, elevated WBC and CRP) are most consistent with a diagnosis of

Answer 35

discitis

Question 36

However, inflammatory arthritis is much more likely to affect multiple joints in a symmetrical/asymmetrical pattern as opposed to presenting in a single joint.

Answer 36

true

Question 37

how do you manage ankle fractures

Answer 37

also reduce an ankle as soon as possible to reduce risk of damage to the skin

Question 38

scaphoid fractures managed how

weakened left sided grip
pain on longitudinal compressuon of thub
ulnar deviation

Answer 38

Immobilisation with a Futuro splint before orthopaedic review

or standard below-elbow backslab

Question 39

An asymmetrical presentation suggests psoriatic arthritis rather than rheumatoid

Question 40

allergic to aspirin also to

Answer 40

sulfasalazine

Question 41

Inflammatory back pain (e.g. ankylosing spondylitis) typically improves with exercise

Question 42

Arterial/venous thrombosis, miscarriage, livedo reticularis → anticardiolipin antibody +ve

Answer 42

antiphospholipi dsyndropme

Question 43

A 24-year-old man is seen in gastroenterology clinic with severe ulcerative colitis. It is recommended that he should commence azathioprine to improve his symptoms.

What should be ruled out prior to starting this medication?

Answer 43

Azathioprine - check thiopurine methyltransferase deficiency (TPMT) before treatment

Question 44

A 78-year-old woman on hormonal replacement therapy presents with increasing back and joint pain, reducing her mobility. Specifically, she reports lumbar discomfort which has increased in the past week.

An examination is generally unremarkable except for point tenderness over the L3-4 region. X-rays of the area reveal several vertebral compression fractures at L3 and L4.

Further blood tests are performed and are shown below.

Answer 44

osteoalacia - present with compression fractures

Question 45

On examination, there is no visible deformity of her right hip, but it is tender on palpation. She walks with a visible limp and appears to be in discomfort.

Answer 45

avascular necrosis

Question 46

cx of avascular necrosis

Answer 46

long-term steroid use
chemotherapy
alcohol excess
trauma

Question 47

ganglions most common seen on who and where presenting how

Answer 47

e dorsal aspect of the wrist and are 3 times more common in women.

Features
a firm and well-circumscribed mass that transilluminates

Question 48

Anterior shoulder dislocation results in external rotation and abduction of the upper limb.

Answer 48

what complicstion can occur

Question 49

compartment syndrome mx

Answer 49

keep limb level with body - promote venous return
IV fluids - prevent renal failure due to myoglobulinuraemia
pain control
fasciotomy