Passmedicine Mcqs-Surgical and Musculoskeletal Problems

SURGICAL AND MUSCULO SKELETAL PROBLEMS
ORTHOPAEDICS MCQs
Q-1
A 35-year-old lady has been experiencing intermittent pins and needles in her right hand for the past
month. As part of your neurological examination, you attempt to elicit the triceps reflex by placing the
lady's arm across her chest and striking the triceps tendon with a tendon hammer. Which nerve (and its
nerve root) are you testing?
A. Radial nerve C7
B. Median nerve C6
C. Median nerve C7
D. Ulnar nerve C5
E. Radial nerve C6
ANSWER:
A. Radial nerve C7
EXPLANATION:
The radial nerve innervates the triceps muscle. It is primarily derived from the C7 nerve root.
The radial nerve is the motor supply to the extensor compartments of the upper arm.
The triceps muscle is the chief extensor of the forearm. Its name derives from its three heads of origin; the
long, lateral and medial heads. It attaches to the olecranon of the ulna.
It is these components which form the triceps reflex arc.
UPPER LIMB ANATOMY

The information below contains selected facts which commonly appear in examinations:
Typical mechanism of
Nerve Motor Sensory injury & notes
Musculocutaneous Elbow flexion Lateral part of the Isolated injury rare -
nerve (C5-C7) (supplies biceps brachii) forearm usually injured as part of
and supination brachial plexus injury
Axillary nerve (C5,C6) Shoulder Inferior region of the Humeral neck
abduction (deltoid deltoid muscle fracture/dislocation
muscle)
Results in flattened deltoid
Radial nerve (C5-C8) Extension (forearm, wrist, Small area between Humeral midshaft fracture
fingers, thumb) the dorsal aspect of
Palsy results in wrist drop
Typical mechanism of
Nerve Motor Sensory injury & notes
the 1st and 2nd
metacarpals
Median nerve (C6, C8, LOAF* muscles Palmar aspect of Wrist lesion → carpal
T1) lateral 3½ fingers tunnel syndrome
Features depend on the
site of the lesion:
 wrist: paralysis of
thenar muscles,
opponens pollicis
 elbow: loss of
pronation of
forearm and weak
wrist flexion
Ulnar nerve (C8, T1) Intrinsic hand muscles Medial 1½ fingers Medial epicondyle fracture
except LOAF*
Damage may result in a
Wrist flexion 'claw hand'
Long thoracic nerve Serratus anterior Often during sport e.g.
(C5-C7) following a blow to the
ribs. Also possible
complication of
mastectomy
Damage results in
a winged scapula
Diagram of the brachial plexus
Erb-Duchenne palsy ('waiter's tip')

 due to damage of the upper trunk of the brachial plexus (C5,C6)
 may be secondary to shoulder dystocia during birth
 the arm hangs by the side and is internally rotated, elbow extended
Klumpke injury
 due to damage of the lower trunk of the brachial plexus (C8, T1)
 as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward
jerk of the hand
 associated with Horner's syndrome
*LOAF muscles
 Lateral two lumbricals
 Opponens pollis
 Abductor pollis brevis
 Flexor pollis brevis
Q-2
A 38-year-old woman develops lower back pain radiating down her right leg whilst performing DIY. She
describes a severe, sharp, stabbing pain which is worse on movement. Clinical examination reveals a
positive straight leg raise test on the right-hand side. Appropriate analgesia is prescribed. Of the following,
what is the most suitable next-step in management?
A. Check ESR
B. Arrange physiotherapy
C. Refer for MRI
D. Perform a vaginal examination
E. Lumbar spine x-ray
ANSWER:
EXPLANATION:
This patient has symptoms consistent with a prolapsed disc. Even if this is proven by a MRI scan it would
not change the initial management as the vast majority of patients improve with conservative treatment
such as physiotherapy.
LOWER BACK PAIN: PROLAPSED DISC

A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits.
Features
 leg pain usually worse than back
 pain often worse when sitting
The table below demonstrates the expected features according to the level of compression:
Site of compression Features

L3 nerve root compression Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compression Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Management
 similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
 if symptoms persist 9e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate
Q-3
You review a middle-aged man with shoulder pain. He has limited movement of the right shoulder in all
directions. Which of the following clinical findings is most consistent with a diagnosis of frozen shoulder
(adhesive capsulitis)?
A. Only active movement limited + internal rotation most affected

B. Active and passive movement limited + abduction most affected
C. Active and passive movement limited + external rotation most affected
D. Active and passive movement limited + internal rotation most affected
E. Only active movement limited + external rotation most affected
ANSWER:
C. Active and passive movement limited + external rotation most affected
EXPLANATION:
ADHESIVE CAPSULITIS
Adhesive capsulitis (frozen shoulder) is a common cause of shoulder pain. It is most common in middle-aged
females. The aetiology of frozen shoulder is not fully understood.
Associations
 diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder
Features typically develop over days

 external rotation is affected more than internal rotation or abduction
 both active and passive movement are affected
 patients typically have a painful freezing phase, an adhesive phase and a recovery phase
 bilateral in up to 20% of patients
 the episode typically lasts between 6 months and 2 years
The diagnosis is usually clinical although imaging may be required for atypical or persistent symptoms.
Management
 no single intervention has been shown to improve outcome in the long-term
 treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids
Q-4
A 64-year-old woman who is known to have rheumatoid arthritis presents with pain in her right ring finger
when she flexes it. On one occasion she reports it became 'stuck'. Clinical examination is unremarkable
other than a palpable nodule at the base of the finger. What is the most likely diagnosis?
A. Swan-neck deformity
B. Dupuytren's contracture
C. Trigger finger
D. Mallet finger
E. Boutonniere deformity
ANSWER:
C. Trigger finger
EXPLANATION:
TRIGGER FINGER
Trigger finger is a common condition associated with abnormal flexion of the digits. It is thought to be
caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms
the tendon becomes 'stuck' and cannot pass smoothly through the pulley.
Associations* (idiopathic in the majority)

 more common in women than men
 rheumatoid arthritis
 diabetes mellitus
Features
 more common in the thumb, middle, or ring finger
 initially stiffness and snapping ('trigger') when extending a flexed digit
 a nodule may be felt at the base of the affected finger
Management
 steroid injection is successful in the majority of patients. A finger splint may be applied afterwards
 surgery should be reserved for patients who have not responded to steroid injections
*there is scanty evidence to support a link with repetitive use
Q-5
A 59-year-old woman presents to surgery. She has arranged a DEXA scan privately after her friend broke
her hip whilst on holiday. This has shown a T-score of -1.9 for the femoral neck. She is wondering what
needs doing. You perform a general examination of the lady which is normal. What is the most
appropriate next step in management?
A. Prescribe a calcium and vitamin D supplement and repeat the DEXA in 3 years
B. Do a FRAX assessment
C. Prescribe a calcium and vitamin D supplement and repeat the DEXA in 12 months
D. Prescribe a calcium and vitamin D supplement + alendronate
E. Refer to rheumatology
ANSWER:
B. Do a FRAX assessment
EXPLANATION:
The FRAX assessment is needed to assess this ladies true fracture risk. The bone mineral density
measurement is a part of this, albeit an important factor.
OSTEOPOROSIS: ASSESSING RISK

We worry about osteoporosis because of the increased risk of fragility fractures. So how do we assess which
patients are at risk and need further investigation?
NICE produced guidelines in 2012: Osteoporosis: assessing the risk of fragility fracture. The following is
based on those guidelines.
They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger
patients should be assessed in the presence of risk factors, such as:
 previous fragility fracture
 current use or frequent recent use of oral or systemic glucocorticoid
 history of falls
 family history of hip fracture
 other causes of secondary osteoporosis
 low body mass index (BMI) (less than 18.5 kg/m²)
 smoking
 alcohol intake of more than 14 units per week for women and more than 14 units per week for men.
Methods of risk assessment

NICE recommend using a clinical prediction tool such as FRAX or QFracture to assess a patients 10 year risk
of developing a fracture. This is analogous to the cardiovascular risk tools such as QRISK.
FRAX
 estimates the 10-year risk of fragility fracture
 valid for patients aged 40-90 years
 based on international data so use not limited to UK patients
 assesses the following factors: age, sex, weight, height, previous fracture, parental fracture, current
smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol intake
 bone mineral density (BMD) is optional, but clearly improves the accuracy of the results. NICE
recommend arranging a DEXA scan if FRAX (without BMD) shows an intermediate result
QFracture
 estimates the 10-year risk of fragility fracture
 developed in 2009 based on UK primary care dataset
 can be used for patients aged 30-99 years (this is stated on the QFracture website, but other sources give
a figure of 30-85 years)
 includes a larger group of risk factors e.g. cardiovascular disease, history of falls, chronic liver disease,
rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants
There are some situations where NICE recommend arranging BMD assessment (i.e. a DEXA scan) rather than
using one of the clinical prediction tools:
 before starting treatments that may have a rapid adverse effect on bone density (for example, sex
hormone deprivation for treatment for breast or prostate cancer).
 in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture,
major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic
glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).
Interpreting the results of FRAX

Once we've decided that we need to do a risk assessment using FRAX and have entered all the data we are
left with results to interpret.
If the FRAX assessment was done without a bone mineral density (BMD) measurement the results (10-year
risk of a fragility fracture) will be given and categorised automatically into one of the following:
 low risk: reassure and give lifestyle advice
 intermediate risk: offer BMD test
 high risk: offer bone protection treatment
Therefore, with intermediate risk results FRAX will recommend that you arrange a BMD test to enable you to
more accurately determine whether the patient needs treatment
If the FRAX assessment was done with a bone mineral density (BMD) measurement the results (10-year risk
of a fragility fracture) will be given and categorised automatically into one of the following:
 reassure
 consider treatment
 strongly recommend treatment
If you use QFracture instead patients are not automatically categorised into low, intermediate or high risk.
Instead the 'raw data' relating to the 10-year risk of any sustaining an osteoporotic fracture. This data then
needs to be interpreted alongside either local or national guidelines, taking into account certain factors such
as the patient's age.
When should we reassess a patient's risk?

NICE recommend that we recalculate a patient's risk (i.e. repeat the FRAX/QFracture):
 if the original calculated risk was in the region of the intervention threshold for a proposed treatment and
only after a minimum of 2 years, or
 when there has been a change in the person's risk factors
Q-6
A 75-year-old man presents with back pain that comes on when he walks. After taking a full history and
completing a neurological and vascular examination which is normal a diagnosis of spinal stenosis is
suspected. After prescribing analgesia, what is the most appropriate next step?
A. Lumbar spine x-ray

C. Refer for duplex scan
D. Refer for MRI
E. Perform a myeloma screen
ANSWER:
D. Refer for MRI
EXPLANATION:
This presentation requires a MRI to confirm the diagnosis and exclude other causes
LOWER BACK PAIN

Lower back pain (LBP) is one of the most common presentations seen in practice. Whilst the majority of
presentations will be of a non-specific muscular nature it is worth keeping in mind possible causes which
may need specific treatment.
Red flags for lower back pain
 age < 20 years or > 50 years
 history of previous malignancy
 night pain
 history of trauma
 systemically unwell e.g. weight loss, fever
The table below indicates some specific causes of LBP:
May be acute or chronic

Pain worse in the morning and on standing
On examination there may be pain over the facets. The pain is typically worse
Facet joint on extension of the back
Spinal stenosis 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
Ankylosing Typically a young man who presents with lower back pain and stiffness
spondylitis Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
Peripheral Pain on walking, relieved by rest
arterial Absent or weak foot pulses and other signs of limb ischaemia
disease Past history may include smoking and other vascular diseases
Q-7
You review a femoral X-ray of a 13-year-old boy which you requested yesterday. He presented with bony
pain in his distal femur which had been constant over 1 month. The X-ray shows medullary and cortical
bone destruction of the distal femur. How should this X-ray be followed up?
A. Prescribe alendronate
B. Ensure patient is seen by a specialist within 2 weeks
C. Prescribe vitamin D and calcium
D. Ensure patient is seen by a specialist within 48 hours
E. Refer directly for a bone marrow biopsy
ANSWER:
D. Ensure patient is seen by a specialist within 48 hours
EXPLANATION:
Consider a very urgent (<48hr) referral for specialist assessment of children and young people with an
X‑ray which could suggest bone sarcoma
This child has presented with symptoms suspicious of an osteosarcoma. He has been urgently investigated
for this as should have been inferred by the fact that you only ordered an X-ray yesterday and you already
have the results. Bony destruction is clearly not normal and is a typical finding of an osteosarcoma. Hence
according to the NICE guidelines, this child should be urgently referred to see a specialist within 48 hours.
The typical referral time for suspected cancer in children is 48 hours rather than the 2-week pathway
typically used for adults. Vitamin D, calcium and alendronate are medications used to treat osteoporosis,
which is not likely to be the primary cause of this child's X-ray, hence making these incorrect. A bone
marrow biopsy will likely be requested by the specialists if required and it would not be suitable to
investigate this from the GP surgery.
SARCOMAS
Sarcomas are malignant tumours of mesenchymal origin
Types
May be either bone or soft tissue in origin.
Bone sarcoma include:

 Osteosarcoma
 Ewings sarcoma (although non bony sites recognised)
 Chondrosarcoma - originate from Chondrocytes
Soft tissue sarcoma are a far more heterogeneous group and include:
 Liposarcoma-adipocytes
 Rhabdomyosarcoma-striated muscle
 Leiomyosarcoma-smooth muscle
 Synovial sarcomas- close to joints (cell of origin not known but not synovium)
Malignant fibrous histiocytoma is a sarcoma that may arise in both soft tissue and bone.
Features
Certain features of a mass or swelling should raise suspicion for a sarcoma these include:
 Large >5cm soft tissue mass
 Deep tissue location or intra muscular location
 Rapid growth
 Painful lump
Assessment
Imaging of suspicious masses should utilise a combination of MRI, CT and USS. Blind biopsy should not be
performed prior to imaging and where required should be done in such a way that the biopsy tract can be
subsequently included in any resection.
Ewings sarcoma
 Commoner in males
 Incidence of 0.3 / 1, 000, 000
 Onset typically between 10 and 20 years of age
 Location by femoral diaphysis is commonest site
 Histologically it is a small round tumour
 Blood borne metastasis is common and chemotherapy is often combined with surgery
Osteosarcoma
 Mesenchymal cells with osteoblastic differentiation
 20% of all primary bone tumours
 Incidence of 5 per 1,000,000
 Peak age 15-30, commoner in males
 Limb preserving surgery may be possible and many patients will receive chemotherapy
Liposarcoma
 Malignancy of adipocytes
 Rare, approximately 2.5 per 1,000,000. They are the second most common soft tissue sarcoma
 Typically located in deep locations such as retroperitoneum
 Affect older age group usually >40 years of age
 May be well differentiated and thus slow growing although may undergo de-differentiation and disease
progression
 Many tumours will have a pseudocapsule that can misleadingly allow surgeons to feel that they can 'shell
out' these lesions. In reality, tumour may invade at the edge of the pseudocapsule and result in local
recurrence if this strategy is adopted
 Usually resistant to radiotherapy, although this is often used in a palliative setting
Malignant Fibrous Histiocytoma

 Tumour with large number of histiocytes
 Most common sarcoma in adults
 Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of origin is not known)
 Four major subtypes are recognised: storiform-pleomorphic (70% cases), myxoid (less aggressive), giant
cell and inflammatory
 Treatment is usually with surgical resection and adjuvant radiotherapy as this reduces the likelihood of
local recurrence
Q-8
Which one of the following statements regarding slipped upper femoral epiphysis is true?
A. Suprapubic pain is the most common symptom

B. A chronic slip, with symptoms over weeks to months is the most common presentation
C. Typical age group is 5-10 years
D. More common in girls
E. Bilateral in less than 5% of cases
ANSWER:
B. A chronic slip, with symptoms over weeks to months is the most common presentation
EXPLANATION:
HIP PROBLEMS IN CHILDREN
The table below provides a brief summary of the potential causes of hip problems in children
Condition Notes
Development Often picked up on newborn examination
dysplasia of the hip Barlow's test, Ortolani's test are positive
Unequal skin folds/leg length
Transient synovitis Typical age group = 2-10 years

(irritable hip) Acute hip pain associated with viral infection
Commonest cause of hip pain in children
Perthes disease Perthes disease is a degenerative condition affecting the hip joints of
children, typically between the ages of 4-8 years. It is due to avascular
necrosis of the femoral head
Perthes disease is 5 times more common in boys. Around 10% of cases are
bilateral
Features
 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
Slipped upper Typical age group = 10-15 years

femoral epiphysis More common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
Bilateral slip in 20% of cases
May present acutely following trauma or more commonly with chronic,
persistent symptoms
Features
 knee or distal thigh pain is common

 loss of internal rotation of the leg in flexion
Juvenile idiopathic Preferred to the older term juvenile chronic arthritis, describes arthritis
arthritis (JIA) occurring in someone who is less than 16 years old that lasts for more than
three months. Pauciarticular JIA refers to cases where 4 or less joints are
affected. It accounts for around 60% of cases of JIA
Condition Notes
Features of pauciarticular JIA
 joint pain and swelling: usually medium sized joints e.g. knees, ankles,
elbows
 limp
 ANA may be positive in JIA - associated with anterior uveitis
Septic arthritis Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe
limitation of affected joint
Image gallery
Perthes disease - both femoral epiphyses show extensive destruction, the acetabula are deformed
Perthes disease - bilateral disease

Slipped upper femoral epiphysis - left side
Slipped upper femoral epiphysis - left side
Q-9
Mr Patel is a 70-year-old man who presents with a burning pain in his buttock when walking. The pain
radiates down his leg. He does not complain of any back pain. He finds that sitting helps ease the pain. In
addition, he did find that leaning forwards on the shopping trolley at the supermarket made it easier to
walk. On examination of his lower legs, there was no focal neurology and foot pulses were palpable.
Which of the following investigations is most likely to be useful in diagnosing this condition?
A. Arterial duplex scan

B. Ankle brachial pressure index
C. MRI lumbar spine
D. Nerve conduction studies
E. Angiogram
ANSWER:
C. MRI lumbar spine
EXPLANATION:
In a patient with suspected spinal stenosis, an MRI is the imaging of choice
The key differentials here are peripheral vascular disease (intermittent claudication) and spinal stenosis.
Normal foot pulses point away from a diagnosis of peripheral vascular disease and the key fact in the
history is the improvement in the pain when leaning forward, which is characteristic of spinal stenosis.
Spinal stenosis is diagnosed with an MRI lumbar spine.
Nerve conduction studies are for peripheral neuropathy.
An arterial duplex scan, ankle brachial pressure index and angiogram are all possible investigations for
peripheral vascular disease.
LUMBAR SPINAL STENOSIS

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or
other similar degenerative changes.
Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking
claudication. One of the main features that may help to differentiate it from true claudication in the history
is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk
uphill rather than downhill. The neurogenic claudication type history makes lumbar spinal stenosis a likely
underlying diagnosis, the absence of such symptoms makes it far less likely.
Pathology
Degenerative disease is the commonest underlying cause. Degeneration is believed to begin in the
intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content
lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to the
posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation;
this is associated with thickening and distortion of the ligamentum flavum. The combination of the ventral
disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to
circumferentially narrow the spinal canal and the space available for the neural elements. The compression
of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar
spinal stenosis.
Diagnosis
MRI scanning is the best modality for demonstrating the canal narrowing. Historically a bicycle test was used
as true vascular claudicants could not complete the test.
Treatment
Laminectomy
Q-10
A 55-year-old man presents to his GP with a gradual onset of back pain over the past 8 months. The back
pain is worse on activity and walking causes bilateral pain and weakness in his calves. The back pain is
relieved by sitting or leaning forward.
On examination, no neurological findings are present. He has no relevant past medical history, smokes
socially and drinks a glass of wine with dinner each night. He is currently a builder and is concerned
because his back is starting to interfere with his ability to work.
What is the most likely diagnosis?
A. Ankylosing spondylitis
B. Epidural abscess
C. Osteoarthritis of the hip
D. Peripheral vascular disease
E. Spinal stenosis
ANSWER:
E. Spinal stenosis
EXPLANATION:
Spinal stenosis is often relieved by sitting down or leaning forward
Ankylosing spondylitis is typically seen in younger men with onset at age 30 to 40. It typically presents
with morning back stiffness, hip pain, and swelling that is not relieved with rest and improves with
exercise.
Epidural abscesses may present non specifically and can develop from spread from osteodiscitis,
haematogenous spread or from direct inoculation post-injection, surgery or penetrating trauma. Fever,
malaise, and back pain are the most common early symptoms. There may be local tenderness with or
without neurological deficit.
Osteoarthritis of the hip typically causes hip pain that may radiate to the lateral aspect of the thigh but
rarely extends below the knee. Walking, exercise and lying on the affected side may exacerbate pain and
rest may relieve it but leaning forward would not.
Peripheral vascular disease might present with intermittent claudication (IC), which also typically affects
older patients. Leg pain is typically cramping, beginning distally and progressing proximally. There will be
no improvement of symptoms with lumbar flexion.
Spinal stenosis typically presents with back pain that might radiate to the thigh and/ or calves. The pain is
worse on exercise and is relieved by sitting down or leaning forward. Patients will often find walking uphill
easier. It typically presents in older patients and risk factors include previous back surgery and manual
labour.
Please see Q-9 for Lumbar Spinal Stenosis
Q-11
A 28-year-old male presents with a 5-month history of stiffness and lower back pain, which occasionally
wakes him up at night and improves on movement. He has a family history of ankylosing spondylitis
through his father. The GP performs an HLA-B27 test which is positive and refers him to rheumatology for
assessment. In the meantime, the patient asks for some help managing the pain and stiffness.
What is the most appropriate management?
A. Adalimumab
B. Etanercept
C. Ibuprofen
D. Intra-articular prednisolone
E. Paracetamol
ANSWER:
C. Ibuprofen
EXPLANATION:
NSAIDS are first line for lower back pain
The most appropriate management for this patient is analgesia. This patient has not received a diagnosis
of ankylosing spondylitis, however, NICE guidelines recommend the use of NSAIDs whilst waiting for a
referral.
The first line for lower back pain is NSAIDs such as ibuprofen. Paracetamol is not effective as analgesia for
lower back pain. Etanercept and adalimumab are part of the management for ankylosing spondylitis, but
this is not yet diagnosed and is not first-line management. Intra-articular prednisolone is not part of the
management for lower back pain.
LOWER BACK PAIN: INVESTIGATION AND MANAGEMENT

NICE updated their guidelines on the management of lower back pain in 2016. They apply to patients with
non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc)
NSAIDs are now first-line for back pain
Investigation
 lumbar spine x-ray should not be offered
 MRI
 should only be offered to patients with non-specific back pain 'only if the result is likely to change
management' and to patients where malignancy, infection, fracture, cauda equina or ankylosing
spondylitis is suspected
 it is the most useful imaging modality as no other imaging can see neurological / soft tissue structures
Advice to people with low back pain

 try to encourage self-management
 stay physically active and exercise
Analgesia
 NSAIDS are now recommended first-line for patients with back pain. This follows studies that show
paracetamol monotherapy is relatively ineffective for back pain
 proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given
NSAIDs
 NICE guidelines on neuropathic pain should be followed for patients with sciatica
Other possible treatments

 exercise programme: 'Consider a group exercise programme (biomechanical, aerobic, mindbody or a
combination of approaches) within the NHS for people '
 manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) 'but only
as part of a treatment package including exercise, with or without psychological therapy.'
 radiofrequency denervation
 epidural injections of local anaesthetic and steroid for acute and severe sciatica
Q-12
You see a 43-year-old male patient who has back pain. He can't remember a particular injury but reports
lower back pain which has been getting worse for 2 months. He has had episodes of muscle spasm in his
lower back over the last 2 days which have been particularly painful and have meant he has been off
work. He works in a warehouse and does frequently do some heavy lifting. He is overweight but otherwise
has no other relevant past medical history. He has no red flag symptoms of back pain.
Which statement regarding non-specific lower back pain is correct?
A. Paracetamol +/- codeine is first line for analgesia

B. 'StarT BACK' is an online risk stratification tool which can be used to assess a person with lower back
pain
C. Diazepam should not be used in the management of lower back pain
D. Advise the patient to not return to work or normal activities until they are pain-free
E. Advise the patient that the risk of recurrence is low
ANSWER:
B. 'StarT BACK' is an online risk stratification tool which can be used to assess a person with lower back pain
EXPLANATION:
'StarT BACK' is an online risk stratification tool which can be used to assess a person with lower back pain
without any red flags and identify modifiable risk factors
'StarT BACK' is an online risk stratification tool which can be used to assess a person with lower back pain
without any red flags and identify modifiable risk factors. Therefore, option 2 is correct.
Unless contraindicated an NSAID is the first line analgesia. Therefore, option 1 is incorrect.
A short course of diazepam can be used if muscle spasm is a feature of the back pain. Therefore, option 3 is
wrong.
The patient does not need to be pain-free in order to return to work and normal activities. According to
the NICE CKS guidelines:
Encourage the person to stay active, resume normal activities, and return to work as soon as possible.
Advise that:
Prolonged bed rest is not recommended, and that normal movement may produce some pain which should
not be harmful if activities are resumed gradually and as tolerated.
The person does not need to be pain-free before returning to normal activities or work. Work adjustments
can make an early return to work possible; this may be arranged by an Occupational Health department if
available.
Keeping as active as possible and exercising regularly is important to reduce the risk of recurrence.
Therefore, option 4 is wrong.
Unfortunately, people who have had low back pain often have episodes of recurrence and may develop
repeated 'acute on chronic' symptoms. Therefore, option 5 is wrong.
Please see Q-6 for Lower Back Pain
Q-13
A newborn baby is noted to have bilateral clubfoot. What is the treatment of choice?
A. Manipulation and progressive casting starting after 3 months

B. Surgical correction at 1 year
C. Surgical correction at 6 months
D. Manipulation and progressive casting starting soon after birth
E. Surgical correction at 3 months
ANSWER:
D. Manipulation and progressive casting starting soon after birth
EXPLANATION:
TALIPES EQUINOVARUS
Talipes equinovarus, or club foot, describes an inverted (inward turning) and plantar flexed foot. It is usually
diagnosed on the newborn exam.
Talipes equinovarus is twice as common in males than females and has an incidence of 1 per 1,000 births.
Around 50% of cases are bilateral.
Most commonly idiopathic. Associations include:

 spina bifida
 cerebral palsy
 Edward's syndrome (trisomy 18)
 oligohydramnios
 arthrogryposis
The diagnosis is clinical (the deformity is not passively correctable) and imaging is not normally needed.
Management*
 in recent years there has been a move away from surgical intervention to more conservative methods
such as the Ponseti method
 the Ponseti method consists of manipulation and progressive casting which starts soon after birth. The
deformity is usually corrected after 6-10 weeks. An Achilles tenotomy is required in around 85% of cases
but this can usually be done under local anaesthetic
 night-time braces should be applied until the child is aged 4 years. The relapse rate is 15%
*reference: BMJ 2010; 340:c355: Current management of clubfoot. Bridgens J, Kiely N
Q-14
Tim is a 40-year-old man who presents with pain in his right elbow that runs along the inside of his
forearm. The pain is sometimes associated with numbness and tingling. He is a keen badminton player
and is finding it hard to play properly with his symptoms. On examination, neurology is normal, however
the pain is reproduced on flexion the wrist with the palm up.
What is the most likely cause of Tim's pain?
A. Lateral epicondylitis
B. Medial epicondylitis
C. De-Quervain's tenosynovitis
D. Carpal tunnel syndrome
E. Ulnar nerve palsy
ANSWER:
B. Medial epicondylitis
EXPLANATION:
Medial epicondylitis is typically aggravated by wrist flexion and pronation
Medial epicondylitis (Golfer's elbow) is characterised by pain on the medial side of the elbow. The
symptoms may worsen with restated pronation or wrist flexion.
Lateral epicondylitis (Tennis Elbow) is characterised by pain on the lateral side of the elbow and is
exacerbated by resisted extension.
De-Quervains tenosynovitis causes pain and swelling near the base of the thumb.
Carpal tunnel syndrome is caused by pressure on the median nerve at the wrist. The symptoms include
ache in the fingers/ hand and numbness and tingling. The symptoms are usually worse at night.
Ulnar nerve palsy occurs when the ulnar nerve is pinched resulting in numbness and tingling. The
impingement can occur at the elbow or the wrist. The ulnar nerve supplies sensation to the ring and little
finger, and therefore compression of the nerve leads to numbness and tingling in that distribution.
MEDIAL EPICONDYLITIS
Medial epicondylitis is also known as golfer's elbow.
Features
 pain and tenderness localised to the medial epicondyle
 pain is aggravated by wrist flexion and pronation
 symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve
involvement
Q-15
A 46-year-old female presents with a burning sensation over the antero-lateral aspect of her right thigh. A
diagnosis of meralgia paraesthetica is suspected. Which nerve is most likely to be affected?
A. Common peroneal nerve

B. Anterior cutaneous nerve of thigh
C. Posterior cutaneous nerve of thigh
D. Lateral cutaneous nerve of thigh
E. Sciatic nerve
ANSWER:
D. Lateral cutaneous nerve of thigh
EXPLANATION:
Burning thigh pain - ? meralgia paraesthetica - lateral cutaneous nerve of thigh compression
MERALGIA PARAESTHETICA
Meralgia paraesthetica comes from the Greek words meros for thigh and algos for pain and is often
described as a syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous
nerve (LFCN). It is an entrapment mononeuropathy of the LFCN, but can also be iatrogenic after a surgical
procedure, or result from a neuroma. Although uncommon, meralgia paraesthetica is not rare and is hence
probably underdiagnosed.
Anatomy
 The LFCN is primarily a sensory nerve, carrying no motor fibres.
 It most commonly originates from the L2/3 segments.
 After passing behind the psoas muscle, it runs beneath the iliac fascia as it crosses the surface of the iliac
muscle and eventually exits through or under the lateral aspect of the inguinal ligament.
 As the nerve curves medially and inferiorly around the anterior superior iliac spine (ASIS), it may be
subject to repetitive trauma or pressure.
 Compression of this nerve anywhere along its course can lead to the development of meralgia
paraesthetica.
Epidemiology
 The majority of cases occur in people aged between 30 and 40.
 In some, both legs may be affected.
 It is more common in men than women.
 Occurs more commonly in those with diabetes than in the general population.
Risk factors 3
 Obesity
 Pregnancy
 Tense ascites
 Trauma
 Iatrogenic, such as pelvic osteotomy, spinal surgeries, laparoscopic hernia repair and bariatric surgery. In
some cases, may result from abduction splints used in the management of Perthe's disease.
 Various sports have been implicated, including gymnastics, football, bodybuilding and strenuous
exercise.
 Some cases are idiopathic.
Patients typically present with the following symptoms in the upper lateral aspect of the thigh:
 Burning, tingling, coldness, or shooting pain
 Numbness
 Deep muscle ache
 Symptoms are usually aggravated by standing, and relieved by sitting
 They can be mild and resolve spontaneously or may severely restrict the patient for many years.
Signs:
 Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by
extension of the hip.
 There is altered sensation over the upper lateral aspect of the thigh.
 There is no motor weakness.
Investigations:
 The pelvic compression test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based
on this test alone
 Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for
diagnosis and guiding injection therapy in meralgia paraesthetica
 Nerve conduction studies may be useful.
Q-16
A 50-year-old woman complains of pain in her right elbow. This has been present for the past four weeks
and is maximal around 4-5cm distal from the lateral aspect of the elbow joint. The pain is made worse by
extending the elbow and pronating the forearm. What is the most likely diagnosis?
A. Lateral epicondylitis
B. Radial tunnel syndrome
C. De Quervain's tenosynovitis
D. Cubital tunnel syndrome
E. Medial epicondylitis
ANSWER:
B. Radial tunnel syndrome
EXPLANATION:
ELBOW PAIN
The table below details some of the characteristic features of conditions causing elbow pain:
Condition Notes
Lateral Features
epicondylitis
(tennis elbow)
 pain and tenderness localised to the lateral epicondyle
 pain worse on resisted wrist extension with the elbow extended or
supination of the forearm with the elbow extended
 episodes typically last between 6 months and 2 years. Patients tend to
have acute pain for 6-12 weeks
Medial Features
epicondylitis
(golfer's elbow)
 pain and tenderness localised to the medial epicondyle
 pain is aggravated by wrist flexion and pronation
 symptoms may be accompanied by numbness / tingling in the 4th and
5th finger due to ulnar nerve involvement
Radial tunnel Most commonly due to compression of the posterior interosseous branch of
syndrome the radial nerve. It is thought to be a result of overuse.
Features
 symptoms are similar to lateral epicondylitis making it difficult to

diagnose
 however, the pain tends to be around 4-5 cm distal to the lateral
epicondyle
 symptoms may be worsened by extending the elbow and pronating the
forearm
Cubital tunnel Due to the compression of the ulnar nerve.

syndrome
Features
 initially intermittent tingling in the 4th and 5th finger

 may be worse when the elbow is resting on a firm surface or flexed for
extended periods
Condition Notes
 later numbness in the 4th and 5th finger with associated weakness
Olecranon bursitis Swelling over the posterior aspect of the elbow. There may be associated pain,
warmth and erythema. It typically affects middle-aged male patients.
Q-17
A 14-year-old boy is brought to surgery by his mother. For the past two weeks he has been complaining of
pain in his distal right thigh, which is made worse when he runs. On examination he is noted to be obese
and have a full range of movement in the right knee. He is able to flex his right hip fully but internal
rotation is painful. What is the most likely diagnosis?
A. Transient synovitis
B. Perthes disease
C. Trochanteric bursitis
D. Medial collateral ligament strain
E. Slipped upper femoral epiphysis
ANSWER:
EXPLANATION:
Slipped upper femoral epiphysis - typically an overweight adolescent boy with knee / hip problems
This is a classic presentation of slipped upper femoral epiphysis. The child's obesity is a strong clue.
Please see Q-8 for Hip Problems in Children
Q-18
Which one of the following statements regarding joint replacement surgery is correct?
A. Following a hip replacement patients should avoid crossing their legs

B. Hip resurfacing is now the most common type of hip replacement operation performed in the UK
C. Patients should be encouraged to avoid using walking sticks in weeks 2-6 following a hip operation
D. Patients who are under the age of 60 years should be discouraged from having joint replacement
surgery
E. Hip replacement surgery should not be offered to patients with a BMI > 28 kg/m^2
ANSWER:
A. Following a hip replacement patients should avoid crossing their legs
EXPLANATION:
This is to reduce the chance of dislocation.
OSTEOARTHRITIS: JOINT REPLACEMENT

Joint replacement (arthroplasty) remains the most effective treatment for osteoarthritis patients who
experience significant pain.
Selection criteria
 around 25% of patients are now younger than 60-years-old
 whilst obesity is often thought to be a barrier to joint replacement there is only a slight increase in short-
term complications. There is no difference in long-term joint replacement survival
Surgical techniques
 for hips the most common type of operation is a cemented hip replacement. A metal femoral
component is cemented into the femoral shaft. This is accompanied by a cemented acetabular
polyethylene cup
 uncemented hip replacements are becoming increasingly popular, particularly in younger more active
patients. They are more expensive than conventional cemented hip replacements
 hip resurfacing is also sometimes used where a metal cap is attached over the femoral head. This is often
used in younger patients and has the advantage that the femoral neck is preserved which may be useful
if conventional arthroplasty is needed later in life
Post-operative recovery
 patients receive both physiotherapy and a course of home-exercises
 walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery
 Patients who have had a hip replacement operation should receive basic advice to minimise the risk of
dislocation:
 avoiding flexing the hip > 90 degrees
 avoid low chairs
 do not cross your legs
 sleep on your back for the first 6 weeks
Complications
 wound and joint infection
 thromboembolism: NICE recommend patients receive low-molecular weight heparin for 4 weeks
following a hip replacement
 dislocation
Q-19
A 58-year-old lady presents with a sharp pain in her left foot. It is located between two of the digits and is
exacerbated on movement. As well as this, she has noticed the area become numb for short periods of
time. She alludes to leading a walking group which she has had to abandon because of this problem. There
is no relevant past medical history.
On examination, pain is elicited when palpating the 3rd metatarsal space and there is slight outward
deviation of the adjacent toes.
Which of the following investigations is most appropriate to confirm the most likely diagnosis?
A. MRI
B. CT
C. Ultrasound
D. X-ray
E. Electromyograph
ANSWER:
C. Ultrasound
EXPLANATION:
If there is doubt an ultrasound is used to confirm a Morton's neuroma
This history is typical for Morton’s neuroma (also known as Morton’s metatarsalgia). The neuroma itself is
not always palpable and a small percentage of patients may experience a Mulder’s click. The diagnosis is
mainly clinical, but investigations can be utilised to confirm the diagnosis. Other possible differentials for
the presentation include bursitis, fracture, synovitis and neoplasm.
MRI, CT and ultrasound all have high diagnostic sensitivities, the latter being preferred first due to its wide
availability and lower cost.
X-ray can be used to rule out other pathologies like fractures but would not visualise the neuroma.
EMG is rarely used as it is difficult to perform.
MORTON'S NEUROMA
Morton's neuroma is a benign neuroma affecting the intermetatarsal plantar nerve, most commonly in the
third inter-metatarsophalangeal space. The female to male ratio is around 4:1.
Features
 forefoot pain, most commonly in the third inter-metatarsophalangeal space
 worse on walking. May be described as a shooting or burning pain. Patients may feel they have a pebble
in their shoe
 Mulder's click: one hand tries to hold the neuroma between the finger and thumb. The other hand
squeezes the metatarsals together. A click may be heard as the neuroma moves between the metatarsal
heads
 there may be loss of sensation distally in the toes
Diagnosis is usually clinical although ultrasound may be helpful in confirming the diagnosis.
Management
 avoid high-heels
 metatarsal pad
 CKS recommends referral if symptoms persist for > 3 months despite footwear modifications and the use
of metatarsal pads
 orthotists may give the patient a metatarsal dome orthotic
 other secondary care options include corticosteroid injection and neurectomy of the involved interdigital
nerve and neuroma
Q-20
You see a 32-year-old lady who is complaining of lower back pain. She says the pain started 2 months ago
but for the last week it has begun to radiate down her left leg. She can't remember anything that
specifically caused the pain. The back pain is now less severe than the leg pain. The pain extends from her
buttock down the back of her leg and into her foot. She occasionally has a tingling sensation down the
back of her leg. She finds the pain is worse when she has been standing for a long time. She is normally fit
and well, with no relevant past medical history. She is, however, overweight.
You examine the patient and doing a straight leg raise test gives her the symptoms. Her examination is
otherwise normal and she has no red flag symptoms.
You think that this patient has sciatica and discuss self-management advise including weight loss,
exercises and analgesia.
She asks how long she should expect these symptoms for. How long does it normally take for sciatica
symptoms to settle?
A. 2 weeks
B. 4-6 weeks
C. 12-16 weeks
D. 3-4 months
E. 6-12 months
ANSWER:
B. 4-6 weeks
EXPLANATION:
Sciatica symptoms usually settle within 4–6 weeks
Sciatica symptoms usually settle within 4–6 weeks. Therefore, option 2 is correct.
Q-21
A 45-year-old man presents with a painful swelling on the posterior aspect of his elbow. There is no
history of trauma. On examination an erythematous tender swelling is noted. What is the most likely
diagnosis?
A. Synovial cyst
B. Haemarthrosis
C. Septic arthritis
D. Gout
E. Olecranon bursitis
ANSWER:
EXPLANATION:
Please see Q-16 for Elbow Pain
Q-22
An 80-year-old man presents to his GP with a 1-month history of gradual onset lower back pain and
stiffness. He sometimes uses a hot water bottle, which he finds helps a little. There has been no loss of
bladder or bowel control. His neurological examination is normal.
What is the most appropriate management of this patient?
A. Codeine IM
B. Codeine PO
C. Epidural with anaesthetic
D. Ibuprofen
E. Paracetamol
ANSWER:
D. Ibuprofen
EXPLANATION:
Codeine is part of the opioid pain ladder and would not be considered as part of the management for non-
specific lower back pain as it is likely to result in a cycle of dose escalation and dependence. Furthermore,
codeine IM is reserved for patients who are unable to tolerate oral medication, which is not suggested by
this man's presentation.
Oral codeine would not be considered as part of the first-line pain management of non-specific lower back
pain due to the likelihood of dose escalation and dependence.
Paracetamol is not recommended as part of the management of non-specific lower back pain. Trials have
shown that paracetamol monotherapy is relatively ineffective for back pain.
Epidural injections of local anaesthetic and steroid are only indicated for acute and severe sciatica. The
first-line management of lower back pain is an NSAID.
Please see Q-11 for Lower Back Pain: Investigation and Management
Q-23
You see a 28-year-old man with severe back pain. He has had lumbar back pain for 2 years on and off but
today the pain became much worse when he lent over to pick up a sock yesterday. He complains of pain
down the posterolateral side of his right leg. He also says when he touches this area it feels numb. He says
that his right leg feels weak.
On examination, he has sensory loss of the posterolateral aspect of his right leg and lateral aspect of his
foot. He has weakness in plantar flexion of his right foot, a reduced ankle reflex on the right, and a
positive sciatic nerve stretch test.
You believe he has slipped a disc. Where is the sit of the compression?
A. L2
B. L3
C. L4
D. L5
E. S1
ANSWER:
E. S1
EXPLANATION:
S1 lesion features = Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in
plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
The correct answer here is an S1 lesion. An S1 lesion causes sensory loss of the posterolateral aspect of the
leg and lateral aspect of the foot, weakness in plantar flexion of the foot, reduced ankle reflexes, and a
positive sciatic nerve stretch test.
An L2 lesion would cause pain that radiates to the anterior thigh but also would involve the posterior
pelvis and possibly the buttocks. Weakness would involve the Iliopsoas muscle, so a patient might
complain of weak hip flexion (eg when climbing the stairs). This muscle also pulls the leg forward when
walking so weakness will reduce the length of the stride and cause a limp. Therefore, option 1 is wrong.
Please see Q-2 for Lower Back Pain: Prolapsed Disc
Q-24
A 70-year-old woman who has a strong family history of fragility fractures secondary to osteoporosis
presents as she is concerned about her own risk. What is the most appropriate way to assess her risk?
A. Order an x-ray of her hips and lumbar spine

B. Assess her using the Birmingham Hip Score tool
C. Order a MRI of her hips and lumbar spine
D. Check her calcium and phosphate levels
E. Assess her using the FRAX tool
ANSWER:
E. Assess her using the FRAX tool
EXPLANATION:
Radiographs may show osteopenia but it is not possible to determine the severity of
osteopenia/osteoporosis accurately using this method alone. Calcium and phosphate levels are normal in
osteoporosis.
There is no such thing as a Birmingham Hip Score tool.

Please see Q-5 for Osteoporosis: Assessing Risk
Q-25
You are performing a newborn examination. Which one of the following best describes the clinical
findings of a clubfoot?
A. Inverted + plantar flexed foot which is not passively correctable

B. Inverted + dorsiflexed foot + pes planus which is not passively correctable
C. Inverted + plantar flexed foot + pes planus which is passively correctable
D. Everted + dorsiflexed foot which is not passively correctable
E. Inverted + plantar flexed foot which is passively correctable
ANSWER:
A. Inverted + plantar flexed foot which is not passively correctable
EXPLANATION:
Please see Q-13 for Talipes Equinovarus
Q-26
Which one of the following statements regarding Morton's neuroma is correct?
A. Occurs most commonly in the second inter-metatarsophalangeal space

B. There may be a distal neurological deficit
C. There are more common in patients who have multiple sclerosis
D. Has malignant potential in around 1% of patients
E. There is roughly equal incidence in males and females
ANSWER:
B. There may be a distal neurological deficit
EXPLANATION:
Please see Q-19 for Morton’s Neuroma
Q-27
A 50-year-old plumber presents with a 3 month history of a hand deformity. Dupuytren's disease is
diagnosed. Which condition from his past medical history is a risk factor?
A. Hypertension
B. Hypercholesterolaemia
C. Hypothyroidism
D. Psoriasis
E. Diabetes
ANSWER:
E. Diabetes
EXPLANATION:
Diabetes is a risk factor for Dupuytren’s disease
Dupuytren's contracture risk factors include: liver disease, diabetes, trauma, family history, phenytoin
treatment and smoking however this list is not exhaustive.
DUPUYTREN'S CONTRACTURE
Dupuytren's contracture has a prevalence of about 5%. It is more common in older male patients and
around 60-70% have a positive family history
Specific causes include:

 manual labour
 phenytoin treatment
 alcoholic liver disease
 trauma to the hand
Features
 the ring finger and little finger are the fingers most commonly affected
Management
 consider surgical treatment of Dupuytren's contracture when the metacarpophalangeal joints cannot be
straightened and thus the hand cannot be placed flat on the table
Q-28
Mrs Macdonald is an 80-year-old woman who presents with back pain after bending down to lift her
suitcase. The pain is worse on movement and is affecting her sleep. There is no history of trauma. On
examination, she is tender over the thoracic spine. There is no disturbance of bowel or bladder function.
What is the most appropriate investigation?
A. CT thoracic spine
B. DEXA scan
C. X-Ray thoracic spine
D. MRI spine
E. No investigation needed
ANSWER:
C. X-Ray thoracic spine
EXPLANATION:
X-ray of the spine is the first-line investigation for a suspected osteoporotic vertebral fracture
The symptoms likely represent an osteoporotic vertebral fracture. The first line investigation for this is a
spinal X-Ray.
A DEXA scan is necessary to assess the severity of osteoporosis, however it is not used to diagnose the
fracture.
CT and MRI scans would not be the first line investigation, however may be needed to further assess any
injuries subsequently.
OSTEOPOROTIC VERTEBRAL FRACTURE

Osteoporosis is a condition where bones gradually decrease in bone mineral density, thus increasing the
likelihood of fragility fractures. Fragility fractures are fractures that occur as a result of mechanical forces
which would not usually lead to a fracture. According to NICE, one of the most common sites of osteoporotic
fractures is the spine (vertebra). These types of fractures often present with acute onset back pain, however,
patients can also be asymptomatic. Osteoporosis is commonly associated with advancing age and is a major
cause of disability and reduced life expectancy in older populations.
Epidemiology
 Osteoporosis is far more common in females than in males. The male-to-female ratio is 1:6.
 25% of women will have developed osteoporosis by the age of 80 .
 The prevalence of vertebral osteoporotic fractures is difficult to determine, as not all patients present to
a clinician and fractures may not always be clearly identifiable on X-ray .
Risk factors for osteoporotic fractures

 Advancing age is a major risk factor osteoporotic fractures: Women ≥ 65 years old and men ≥ 75 years
old should be considered for fracture risk assessment. Women in this age bracket are almost certainly
post-menopausal, therefore have reduced oestrogen levels - this is a risk factor for osteoporosis.
 Previous history of a fragility fracture
 Frequent or prolonged use of glucocorticoids
 History of falls
 Family history of hip fracture
 Alternative causes of secondary osteoporosis e.g. Cushing’s disease, hyperthyroidism, chronic renal
disease
 Low BMI (< 18.5)
 Tobacco smoking
 High alcohol intake: > 14 units/week for women, > 21 units/week for men
Patients with osteoporotic vertebral fractures typically present with:

 Asymptomatic: an osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-
ray
 Acute back pain
 Breathing difficulties: changes in the shape and length of vertebrae lead to the compression of organs
such as the lungs, heart and intestine
 Gastrointestinal problems: due to compression of abdominal organs
 Only a minority of patients will have a history of fall/trauma
Signs:
 Loss of height: vertebral osteoporotic fractures of lead to compression of the spinal vertebrae hence a
reduction in overall length of the spine and thus the patient becomes shorter
 Kyphosis (curvature of the spine)
 Localised tenderness on palpation of spinous processes at the fracture site
Investigations:
 X-ray of the spine: This should be the first investigation ordered and may show wedging of the vertebra
due to compression of the bone. An X-ray of the spine may also show old fractures (which can have a
sclerotic appearance)
Other investigations:
 CT spine: gives a more detailed view of the bone structure, therefore can visualise the extent/features of
the fracture more clearly
 MRI spine: Useful for differentiating osteoporotic fractures from those caused by another pathology e.g.
a tumour
In order to assess the likelihood of future fractures, risk factors are taken into account and a dual-energy X-
ray absorptiometry (DEXA) scan should be considered. DEXA scans essentially assess bone mineral density.
According to NICE, the FRAX tool or QFracture tool can be used to estimate the 10-year risk of a fracture.
These tools each require the clinician to input patient information into a form and this information is used by
the programme to calculate the risk.
Q-29
A 34-year-old kitchen worker presents with a two week history of pain in her right wrist. She has recently
emigrated from Ghana and has no past medical history of note. On examination she is tender over the
base of her right thumb and also over the radial styloid process. Ulnar deviation of the wrist recreates the
pain. What is the most likely diagnosis?
A. Rheumatoid arthritis
B. Osteoarthritis of the carpometacarpal joint
D. Carpal tunnel syndrome
E. Systemic lupus erythematosus
ANSWER:
EXPLANATION:
DE QUERVAIN'S TENOSYNOVITIS
De Quervain's tenosynovitis is a common condition in which the sheath containing the extensor pollicis
brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old.
Features
 pain on the radial side of the wrist
 tenderness over the radial styloid process
 abduction of the thumb against resistance is painful
 Finkelstein's test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal
traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along
the length of extensor pollisis brevis and abductor pollicis longus
Management
 analgesia
 steroid injection
 immobilisation with a thumb splint (spica) may be effective
 surgical treatment is sometimes required
Q-30
Piotr is a 36-year-old man who has presented to his GP with acute lower back pain. There are no red flags
in the history and his neurological examination is normal.
What analgesia should the GP offer first line?

A. Codeine
B. Diazepam
C. Ibuprofen
D. Paracetamol
E. Topical diclofenac
ANSWER:
C. Ibuprofen
EXPLANATION:
NSAIDS such as ibuprofen or naproxen should be offered first line for lower back pain.
Codeine with or without paracetamol is second line.
Benzodiazepines can be considered if there is muscle spasm.
Topical NSAIDS are not recommended by NICE for lower back pain.
Q-31
You see a 13-year-old girl with her mother. She is normally completely fit and well and extremely active.
She is a keen netball player and also enjoys dancing. She noticed a lump behind her right knee one week
ago, it seemed to come on suddenly. She can't remember ever injuring her knee. It is not painful but her
knee does feel 'tight'.
On examination, she has a round, soft fluctuant mass behind her right knee in the medial popliteal fossa.
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.
What is the most likely diagnosis here?
A. Anterior cruciate ligament tear
B. Popliteal artery aneurysm
C. Rhabdomyosarcoma
D. Baker's cyst
E. Osgood–Schlatter disease
F.
ANSWER:
D. Baker's cyst
EXPLANATION:
In a child with an asymptomatic, fluctuant swelling behind the knee the most likely diagnosis is a Baker's
cyst
In a child with an asymptomatic, fluctuant swelling behind the knee the most likely diagnosis is a Baker's
cyst. Therefore, option 4 is correct.
An anterior cruciate ligament tear would normally follow a twisting injury, it is likely to be painful and
wouldn't commonly present with a lump in the popliteal fossa. Therefore, option 1 is wrong.
A popliteal artery aneurysm would be pulsatile and unlikely in this age group. Therefore, option 2 is
incorrect.
A rhabdomyosarcoma is unlikely to be fluctuant and the patient may have other symptoms of systemic
disease. It is unlikely to be asymptomatic. Therefore, option 3 is wrong.
Osgood–Schlatter disease causes anterior knee pain during adolescence. It is caused by multiple small
avulsion fractures within the ossification centre of the tibial tuberosity at the inferior attachment of the
patellar ligament. This patient does not have knee pain, therefore, option 5 is wrong.
BAKER'S CYST
Baker's cysts (also known as a popliteal cyst) are not true cysts but rather a distension of the gastrocnemius-
semimembranosus bursa. They may be primary or secondary:
 Primary: no underlying pathology, typically seen in children
 Secondary: underlying condition such as osteoarthritis, typically seen in adults
They present as swellings in the popliteal fossa behind the knee.
Rupture may occur resulting in similar symptoms to a deep vein thrombosis, i.e. pain, redness and swelling
in the calf. However, the majority of ruptures are asymptomatic.
Baket's cysts in children typically resolve and do not require treatment.
In adults, the underlying cause should be treated where appropriate.
Q-32
You see a 10-year-old girl with a swelling behind her left knee. She noticed the swelling 4 days ago, it is
not painful and isn't growing. The swelling is not associated with a prior injury. She is otherwise fit and
well.
You examine the patient and find a round, smooth, and fluctuant swelling in the popliteal fossa of her left
knee. It is not tender.
You diagnose a Baker's cyst and give the patient and her mum some information.
Which statement below regarding Baker's cysts is correct?
A. Secondary Baker's cysts are idiopathic and have no communication between the bursa and the knee
joint
B. Primary Baker's cysts tend to have a communication between the bursa and the rest of the knee joint
allowing synovial fluid to fill the cyst
C. Almost all Baker's cysts in adults are primary cysts
D. Primary Baker's cysts are found mainly in children
E. Juvenile idiopathic arthritis is not a cause of a secondary Baker's cyst in children
ANSWER:
D. Primary Baker's cysts are found mainly in children
EXPLANATION:
Primary Baker's cysts are found mainly in children
Baker's cysts are described as primary or secondary:

 Primary cysts are idiopathic and have no communication between the bursa and the knee joint. They
are not associated with disease of the knee joint and are found most commonly in children. Therefore,
option 4 is correct.
 Secondary cysts are associated with underlying disease of the knee joint (such as osteoarthritis) and
tend to have a communication between the bursa and the rest of the knee joint allowing synovial fluid
to fill the cyst. Almost all Baker's cysts in adults are secondary cysts. Juvenile idiopathic arthritis is a
cause of secondary cysts in children.
Please see Q-31 for Baker’s Cyst
Q-33
A 33-year-old woman presents with back pain which radiates down her right leg. This came on suddenly
when she was bending down to pick up her child. On examination straight leg raising is limited to 30
degrees on the right hand side due to shooting pains down her leg. Sensation is reduced on the dorsum of
the right foot, particularly around the big toe and foot dorsiflexion is also weak. The ankle and knee
reflexes appear intact. A diagnosis of disc prolapse is suspected. Which nerve root is most likely to be
affected?
A. L2
B. L3
C. L4
D. L5
E. S1
ANSWER:
D. L5
EXPLANATION:
L5 lesion features = loss of foot dorsiflexion + sensory loss dorsum of the foot
Q-34-36
Theme: Lower back pain
A. Peripheral arterial disease

B. Prolapsed disc
C. Facet joint pain
D. Perforated duodenal ulcer
E. Leaking abdominal aortic aneurysm
F. Pyelonephritis
G. Ankylosing spondylitis
H. Rheumatoid arthritis
I. Crush fracture
J. Spinal stenosis
For each one of the following scenarios please select the most likely diagnosis:
Q-34
A 34-year-old man reports the sudden onset of back pain after bending over to tie his shoe laces. There is
tenderness over the lumbar spine on examination and leaning back worsens the pain. Neurological
examination and straight leg raising is normal
ANSWER:
C. Facet joint pain
EXPLANATION:
Although patients often give a history of bending prior to disc prolapse the normal straight leg raising makes
this diagnosis less likely.
Q-35
A 76-year-old man reports pain is his buttocks when he walks the dog. The pain comes on after around
500 yards and resolves when he stops. He has a past history of chronic obstructive pulmonary disease and
ischaemic heart disease. Neurological examination is normal and the foot pulses are difficult to feel in
both feet
ANSWER:
A. Peripheral arterial disease
Q-36
A 68-year-old obese man presents with a one-day history of progressively more severe lower back pain.
There was no obvious trigger. Abdominal examination is unremarkable. Blood pressure is 90/60 mmHg
and his pulse is 120 bpm
ANSWER:
E. Leaking abdominal aortic aneurysm
EXPLANATION:
Whilst patients often suffer an acute haemodynamic collapse a number of patients will have more sub-acute
symptoms if the aneurysm is leaking prior to rupture.
EXPLANATION Q-34-36:
Q-37
A 44-year-old man is diagnosed with lower back pain. This has been present for around 2 weeks and there
are no red flags such as trauma or systemic symptoms. Clinical examination including neurological
examination is unremarkable. You encourage him to remain active and give him a 'back sheet' detailing
some exercises he could do. He asks for analgesia to 'help him through the day'. What is the most
appropriate initial medication?
A. Oral paracetamol
B. Oral codeine
C. Oral naproxen
D. Topical ibuprofen
E. Oral amitriptyline
ANSWER:
C. Oral naproxen
EXPLANATION:
From the 2016 NICE guidelines:
1.2.17 Consider oral non-steroidal anti-inflammatory drugs (NSAIDs) for managing low back pain, taking
into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk
factors, including age.
1.2.18 When prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment,
ongoing monitoring of risk factors, and the use of gastroprotective treatment.
1.2.19 Prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period
of time.
1.2.20 Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an
NSAID is contraindicated, not tolerated or has been ineffective.
1.2.21 Do not offer paracetamol alone for managing low back pain.
Q-38
Please look at the image below:
Which one of the following statements regarding this condition is true?
A. The majority of cases are idiopathic

B. It is most commonly diagnosed at the six-week check
C. It is bilateral in 80-90% of cases
D. The incidence is 5 per 1,000 live births
E. X-rays should be performed to confirm the diagnosis
ANSWER:
A. The majority of cases are idiopathic
EXPLANATION:

Q-39
You see a 65-year-old man with lower back and bilateral leg pain. The lower back pain has been present
for 2 years but gradually getting worse. Recently he has noticed that his legs ache when he walks further
than about 500 meters. He is normally very fit and active. The pain radiates to his buttocks, thighs and
legs bilaterally (but his left leg is worse than the right). He describes the pain as 'cramping' and 'burning'. If
he walks further than about 500 metres his legs become weak and numb. If he sits down and leans
forward the symptoms go, and he can then carry on for another 500 metres. He says that the pain is
better if he walks uphill. He finds standing exacerbates the symptoms but he can cycle on his static bike
without any problems.
He has no relevant past medical history and has never smoked.
You find no abnormalities on examination. His peripheral pulses are good.
Given the most likely diagnosis here, what is the first line investigation confirm the diagnosis?
A. Lumbar spine x-ray

B. Abdominal ultrasound scan to assess the aorta
C. Spinal MRI
D. Lower limb dopplers
E. Spinal CT scan
ANSWER:
C. Spinal MRI
EXPLANATION:
In a patient with suspected spinal stenosis, an MRI is the imaging of choice
Spinal stenosis is the most likely diagnosis in a patient with gradual onset leg and back pain, weakness
and numbness which is brought on by walking (with a normal clinical examination). Classically they
complain of pain which improves when sitting, leaning forward or crouching and they often find walking
uphill less painful, and cycling does not bring on the pain. The imaging of choice for spinal stenosis is an
MRI. Therefore, option 3 is correct.
The most likely differential is peripheral vascular disease causing claudication, but this patient has good
pulses and no risk factors (and he can also cycle a bike without symptoms). Lower limb dopplers would be
used if you suspected vascular disease. Therefore, option 4 is wrong.
A spinal CT can be used if an MRI is contraindicated, but is not the first line. Therefore, option 5 is wrong.
An abdominal USS and a spinal x-ray are not used to assess a patient with possible spinal stenosis so both
these answers are wrong.
Q-40
You see a 36-year-old lady who twisted her ankle whilst ice-skating. She was able to get up and limp off
the ice. She has a swelling over her lateral malleolus with tenderness over the anterior aspect of the distal
fibula only. There is no other tenderness. She has an antalgic gait. What is the likely diagnosis?
A. Metatarsalgia
B. Avulsion fracture
C. Anterior talofibular ligament sprain
D. Muscular injury
E. Simple fracture
ANSWER:
C. Anterior talofibular ligament sprain
EXPLANATION:
The Ottawa ankle rules determine the need to perform an ankle x-ray for patients presenting with foot or
ankle pain. If an ankle x-ray is not indicated by the Ottawa ankle rules the probability of a fracture is very
low. The rules state an x-ray is only required if there is an inability to weight bear both immediately after
the injury and on assessment, or there is tenderness along the distal 6cm of the posterior edge of the tibia
or fibula or distal tip of either malleoli.
In this case, the patient has tenderness of the anterior aspect of the fibula due to the very common sprain
of the anterior talofibular ligament which inserts in the anterior part of the fibula.
ANKLE INJURY: OTTAWA RULES

The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100%
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
There are also Ottawa rules available for both foot and knee injuries
Q-41
Which one of the following statements regarding adhesive capsulitis (frozen shoulder) is correct?
A. It is bilateral in around 40% of cases

B. Each episode typically lasts between 6 months and 2 years
C. Abduction is most severely affected
D. It is most common in elderly patients (> 70 years of age)
E. Early physiotherapy has been shown to resolve 60% of cases within 6 months
ANSWER:
B. Each episode typically lasts between 6 months and 2 years
EXPLANATION:
Please see Q-3 for Adhesive Capsulitis
Q-42
Which one of the following statements regarding the FRAX tool for assessing the risk of fragility fractures
is true?
A. The FRAX score can be calculated with or without a DEXA scan result
B. Estimates the 5-year risk of having a fragility fracture
C. Only assesses the risk of developing a hip fracture
D. Includes questions about ethnicity
E. Cannot be used in patients older than 70-years
ANSWER:
A. The FRAX score can be calculated with or without a DEXA scan result
EXPLANATION:
Q-43
A 65-year-old woman phones for advice following a recent elective hip replacement. She has been told
she needs to have 'blood-thinning' injections but is unsure how long these should continue. According to
NICE guidelines how long should patients receive low-molecular weight heparin following an elective hip
replacement?
A. 7 days
B. 14 days
C. 4 weeks
D. 2 months
E. 3 months
ANSWER:
C. 4 weeks
EXPLANATION:
Hip replacement: LMWH for 4 weeks
Please see Q-18 for Osteoarthritis: Joint Replacement

Q-44
A 45-year-old man presents with a three-month history of posterior heel pain. This is generally worse on
the mornings and after playing squash. On examination, his Achilles is tender and thickened but there is
no palpable gap or other signs of rupture. You advise simple analgesia and refraining from exacerbating
activities. What else may improve his symptoms?
A. Achilles tendon massage
B. Ankle rotation exercises
C. Ankle dorsiflexion stretches
D. Calf muscle concentric exercises
E. Calf muscle eccentric exercises
ANSWER:
E. Calf muscle eccentric exercises
EXPLANATION:
Calf muscle eccentric exercises are beneficial in Achilles tendinopathy
ACHILLES TENDON DISORDERS

Achilles tendon disorders are the most common cause of posterior heel pain. Possible presentations include
tendinopathy (tendinitis), partial tear and complete rupture of the Achilles tendon.
Risk factors
 quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
 hypercholesterolaemia (predisposes to tendon xanthomata)
Achilles tendinopathy (tendinitis)

Features
 gradual onset of posterior heel pain that is worse following activity
 morning pain and stiffness are common
The management is typically supportive

 simple analgesia
 reduction in precipitating activities
 calf muscle eccentric exercises: this may be self-directed or under the guidance of physiotherapy
Achilles tendon rupture

Achilles tendon rupture should be suspected if the person describes the following whilst playing a sport or
running; an audible 'pop' in the ankle, sudden onset significant pain in the calf or ankle or the inability to
walk or continue the sport.
An examination should be conducted using Simmond's triad, to help exclude Achilles tendon rupture. This
can be performed by asking the patient to lie prone with their feet over the edge of the bed. The examiner
should look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of
the injured foot compared to the uninjured limb. They should also feel for a gap in the tendon and gently
squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the
neutral position when the calf is squeezed.
Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture
An acute referral should be made to an orthopaedic specialist following a suspected rupture.
Q-45
Thomas is a 45-year-old man who has presented with left groin pain. He has also noticed a clicking
sensation in his hip when he moves. He is a keen hockey player and is unable to participate in matches. He
thinks the pain may have started after a twisting injury he had during one of his games. On examination,
you notice that he complains of pain adduction and internal rotation of the hip. He is afebrile, and there is
no pain on palpation of the outside of the hip and no joint swelling. A recent X-ray of his hip was normal.
Which of the following is a possible cause of his pain?
A. Left hip osteoarthritis

B. Septic arthritis of the hip
C. Trochanteric bursitis
D. Acetabula labral tear
E. Acetabular fracture
ANSWER:
D. Acetabula labral tear
EXPLANATION:
Acetabular labral tears typically present with hip/groin pain and a snapping sensation
Left hip osteoarthritis and an acetabular fracture would be seen on a plain radiograph.
Septic arthritis usually presents with hint swelling and fever.
Trochanteric bursitis usually causes pain on palpation of the side of the hip.
Acetabular labral tears are a cause of mechanical hip pain. They may be associated with mild trauma such
as twisting or falling. The pain is usually in the groin and there may also be a clicking or snapping
sensation. An MRI is usually needed to diagnose this condition.
ACETABULAR LABRAL TEAR

Labral tears may occur following trauma (most commonly in younger adults) or as a result of degenerative
change (typically in older adults).
Features
 hip/groin pain
 snapping sensation around hip
 there may occasionally be the sensation of locking
Q-46
A 30-year-old man attends complaining of pain on the inner side of his right elbow and forearm since he
built a bookcase at home 3 days ago. He is normally fit and well and on no regular medication. On
examination you elicit some tenderness of the medial elbow joint and the patient reports discomfort felt
in the elbow on resisted pronation of the wrist. What is the likely diagnosis?
A. Golfer's elbow
B. Tennis elbow
D. Radial tunnel syndrome
ANSWER:
A. Golfer's elbow
EXPLANATION:
Epicondylitis is caused by repeated strain leading to inflammation of the common extensor tendon at the
epicondyle.
 Golfer's elbow or medial epicondylitis produces tenderness over the medial epicondyle and medial
wrist pain on resisted wrist pronation.
 Tennis elbow or lateral epicondylitis produces tenderness over the lateral epicondyle and lateral elbow
pain on resisted wrist extension.
Q-47
A 30 years old basket ball player injures his knee while twisting. He is taken to the emergency department
where he tells the doctor that he heard a' squelch' and is unable to bear weight on the affected knee. On
examination, the doctor notices that the affected knee is locked.
Which of the following test is used to help in the diagnosis?
A. Froment's test
B. Phalen's test
C. Tinel's test
D. Allen's test
E. Thessaly's test
ANSWER:
E. Thessaly's test
EXPLANATION:
Thessaly's test is used to assess meniscal tear. The patient is supported by doctor and is asked to stand on
the affected leg, flexed to 20 degree. The test is positive if there is pain on twisting knee
Thessaly's test is used to assess meniscal tear. In this test, the patient is supported by a doctor and is asked
to stand on the affected leg, flexed to 20 degrees. The test is positive if there is pain on twisting the knee.
Froment's test assesses if adductor pollicis is working which is innervated by ulnar nerve.
Phalen's test and Tinel test is used to asses carpal tunnel syndrome. In Phalen's test, the patient's wrist is
held in maximum flexion (reverse prayer sign) for 30-60 second. The test is positive if there is numbness in
the median nerve distribution.
In Tinel's test, the doctor taps over median nerve at the wrist. The test is positive if there is
tingling/numbness in the median nerve distribution.
Allen test assesses the patency of the arterial blood supply of the hand.
Another test such as McMurray test could be performed as well. McMurray test is more sensitive to lateral
meniscal tear while Thessaly's test is more sensitive for both; medial and lateral meniscal tear.
KNEE PAIN: MENISCAL TEAR
Typically result from twisting injuries.
Features
 pain worse on straightening the knee
 knee may 'give way'
 displaced meniscal tears may cause knee locking
 tenderness along the joint line
 Thessaly's test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if
pain on twisting knee
Q-48
A 23-year-old female presents with a painless swelling on the back of her wrist:
Of the following options, what is the most appropriate management?
A. Check rheumatoid factor and refer to rheumatology

B. Check full blood count
C. Reassurance and review if not settling
D. Inject with sclerosing agent
E. Arrange ultrasound
ANSWER:
C. Reassurance and review if not settling
EXPLANATION:
GANGLION
A ganglion presents as a 'cyst' arising from a joint or tendon sheath. They are most commonly seen around
the back of the wrist and are 3 times more common in women
Ganglions often disappear spontaneously after several months
Q-49
Reshma is a 68-year-old with a history of type 2 diabetes who has presented with intermittent tingling of
her left 4th and 5th fingers.
A. Alcohol excess
B. Carpal tunnel syndrome
C. Cubital tunnel syndrome
D. Multiple sclerosis
E. B12 deficiency
ANSWER:
C. Cubital tunnel syndrome
EXPLANATION:
Cubital tunnel syndrome is caused by compression of the ulnar nerve and can present with
tingling/numbness of the 4th and 5th finger
Cubital tunnel syndrome is caused by ulnar nerve entrapment at the elbow. It initially presents with
sensory symptoms affecting the 4th and 5th fingers. Diabetes is a risk factor for peripheral neuropathies.
Carpal tunnel syndrome is caused by median nerve entrapment in the wrist. It affects the first, second and
third fingers, plus the lateral side of the 4th finger.
It would be possible for multiple sclerosis to present like this but much less likely.
Alcohol excess and B12 deficiency are more likely to present with symmetrical neurological symptoms.
CUBITAL TUNNEL SYNDROME

Cubital tunnel syndrome occurs due to compression of the ulnar nerve as it passes through the cubital
tunnel.
Clincial features
 Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes
constant.
 Over time patients may also develop weakness and muscle wasting
 Pain worse on leaning on the affected elbow
 Often a history of osteoarthritis or prior trauma to the area.
Investigations
 the diagnosis is usually clinical
 however, in selected cases nerve conduction studies may be used
Management
 Avoid aggravating activity
 Physiotherapy
 Steroid injections
 Surgery in resistant cases
Q-50
A 14-year-old boy is brought to the GP by his mother. He has been complaining of pain in his right leg
which feels like it is coming from his bone just below his knee. He says that the pain has been there for
several weeks and is constant and dull, often worsening at nighttime. On examination, there is a bony
swelling on his tibia, just below his knee joint. Which of the following investigations should this child be
referred to have within 48 hours?
A. Full body MRI

B. Ultrasound of the lump
C. CT CAP
D. X-ray of his right leg
E. DEXA scan of his right leg
ANSWER:
D. X-ray of his right leg
EXPLANATION:
Children and young people with unexplained bone swelling or pain: consider very urgent direct access X-
ray to assess for bone sarcoma
This child has unexplained bone pain and a bony swelling on examination. Teenagers are particularly at
risk of osteosarcoma and hence it is very important to investigate for this differential. For these symptoms,
it is advised that an X-ray should be performed within 48 hours.
Whilst the other investigations might provide useful information and may indeed be used down the line,
they are not first-line investigations and certainly do not need to be performed within 48 hours. A DEXA
scan is a special type of X-ray which measures bone density and is used to investigate for osteoporosis. A
standard X-ray should be used to investigate for an osteosarcoma making this incorrect.
Please see Q-7 for Sarcomas
Q-51
Which one of the following statements regarding QFracture is correct?
A. Estimates the 5-year risk of fragility fracture

B. Should not be used for Asian patients
C. Is based on UK primary care data
D. Asks about fewer risk factors than FRAX
E. Cannot be used to assess fracture risk in a 40-year-old man
ANSWER:
C. Is based on UK primary care data
EXPLANATION:
QFracture is based on UK primary care data.
Q-52
You review a 57-year-old woman. She has read in the paper about the risks of osteoporosis and wants
advice on whether she is at risk or not. She is fit and well, doesn't smoke and drinks only 1-2 units of
alcohol per week.
At what age do NICE recommend that we start to assess women regarding their risk suffering a fragility
fracture?
A. At the menopause
B. After the age of 55 years
C. After the age of 60 years
D. After the age of 65 years
E. After the age of 70 years
ANSWER:
D. After the age of 65 years
EXPLANATION:
Q-53
Which one of the following statements regarding the FRAX risk score is correct?
A. Estimates the 20-year risk of a patient sustaining a fragility fracture

B. A bone mineral density measurement within the past 12 months is required
C. Asks about the age of menopause for women
D. Can only be used for UK-based patients
E. Valid for patients aged 40-90 years
ANSWER:
E. Valid for patients aged 40-90 years
EXPLANATION:
FRAX may be used for patients aged 40-90 years.
Q-54
A 55-year-old man presents as he has noticed thickening of the 'tendons' on both hands:
Which one of the following is least associated with this condition?
A. Positive family history

B. Phenytoin treatment
C. Manual labour
D. Alcoholic liver disease
E. Chronic kidney disease
ANSWER:
EXPLANATION:
Dupuytren's contracture is actually a thickening of the palmar fascia rather than the tendons
Please see Q-27 for Dupuytren’s Contracture
Q-55
A 65-year-old man presents with bilateral leg pain that is brought on by walking. His past medical history
includes peptic ulcer disease and osteoarthritis. He can typically walk for around 5 minutes before it
develops. The pain subsides when he sits down. He has also noticed that leaning forwards or crouching
improves the pain. Musculoskeletal and vascular examination of his lower limbs is unremarkable. What is
the most likely diagnosis?
A. Inflammatory arachnoiditis
B. Peripheral arterial disease
C. Raised intracranial pressure
D. Spinal stenosis
E. Lumbar vertebral crush fracture
ANSWER:
D. Spinal stenosis
EXPLANATION:
This is a classic presentation of spinal stenosis. Whilst peripheral arterial disease is an obvious differential
the characteristic relieving factors of the pain and normal vascular examination point away from this
diagnosis.
Q-56
You see a 62-year-old man with a Baker's cyst behind his right knee. He has had troublesome
osteoarthritis (OA) for 10 years in both his knees. The cyst appeared last week and doesn't seem to be
going down. It is not painful but he would like some advice about it.
Which statement below is correct regarding Baker's cysts?
A. His cyst is likely to be a primary Baker's cyst

B. Treatment of his OA should treat the Baker's cyst
C. He will require excision of the cyst in order to prevent recurrence
D. Aspiration of the cyst in primary care is appropriate
E. Cyst aspiration and intra-cystic corticosteroid injection in primary care is appropriate
ANSWER:
B. Treatment of his OA should treat the Baker's cyst
EXPLANATION:
A patient with a secondary Baker's cyst requires treatment of the underlying condition in order to treat the
cyst
This patients cyst is likely to be secondary to his knee OA. Therefore, option 1 is wrong.
Treatment of his OA will treat the cyst, therefore, option 2 is correct.
Excision of the cyst will not prevent recurrence. He needs treatment of the underlying cause. Therefore,
option 3 is wrong.
Direct aspiration of a Baker's cyst in primary care is not recommended, therefore, option 4 and 5 is correct.
These may be offered in secondary care for a particularly troublesome cyst.
Q-57
A 56-year-old man complains of pain in his foot. You suspect a diagnosis of Morton's neuroma.
Where is the pain most likely to be located?
A. Marker A
B. Marker B
C. Marker C
D. Marker D
E. Marker E
ANSWER:
B. Marker B
EXPLANATION:
Q-58
You see a 70-year-old male patient with back pain. He says he has had lower back pain for about 12
months which is slowly getting worse. It now radiates to his buttocks, thighs and legs bilaterally (but his
left leg is worse than the right). He describes the pain as 'cramping' and 'burning'. He says that when he
walks for more than a few minutes his legs become weak and numb. If he sits down and leans forward the
symptoms go. He finds standing exacerbates the symptoms. He is worried as he is losing his independence
as he does not feel stable on his feet, he now has a walking aid. His wife thinks he has a more stooped
posture than 12 months ago.
His past medical history includes tablet controlled hypertension. He has never smoked and has a normal
BMI.
On examination, he has a wide-based gate. Neurological examination of his lower limbs is normal. His
peripheral pulses feel normal.
What diagnosis is most likely given the presentation and examination findings?
A. Ankylosing spondylitis
B. Spinal stenosis
C. Sciatica
D. Vascular claudication
E. Non-specific lower back pain
ANSWER:
B. Spinal stenosis
EXPLANATION:
Spinal stenosis is the most likely diagnosis in a patient with gradual onset leg and back pain, weakness
and numbness which is brought on by walking (with a normal clinical examination)
This man's presentation is most consistent with a diagnosis of spinal stenosis. Spinal stenosis typically
presents with gradual onset leg and back pain, weakness and numbness which is brought on by walking.
Patients often say that the pain is relieved by sitting and leaning forward and is better if walking up a hill.
Physical examination findings are frequently normal in patients with lumbar spinal stenosis. Therefore, the
correct answer is 2.
The main differential diagnosis is vascular claudication but he has normal pulses peripherally. Therefore,
option 4 is wrong.
Sciatica is more likely to present with unilateral leg pain. Therefore, option 3 is incorrect.
Non-specific lower back pain is common but does not present with lower limb symptoms. Therefore,
option 5 is wrong.
Q-59
Please look at the image of the toe below:
Which underlying condition is this appearance most associated with?
B. Osteoarthritis
C. Diabetes mellitus
D. Gout
E. Pseudogout
ANSWER:
B. Osteoarthritis
EXPLANATION:
MYXOID CYST
Myxoid cysts (also known as mucous cysts) are benign ganglion cysts usually found on the distal, dorsal
aspect of the finger. There is usually osteoarthritis in the surrounding joint. They are more common in
middle-aged women.
Q-60
Which one of the following is a risk factor for clubfoot?
A. Spina bifida
B. Maternal diabetes mellitus
C. Down's syndrome
D. Female gender
E. Polyhydramnios
ANSWER:
A. Spina bifida
EXPLANATION:
Q-61
A 73-year-old woman who has previously had a total hip replacement (THR) presents for review due to
pain on the side of her prosthesis. What is the most common reason that a revision operation would need
to be performed in a patient who has had a THR?
A. Aseptic loosening of the implant

B. Autoimmune reaction to the implant
C. Infection
D. Fracture of the implant or surrounding bone
E. Implant passes expiry date
ANSWER:
A. Aseptic loosening of the implant
EXPLANATION:
Aseptic loosening is the most common reason total hip replacements need to be revised
Other common reasons for revision include pain and dislocation.
OSTEOARTHRITIS OF THE HIP

Osteoarthritis (OA) of the hip is the second most common presentation of OA after the knee. It accounts for
significant morbidity and total hip replacement is now one of the most common operations performed in
the developed world.
Risk factors
 increasing age
 female gender (twice as common)
 obesity
 developmental dysplasia of the hip
Features
 chronic history of groin ache following exercise and relieved by rest
 red flag features suggesting an alternative cause include rest pain, night pain and morning stiffness > 2
hours
 the Oxford Hip Score is widely used to assess severity
Investigations
 NICE recommends that if the features are typical then a clinical diagnosis can be made
 otherwise plain x-rays are the first-line investigation
Management
 oral analgesia
 intra-articular injections: provide short-term benefit
 total hip replacement remains the definitive treatment
Complications of total hip replacement
 venous thromboembolism
 intraoperative fracture
 nerve injury
Reasons for revision of total hip replacement
 aseptic loosening (most common reason)
 pain
 dislocation
 infection
Q-62
What is the first-line treatment for Morton's neuroma?
A. Avoid high heels + supinatory insoles + NSAIDs
B. Avoid high heels + supinatory insoles
C. Avoid high heels + physiotherapy
D. Avoid high heels + NSAIDs
E. Avoid high heels + metatarsal pads
ANSWER:
E. Avoid high heels + metatarsal pads
EXPLANATION:
Clinical Knowledge Summaries do not recommend the routine use of NSAIDs for patients with Morton's
neuroma
Q-63
You are working in a rural GP setting. David, a 30-year-old maths teacher, comes to see you with pain at
the back of his left heel, which came on suddenly whilst running as if he'd been struck by something. He
has noticed some bruising and swelling since.
Which of the following should be performed to assess for Achilles tendon rupture?
A. Palpation of the Achilles tendon

B. Thompson test (calf squeeze test)
C. Pivot-shift test
D. Simmonds triad (palpation of tendon, angle of declination at rest and calf squeeze test)
E. Ultrasound scan
ANSWER:
D. Simmonds triad (palpation of tendon, angle of declination at rest and calf squeeze test)
EXPLANATION:
Use Simmonds triad (palpation, examining the angle of declination at rest and the calf squeeze test) to
assess for evidence of Achilles tendon rupture
Using Simmonds triad (palpation for a gap in the Achilles tendon, examining the angle of declination at
rest and the Thompson test) has been reported by studies to have a greater sensitivity than using the
Thompson test alone,(quoted by some studies as 100% vs 96% respectively).
Palpation of the Achilles tendon alone is reported to be 73% sensitive for detecting Achilles tendon rupture
and hence would not be recommended in isolation.
Some luckier GPs may have access to and skills to perform ultrasounds, however Achilles tendon rupture
can be reliably diagnosed from clinical examination and requesting ultrasounds prior to referring to
orthopaedics causes unnecessary delays in the management of these patients.
The pivot-shift test tests for anterior cruciate ligament injury and instability in the knee and is therefore an
incorrect answer.
Please see Q-44 for Achilles Tendon Disorders
Q-64
You see a 15-year-old girl with a soft, round fluctuant swelling behind her left knee. It came on
unprovoked and isn't causing her any symptoms at all.
You suspect that she has a Baker's cyst.
Which statement regarding Baker's cysts is true?
A. A child with a Baker's cyst requires a knee x-ray to look for underlying disease
B. A child with a suspected Baker's cyst requires an USS to confirm the diagnosis
C. Aspiration of the cyst is required to remove it
D. Primary Baker's cysts rarely resolve without treatment
E. Juvenile idiopathic arthritis is not a cause of secondary Baker's cysts in children
ANSWER:
B. A child with a suspected Baker's cyst requires an USS to confirm the diagnosis
EXPLANATION:
A child with a suspected Baker's cyst requires an USS to confirm the diagnosis
According to the NICE guidelines, a child with a suspected Baker's cyst requires an USS to confirm the
diagnosis. Therefore, option 2 is correct.
The majority of Baker's cysts in children are primary cysts and not due to underlying disease so a knee x-
ray is not normally required. Therefore, option 1 is wrong. An x-ray may be appropriate in an adult of you
are looking for underlying knee pathology.
Juvenile idiopathic arthritis is a rare cause of a secondary cyst in a child. Therefore, option 5 is wrong.
Most primary Baker's cysts usually resolve without treatment. Therefore, option 3 and 4 are wrong.
Q-65
A 45-year-old female presents with a painless lump at the back of her left knee. Examination is suggestive
of an uncomplicated Baker's cyst. What would be the recommended management?
A. Aspiration
B. Excision
C. Antibiotics
D. Low molecular weight heparin
E. No treatment required
ANSWER:
E. No treatment required
EXPLANATION:
Baker's cyst - if asymptomatic, no treatment is required
This patient has an uncomplicated baker's cyst so would not require aspiration, excision or antibiotics. Low
molecular weight heparin is not indicated in the management of Baker's cysts. This option acts as a
distractor as it can be used in the prevention and treatment of DVT.
Q-66
A 55-year-old woman presents for review. Her mother has just been discharged after suffering a hip
fracture. She is concerned that she may have 'inherited' osteoporosis and is asking what she should do.
She has no significant past medical history of note, takes no regular medication and has never sustained
any fractures. She smokes around 20 cigarettes per day and drinks about 3-4 units of alcohol per day.
What is the most appropriate course of action?
A. Arrange bone mineral density measurement (DEXA scan)

B. Reassure her that assessment of fragility fracture risk does not need to be done until 65 years
C. Refer her to the genetics team for a risk assessment
D. Start first-line bone protection (i.e. ensure calcium/vitamin D replete + oral bisphosphonate)
E. Use the FRAX tool
ANSWER:
E. Use the FRAX tool
EXPLANATION:
This lady has a number of risk factors for developing osteoporosis:
 positive family history
 smoking
 excess alcohol intake
She should therefore have an immediate FRAX assessment, rather than waiting until 65 years as we would
for women without any relevant risk factors
Q-67
Pravin is a 24-year-old athlete. He has presented with groin pain and a clicking sensation in his right hip.
A. Acetabular labral tear

B. Osteoarthritis
C. Piriformis syndrome
D. Slipped upper femoral epiphysis
E. Trochanteric bursitis
ANSWER:
A. Acetabular labral tear
EXPLANATION:
Acetabular labral tears typically present with hip/groin pain and a snapping sensation
Acetabular labral tears usually present with hip/groin pain and a clicking sensation in the hip that occurs
with leg movement.
This patient is unlikely to have osteoarthritis given his age.
Piriformis syndrome usually causes buttock pain.
Slipped upper femoral epiphyses usually present in overweight adolescents.
Trochanteric bursitis causes lateral hip pain.
Please see Q-45 for Acetabular Labral Tear
Q-68-70
Theme: Limping child
A. Septic arthritis
B. Perthes disease
C. Transient synovitis
D. Osteochondritis dissecans
E. Juvenile idiopathic arthritis
F. Development dysplasia of the hip
G. Slipped upper femoral epiphysis
H. Metaphyseal dysplasia
I. Ewing's sarcoma
J. Psoas abscess
For each one of the following presentations please select the most likely diagnosis:
Q-68
6-year-old boy with a limp. His parents report that this has been getting steadily worse over the past few
weeks. He complains of pain in the right groin/hip region. An x-ray shows widening of the right hip joint
space with flattening of the femoral head.
ANSWER:
B. Perthes disease
EXPLANATION:
Pointers to Perthes:
 gender: 5 times more common in boys
 age: typical presents in children aged 4-8 years
 x-ray findings
Q-69
A 7-year-old boy is brought in by his mother. For the past day he has felt generally unwell with a headache
and nausea. This morning he complained of pain in his right hip and now just able to walk with a limp. On
examination flexion, extension and rotation of the hip is painful and limited. Examination of the ears,
throat and chest is normal. His temperature is 38.2ºC.
ANSWER:
A. Septic arthritis
EXPLANATION:
This boy needs to admitted for further evalulation of a suspected septic hip joint. There is no obvious
alternative focus to explain his fever.
This degree of pain and fever is not common in transient synovitis.
Q-70
4-year-old girl with a three month history of a limp. Her parents report that she has 'not been right' for a
few weeks now. She typically complains of pain in her left hip and right knee in the morning which gets
better during the day.
ANSWER:
E. Juvenile idiopathic arthritis
EXPLANATION:
This is a typical presentation of pauciarticular juvenile idiopathic arthritis.
Q-71
A 40-year-old woman complains of a permanent 'funny-bone' sensation in her right elbow. This is
accompanied by tingling in the little and ring finger. Her symptoms are worse when the elbow is bent for
prolonged periods. What is the most likely diagnosis?
A. Cubital tunnel syndrome
B. Lateral epicondylitis
C. Medial epicondylitis
D. Median nerve entrapment syndrome
E. Radial tunnel syndrome
ANSWER:
A. Cubital tunnel syndrome
EXPLANATION:
Q-72
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
A. C6 entrapment neuropathy
B. Thoracic outlet syndrome
C. Carpal tunnel syndrome
D. Cervical rib
E. Pancoast's tumour
ANSWER:
C. Carpal tunnel syndrome
EXPLANATION:
More proximal symptoms would be expected with a C6 entrapment neuropathy e.g. weakness of the
biceps muscle or reduced biceps reflex.
Patients with carpal tunnel syndrome often get relief from shaking their hands and this may be an
important clue in exam questions.
CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome is caused by compression of median nerve in the carpal tunnel.
History
 pain/pins and needles in thumb, index, middle finger
 unusually the symptoms may 'ascend' proximally
 patient shakes his hand to obtain relief, classically at night
Examination
 weakness of thumb abduction (abductor pollicis brevis)
 wasting of thenar eminence (NOT hypothenar)
 Tinel's sign: tapping causes paraesthesia
 Phalen's sign: flexion of wrist causes symptoms
Causes
 idiopathic
 pregnancy
 oedema e.g. heart failure
 lunate fracture
Electrophysiology
 motor + sensory: prolongation of the action potential
Treatment
 corticosteroid injection
 wrist splints at night
 surgical decompression (flexor retinaculum division)
Q-73
A 50-year-old woman presents with pain in the right forefoot for the past three months. The pain is
described as a burning which is brought on by walking. There is no history of trauma and the patient does
not do any regular exercise. Her alcohol intake is 28 units per week. On examination she complains of
tenderness in the middle of the forefoot and her symptoms are recreated by squeezing the metatarsals
together. What is the most likely diagnosis?
A. Metatarsal stress fracture

B. Gout
C. Alcohol-related peripheral neuropathy
D. Plantar fasciitis
E. Morton's neuroma
ANSWER:
E. Morton's neuroma
EXPLANATION:
The examination findings would not support a diagnosis of alcohol-related peripheral neuropathy.
Q-74
You see a 55-year-old lady with a lump behind her left knee. She is obese and was diagnosed with bilateral
knee osteoarthritis last year. She has been trying to swim to lose weight but last week at the pool
someone spotted a swelling behind her left leg. He knees are still moderately painful when she walks,
especially climbing stairs.
On examination, she has a smooth fluctuant tennis ball sized mass in her left popliteal fossa. It is not
tender. She has a tender joint line, particularly in the medial aspect of her knee.
Regarding Baker's cysts, which statement is correct?
A. Children with a Baker's cyst usually present with a limp

B. Almost all Baker's cysts in adults are secondary cysts
C. Baker's cysts are typically found in the lateral popliteal fossa
D. Anterior cruciate ligament rupture is not a cause of a secondary Baker's cyst
E. Excision is recommended to prevent recurrence
ANSWER:
B. Almost all Baker's cysts in adults are secondary cysts
EXPLANATION:
Almost all Baker's cysts in adults are secondary cysts (due to underlying knee joint disease)
Baker's cysts are described as primary or secondary:
Primary cysts are idiopathic and have no communication between the bursa and the knee joint. They are
not associated with disease of the knee joint and are found most commonly in children. In children,
Baker’s cysts are often found incidentally (therefore, option 1 is wrong).
Secondary cysts are associated with underlying disease of the knee joint (such as osteoarthritis) and tend
to have a communication between the bursa and the rest of the knee joint allowing synovial fluid to fill the
cyst. Almost all Baker's cysts in adults are secondary cysts. Juvenile idiopathic arthritis is a cause of
secondary cysts in children. Therefore, option 2 is correct.
Baker's cysts are typically found in the medial popliteal fossa. Therefore, option 3 is incorrect.
Anterior cruciate ligament injury can cause a secondary Baker's cyst. Therefore, option 4 is incorrect.
Excision is not recommended as the Baker's cyst may resolve by treating any underlying condition.
Q-75
Terry is a 45-year-old man who presents to his GP with a burning pain on the outer part of his right knee.
The pain is present on movement and he has not noticed any swelling of the knee. There is no history of
trauma and no locking of the knee joint. He is an endurance runner and is training for the London
marathon. On examination, there is pain on palpation of the lateral aspect of the joint line. He has a good
range of movement of his knee joint. However, you do notice a snapping sensation on the lateral aspect of
the knee during repeated flexion and extension of his joint .
A. Patellofemoral syndrome
B. Meniscal tear
C. Rheumatoid arthritis
D. Iliotibial band syndrome
E. Osteoarthritis
ANSWER:
D. Iliotibial band syndrome
EXPLANATION:
Iliotibial band syndrome is a common cause of knee pain, particularly in runners
Iliotibial band syndrome is a common cause of lateral knee pain in runners. Athletes commonly present
with a sharp or burning pain around the lateral knee joint line.
Meniscal tears present with locking of joint, pain and swelling.
Patellofemoral syndrome causes pain in the knee cap worse with climbing up and down stairs and
excessive use. It can also cause pain after sitting for a prolonged time.
Rheumatoid arthritis typically affects the small joints in the hands and feet first. It can also affect other
joints and symptoms include stiffness, pain and swelling.
Osteoarthritis causes pain and knee swelling. On examination, there may be crepitus of the joint. Risk
factors include being older in age, large body mass index and a physical/ manual occupation.
ILIOTIBIAL BAND SYNDROME

Iliotibial band syndrome is a common cause of lateral knee pain in runners, occurring in around 1 in 10
people who run regularly.
Features
 tenderness 2-3cm above the lateral joint line
Management
 activity modification and iliotibial band stretches
 if not improving then physiotherapy referral
Q-76
A 60-year-old woman presents with a swelling just proximal to the nail bed on the left great toe. She has a
history of osteoarthritis but is usually well.
A. Basal cell carcinoma

B. Epidermoid cyst
C. Orf
D. Myxoid cyst
E. Rheumatoid nodule
ANSWER:
D. Myxoid cyst
EXPLANATION:
Please see Q-59 for Myxoid Cyst
Q-77
Which one of the following statements regarding trigger finger is true?
A. Steroid injection is an appropriate first-line treatment

B. It is most common in the index finger
C. It is associated with alcohol excess
D. Men are more commonly affected
E. A history of repetitive use is found in most patients
ANSWER:
A. Steroid injection is an appropriate first-line treatment
EXPLANATION:
Please see Q-4 for Trigger Finger
Q-78
A 23-year-old female presents with a painful ankle following an inversion injury whilst playing tennis.
Which one of the following findings is least relevant when deciding whether an x-ray is needed?
A. Swelling immediately after the injury and now

B. Pain in the malleolar zone
C. Tenderness at the medial malleolar zone
D. Tenderness at the lateral malleolar zone
E. Cannot walk 4 steps immediately after the injury and now
ANSWER:
A. Swelling immediately after the injury and now
EXPLANATION:
Please see Q-40 for Ankle Injury: Ottawa Rules
Q-79
Which one of the following is not associated with carpal tunnel syndrome?
A. Tinel's sign
B. Compression of the median nerve
C. Wasting of the hypothenar eminence
D. Flexion of the wrist reproduces symptoms
E. Weakness of thumb abduction
ANSWER:
D. Wasting of the hypothenar eminence
EXPLANATION:
Please see Q-72 for Carpal Tunnel Syndrome
Q-80
You see an 81-year-old lady with a history of diabetes, osteoarthritis and hypertension. She twisted her
leg whilst getting out of a car and developed increasing pain weight bearing which has eased with simple
analgesia. She also tells you she has a lump under her knee. On examination, she has a 4cm non-tender
lump just below the popliteal fossa which becomes tense on extending the leg. She has full power
throughout. What is the most likely diagnosis?
A. Deep vein thrombosis

B. Popliteal artery aneurysm
C. Sprain
D. Baker's cyst
E. Ruptured head of gastrocnemius
ANSWER:
D. Baker's cyst
EXPLANATION:
This describes the typical patient with a Baker's cyst. They are more likely to develop in patients with
arthritis or gout and following a minor trauma to the knee. Foucher's sign describes the increase in tension
of the Baker's cyst on extension of the knee.
A DVT (deep vein thrombosis) needs to be considered because it can mimic a Baker's cyst. A DVT can also
co-exist with a Baker's cyst and a low threshold for ultrasound should be considered.
http://patient.info/doctor/Baker's-Cyst.htm
KNEE PROBLEMS: OLDER ADULTS

The table below summarises the key features of common knee problems:
Condition Key features
Osteoarthritis of the Patient is typically > 50 years, often overweight
knee Pain may be severe
Intermittent swelling, crepitus and limitation of movement may occur
Infrapatellar bursitis Associated with kneeling
(Clergyman's knee)
Prepatellar bursitis Associated with more upright kneeling
(Housemaid's knee)
Anterior cruciate May be caused by twisting of the knee - 'popping' noise may have been
ligament noted
Rapid onset of knee effusion
Positive draw test
Posterior cruciate May be caused by anterior force applied to the proximal tibia (e.g. knee
ligament hitting dashboard during car accident)
Collateral ligament Tenderness over the affected ligament
Knee effusion may be seen
Meniscal lesion May be caused by twisting of the knee
Locking and giving-way are common feature
Tender joint line
Q-81
A 56-year-old gentleman presents to your surgery with on-going pain in his right hip. He had a metal-on-
metal hip resurfacing arthroplasty 2 years ago for early osteoarthritis. Although he has more mobility
since the operation he has continued to have discomfort in his hip?
What is the most important next step in your management?
A. Analgesic ladder
B. Physiotherapy
C. Refer to orthopaedics
D. Refer to pain clinic
E. Watch and wait
ANSWER:
C. Refer to orthopaedics
EXPLANATION:
Pain following hip resurfacing (metal-on-metal bearing) should be referred for investigations such as an
MRI to exclude pseudotumour
Analgesic ladder / refer to pain clinic/watch and wait: while the patient will need analgesic control, the
most important next step in his management referral to orthopaedics for further investigations to exclude
a pseudotumour. Watching and waiting will delay investigations of an important complication of metal-
on-metal hip replacements.
Physiotherapy: This may be useful later should there be no evidence of pseudotumour or other pathologies
but will cause a delay in investigations if used as the next step in management.
Refer to orthopaedics: this is the most important next step in management to exclude a pseudotumour.
Please see Q-18 for Osteoarthritis: Joint Replacement
Q-82
An 11-year-old boy comes to see you in clinic with left hip pain. He is a very keen runner. His mum tells
you that he has an intermittent limp and his gait has altered over the past few weeks.
On examination, the left leg is externally rotated and shortened. He has reduced internal rotation and an
antalgic gait.
What is the likely diagnosis?
A. Acute transient synovitis

B. Osgood-Schlatter disease
C. Osteochondritis
D. Perthes disease
ANSWER:
EXPLANATION:
This boy has features in keeping with slipped upper femoral epiphysis. This diagnosis can often be delayed
resulting in worse prognosis and is an area of high medico-legal interest. Patients present with hip pain (or
sometimes referred knee pain). This pain can be exacerbated by running. An altered gait is reported and
examination can reveal reduced internal rotation and external rotation whilst walking. Acute transient
synovitis is usually a more acute presentation and is usually secondary to a viral infection is younger
children. Osgood-Schlatter's disease presents with knee pain. Osteochondritis most often presents with
knee pain in adolescents. Perthes disease usually affects younger children and examination includes
stiffness and reduced global range of motion.
Q-83
You are reviewing a patient who is complaining of hip pain. You suspect a diagnosis of osteoarthritis.
Which of the following symptoms should prompt further investigations for an alternative diagnosis?
A. A 6-month history of symptoms

B. The patient being 59-years-old
C. A history of development dysplasia of the hip
D. Morning stiffness lasting 4 hours
E. A body mass index of 33 kg/m²
ANSWER:
D. Morning stiffness lasting 4 hours
EXPLANATION:
Morning stiffness lasting > 2 hours may be an indication of inflammatory arthritis. This would warrant
further investigations.
Please see Q-61 for Osteoarthritis of the Hip
Q-84
A 62-year-old poorly controlled, diabetic lady re-presents to your surgery with continuing swelling and
pain of her left ankle for the last 4 weeks. She has been seen by your colleague who requested an ankle x-
ray. This showed 'significant disruption and subluxation of the tarsometatarsal joints'. Her HbA1c 2
months ago was 74mmol/mol.
A. Septic arthritis
B. Gout
C. Anterior talo-fibular ligament tear
D. Charcot joint
E. Pseudogout
ANSWER:
D. Charcot joint
EXPLANATION:
Charcot joint must be considered for a patient presenting with foot pain (>1 week) in a poorly controlled
diabetic
Septic arthritis is an important diagnosis to exclude in a hot swollen joint. However, this patient has had
symptoms for several weeks whereas septic arthritis will present more acutely.
Gout or pseudogout is a possibility for any hot swollen joint. However, the most common joint affected is
the 1st MTPJ and most patients would have had previous episodes.
Anterior talo-fibular ligament tear can be a possibility with forefoot pain and swelling. However, there
would be a history of trauma.
Charcot joint is the diagnosis in this patient and should be considered in poorly controlled diabetics.
CHARCOT JOINT
A Charcot joint is also commonly referred to as a neuropathic joint. It describes a joint which has become
badly disrupted and damaged secondary to a loss of sensation. In years gone by they were most commonly
caused by neuropathy secondary to syphilis (tabes dorsalis) but are now most commonly seen in diabetics.
Features
 Charcot joints are typically a lost less painful than would be expected given the degree of joint disruption
due to the sensory neuropathy. However, 75% of patients report some degree of pain
 the joint is typically swollen, red and warm
Extensive bone remodeling / fragmentation involving the midfoot in this patient with a poorly controlled diabetes,
compatible with Charcot's joint (neuropathic arthropathy)
Q-85
A 23-year-old canoeist presents with pain in the right distal dorsoradial forearm, around 5-10 cm from the
wrist joint. On examination the area is slightly erythematous and swollen. Crepitus can be felt when the
patient moves his right hand. What is the most likely diagnosis?
A. Carpo-metacarpal osteoarthritis
B. Carpal tunnel syndrome
D. Intersection syndrome
E. Ganglion cyst
ANSWER:
D. Intersection syndrome
EXPLANATION:
INTERSECTION SYNDROME
Intersection syndrome is a tenosynovitis caused by inflammation where the abductor pollicis longus and
extensor pollicis brevis muscles cross over (or intersect) the tendons of the extensor carpi radialis longus and
the extensor carpi radialis brevis.
Features
 intersection syndrome is commonly misdiagnosed as de Quervain's tenosynovitis
 pain in the distal dorsoradial forearm, around 5-10 cm proximal of the wrist joint
 swelling and erythema may be seen
Intersection syndrome is commonly seen in skiers, tennis players, weight lifters and canoeists.
Management
 NSAIDs
 physiotherapy
 surgical treatment is rarely required
Q-86-88
Theme: Lower back pain: prolapsed disc
A. L2
B. L3
C. L4
D. L5
E. S1
F. S2
G. S3
For each one of the following scenarios select the nerve root which is most likely to be compressed:
Q-86
A 52-year-old woman develops pain shooting down the posterior aspect of the left leg. On examination
she has reduced sensation on the lateral aspect of the left foot and weakness of left foot plantar flexion.
ANSWER:
E. S1
Q-87
A 31-year-old man with sudden onset back pain radiating to the anterior aspect of his right knee.
Examination reveals an absent knee jerk with reduced sensation over the patella and the medial aspect of
his calf. The quadriceps are also noted to be weak on the affected side.
ANSWER:
C. L4
Q-88
A 44-year-old man complains of pain radiating from his left hip to foot for the past week. On examination
all reflexes are intact and the only positive finding is weak dorsiflexion of the left big toe
ANSWER:
D. L5
EXPLANATION:
The clue here is normal reflexes - this excludes L3,L4 (knee) and S1,S2 (ankle)
Q-89
You see a 61-year-old man with severe lower back pain on a home visit. He has had lumbar back pain on
and off for 3 years but it got much worse yesterday when he bent over. His back is in severe spasm and he
has taken to his bed, he was unable to get to the practice today in the car due to the pain. He has no
bladder or bowel symptoms and no symptoms in his legs. He is taking regular co-codamol and ibuprofen.
On examination, he has normal neurology in his lower limbs.
What statement below regarding this patient is true?
A. Ice packs on the lower back may relieve pain and muscle spasm
B. A short course of benzodiazepine can be used to relieve the muscle spasms
C. Paracetamol is first line for analgesia
D. Bed rest is recommended if a patient has severe muscle spasms
E. He should wait until he is pain free before returning to normal activities and work
ANSWER:
B. A short course of benzodiazepine can be used to relieve the muscle spasms
EXPLANATION:
If a patient has muscle spasm associated with back pain offer a short course of a benzodiazepine such as
diazepam
If a patient has muscle spasm associated with back pain a short course of a benzodiazepine such as
diazepam can be offered. Therefore, option 2 is correct.
Self-help advise includes the use of warm compresses (providing the skin is protected). Therefore, option 1
is wrong.
First line analgesia is an NSAID. Therefore, option 3 is wrong.
Prolonged bed rest is not recommended, normal movements may produce some pain which should not be
harmful if activities are resumed gradually and as tolerated. Therefore, option 4 is wrong.
The person does not need to be pain-free before returning to normal activities or work. Work adjustments
can make an early return to work possible. This may be arranged by an Occupational Health department if
available. Therefore, option 5 is wrong.
RHEUMATOLOGY MCQs
Q-1
A 41-year-old female presents with lethargy and pain all over her body. This has been present for the past
six months and is often worse when she is stressed or cold. Clinical examination is unremarkable other
than a large number of tender points throughout her body. A series of blood tests including an
autoimmune screen, inflammatory markers and thyroid function are normal. Given the likely diagnosis,
which one of the following is not helpful in management?
A. Amitriptyline
B. Trigger point injections
C. Cognitive behavioural therapy
D. Exercise programme
E. Paracetamol
ANSWER:
B. Trigger point injections
EXPLANATION:
A recent JAMA paper supported the use of anti-depressants in fibromyalgia
Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis; 2009 Jan 14;301(2):198-209
FIBROMYALGIA
Fibromyalgia is a syndrome characterised by widespread pain throughout the body with tender points at
specific anatomical sites. The cause of fibromyalgia is unknown.
Epidemiology
 women are around 5 times more likely to be affected
 typically presents between 30-50 years old
Features
 chronic pain: at multiple site, sometimes 'pain all over'
 lethargy
 cognitive impairment: 'fibro fog'
 sleep disturbance, headaches, dizziness are common
Diagnosis is clinical and sometimes refers to the American College of Rheumatology

classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of
these 18 points it makes a diagnosis of fibromyalgia more likely
The management of fibromyalgia is often difficult and needs to be tailored to the individual patient. A
psychosocial and multidisciplinary approach is helpful. Unfortunately there is currently a paucity of evidence
and guidelines to guide practice. The following is partly based on consensus guidelines from the European
League against Rheumatism (EULAR) published in 2007 and also a BMJ review in 2014.
 explanation
 aerobic exercise: has the strongest evidence base
 cognitive behavioural therapy
 medication: pregabalin, duloxetine, amitriptyline
Q-2
A 36-year-old man describes a 4 to 5 month history of tiredness and weakness. He reports that swallowing
has felt more difficult and he has lost 3kg. He struggles to get up from sitting and climb stairs. On
examination you find slightly tender and weak proximal muscles with preserved reflexes. Bloods show a
markedly raised creatine kinase.
Which is the gold standard diagnostic test to confirm this diagnosis?
A. Chest X-ray
B. Serum calcium
C. Muscle biopsy
D. Low dose dexamethasone suppression test
E. Lumbar puncture
ANSWER:
C. Muscle biopsy
EXPLANATION:
EMG and muscle biopsy are used to confirm a diagnosis of polymyositis
Rarer conditions and specific diagnostic tests which may feel irrelevant to GP do feature in the AKT.
Polymyositis tends to present with a steadily progressive, painless weakness of the proximal muscles.
Creatine kinase is usually dramatically raised. The gold standard diagnostic test for this condition is a
muscle biopsy.
POLYMYOSITIS
Overview
 inflammatory disorder causing symmetrical, proximal muscle weakness
 thought to be a T-cell mediated cytotoxic process directed against muscle fibres
 may be idiopathic or associated with connective tissue disorders
 associated with malignancy
 dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a
purple (heliotrope) rash on the cheeks and eyelids
 typically affects middle-aged, female:male 3:1
Features
 proximal muscle weakness +/- tenderness
 Raynaud's
 respiratory muscle weakness
 interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia
 dysphagia, dysphonia
Investigations
 elevated creatine kinase
 other muscle enzymes (lactate dehydrogenase (LD), aldolase, AST and ALT) are also elevated in 85-95%
of patients
 EMG
 muscle biopsy
 anti-synthetase antibodies
o anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud's and
fever
Q-3
A 45-year-old female is referred to rheumatology having presented to her GP with fatigue and joint pain in
the fingers of both hands. She has a past medical history of mild asthma, controlled by a salbutamol
reliever inhaler, and a documented allergy to co-trimoxazole.
Blood tests were reported as:

Rheumatoid factor positive
Anti-CCP antibody 150u/ml (< 20u/ml)
Which drug might cause an allergic reaction in this patient?
A. Hydroxychloroquine
B. Leflunomide
C. Methotrexate
D. Sarilumab
E. Sulfasalazine
ANSWER:
E. Sulfasalazine
EXPLANATION:
Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take sulfasalazine
Hydroxychloroquine is not contraindicated in this patient. Hydroxychloroquine might be offered as one of

the first line disease-modifying anti-rheumatic drugs for rheumatoid arthritis.
Leflunomide is not contraindicated in this patient. Leflunomide might be offered as one of the first line
disease-modifying anti-rheumatic drugs for rheumatoid arthritis.
Methotrexate would not be contraindicated in this patient. Methotrexate might be offered as one of the
first line disease-modifying anti-rheumatic drugs for rheumatoid arthritis.
Sarilumab is not contraindicated in this patient. However, in order to receive sarilumab, the patient must
have an inadequate response to polypharmacy with disease-modifying anti-rheumatic drugs and a disease
activity score of greater than 5.1.
Although sulfasalazine is one of the first line disease-modifying anti-rheumatic drugs for rheumatoid
arthritis, patients with a documented allergy to a sulfa drug, such as co-trimoxazole, should not take
sulfasalazine.
SULFASALAZINE
Sulfasalazine is a disease modifying anti-rheumatic drug (DMARDs) used in the management of
inflammatory arthritis, especially rheumatoid arthritis. It is also used in the management of inflammatory
bowel disease.
Sulfasalazine is a prodrug for 5-ASA which works through decreasing neutrophil chemotaxis alongside
suppressing proliferation of lymphocytes and pro-inflammatory cytokines.
Cautions
 G6PD deficiency
 allergy to aspirin or sulphonamides (cross-sensitivity)
Adverse effects
 oligospermia
 Stevens-Johnson syndrome
 pneumonitis / lung fibrosis
 myelosuppression, Heinz body anaemia, megaloblastic anaemia
 may colour tears → stained contact lenses
In contrast to other DMARDs, sulfasalazine is considered safe to use in both pregnancy and breastfeeding.
Q-4
A 28-year-old man presents to the surgery concerned about his bone health. He has a background of
chronic kidney disease secondary to polycystic-kidney disease.
He is a non-smoker and he does not drink alcohol. His body mass index is 23 kg/m2. His mother had a hip
fracture when she was 50-years-old.
What is the next most appropriate management step?
A. Commence him on a bisphosphonate, vitamin d and calcium supplement immediately

B. Reassure him that the risk of osteoporosis is low and commence vitamin d and calcium supplements
only
C. Refer to the osteoporosis clinic and arrange a dual-energy X-ray absorptiometry (DEXA) scan
D. Calculate his FRAX score. Consider dual-energy X-ray absorptiometry (DEXA) scan depending on results
E. Calculate his QFracture. Consider a dual-energy X-ray absorptiometry (DEXA) scan depending on
results
ANSWER:
C. Refer to the osteoporosis clinic and arrange a dual-energy X-ray absorptiometry (DEXA) scan
EXPLANATION:
According to current NICE guidance, a patient under 40 years old with major risk factors for fragility
fracture should be referred for DEXA
According to current NICE guidance, a major risk factor for fragility fracture is chronic kidney disease. A
dual-energy X-ray absorptiometry (DEXA) scan is recommended for any patients younger than 40 years of
age who have a major risk factor for fragility fracture. Given the patient's age, a referral to the
osteoporosis clinic would be advised.
There is no indication for commencing him on bisphosphonates at this point without the results of the
DEXA scan.
FRAX and QFracture risk may underestimate risk in this age group, and therefore arranging a DEXA scan is
the most appropriate option.
He is potentially at increased risk of osteoporosis, and therefore reassuring him only is not the correct
option.
OSTEOPOROSIS: ASSESSING PATIENTS FOLLOWING A FRAGILITY FRACTURE

The management of patients following a fragility fracture depends on age.
Patients >= 75 years of age

Patients who've had a fragility fracture and are >= 75 years of age are presumed to have underlying
osteoporosis and should be started on first-line therapy (an oral bisphosphonate), without the need for a
DEXA scan.
It should be noted that the 2014 NOGG guidelines have a different threshold, suggesting treatment is
started in all women over the age of 50 years who've had a fragility fracture - 'although BMD measurement
may sometimes be appropriate, particularly in younger postmenopausal women.'
Patients < 75 years of age

If a patient is under the age of 75 years a DEXA scan should be arranged. These results can then be entered
into a FRAX assessment (along with the fact that they've had a fracture) to determine the patients ongoing
fracture risk.
For example, a 79-year-old woman falls over on to an outstretched hand and sustains a Colles' fracture
(fracture of the distal radius). Given her age she is presumed to have osteoporosis and therefore started on
oral alendronate 70mg once weekly. No DEXA scan is arranged.
Q-5
Which one of the following is an indication for the use of denosumab?
A. Preventing pathological fractures in adults with bone metastases from solid tumours
B. Managing hypercalcaemia in patients with multiple myeloma
C. Paget's disease
D. Managing hypercalcaemia in patients with primary hyperparathyroidism
E. Osteogenesis imperfecta
ANSWER:
A. Preventing pathological fractures in adults with bone metastases from solid tumours
EXPLANATION:
Denosumab is recommend by NICE for the prevention of pathological fractures in adults with bone
metastases from solid tumours. The other conditions are indications for bisphosphonates.
DENOSUMAB
Denosumab is a relatively new treatment for osteoporosis. It is a human monoclonal antibody that prevents
the development of osteoclasts by inhibiting RANKL. Remember that osteoblasts build bone, osteoclasts eat
bone. It is given as a subcutaneous injection, at a dose of 60mg, every 6 months.
A larger dose of denosumab (120mg) may also be given every 4 weeks for the prevention of skeletal-related
events (i.e. pathological fractures) in adults with bone metastases from solid tumours. For example, you may
have noticed some of your breast cancer patients have been prescribed denosumab.
Where does it fit in the management of osteoporosis?

Oral bisphosphonates are still given first-line, with oral alendronate being the first-line treatment. If
alendronate is not tolerated then NICE recommend using an alternative bisphosphonate - either risedronate
or etidronate. Following this the advice becomes more complicated with the next-line medications only
being started if certain T score and other risk factor criteria being met. Raloxifene and strontium ranelate
were recommended as next-line drugs in the NICE criteria but following recent safety concerns regarding
strontium ranelate it is likely there will be an increasing role for denosumab.
NICE published a technology appraisal looking at the role of denosumab in 2010. A link is provided.
What are the known side-effects of denosumab?

Denosumab is generally well tolerated. Dyspnoea and diarrhoea are generally considered the two most
common side effects, occuring in around 1 in 10 patients. Other less common side effects include
hypocalcaemia and upper respiratory tract infections.
What does the Drug Safety Update add?

Cases of atypical femoral fractures have been noted in patients taking denosumab. Doctors are advised to
look out for patients complaining of unusual thigh, hip or groin pain.
Q-6
You review a 48-year-old woman who is taking methotrexate for rheumatoid arthritis. Concurrent
prescription of which other medication should be avoided?
A. Erythromycin
B. Trimethoprim
C. Sumatriptan
D. Lansoprazole
E. Sodium valproate
ANSWER:
B. Trimethoprim
EXPLANATION:
The concurrent use of methotrexate and trimethoprim containing antibiotics may cause bone marrow
suppression and severe or fatal pancytopaenia
There is an increased risk of haematological toxicity when trimethoprim is prescribed alongside

methotrexate.
METHOTREXATE
Methotrexate is an antimetabolite that inhibits dihydrofolate reductase, an enzyme essential for the
synthesis of purines and pyrimidines. It is considered an 'important' drug as whilst it can be very effective in
controlling disease the side-effects may be potentially life-threatening - careful prescribing and close
monitoring is essential.
Indications
 inflammatory arthritis, especially rheumatoid arthritis
 psoriasis
 some chemotherapy acute lymphoblastic leukaemia
Adverse effects
 mucositis
 myelosuppression
 pneumonitis
 pulmonary fibrosis
 liver fibrosis
 mucositis
Pregnancy
 women should avoid pregnancy for at least 6 months after treatment has stopped
 the BNF also advises that men using methotrexate need to use effective contraception for at least 6
months after treatment
Prescribing methotrexate
 methotrexate is a drug with a high potential for patient harm. It is therefore important that you are
familiar with guidelines relating to its use
 methotrexate is taken weekly, rather than daily
 FBC, U&E and LFTs need to be regularly monitored. The Committee on Safety of Medicines recommend
'FBC and renal and LFTs before starting treatment and repeated weekly until therapy stabilised,
thereafter patients should be monitored every 2-3 months'
 folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose
 the starting dose of methotrexate is 7.5 mg weekly (source: BNF)
 only one strength of methotrexate tablet should be prescribed (usually 2.5 mg)
Interactions
 avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia
 high-dose aspirin increases the risk of methotrexate toxicity secondary to reduced excretion
Methotrexate toxicity
 the treatment of choice is folinic acid
Q-7
A 35-year-old woman presents with alopecia. For the past few months she has noticed some 'scaly'
patches on her scalp. Once healed they normally leave a scar and no hair seems to grow back. Her scalp
has the following appearance:
A. Discoid lupus erythematosus

B. Alopecia areata
C. Psoriasis
D. Trichotillomania
E. Squamous cell carcinoma
ANSWER:
A. Discoid lupus erythematosus
EXPLANATION:
Remember that alopecia may be divided into scarring (destruction of hair follicle) and non-scarring
(preservation of hair follicle):
Scarring alopecia
• trauma, burns
• radiotherapy
• lichen planus
• discoid lupus
• tinea capitis (if untreated)
Non-scarring alopecia
• male-pattern baldness
• drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine
• nutritional: iron and zinc deficiency
• autoimmune: alopecia areata
• telogen effluvium (hair loss following stressful period e.g. surgery)
• trichotillomania
Even if you are not familiar with the appearance of discoid lupus erythematosus (along with most non-
dermatologists) this leaves it as the only possible answer.
DISCOID LUPUS ERYTHEMATOUS

Discoid lupus erythematosus is a benign disorder generally seen in younger females. It very rarely progresses
to systemic lupus erythematosus (in less than 5% of cases). Discoid lupus erythematosus is characterised by
follicular keratin plugs and is thought to be autoimmune in aetiology
Features
 erythematous, raised rash, sometimes scaly
 may be photosensitive
 more common on face, neck, ears and scalp
 lesions heal with atrophy, scarring (may cause scarring alopecia), and pigmentation
Management
 topical steroid cream
 oral antimalarials may be used second-line e.g. hydroxychloroquine
 avoid sun exposure
Discoid lupus erythematous affecting the scalp
Q-8
Which one of the following is not a risk factor for developing osteoporosis?
A. Smoking
B. Obesity
C. Sedentary lifestyle
D. Premature menopause
E. Female sex
ANSWER:
B. Obesity
EXPLANATION:
Low body mass, rather than obesity is associated with an increased risk of developing osteoporosis
OSTEOPOROSIS: CAUSES
Advancing age and female sex are significant risk factors for osteoporosis. Prevalence of osteoporosis
increases from 2% at 50 years to more than 25% at 80 years in women.
There are many other risk factors and secondary causes of osteoporosis. We'll start by looking at the most
'important' ones - these are risk factors that are used by major risk assessment tools such as FRAX:
 history of glucocorticoid use
 alcohol excess
 history of parental hip fracture
 low body mass index
 current smoking
Other risk factors

 sedentary lifestyle
 premature menopause
 Caucasians and Asians
 endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth
hormone deficiency, hyperparathyroidism, diabetes mellitus
 multiple myeloma, lymphoma
 gastrointestinal disorders: inflammatory bowel disease, malabsorption (e.g. Coeliac's), gastrectomy, liver
disease
 chronic kidney disease
 osteogenesis imperfecta, homocystinuria
Medications that may worsen osteoporosis (other than glucocorticoids):

 SSRIs
 antiepileptics
 proton pump inhibitors
 glitazones
 long term heparin therapy
 aromatase inhibitors e.g. anastrozole
Investigations for secondary causes

If a patient is diagnosed with osteoporosis or has a fragility fracture further investigations may be
warranted. NOGG recommend testing for the following reasons:
 exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma);
 identify the cause of osteoporosis and contributory factors;
 assess the risk of subsequent fractures;
 select the most appropriate form of treatment
The following investigations are recommended by NOGG:
 History and physical examination
 Blood cell count, sedimentation rate or C-reactive protein, serum calcium,
 albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases
 Thyroid function tests
 Bone densitometry ( DXA)
Other procedures, if indicated

 Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging
 Protein immunoelectrophoresis and urinary Bence-Jones proteins
 25OHD
 PTH
 Serum testosterone, SHBG, FSH, LH (in men),
 Serum prolactin
 24 hour urinary cortisol/dexamethasone suppression test
 Endomysial and/or tissue transglutaminase antibodies (coeliac disease)
 Isotope bone scan
 Markers of bone turnover, when available
 Urinary calcium excretion
So from the first list we should order the following bloods as a minimum for all patients:
 full blood count
 urea and electrolytes
 liver function tests
 bone profile
 CRP
 thyroid function tests
Q-9
A 43-year-old woman who has rheumatoid arthritis is reviewed in clinic. She has responded poorly to
methotrexate and consideration is being given to starting sulfasalazine. An existing allergy to which one of
the following drugs may be a contradiction to the prescription?
A. Penicillin
B. Trimethoprim
C. Aspirin
D. Sulpiride
E. Leflunomide
ANSWER:
C. Aspirin
EXPLANATION:
Patients who are allergic to aspirin may also react to sulfasalazine
Please see Q-3 for Sulfasalazine

Q-10
You review a 40-year-old mechanic who presents with joint pains. For the past two months he has noticed
intermittent pain, stiffness and swelling of the joints in his hands and feet. The stiffness tends to improve
during the day but the pain tends to get worse. He has also noticed stiffness in his back but cannot
remember any aggravating injury. You order some blood tests (taken during an acute attack) which are
reported as follows:
Rheumatoid factor Negative

Anti-cyclic citrullinated peptide antibody Positive
Uric acid 0.3 mmol/l (0.18 - 0.48)
ESR 41 mm/hr
A. Reactive arthritis
B. Ankylosing spondylitis
C. Gout
D. Osteoarthritis
E. Rheumatoid arthritis
ANSWER:
EXPLANATION:
Anti-cyclic citrullinated peptide antibodies are associated with rheumatoid arthritis
Anti-cyclic citrullinated peptide antibody is highly specific for rheumatoid arthritis.
RHEUMATOID ARTHRITIS: ANTIBODIES

Rheumatoid factor
Rheumatoid factor (RF) is a circulating antibody (usually IgM) which reacts with the Fc portion of the
patients own IgG.
RF can be detected by either

 Rose-Waaler test: sheep red cell agglutination
 Latex agglutination test (less specific)
RF is positive in 70-80% of patients with rheumatoid arthritis, high titre levels are associated with severe
progressive disease (but NOT a marker of disease activity)
Other conditions associated with a positive RF include:

 Sjogren's syndrome (around 100%)
 Felty's syndrome (around 100%)
 infective endocarditis (= 50%)
 SLE (= 20-30%)
 systemic sclerosis (= 30%)
 general population (= 5%)
 rarely: TB, HBV, EBV, leprosy
Anti-cyclic citrullinated peptide antibody
Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of
rheumatoid arthritis. It may therefore play a key role in the future of rheumatoid arthritis, allowing early
detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity similar to rheumatoid factor
(around 70%) with a much higher specificity of 90-95%.
NICE recommends that patients with suspected rheumatoid arthritis who are rheumatoid factor negative
should be test for anti-CCP antibodies.
Q-11
A 64-year-old female is referred to rheumatology out-patients by her GP with a history of arthritis in both
hands. Which one of the following x-ray findings would most favour a diagnosis of rheumatoid arthritis
over other possible causes?
A. Loss of joint space

B. Juxta-articular osteoporosis
C. Subchondral sclerosis
D. Osteophytes
E. Subchondral cysts
ANSWER:
B. Juxta-articular osteoporosis
EXPLANATION:
Juxta-articular osteoporosis/osteopenia is an early x-ray feature of rheumatoid arthritis
Juxta-articular osteoporosis would point towards a diagnosis of rheumatoid arthritis (RA). Loss of joint
space is common in both RA and osteoarthritis
RHEUMATOID ARTHRITIS: X-RAY CHANGES

Early x-ray findings
 loss of joint space
 juxta-articular osteoporosis
 soft-tissue swelling
Late x-ray findings

 periarticular erosions
 subluxation
Q-12
Which one of the following features is least typical of polymyalgia rheumatica?
A. Elevated creatine kinase

B. Low-grade fever
C. Morning stiffness in proximal limb muscles
D. Polyarthralgia
E. Anorexia
ANSWER:
A. Elevated creatine kinase
EXPLANATION:
POLYMYALGIA RHEUMATICA
Polymyalgia rheumatica (PMR) is a relatively common condition seen in older people characterised by
muscle stiffness and raised inflammatory markers. Whilst it appears to be closely related to temporal
arteritis the underlying cause is not fully understood and it does not appear to be a vasculitic process.
Features
 typically patient > 60 years old
 usually rapid onset (e.g. < 1 month)
 aching, morning stiffness in proximal limb muscles
o weakness is not considered a symptom of polymyalgia rheumatica
 also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
Investigations
 raised inflammatory markers e.g. ESR > 40 mm/hr
 note creatine kinase and EMG normal
Treatment
 prednisolone e.g. 15mg/od
o patients typically respond dramatically to steroids, failure to do so should prompt consideration of an
alternative diagnosis
Q-13
A 55-year-old woman presents to her GP with a 6-week history of pain in the joints of her hands and feet
which is worse in the morning and improves slightly with ibuprofen. She is an ex-smoker with a 30 pack-
year history. On examination of her hands, ulnar deviation, and swan neck deformity is observed.
Given her likely diagnosis, what medication is most appropriate to manage this acute flare?
A. Anakinra
B. Codeine PO
C. Infliximab IV
D. Paracetamol PO
E. Steroids IM
ANSWER:
E. Steroids IM
EXPLANATION:
Intramuscular steroids such as methylprednisolone are used to manage the acute flares of rheumatoid
arthritis
NICE guidelines recommend that for adults with newly diagnosed active rheumatoid arthritis, such as this
patient. For adults with newly diagnosed active RA:
(1) Offer first-line treatment with conventional disease-modifying anti-rheumatic drug (cDMARD)
monotherapy using oral methotrexate, leflunomide, or sulfasalazine as soon as possible and ideally within
3 months of onset of persistent symptoms.
(2) Consider short-term bridging treatment with glucocorticoids (oral, intramuscular or intra-articular)
when starting a new cDMARD.
Although most GPs may be more likely to prescribe PO or intra-articular prednisolone as their first line, it is
important to be aware of alternatives. As PO or intra-articular steroids or any cDMARDs are not available
as answers, the only appropriate initial management is to give steroids IM.
Anakinra is a biological disease modifying anti-rheumatic drug (DMARD) that is not recommended by the
NICE guidelines for the treatment of rheumatoid arthritis (RA), except in the context of a controlled long-
term clinical study.
Codeine is part of the opioid pain ladder and is not indicated in the management of either an acute flare or
chronic management of rheumatoid arthritis.
Initial treatment of active RA involves first-line treatment with a conventional disease-modifying anti-
rheumatic drug (cDMARD). The step-up strategy involves an escalation of dose, followed by the offer of an
additional DMARD. Although infliximab IV is an effective treatment for rheumatoid arthritis, it is not
recommended the first line.
Paracetamol PO is might provide some symptomatic pain relief but is not recommended as a treatment in
the management of rheumatoid arthritis. NSAIDs such as ibuprofen or naproxen are indicated for
symptom control in patients with an acute flare or early disease.
NICE guidelines currently recommend short term treatment with steroids (oral, intramuscular or intra-
articular) for managing acute flares in recent-onset as a 'bridging treatment' when starting a new disease-
modifying anti-rheumatic drug (DMARD) or in established disease to rapidly decrease inflammation.
RHEUMATOID ARTHRITIS: MANAGEMENT

The management of rheumatoid arthritis (RA) has been revolutionised by the introduction of disease-
modifying therapies in the past decade.
Patients with evidence of joint inflammation should start a combination of disease-modifying drugs
(DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy and
surgery.
Initial therapy
 In 2018 NICE updated their rheumatoid arthritis guidelines. They now recommend DMARD monotherapy
+/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial
step.
Monitoring response to treatment

 NICE recommends using a combination of CRP and disease activity (using a composite score such as
DAS28) to assess response to treatment
Flares
 flares of RA are often managed with corticosteroids - oral or intramuscular
DMARDs
 methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of
myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
 sulfasalazine
 leflunomide
 hydroxychloroquine
TNF-inhibitors
 the current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including
methotrexate
 etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous
administration, can cause demyelination, risks include reactivation of tuberculosis
 infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors,
intravenous administration, risks include reactivation of tuberculosis
 adalimumab: monoclonal antibody, subcutaneous administration
Rituximab
 anti-CD20 monoclonal antibody, results in B-cell depletion
 two 1g intravenous infusions are given two weeks apart
 infusion reactions are common
Abatacept
 fusion protein that modulates a key signal required for activation of T lymphocytes
 leads to decreased T-cell proliferation and cytokine production
 given as an infusion
 not currently recommend by NICE
Q-14
A 71-year-old woman is diagnosed with polymyalgia rheumatica. She is started on prednisolone 15mg od.
What is the most appropriate approach to bone protection?
A. Arrange a DEXA scan

B. Ensure calcium and vitamin D replete
C. Do a FRAX assessment
D. Reassess fracture risk after 3 months
E. Start oral alendronate + ensure calcium and vitamin D replete
ANSWER:
E. Start oral alendronate + ensure calcium and vitamin D replete
EXPLANATION:
Bone protection for patients who are going to take long-term steroids should start immediately
OSTEOPOROSIS: GLUCOCORTICOID-INDUCED
We know that one of the most important risk factors for osteoporosis is the use of corticosteroids. As these
drugs are so widely used in clinical practice it is important we manage this risk appropriately.
The most widely followed guidelines are based around the 2002 Royal College of Physicians (RCP)
'Glucocorticoid-induced osteoporosis: A concise guide to prevention and treatment'.
The risk of osteoporosis is thought to rise significantly once a patient is taking the equivalent of prednisolone
7.5mg a day for 3 or more months. It is important to note that we should manage patients in an anticipatory,
i.e. if it likely that the patient will have to take steroids for at least 3 months then we should start bone
protection straight away, rather than waiting until 3 months has elapsed. A good example is a patient with
newly diagnosed polymyalgia rheumatica. As it is very likely they will be on a significant dose of prednisolone
for greater than 3 months bone protection should be commenced immediately.
Management of patients at risk of corticosteroid-induced osteoporosis

The RCP guidelines essentially divide patients into two groups.
1. Patients over the age of 65 years or those who've previously had a fragility fracture should be offered
bone protection.
2. Patients under the age of 65 years should be offered a bone density scan, with further management
dependent:
T score Management
Greater than 0 Reassure
Between 0 and -1.5 Repeat bone density scan in 1-3 years
Less than -1.5 Offer bone protection
The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.
Q-15
You see a 28 year old woman for her routine post-natal check. She is well, and has no underlying medical
comorbidities. She is breastfeeding her baby. She herself eats a normal, varied diet. What daily
supplements, if any, should you advise her to take?
A. No supplement needed
B. Folic acid
C. Vitamin D
D. Vitamin B12
E. Multivitamin tablet
ANSWER:
C. Vitamin D
EXPLANATION:
The NHS advises that all pregnant and breastfeeding women should take a daily supplement of vitamin D
10mcg for the bone health of themselves and their child. Some women may be eligible for free
supplements, if they qualify for Healthy Start vouchers; the Health Visitor can advise.
Folic acid 400mcg is recommended for women trying to conceive through to 12 weeks gestation. A B12
supplement may be indicated for breastfeeding women who eat a vegan diet. Pregnant women should be
advised that if they wish to take a multivitamin tablet, to ensure it does not contain vitamin A, as this can
be teratogenic in high doses.
Source: NHS choices

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/lifestyle-breastfeeding.aspx#close
VITAMIN D SUPPLEMENTATION
Vitamin D supplementation has been a hot topic for a number of years now. The muddied waters are now
slightly clearer following the release of the following:
 2012: letter by the Chief Medical Officer regarding vitamin D supplementation
 2013: National Osteoporosis Society (NOS) release UK Vitamin D guideline
The following groups should be advised to take vitamin D supplementation:

 all pregnant and breastfeeding women should take a daily supplement containing 10µg of vitamin D
 all children aged 6 months - 5 years. Babies fed with formula milk do not need to take a supplement if
they are taking more than 500ml of milk a day, as formula milk is fortified with vitamin D
 adults > 65 years
 'people who are not exposed to much sun should also take a daily supplement' e.g. housebound patients
Testing for vitamin D deficiency

The key message is that not many people warrant a vitamin D test. The NOS guidelines specify that testing
may be appropriate in the following situtations:
 patients with bone diseases that may be improved with vitamin D treatment e.g. known osteomalacia or
Paget's disease
 patients with bone diseases, prior to specific treatment where correcting vitamin deficiency is
appropriate e,g, prior to intravenous zolendronate or denosumab
 patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency e.g. bone pain
?osteomalacia
Patients with osteoporosis should always be given calcium/vitamin D supplements so testing is not
considered necessary. People who are at higher risk of vitamin D deficiency (see above) should be treated
anyway so again testing is not necessary.
Q-16
You review a 24-year-old man who has just been discharged from the local hospital after having a
pneumothorax aspirated. This is his second admission in two years for such a problem. On reviewing him
today the chest is clear with good air entry in all fields. You do however note he has pectus excavatum. He
is 1.83m tall and weighs 72kg. The only other history of note is joint hypermobility for which he was
referred to the physio last year. What is the most likely underlying diagnosis?
A. Homocystinuria
B. Marfan's syndrome
C. Asthma
D. Rheumatoid arthritis
E. Ehlers-Danlos syndrome
ANSWER:
B. Marfan's syndrome
EXPLANATION:
Marfan's syndrome is associated with repeated pneumothoraces
The history of pneumothoraces combined with hypermobility points towards a diagnosis of Marfan's
syndrome.
MARFAN'S SYNDROME
Marfan's syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the FBN1
gene on chromosome 15 that codes for the protein fibrillin-1. It affects around 1 in 3,000 people.
Features
 tall stature with arm span to height ratio > 1.05
 high-arched palate
 arachnodactyly
 pectus excavatum
 pes planus
 scoliosis of > 20 degrees
 heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection,
aortic regurgitation, mitral valve prolapse (75%),
 lungs: repeated pneumothoraces
 eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
 dural ectasia (ballooning of the dural sac at the lumbosacral level)
The life expectancy of patients used to be around 40-50 years. With the advent of regular echocardiography
monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly over recent years. Aortic
dissection and other cardiovascular problems remain the leading cause of death however.
Q-17
A 54-year-old woman is reviewed four weeks after an episode of gout in the first metatarsophalangeal
joint. This is her third episode of gout in the past 12 months.
Serum uric acid 485 µmol/l
What is the most appropriate future management?
A. Start allopurinol 300mg od

B. Refer to rheumatology
C. Start allopurinol 300mg od, with naproxen / proton pump inhibitor cover for 4 weeks
D. Wait a further four weeks then start allopurinol 300mg od
E. Start allopurinol 100mg od, with naproxen / proton pump inhibitor cover for 4 weeks
ANSWER:
E. Start allopurinol 100mg od, with naproxen / proton pump inhibitor cover for 4 weeks
EXPLANATION:
NSAID or colchicine 'cover' should be used when starting allopurinol
Clinical Knowledge Summaries recommend starting allopurinol at a low dose and titrating up.
As starting allopurinol can sometimes precipitate a flare it is good practice to 'cover' this period with
either colchicine or an NSAID. The proton pump inhibitor is used for gastroprotection.
GOUT: MANAGEMENT
Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the
synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)
Acute management
 NSAIDs or colchicine are first-line
 the maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled.
Gastroprotection (e.g. a proton pump inhibitor) may also be indicated
 colchicine* has a slower onset of action. The main side-effect is diarrhoea
 oral steroids may be considered if NSAIDs and colchicine are contraindicated. A dose of prednisolone
15mg/day is usually used
 another option is intra-articular steroid injection
 if the patient is already taking allopurinol it should be continued
Indications for urate-lowering therapy (ULT)

 the British Society of Rheumatology Guidelines now advocate offering urate-lowering therapy to all
patients after their first attack of gout
 ULT is particularly recommended if:
 → >= 2 attacks in 12 months
 → tophi
 → renal disease
 → uric acid renal stones
 → prophylaxis if on cytotoxics or diuretics
Urate-lowering therapy
 allopurinol is first-line
 it has traditionally been taught that urate-lowering therapy should not be started until 2 weeks after an
acute attack, as starting too early may precipitate a further attack. The evidence base to support this
however looks weak
 in 2017 the BSR updated their guidelines. They still support a delay in starting urate-lowering therapy
because it is better for a patient to make long-term drug decisions whilst not in pain
 initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 300
µmol/l. Lower initial doses should be given if the patient has a reduced eGFR
 colchicine cover should be considered when starting allopurinol. NSAIDs can be used if colchicine cannot
be tolerated. The BSR guidelines suggest this may need to be continued for 6 months
 the second-line agent when allopurinol is not tolerated or ineffective is febuxostat (also a xanthine
oxidase inhibitor)
 in refractory cases other agents may be tried:
o uricase (urate oxidase) is an enzyme that catalyzes the conversion of urate to the degradation
product allantoin. It is present in certain mammals but not humans
o in patients who have persistent symptomatic and severe gout despite the adequate use of urate-
lowering therapy, pegloticase (polyethylene glycol modified mammalian uricase) can achieve rapid
control of hyperuricemia. It is given as an infusion once every two weeks
Lifestyle modifications
 reduce alcohol intake and avoid during an acute attack
 lose weight if obese
 avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products
Other points
 consideration should be given to stopping precipitating drugs (such as thiazides)
 losartan has a specific uricosuric action and may be particularly suitable for the many patients who have
coexistent hypertension
 increased vitamin C intake (either supplements or through normal diet) may also decrease serum uric
acid levels
*inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil
motility and activity
Q-18
A 57-year-old woman presents with a three month history of right-sided hip pain. This seems to have
come on spontaneously without any obvious precipitating event. The pain is described as being worse on
the 'outside' of the hip and is particularly bad at night when she lies on the right hand side.
On examination there is a full range of movement in the hip including internal and external rotation. Deep
palpation of the lateral aspect of the right hip joint recreates the pain.
An x-ray of the right hip is reported as follows:
Right hip: Minor narrowing of the joint space otherwise normal appearance
A. Fibromyalgia
B. Lumbar nerve root compression
C. Osteoarthritis
D. Greater trochanteric pain syndrome
E. Meralgia paraesthetica
ANSWER:
D. Greater trochanteric pain syndrome
EXPLANATION:
Greater trochanteric pain syndrome is now the preferred term for trochanteric bursitis.
Whilst the x-ray shows joint space narrowing this is not an uncommon finding. Osteoarthritis would also
be less likely given the palpable nature of the pain and relatively short duration of symptoms.
HIP PAIN IN ADULTS
The table below provides a brief summary of the potential causes of hip pain in adults
Condition Features
Osteoarthritis Pain exacerbated by exercise and relieved by rest
Reduction in internal rotation is often the first sign
Age, obesity and previous joint problems are risk factors
Inflammatory arthritis Pain in the morning
Systemic features
Raised inflammatory markers
Referred lumbar spine Femoral nerve compression may cause referred pain in the hip
pain Femoral nerve stretch test may be positive - lie the patient prone. Extend the
hip joint with a straight leg then bend the knee. This stretches the femoral
nerve and will cause pain if it is trapped
Greater trochanteric Due to repeated movement of the fibroelastic iliotibial band
pain syndrome Pain and tenderness over the lateral side of thigh
(Trochanteric bursitis) Most common in women aged 50-70 years
Meralgia Caused by compression of lateral cutaneous nerve of thigh
paraesthetica Typically burning sensation over antero-lateral aspect of thigh
Avascular necrosis Symptoms may be of gradual or sudden onset
May follow high dose steroid therapy or previous hip fracture of dislocation
Pubic symphysis Common in pregnancy
dysfunction Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial
aspects of the thighs. A waddling gait may be seen
Transient idiopathic An uncommon condition sometimes seen in the third trimester of pregnancy
osteoporosis Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated
Q-19
Which one of the following X-ray changes is not associated with osteoarthritis?
A. Decreased joint space

B. Subchondral sclerosis
C. Subchondral cysts
D. Osteophytes at the joint margin
E. Periarticular erosions
ANSWER:
E. Periarticular erosions
EXPLANATION:
Periarticular erosions are seen in rheumatoid arthritis. The other four changes are classically seen in
osteoarthritis
OSTEOARTHRITIS: X-RAY CHANGES

X-ray changes of osteoarthritis
 decrease of joint space
 subchondral sclerosis
 subchondral cysts
 osteophytes forming at joint margins
Q-20
What is the minimum steroid intake a patient should be taking before they are offered osteoporosis
prophylaxis?
A. Equivalent of prednisolone 10 mg or more each day for 6 months

B. Equivalent of prednisolone 7.5 mg or more each day for 6 weeks
C. Equivalent of prednisolone 5 mg or more each day for 6 weeks
D. Equivalent of prednisolone 7.5 mg or more each day for 3 months
E. Equivalent of prednisolone 10 mg or more each day for 6 weeks
ANSWER:
D. Equivalent of prednisolone 7.5 mg or more each day for 3 months
EXPLANATION:
Please see Q-14 for Osteoporosis: Glucocorticoid-Induced
Q-21
Which one of the following drugs has been associated with an increased risk of atypical stress fractures of
the proximal femoral shaft?
A. Spironolactone
B. Alendronate
C. Quetiapine
D. Venlafaxine
E. Clopidogrel
ANSWER:
B. Alendronate
EXPLANATION:
Bisphosphonates are associated with an increased risk of atypical stress fractures
BISPHOSPHONATES
Bisphosphonates are analogues of pyrophosphate, a molecule which decreases demineralisation in bone.
They inhibit osteoclasts by reducing recruitment and promoting apoptosis.
Clinical uses
 prevention and treatment of osteoporosis
 hypercalcaemia
 Paget's disease
 pain from bone metatases
Adverse effects
 oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
 osteonecrosis of the jaw
 increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
 acute phase response: fever, myalgia and arthralgia may occur following administration
 hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant
The BNF suggests the following counselling for patients taking oral bisphosphonates
 'Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an
empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand
or sit upright for at least 30 minutes after taking tablet'
Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates. However, when

starting bisphosphonate treatment for osteoporosis, calcium should only be prescribed if dietary intake is
inadequate. Vitamin D supplements are normally given.
The duration of bisphosphonate treatment varies according to the level of risk. Some authorities
recommend stopping bisphosphonates at 5 years if the following apply:
 patient is < 75-years-old
 femoral neck T-score of > -2.5
 low risk according to FRAX/NOGG
Q-22
A 70-year-old woman presents with loss of vision in her left eye. For the past two weeks she has painful
frontal headaches and has been feeling generally lethargic. On examination visual acuity is 6/9 in the right
eye but on the left side only hand movements can be made seen. Fundoscopy of the left side reveals a
pale and oedematous optic disc. What is the most likely diagnosis?.
A. Acute angle closure glaucoma

B. Central retinal artery occlusion
C. Multiple sclerosis
D. Methanol poisoning
E. Temporal arteritis
ANSWER:
EXPLANATION:
This patient has likely developed anterior ischemic optic neuropathy on the left side
TEMPORAL ARTERITIS
Temporal arteritis is large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR). Histology
shows changes which characteristically 'skips' certain sections of affected artery whilst damaging others.
Features
 typically patient > 60 years old
 usually rapid onset (e.g. < 1 month)
 headache (found in 85%)
 jaw claudication (65%)
 visual disturbances secondary to anterior ischemic optic neuropathy
 tender, palpable temporal artery
 around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
 also lethargy, depression, low-grade fever, anorexia, night sweats
Investigations
 raised inflammatory markers: ESR > 50 mm/hr (note ESR < 30 in 10% of patients). CRP may also be
elevated
 temporal artery biopsy: skip lesions may be present
 note creatine kinase and EMG normal
Treatment
 high-dose prednisolone - there should be a dramatic response, if not the diagnosis should be
reconsidered
 urgent ophthalmology review. Patients with visual symptoms should be seen the same-day by an
ophthalmologist. Visual damage is often irreversible
Q-23
A 72-year-old female known to have osteoporosis is started on alendronate. Which one of the following
side-effects is it most important to warn her about?
A. Sore throat
B. Heartburn
C. Headache
D. Diarrhoea
E. Palpitations
ANSWER:
B. Heartburn
EXPLANATION:
Bisphosphonates can cause a variety of oesophageal problems
Whilst the development of any new problem following the introduction of a new drug warrants medical
review it is particularly important to warn patients starting bisphosphonates about symptoms which could
suggest an oesophageal reaction, especially with alendronate
Please see Q-21 for Bisphosphonates
Q-24
A 34-year-old is diagnosed with chronic fatigue syndrome. Which one of the following interventions is
least useful?
A. Advice to go to the gym

B. Cognitive behaviour therapy
C. Referral to a pain management clinic if pain is a predominant feature
D. Advice about pacing of activities
E. Low-dose amitriptyline for poor sleep
ANSWER:
A. Advice to go to the gym
EXPLANATION:
CHRONIC FATIGUE SYNDROME
Diagnosed after at least 4 months of disabling fatigue affecting mental and physical function more than 50%
of the time in the absence of other disease which may explain symptoms
Epidemiology
 more common in females
 past psychiatric history has not been shown to be a risk factor
Fatigue is the central feature, other recognised features include

 sleep problems, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep-wake cycle
 muscle and/or joint pains
 headaches
 painful lymph nodes without enlargement
 sore throat
 cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term
memory, and difficulties with word-finding
 physical or mental exertion makes symptoms worse
 general malaise or 'flu-like' symptoms
 dizziness
 nausea
 palpitations
Investigation
 NICE guidelines suggest carrying out a large number of screening blood tests to exclude other pathology
e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin*, coeliac screening and also urinalysis
Management
 cognitive behaviour therapy - very effective, number needed to treat = 2
 graded exercise therapy - a formal supervised program, not advice to go to the gym
 'pacing' - organising activities to avoid tiring
 low-dose amitriptyline may be useful for poor sleep
 referral to a pain management clinic if pain is a predominant feature
Better prognosis in children
*children and young people only
Q-25
You receive a letter about one of your patients who has been prescribed methotrexate by one of the
rheumatologists for severe rheumatoid arthritis. You have been asked to arrange regular blood tests every
2 weeks until treatment is stabilised. Which of the following groups of tests need to be performed each
time?
A. Full blood count, urea and electrolytes and liver function tests
B. Full blood count and liver function tests
C. Full blood count and urea and electrolytes
D. Full blood count, urea and electrolytes and folic acid
E. Full blood count, urea and electrolytes and calcium
ANSWER:
A. Full blood count, urea and electrolytes and liver function tests
EXPLANATION:
Full blood count, urea and electrolytes and liver function tests need to be monitored when taking
methotrexate.
April 2016 AKT report: 'Candidates had difficulty with regard to management of longterm conditions
where a step up on treatment was required for an exacerbation. GPs are sometimes asked by secondary
care to prescribe drugs with which they are less familiar, or drugs that are used following advice in shared
care guidelines, and should be aware of indications/interactions, especially as the final responsibility for
the prescription remains with the GP.
Please see Q-6 for Methotrexate
Q-26
A 34-year-old man comes to surgery. He has been generally unwell since an episode of diarrhoea four
weeks ago, with joint pains, pain on passing water and a rash on the soles of his feet:
What does this rash likely represent?
A. Pompholyx
B. HIV-associated dermopathy
C. Plantar pustular psoriasis
D. Mosaic warts
E. Keratoderma blennorrhagica
ANSWER:
E. Keratoderma blennorrhagica
EXPLANATION:
REACTIVE ARTHRITIS: FEATURES
Reactive arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies. It encompasses
Reiter's syndrome, a term which described a classic triad of urethritis, conjunctivitis and arthritis following a
dysenteric illness during the Second World War. Later studies identified patients who developed symptoms
following a sexually transmitted infection (post-STI, now sometimes referred to as sexually acquired reactive
arthritis, SARA).
Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot
be recovered from the joint.
Features
 typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months
 arthritis is typically an asymmetrical oligoarthritis of lower limbs
 dactylitis
 symptoms of urethritis
 eye: conjunctivitis (seen in 10-30%), anterior uveitis
 skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma
blenorrhagica (waxy yellow/brown papules on palms and soles)
Around 25% of patients have recurrent episodes whilst 10% of patients develop chronic disease
'Can't see, pee or climb a tree'
Keratoderma blenorrhagica
Q-27
A 79-year-old man presents to his GP with a history of lower back pain and right hip pain. Blood tests
reveal the following:
Calcium 2.20 mmol/l

Phosphate 0.8 mmol/l
ALP 890 u/L
A. Primary hyperparathyroidism
B. Chronic renal failure
C. Osteomalacia
D. Osteoporosis
E. Paget's disease
ANSWER:
E. Paget's disease
EXPLANATION:
Paget's disease - old man, bone pain, raised ALP
The normal calcium and phosphate combined with a raised alkaline phosphate points to a diagnosis of
Paget's
PAGET'S DISEASE OF THE BONE

Paget's disease is a disease of increased but uncontrolled bone turnover. It is thought to be primarily a
disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity.
Paget's disease is common (UK prevalence 5%) but symptomatic in only 1 in 20 patients. The skull,
spine/pelvis, and long bones of the lower extremities are most commonly affected.
Predisposing factors
 increasing age
 male sex
 northern latitude
 family history
Clinical features - only 5% of patients are symptomatic

 the stereotypical presentation is an older male with bone pain and an isolated raised ALP
 bone pain (e.g. pelvis, lumbar spine, femur)
 classical, untreated features: bowing of tibia, bossing of skull
 raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal
 other markers of bone turnover include: procollagen type I N-terminal propeptide (PINP), serum C-
telopeptide (CTx), urinary N-telopeptide (NTx), and urinary hydroxyproline
 skull x-ray: thickened vault, osteoporosis circumscripta
Indications for treatment include bone pain, skull or long bone deformity, fracture, periarticular Paget's
 bisphosphonate (either oral risedronate or IV zoledronate)
 calcitonin is less commonly used now
Complications
 deafness (cranial nerve entrapment)
 bone sarcoma (1% if affected for > 10 years)
 fractures
 skull thickening
 high-output cardiac failure
The radiograph demonstrates marked thickening of the calvarium. There are also ill-defined sclerotic and lucent areas
throughout. These features are consistent with Paget's disease.
Pelvic x-ray from an elderly man with Paget's disease. There is a smooth cortical expansion of the left hemipelvic bones
with diffuse increased bone density and coarsening of trabeculae.
Isotope bone scan from a patient with Paget's disease showing a typical distribution in the spine, asymmetrical pelvic
disease and proximal long bones.
*usually normal in this condition but hypercalcaemia may occur with prolonged immobilisation
Q-28
One of your patients who has a family history of Marfan's syndrome has recently been diagnosed with the
condition. What is the most important investigation to monitor their condition?
A. Urea and electrolytes

B. Echocardiography
C. Spirometry
D. Electrocardiogram
E. DEXA scan
ANSWER:
B. Echocardiography
EXPLANATION:
Marfan's syndrome is associated with dilation of the aortic sinuses which may predispose to aortic
dissection
Please see Q-16 for Marfan’s Syndrome

Q-29
You refer a 24-year-old female to rheumatology with intermittent pain and swelling of the metacarpal
phalangeal joints for the past 3 months. An x-ray shows loss of joint space and soft-tissue swelling.
Rheumatoid factor is positive and a diagnosis of rheumatoid arthritis is made. What initial management is
she most likely to be given to help slow disease progression?
A. Infliximab
B. Methotrexate + short-course of prednisolone
C. Methotrexate + Infliximab
D. Methotrexate + sulfasalazine + short-course of prednisolone
E. Diclofenac
ANSWER:
B. Methotrexate + short-course of prednisolone
EXPLANATION:
In 2018 NICE updated their rheumatoid arthritis guidelines. They now recommend disease-modifying
antirheumatic drug (DMARD) monotherapy with a short-course of bridging prednisolone. In the past dual
DMARD therapy was advocated as the initial step.
Please see Q-13 for Rheumatoid Arthritis: Management
Q-30
A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal
joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol
therapy?
A. Stop and recommence 4 weeks after acute inflammation has settled

B. Reduce allopurinol to 100mg od until acute attack has settled
C. Stop and switch to colchicine prophylaxis
D. Stop and recommence 2 weeks after acute inflammation has settled
E. Continue allopurinol in current dose
ANSWER:
E. Continue allopurinol in current dose
EXPLANATION:
Please see Q-17 for Gout: Management
Q-31
You see a 35-year-old hairdresser who has recently been diagnosed with Crohn's disease following
presentation with abdominal pain, loose stools and a microcytic anaemia.
She would like some more information on Crohn's disease.
Which statement below is correct?

A. Smoking is not a risk factor for Crohn's disease
B. Osteoporosis occurs in up to 30% of patients with inflammatory bowel disease
C. 10% of patients with inflammatory bowel disease have anaemia at diagnosis
D. The median age of diagnosis is 20 years old for Crohn's disease
E. The incidence and prevalence of Crohn's disease is decreasing worldwide
ANSWER:
B. Osteoporosis occurs in up to 30% of patients with inflammatory bowel disease
EXPLANATION:
Osteoporosis occurs in up to 30% of men and women with inflammatory bowel disease
The risk of Crohn's disease is increased in smokers (in contrast to ulcerative colitis, where the risk is
decreased). Therefore, option 1 is incorrect.
Osteoporosis occurs in up to 30% of men and women with inflammatory bowel disease. Therefore, option
2 is correct.
About two-thirds of people with inflammatory bowel disease have anaemia at diagnosis. Therefore,
option 3 is incorrect.
The median age at diagnosis is about 30 years for Crohn's disease. Therefore, option 4 is incorrect.
The incidence and prevalence of Crohn's disease are increasing worldwide. Therefore, option 5 is incorrect.
Please see Q-8 for Osteoporosis: Causes
Q-32
In line with NICE guidelines on the secondary prevention of osteoporotic fractures in postmenopausal
women, which one of the following patients should not automatically be started on treatment?
A. A 81-year-old woman who has had a fractured neck of femur

B. A 64-year-old women with a wedge fractures of her thoracic spine. DEXA scan shows a T-score of -3.1
SD
C. A 55-year-old women who had a Colles fracture of the wrist. DEXA scan shows a T-score of -3.3 SD
D. A 64-year-old women with a BMI of 18 kg/m2. She has a wedge fractures of her thoracic spine. DEXA
scan shows a T-score of -2.7 SD
E. A 71-year-old women who had a Colles fracture of the wrist. DEXA scan shows a T-score of -2.1 SD
ANSWER:
E. A 71-year-old women who had a Colles fracture of the wrist. DEXA scan shows a T-score of -2.1 SD
EXPLANATION:
OSTEOPOROSIS: MANAGEMENT
NICE guidelines were updated in 2008 on the secondary prevention of osteoporotic fractures in
postmenopausal women.
Key points include
 treatment is indicated following osteoporotic fragility fractures in postmenopausal women who are
confirmed to have osteoporosis (a T-score of - 2.5 SD or below). In women aged 75 years or older, a
DEXA scan may not be required 'if the responsible clinician considers it to be clinically inappropriate or
unfeasible'
 vitamin D and calcium supplementation should be offered to all women unless the clinician is confident
they have adequate calcium intake and are vitamin D replete
 alendronate is first-line
 around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems.
These patients should be offered risedronate or etidronate (see treatment criteria below)
 strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates (see
treatment criteria below)
Treatment criteria for patients not taking alendronate

Unfortunately, a number of complicated treatment cut-off tables have been produced in the latest
guidelines for patients who do not tolerate alendronate
These take into account a patients age, theire T-score and the number of risk factors they have from the
following list:
 parental history of hip fracture
 alcohol intake of 4 or more units per day
It is very unlikely that examiners would expect you to have memorised these risk tables so we've not
included them in the revision notes but they may be found by following the NICE link. The most important
thing to remember is:
 the T-score criteria for risedronate or etidronate are less than the others implying that these are the
second line drugs
 if alendronate, risedronate or etidronate cannot be taken then strontium ranelate or raloxifene may be
given based on quite strict T-scores (e.g. a 60-year-old woman would need a T-score < -3.5)
 the strictest criteria are for denosumab
Supplementary notes on treatment

Bisphosphonates
 alendronate, risedronate and etidronate are all licensed for the prevention and treatment of post-
menopausal and glucocorticoid-induced osteoporosis
 all three have been shown to reduce the risk of both vertebral and non-vertebral fractures although
alendronate, risedronate may be superior to etidronate in preventing hip fractures
 ibandronate is a once-monthly oral bisphosphonate
Vitamin D and calcium

 poor evidence base to suggest reduced fracture rates in the general population at risk of osteoporotic
fractures - may reduce rates in frail, housebound patients
Raloxifene - selective oestrogen receptor modulator (SERM)

 has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been
shown to reduce the risk of non-vertebral fractures
 has been shown to increase bone density in the spine and proximal femur
 may worsen menopausal symptoms
 increased risk of thromboembolic events
 may decrease risk of breast cancer
Strontium ranelate
 'dual action bone agent' - increases deposition of new bone by osteoblasts (promotes differentiation of
pre-osteoblast to osteoblast) and reduces the resorption of bone by inhibiting osteoclasts
 concerns regarding the safety profile of strontium have been raised recently. It should only be prescribed
by a specialist in secondary care
 due to these concerns the European Medicines Agency in 2014 said it should only be used by people for
whom there are no other treatments for osteoporosis
 increased risk of cardiovascular events: any history of cardiovascular disease or significant risk of
cardiovascular disease is a contraindication
 increased risk of thromboembolic events: a Drug Safety Update in 2012 recommended it is not used in
patients with a history of venous thromboembolism
 may cause serious skin reactions such as Stevens Johnson syndrome
Denosumab
 human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of
osteoclasts
 given as a single subcutaneous injection every 6 months
 initial trial data suggests that it is effective and well tolerated
Teriparatide
 recombinant form of parathyroid hormone
 very effective at increasing bone mineral density but role in the management of osteoporosis yet to be
clearly defined
Hormone replacement therapy

 has been shown to reduce the incidence of vertebral fracture and non-vertebral fractures
 due to concerns about increased rates of cardiovascular disease and breast cancer it is no longer
recommended for primary or secondary prevention of osteoporosis unless the woman is suffering from
vasomotor symptoms
Hip protectors
 evidence to suggest significantly reduce hip fractures in nursing home patients
 compliance is a problem
Falls risk assessment

 no evidence to suggest reduced fracture rates
 however, do reduce rate of falls and should be considered in management of high risk patients
MRI showing osteoporotic fractures of the 8th and 10th thoracic vertebrae.
Q-33
You receive a discharge summary for an elderly patient who was admitted with back pain and found to
have vertebral wedge fractures. She has been started on high dose vitamin D replacement for proven
vitamin D deficiency found during the work-up for the wedge fractures. What monitoring should be
arranged?
A. Calcium
B. Parathyroid hormone
C. Vitamin D
D. Alkaline phosphatase
E. Phosphate
ANSWER:
A. Calcium
EXPLANATION:
Calcium levels should be monitored after commencing vitamin D because it can unmask underlying
hyperparathyroidism - hypercalcaemia can occur. For this reason vitamin D may not be suitable for
patients with renal calculi, granulomatous disease, or bone metastases. The National Osteoporosis Society
suggests checking serum calcium at one month. Vitamin D levels do not need routinely checked after
commencing replacement.
Source: National Osteoporosis Society Vitamin D and Bone Health: A Practical Clinical Guideline for Patient
Management
https://www.nos.org.uk/document.doc?id=1352
Please see Q-15 for Vitamin D Supplementation
Q-34
Miss Starr, a 26-year-old woman who is currently 14 weeks into her first pregnancy, attends with
symptoms of vaginal thrush. At the end of the consultation, she asks for your advice about pregnancy
supplements. She has been taking a branded pregnancy multivitamin but asks if she is ok to stop it now
that she is past the first trimester, because the supplements are expensive. She is generally well, on no
regular medications, and is under midwife-led care as her pregnancy has been assessed as low risk. She
has no family history of spina bifida.
What should you advise Miss Starr?
A. No supplement needed - encourage healthy diet

B. Folic acid, vitamin D, and calcium throughout the whole pregnancy
C. Folic acid pre-conception and throughout the whole pregnancy
D. Folic acid pre-conception and until 12 weeks gestation, vitamin A throughout the whole pregnancy
E. Folic acid pre-conception and until 12 weeks gestation, vitamin D throughout the whole pregnancy
(except summer months)
ANSWER:
E. Folic acid pre-conception and until 12 weeks gestation, vitamin D throughout the whole pregnancy
(except summer months)
EXPLANATION:
DoH advises all pregnant women should take vitamin D supplement throught the whole of pregnancy
No supplement needed - encourage healthy diet: Incorrect answer, the Department of Health currently
advises all pregnant women take 400mcg folic acid from when they are trying to get pregnant to the end
of the first trimester, and to consider a 10mcg vitamin D supplement throughout the whole of pregnancy
and breastfeeding. Higher doses of folic acid are recommended when there is a higher risk spina bifida eg.
diabetes.
Folic acid, vitamin D, and calcium throughout the whole pregnancy: Incorrect, calcium supplements are
not currently recommended.
Folic acid pre-conception and throughout the whole pregnancy: Folic acid need only be taken until 12
weeks (although would not be harmful if continued longer).
Folic acid pre-conception and until 12 weeks gestation, vitamin A throughout the whole pregnancy:
Incorrect, vitamin A is teratogenic. If a pregnant lady is choosing multivitamins, she should make sure it
does not contain vitamin A (retinol).
Folic acid pre-conception and until 12 weeks gestation, vitamin D throughout the whole pregnancy:
Correct answer. The Department of Health currently advises all pregnant women take 400mcg folic acid
from when they are trying to get pregnant to the end of the first trimester, and to consider a 10mcg
vitamin D supplement throughout the whole of pregnancy (and breastfeeding). They might choose not to
over summer months when sun exposure is likely to produce enough vitamin D. Higher doses of folic acid
are recommended when there is a higher risk spina bifida eg. diabetes. Expensive branded pregnancy
multivitamins are not necessary; and patients who qualify for Healthy Start vouchers may be eligible to
get supplements on prescription.
Q-35
You are reviewing a 35-year-old lady who has recently been diagnosed with rheumatoid arthritis (RA). She
presented to you with swollen and tender multiple metacarpal-phalangeal (MCP) joints. Blood tests
revealed a raised rheumatoid factor, and you referred her urgently to rheumatology.
She was seen by a rheumatologist last week who diagnosed RA and started treatment.
She would like some more information about RA from you.
Which statement below is correct regarding RA?
A. RA occurs in men and women at approximately equal rates

B. Rheumatoid arthritis predisposes a patient to lymphoproliferative diseases
C. The prevalence of confirmed RA is about 3% of the UK population
D. RA does not increase your risk of infection
E. RA does not increase your risk of cardiovascular disease
ANSWER:
B. Rheumatoid arthritis predisposes a patient to lymphoproliferative diseases
EXPLANATION:
Rheumatoid arthritis predisposes to lymphoproliferative diseases
RA is two to four times more common in women than in men. Therefore, option 1 is wrong.
The prevalence of confirmed RA is about 1% of the UK population. Therefore, option 3 is wrong.
RA itself predisposes to lymphoproliferative diseases (particularly lymphoma). Therefore, option 2 is

correct.
RA is associated with an approximate doubling of the risk of infection; chest infection and generalized
sepsis are particular risks. Therefore, option 4 is wrong.
People with RA are at increased risk of CVD compared with the general population. Therefore, option 5 is
wrong.
RHEUMATOID ARTHRITIS: COMPLICATIONS

A wide variety of extra-articular complications occur in patients with rheumatoid arthritis (RA):
 respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans,
methotrexate pneumonitis, pleurisy
 ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis,
steroid-induced cataracts, chloroquine retinopathy
 osteoporosis
 ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
 increased risk of infections
 depression
Less common
 Felty's syndrome (RA + splenomegaly + low white cell count)
 amyloidosis
Q-36
A 76-year-old woman presents two months after starting alendronate. Around three months ago she fell
and broke her wrist. She was immediately started on alendronate and has not had a DEXA scan.
Unfortunately she has been experiencing some heartburn since starting alendronate. Her past medical
history includes ischaemic heart disease. You discuss how she took alendronate and it seems she took it
correctly. She stopped taking alendronate two weeks ago, given the symptoms and reports some
improvement. What is the most appropriate course of action?
A. Co-prescribe a proton pump inhibitor and restart alendronate

B. Advise her to use an alginate raft-forming suspension (such as Gaviscon) on the days she takes
alendronate
C. Switch her to strontium ranelate
D. Switch her to risedronate
E. Refer for an endoscopy
ANSWER:
D. Switch her to risedronate
EXPLANATION:
Please see Q-32 for Osteoporosis: Management
Q-37
A 67-year-old woman comes for her medication review. Three years ago she was started on alendronate
after sustaining a wrist fracture and subsequently being diagnosed with osteoporosis. She asks you how
long she will need to take bone protection therapy.
What is the most appropriate time to reassess her risk and consider the need to continue treatment?
A. Lifelong treatment is needed

B. At 1 year
C. At 5 years
D. At 10 years
E. At 15 years
ANSWER:
C. At 5 years
EXPLANATION:
OSTEOPOROSIS: MONITORING TREATMENT
Two of the main questions that patients ask after starting bone protection treatment are:
 How do I know if the treatment is working? Should we repeat the DEXA scan?
 How long do I need to stay on treatment?
Unfortunately there is little clear guidance from the major guidelines relating to these issues.
What is the consensus view?

The general consensus is that patients do not require assessment of bone mineral density once bone
protection has been started. This is partly because there is limited evidence of any link between
improvement in bone mineral density and reduction in fracture risk.
With respect to length of treatment, the NOGG state the following in their patient-information leaflet (more
detail seems to be given here than the guidelines aimed at healthcare professionals!)
A treatment review is recommended after 5 years of treatment for alendronate, risedronate or ibandronate
and after 3 years for zoledronic acid. The review is likely to involve a recalculation of your fracture risk and a
DXA scan.
Q-38
A 67-year-old gentleman presents for review 1 month after he was prescribed colchicine for his first acute
attack of gout. He has fully recovered with no residual symptoms. Aside from a resolved acute kidney
injury (AKI) after a bout of diarrhoea last year, he has no past medical history of significance and is not on
any regular medication.
What is the most appropriate course of action with regards to long-term urate-lowering therapy?
A. Offer allopurinol today

B. Advise he can continue taking colchicine as long term urate lowering therapy
C. Advise he needs to wait a further month after taking the colchicine before he can commence
allopurinol
D. Test his renal function and only prescribe allopurinol if he has normal renal function
E. Offer febuxostat today
ANSWER:
A. Offer allopurinol today
EXPLANATION:
Offer allopurinol to all patients after their first attack of gout
The British Society for Rheumatology updated their guidelines in 2017 to recommend early initiation of
urate-lowering therapy following an acute episode of gout. It is therefore now suggested that all patients
should be offered urate-lowering therapy after their first attack of gout, rather than waiting for two or
more episodes or the development of ongoing symptoms (e.g. tophi, chronic gout).
Option 2 is incorrect as colchicine cannot be used alone as a long-term urate-lowering medication.

Option 3 is incorrect as he does not need to wait a further month before commencing allopurinol - he can
start today as the acute attack has resolved (it should not be started during an ongoing acute attack).
Option 4 is incorrect as allopurinol can still be prescribed in renal impairment, but caution must be taken
with doses (see BNF).
Option 5 is incorrect as Febuxostat should only be offered as a second line medication if allopurinol is
contra-indicated or the patient has not tolerated it.
Q-39
A 65-year-old lady presents with a feeling of a shade covering part of her left eye. She has also had
intermittent headaches on that side. She describes jaw pain when chewing.
On examination, fundoscopy and eye examination is normal. There is mild tenderness to the left side of
the head.
A. Acute glaucoma
B. Amaurosis fugax
C. Episcleritis
D. Giant cell arteritis
E. Shingles
ANSWER:
D. Giant cell arteritis
EXPLANATION:
An elderly patient presenting with a unilateral headache with jaw claudication should be considered as
having giant cell arteritis and investigations should be carried out. Acute glaucoma usually presents with
eye pain and seeing halos in people's vision. People also feel unwell and have nausea. Amaurosis fugax is
a transient painless loss of vision. People with episcleritis usually have mild eye pain along with watering
and redness of the eye. Shingles affecting the ophthalmic region gives numbness and a neuropathic pain
around the eye as well as a rash.
Please see Q-22 for Temporal Arteritis
Q-40
Which one of the following statements regarding raloxifene in the management of osteoporosis is
incorrect?
A. Has been shown to prevent bone loss and to reduce the risk of vertebral fractures
B. Is a selective oestrogen receptor modulator
C. May worsen menopausal symptoms
D. Increases risk of thromboembolic events
E. Increases the risk of breast cancer
ANSWER:
E. Increases the risk of breast cancer
EXPLANATION:
Raloxifene may actually decrease the risk of breast cancer
Q-41
A 47-year-old man who is known to have dermatomyositis secondary to small cell lung cancer is noted to
have roughened red papules over the extensor surfaces of the fingers. What are these lesions called?
A. Heberden's node
B. Aschoff nodules
C. Gottron's papules
D. Bouchard's nodes
E. Muehrcke's lines
ANSWER:
C. Gottron’s papules
EXPLANATION:
Gottron's papules are roughened red papules over the extensor surfaces and are seen in dermatomyositis
Heberden's and Bouchard's nodes are seen in osteoarthritis. Aschoff nodules are pathognomonic of
rheumatic fever whilst Muehrcke's lines are white, transverse lines of the fingernail seen in
hypoalbuminaemia
DERMATOMYOSITIS
Overview
 an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
 may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically
ovarian, breast and lung cancer, found in 20-25% - more if patient older). Screening for an underlying
malignancy is usually performed following a diagnosis of dermatomyositis
 polymyositis is a variant of the disease where skin manifestations are not prominent
Skin features
 photosensitive
 macular rash over back and shoulder
 heliotrope rash in the periorbital region
 Gottron's papules - roughened red papules over extensor surfaces of fingers
 'mechanic's hands': extremely dry and scaly hands with linear 'cracks' on the palmar and lateral aspects
of the fingers
 nail fold capillary dilatation
Other features
 proximal muscle weakness +/- tenderness
 Raynaud's
 respiratory muscle weakness
 interstitial lung disease: e.g. Fibrosing alveolitis or organising pneumonia
 dysphagia, dysphonia
Investigations
 the majority of patients (around 80%) are ANA positive
 around 30% of patients have antibodies to aminoacyl-tRNA synthetases (anti-synthetase antibodies),
including:
 antibodies against histidine-tRNA ligase (also called Jo-1)
 antibodies to signal recognition particle (SRP)
 anti-Mi-2 antibodies
Q-42
A 41-year-old man presents with persistent fatigue for the past 8 months. Which one of the following
features is least consistent with a diagnosis of chronic fatigue syndrome?
A. Dizziness
B. Painful lymph nodes without enlargement
C. Having a busy day improves the symptoms
D. Palpitations
E. Headaches
ANSWER:
C. Having a busy day improves the symptoms
EXPLANATION:
Physical or mental exertion usually makes the symptoms worse
Please see Q-24 for Chronic Fatigue Syndrome
Q-43
A 34-year-old woman is reviewed in surgery. She has difficult to control asthma and is currently on a
reducing course of steroids. Her respiratory consultant has asked you to consider bone protection. Looking
back at the records she has had 11 courses of oral prednisolone over the past 12 months, some of which
have lasted more than one week. What is the most appropriate course of action?
A. Start oral alendronate

B. Reassure her that she is very low risk
C. Give her advice on fracture prevention and ensuring adequate exercise
D. Arrange a DEXA scan
E. Perform a FRAX assessment
ANSWER:
D. Arrange a DEXA scan
EXPLANATION:
Bone protection for patients taking corticosteroids
< 65 years: DEXA scan first
>= 65 years: start alendronate
Please see Q-14 for Osteoporosis: Glucorticoid-Induced
Q-44
A 25-year-old man with a history of Crohn's disease presents asking for advice. He currently takes
methotrexate and asks if it is alright for him and his partner to try for a baby.
What is the most appropriate advice?
A. He should wait at least 6 months after stopping treatment

B. He should wait at least 12 months after stopping treatment
C. He should have semen analysis 8 weeks after stopping treatment prior to trying to conceive
D. There are no limitations on male patients
E. He should wait at least 3 months and his partner should take folic 5 mg od
ANSWER:
A. He should wait at least 6 months after stopping treatment
EXPLANATION:
Patients using methotrexate require effective contraception during and for at least 6 months after
treatment in men or women
Q-45
A 32-year-old man presents to the GP with a painful knee and ankle joint. He describes malaise, fatigue,
and fever following his holiday to Thailand 3 weeks ago where he developed profuse diarrhoea. A
diagnosis of reactive arthritis is suspected.
What other sign on examination may help point towards the suspected diagnosis?
A. Z-thumb deformity
B. Leukonychia
C. Clubbing
D. Dactylitis
E. Bouchard's nodes
ANSWER:
D. Dactylitis
EXPLANATION:
Reactive arthritis is a cause of dactylitis
This question is about a man presenting with lower limb joint pain following a gastrointestinal infection.
This the typical pattern of reactive arthritis. The question is asking for the clinical sign associated with the
condition and thus the correct answer is dactylitis which is most commonly caused by
spondyloarthropathies such as psoriatic and reactive arthritis.
 A Z-thumb deformity is associated with rheumatoid arthritis

 Leukonychia is caused by hypoalbuminemia
 Clubbing has many different causes including congenital heart defects and many cancers
 Bouchard's nodes are associated with osteoarthritis
DACTYLITIS
Dactylitis describes the inflammation of a digit (finger or toe).
Causes include:
 spondyloarthritis: e.g. Psoriatic and reactive arthritis
 sickle-cell disease
 other rare causes include tuberculosis, sarcoidosis and syphilis
Q-46
You are carrying out a medication review for Mrs Smith, a 73-year-old woman. You note that she has been
taking alendronate for the last 5 years after a FRAX score indicated she was at risk of fracture. She has had
no previous fractures. Her other medications include ramipril, amlodipine, atorvastatin and allopurinol.
She describes no medication side effects.
What is the most appropriate action with regards to her bisphosphonate therapy?
A. Arrange an zoledronate infusion

B. Switch to an alternative bisphosphonate such as risedronate
C. Stop alendronate, no further follow up required
D. Continue alendronate for now as ongoing risk factors
E. Arrange a repeat DEXA scan and reassess need to continue alendronate
ANSWER:
E. Arrange a repeat DEXA scan and reassess need to continue alendronate
EXPLANATION:
In osteoporosis, 10 year fracture risk should be reassessed after 5 years of treatment with alendronate
The National Osteoporosis Guideline Group and NICE guidelines suggest reassessing patients after 5 years
of oral bisphosphonate therapy (or 3 years of zoledronate) and to consider stopping.
They recommend continuing therapy in those over 75, those with previous hip or vertebral fracture, those
with any low trauma fracture while on treatment, or those continuing on steroid therapy.

Q-47
This 60-year-old woman who is being treated for heartburn comes for review. She has developed some
spots on her lips:
A. CREST syndrome
B. Oesophageal cancer
C. Vitamin C deficiency
D. Peutz-Jeghers syndrome
E. Iron-deficiency anaemia
ANSWER:
A. CREST syndrome
EXPLANATION:
The heartburn may be explained by oesophageal dysmotility, a feature of CREST syndrome. The lesions on
her lips are telangiectasia. She also has the typical tightening of the facial skin seen in patients with
systemic sclerosis.
SYSTEMIC SCLEROSIS
Systemic sclerosis is a condition of unknown aetiology characterised by hardened, sclerotic skin and other
connective tissues. It is four times more common in females.
There are three patterns of disease:
Limited cutaneous systemic sclerosis

 Raynaud's may be first sign
 scleroderma affects face and distal limbs predominately
 associated with anti-centromere antibodies
 a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud's phenomenon,
oEsophageal dysmotility, Sclerodactyly, Telangiectasia
Diffuse cutaneous systemic sclerosis
 scleroderma affects trunk and proximal limbs predominately
 associated with scl-70 antibodies
 the most common cause of death is now respiratory involvement, which is seen in around 80%:
interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
 other complications include renal disease and hypertension
 poor prognosis
Scleroderma (without internal organ involvement)

 tightening and fibrosis of skin
 may be manifest as plaques (morphoea) or linear
Antibodies
 ANA positive in 90%
 RF positive in 30%
 anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
 anti-centromere antibodies associated with limited cutaneous systemic sclerosis
Q-48
You see a 29-year-old patient with a swollen left knee. It has been getting worse for a number of months
and is now affecting his ability to work as a postman. The pain and stiffness are worse overnight and in
the morning and gets better throughout the day. He denies any trauma or fever. He also has some pain
and stiffness in his fingers which is also worse in the morning. His joints are worse after rest.
He is normally fit and well and denies any previous joint problems or psoriasis. However, his father has a
history of psoriasis. He says there is no family history of joint problems to his knowledge.
On examination, his knee is red, warm and tender to palpate. There is a moderate knee effusion and
flexion is limited due to pain. His distal interphalangeal joints (DIPs) are tender and slightly swollen.
There are no skin rashes. Although his knee is painful the patient looks well and has a heart rate of 80
beats per minute and his temperature is 36.8ºC.
Blood tests reveal a raised CRP at 85 but a negative rheumatoid factor.
A. Juvenile idiopathic arthritis

B. Seronegative rheumatoid arthritis
C. Psoriatic arthritis
D. Septic arthritis
ANSWER:
EXPLANATION:
Psoriatic arthropathy can present before psoriatic skin lesions - a positive family history of psoriasis may
point towards this diagnosis
Given the inflammatory pattern of pain and swelling (worse in the morning and after rest), the joints
involved (DIPs and knee) and family history of psoriasis, the most likely diagnosis is psoriatic arthritis.
Psoriatic arthropathy can present before psoriatic skin changes. Therefore, option 3 is the correct answer.
Rheumatoid arthritis and seronegative rheumatoid arthritis classically affect the metacarpal phalangeal
joints (MCPs) of the hands, not the DIPs. You would also expect the rheumatoid factor to be raised in
rheumatoid arthritis (but not seronegative rheumatoid arthritis).
Idiopathic juvenile arthritis presents like rheumatoid arthritis in patients under 16 years old. Given the age
of this patient, this is not a likely diagnosis.
Septic arthritis presents with a swollen, red and very painful joint. The patient would classically be pyrexial
and unwell. Therefore, this is not the most likely diagnosis.
Therefore, option 3 is the most likely diagnosis.
PSORIATIC ARTHROPATHY
Psoriatic arthropathy correlates poorly with cutaneous psoriasis and often precedes the development of skin
lesions. Around 10-20% percent of patients with skin lesions develop an arthropathy with males and females
being equally affected
Types*
 rheumatoid-like polyarthritis: (30-40%, most common type)
 asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
 sacroilitis
 DIP joint disease (10%)
 arthritis mutilans (severe deformity fingers/hand, 'telescoping fingers')
Management
 should be managed by a rheumatologist
 treat as rheumatoid arthritis but better prognosis
Notice the nail changes on this image as well

X-ray showing some of changes in seen in psoriatic arthropathy. Note that the DIPs are predominately affected, rather
than the MCPs and PIPs as would be seen with rheumatoid. Extensive juxta-articular periostitis is seen in the DIPs but
the changes have not yet progressed to the classic 'pencil-in-cup' changes that are often seen.
This x-ray shows changes affecting both the PIPs and DIPs. The close-up images show extensive changes including large
eccentric erosions, tuft resorption and progresion towards a 'pencil-in-cup' changes.
*Until recently it was thought asymmetrical oligoarthritis was the most common type, based on data from
the original 1973 Moll and Wright paper. Please see the link for a comparison of more recent studies
Q-49
Which of the following findings is not typical in a patient with antiphospholipid syndrome?
A. Prolonged APTT
B. Thrombocytosis
C. Recurrent venous thrombosis
D. Recurrent arterial thrombosis
E. Livedo reticularis
ANSWER:
B. Thrombocytosis
EXPLANATION:
Antiphospholipid syndrome: arterial/venous thrombosis, miscarriage, livedo reticularis
Thrombocytopenia is associated with antiphospholipid syndrome
ANTIPHOSPHOLIPID SYNDROME
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and
arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or
secondary to other conditions, most commonly systemic lupus erythematosus (SLE)
A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in the
APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids
involved in the coagulation cascade
Features
 venous/arterial thrombosis
 recurrent fetal loss
 livedo reticularis
 thrombocytopenia
 prolonged APTT
 other features: pre-eclampsia, pulmonary hypertension
Associations other than SLE

 other autoimmune disorders
 lymphoproliferative disorders
 phenothiazines (rare)
Management - based on BCSH guidelines

 initial venous thromboembolic events: evidence currently supports use of warfarin with a target INR of
2-3 for 6 months
 recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then
increase target INR to 3-4
 arterial thrombosis should be treated with lifelong warfarin with target INR 2-3
Q-50
Angela is a 45-year-old woman who has suddenly developed pain in her fingers bilaterally when she goes
out in the cold. She has also noticed that they change colour from white to blue then red. She is otherwise
well in herself, her only past medical history being blepharitis. However, on further questioning she does
admit to experiencing some stiffness in her hands when she wakes up.
What is the best way to manage this patient?
A. Wear thick gloves when outdoors

C. Prescribe amlodipine
D. Prescribe a course of prednisolone
E. Refer to orthopaedics
ANSWER:
EXPLANATION:
All patients with suspected secondary Raynaud's phenomenon should be referred to secondary care
The patient is suffering from Raynaud's phenomenon and the fact that she has joint stiffness and dry eyes
make secondary Raynaud's phenomenon very likely. All patients with secondary Raynaud's should be
referred to secondary care (rheumatology not orthopaedics).
Symptomatic management of Raynaud's includes keeping the hands and feet warm. If lifestyle measures
fail then nifedipine (not amlodipine) can be trialled.
Prednisolone may be used to treat any underlying autoimmune disease.
RAYNAUD'S
Raynaud's phenomena may be primary (Raynaud's disease) or secondary (Raynaud's phenomenon)
Raynaud's disease typically presents in young women (e.g. 30 years old) with bilateral symptoms.
Factors suggesting underlying connective tissue disease

 onset after 40 years
 unilateral symptoms
 rashes
 presence of autoantibodies
 features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages
 digital ulcers, calcinosis
 very rarely: chilblains
Secondary causes
 connective tissue disorders: scleroderma (most common), rheumatoid arthritis, SLE
 leukaemia
 type I cryoglobulinaemia, cold agglutinins
 use of vibrating tools
 drugs: oral contraceptive pill, ergot
 cervical rib
Management
 all patients with suspected secondary Raynaud's phenomenon should be referred to secondary care
 first-line: calcium channel blockers e.g. nifedipine
 IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months
Q-51
A 56 year old gentleman is being treated as an inpatient for a duodenal ulcer. He notices that his first
metatarsophalangeal joint is severely inflamed on waking this morning. There is swelling and tenderness
of the joint, and fluid is sent for microscopy. He has a past medical history of hypertension. What is the
best initial medication to prescribe?
A. Diclofenac
B. Allopurinol
C. Cyclizine
D. Colchicine
E. Indomethacin
ANSWER:
D. Colchicine
EXPLANATION:
Diclofenac and indomethacin are contraindicated because of his duodenal ulcer. Colchicine is a suitable
alternative. Allopurinol should not be given in the acute phase, but is good for preventing recurrent
attacks.
Gout can be a precursor to conditions such as ischaemic heart disease and hypertension, which should be
investigated for.
Weight loss and alcohol avoidance should be encouraged in patients with gout.
The January 2016 AKT feedback report stated:
In AKT 26, candidates found a scenario difficult which involved a patient with acute gout, who was also on
a range of medication to treat long term conditions. In particular there was a lack of awareness of drug
interactions.

Q-52
During a routine medication review, you notice your patient, a 55 year-old female, has some skin changes.
There are purplish plaques on the knuckles of both hands, and the patient's eyelids also appear purple.
She has never suffered from skin problems in the past. What is the likely diagnosis?
A. Dermatomyositis
B. Tinea infection
C. Psoriasis
D. Systemic sclerosis
E. Contact dermatitis
ANSWER:
A. Dermatomyositis
EXPLANATION:
This is a description of the typical skin changes seen in dermatomyositis, a connective tissue disease. In
addition to the plaques on the knuckles (Gottron's papules) and eyelids (heliotrope rash) there may be
scaling of the scalp and changes to the nail beds and cuticles. There is inflammation of the proximal
muscles causing weakness, but the skin changes often are the first presenting feature. Dermatomyositis is
usually an autoimmune condition, in which case it is controlled with immunosuppressants, but may also be
a paraneoplastic syndrome.
Please see Q-41 for Dermatomyositis
Q-53
An 80-year-old woman is started on oral alendronate following a fractured neck of femur. How would you
explain how to take the tablet?
A. Take it on a full stomach to minimise gastric irritation and avoid lying down for 30 minutes afterwards
B. Dissolve tablet in water and take just before breakfast + sit-upright for 30 minutes following
C. Take during main evening meal + sit-upright for 2 hours following
D. Take at least 30 minutes before breakfast with plenty of water + sit-upright for 30 minutes following
E. Take at least 30 minutes after a main meal + sit-upright for 30 minutes following
ANSWER:
D. Take at least 30 minutes before breakfast with plenty of water + sit-upright for 30 minutes following
EXPLANATION:
Bisphosphonates can cause a variety of oesophageal problems
Q-54
Which one of the following is most likely to increase the risk of a patient developing an osteoporotic
fracture later in life?
A. Menopause at the age of 54 years

B. Obesity
C. Hypothyroidism
D. Ischaemic heart disease
E. Crohn's disease
ANSWER:
E. Crohn's disease
EXPLANATION:
Osteoporosis occurs in up to 30% of men and women with inflammatory bowel disease
Q-55
An 82-year-old woman comes to see you to discuss her recent blood results. She is due to attend hospital
the in a few weeks' time for a zoledronate infusion and has had bloods in preparation for this. She had her
first infusion a year previously after sustaining a fractured neck of femur. She originally tried oral
bisphosphonates but did not tolerate them due to gastrointestinal side effects. You note that she has not
been requesting her calcium/vitamin D supplements and she concedes that she has not been taking them.
Her blood results are shown below:
Na+ 140 mmol/L (135 - 145)

K+ 3.6 mmol/L (3.5 - 5.0)
Creatinine 76 µmol/L (55 - 120)
eGFR 67 ml/min/1.73m2
Corrected Calcium 2.2 mmol/L (2.1-2.6)
Vitamin D 9 nmol/L (>50)
A. Commence sando-K prior to the zoledronate infusion

B. No action needed, attend for the zoledronate infusion as planned
C. Advise her to restart her calcium/vitamin D supplements
D. Commence high dose vitamin D replacement prior to the zolendronate infusion
E. Check the patient's parathyroid hormone (PTH) prior to the zolendronate infusion
ANSWER:
D. Commence high dose vitamin D replacement prior to the zolendronate infusion
EXPLANATION:
Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates
It is important that a patient is calcium and vitamin D replete prior to being given bisphosphonates such as
zoledronate. Bisphosphonates act by inhibiting osteoclastic activity to in order to prevent osteoporosis.
Without the ability to release calcium from the bones the body becomes reliant on calcium absorbed from
the gut, if the patient is vitamin D deficient this cannot occur efficiently and hypocalcaemia is the result.
Zolendronate and denosumab in particular rapidly impede bone turnover so it is essential vitamin D and
calcium levels are corrected prior to administration.
There would be no need to supplement potassium.
Vitamin D/calcium supplements would need to be restarted however they would not not replace vitamin D
fast enough at this level of deficiency, hence high dose replacement is needed.
PTH measurement would be needed if there were unexplained hypocalcaemia however in this case
vitamin D deficiency is the most likely cause.
Q-56
A 25-year-old female presents with a swollen first finger and wrist pain associated with a 4 month history
of generalised fatigue. She has no other symptoms including no skin changes, and no previous medical
history. Her mother suffers from psoriasis. She had the following blood tests as part of her investigations.
Hb 125 g/l
Platelets 390 * 109/l
WBC 14.5 * 109/l
ESR 78 mm/h
Rheumatoid Factor Negative
Antinuclear Antibody Negative
A. Gout
B. Rheumatoid arthritis
C. Systemic lupus erythematosus (SLE)
D. Psoriatic arthritis
E. Osteoarthritis
ANSWER:
D. Psoriatic arthritis
EXPLANATION:
Whilst SLE and rheumatoid arthritis can affect females of this age group, the most likely option is psoriatic
arthritis as the patient has dactylitis and a first- degree relative with psoriasis. In addition, rheumatoid
factor and antinucleur antibody are often positive in rheumatoid arthritis, and antinucleur antibody is
predominantly positive in SLE.
Gout often affects the first metatarsophalangeal joint of the first toe.
Osteoarthritis is unlikely as the patient is young, has constitutional symptoms (fatigue), a raised ESR and
there is no mention of previous injury to the wrist or first finger.
Please see Q-48 for Psoriatic Arthropathy
Q-57
A 48-year-old patient presents with a very tender swollen red big right toe. It is very sensitive to the
touch. He does not have a fever and can move his toe in all directions (although this is painful). He also
suffers with chronic kidney disease and takes ramipril for his hypertension. He has had a previous
duodenal ulcer.
Which of the following medications is first-line management?
A. Colchicine
B. Indomethacin
C. Naproxen
D. Prednisolone
E. Tramadol
ANSWER:
A. Colchicine
EXPLANATION:
Gout is a painful condition resulting in a swollen red tender joint. Ideally indomethacin and prednisolone
should not be used because of the person's past medical history of a duodenal ulcer. Naproxen can also
exacerbate ulcer disease and worsen kidney function. Although tramadol is an analgesic, it is not very
specific to joint disease. Gout can respond well to treatment with colchicine and this medication can be
used in a person with the listed co-morbidities.
Q-58
How should folic acid be prescribed for patients taking methotrexate?
A. Folic acid 5 mg once daily except on methotrexate day

B. Folic acid 400 mcg once daily
C. Folic acid 5 mg once daily
D. Folic acid 5 mg once weekly at same time as methotrexate dose
E. Folic acid 5 mg once weekly at least 24 hours after methotrexate dose
ANSWER:
E. Folic acid 5 mg once weekly at least 24 hours after methotrexate dose
EXPLANATION:
NICE Clinical Knowledge Summaries state the following:
Methotrexate is usually prescribed as a once a week treatment. Folic acid is routinely co-prescribed with
methotrexate in order to reduce adverse effects and toxicity (folic acid is usually taken on a 'non-
methotrexate' day).
The BNF states:
Prevention of methotrexate-induced side-effects in rheumatic disease
For Adult
5 mg once weekly, dose to be taken on a different day to methotrexate dose.

Q-59
Which one of the following is most likely to indicate an underlying connective tissue disorder in a patient
with Raynaud's phenomenon?
A. Chilblains
B. Bilateral symptoms
C. Female patient
D. Onset at 18 years old
E. Recurrent miscarriages
ANSWER:
E. Recurrent miscarriages
EXPLANATION:
Raynaud's disease (i.e. primary) presents in young women with bilateral symptoms
A history of recurrent miscarriages could indicate systemic lupus erythematous or anti-phospholipid

syndrome. Chilblains (pernio) are itchy, painful purple swellings which occur on the fingers and toes after
exposure to the cold. They are occasionally associated with underlying connective tissue disease but this is
rare
Please see Q-50 for Raynaud’s
Q-60
A 54-year-old man is diagnosed as having gout. You are discussing ways to help prevent future attacks.
Which one of the following is most likely to precipitate an attack of gout?
A. Chocolate
B. Brazil nuts
C. Eggs
D. Sardines
E. Smoking
ANSWER:
D. Sardines
EXPLANATION:
Foods to avoid include those high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and
yeast products
Q-61
A 62-year-old man presents to his GP with hip pain, The pain started about a week ago when he bent over
to pick up one of his nephew's toys. Which of the following may indicate that his hip pain is in fact
referred from his lumbar spine?
A. A positive femoral nerve stretch test
B. A negative femoral nerve stretch test
C. A positive obturator nerve stretch test
D. A negative obturator nerve stretch test
E. A negative sciatic nerve stretch test
ANSWER:
A. A positive femoral nerve stretch test
EXPLANATION:
A positive femoral nerve stretch test may indicate referred lumbar spine pain as a cause of hip pain
This question is asking about signs that may be present in referred lumbar spine pain. If this mans pain is
referred you may find a positive femoral nerve stretch test. This is due to the fact his pain may be caused
by compression of the femoral nerve and thus stretching this nerve will recreate his pain.
Please see Q-18 for Hip Pain in Adults
Q-62
A 54-year-old gentleman with a background of chronic obstructive pulmonary disease (COPD), ulcerative
colitis, hypertension and hypothyroidism attended your surgery for review. He has recently been
discharged from hospital following an episode of pneumonia. From the discharge letter, you note that he
developed an allergic reaction to co-trimoxazole during this admission. One of his regular medication was
stopped as a consequence of this drug allergy and he has been advised to see the GP regarding this.
Which of the following medication was it likely to be?
A. Levothyroxine
B. Lisinopril
C. Sulfasalazine
D. Simvastatin
E. Azathioprine
ANSWER:
C. Sulfasalazine
EXPLANATION:
Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take sulfasalazine
Sulfasalazine is the correct answer. It is a sulfa drug and should be stopped in patients with a documented
allergy to other sulfa drug, in this case, it is co-trimoxazole.
Please see Q-3 for Sulfasalazine
Q-63
A 56-year-old woman who has history of type 2 diabetes mellitus complains of painful and stiff hands:
A. Psoriatic arthropathy
B. Osteoarthritis
C. Gout
E. Medication-related dependent oedema
ANSWER:
A. Psoriatic arthropathy
EXPLANATION:
The image clearly shows nail changes which suggests a diagnosis of psoriatic arthritis.
Q-64
A 63-year-old woman is diagnosed with osteoporosis after sustaining a Colles' fracture. Following National
Osteoporosis Guideline Group (NOGG) guidelines what is the minimum set of blood tests that should be
ordered as part of the work up?
A. FBC, U&E, LFTs, bone profile, CRP, TFTs

B. Immunoelectrophoresis, bone profile, ESR, testosterone
C. FBC, HbA1c, vitamin D, parathyroid hormone, bone profile
D. Immunoelectrophoresis, bone profile, ESR, CRP, TFTs
E. Vitamin D, parathyroid hormone, bone profile, CRP, TFTs
ANSWER:
A. FBC, U&E, LFTs, bone profile, CRP, TFTs
EXPLANATION:
Q-65
A 19 year old vegan patient attends because she is 8 weeks pregnant. Her past medical history includes
anxiety and febrile seizures. She takes no regular medications. She would like to know if she should take
any vitamin supplements. Which of the following is the best recommendation?
A. Folic acid 5mg

B. Vitamin D 10mcg and Folic acid 5mg
C. Vitamin D 10mcg and Folic acid 400mcg
D. Folic acid 400mcg
E. No vitamin supplements needed
ANSWER:
C. Vitamin D 10mcg and Folic acid 400mcg
EXPLANATION:
10mcg vitamin D is now recommended throughout pregnancy for all women.
Low dose folic acid is recommended for all women for the first 12 weeks of pregnancy. Women with
pregnancies at risk of neural tube defects should take 5mg folic acid for the first 12 weeks of pregnancy.
Pregnancies at high risk of neural tube defects are those in which either partner has a neural tube defect
(or either partner has a family history of neural tube defects), if they have had a previous pregnancy
affected by a neural tube defect, or if the woman has coeliac disease (or other condition causing
malabsorption), diabetes mellitus, sickle-cell anaemia, or is taking antiepileptic medicines.
http://www.nice.org.uk/guidance/ph56/chapter/1-recommendations
https://www.medicinescomplete.com/mc/ [BNF]
Q-66
A 34-year-old man presents with multiple swollen MCP joints, a swollen left wrist, and a swollen right
knee. Anti CCP is positive and you suspect rheumatoid arthritis and refer him to rheumatology. Which
medication(s) is he likely to be started on initially?
A. Prednisolone monotherapy
B. Methotrexate + sulfasalazine monotherapy
C. Adalimumab monotherapy
D. Prednisolone, methotrexate and hydroxychloroquine
E. Prednisolone and methotrexate
ANSWER:
E. Prednisolone and methotrexate
EXPLANATION:
In 2018 NICE updated their rheumatoid arthritis guidelines. They now recommend disease-modifying
antirheumatic drug (DMARD) monotherapy with a short-course of bridging prednisolone. In the past dual
DMARD therapy was advocated as the initial step.
Q-67
Jean is a 55-year-old lady who has Crohn's disease and you have organised for a routine DEXA scan. The
DEXA results are as follows:
Spine (L2-4) T: -2.6 Z: -1.7

Left femur T: -1.5 Z: -0.9
Right femur T: -2.3 Z: -1.5
How would you interpret this result?
A. Osteoporosis of the spine Osteopenia of the left and right femur

B. Osteopenia of spine, left and right femur
C. Osteopenia of the spine and right femur Normal left femur
D. Osteoporosis of the spine, left and right femur
E. Osteoporosis of the spine Normal left and right femur
ANSWER:
A. Osteoporosis of the spine Osteopenia of the left and right femur
EXPLANATION:
The DEXA scan results indicate osteoporosis of the spine as the T-score is <-2.5, with osteopenia of the left
and right femur (T-score between -1 and -2.5).
Osteoporosis is defined as a T score < -2.5. Osteopenia is defined as a T score of between -1 and -2.5.
Normal bone density is defined as more than -1. The z score is corrected for age, gender and ethnic factors,
however the T score is used in the diagnosis of osteoporosis and osteopenia.
Therefore the correct option is 1.
AKT report Jan 2014 - 'Questions on osteoporosis, in particular relating to DEXA scans, were not well
answered. This is an increasingly important clinical area and GPs should be able to interpret DEXA scans
and act appropriately on the results'
OSTEOPOROSIS: DEXA SCAN
Basics
 T score: based on bone mass of young reference population
 T score of -1.0 means bone mass of one standard deviation below that of young reference population
 Z score is adjusted for age, gender and ethnic factors
T score
 > -1.0 = normal
 -1.0 to -2.5 = osteopaenia
 < -2.5 = osteoporosis
Q-68
Which of the following skin disorders is most associated with antiphospholipid syndrome?
A. Lichen sclerosis
B. Lichen planus
C. Livedo reticularis
D. Lupus vulgaris
E. Psoriasis
ANSWER:
C. Livedo reticularis
EXPLANATION:
Antiphospholipid syndrome: arterial/venous thrombosis, miscarriage, livedo reticularis
Livedo reticularis is the skin rash most commonly associated with antiphospholipid syndrome. Lupus
vulgaris is seen in tuberculosis
Please see Q-49 for Antiphospholipid Syndrome
Q-69
A 58-year-old woman complains of aches and pains in her bones. Her family have noticed she is generally
weak and lethargic. A series of blood tests are requested:
Calcium 2.04 mmol/l

Albumin 39 g/l
Alkaline phosphatase 271 U/l
Vitamin D3 15 nmol/l (75-200 nmol/l)
Parathyroid hormone 10.8 pmol/l (0.8 - 8.5 pmol/l)
A. Arrange a liver ultrasound

B. Refer for a technetium-MIBI subtraction scan
C. Arrange a DEXA scan
D. Arrange serum electrophoresis and a skeletal survery
E. Start vitamin D3 supplementation
ANSWER:
E. Start vitamin D3 supplementation
EXPLANATION:
The low calcium, phosphate and vitamin D levels combined with a raised alkaline phosphatase and
parathyroid hormone level is entirely consistent with osteomalacia, or vitamin D deficiency. The treatment
of choice is therefore vitamin D3 supplementation.
Remember blood values are normal in osteoporosis. Myeloma ('Arrange serum electrophoresis and a
skeletal survery') and primary hyperparathyroidism ('Refer for a technetium-MIBI subtraction scan') are
associated with hyper- rather than hypocalcaemia.
OSTEOMALACIA
Basics
 normal bony tissue but decreased mineral content
 rickets if when growing
 osteomalacia if after epiphysis fusion
Types
 vitamin D deficiency e.g. malabsorption, lack of sunlight, diet
 renal failure
 drug induced e.g. anticonvulsants
 vitamin D resistant; inherited
 liver disease, e.g. cirrhosis
Features
 rickets: knock-knee, bow leg, features of hypocalcaemia
 osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy
Investigation
 low 25(OH) vitamin D (in 100% of patients, by definition)
 raised alkaline phosphatase (in 95-100% of patients)
 low calcium, phosphate (in around 30%)
 x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or
pseudofractures)
Treatment
 calcium with vitamin D tablets
Q-70
A 77-year-old woman is reviewed in surgery. She has a history of vertebral fractures secondary to
osteoporosis. Unfortunately she is intolerant of bisphosphonates and her consultant has therefore started
raloxifene. Which one of the following would be a contraindication for the prescription of raloxifene?
A. A history of venous thromboembolism

B. A history of cervical cancer
C. Depression
D. Ischaemic heart disease
E. Epilepsy
ANSWER:
A. A history of venous thromboembolism
EXPLANATION:
Raloxifene increases the risk of venous thromboembolism
OSTEOPOROSIS: THERAPEUTIC MANAGEMENT

The 2008 NICE guidelines probably provide the most comprehensive guidance on the use of specific
therapies for osteoporosis.
The recommend first-line treatment is oral alendronate. This is usually taken once weekly at a dose of 70mg.
It is tolerated in around 75% of patients.
If oral alendronate is not tolerated NICE recommend the use of risk tables to see whether it is 'worth' trying
another treatment. The tables display a minimum T score based on a patients age and number of clinical risk
factors.
These are not reproduced here but may be found in the links section.
Clearly a degree of clinical judgement may be required when determining the best course of action,
particularly as the guidelines were released in 2008.
Assuming that it is thought appropriate to try another treatment alternative oral bisphosphonates (either
risedronate or etidronate) are recommended as the second-line treatment. NICE recommend that
risedronate and etidronate are suitable for both the primary and secondary prevention of fragility fractures.
What does NICE recommend if bisphosphonates are not tolerated?
Again NICE recommend that we review some risk tables based on minimum T scores to see if further
treatment is indicated. If it is then strontium ranelate or raloxifene are recommended.
Strontium ranelate
 'dual action bone agent' - increases deposition of new bone by osteoblasts (promotes differentiation of
pre-osteoblast to osteoblast) and reduces the resorption of bone by inhibiting osteoclasts
 concerns regarding the safety profile of strontium have been raised recently. It should only be prescribed
by a specialist in secondary care
 due to these concerns the European Medicines Agency in 2014 said it should only be used by people for
whom there are no other treatments for osteoporosis
 increased risk of cardiovascular events: any history of cardiovascular disease or significant risk of
cardiovascular disease is a contraindication
 increased risk of thromboembolic events: a Drug Safety Update in 2012 recommended it is not used in
patients with a history of venous thromboembolism
 may cause serious skin reactions such as Stevens Johnson syndrome
Raloxifene - selective oestrogen receptor modulator (SERM)

 has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been
shown to reduce the risk of non-vertebral fractures
 has been shown to increase bone density in the spine and proximal femur
 may worsen menopausal symptoms
 increased risk of thromboembolic events
 may decrease risk of breast cancer
Q-71
A 45-year-old woman attends for review complaining of pain in her hands. This has gradually got worse
over the past eight weeks. She works as a hairdresser but is finding it increasingly difficult to use scissors
at work.
She has significant stiffness in her in the morning lasting for around 60 minutes. She has no other medical
conditions and takes no regular medications.
On examination, she has boggy swelling and erythema at four of her proximal interphalangeal (PIP) joints
in both hands. She is apyrexial.
Given the likely underlying diagnosis, what is the next most appropriate action?
A. Urgent referral to secondary care for rheumatology review

B. Commence prednisolone treatment
C. Routine referral to secondary care for rheumatology review
D. Arrange x-rays of both hands
E. Await blood tests for rheumatoid factor (RF) and erythrocyte sedimentation rate (ESR)
ANSWER:
EXPLANATION:
Any patient presenting with new synovitis should be referred urgently to rheumatology
The history and examination findings are consistent with a diagnosis of new synovitis, with rheumatoid
arthritis as a potential underlying cause.
Guidance dictates we should refer people with persistent synovitis with an unknown cause to a
rheumatologist or an appointment (within 3 weeks of referral) for specialist assessment.
We should refer urgently, within 3 working days of presentation (even with a normal acute-phase
response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if there are any
of the following: small joints of the hands or feet are affected, more than one joint is affected or if there
has been a delay of 3 months or longer between the onset of symptoms and the person seeking medical
advice.
Prednisolone should not be commenced prior to diagnosis in primary care.
A routine referral is not appropriate as outlined previously.
Although x-rays may show features consistent with rheumatoid arthritis, referral should not be delayed on
waiting for results of these.
Blood tests are advantageous but awaiting results or indeed, negative results in the presence of clinical
synovitis should not delay referral to secondary care.
RHEUMATOID ARTHRITIS: DIAGNOSIS

NICE have stated that clinical diagnosis is more important than criteria such as those defined by the
American College of Rheumatology.
2010 American College of Rheumatology criteria
Target population. Patients who

1) have at least 1 joint with definite clinical synovitis
2) with the synovitis not better explained by another disease
Classification criteria for rheumatoid arthritis (add score of categories A-D;

a score of 6/10 is needed definite rheumatoid arthritis)
Key
 RF = rheumatoid factor
 ACPA = anti-cyclic citrullinated peptide antibody
Factor Scoring
A. Joint involvement
1 large joint 0
2 - 10 large joints 1
1 - 3 small joints (with or without involvement of large 2
joints)
4 - 10 small joints (with or without involvement of large 3
joints)
10 joints (at least 1 small joint) 5
B. Serology (at least 1 test result is
needed for classification)
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
C. Acute-phase reactants (at least 1
test result is needed for classification)
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
D. Duration of symptoms
< 6 weeks 0
> 6 weeks 1
Q-72
A 77-year-old lady presents to your clinic reporting that she would like to receive the shingles vaccine. She
is due to turn 78 in 2 months and is wondering if she has missed the boat, as her friend had the vaccine
after turning 70. Her past medical history includes hypertension, hyperthyroidism and rheumatoid
arthritis. She also had one episode of shingles when she was 55 and had chickenpox as a young girl. Her
current medications include amlodipine 5mg, levothyroxine 75 micrograms and rituximab, which is
administered for her at the local hospital.
A. Advise she cannot have the vaccine anymore as she is only eligible from the ages of 70-75
B. Advise that she can have the vaccine once she turns 80
C. Advise there is no benefit to her having the vaccination as she has had shingles previously
D. Advise she should be immune if she has already had shingles previously
E. Advise that she cannot have the shingles vaccine at the moment due to the current medication she is
on
ANSWER:
E. Advise that she cannot have the shingles vaccine at the moment due to the current medication she is on
EXPLANATION:
Patients on biological DMARDS should NOT receive live vaccines
This lady is on a biological disease-modifying antirheumatic drug and, as a result, is immunosuppressed.

Any kind of live vaccine is therefore contraindicated.
The shingles vaccine is a live vaccine that is available on the NHS to people in their 70s. It does not matter
if they have had chickenpox or shingles before, as having the vaccine reduces the risk of future
occurrences.
The vaccine does not work as well in people over the age of 80, therefore it is only available to people who
are in their 70s, born after 1st September 1942.
Having shingles previously does not result in immunity to future episodes.
Q-73
A 29-year-old woman who has just been diagnosed with rheumatoid arthritis presents for review. Her
rheumatologist has started methotrexate to help control her symptoms. She currently has no children but
is planning to start a family in the next two years. What is the BNF advice regarding methotrexate and
pregnancy?
A. She can conceive on methotrexate but should be on a folic acid dose of 5mg, rather than 400mcg/day
B. She can conceive as soon as methotrexate is stopped
C. She should wait at least 3 months after stopping methotrexate before trying to conceive
D. She should wait at least 6 months after stopping methotrexate before trying to conceive
E. She should wait at least 12 months after stopping methotrexate before trying to conceive
ANSWER:
D. She should wait at least 6 months after stopping methotrexate before trying to conceive
EXPLANATION:
Patients using methotrexate require effective contraception during and for at least 6 months after
treatment in men or women
Q-74
A 68-year-old female presents to her GP with a two week history of intermittent headaches and lethargy.
Blood tests reveal the following:
ESR 67 mm/hr
A. Polymyalgia rheumatica
B. Cluster headaches
C. Polyarteritis nodosa
D. Migraine
ANSWER:
EXPLANATION:
This is a classic history of temporal arteritis. Treatment should be started immediately with high dose
steroids (e.g. prednisolone 1mg/kg/day) to reduce the chance of visual loss
Q-75-77
Theme: Rheumatoid arthritis: drug side-effects
A. Methotrexate
B. Gold
C. Etanercept
D. Azathioprine
E. Prednisolone
F. Ciclosporin
G. Sulfasalazine
H. Hydroxychloroquine
For each one of the following side effects please select the drug that is most characteristically associated
with it. Each options may be used once, more than once or not at all.
Q-75
Retinopathy
ANSWER:
Q-76
Demyelination
ANSWER:
C. Etanercept
Q-75-77
Pneumonitis
ANSWER:
A. Methotrexate
EXPLANATION:
RHEUMATOID ARTHRITIS: DRUG SIDE-EFFECTS
The table below lists some of the characteristic (if not common) side-effects of drugs used to treat
rheumatoid arthritis:
Drug Side-effects
Methotrexate Myelosuppression
Liver cirrhosis
Pneumonitis
Sulfasalazine Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease
Leflunomide Liver impairment
Hypertension
Hydroxychloroquine Retinopathy
Corneal deposits
Prednisolone Cushingoid features
Osteoporosis
Impaired glucose tolerance
Hypertension
Cataracts
Gold Proteinuria
Penicillamine Proteinuria
Exacerbation of myasthenia gravis
Drug Side-effects
Etanercept Demyelination
Reactivation of tuberculosis
Infliximab Reactivation of tuberculosis
Adalimumab Reactivation of tuberculosis
Rituximab Infusion reactions are common
NSAIDs (e.g. naproxen, ibuprofen) Bronchospasm in asthmatics
Dyspepsia/peptic ulceration
Q-78
Which one of the following patients should have their vitamin D status checked?
A. A patient with newly diagnosed osteoporosis who is about to start oral alendronate
B. A patient who has been found to be hypercalcaemic
C. An immigrant from South-East Asia who is 70-years-old
D. A patient with newly diagnosed Paget's disease
E. A woman who 10-weeks pregnant
ANSWER:
D. A patient with newly diagnosed Paget's disease
EXPLANATION Q-78:
Q-79
A 47-year-old female presents to her GP concerned about elbow pain. She has just spent the weekend
painting the house. On examination there is localised pain around the lateral epicondyle and a diagnosis
of lateral epicondylitis is suspected. Which one of the following movements would characteristically
worsen the pain?
A. Resisted thumb flexion

B. Thumb extension
C. Flexion of the elbow
D. Pronation of the forearm with the elbow flexed
E. Resisted wrist extension with the elbow extended
ANSWER:
E. Resisted wrist extension with the elbow extended
EXPLANATION:
Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow extended
LATERAL EPICONDYLITIS
Lateral epicondylitis typically follows unaccustomed activity such as house painting or playing tennis ('tennis
elbow'). It is most common in people aged 45-55 years and typically affects the dominant arm.
Features
 pain and tenderness localised to the lateral epicondyle
 pain worse on wrist extension against resistance with the elbow extended or supination of the forearm
with the elbow extended
 episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
Management options
 advice on avoiding muscle overload
 simple analgesia
 physiotherapy
Q-80
A 55-year-old man presents with pain and stiffness in his hands. This has been getting gradually worse
over the past few months and is associated with stiffness in the mornings.
On examination, you note bilateral swelling of the metacarpal phalangeal (MCP) and distal
interphalangeal (DIP). One of the digits is swollen along the whole length.
A. Osteoarthritis
D. Gout
E. Reactive arthritis
ANSWER:
EXPLANATION:
Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of psoriatic arthritis
The morning stiffness points to an inflammatory arthritis such as rheumatoid or psoriatic. However, DIP
and dactylitis are much more common in psoriatic arthritis, making this the most likely diagnosis.
Q-81
You make a routine home visit to Mrs Stark, an 84-year-old lady who finds it hard to get down to the
surgery. She is due her ischaemic heart disease check-up so you ask abut her symptoms and examine the
cardiovascular system. She gets short of breath on exertion and has osteoarthritis of the hips so she is
mainly housebound now. Her medication review is also due so you go through the list together. It includes
aspirin, clopidogrel, atorvastatin, ramipril, bisoprolol, furosemide, paracetamol and GTN spray.
What other item does Public Health England recommend she have?
A. Ezetimibe
B. Calcium and vitamin D
C. Shingles vaccination
D. Vitamin D
E. Compression hosiery
ANSWER:
D. Vitamin D
EXPLANATION:
Consider daily vitamin D supplements in all housebound patients
Ezetimibe. Incorrect answer, this is a lipid modifying drug but is not indicated from the history above.
Calcium and vitamin D. Incorrect answer, this would be considered if she were being treated for
osteoporosis.
Shingles vaccination. Incorrect answer, this is not offered to patients over 80 on the NHS due to reduced
efficacy in this age group.
Vitamin D. Correct answer, 10mcg (400iU) daily is advised for all housebound/care home patients, or
patients who cover most of their skin when outside.
Compression hosiery. Incorrect answer, there is no indication in the history above (and applying
compression hosiery in heart failure can increase preload on the heart so must be carefully considered).
Q-82
Each of the following features is seen in Marfan's syndrome, except:
A. Pectus excavatum
B. Tall stature
C. Learning difficulties
D. High-arched palate
E. Upwards lens dislocation
ANSWER:
C. Learning difficulties
EXPLANATION:
Q-83
A 58-year-old presents with a painful swollen left knee which has failed to settle after a weeks rest. There
is no history of trauma. On examination he has a moderate sized effusion. A plain radiograph is reported
as follows:
Some loss of joint space
Linear calcification of the articular cartilage
A. Pseudogout
C. Sarcoidosis
D. Gout
E. Osteoarthritis
ANSWER:
A. Pseudogout
EXPLANATION:
Chondrocalcinosis helps to distinguish pseudogout from gout
This x-ray describes chondrocalcinosis. Non-specific changes such as loss of joint space are common in this
age group and pseudogout itself may cause osteoarthritic-like changes.
PSEUDOGOUT
Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate
crystals in the synovium.
Risk factors
 haemochromatosis
 hyperparathyroidism
 acromegaly
 low magnesium, low phosphate
 Wilson's disease
Features
 knee, wrist and shoulders most commonly affected
 joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
 x-ray: chondrocalcinosis
o in the knee this can be seen as linear calcifications of the meniscus and articular cartilage
Management
 aspiration of joint fluid, to exclude septic arthritis
 NSAIDs or intra-articular, intra-muscular or oral steroids as for gout
Q-84
A 24-year-old nulliparous female with a history of recurrent deep vein thrombosis presents with shortness
of breath. The full blood count and clotting screen reveals the following results:
Hb 12.4 g/dl
Plt 137
WBC 7.5 * 109/l
PT 14 secs
APTT 46 secs
What is the most likely underlying diagnosis?
A. Third generation oral contraceptive pill use

B. Protein C deficiency
C. Antithrombin III deficiency
D. Antiphospholipid syndrome
E. Activated protein C resistance
ANSWER:
D. Antiphospholipid syndrome
EXPLANATION:
Antiphospholipid syndrome: (paradoxically) prolonged APTT + low platelets
The combination of a prolonged APTT and thrombocytopenia make antiphospholipid syndrome the most
likely diagnosis
Q-85
A 68-year-old Asian women comes for advice. She is concerned about vitamin D deficiency after reading
an article in the newspaper. She is generally fit and well and specifically does not have any muscle/bone
pain or weakness. Her only past medical history of note is hypertension and spinal stenosis. She does not
cover her head for cultural reasons. What is the most appropriate advice to give?
A. Without any symptoms of osteomalacia no further action is required

B. She should take vitamin D 10mcg od
C. She should complete a food diary and come back in 2 weeks time for review
D. A vitamin D test should be done
E. A DEXA scan should be arranged
ANSWER:
B. She should take vitamin D 10mcg od
EXPLANATION:
People who are at higher risk of vitamin D deficiency (in this scenario age > 65 years, pigmented skin)
should be treated anyway so testing is not necessary.

Q-86
A 62-year-old woman presents to the surgery following a Colles fracture which she had following a
mechanical fall from standing height whilst on holiday in Spain. She was seen by the fracture clinic who
diagnosed a fragility fracture and recommended that she sees her GP back in the UK to discuss bone
protection. She is a non-smoker, not on hormone replacement therapy and there is no significant family
history of hip fracture or osteoporosis. She does not drink alcohol. Her body mass index is 23 kg/m2. She
has no other significant medical conditions.
What is the next most appropriate management step?
A. Arrange a dual-energy X-ray absorptiometry (DEXA) scan

B. Calculate her FRAX score then arrange a dual-energy X-ray absorptiometry (DEXA) scan depending on
results
C. Calculate her QFracture score then arrange a dual-energy X-ray absorptiometry (DEXA) scan depending
on results
D. Reassure her that the risk of osteoporosis is low and commence vitamin d and calcium supplements
only
E. Commence her on a bisphosphonate, vitamin d and calcium supplement immediately
ANSWER:
A. Arrange a dual-energy X-ray absorptiometry (DEXA) scan
EXPLANATION:
According to current NICE guidance, a patient over 50-years old with a previous fragility fracture should be
referred for DEXA
According to current NICE CKS guidance, a dual-energy X-ray absorptiometry (DEXA) scan to measure bone
mineral density (BMD) should be offered to all patients over 50 years of age with a history of fragility
fracture without calculating the fragility fracture risk in people first. This is based on a meta-analysis of 11
cohort studies (n = 60,161) which found that in this group, previous fragility fracture was associated with
an increased risk of any future fracture.
There is no need to calculate her QFracture risk or FRAX score before arranging a DEXA scan according to
current NICE guidance. Indeed her QFracture risk would put her within the low risk bracket. The FRAX
score in this instance would suggest arranging a DEXA scan, but in other cases may be more borderline
without BMD results.
It is not appropriate to reassure her that her risk of osteoporosis is low, as she is at risk given her history of
fragility fracture.
Patients who have had a fragility fracture and are over 75 years of age are presumed to have underlying
osteoporosis and should be started on treatment immediately (oral bisphosphonates first line) without the
need for a DEXA scan. Note, this is different to the NOGG guidelines 2014, which suggests treatment in all
women over 50 years who've had a fragility fracture.
Please see Q-4 for Osteoporosis: Assessing Patients Following a Fragility Fracture
Q-87-89
Theme: Hip pain in adults
A. Inflammatory arthritis
B. Trochanteric bursitis
C. Pubic symphysis dysfunction
D. Osteoarthritis
F. Avascular necrosis
G. Transient idiopathic osteoporosis
H. Referred lumbar spine pain
I. Perthes' disease
J. Slipped upper femoral epiphysis
Q-87
A 62-year-old man complains of pain in his right hip which is worse when he walks. Heberden's nodes are
noted on examination of the distal interphalangeal joints
ANSWER:
D. Osteoarthritis
Q-88
A 34-year-old man with a history of ulcerative colitis complains of pain and stiffness in his left hip which is
worse in the mornings
ANSWER:
Q-89
A 29-year-old man who is a keen jogger complains of pain on the lateral aspect of his left hip. On
examination there is a full range of movement but tenderness is noted on the anterolateral aspect of the
joint
ANSWER:
EXPLANATION:
Q-90
A 36-year-old former intravenous drug user is to commence treatment for hepatitis C with interferon-
alpha and ribavirin. Which of the following adverse effects are most likely to occur when patients are
treated with interferon-alpha?
A. Diarrhoea and transient rise in ALT
B. Cough and haemolytic anaemia
C. Flu-like symptoms and transient rise in ALT
D. Haemolytic anaemia and flu-like symptoms
E. Depression and flu-like symptoms
ANSWER:
E. Depression and flu-like symptoms
EXPLANATION:
INTERFERON
Interferons (IFN) are cytokines released by the body in response to viral infections and neoplasia. They are
classified according to cellular origin and the type of receptor they bind to. IFN-alpha and IFN-beta bind to
type 1 receptors whilst IFN-gamma binds only to type 2 receptors.
Interferon-alpha
 produced by leucocytes
 antiviral action
 useful in hepatitis B & C, Kaposi's sarcoma, metastatic renal cell cancer, hairy cell leukaemia
 adverse effects include flu-like symptoms and depression
Interferon-beta
 produced by fibroblasts
 antiviral action
 reduces the frequency of exacerbations in patients with relapsing-remitting MS
Interferon-gamma
 predominately natural killer cells. Also by T helper cells
 weaker antiviral action, more of a role in immunomodulation particularly macrophage activation
 may be useful in chronic granulomatous disease and osteopetrosis
Q-91
You are reviewing a 63-year-old woman who is being treated for polymyalgia rheumatica. She has been on
a slowly reducing course of prednisolone for the last 2 months. She is currently on 30mg prednisolone
daily, with a plan to reduce by 5mg every week. Her symptoms are currently controlled, but she has been
worried about osteoporosis, and asks whether she should be on any treatment for this. She has no history
of fractures and no other risk factors for osteoporosis.
What is the most appropriate advice to give?
A. Advise no action needed as will be finishing the course soon

B. Advise she should decrease and stop the prednisolone as soon as possible
C. Advise to increase dietary calcium intake only
D. Advise to commence vitamin D supplementation only
E. Calculate the 10 year fragility fracture risk score to guide further investigation and treatment
ANSWER:
E. Calculate the 10 year fragility fracture risk score to guide further investigation and treatment
EXPLANATION:
Consider the risk of osteoporosis and need for bone protection in patients taking the equivalent of 7.5mg
prednisolone daily for 3 months or more
This patient has already been on more than 30mg prednisolone for the last 2 months, and will remain on
treatment for at least the next 6 weeks, therefore she is at risk of osteoporosis and this needs to be
assessed with the 10 year fragility fracture risk score, therefore option 1 is incorrect and option 5 is
correct.
It would be dangerous to rapidly decrease and stop the prednisolone, therefore option 2 is incorrect.
Adequate calcium and vitamin D intake is important, however this patient needs full risk assessment and
consideration of bisphosphonate therapy while she is still on steroids, therefore options 3 and 4 are
incorrect.
Please see Q-14 for Osteoporosis: Glucocorticoid-Induced
Q-92
You receive the results of a DEXA scan you requested for Mrs Wallace, a 62-year-old teacher, which
reports bone density in the osteoporotic range. You had recommended the investigation after she broke
her wrist in a fall from standing in the icy school playground. You arrange a telephone consultation to
discuss the results and give her some lifestyle advice on bone health. You discuss weight bearing exercise
and diet. You assess her dietary calcium intake is good, as she says she has always made sure she ate milk
products like yoghurt daily because her mum had broken her hip so she had hoped by doing this she
would have avoided osteoporosis. You discuss starting a bisphosphonate, and she is happy to commence
alendronate 70mg weekly.
What other medication(s) should you consider prescribing Mrs Wallace?
A. Vitamin D
B. Naproxen
C. Calcium with vitamin D (combined)
D. Hormone replacement therapy (HRT)
E. Glucosamine
ANSWER:
A. Vitamin D
EXPLANATION:
When starting bisphosphonate treatment for osteoporosis, calcium should only be prescribed if dietary
intake is inadequate
Vitamin D: Correct answer, NICE advises consider if vitamin D intake is likely to be adequate when starting
bisphosphonate and prescribe if not. Given that is is also advised that most adults in the UK probably don't
get enough vitamin D over autumn and winter, most prescribers will start vitamin D supplementation
alongside bisphosphonates.
Naproxen: Incorrect answer, this might be used for treating osteoarthritis, not for osteoporosis.
Calcium with vitamin D (combined): Incorrect answer, due to a link between calcium supplementation and
increased cardiovascular risk, NICE advises dietary calcium intake should be assessed, and only prescribed
if inadequate. It is advised calcium with vitamin D is prescribed for elderly housebound or nursing home
patients.
Hormone replacement therapy (HRT): Incorrect answer, although bone density does decline after the
menopause, osteoporosis is not an indication for HRT. HRT should be considered to prevent osteoporosis in
patients with premature menopause.
Glucosamine: Incorrect answer, this is a supplement some people use for osteoarthritis (evidence lacking).
Q-93
A 79-year-old woman is diagnosed as having osteoporosis after sustaining a Colle's fracture. Which one of
her following medications is most likely to have contributed to her osteoporosis?
A. Indapamide
B. Lansoprazole
C. Gliclazide
D. Sitagliptin
E. Naproxen
ANSWER:
B. Lansoprazole
EXPLANATION:
Long-term use of proton pump inhibitors is associated with reduced bone mineral density

Q-94
Mrs Salsi, a 22-year-old lady presents to her GP due to abdominal pain and changes to her bowel habits.
She has been experiencing loose stool, sometimes with a teaspoon volume of blood. She also has lower
abdominal cramps and experiences urgency. She does not report any joint pains but has previously
noticed a red eye. Her mother suffers from rheumatoid arthritis.
She has had a rheumatological screen which comes back positive for pANCA. No other antibodies returned
above normal levels.
Which condition is most likely responsible for this result?
A. Ulcerative colitis
B. Churg-Strauss syndrome
C. Microscopic polyangiitis
D. Granulomatosis with polyangiitis
ANSWER:
A. Ulcerative colitis
EXPLANATION:
ANCA is not specific to vasculitis. Some inflammatory conditions can cause positive ANCA (usually pANCA)
This patient has presented with symptoms typical of ulcerative colitis which can cause a raised ANCA
(typically pANCA).
Whilst microscopic polyangiitis can also cause raised pANCA, microscopic polyangiitis usually affects
middle aged people and would usually present as tiredness, loss of appetite and joint and muscle aches.
Whilst it can present local to one body system, this is certainly not the usual manner of presentation.
Churg-Strauss syndrome can also present with raised pANCA however this condition usually presents as
respiratory symptoms and the above symptoms are certainly not typical of Churg-Strauss.
Rheumatoid arthritis can also cause a raised pANCA, however the patient does not report any symptoms
consistent with rheumatoid arthritis.
Granulomatosis with polyangiitis more commonly presents with positive cANCA, but can present with
positive pANCA. It is also more common in middle aged/older patients and usually affects the ears, nose,
sinuses, kidneys and lungs.
ANCA
There are two main types of anti-neutrophil cytoplasmic antibodies (ANCA) - cytoplasmic (cANCA) and
perinuclear (pANCA)
For the exam, remember:

 cANCA - granulomatosis with polyangiitis (Wegener's granulomatosis)
 pANCA - Churg-Strauss syndrome + others (see below)
cANCA
 most common target serine proteinase 3 (PR3)
 some correlation between cANCA levels and disease activity
 granulomatosis with polyangiitis, positive in > 90%
 microscopic polyangiitis, positive in 40%
pANCA
 most common target is myeloperoxidase (MPO)
 cannot use level of pANCA to monitor disease activity
 associated with immune crescentic glomerulonephritis (positive in c. 80% of patients)
 microscopic polyangiitis, positive in 50-75%
 Churg-Strauss syndrome, positive in 60%
 primary sclerosing cholangitis, positive in 60-80%
 granulomatosis with polyangiitis, positive in 25%
Other causes of positive ANCA (usually pANCA)
 inflammatory bowel disease (UC > Crohn's)
 connective tissue disorders: RA, SLE, Sjogren's
 autoimmune hepatitis
Q-95
This patient is known to suffer from Raynaud's phenomenon:
What does the lesion on her thumb most likely represent?
A. Arterial ulcer
B. Gouty tophus
C. Calcium deposit
D. Orf
E. Xanthomata
ANSWER:
C. Calcium deposit
EXPLANATION:
This lesion represents calcinosis.
Please see Q-47 for Systemic Sclerosis
Q-96
The Chief Medical Officer issued guidance in 2012 relating to vitamin D supplementation. What advice
should be given to parents?
A. All Asian and Afro-Caribbean children should be given vitamin D supplementation until the age of 11
B. There is no evidence that vitamin D supplementation is beneficial in childhood
C. Children who have a diet low in dairy products should be given vitamin D supplementation
D. All children aged between 12 months and 3 years should be given vitamin D supplementation
E. All children aged between 6 months and 5 years should be given vitamin D supplementation
ANSWER:
E. All children aged between 6 months and 5 years should be given vitamin D supplementation
EXPLANATION:
Q-97
You are doing the annual review of a 50-year-old woman who has rheumatoid arthritis. Which one of the
following complications is most likely to occur as a result of her disease?
A. Chronic lymphocytic leukaemia

B. Hypertension
C. Colorectal cancer
D. Type 2 diabetes mellitus
E. Ischaemic heart disease
ANSWER:
E. Ischaemic heart disease
EXPLANATION:
Rheumatoid arthritis: patients have an increased risk of IHD
Please see Q-35 for Rheumatoid Arthritis: Complications
Q-98
A 54-year-old woman who has had two Colle's fractures in the past three years has a DEXA scan:
T-score
L2-4 -1.4
Femoral neck -2.7
What does the scan show?
A. Osteoporosis in both the vertebrae and femoral neck

B. Osteoporosis in vertebrae, osteopaenia in femoral neck
C. Osteopaenia in both the vertebrae and femoral neck
D. Osteopaenia in vertebrae, osteoporosis in femoral neck
E. Normal bone density in vertebrae, osteoporosis in femoral neck
ANSWER:
D. Osteopaenia in vertebrae, osteoporosis in femoral neck
EXPLANATION:
Please see Q-67 for Osteoporosis: DEXA Scan

Q-99
Bill is a 65-year-old man who presents to his GP with painless swelling of lymph nodes in his left armpit.
On further questioning, he admits to feeling hot at night and says he has lost some weight. He has a
background of Sjogrens syndrome and is on hydroxychloroquine. On examination, you can feel a 3cm
rubbery lump in his left axilla. There are no other palpable lumps anywhere else. His observations are
normal.
A. Lymphoma
B. Breast cancer
C. Tuberculosis
D. Hidradenitis suppurativa
E. Folliculitis
ANSWER:
A. Lymphoma
EXPLANATION:
Patients with Sjogren's syndrome have an increased risk of lymphoid malignancies
The weight loss, night sweats and painless swelling make a diagnosis of lymphoma likely. In addition,
patients with Sjogren's syndrome have an increased risk of lymphoid malignancies.
The fact that this is a male patient as well as the absence of a breast lump makes a diagnosis of breast
cancer very unlikely.
TB of the lymph glands is normally localised to the cervical chains or supraclavicular fossa. In addition, it is
often bilateral.
Hidradenitis suppurativa is a condition that can lead to painful abscesses forming in the axilla. As these
lumps are painless, this diagnosis is unlikely.
Folliculitis is inflammation of the hair follicle. It usually causes a tender boil with a pustule at the surface.
SJOGREN'S SYNDROME
Sjogren's syndrome is an autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. It
may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it
usually develops around 10 years after the initial onset. Sjogren's syndrome is much more common in
females (ratio 9:1). There is a marked increased risk of lymphoid malignancy (40-60 fold).
Features
 dry eyes: keratoconjunctivitis sicca
 dry mouth
 vaginal dryness
 arthralgia
 Raynaud's, myalgia
 sensory polyneuropathy
 recurrent episodes of parotitis
 renal tubular acidosis (usually subclinical)
Investigation
 rheumatoid factor (RF) positive in nearly 100% of patients
 ANA positive in 70%
 anti-Ro (SSA) antibodies in 70% of patients with PSS
 anti-La (SSB) antibodies in 30% of patients with PSS
 Schirmer's test: filter paper near conjunctival sac to measure tear formation
 histology: focal lymphocytic infiltration
 also: hypergammaglobulinaemia, low C4
Management
 artificial saliva and tears
 pilocarpine may stimulate saliva production
Q-100
You review the hands of a 60-year-old man who is complaining of 'arthritis' in his hands:
B. Systemic sclerosis
C. Systemic fungal infection
D. Psoriatic arthropathy
E. Reiter's syndrome
ANSWER:
D. Psoriatic arthropathy
EXPLANATION:
The combination of nail changes, skin changes and arthritis points to a diagnosis of psoriatic arthropathy.
Q-101
A 46-year-old woman presents to surgery complaining of a dry mouth and dry eyes for the past 6 months.
She has also generalised arthralgia and is more tired than normal. Which one of the following
autoantibodies is most associated with primary Sjogren's syndrome?
A. Anti-RNP
B. Anti-Ro
C. Anti-smooth muscle
D. Anti-centromere
E. Anti-Sm
ANSWER:
B. Anti-Ro
EXPLANATION:
Please see Q-99 for Sjogren’s Syndrome
Q-102
Which of the following is least likely to be associated with ankylosing spondylitis?
A. Apical fibrosis
B. Achilles tendonitis
C. Amyloidosis
D. Achalasia
E. Heart block
ANSWER:
D. Achalasia
EXPLANATION:
Ankylosing spondylitis features - the 'A's
 Apical fibrosis
 Anterior uveitis
 Aortic regurgitation
 Achilles tendonitis
 AV node block
 Amyloidosis
ANKYLOSING SPONDYLITIS: FEATURES

Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio
3:1) aged 20-30 years old.
Features
 typically a young man who presents with lower back pain and stiffness of insidious onset
 stiffness is usually worse in the morning and improves with exercise
 the patient may experience pain at night which improves on getting up
Clinical examination
 reduced lateral flexion
 reduced forward flexion - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples
(dimples of Venus). The distance between the two lines should increase by more than 5 cm when the
patient bends as far forward as possible
 reduced chest expansion
Other features - the 'A's

 Apical fibrosis
 AV node block
 Amyloidosis
 and cauda equina syndrome
 peripheral arthritis (25%, more common if female)
Q-103
Which of the following is associated with a good prognosis in rheumatoid arthritis?
A. Rheumatoid factor negative

B. HLA DR4
C. Anti-CCP antibodies
D. Rheumatoid nodules
E. Insidious onset
ANSWER:
A. Rheumatoid factor negative
EXPLANATION:
RHEUMATOID ARTHRITIS: PROGNOSTIC FEATURES
A number of features have been shown to predict a poor prognosis in patients with rheumatoid arthritis, as
listed below
Poor prognostic features

 rheumatoid factor positive
 poor functional status at presentation
 HLA DR4
 X-ray: early erosions (e.g. after < 2 years)
 extra articular features e.g. nodules
 insidious onset
 anti-CCP antibodies
In terms of gender there seems to be a split in what the established sources state is associated with a poor
prognosis. However both the American College of Rheumatology and the recent NICE guidelines (which
looked at a huge number of prognosis studies) seem to conclude that female gender is associated with a
poor prognosis.
Q-104
You are reviewing a 29-year-old woman who is under the care of rheumatology. She had an unsatisfactory
response to methotrexate and sulfasalazine and is currently taking leflunomide. On the advice of the
rheumatologist she is taking her combined oral contraceptive pill regularly but is keen to start a family at
some point. How long after stopping leflunomide should she wait before trying to conceive?
A. She can start trying straight away after stopping

B. At least 3 months
C. At least 6 months
D. At least 12 months
E. At least 2 years
ANSWER:
E. At least 2 years
EXPLANATION:
For patients taking leflunomide, effective contraception is required for at least 2 years in women and 3
months in men after stopping (think leflunomide = thalidomide)
LEFLUNOMIDE
Leflunomide is a disease modifying anti-rheumatic drug (DMARD) mainly used in the management of
rheumatoid arthritis. It has a very long half-life which should be remembered considering it's teratogenic
potential.
Contraindications
 pregnancy - the BNF advises: 'Effective contraception essential during treatment and for at least 2 years
after treatment in women and at least 3 months after treatment in men (plasma concentration
monitoring required'
 caution should also be exercised with pre-existing lung and liver disease
Adverse effects
 gastrointestinal, especially diarrhoea
 hypertension
 weight loss/anorexia
 peripheral neuropathy
 pneumonitis
Monitoring
 FBC/LFT and blood pressure
Stopping
 leflunomide has a very long wash-out period of up to a year which requires co-administration of
cholestyramine
Q-105
A 25-year-old woman presents for review. She has a history of depression and is currently prescribed
citalopram. Despite returning from a recent holiday in Spain she complains of feeling tired all the time. On
examination you notice a slightly raised red rash on the bridge of her nose and cheeks. Although she
complains of having 'stiff joints' you can find no evidence of arthritis. You order some basic blood tests:
Hb 12.7 g/dl
Platelets 130 * 109/l
WBC 3.3 * 109/l
Na+ 138 mmol/l

K+ 4.0 mmol/l
Urea 3.4 mmol/l
Creatinine 77 µmol/l
Free T4 12.2 pmol/l

TSH 1.25 mu/l
CRP 9 mg/l
A. Systemic lupus erythematosus

B. Acne rosacea
C. Fibromyalgia
D. Lyme Disease
E. HIV seroconversion illness
ANSWER:
A. Systemic lupus erythematosus
EXPLANATION:
The malar rash, arthralgia, lethargy and history of mental health points towards a diagnosis of SLE.
Remember that the CRP (in contrast to the ESR) is typically normal in SLE.
SYSTEMIC LUPUS ERYTHEMATOSUS: FEATURES

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disorder. It typically presents in early
adulthood and is more common in women and people of Afro-Caribbean origin.
General features
 fatigue
 fever
 mouth ulcers
 lymphadenopathy
Skin
 malar (butterfly) rash: spares nasolabial folds
 discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas. Lesions may progress to
become pigmented and hyperkeratotic before becoming atrophic
 photosensitivity
 Raynaud's phenomenon
 livedo reticularis
 non-scarring alopecia
Musculoskeletal
 arthralgia
 non-erosive arthritis
Cardiovascular
 pericarditis: the most common cardiac manifestation
 myocarditis
Respiratory
 pleurisy
 fibrosing alveolitis
Renal
 proteinuria
 glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)
Neuropsychiatric
 anxiety and depression
 psychosis
 seizures
Q-106
A 38-year-old woman is reviewed. She has a diagnosis of rheumatoid arthritis. She has recently been
switched from methotrexate to leflunomide. Monitoring of the full blood count and liver function tests
has been arranged. What else should be monitored during treatment?
A. Peak expiratory flow rate

B. Blood pressure
C. QT interval on ECG
D. Blood glucose
E. Urine for microscopic haematuria
ANSWER:
B. Leflunomide may cause hypertension
EXPLANATION:
Leflunomide may cause hypertension
LEFLUNOMIDE
Leflunomide is a disease modifying anti-rheumatic drug (DMARD) mainly used in the management of
rheumatoid arthritis. It has a very long half-life which should be remembered considering it's teratogenic
potential.
Contraindications
 pregnancy - the BNF advises: 'Effective contraception essential during treatment and for at least 2 years
after treatment in women and at least 3 months after treatment in men (plasma concentration
monitoring required'
 caution should also be exercised with pre-existing lung and liver disease
Adverse effects
 gastrointestinal, especially diarrhoea
 hypertension
 weight loss/anorexia
 peripheral neuropathy
 pneumonitis
Monitoring
 FBC/LFT and blood pressure
Stopping
 leflunomide has a very long wash-out period of up to a year which requires co-administration of
cholestyramine
Q-107
A 64-year-old man with chronic kidney disease stage 3 secondary to type 2 diabetes mellitus presents with
pain and swelling at the right first metatarsophalangeal joint. On examination the joint is hot,
erythematous and tender to touch, although he can still flex the big toe. What is the most appropriate
initial management?
A. Colchicine
B. Prednisolone
C. Co-codamol 30/500
D. Allopurinol
E. Indomethacin
ANSWER:
A. Colchicine
EXPLANATION:
Colchicine is useful in patients with renal impairment who develop gout as NSAIDs are relatively
contraindicated. The BNF advises to reduce the dose by up to 50% if creatinine clearance is less than 50
ml/min and to avoid if creatinine clearance is less than 10 ml/min.
Co-codamol 30/500 may be used as an adjunct but would not provide relief as monotherapy.
Prednisolone is an option but would adversely affect his diabetic control.

interactions.
Q-108
A 70-year-old man with a history of psoriasis presents with dyspnoea on exertion. On examination,
respiratory rate 24/min, Sats 94% OA, heart rate 90/min and chest has widespread fine inspiratory
crackles. Spirometry: FEV1/FVC = 0.8.
Which medication could have caused this presentation?
A. Terbinafine
B. Paracetamol
C. Montelukast
D. Methotrexate
E. Tramadol
ANSWER:
D. Methotrexate
EXPLANATION:
Methotrexate is a cause of pulmonary fibrosis
Pulmonary fibrosis is a known adverse effect of methotrexate and can manifest in the order of weeks to
months of using low-dose methotrexate. Terbinafine, paracetamol, montelukast and tramadol are not
known to cause this.
Q-109
A 62-year-old man with chronic kidney disease stage 4 complains of recurrent foot pain. You suspect a
diagnosis of gout.
Where on the foot is gout most likely to affect?
A. Marker A
B. Marker B
C. Marker C
D. Marker D
E. Marker E
ANSWER:
E. Marker E
EXPLANATION:
The most common joint that gout affects is the first metatarsophalangeal joint.
Q-110
You are reviewing a 31-year-old man with psoriasis. He has chronic plaque psoriasis that is reasonably
well controlled with with calcipotriol monotherapy. He has used potent corticosteroids in the past to help
control flares of his disease. He also asks you to look at a swollen finger. There is no history of trauma but
for the past three weeks he has noticed that his left middle finger is swollen, stiff and slightly painful. This
is confirmed on examination. What is the most appropriate next step?
A. Arrange an x-ray to exclude a pathological fracture

B. Refer him to rheumatology
C. Refer him to dermatology for consideration of systemic therapy
D. Prescribe a course of naproxen and review in 4 weeks
E. Arrange a DEXA scan
ANSWER:
B. Refer him to rheumatology
EXPLANATION:
All patients with suspected psoriatic arthropathy should be referred to a rheumatologist
Q-111-113
A. Paracetamol
B. Diclofenac
C. Naproxen
D. Basiliximab
E. Prednisolone
F. Ciclosporin
G. Sulfasalazine
with it . Each options may be used once, more than once or not at all.
Q-111
Cataracts
ANSWER:
E. Prednisolone
Q-112
ANSWER:
G. Sulfasalazine
Q-113
Corneal opacities
ANSWER:
EXPLANATION:
Gold may also cause corneal opacities.
Please see Q-75-77 for Rheumatoid Arthritis: Drug Side-Effects
Q-114
You review a 40-year-old man with Marfan's syndrome. What is the most likely cause of death in such
patients?
A. Tension pneumothorax
B. Myocardial infarction
C. Colorectal cancer
D. Aortic dissection
E. Pulmonary embolism
ANSWER:
D. Aortic dissection
EXPLANATION:
Marfan's syndrome is associated with dilation of the aortic sinuses which may predispose to aortic
dissection

Q-115
A 65-year-old Asian female presents to her GP with generalised bone pain and muscle weakness.
Investigations show:
Calcium 2.07 mmol/l

ALP 256 U/l
A. Bone tuberculosis
B. Hypoparathyroidism
C. Myeloma
D. Osteomalacia
E. Paget's disease
ANSWER:
D. Osteomalacia
EXPLANATION:
The low calcium and phosphate combined with the raised alkaline phosphatase point towards
osteomalacia
Please see Q-69 for Osteomalacia
Q-116
A 15-year-old girl presents with an urticarial rash, angioedema and wheezing. Her mother states that she
has just come from her younger sister's party where she had been helping to blow up balloons. What is
A. C1-esterase deficiency (hereditary angioedema)

B. Allergic contact dermatitis
C. Peanut allergy
D. Latex allergy
E. Irritant contact dermatitis
ANSWER:
D. Latex allergy
EXPLANATION:
Type I hypersensitivity reaction - anaphylaxis
This is a typical history of latex allergy. Adrenaline should be given immediately and usual anaphylaxis
management followed
HYPERSENSITIVITY
The Gell and Coombs classification divides hypersensitivity traditionally divides reactions into 4 types:
Type Mechanism Examples
Type I - Anaphylactic Antigen reacts with IgE • Anaphylaxis
bound to mast cells • Atopy (e.g. asthma, eczema and hayfever)
Type II - Cell bound IgG or IgM binds to • Autoimmune haemolytic anaemia
antigen on cell surface • ITP
• Goodpasture's syndrome
• Pernicious anaemia
• Acute haemolytic transfusion reactions
• Rheumatic fever
• Pemphigus vulgaris / bullous pemphigoid
Type III - Immune Free antigen and • Serum sickness
complex antibody (IgG, IgA) • Systemic lupus erythematosus
combine • Post-streptococcal glomerulonephritis
• Extrinsic allergic alveolitis (especially acute
phase)
Type IV - Delayed T-cell mediated • Tuberculosis / tuberculin skin reaction
hypersensitivity • Graft versus host disease
• Allergic contact dermatitis
• Scabies
• Extrinsic allergic alveolitis (especially chronic
phase)
• Multiple sclerosis
• Guillain-Barre syndrome
In recent times a further category has been added:
Type Mechanism Examples

Type V Antibodies that recognise and bind to the cell surface receptors. • Graves' disease
• Myasthenia gravis
This either stimulating them or blocking ligand binding
Q-117
A 25-year-old man presents to his GP complaining of dysuria and pain in his left knee. Three weeks
previously he had suffered a severe bout of diarrhoea. What is the most likely diagnosis?
B. Disseminated gonococcal infection
C. Behcet's syndrome
D. Ulcerative colitis
ANSWER:
EXPLANATION:
Urethritis + arthritis + conjunctivitis = reactive arthritis
Two of the classic three features of reactive arthritis (urethritis, arthritis and conjunctivitis) are present in
this patient
REACTIVE ARTHRITIS
Reactive arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies. It encompasses
Reiter's syndrome, a term which described a classic triad of urethritis, conjunctivitis and arthritis following a
dysenteric illness during the Second World War. Later studies identified patients who developed symptoms
following a sexually transmitted infection (post-STI, now sometimes referred to as sexually acquired reactive
arthritis, SARA).
Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot
be recovered from the joint.
'Can't see, pee or climb a tree'
Epidemiology
 post-STI form much more common in men (e.g. 10:1)
 post-dysenteric form equal sex incidence
The table below shows the organisms that are most commonly associated with reactive arthritis:
Post-dysenteric form Post-STI form

Shigella flexneri Chlamydia trachomatis
Salmonella typhimurium
Salmonella enteritidis
Yersinia enterocolitica
Campylobacter
Management
 symptomatic: analgesia, NSAIDS, intra-articular steroids
 sulfasalazine and methotrexate are sometimes used for persistent disease
 symptoms rarely last more than 12 months
Q-118
A 75 year-old male patient presents with a feeling of weakness of the legs. On examination there are also
some skin changes present, with purple plaques on the dorsum of the hands. You suspect a diagnosis of
dermatomyositis. Which of the following underlying conditions is associated with dermatomyositis and
should be considered?
A. Liver cirrhosis
B. Chronic renal failure
C. Haemochromatosis
D. Internal malignancy
E. Pulmonary fibrosis
ANSWER:
D. Internal malignancy
EXPLANATION:
Dermatomyositis is usually an autoimmune condition, being most common in women aged 50-70.
However, it can also be a paraneoplastic disease, with ovarian, breast and lung tumours being the most
common underlying cancers. The possibility of underlying malignancy should be considered, especially in
older patients.
Please see Q-41 for Dermatomyositis
Q-119
A 13-year-old female presents to clinic with her mother. She describes a 5 week history of left knee pain.
There is no history of trauma. She is not systemically unwell although she reports feeling more tired than
usual. On examination, normal BMI, observations are unremarkable. There is a normal appearance and
range of movement of the left knee, and examination of all other joints are unremarkable. Which of the
following options is the most appropriate course of action?
A. Very urgent referral (within 48 hours) for specialist assessment

B. Watch and wait, review in 2 weeks if no better
C. Refer to Physiotherapy
D. Direct access X ray (within 48 hours)
E. Urgent referral (within 2 weeks) to a specialist
ANSWER:
D. Direct access X ray (within 48 hours)
EXPLANATION:
Osteosarcoma is the most common primary bone malignancy in children.The incidence is highest in 15-19
year olds and the male: female ratio is 1.4:1. It occurs in the metaphysis of long bones, most commonly
around the knee (75%) or proximal humerus. It often presents as a relatively painless tumour. As it
progresses, it destroys bone and spreads into the surrounding tissue. The lung is a common site of
metastasis. X-ray findings feature a combination of bone destruction and formation, with soft tissue
calcification producing a 'sunburst' appearance.
(source: patient.co.uk)
The AKT Examiners feedback report October 2016 specifically mentions candidates should have an
awareness of rare conditions, and in this case there were difficulties around cancer diagnosis and
investigation in children. The NICE 2015 Suspected Cancer guidance includes recommendations on children
and young people.
NICE referral guidelines for suspected cancer (June 2015) state:
Consider a very urgent referral (within 48 hours) for specialist assessment for children and young people if
an X ray suggests the possibility of bone sarcoma. [new 2015]
Consider a very urgent direct access X ray (within 48 hours) to assess for bone sarcoma in children and
young people with unexplained bone swelling or pain. [new 2015]
BONE TUMOURS
Benign tumours
Tumour Notes
Osteoma  benign 'overgrowth' of bone, most typically occuring on the skull
 associated with Gardner's syndrome (a variant of familial adenomatous
polyposis, FAP)
Osteochondroma  most common benign bone tumour

(exotosis)  more in males, usually diagnosed in patients aged < 20 years
 cartilage-capped bony projection on the external surface of a bone
Giant cell tumour  tumour of multinucleated giant cells within a fibrous stroma
 peak incidence: 20-40 years
 occurs most frequently in the epiphyses of long bones
 X-ray shows a 'double bubble' or 'soap bubble' appearance
Malignant tumours
Tumour Notes
Osteosarcoma  most common primary malignant bone tumour
 seen mainly in children and adolescents
 occurs most frequently in the metaphyseal region of long bones prior to
epiphyseal closure, with 40% occuring in the femur, 20% in the tibia, and
10% in the humerus
 x-ray shows Codman triangle (from periosteal elevation) and 'sunburst'
pattern
 mutation of the Rb gene significantly increases risk of osteosarcoma (hence
association with retinoblastoma)
 other predisposing factors include Paget's disease of the bone and
radiotherapy
Ewing's sarcoma  small round blue cell tumour

 seen mainly in children and adolescents
 occurs most frequently in the pelvis and long bones. Tends to cause severe
pain
 associated with t(11;22) translocation which results in an EWS-FLI1 gene
product
 x-ray shows 'onion skin' appearance
Chondrosarcoma  malignant tumour of cartilage

Tumour Notes
 most commonly affects the axial skeleton
 more common in middle-age
Q-120
A 55-year-old woman presents with a four week history of shoulder pain. There has been no obvious
precipitating injury and no previous experience. The pain is worse on movement and there is a grating
sensation if she moves the arm too quickly. She also gets pain at night, particularly when she lies on the
affected shoulder. On examination there is no obvious erythema or swelling. Passive abduction is painful
between between 60 and 120 degrees. She is unable to abduct the arm herself past 70-80 degrees. Flexion
and extension are preserved. What is the most likely diagnosis?
A. Adhesive capsulitis (frozen shoulder)

B. Supraspinatus tendonitis
C. Acromioclavicular joint injury
D. Glenohumeral arthritis
E. Superior labral lesion
ANSWER:
B. Supraspinatus tendonitis
EXPLANATION:
This patient has a classic 'painful arc' which is a sign of shoulder impingement, most commonly secondary
to supraspinatus tendonitis.
ROTATOR CUFF MUSCLES
SItS - small t for teres minor
Supraspinatus
Infraspinatus
teres minor
Subscapularis
Muscle Notes
Supraspinatus aBDucts arm before deltoid
Most commonly injured
Infraspinatus Rotates arm laterally
teres minor aDDucts & rotates arm laterally
Subscapularis aDDuct & rotates arm medially
Q-121
Approximately what percentage of patients with psoriasis develop an associated arthropathy?
A. 5-6%
B. 30-40%
C. 2-3%
D. 1%
E. 10-20%
ANSWER:
E. 10-20%
EXPLANATION:
Q-122
Which one of the following statements regarding ankylosing spondylitis is correct?
A. Schober's test assesses reduced chest expansion

B. HLA-B27 is positive in 50% of patients
C. Achilles tendonitis is a recognised association
D. It is equally common in men and women
E. The typical age of presentation is between 40-50 years
ANSWER:
C. Achilles tendonitis is a recognised association
EXPLANATION:
Ankylosing spondylitis features - the 'A's
 Apical fibrosis
 AV node block
 Amyloidosis
HLA-B27 is positive in 90% of patients.

Please see Q-102 for Ankylosing Spondylitis: Features
Q-123
A 28-year-old man is diagnosed with having ankylosing spondylitis. He presented with a six month history
of back pain. On examination there is reduced lateral flexion of the spine but no evidence of any other
complications. Which one of the following is he most likely to offered as first-line treatment?
A. Exercise regime + NSAIDs

B. Exercise regime + infliximab
C. Physiotherapy + sulfasalazine
D. Physiotherapy + etanercept
E. Exercise regime + paracetamol
ANSWER:
A. Exercise regime + NSAIDs
EXPLANATION:
Exercise regimes and NSAIDs are the 1st line management for ankylosing spondylitis
The anti-TNF drugs are currently only used for patients with severe ankylosing spondylitis which has failed
to respond to NSAIDs.
ANKYLOSING SPONDYLITIS: INVESTIGATION AND MANAGEMENT

Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio
3:1) aged 20-30 years old.
Investigation
Inflammatory markers (ESR, CRP) are typically raised although normal levels do not exclude ankylosing
spondylitis.
HLA-B27 is of little use in making the diagnosis as it is positive in:

 90% of patients with ankylosing spondylitis
 10% of normal patients
Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis. Radiographs
may be normal early in disease, later changes include:
 sacroiliitis: subchondral erosions, sclerosis
 squaring of lumbar vertebrae
 'bamboo spine' (late & uncommon)
 syndesmophytes: due to ossification of outer fibers of annulus fibrosus
 chest x-ray: apical fibrosis
If the x-ray is negative for sacroiliac joint involvement in ankylosing spondylitis but suspicion for AS remains
high, the next step in the evaluation should be obtaining an MRI. Signs of early inflammation involving
sacroiliac joints (bone marrow oedema) confirm the diagnosis of AS and prompt further treatment.
Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis
of the costovertebral joints.
Management
The following is partly based on the 2010 EULAR guidelines (please see the link for more details):
 encourage regular exercise such as swimming
 NSAIDs are the first-line treatment
 physiotherapy
 the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are
only really useful if there is peripheral joint involvement
 the 2010 EULAR guidelines suggest: 'Anti-TNF therapy should be given to patients with persistently high
disease activity despite conventional treatments'
 research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be
used earlier in the course of the disease
40-year-old male. There is typical appearance of bamboo spine with a single central radiodense line related to
ossification of supraspinous and interspinous ligaments which is called dagger sign. Ankylosing is detectable in both
sacroiliac joints
Ankylosing spondylitis with well formed syndesmophytes

Lateral cervical spine. Complete fusion of anterior and posterior elements in ankylosing spondylitis, so called bamboo
spine
Fusion of bilateral sacroiliac joints. Sacroiliitis may present as sclerosis of joint margins which can be asymmetrical at
early stage of disease, but is bilateral and symmetrical in late disease
Syndesmophytes and squaring of vertebral bodies. Squaring of anterior vertebral margins is due to osteitis of anterior
corners. Syndesmophytes are due to ossification of outer fibers of annulus fibrosus
Q-124
You see a 65-year-old lady who is feeling unwell. She has had a productive cough for 3 days and is
coughing up brown-green sputum. She feels lethargic and feverish. Her past medical history includes
rheumatoid arthritis which she has had for over 30 years. She has been taking etanercept for 3 years and
her disease is very well controlled.
On examination, her temperature is 37.5, her respiratory rate is 17 breaths per/min, her oxygen
saturations are 98% and she has slight crackles in the base of her left lung.
You prescribe 7 days of amoxicillin for a lower respiratory tract infection and give her worsening advice.
A. RA is not associated with an increased risk of infection

B. She can continue the etanercept with the antibiotics
C. A patient with RA taking etanercept who develops an infection needs to stop the etanercept until the
infection is cleared
D. Compared to the general population her risk of tuberculosis (TB) is equivalent
E. A patient who is stable on etanercept needs blood monitoring every 3 months
ANSWER:
A patient with RA taking etanercept who develops an infection needs to stop the etanercept until the
EXPLANATION:
RA is associated with an approximate doubling of the risk of infection; chest infection and generalized
sepsis are particular risks. Therefore, option 1 is wrong.
infection is cleared. Therefore, option 2 is wrong and option 3 is correct.
There is an increased risk of TB, or reactivation of latent TB, during treatment with biologics. Therefore,
A patient on biologic therapy needs blood monitoring. Initially, they need a full blood count, urea and
electrolytes (and creatinine) and liver function tests 3-4 months after starting therapy and then every 6
months once stable (unless clinically indicated). Therefore, option 5 is wrong.
Q-125
A 56-year-old woman with Rheumatoid arthritis presents with a 3-day history of dysuria, frequency and
foul smelling urine. Urinalysis is positive for blood, nitrites, leukocytes and protein. You look at her repeat
prescription and note that she is taking methotrexate for her Rheumatoid disease. She has no allergies.
Which antibiotic is not appropriate to prescribe due to the risk of severe bone marrow suppression?
A. Nitrofurantoin
B. Trimethoprim
C. Amoxicillin
D. Cefalexin
E. Co-amoxiclav
ANSWER:
B. Trimethoprim
EXPLANATION:
The answer here is trimethoprim. Trimethoprim and co-trimoxazole, anti-folate antibiotics, should be
avoided concurrently with methotrexate due to the risk of bone marrow aplasia. This reaction is due to the
additive folate depletion when the medications are combined. Fatal pancytopenia and megaloblastic
anaemia have occurred. Penicillins may reduce the excretion of methotrexate, and there are no
interactions reported in the BNF with nitrofurantoin or cefalexin. (AKT feedback report April 2016) Source
BNF
Q-126
A 58-year-old woman with a history of left hip osteoarthritis presents for review. She is currently taking
co-codamol 30/500 for pain on a regular basis but this is unfortunately not controlling her symptoms.
There is no past medical history of note, in particular no asthma or gastrointestinal problems. What is the
most suitable next step in management?
A. Switch to regular oral tramadol

B. Add topical ibuprofen
C. Add oral ibuprofen + proton pump inhibitor
D. Add oral etoricoxib
E. Add oral diclofenac
ANSWER:
C. Add oral ibuprofen + proton pump inhibitor
EXPLANATION:
NICE recommend co-prescribing a PPI with NSAIDs in all patients with osteoarthritis
Topical NSAIDs are only indicated for osteoarthritis of the knee or hand.
OSTEOARTHRITIS: MANAGEMENT
NICE published guidelines on the management of osteoarthritis (OA) in 2014
 all patients should be offered help with weight loss, given advice about local muscle strengthening
exercises and general aerobic fitness
 paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the
knee or hand
 second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular
corticosteroids. A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors.
These drugs should be avoided if the patient takes aspirin
 non-pharmacological treatment options include supports and braces, TENS and shock absorbing insoles
or shoes
 if conservative methods fail then refer for consideration of joint replacement
What is the role of glucosamine?

 normal constituent of glycosaminoglycans in cartilage and synovial fluid
 a systematic review of several double blind RCTs of glucosamine in knee osteoarthritis reported
significant short-term symptomatic benefits including significantly reduced joint space narrowing and
improved pain scores
 more recent studies have however been mixed
 the 2008 NICE guidelines suggest it is not recommended
 a 2008 Drug and Therapeutics Bulletin review advised that whilst glucosamine provides modest pain
relief in knee osteoarthritis it should not be prescribed on the NHS due to limited evidence of cost-
effectiveness
Q-127
A 71-year-old woman who has recently been diagnosed as having osteoporosis is started on a combined
calcium and vitamin D supplement. She asks about possible side-effects. Which one of the following has
been linked to the use of calcium supplementation?
A. Increased risk of myocardial infarction

B. Increased risk of venous thromoembolism
C. Increased risk of dementia
D. Increased risk of breast cancer
E. Increased risk of Paget's disease
ANSWER:
A. Increased risk of myocardial infarction
EXPLANATION:
Calcium supplementation has been linked to an increased risk of myocardial infarction
OSTEOPOROSIS: CALCIUM AND VITAMIN D SUPPLEMENTATION
In the 2008 NICE guidelines on the secondary prevention of osteoporotic fractures in postmenopausal
women it is advised that 'This guidance assumes that women who receive treatment have an adequate
calcium intake and are vitamin D replete. Unless clinicians are confident that women who receive treatment
meet these criteria, calcium and/or vitamin D supplementation should be considered.'
So, we should just prescribe everyone a combined calcium and vitamin D supplement?
The problem is that there seems to be a potential downside to this approach. For many years there has been
concern about the potential for calcium supplements to increase the risk of ischaemic heart disease. A large
meta-analysis in the BMJ in 2010 (BMJ 2010; 341; c3691) was the first warning shot. This study was criticised
at time for looking at some patients who weren't co-prescribed vitamin D. However, a subsequent analysis
of this study and two later studies seems to confirm the association.
One of these later studies was published in Heart in 2012 (Heart 2012;98:920-925). It looked at over 23,000
and found patients who had been taking calcium supplements had a significantly increased risk of
myocardial infarction (hazard ratio = 2.39; 95% CI 1.12 to 5.12). This same risk was not seen for patients with
high calcium intake via normal dietary means.
None of the major guideline bodies have offered advice about what we should do in this situation. For the
time being it seems sensible to encourage people to aim for a dietary calcium intake of around 1,000mg /
day where possible and prescribe a standalone vitamin D supplement (usually 10mcg/day), which have
become increasingly in recent years.
Q-128
A 16-year-old female is admitted to the paediatric ward with malnutrition secondary to anorexia nervosa.
The paediatrician requested an array of investigations including a DEXA scan which showed the Z score of
-1.6.
 In order to calculate the Z score, the patient’s bone density is compared to which of the following?  
A. Bone mass of the young healthy female population
B. Bone mass of the young healthy population
C. Bone mass of the elderly female population
D. Bone mass of the elderly population
E. Bone mass of the average of the whole population
ANSWER:
A. Bone mass of the young healthy female population
EXPLANATION:
DEXA scans: the Z score is adjusted for age, gender and ethnic factors
 Zscore is the number of standard deviations between the bone density of the patient and the bone density
of a population of the same age, gender and ethnicity. A Z score of <-2.0 suggests that the patient has a
bone mass below the expected range for their demographic. Z scores tend to be used in children, men
below 50 and premenopausal women.   The DEXA scan is a non-invasive, accurate imaging modality which
measures the density and strength of the bone through X-rays. It is useful in diagnosing osteopenia or
osteoporosis which can be linked to a variety of conditions including anorexia nervosa, bulimia, cancers,
long term steroid therapy and more.
Q-129
A 72-year-old woman presents with gradually worsening pain and stiffness in her hands:
On examination she is particularly tender over the carpometacarpal joints. What is the most likely
diagnosis?
A. Osteoarthritis
B. Systemic lupus erythematosus
E. Gout
ANSWER:
A. Osteoarthritis
EXPLANATION:
The presence of Heberden's nodes and thumb symptoms is highly suggestive of osteoarthritis.
Please see Q-126 for Osteoarthritis: Management
Q-130
A patient of yours is reviewed by a rheumatologist and diagnosed with rheumatoid arthritis. They have
suggested you prescribe methotrexate via a shared care agreement.
Which of the following medications, the patient already takes, interacts with methotrexate?
A. Atorvastatin
B. Gliclazide
C. Ranitidine
D. Tramadol
E. Trimethoprim
ANSWER:
E. Trimethoprim
EXPLANATION:
The British National Formulary states there is an increased risk of severe bone marrow suppression when
methotrexate is given with trimethoprim so both should not be prescribed together. The other medications
on the list do not interact with methotrexate.
Q-131
A 57-year-old man presents to his GP due to pain in his right knee. An x-ray shows osteoarthritis. He has
no past medical history of note. What is the most suitable treatment option for the management of his
pain?
A. Oral diclofenac with omeprazole

B. Oral glucosamine
C. Oral diclofenac
D. Oral ibuprofen
E. Oral paracetamol
ANSWER:
E. Oral paracetamol
EXPLANATION:
Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line
Oral NSAIDs should be used second line in osteoarthritis due to their adverse effect profile
Q-132
A 54-year-old man presents to clinic with an acutely painful and red big toe. He is well in himself and there
is no evidence of infection or fever. He has suffered gout for some time and tells you he thinks it has
recurred. He is currently taking regular allopurinol.
What is the next most appropriate option?
A. Stop allopurinol and commence colchicine

B. Continue allopurinol and commence colchicine
C. Admit the patient for same day hospital review
D. Commence the patient on aspirin and continue allopurinol
E. Stop allopurinol and commence oral steroids
ANSWER:
B. Continue allopurinol and commence colchicine
EXPLANATION:
Allopurinol should be continued during an acute attack in patients presenting with an acute flare of gout
who are already established on treatment
According to current NICE CKS guidance, patients suffering gout who are already established on
allopurinol should continue this during an acute attack. Therefore stopping allopurinol is incorrect.
Colchicine is a good option in the acute treatment of gout. Oral steroids can be used if patients cannot
tolerate colchicine or NSAIDs, but allopurinol should be continued.
There is no indication in this case for same day hospital review as no evidence of septic joint or red flag
features have been identified.
Aspirin is not indicated in the treatment of gout.

Q-133
A 25-year-old man presents with a painful, swollen left knee. He returned 4 weeks ago from a holiday in
Spain. There is no history of trauma and he has had no knee problems previously. On examination he has
a swollen, warm left knee with a full range of movement. His ankle joints are also painful to move but
there is no swelling. On the soles of both feet you notice a waxy yellow rash. What is the most likely
diagnosis?
B. Psoriatic arthritis
C. Gout
D. Reactive arthritis
E. Gonococcal arthritis
ANSWER:
D. Reactive arthritis
EXPLANATION:
The rash on the soles is keratoderma blenorrhagica. His reactive arthritis may be secondary to either
gastrointestinal infection or Chlamydia.
Please see Q-26 for Reactive Arthritis: Features
Q-134
A 30-year-old woman is diagnosed with systemic lupus erythematosus after presenting with lethargy,
arthralgia and a facial rash. Her rheumatologists starts her on hydroxychloroquine. Which one of the
following is it most important to monitor?
A. Blood pressure
B. Blood sugar
C. QT interval on ECG
D. Visual acuity
E. Peak expiratory flow rate
ANSWER:
D. Visual acuity
EXPLANATION:
Hydroxychloroquine - may result in a severe and permanent retinopathy
HYDROXYCHLOROQUINE
Hydroxychloroquine is used in the management of rheumatoid arthritis and systemic/discoid lupus
erythematosus. It is pharmacologically very similar to chloroquine which is used to treat certain types of
malaria.
Adverse effects
 bull's eye retinopathy - may result in severe and permanent visual loss
o recent data suggest that retinopathy caused by hydroxychloroquine is more common than previously
thought and the most recent RCOphth guidelines (March 2018) suggest colour retinal photography
and spectral domain optical coherence tomography scanning of the macula
o baseline ophthalmological examination and annual screening is generally recommened
A contrast to many drugs used in rheumatology, hydroxychloroquine may be used if needed in pregnant
women.
Monitoring
 the BNF advises: 'Ask patient about visual symptoms and monitor visual acuity annually using the
standard reading chart'
Q-135
A 66-year-old female presents to her GP due to pain at the base of her left thumb. She has no past medical
history of note. On examination there is diffuse tenderness and swelling of her left first carpometacarpal
joint. What is the most likely diagnosis?
A. Osteoarthritis
B. De Quervain's tenosynovitis
C. Gout
E. Primary hyperparathyroidism
ANSWER:
A. Osteoarthritis
EXPLANATION:
The trapeziometacarpal joint (base of thumb) is the most common site of hand osteoarthritis
Q-136
A 24-year-old man is investigated for chronic back pain. Which one of the following would most suggest a
diagnosis of ankylosing spondylitis?
A. Reduced lateral flexion of the lumbar spine

B. Pain gets worse during the day
C. Accentuated lumbar lordosis
D. Pain on straight leg raising
E. Loss of thoracic kyphosis
ANSWER:
A. Reduced lateral flexion of the lumbar spine
EXPLANATION:
Reduced lateral flexion of the lumbar spine is one of the earliest signs of ankylosing spondylitis. There
tends to be a loss of lumbar lordosis and an accentuated thoracic kyphosis in patients with ankylosing
spondylitis
Q-137
A 60-year-old man attends for an emergency appointment with a flare of gout in his right big toe. You
examine and are happy with the diagnosis. He has a history of asthma and is unable to tolerate NSAIDs.
During his last flare you gave him Colchicine which caused terrible diarrhoea. He is unwilling to take this
again and asks you if there any other options.
What do you suggest?
A. Recommend 15mg daily of Prednisolone

B. Re-prescribe Colchicine
C. Refer him routinely to orthopaedics for a steroid injection into the joint
D. Ice packs and elevation plus paracetamol
E. Topical NSAIDS
ANSWER:
A. Recommend 15mg daily of Prednisolone
EXPLANATION:
For gout, if NSAIDs and colchicine are contraindicated or not tolerated (e.g. chronic kidney disease), the
next option is a steroid
It would be reasonable to try Colchicine again, perhaps starting at a lower dose: diarrhoea is a predictable
side effect. However in this case the patient says he doesn't want it. A steroid injection into the joint is a
reasonable option but a routine referral will be too slow and usually there is not the facility to do this.
Whilst ice packs and simple analgesia may help the symptoms to some extent, they are not recommended
treatments. If someone is unable to tolerate oral NSAIDS, topical NSAIDS are also contra-indicated.
Q-138
Jane, a 12-year-old girl presented with pain in her hip, especially on walking. The pain had been getting
worse. She also described feeling a sensation of snapping when she moved her hip. Her past medical
history includes recurrent left shoulder dislocations. There was no past medical history of congenital hip
dysplasia. Her father suffered from Ehler-Danlos syndrome.
Examination of the hip revealed normal passive and active movement with no restriction in the range of
movement. There was no joint swelling. Which of the following is useful to assess hypermobility?
A. Schirmer's test
B. Plain radiograph
C. MRI scan
D. Beighton score
E. Galeazzi test
ANSWER:
D. Beighton score
EXPLANATION:
Beighton score is a useful tool to assess hypermobility. Beighton score is positive if at least 5/9 in adults, or
at least 6/9 in children
Schirmer's test is used in the investigation of Sjogren syndrome. Plain radiograph and MRI scan are not
helpful in assessing hypermobility. Galeazzi test is a test used to check for any unilateral developmental
dysplasia of the hip.
Beighton score is a useful tool to assess hypermobility. Beighton score is positive if at least 5/9 in adults, or
at least 6/9 in children. See https://www.ehlers-danlos.com/assessing-joint-hypermobility/ on how to
carry out the Beighton score assessment
EHLER-DANLOS SYNDROME
Ehler-Danlos syndrome is an autosomal dominant connective tissue disorder that mostly affects type III
collagen. This results in the tissue being more elastic than normal leading to joint hypermobility and
increased elasticity of the skin.
Features and complications

 elastic, fragile skin
 joint hypermobility: recurrent joint dislocation
 easy bruising
 aortic regurgitation, mitral valve prolapse and aortic dissection
 subarachnoid haemorrhage
 angioid retinal streaks
Q-139
A 54-year-old farm worker presents for review. She has recently been diagnosed with osteoarthritis of the
hand but has no other past medical history of note. Despite regular paracetamol she is still experiencing
considerable pain, especially around the base of both thumbs. What is the most suitable next
management step?
A. Add oral diclofenac + lansoprazole

B. Switch paracetamol for co-codamol 8/500
C. Add topical ibuprofen
D. Add oral ibuprofen
E. Add oral glucosamine
ANSWER:
C. Add topical ibuprofen
EXPLANATION:
Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line
The 2008 NICE guidelines suggest the use of paracetamol and topical NSAIDs first-line
Q-140
A 82 year old man attends your surgery with a four day history of a painful, swollen first
metatarsophalangeal joint on his left foot. He has a history of hypertension, ischaemic heart disease,
hiatus hernia and osteoporosis. His blood tests show:
Na+ 136 mmol/l

K+ 4.6 mmol/l
Urea 12 mmol/l
Creatinine 140 µmol/l
Uric acid 300 µmol/l (200-420µmol/l)
What is the best treatment?
A. Colchicine
B. Allopurinol
C. Naproxen
D. Prednisolone
E. Aspirin
ANSWER:
A. Colchicine
EXPLANATION:
This man has an acute episode of gout. The uric acid levels can be normal as they are sequestered into the
joint space.
Allopurinol reduces uric acid production and is useful for gout prophylaxis but should not be started during
an acute flare. NSAIDs are relatively contraindicated by the ischaemic heart disease, renal dysfunction and
hiatus hernia. Aspirin is generally not used for gout. Prednisolone is relatively contraindicated by the high
blood pressure, osteoporosis and hiatus hernia. This leaves colchicine as the best treatment choice. A
steroid joint injection would be a reasonable alternative but may be detrimental to local osteoporosis.
http://www.aafp.org/afp/2002/0715/p283.html
interactions.
Q-141
A 25-year-old man presents with back pain. Which one of the following may suggest a diagnosis of
ankylosing spondylitis?
A. Rapid onset
B. Gets worse following exercise
C. Bone tenderness
D. Pain at night
E. Improves with rest
ANSWER:
D. Pain at night
EXPLANATION:
Q-142
Which of the following is not a recognised feature of temporal arteritis?
A. Rapid response to high dose prednisolone

B. Pyrexia
C. Skip lesions in temporal artery
D. Visual disturbance
E. Elevated creatine kinase
ANSWER:
E. Elevated creatine kinase
EXPLANATION:
Creatine kinase levels are not elevated in temporal arteritis
Q-143
You see a 62-year-old lady who fractured her right wrist 6 weeks ago when she tripped over her cat. The
orthopaedic team suggested a dual-energy X-ray absorptiometry (DEXA) scan and the results have just
come back to you.
Her T score is -2.8 and her Z score is -2. You explain to the patient that her results suggest osteoporosis.
What is the Z score adjusted for?
A. Age only
B. Age and gender only
C. Age, gender and ethnic factors
D. Age and weight only
E. Weight and gender only
ANSWER:
C. Age, gender and ethnic factors
EXPLANATION:
Bone mineral density (DEXA) scans are used to measure bone mineral density. They are used in patients at
risk of osteoporosis or those who have had fragility fractures. You can use the FRAX or QFracture tools
online to assess someone's risk of osteoporosis.
The results of a DEXA scan include a T score and a Z score. The T score is your bone density compared to a
healthy 30-year-old. The Z score compares your bone density to someone your age and body size. The Z
score is adjusted for age, gender and ethnic factors. Therefore, option 3 is correct.

Q-144-146
Theme: Hip pain in adults
C. Pubic symphysis dysfunction
D. Osteoarthritis
F. Avascular necrosis
I. Perthes' disease
J. Slipped upper femoral epiphysis
Q-144
A woman in her third trimester of pregnancy presents with severe pain in her right groin. She has a very
limited range of movement and has difficulty weight bearing. Inflammatory markers are elevated
ANSWER:
EXPLANATION:
This is classic presentation of a rare condition, transient idiopathic osteoporosis. The severity, location and
raised inflammatory markers point towards this diagnosis
Q-145
A 52-year-old man complains of numbness and pain over the anterior skin of the left thigh
ANSWER:
Q-146
A 43-year-old woman complains of right hip pain. During the examination the patient lies on her left side
and the right hip is extended with a straight leg. Flexing the knee then recreates the pain
ANSWER:
EXPLANATION:
This is a femoral nerve stretch test

Q-147
A 50-year-old female presents to the general practice with aching joints in her hands, knee and foot. The
pain has affected her over the past year and tends to be worse in the morning. She also explains that
regular over the counter medications and creams have kept the pain under control.
On examination, her nails appear yellow and pitted. The 2nd left distal interphalangeal joint (DIP) and the
4th right DIP are tender and swollen. The right Achilles tendon and knee are mildly inflamed. In addition
to this, she has poor visual acuity with slight redness of the sclera.
Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis (RA)

B. Psoriatic arthritis (PA)
C. Systemic lupus erythematosus (SLE)
D. Osteoarthritis (OA)
E. Ankylosing spondylitis (AS)
ANSWER:
B. Psoriatic arthritis (PA)
EXPLANATION:
An asymmetrical presentation suggests psoriatic arthritis rather than rheumatoid
The patient is experiencing a peripheral non-symmetrical oligoarthritis with uveitis and achilles tendonitis.
This presentation is more in line with PA. Other features of this condition include synovitis, sacroiliitis,
dactylitis, enthesitis, nail disease and uveitis. Around 20% of patients develop psoriatic arthritis prior to
the psoriatic rash. It is important to note PA can also present with a symmetrical polyarthritis, distal
interphalangeal arthritis or spondylitis with or without sacroiliitis.
There is much overlap between PA and RA. Patients with PA can experience a rheumatoid-like
polyarthritis. Rheumatoid arthritis (RA) is associated more with a peripheral symmetrical polyarthritis.
Osteoarthritis is the mechanical wear and tear of the joint. This condition affects the weight-bearing joints
and would not explain the extra-articular manifestations that the patient is experiencing.
SLE arthropathy typically presents as an intermittent symmetrical polyarthritis affecting the hands, wrists
and knees. SLE less commonly can present as symmetrical arthritis. There are a wide variety of
complications associated with SLE involving the pulmonary, cardiac and ocular systems.
AS is a spondyloarthropathy which affects the axial skeleton and sacroiliac joints. Peak prevalence is
males aged 20 to 40. This is not in keeping with the patient presentation.
Q-148
A 54-year-old woman, who is known to have systemic sclerosis, complains that her hands change colour in
the cold. This is associated with severe pain. She asks if there is any medication you can prescribe.
Which of the following is a suitable first line option?
A. Amlodipine
B. Atenolol
C. Amitriptyline
D. Bisoprolol
E. Nifedipine
ANSWER:
E. Nifedipine
EXPLANATION:
Nifedipine is a pharmacological option for Raynaud's phenomenon
This question tests your knowledge of the management of Raynaud's phenomenon.
Amlodipine - this is not the correct answer. Although calcium channel blockers are used for the treatment
of Raynaud's, amlodipine has a slower onset of action compared to nifedipine, which is therefore more
suitable.
Amitriptyline - this is not the correct answer. Amitriptyline is a tricyclic antidepressant and neurogenic
pain medication. It is not first line in Raynaud's.
Bisoprolol - this is not the correct answer. Bisoprolol is a beta-blocker used in conditions such as
arrhythmia. It is not first line in Raynaud's.
Nifedipine - this is the correct answer. Nifedipine is a calcium channel blocker with a rapid onset of action.
It allows vasodilatation of vessels in the fingers, which otherwise constrict in Raynaud's.
Q-149
You review a 78-year-old lady who was recently started on alendronate after sustaining vertebral wedge
fractures. She reports she stopped taking the tablet because she couldn't manage the side effects. What
second-line treatment should you offer?
A. Hormone replacement therapy

B. Zoledronate
C. Strontium ranelate
D. Risedronate
E. Raloxifene
ANSWER:
D. Risedronate
EXPLANATION:
Alendronate is the first-line bisphosphonate for patients at risk of fragility fracture; risedronate should be
prescribed as second-line if alendronate is not tolerated. Both can be prescribed as either weekly or
smaller daily doses. If the patient cannot tolerate either alendronate or risedronate, they should be
referred to a specialist for consideration of other treatments such as strontium ranelate or raloxifene.
Hormone replacement therapy is generally only used for the prevention of fragility fractures in women
who have experienced menopause prior to the age of 45 (and only continued until age 50).
Source: NICE CKS

http://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures#!scenario:1
Q-150
A 34-year-old woman with a history of antiphospholipid syndrome presents with a swollen and painful
leg. Doppler ultrasound confirms a deep vein thrombosis (DVT). She had a previous DVT 4 months ago and
was taking warfarin (with a target INR of 2-3) when the DVT occurred. How should her anticoagulation be
managed?
A. Life-long warfarin, increase target INR to 3 - 4

B. Add in life-long low-dose aspirin
C. A further 6 months warfarin, target INR 2 - 3
D. A further 6 months warfarin, target INR 3 - 4
E. Life-long warfarin, target INR 2 - 3
ANSWER:
A. Life-long warfarin, increase target INR to 3 - 4
EXPLANATION:
The evidence base is scanty here but most clinicians would increase the target INR to 3-4 if a patient has
had a further thrombosis with an INR of 2-3. Please see the BCSH guidelines
Q-151
One of your patients is started on denosumab for osteoporosis.
Which one of the following adverse effects has been linked to denosumab therapy?
A. Benign intracranial hypertension

B. Sarcoma
C. Acute pancreatitis
D. Atypical femoral fractures
E. Ovarian hyperstimulation syndrome
ANSWER:
D. Atypical femoral fractures
EXPLANATION:
Denosumab is generally well tolerated but may cause atypical femoral fractures
Please see Q-5 for Denosumab
Q-152-154
A. Methotrexate
B. Gold
C. Infliximab
D. Azathioprine
E. Prednisolone
F. Ciclosporin
G. Sulfasalazine
Q-152
Proteinuria
ANSWER:
B. Gold
Q-153
Oligospermia
ANSWER:
G. Sulfasalazine
Q-154
Reactivation of tuberculosis
ANSWER:
C. Infliximab
Please see Q-75-77 for Rheumatoid Arthritis: Drug Effects
Q-155
An 80-year-old woman comes to you for advice. She is concerned about the risk of osteoporosis as her
friend has recently suffered a hip fracture. What is the chance that this patient has osteoporosis, assuming
that she has average risk for her age and gender?
A. 2-3%
B. 5-7%
C. 10%
D. 15%
E. 25%
ANSWER:
E. 25%
EXPLANATION:
Q-156
A 31-year-old woman presents as her fingers intermittently turn white and become painful. She describes
the fingers first turning white, then blue and finally red. This is generally worse in the winter months but it
is present all year round. Wearing gloves does not help. Clinical examination of her hands, other joints and
skin is unremarkable. Which one of the following treatments may be beneficial?
A. Amitriptyline
B. Aspirin
C. Pregabalin
D. Propranolol
E. Nifedipine
ANSWER:
E. Nifedipine
EXPLANATION:
Nifedipine is a pharmacological option for Raynaud's phenomenon
This lady has Raynaud's disease.
Q-157
The presence of anti-cyclic citrullinated peptide antibody is suggestive of which one of the following
conditions?
A. Systemic lupus erythematous

C. Type 1 diabetes mellitus
D. Addison's disease
E. Dermatomyositis
ANSWER:
EXPLANATION:
Anti-cyclic citrullinated peptide antibodies are associated with rheumatoid arthritis
Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of
rheumatoid arthritis. It may therefore play a key role in the future of rheumatoid arthritis, allowing early
detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity similar to rheumatoid
factor (70-80%, see below) with a much higher specificity of 90-95%.
NICE recommends that patients with suspected rheumatoid arthritis who are rheumatoid factor negative
should be test for anti-CCP antibodies.
Please see Q-10 for Rheumatoid Arthritis: Antibodies
Q-158
You are reviewing a 67-year-old woman with a history of osteoporosis. She has recently been started on
denosumab by the rheumatologists.
Which one of the following statements regarding denosumab is correct?
A. It is contraindicated in patients with a history of ischaemic heart disease

B. It is taken as a once a week tablet
C. Dyspnoea and diarrhoea are common side-effects
D. Patients should have the Zostavax vaccine before starting treatment
E. It should not be prescribed in patients with a family history of sarcoma
ANSWER:
C. Dyspnoea and diarrhoea are common side-effects
EXPLANATION:
Please see Q-5 for Denosumab
Q-159
A 78-year-old woman is discharged following a fractured neck of femur. On review she is making good
progress but consideration is given to secondary prevention of further fractures. What is the most suitable
management?
A. Arrange DEXA scan + start strontium ranelate if T-score < -2.5 SD

B. Start oral bisphosphonate
C. Arrange DEXA scan + start oral bisphosphonate if T-score < -1.0 SD
D. Arrange DEXA scan + start hormone replacement therapy if T-score < -2.5 SD
E. Arrange DEXA scan + start oral bisphosphonate if T-score < -1.5 SD
ANSWER:
B. Start oral bisphosphonate
EXPLANATION:
NICE guidelines support starting a bisphosphonate without waiting for a DEXA scan in such scenarios
Q-160
A 55-year-old lady presents with a feeling of a shade covering part of her left eye. She has also had
intermittent headaches on that side. She describes jaw pain when chewing. Her temporal artery is tender.
Blood test reveals an erythrocyte sedimentation rate of 58mm/hr.
A. Aspirin 300mg straight away

B. Prednisolone 40mg
C. Prednisolone 60mg immediately
D. Refer to ophthalmology urgently (within 2 weeks)
E. Refer to rheumatology urgently (within 2 weeks)
ANSWER:
C. Prednisolone 60mg immediately
EXPLANATION:
Giant cell arteritis should be treated as a emergency as it can cause sight loss. If there is visual
involvement, 60mg of prednisolone as a one-off dose is advised and then they should be referred for a
ophthalmology review the same day. Aspirin should be started at a dose of 75mg daily unless there are
clear contraindications. 2 weeks is too long to wait if there are already visual symptoms. 40mg of
prednisolone can be used if there is no eye involvement.
Q-161
A 42-year-old woman with a past medical history of rheumatoid arthritis presents to her GP with a 2-week
history of increased inflammation and pain in the wrist of her right hand. She feels more generally
fatigued and has noticed the drop in her energy as she has taken to having an afternoon nap. She is
currently treated with sulfasalazine.
On examination, the wrist is swollen but is not erythematous or hot. The GP takes some bloods which
show the following:
Hb 116 g/L Male: (135-180) Female: (115 - 160)

Platelets 220 * 109/L (150 - 400)
WBC 10.5 * 109/L (4.0 - 11.0)
Na+ 142 mmol/L (135 - 145)
K+ 3.7 mmol/L (3.5 - 5.0)
Urea 6.0 mmol/L (2.0 - 7.0)
CRP 110 mg/L (< 5)
What is the most appropriate initial management?
A. Empirical antibiotics IV
B. Hydrocortisone IV
C. Increase sulfasalazine dose PO
D. Methotrexate PO
E. Methylprednisolone IM
ANSWER:
E. Methylprednisolone IM
EXPLANATION:
Intramuscular steroids such as methylprednisolone are used to manage the acute flares of rheumatoid
arthritis
The presentation of increased swelling and pain of a joint and fatigue on a background of rheumatoid
arthritis suggests an acute flare of the disease. Although one of the differentials is septic arthritis, for
which the treatment would be empirical antibiotics IV. The findings on examination of a swollen but not
erythematous or hot joint combined with the blood results, which show a normal WCC make an acute flare
the primary differential.
As per the NICE guidelines, acute flares of rheumatoid arthritis are typically managed with oral or
intramuscular steroids such as methylprednisolone. The guidelines recommend the use of IM or PO
steroids if intra-articular steroids are not possible or appropriate. IV steroids are not recommended in the
treatment of rheumatoid arthritis.
An increase in the dose of sulfasalazine may be warranted, likely after a review in secondary care.
However, this question asks about the best initial management for which oral or intramuscular steroids
are the best answer.
Q-162
A 57-year-old woman with a history of polymyalgia rheumatica has been taking prednisolone 10 mg for
the past 5 months. A DEXA scan is reported as follows:
L2 T-score -1.6 SD
Femoral neck T-score -1.7 SD
What is the most suitable management?
A. No treatment
B. Vitamin D + calcium supplementation + repeat DEXA scan in 6 months
C. Vitamin D + calcium supplementation
D. Vitamin D + calcium supplementation + hormone replacement therapy
E. Vitamin D + calcium supplementation + oral bisphosphonate
ANSWER:
E. Vitamin D + calcium supplementation + oral bisphosphonate
EXPLANATION:
Whilst DEXA scans were commonly used in this scenario in the past, more recent guidelines advocate
giving patients on long-term corticosteroids prophylaxis without seeking a DEXA scan. NICE Clinical
Knowledge Summaries advocate the following:
If bone-sparing treatment is recommended, prescribe a bisphosphonate (alendronate 10 mg once daily or

70 mg once weekly, or risedronate 5 mg once daily or 35 mg once weekly), if there are no
contraindications and after appropriate counselling to:
 ...
 Consider prescribing to:
 People who are taking high doses of oral corticosteroids (more than or equivalent to prednisolone
7.5 mg daily for 3 months or longer).
 ...
Please see Q-14 for Osteoporosis: Glucocorticoid: Induced
Q-163
A 71-year-old man presents with an erythematous, swollen first metatarsophalangeal joint on the left
foot. This is causing him considerable pain and he is having difficulty walking. He has never had any
previous similar episodes. His past medical history includes atrial fibrillation and type 2 diabetes mellitus
and his current medications are warfarin, metformin and simvastatin. What is the most appropriate
treatment of this episode?
A. Intra-articular corticosteroid
B. Colchicine
C. Ibuprofen
D. Diclofenac
E. Prednisolone
ANSWER:
B. Colchicine
EXPLANATION:
NSAIDs should be avoided in elderly patients taking warfarin due to the risk of a life-threatening
gastrointestinal haemorrhage. Oral steroids are an option but would upset his diabetic control.
Whilst anticoagulation is not a contraindication to joint injection it would make this option less attractive
interactions.
Q-164
A 67-year-old woman presents with a rash. For the past two weeks she has felt tired and 'achey'. She also
has a dry cough and some pleuritic chest pain. She is most concerned however with a new rash on her
face:
Which drug is most likely to cause this presentation?
A. Procainamide
B. Digoxin
C. Sodium valproate
D. Methyldopa
E. Allopurinol
ANSWER:
A. Procainamide
EXPLANATION:
DRUG-INDUCED LUPUS
In drug-induced lupus not all the typical features of systemic lupus erythematosus are seen, with renal and
nervous system involvement being unusual. It usually resolves on stopping the drug.
Features
 arthralgia
 myalgia
 skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
 ANA positive in 100%, dsDNA negative
 anti-histone antibodies are found in 80-90%
 anti-Ro, anti-Smith positive in around 5%
A woman with drug-induced lupus
Most common causes

 procainamide
 hydralazine
Less common causes

 isoniazid
 minocycline
 phenytoin
Q-165
A 70-year-old woman is reviewed. She sustained a fracture of her wrist one year ago, following which a
DEXA scan was performed. This showed a T-score of -2.8 SD. Calcium and vitamin D supplementation was
started along with oral alendronate. This however was stopped due to oesophagitis. In accordance with
NICE guidelines, what is the most suitable next management step?
A. Start hormone replacement therapy

B. Start raloxifene
C. Start teriparatide
D. Switch to risedronate
E. Refer for hip protectors
ANSWER:
D. Switch to risedronate
EXPLANATION:
The 2008 NICE guidelines suggest switching to risedronate or etidronate in patients unable to tolerate
alendronate

Q-166
An active 14-year-old girl presents to you having seen your colleague 4 weeks ago with right sided knee
pain. She plays netball and 6 weeks ago fell on the court landing awkwardly. Since the initial consultation,
her pain has not improved, it is most noticeable at night time and disturbs her sleep. On examination, you
palpate a firm, fixed swelling over her distal femur. What is the most appropriate next step?
A. Referral to physiotherapy
B. Urgent outpatient orthopaedic referral
C. Reassure
D. Urgent XR of right knee (within 48 hours)
E. USS of palpable mass
ANSWER:
D. Urgent XR of right knee (within 48 hours)
EXPLANATION:
Unresolved, persistent night time pain in an adolescent with a palpable bony mass gives cause for grave
concern. This history is consistent with a potential bone tumour until proven otherwise. According to the
NICE guidelines relating to childhood cancer, the correct answer for suspected sarcoma is to get an urgent
XR within 48 hours. Referral to physiotherapy and reassurance are incorrect answers as they do not
address the red flag symptoms given in the history. Ultrasound is incorrect as it is not the most
appropriate imaging for bone pain and swelling. Urgent outpatient orthopaedic referral is incorrect as it
will cause time delay for further investigation and management.
Source: NICE childhood cancer - suspected sarcoma. (AKT report 2016)
Please see Q-119 for Bone Tumours
Q-167
A 45-year-old man presents with a painful, swollen and red left middle toe, which he describes as looking
like a 'sausage'. There is no history of trauma and his symptoms have been present for around a week. On
examination he is apyrexial and the pulse is 72/min. The toe is swollen and red as described but there is
no proximal extension of the erythema. Which one of the following conditions is most associated with this
presentation?
A. Diabetes mellitus
B. Systemic sclerosis
C. Rheumatoid arthritis
D. Bisphosphonate use
E. Psoriatic arthritis
ANSWER:
E. Psoriatic arthritis
EXPLANATION:
A 'sausage-shaped' digit is a classical description of dactylitis. It would be unusual for gout to affect the
middle toe, the vast majority of cases occur in the first metatarsophalangeal joint.
The lack of systemic upset, length of history and confined erythema go against a diagnosis of septic
arthritis (e.g. linked to diabetes).
Dactylitis is not a feature of rheumatoid arthritis.
Please see Q-45 for Dactylitis
Q-168
A 64-year-old man with progressive pain and stiffness in his right knee presents to surgery. There is no
history of locking, giving way or trauma. An x-ray is reported as follows:
Plain film: right knee
Moderate degenerative changes consistent with osteoarthritis. Intra-articular calcification likely to

represent a loose body
A. Check serum calcium

B. Continue to manage as per osteoarthritis guidelines
C. Check serum urate
D. Refer for joint replacement
E. Refer for arthroscopic exploration and washout
ANSWER:
B. Continue to manage as per osteoarthritis guidelines
EXPLANATION:
In an asymptomatic patient (i.e. not locking) there is no need to refer a patient with x-ray evidence of a
loose body. NICE make specific mention of this in their recent guidelines
Q-169
A 79-year-old woman falls over on to an outstretched hand and sustains a Colles' fracture (fracture of the
distal radius). She has no past medical history of note other than depression and osteoarthritis. What is
the most appropriate next course of action with regards to her risk of sustaining a further fracture?
A. Arrange a DEXA scan

B. Perform a FRAX (without bone mineral density) assessment
C. Start alendronate 70mg once weekly
D. No further action is required
E. Arrange a myeloma screen
ANSWER:
C. Start alendronate 70mg once weekly
EXPLANATION:
Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan
Given her age she is presumed to have osteoporosis and therefore started on oral alendronate 70mg once
weekly. A DEXA scan does not need to be arranged.
Please see Q-4 for Osteoporosis: Assessing Patients Following a Fragility Fracture
Q-170-172
Theme: Adverse effects of drugs used in rheumatoid arthritis drugs
A. Naproxen
B. Etanercept
C. Sulfasalazine
D. Rituximab
E. Methotrexate
F. Infliximab
G. Adalimumab
H. Abatacept
I. Penicillamine
J. Ciclosporin
Q-170
Exacerbation of myasthenia gravis
ANSWER:
I. Penicillamine
Q-171
Bronchospasm in an asthmatic
ANSWER:
A. Naproxen
Q-172
Proteinuria
ANSWER:
I. Penicillamine
Please see Q-75-77 for Rheumatoid Arthritis: Drug Side-Effects
Q-173
A 64-year-old woman books into an early morning duty appointment. She reports that over the last week
she has been feeling progressively more fatigued with new abdominal pain, vomiting and excessive thirst.
She has a background of hypertension well controlled with amlodipine only. Her only other medication is
atorvastatin. One week ago she started a six week course of once-weekly high dose colecalciferol, started
by another GP. She has not yet taken the second dose.
Her observations and examination are unremarkable, but she is clearly fatigued and drowsy.
You organise urgent bloods that morning and arrange to see her again that afternoon with the results.
You later receive a phone call from the lab to notify you of her blood results:
Hb 124 g/L Male: (135-180) Female: (115 - 160)

Platelets 224 * 109/L (150 - 400)
WBC 6.4 * 109/L (4.0 - 11.0)
Na+ 141 mmol/L (135 - 145)

K+ 4.0 mmol/L (3.5 - 5.0)
Urea 6.9 mmol/L (2.0 - 7.0)
Calcium 3.7 mmol/L (2.1-2.6)
Phosphate 1.1 mmol/L (0.8-1.4)
Magnesium 1.0 mmol/L (0.7-1.0)
Thyroid stimulating hormone (TSH) 3.24 mU/L (0.5-5.5)
You look back at her blood results from the week before:
Calcium 2.56 mmol/L (2.1-2.6)

Phosphate 1.2 mmol/L (0.8-1.4)
Magnesium 0.8 mmol/L (0.7-1.0)
Vitamin D 7 nmol/L (>50)
You admit her directly under the acute medical team for further management.
What is the most likely underlying diagnosis?
A. Multiple myeloma
B. Paget’s disease
C. Graves disease
D. Primary hyperparathyroidism
ANSWER:
D. Primary hyperparathyroidism
EXPLANATION:
Rapid vitamin D replacement can cause toxicity if there is coexistent hyperparathyroidism
This woman has severe hypercalcaemia and needs acute admission under the medical team. This is most
likely due to vitamin D toxicity and unidentified primary hyperparathyroidism. The previous bloods show a
severe vitamin D deficiency yet with calcium level that is at the higher end of normal. This suggests an
overactive parathyroid, the effects of which have been masked by the low vitamin D. This could have been
clarified by testing the parathyroid hormone prior to giving vitamin D. Generally advice from
endocrinology should be sort prior to rapid vitamin D replacement if the baseline corrected calcium is >2.5.
Multiple myeloma can certainly cause hypercalcaemia but not so rapidly.
Paget's disease causes an increased ALP with a normal calcium level.
Thyrotoxicosis due to Graves disease can cause hypercalcaemia due to increased bone turnover but a
suppressed TSH would be expected.
Chronic kidney disease can disturb calcium metabolism but this would not be expected with a creatinine of
this level.
Q-174
Please look at the hands of this 50-year-old lady. She complains of tight, stiff fingers that turn white in the
cold.
A. Osteoarthritis
C. Systemic lupus erythematosus
D. Cryoglobulinaemia
E. Limited cutaneous systemic sclerosis
ANSWER:
E. Limited cutaneous systemic sclerosis
EXPLANATION:
This patient has Sclerodactyly and Raynaud's phenomenon. Telangiectasia can also be seen on the hands.
She therefore has the RST of CREST syndrome, or more accurately limited cutaneous systemic sclerosis.
Please see Q-47 for Systemic Sclerosis
Q-175
After a fall at home, an 85-year-old Caucasian female presents to her GP. After a FRAX assessment, she is
referred for a DEXA scan. The results of the scan are as follows:
> -1.0 = normal

T score -2.25 -1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
< -2.0 = below the expected range for age

Z score 0
> -2.0 = within the expected range for age
Which of the following factors is the Z score adjusted for?
A. Age, gender, ethnic factors

B. Fracture history, gender, ethnic factors
C. Age, fracture history, gender
D. Glucocorticoid treatment, age, gender
E. Glucocorticoid treatment, age, fracture history
ANSWER:
A. Age, gender, ethnic factors
EXPLANATION:
The Z score is a comparison of a person's bone density with that of an average person of the same age,
sex, and ethnic background.
Glucocorticoid treatment and fracture history do not affect the Z score.

Q-176
A 66-year-old female starts colchicine to try to settle the symptoms of gout which are not being controlled
with diclofenac. What side-effect is it most important to warn her about?
A. Diarrhoea
B. Heartburn
C. Chest pain
D. Sore throat
E. Visual disturbance
ANSWER:
A. Diarrhoea
EXPLANATION:
SURGERY MCQs
Q-1
Which one of the following ethnic groups have an increased incidence of prostate cancer?
A. Afro-Caribbean
B. Ashkenazi Jews
C. Chinese
D. Indian subcontinent
E. White
ANSWER:
A. Afro-Caribbean
EXPLANATION:
Prostate cancer - more common in the Afro-Caribbean population
PROSTATE CANCER: FEATURES

Prostate cancer is now the most common cancer in adult males in the UK and is the second most common
cause of death due to cancer in men after lung cancer.
Risk factors
 increasing age
 obesity
 Afro-Caribbean ethnicity
 family history: around 5-10% of cases have a strong family history
Localised prostate cancer is often asymptomatic. This is partly because cancers tend to develop in the
periphery of the prostate and hence don't cause obstructive symptoms early on. Possible features include:
 bladder outlet obstruction: hesitancy, urinary retention
 haematuria, haematospermia
 pain: back, perineal or testicular
 digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus
Isotope bone scan (using technetium-99m labelled diphosphonates which accumulate in the bones) from a patient with
metastatic prostate cancer. The scan demonstrates multiple, irregular, randomly distributed foci of high grade activity
involving the spine, ribs, sternum, pelvic and femoral bones. The findings are in keeping with multiple osteoblastic
metastasis.
Q-2
A 45-year-old man presents with a right sided scrotal swelling. He describes this getting worse over the
last 2 weeks and comes to see you because it appears unsightly and he has developed an unpleasant
dragging sensation. On examination of the patient lying flat, there is a tense, right sided varicocele. What
is the most appropriate management?
A. Refer urgently to Urology

B. Consider delayed referral to Urology if the discomfort worsens
C. Reassure the patient
D. Refer for an ultrasound scan of the testis
E. Refer to urology to consider ablative therapy
ANSWER:
A. Refer urgently to Urology
EXPLANATION:
Rapidly developing varicoceles, solitary right sided varicoceles and varicoceles that remain tense with the
patient lying down especially if the patient are over 40 years of age are red flags for testicular tumours
and these patients should be urgently referred to Urology to exclude cancer. As this patient has several red
flags he needs an urgent referral. The other options are not appropriate as they may lead to delays in
diagnoses and appropriate management.
(AKT feedback report October 2016) Source NICE CKS Varicocele
SCROTAL PROBLEMS
Epididymal cysts
Epididymal cysts are the most common cause of scrotal swellings seen in primary care.
Features
 separate from the body of the testicle
 found posterior to the testicle
Associated conditions
 polycystic kidney disease
 cystic fibrosis
 von Hippel-Lindau syndrome
Diagnosis may be confirmed by ultrasound.
Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or
symptomatic cysts.
Hydrocele
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into
communicating and non-communicating:
 communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down
into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-
10%) and usually resolve within the first few months of life
 non-communicating: caused by excessive fluid production within the tunica vaginalis
Hydroceles may develop secondary to:

 epididymo-orchitis
 testicular torsion
 testicular tumours
Features
 soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
 the swelling is confined to the scrotum, you can get 'above' the mass on examination
 transilluminates with a pen torch
 the testis may be difficult to palpate if the hydrocele is large
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the
underlying testis cannot be palpated.
Management
 infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
 in adults a conservative approach may be taken depending on the severity of the presentation. Further
investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a
tumour
Varicocele
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be
important as they are associated with infertility.
Varicoceles are much more common on the left side (> 80%). Features:
 classically described as a 'bag of worms'
 subfertility
Diagnosis
 ultrasound with Doppler studies
Management
 usually conservative
 occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the
effectiveness of surgery to treat infertility
Q-3
A 68-year-old woman is assessed in the breast clinic after having an abnormal mammogram. Clinical exam
of the breast reveals a small fixed lump in the right breast. What is the most common type of breast
cancer?
A. Invasive lobular carcinoma

B. Inflammatory breast cancer
C. Invasive ductal carcinoma (no special type)
D. Paget's disease of the nipple
E. Tubular breast cancer
ANSWER:
C. Invasive ductal carcinoma (no special type)
EXPLANATION:
Invasive ductal carcinoma (no special type) is the most common type of breast cancer
BREAST CANCER: TYPES AND CLASSIFICATION

The terminology surrounding breast cancer can sometimes be confusing and has changed over recent years.
It is useful to start by considering basic breast anatomy
Basic breast anatomy
Most breast cancers arise from duct tissue followed by lobular tissue, described as ductal or lobular
carcinoma respectively. These can be further subdivided as to whether the cancer hasn't spread beyond the
local tissue (described as carcinoma-in-situ) or has spread (described as invasive). Therefore, common
breast cancer types include:
 Invasive ductal carcinoma. This is the most common type of breast cancer. To complicate matters
further this has recently been renamed 'No Special Type (NST)'. In contrast, lobular carcinoma and other
rarer types of breast cancer are classified as 'Special Type'
 Invasive lobular carcinoma
 Ductal carcinoma-in-situ (DCIS)
 Lobular carcinoma-in-situ (LCIS)
Rarer types of breast cancer are shown in the following list. These are classed as 'Special Type' but as noted
previously remember that a relatively common type of breast cancer (lobular) is also Special Type:
 Medullary breast cancer
 Mucinous (mucoid or colloid) breast cancer
 Tubular breast cancer
 Adenoid cystic carcinoma of the breast
 Metaplastic breast cancer
 Lymphoma of the breast
 Basal type breast cancer
 Phyllodes or cystosarcoma phyllodes
 Papillary breast cancer
Other types of breast cancer include the following (although please note they may be associated with the
underlying lesions seen above, rather than completely separate subtypes):
Paget's disease of the nipple is an eczematoid change of the nipple associated with an underlying breast
malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated
with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients
without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma
in situ.
Inflammatory breast cancer where cancerous cells block the lymph drainage resulting in an inflamed
appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.
Q-4
You see a 62-year-old gentleman for his annual health review. He has hypertension, a previous myocardial
infarction 12 months ago and depression. He takes amlodipine, ramipril, sertraline, atorvastatin and
aspirin.
He says he feels very well but his only issue is erectile dysfunction which he has had since his heart attack
when he started all of his medications.
Which medication that this man is taking is most likely to be causing this symptom?
A. Amlodipine
B. Ramipril
C. Sertraline
D. Atorvastatin
E. Aspirin
ANSWER:
C. Sertraline
EXPLANATION:
SSRIs are a common drug cause of ED
Whilst amlodipine and ramipril may cause erectile dysfunction this is listed in the BNF as an 'uncommon'
side-effect. Sexual dysfunction is common with SSRIs, making it the most likely culprit.
ERECTILE DYSFUNCTION
Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit
satisfactory sexual performance. It is a symptom and not a disease and the causes can broadly be split into
organic, psychogenic and mixed.
It is important to try and differentiate between organic and psychogenic causes of erectile dysfunction.
Factors favouring an organic cause Factors favouring a psychogenic causes

Gradual onset of symptoms Sudden onset of symptoms
Lack of tumescence Decreased libido
Normal libido Good quality spontaneous or self-stimulated erections
Major life events
Problems or changes in a relationship
Previous psychological problems
History of premature ejaculation
Other than increasing age, risk factors include:

 cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome,
hypertension, smoking
 alcohol use
 drugs: SSRIs, beta-blockers
Investigations
As part of the assessment for erectile dysfunction Clinical Knowledge Summaries (CKS) recommend that all
men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels.
Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low
or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and
prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.
Opinion on testosterone measurement differs between some experts but CKS advises universal
measurement of testosterone in men with erectile dysfunction as recommended by the British Society for
Sexual Medicine and the European Association of Urology.
Management
PDE-5 inhibitors (such as sildenafil, 'Viagra') have revolutionised the management of ED
 they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
 sildenafil can be purchased over-the-counter without a prescription.
Vacuum erection devices are recommended as first-line treatment in those who can't/won't take a PDE-5
inhibitor.
Other points
 for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
 people with erectile dysfunction who cycle for more than three hours per week should be advised to
stop
Q-5
A 62-year-old man with no significant past medical history presents with a right sided groin lump which he
noticed whilst having a shower. It has been present for 2 weeks and disappears when he lies down. It
never causes him any discomfort and there are no other gastrointestinal symptoms of note. Examination
reveals an small reducible swelling in the right groin. What is the most appropriate management?
A. Refer for fitting of a truss

B. Refer to vascular surgeon
C. Routine referral for surgical repair
D. Advise no action as it will probably improve with time
E. Fast-track referral to colorectal service
ANSWER:
C. Routine referral for surgical repair
EXPLANATION:
This patient has an asymptomatic inguinal hernia. Studies looking at conservative management tend to
find that many patients become symptomatic and eventually have surgery anyway. As this patient is
medically fit most clinicians would refer for surgical repair.
Inguinal hernias do not resolve spontaneously.
A number of PCTs have begun to put asymptomatic inguinal hernias on the 'low clinical priority' list. Whilst
this may be reasonable for older patients who are 'not bothered' by their condition it is debatable how
feasible such a blanket policy is for all patients.
INGUINAL HERNIA
Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have
around a 25% lifetime risk of developing an inguinal hernia.
Features
 groin lump: disappears on pressure or when the patient lies down
 discomfort and ache: often worse with activity, severe pain is uncommon
 strangulation is rare
Whilst traditional textbooks describe the anatomical differences between indirect (hernia through the
inguinal canal) and direct hernias (through the posterior wall of the inguinal canal) this is of no relevance to
the clinical management.
Management
 the clinical consensus is currently to treat medically fit patients even if they are asymptomatic
 a hernia truss may be an option for patients not fit for surgery but probably has little role in other
patients
 mesh repair is associated with the lowest recurrence rate
The Department for Work and Pensions recommend that following an open repair patients return to non-
manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks
Complications
 early: bruising, wound infection
 late: chronic pain, recurrence
Q-6
You see a 4-year-old boy with recurrent balanitis. His glans penis and foreskin are swollen and red. His
mum says that there are a foul odour and a slight discharge.
What is the most common organism isolated in balanitis?
A. C. albicans
B. Group B beta-haemolytic streptococci
C. Gardnerella
D. Staphylococcus
E. Trichomonas
ANSWER:
A. C. albicans
EXPLANATION:
C. albicans is the most common organism isolated in balanitis
C. albicans is the most common organism isolated in balanitis. Therefore, option 1 is correct. All the other
answers are wrong. They are all possible causes but are less frequently isolated.
Of bacterial infection group B beta-haemolytic streptococci are most frequently isolated in balanitis.
BALANITIS
Balanitis is inflammation of the glans penis and sometimes extends to the underside of the foreskin which is
known as balanoposthitis. There are a number of causes of balanitis and the most common causes are
infective (both bacterial and candidal) although there are a number of other autoimmune causes that are
important to know. Simple hygiene is a key part of the treatment of balanitis and both improper washing
under the foreskin and the presence of a tight foreskin can make balanitis worse. The presentation can
either be acute or more chronic and children and adults are affected by the causes differently.
Assessment:
 Most diagnoses are made clinically based on the history and examination.
 The history will tell you how acute the presentation is and other key features that are important to note
are whether there is itching or discharge.
 In the history also look for the presence of other systemic conditions affecting the skin such as eczema,
psoriasis or connective tissue diseases.
The table below shows the clinical features associated with the most common causes of balanitis, whether
they occur in children or adults and how common they are:
Acute or Children
Diagnosis Frequency Chronic? Features or Adults?
Candidiasis Very Acute Usually occurs after intercourse and Both
common associated with itching and white non-
urethral discharge
Dermatitis (contact Very Acute Itchy, sometimes painful and occasionally Both
or allergic) common associated with a clear non-urethral
discharge. Often there is no other body area
affected
Dermatitis (eczema Very Both Very itchy but not associated with any Both
or psoriasis) common discharge and there will be a medical history
of an inflammatory skin condition with active
areas elsewhere on the body
Bacterial Common Acute Painful and can be itchy with yellow non- Both
urethral discharge and most often due
to Staphylococcus spp.
Anaerobic Common Acute May be itchy but is most associated with a Both
very offensive yellow non-urethral discharge
Acute or Children
Diagnosis Frequency Chronic? Features or Adults?
Lichen planus Uncommon Both May be itchy, the main diagnostic feature is More
the presence of Wickham's striae and commonly
violaceous papules adults
Lichen sclerosus Rare Chronic May be itchy, associated with white plaques Both
(balanitis xerotica and can cause significant scarring
obliterans)
Plasma cell Rare Chronic Not itchy with clearly circumscribed areas of Both
balanitis of Zoon inflammation
Circinate balanitis Uncommon Both Not itchy and not associated with any Adults
discharge. The key feature is painless
erosions and it can be associated with
Reiter's syndrome
Investigations:
 The majority of conditions are diagnosed clinically based on the history and physical appearance of the
glans penis.
 In the cases of suspected infective causes a swab can be taken for microscopy and culture which may
demonstrate bacteria or Candida albicans.
 When there is a doubt about the cause and there is extensive skin change, then a biopsy can be helpful
in confirming the diagnosis.
General treatment:
 There are three things which form the basis of management of all causes of balanitis; gentle saline
washes, ensuring to wash properly under the foreskin, and in the case of more severe irritation and
discomfort then 1% hydrocortisone can be used for a short period.
 When the cause is not clear, these measures can often resolve the condition alone.
Specific treatment:
 In the case of candidiasis the treatment is with topical clotrimazole which has to be applied for two
weeks to fully treat the infection.
 Bacterial balanitis is most often due to Staphylococcus spp. or Group B Streptococcus spp. and can be
treated with oral flucloxacillin or clarithromycin if penicillin allergic.
 Anaerobic balanitis is managed with saline washing and can also be managed with topical or oral
metronidazole if not settling.
 Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g.
hydrocortisone)
 Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids (e.g.
clobetasol).
 Circumcision can help in the case of lichen sclerosus.
References
G. R. Scott. Sexually Transmitted Infections in Davidson’s Principles and Practice of Medicine 21st ed. 2010.
Churchill Livingstone, Elsevier.
Q-7
A 62-year-old man presents with lethargy. This has been getting worse over the past few months and is
not associated with any specific symptoms. A series of blood tests are requested:
Hb 12.3 g/l
MCV 82 fl
Platelets 233* 109/l
WBC 6.4 * 109/l
Iron studies Normal
Vitamin B12/folate Normal
CRP 6 mg/l
TSH 2mU/l
In keeping with NICE guidance, what is the most appropriate next step?
A. Refer for a non-urgent colonoscopy

B. Arrange a chest x-ray
C. Offer faecal occult blood testing
D. Dietary advice then repeat full blood count in 6 months
E. Trial of vitamin B12 injections then repeat full blood count in 6 months
NICE recommend faecal occult blood testing in this scenario, even in the absence of iron-deficiency.
ANSWER:
C. Offer faecal occult blood testing
EXPLANATION:
COLORECTAL CANCER: REFERRAL GUIDELINES
NICE updated their referral guidelines in 2015. The following patients should be referred urgently (i.e. within
2 weeks) to colorectal services for investigation:
 patients >= 40 years with unexplained weight loss AND abdominal pain
 patients >= 50 years with unexplained rectal bleeding
 patients >= 60 years with iron deficiency anaemia OR change in bowel habit
 tests show occult blood in their faeces (see below)
An urgent referral (within 2 weeks) should be 'considered' if:

 there is a rectal or abdominal mass
 there is an unexplained anal mass or anal ulceration
 patients < 50 years with rectal bleeding AND any of the following unexplained symptoms/findings:
 -→ abdominal pain
 -→ change in bowel habit
 -→ weight loss
 -→ iron deficiency anaemia
Faecal Occult Blood Testing (FOBT)

This was one of the main changes in 2015. Remember that the NHS now has a national screening
programme offering screening every 2 years to all men and women aged 60 to 74 years. Patients aged over
74 years may request screening.
In addition FOBT should be offered to:
 patients >= 50 years with unexplained abdominal pain OR weight loss
 patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
 patients >= 60 years who have anaemia even in the absence of iron deficiency
Q-8
A 35-year-old woman attends surgery following a recent diagnosis of breast cancer. Her oncologist has
advised she commence anastrozole (an aromatase inhibitor) as her cancer is oestrogen-receptor positive.
The oncologist has requested you discuss bone health with the patient.
What is the next most appropriate management?
A. Commence her on a bisphosphonate, vitamin d and calcium supplement immediately

B. Reassure her that the risk of osteoporosis is low and commence vitamin d and calcium supplements
only
C. Arrange a dual-energy X-ray absorptiometry (DEXA) scan
D. Calculate her FRAX score then arrange a dual-energy X-ray absorptiometry (DEXA) scan depending on
results
E. Calculate her QFracture score then arrange a dual-energy X-ray absorptiometry (DEXA) scan depending
on results
ANSWER:
C. Arrange a dual-energy X-ray absorptiometry (DEXA) scan
EXPLANATION:
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
According to current NICE guidance, a dual-energy X-ray absorptiometry (DEXA) scan should be offered to
any patient when initiating an aromatase inhibitor for breast cancer. This is because they reduce
peripheral synthesis of oestrogen which can increase the risk of osteoporosis.
There is no indication for commencing her on bisphosphonates at this point without the results of the
DEXA scan.
FRAX and QFracture risk may underestimate risk in this group, and therefore arranging a DEXA scan is the
most appropriate option.
She is potentially at increased risk of osteoporosis owing to the medication, and therefore reassuring her
only is not the correct option.
ANTI-OESTROGEN DRUGS
Selective oEstrogen Receptor Modulators (SERM)

Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist. It is used in the
management of oestrogen receptor-positive breast cancer.
Adverse effects
 menstrual disturbance: vaginal bleeding, amenorrhoea
 hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
 venous thromboembolism
 endometrial cancer
 osteoporosis
Aromatase inhibitors
Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is
important as aromatisation accounts for the majority of oestrogen production in postmenopausal women
and therefore anastrozole is used for ER +ve breast cancer in this group.
Adverse effects
 osteoporosis
o NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
 hot flushes
 arthralgia, myalgia
 insomnia
Q-9
You see an 18-year-old boy with a left-sided varicocele. It has been present for a few months and doesn't
cause him any discomfort and has not increased in size. It is about 2 cm in diameter.
On examination, the varicocele is only present when the patient performs the Valsalva manoeuvre.
He is particularly concerned about future fertility, although he currently has no plans to have children.
A. Surgery for varicoceles increases the chance of spontaneous pregnancy

B. 30% of men who have a varicocele have no problem fathering children
C. Abnormal sperm production with a decreased FSH is consistent with impaired spermatogenesis
D. There is no link between the size of the varicocele and the chance of infertility
E. Men should not be offered surgery for varicoceles as a form of fertility treatment
ANSWER:
E. Men should not be offered surgery for varicoceles as a form of fertility treatment
EXPLANATION:
Men should not be offered surgery for varicoceles as a form of fertility treatment, because it does not
improve pregnancy rates
Although varicoceles may be associated with fertility problems, nearly two-thirds of men who have a
varicocele have no difficulty in fathering children. Therefore, option 2 is incorrect.
Men with varicoceles who have concerns about fertility should be offered semen analysis. Abnormal sperm
production with an elevated FSH is consistent with impaired spermatogenesis. Therefore, option 3 is
wrong.
Only larger varicoceles, which are typically easily palpable, have been clearly associated with infertility.
Men should not be offered surgery for varicoceles as a form of fertility treatment because it does not
improve spontaneous pregnancy rates. Therefore, option 1 is wrong.
VARICOCELE
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be
important as they are associated with infertility.
Varicoceles are much more common on the left side (> 80%). Features:
 classically described as a 'bag of worms'
 subfertility
Diagnosis
 ultrasound with Doppler studies
Management
 usually conservative
 occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the
effectiveness of surgery to treat infertility
Q-10
A 77-year-old man with a background of diabetes, hypertension, hypercholesterolaemia and previous
myocardial infarction (MI) sees his GP about intermittent abdominal pain that he has been having for two
months. It is dull in nature and radiates to his lower back. On examination, he has a pulsatile expansile
mass in the central abdomen. He has had a previous US abdomen 6 months ago which showed an
abdominal aortic diameter of 5.1cm. His GP repeats the US abdomen and refers to vascular clinic. The
vascular surgeon sees the patient with the US report:
US abdomen No focal pancreatic, liver or gall-bladder disease. Trace free fluid. Abdominal aorta has
diameter of 5.4cm. No biliary duct dilation. Kidneys look normal-sized and mildly echogenic.
What factor in the history most suggests that this patient needs surgery?
A. Abdominal pain
B. Abdominal aortic diameter 5.4cm
C. Trace free fluid
D. Cardiovascular risk factors (e.g. diabetes, hypertension etc.)
E. Velocity of increase of abdominal aortic diameter
ANSWER:
A. Abdominal pain
EXPLANATION:
Symptomatic AAA have high rupture risk and should undergo endovascular repair (EVAR)
The presence of abdominal pain (1) indicates a symptomatic AAA which has a high risk of rupture, and
these need surgical intervention rather than watching/medical treatment
(2) Abdominal aortic diameter needs to be >5.5cm to be classified as high rupture risk (it is close!)
(3) Trace free fluid can generally be considered a normal finding
(4) Cardiovascular risk factors should be tackled through conservative measures (e.g. stop smoking)
(5) The velocity of growth is 0.3cm over 6 months which equates to 0.6cm over 1 year, a high-risk AAA due
to velocity of growth would only be indicated if increase >1cm/year
Of course, the decision to proceed with elective surgery (e.g. endovascular repair/EVAR) is between the
patient and surgeon and is multi-faceted.
ABDOMINAL AORTIC ANEURSYM: SCREENING AND MANAGEMENT OF UNRUPTURED ANEURYSMS

Screening for an abdominal aortic aneurysm consists of a single abdominal ultrasound for males aged 65.
Screening outcome
Aorta width Interpretation Action

< 3 cm Normal - No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
>= 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable
intervention
Only found in 1 per 1,000 screened patients
Further management
Low rupture risk
 asymptomatic, aortic diameter < 5.5cm (i.e. small and medium aneurysms)
 abdominal US surveillance (on time-scales outlines above) and optimise cardiovascular risk factors (e.g.
stop smoking)
High rupture risk

 symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year)
 refer within 2 weeks to vascular surgery for probable intervention
 treat with elective endovascular repair (EVAR) or open repair if unsuitable. In EVAR a stent is placed into
the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. A
complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and
usually presents without symptoms on routine follow-up.
Q-11-13
Theme: Breast disorders
A. Lipoma
B. Paget's disease of the breast
C. Breast cancer
D. Sebaceous cysts
E. Fibroadenoma
F. Fibroadenosis
G. Duct papilloma
H. Breast abscess
I. Fat necrosis
J. Mammary duct ectasia
For each one of the following please select the most appropriate answer:
Q-11
A 72-year-old woman complains of 'eczema' on her left nipple. On examination the areola is
erythematous and thickened.
ANSWER:
Paget's disease of the breast
Q-12
A 26-year-old woman has noticed a discrete, non-tender lump which is highly mobile on examination.
ANSWER:
E. Fibroadenoma
Q-13
A 35-year-old woman complains of 'lumpy' breasts. Her symptoms are worse in the premenstrual period.
ANSWER:
F. Fibroadenosis
BREAST DISORDERS
The table below describes some of the features seen in the most common breast disorders:
Disorder Features
Fibroadenoma Common in women under the age of 30 years
Often described as 'breast mice' due as they are discrete, non-
tender, highly mobile lumps
Fibroadenosis (fibrocystic Most common in middle-aged women
disease, benign mammary 'Lumpy' breasts which may be painful. Symptoms may worsen
dysplasia) prior to menstruation
Breast cancer Characteristically a hard, irregular lump. There may be associated
nipple inversion or skin tethering
Paget's disease of the breast - intraductal carcinoma associated

with a reddening and thickening (may resemble eczematous
changes) of the nipple/areola
Mammary duct ectasia Dilatation of the large breast ducts
Most common around the menopause
Disorder Features
May present with a tender lump around the areola +/- a green
nipple discharge
If ruptures may cause local inflammation, sometimes referred to
as 'plasma cell mastitis'
Duct papilloma Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
Fat necrosis More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round
but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is
always warranted
Breast abscess More common in lactating women
Red, hot tender swelling
Lipomas and sebaceous cysts may also develop around the breast tissue.
Q-14
You see a 42-year-old Afro-Caribbean patient who would like to talk to you about erectile dysfunction. He
has been having difficulty with his erections for approximately 6 months.
His past medical history includes sickle cell disease and hypertension. He takes ramipril and amlodipine.
He has a normal body mass index and exercises for an hour in the gym five days a week, mostly using the
treadmill and weights. He does not smoke and drinks approximately 4 units of alcohol daily.
What risk factor does this patient have for erectile dysfunction?
A. Sickle cell anaemia

B. Amlodipine
C. High alcohol intake
D. Ramipril
E. Over-exercising
ANSWER:
C. High alcohol intake
EXPLANATION:
High alcohol intake is a risk factor for ED
Erectile dysfunction (ED) is a symptom and not a disease. It may have an organic and/or a psychogenic
cause and it can also be caused by certain drugs. Common drug causes include antihypertensives including
beta-blockers, verapamil, methyldopa, and clonidine. However, calcium channel blockers or angiotensin-
converting enzyme (ACE) inhibitors are not thought to cause erectile dysfunction. Therefore, options 2 and
4 are incorrect. Other common drug causes of ED include diuretics, anti-depressants and recreational
drugs such as marijuana.
High alcohol intake is also a well-known cause. This patient drinks approximately 28 units a week which is
well over the recommended safe amount. Therefore, the correct answer is option 3.
Of organic causes, vasculogenic causes are the most common. This includes cardiovascular disease (CVD),
hypertension, hyperlipidaemia, diabetes mellitus, and smoking. By modifying risk factors along with
treatment most patients can get a significant improvement. This includes blood pressure control, lipid
control, weight loss, stopping smoking, increasing exercise and reducing alcohol intake. Therefore, option
5 is incorrect as regular exercising is known to reduce ED (unless the patient is excessively cycling).
Treatment includes the use of phosphodiesterase inhibitors (PDE5) unless there are any contraindications.
Sickle cell disease increases the rate of priapism (persistent erection) so you would need to be very
cautious prescribing them to this man. However, sickle cell disease does not increase the risk of erectile
dysfunction per se so option 1 is incorrect.
Please see Q-4 for Erectile Dysfunction
Q-15
A patient has booked a telephone consultation requesting a referral for an endoscopy. Mr Olupitan is a
57-year-old man with a past medical history of hypertension and gallstones. He is an ex-smoker. He says
he was invited for a sigmoidoscopy for bowel cancer screening 2 year ago but he was travelling abroad a
lot to see his mother who was ill, so he didn't respond to the letter. He would now like to go ahead with
bowel screening. You ask about any symptoms: there is no rectal bleeding, abdominal pain, change in
bowel habit or weight loss.
What should you advise him?
A. He is no longer eligible for screening

B. You will make a routine referral to general surgery
C. He can self-refer for bowel scope screening by calling the number on the NHS website up until his 60th
birthday
D. He should wait until he is sent a home test kit (FIT/FOB) at age 60
E. You will make a two week wait referral to general surgery
ANSWER:
C. He can self-refer for bowel scope screening by calling the number on the NHS website up until his 60th
birthday
EXPLANATION:
Patients can self-refer for bowel screening with sigmoidoscopy up to the age of 60, if the offer of routine
one-off screening at age 55 had not been taken up
Patients are invited for a one-off flexible sigmoidoscopy as a screening test for bowel cancer, at the age of
55 (not yet rolled out in all parts of the UK). Patients can self-refer up until their 60th birthday if they don't
take up the initial offer. They can find the phone number on the NHS website. Referral to general surgery
is not the right route to access the screening program.
This program runs in parallel with the home test (FIT/FOB) screening for bowel cancer. The kit is sent out
every 2 years to patients aged 60-74, and patients can self-refer 2-yearly after this if they wish.
COLORECTAL CANCER: SCREENING

Overview
most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce
mortality by 16%
the NHS offers home-based, Faecal Immunochemical Test (FIT) screening to older adults
another type of screening is also being rolled out - a one-off flexible sigmoidoscopy
Faecal Immunochemical Test (FIT) screening

Key points
 the NHS now has a national screening programme offering screening every 2 years to all men and
women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may
request screening
 eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post
 a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human
haemoglobin (Hb)
 used to detect, and can quantify, the amount of human blood in a single stool sample
 advantages over conventional FOB tests is that it only detects human haemoglobin, as opposed to
animal haemoglobin ingested through diet
 only one faecal sample is needed compared to the 2-3 for conventional FOB tests
 whilst a numerical value is generated, this is not reported to the patient or GP, who will instead be
informed if the test is normal or abnormal
 patients with abnormal results are offered a colonoscopy
At colonoscopy, approximately:
 5 out of 10 patients will have a normal exam
 4 out of 10 patients will be found to have polyps which may be removed due to their premalignant
potential
 1 out of 10 patients will be found to have cancer
Flexible sigmoidoscopy screening

Key points
 screening for bowel cancer using sigmoidoscopy is being rolled out as part of the NHS screening program
 the aim (other than to detect asymptomatic cancers) is to allow the detection and treatment of polyps,
reducing the future risk of colorectal cancer
 this is being offered to people who are 55-years-old
 NHS patient information leaflets refer to this as 'bowel scope screening'
 patients can self-refer for bowel screening with sigmoidoscopy up to the age of 60, if the offer of routine
one-off screening at age 55 had not been taken up
Q-16
You see a 62-year-old gentleman with diabetes and hypertension. He has come to see you as he has been
having problems with erectile dysfunction for the last 6 months. You prescribed sildenafil which helped
him a little bit. You increased the dose of sildenafil but he is now having side effects. He would like to
know what other options are available to him.
Which medications can this man have prescribed for his condition on the NHS?
A. There are no treatments available on the NHS for erectile dysfunction

B. Only generic sildenafil
C. Only generic sildenafil and alprostadil
D. Only generic sildenafil and other phosphodiesterase inhibitors (PDE5)
E. Generic sildenafil, other PDE5 inhibitors and alprostadil
ANSWER:
E. Generic sildenafil, other PDE5 inhibitors and alprostadil
EXPLANATION:
Men with diabetes can have other PDE5 inhibitors and alprostadil prescribed on the NHS
Generic sildenafil can be prescribed without restriction on the NHS.
However, Viagra®, tadalafil (Cialis®), vardenafil (Levitra®), and avanafil (Spedra®) and alprostadil are not
prescribable on an NHS prescription except for men who:
 Have diabetes, multiple sclerosis, Parkinson's disease, poliomyelitis, prostate cancer, severe pelvic
injury, single-gene neurological disease (for example Huntington's disease), spina bifida, or spinal cord
injury.
 Are receiving renal dialysis for renal failure.
 Have had radical pelvic surgery, prostatectomy (including transurethral resection of the prostate), or a
kidney transplant.
 Were receiving Caverject®, Erecnos®, MUSE®, Uprima®, Viagra®, Cialis®, or Viridal® at the expense of
the NHS on 14 September 1998.
In addition, specialist centres can prescribe phosphodiesterase-5 (PDE-5) inhibitors on the NHS if the man
is 'suffering severe distress as a result of impotence'.
Therefore, as this man has diabetes the correct answer is option 5.
Q-17
One of the practice administration team is sorting the incoming documents and mentions that endoscopy
results for bowel cancer screening are starting to come through since the roll out of the NHS screening
program in the area. She wonders if she is going to get 'called up.'
What patient group is it offered to?
A. Men aged 65 (one-off)

B. Men and women aged 55 (one-off)
C. Men and women aged 60-74 (2-yearly)
D. Patients aged over 60 with change in bowel habit
E. Patients aged over 40 with weight loss and abdominal pain
ANSWER:
B. Men and women aged 55 (one-off)
EXPLANATION:
Sigmoidoscopy to screen for bowel cancer is offered as a one-off test to men and women the year they
turn 55
Men aged 65 (one-off). This is the group offered abdominal aortic aneurysm (AAA) screening.
Men and women aged 55 (one-off). Correct, bowel cancer screening with flexible sigmoidoscopy is being
rolled out as part of the NHS screening program. If patients don't take up the offer at 55, they can self-
refer up until their 60th birthday. Screening using home test kits (FIT/FOB) will continue.
Men and women aged 60-74 (2-yearly). Incorrect, this is the group sent home test kits (FIT/FOB).
Patients aged over 60 with change in bowel habit, patients aged over 40 with weight loss and abdominal
pain. Incorrect, these patients should be referred under the 2 week wait at presentation. Screening is by
definition for the detection of asymptomatic cases.
Please see Q-15 for Colorectal Cancer: Screening
Q-18
A 37-year-old woman with a history of gallstones is listed to have a laparoscopic cholecystectomy in three
months time. She is currently prescribed Microgynon 30 (combined oral contraceptive pill). The patient
asks for advice as she is aware that her contraceptive pill may increase the risk of blood clots. What is the
most appropriate advice in this situation?
A. She is safe to continue taking Microgynon

B. She should stop Microgynon 48 hours before the procedure
C. She should stop Microgynon 7 days before the procedure
D. She should stop Microgynon 28 days before the procedure
E. She should stop Microgynon 3 months before the procedure
ANSWER:
D. She should stop Microgynon 28 days before the procedure
EXPLANATION:
VENOUS THROMBOEMBOLISM: PROPHYLAXIS IN PATIENTS ADMITTED TO HOSPITAL
VTEs can cause severe morbidity and mortality, but they are preventable. Current NICE guidelines (updated
for 2018) outline recommendations for assessment and management of patients at risk of VTE in hospital.
Risk factors
All patients admitted to hospital should be individually assessed to identify risk factors for VTE development
and bleeding risk. For medical and surgical patients the recommended risk proforma is the department of
healths VTE risk assessment tool.
The following inpatients would be deemed at increased risk of developing a VTE:

Medical patients:
 significant reduction in mobility for 3 days or more (or anticipated to have significantly reduced mobility)
Surgical/trauma patients:
 hip/knee replacement
 hip fracture
 general anaesthetic and a surgical duration of over 90 minutes
 surgery of the pelvis or lower limb with a general anaesthetic and a surgical duration of over 60 minutes
 acute surgical admission with an inflammatory/intra-abdominal condition
 surgery with a significant reduction in mobility
General risk factors:

 active cancer/chemotherapy
 aged over 60
 known blood clotting disorder (e.g. thrombophilia)
 BMI over 35
 dehydration
 one or more significant medical comorbidities (e.g. heart disease; metabolic/endocrine pathologies;
respiratory disease; acute infectious disease and inflammatory conditions)
 critical care admission
 use of hormone replacement therapy (HRT)
 use of the combined oral contraceptive pill
 varicose veins
 pregnant or less than 6 weeks post-partum
After a patients VTE risk has been assessed, this should be compared to their risk of bleeding to decide
whether VTE prophylaxis should be offered. If indicated VTE prophylaxis should be started as soon as
possible.
Types of VTE prophylaxis

Mechanical:
 Correctly fitted anti-embolism (aka compression) stockings (thigh or knee height)
 An Intermittent pneumatic compression device
Pharmacological:
 Fondaparinux sodium (SC injection)
 Low molecular weight heparin (LMWH) - e.g. enoxaparin (brand name = Clexane)
 Unfractionated heparin (UFH) - used in patients with chronic kidney disease
Management
In general, all medical patients deemed at risk of VTE after individual assessment are started on
pharmacological VTE prophylaxis. This is providing the risk of VTE outweighs the risk of bleeding (this is often
a clinical judgement) and there are no contraindications. Those at very high risk may be offered anti-embolic
stockings alongside the pharmacological methods.
For surgical patients at low risk of VTE first-line treatment is anti-embolism stockings. If a patient is at high
risk these stockings are used in conjunction with pharmacological prophylaxis.
Advice for patients
Pre-surgical interventions:
 Advise women to stop taking their combined oral contraceptive pill/hormone replacement therapy 4
weeks before surgery.
Post-surgical interventions:
 Try to mobilise patients as soon as possible after surgery
 Ensure the patient is hydrated
Post procedure prophylaxis

For certain surgical procedures (hip and knee replacements) pharmacological VTE prophylaxis is
recommended for all patients to reduce the risk of a VTE developing post-surgery. NICE make the following
recommendations:
Procedure Prophylaxis
Elective hip LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days
or
LMWH for 28 days combined with anti-embolism stockings until discharge
or
Rivaroxaban
Elective knee Aspirin (75 or 150 mg) for 14 days
or
LMWH for 14 days combined with anti-embolism stockings until discharge
or
Rivaroxaban
Fragility fractures of The NICE guidance states the following (our bolding):
the pelvis, hip and
proximal femur
Offer VTE prophylaxis for a month to people with fragility fractures of the
pelvis, hip or proximal
femur if the risk of VTE outweighs the risk of bleeding. Choose either:
 LMWH , starting 6–12 hours after surgery or

 fondaparinux sodium, starting 6 hours after surgery, providing there is
low risk of bleeding.
Q-19
You are the duty doctor and you see a patient who has had an erection for 6 hours which is very painful.
He took sildenafil a phosphodiesterase (PDE-5) inhibitor last night. He was diagnosed with myeloma 4
months ago and is currently having treatment under the haematology team.
What is the correct management for this patient?
A. 300mg aspirin
B. Reassure him that the erection should resolve as the sildenafil wears off over 12 hours
C. Advise the patient to have a warm bath or shower
D. Refer urgently to the haematology team
E. Refer urgently to the surgical team
ANSWER:
E. Refer urgently to the surgical team
EXPLANATION:
A patient with priapism needs urgent assessment in hospital
Priapism is a rare side effect of taking a PDE-5 inhibitor. However, the risk is increased if a patient has a
blood disorder such as sickle cell disease, multiple myeloma or leukaemia.
Priapism is a surgical emergency. Priapism lasting more than 2 hours requires urgent referral to hospital
under the surgical team for treatment. Therefore, option 5 is the only correct answer.
If the priapism has not been present for more than 2 hours the following may help resolve it:
 try to pass urine

 have a warm bath or shower
 drink lots of water
 go for a gentle walk
 try exercises, such as squats or running on the spot
 take painkillers like paracetamol if needed.
PRIAPISM
Priapism is a persistent penile erection, typically defined as lasting longer than 4 hours and is not associated
with sexual stimulation. Priapism can be described as either ischaemic or non-ischaemic with both
categories having a different pathophysiology. Ischaemic priapism is typically due to impaired vasorelaxation
and therefore reduced vascular outflow resulting in congestion and trapping of de-oxygenated blood within
the corpus cavernosa. Non-ischaemic priapism is due to high arterial inflow, typically due to fistula formation
often either as the result of congenital or traumatic mechanisms.
Epidemiology
 Age at presentation has a bimodal distribution, with peaks between 5-10 years and 20-50 years of age
 incidence has been estimated at up to 5.34 per 100,000 patient-years
Causes
 Idiopathic
 Sickle cell disease or other haemoglobinopathies
 Erectile dysfunction medication (e.g. Sildenafil and other PDE-5 inhibitors), this also includes
intracavernosal injected therapies.
 Other drugs both prescribed (anti-hypertensives, anticoagulants, antidepressants etc) and recreational
(specifically cocaine, cannabis and ecstasy).
 Trauma
Patients typically present acutely with:

 A persistent erection lasting over 4 hours
 Pain localised to the penis
 Often a history of either known haemoglobinopathy or use of medications listed above
 Patients may, more rarely, present with either a non-painful erection or an erection that is not fully rigid:
these are both suggestive of non-ischaemic priapism.
 History of trauma to the genital or perineal region: also suggestive of non-ischaemic priapism.
Investigations:
 Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic
priapism pO2 and pH would be reduced whilst pCO2 would be increased.
 Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for
blood flow within the penis.
 A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
 Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-
ischaemic as well as assessing for the underlying cause.
Management
Ischaemic priapism is a medical emergency and delayed treatment can lead to permanent tissue damage
and long-term erectile dysfunction.
 If the priapism has lasted longer than 4 hours, the first-line treatment is aspiration of blood from the
cavernosa, this is often combined with injection of a saline flush to help clear viscous blood that has
pooled.
 If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as
phenylephrine is used and repeated at 5 minute intervals.
 If medical therapy fails then surgical options can be considered.
Non-ischaemic priapism is not a medical emergency and is normally suitable for observation as a first-line
option.
Q-20
A 49-year-old woman presents with a 2 week history of left nipple itching. There has been no discharge
from the nipple and there is no personal or family history of breast disease. The patient's history is
remarkable for asthma and eczema.
On examination, the left nipple and surrounding areola are reddened and the skin appears thickened.
Examination of both breasts is otherwise unremarkable.
What is the most appropriate next step in management?

A. Routine referral to breast clinic
B. Topical emollient
C. Topical emollient + antibiotic
D. Topical steroid
E. Urgent referral to breast clinic
ANSWER:
E. Urgent referral to breast clinic
EXPLANATION:
Reddening and thickening of nipple and areola → think Paget's disease of the breast
This may well be nipple eczema, as the patient has a history of atopy and no personal or family history of
breast disease. However, it is crucial to exclude the diagnosis of Paget's disease of the breast, which
presents in a very similar way, particularly as the problem is unilateral.
Additional symptoms that may be present in Paget's disease are bloody nipple discharge and an
underlying breast lump.
PAGET'S DISEASE OF THE NIPPLE

Paget's disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it
is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying
mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion
will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.
Paget's disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly
spreads to the areolar (the opposite occurs in eczema).
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Treatment will depend on the underlying lesion.
Q-21
A 62-year-old man presents with nocturia, hesitancy and terminal dribbling. Prostate examination reveals
a moderately enlarged prostate with no irregular features and a well defined median sulcus. Blood tests
show:
PSA 1.3 ng/ml
A. Alpha-1 antagonist
B. 5 alpha-reductase inhibitor
C. Non-urgent referral for transurethral resection of prostate
D. Empirical treatment with ciprofloxacin for 2 weeks
E. Urgent referral to urology
Alpha-1 antagonists are first-line in patients with benign prostatic hyperplasia

ANSWER:
A. Alpha-1 antagonist
EXPLANATION:
BENIGN PROSTATIC HYPERPLASIA
Benign prostatic hyperplasia (BPH) is a common condition seen in older men.
Risk factors
 age: around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms. Around
80% of 80-year-old men have evidence of BPH
 ethnicity: black > white > Asian
BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into:
 voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal
dribbling and incomplete emptying
 storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia
 post-micturition: dribbling
 complications: urinary tract infection, retention, obstructive uropathy
Management options
 watchful waiting
 medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. The use of combination therapy was
supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial
 surgery: transurethral resection of prostate (TURP)
Alpha-1 antagonists e.g. tamsulosin, alfuzosin

 decrease smooth muscle tone (prostate and bladder)
 considered first-line, improve symptoms in around 70% of men
 adverse effects: dizziness, postural hypotension, dry mouth, depression
5 alpha-reductase inhibitors e.g. finasteride

 block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
 unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease
progression. This however takes time and symptoms may not improve for 6 months. They may also
decrease PSA concentrations by up to 50%
 adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
Q-22-24
Theme: Abdominal swelling
A. Irritable bowel syndrome

B. Endometrial cancer
C. Ovarian cancer
D. Pregnancy
E. Intestinal obstruction
F. Urinary retention
G. Ascites
H. Gastric cancer
I. Colorectal cancer
J. Bladder cancer
For each one of the following scenarios select the most likely diagnosis:
Q-22
62-year-old woman with a 3 month history of urinary symptoms, early satiety and a raised CA125
ANSWER:
C. Ovarian cancer
EXPLANATION:
Ovarian cancer tends to present late due to non-specific symptoms
Q-23
26-year-old female with a history of constipation, episodic abdominal pain and bloating.
ANSWER:
A. Irritable bowel syndrome
EXPLANATION:
These are classic symptoms of irritable bowel syndrome
Q-24
72-year-old woman with a history of congestive cardiac failure. She reports having a poor appetite and
feeling bloated. She is admitted frequently to hospital with left ventricular failure due to poor compliance
with medication
ANSWER:
G. Ascites
EXPLANATION:
Patients with poorly controlled heart failure may develop 'cardiac cachexia', partly due to gut oedema
ABDOMINAL SWELLING
The table below gives characteristic exam question features for conditions causing abdominal swelling
Condition Characteristic exam feature

Pregnancy Young female
Amenorrhoea
Intestinal obstruction History of malignancy/previous operations
Vomiting
Not opened bowels recently
'Tinkling' bowel sounds
Ascites History of alcohol excess, cardiac failure
Urinary retention History of prostate problems
Dullness to percussion around suprapubic area
Ovarian cancer Older female
Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating
Q-25
A 45-year woman who you have treated for obesity comes for review. Despite ongoing lifestyle
interventions and trials of orlistat and sibutramine she has failed to lose a significant amount of weight.
She is currently taking ramipril for hypertension but a recent fasting glucose was normal. For this patient,
what is the cut-off body mass index (BMI) that would trigger a referral for consideration of bariatric
surgery?
A. BMI > 35 kg/m^2

B. BMI > 40 kg/m^2
C. BMI > 30 kg/m^2
D. BMI > 38 kg/m^2
E. BMI > 45 kg/m^2
ANSWER:
A. BMI > 35 kg/m^2
EXPLANATION:
Obesity - NICE bariatric referral cut-offs
 with risk factors (T2DM, BP etc): > 35 kg/m^2
 no risk factors: > 40 kg/m^2
OBESITY: BARIATRIC SURGERY

The use of bariatric surgery in the management of obesity has developed significantly over the past decade.
It is now recognised that for many obese patients who fail to lose weight with lifestyle and drug
interventions the risks and expense of long-term obesity outweigh those of surgery.
NICE guidelines on bariatric surgery for adults

Consider surgery for people with severe obesity if:
 they have a BMI of 40 kg/m^2 or more, or between 35 kg/m^2 and 40 kg/m^2 and other significant
disease (for example, type 2 diabetes mellitus, hypertension) that could be improved if they lost weight
 all appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial
weight loss for at least 6 months
 they are receiving or will receive intensive specialist management
 they are generally fit for anaesthesia and surgery
 they commit to the need for long-term follow-up
Consider surgery as a first-line option for adults with a BMI of more than 50 kg/m2 in whom surgical
intervention is considered appropriate; consider orlistat before surgery if the waiting time is long
Types of bariatric surgery:

 primarily restrictive: laparoscopic-adjustable gastric banding (LAGB) or sleeve gastrectomy
 primarily malabsorptive: classic biliopancreatic diversion (BPD) has now largely been replaced by
biliopancreatic diversion with duodenal switch
 mixed: Roux-en-Y gastric bypass surgery
Which operation?
 LAGB produces less weight loss than malabsorptive or mixed procedures but as it has fewer
complications it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2
 patients with a BMI > 40 kg/m^2 may be considered for a gastric bypass or sleeve gastrectomy. The
latter may be done as a sole procedure or as an initial procedure prior to bypass
 primarily malabsorptive procedures are usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)
Q-26
Which one of the following statements regarding inguinal hernias is not correct?
A. There is no merit in differentiating between direct and indirect hernias prior to referral
B. Patients should be referred promptly due to the risk of strangulation
C. Symptoms are typically worse following exertion
D. 95% of patients are male
E. Are the most common cause of abdominal wall hernias
ANSWER:
B. Patients should be referred promptly due to the risk of strangulation
EXPLANATION:
Inguinal hernias rarely strangulate
Please see Q-5 for Inguinal Hernia
Q-27
A 54-year-old woman presents to her GP asking if she can be screened for breast cancer, as her friend has
recently died from the condition. She has just moved to the UK from abroad and is unsure whether she is
eligible for screening and what this might involve.
What breast cancer screening, if any, is she eligible for?
A. Breast examination every 3 years

B. Breast examination every 5 years
C. Mammography every 3 years
D. Mammography every 5 years
E. Screening starts at the age of 55
ANSWER:
C. Mammography every 3 years
EXPLANATION:
Breast cancer screening is offered to all women aged 47-73 years (mammogram every 3 years)
In the UK, all women are offered breast cancer screening with mammography every 3 years between the
ages of 50 and 70 years. In many areas, this has recently been extended to include women aged 47-50 and
70-73 as a trial on the NHS.
BREAST CANCER: SCREENING

The NHS Breast Screening Programme is being expanded to include women aged 47-73 years from the
previous parameter of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70
years women may still have mammograms but are 'encouraged to make their own appointments'.
The effectiveness of breast screening is regularly debated although it is currently thought that the NHS
Breast Screening Programme may save around 1,400 lives per year.
Familial breast cancer
NICE published guidelines on the management of familial breast cancer in 2013, giving guidelines on who
needs referral.
If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer
they do NOT need to be referred unless any of the following are present in the family history:
 age of diagnosis < 40 years
 bilateral breast cancer
 male breast cancer
 ovarian cancer
 Jewish ancestry
 sarcoma in a relative younger than age 45 years
 glioma or childhood adrenal cortical carcinomas
 complicated patterns of multiple cancers at a young age
 paternal history of breast cancer (two or more relatives on the father's side of the family)
Women who are at an increased risk of breast cancer due to their family history may be offered screening
from a younger age. The following patients should be referred to the breast clinic for further assessment:
 one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or
 one first-degree male relative diagnosed with breast cancer at any age, or
 one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger
than age 50 years, or
 two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast
cancer at any age, or
 one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree
or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-
degree relative), or
 three first-degree or second-degree relatives diagnosed with breast cancer at any age
Q-28
What is the failure rate of male sterilisation?
A. 1 in 100
B. 1 in 200
C. 1 in 300
D. 1 in 400
E. 1 in 2,000
ANSWER:
E. 1 in 2,000
EXPLANATION:
Male sterilisation - failure rate = 1 in 2,000
VASECTOMY
Male sterilisation - vasectomy
 failure rate: 1 per 2,000 - male sterilisation is a more effective method of contraception than female
sterilisation
 simple operation, can be done under LA (some GA), go home after a couple of hours
 doesn't work immediately
 semen analysis needs to be performed twice following a vasectomy before a man can have unprotected
sex (usually at 16 and 20 weeks)
 complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects
between 5-30% men)
 the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25%
after more than 10 years
Q-29
A 57-year-old gentleman presented with a 3-day history of lower back pain, pain on passing urine and
low-grade fevers. On examination, he had a tender, boggy prostate and diffuse lower abdominal pain. A
urine dip shows 2+ of blood in the urine. What is the most appropriate treatment for the suspected
diagnosis?
A. A 7 day course of co-amoxiclav

B. A 14 day course of ciprofloxacin
C. Refer to secondary care for urgent hospital admission
D. A 28 day course of ofloxacin
E. A 5 day course of trimethoprim
ANSWER:
B. A 14 day course of ciprofloxacin
EXPLANATION:
Prostatitis - quinolone for 14 days
The diagnosis here is prostatitis. A urine sample should be sent for culture and if the patient is deemed
well enough to be treated in the community, they should be started on a 14-day course of a quinolone
(ciprofloxacin or ofloxacin). Refer urgently to secondary care if the man is severely unwell, septic, unable
to take oral antibiotics or in urinary retention.
Options 1/4/5 all contain the incorrect antibiotic or duration of time.
Option 3 suggests referring when the patient could be managed in the community.
ACUTE BACTERIAL PROSTATITIS

Acute bacterial prostatitis is typically caused by gram-negative bacteria entering the prostate gland via the
urethra.
Escherichia coli is the most commonly isolated pathogen.
Risk factors for acute bacterial prostatitis include recent urinary tract infection, urogenital instrumentation,
intermittent bladder catheterisation and recent prostate biopsy.
Features
 the pain of prostatitis may be referred to a variety of areas including the perineum, penis, rectum or
back
 obstructive voiding symptoms may be present
 fever and rigors may be present
 digital rectal examination: tender, boggy prostate gland
Management
 Clinical Knowledge Summaries currently recommend a 14-day course of a quinolone
 consider screening for sexually transmitted infections
Q-30
A 38-year-old man presents to surgery due to a 3 month history of scrotal swelling and discomfort.
On examination, there is unilateral swelling in the left scrotum which transilluminates. The swelling is soft
and non-tender. Due to the presence of fluid, the testis is not fully palpable.
What is the most appropriate next course of action?
A. Reassess in 3 months' time

B. Provide reassurance
C. Refer urgently for testicular biopsy
D. Refer urgently for CT abdomen and pelvis
E. Refer urgently for testicular ultrasound
ANSWER:
E. Refer urgently for testicular ultrasound
EXPLANATION:
Adult patients with a hydrocele require an ultrasound to exclude underlying causes such as a tumour
Adult patients with a hydrocele require an ultrasound to exclude underlying causes such as a tumour.
Whilst the most common aetiology of a non-acute hydrocele such as the one presented here is idiopathic,
malignancy should always be ruled out first. Hence, reassessing the patient at a later date or providing
reassurance would only be appropriate after testicular ultrasound excludes malignancy.
Testicular biopsy has no place in the investigation of suspected testicular cancer as it may cause
dissemination of the malignancy through seeding along the needle's track.
Whilst a unilateral hydrocele can be an unusual presentation of a renal carcinoma invading the renal vein,
a CTAP would not be the first-line investigation in this scenario. If malignancy is confirmed, CT may have a
role in staging the malignancy.
HYDROCELE
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into
communicating and non-communicating:
 communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down
into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-
10%) and usually resolve within the first few months of life
 non-communicating: caused by excessive fluid production within the tunica vaginalis
Hydroceles may develop secondary to:

 epididymo-orchitis
 testicular torsion
 testicular tumours
Features
 soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
 the swelling is confined to the scrotum, you can get 'above' the mass on examination
 transilluminates with a pen torch
 the testis may be difficult to palpate if the hydrocele is large
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the
underlying testis cannot be palpated.
Management
 infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
 in adults a conservative approach may be taken depending on the severity of the presentation. Further
investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a
tumour
Q-31
A 19-year-old man attends his GP after noticing a lump in his scrotum while showering. He reports some
discomfort in the area but no pain. He is in a long-term relationship with his girlfriend and his last sexual
health screen two weeks previously was clear.
On examination, there is a soft mass on the anterior aspect of the left testis that is indistinguishable from
the testis itself. It is not tender to touch and transilluminates.
Which of the following is the most likely diagnosis?
A. Testicular tumour
B. Hydrocoele
C. Varicocoele
D. Epididymal cyst
E. Sperm granuloma
ANSWER:
B . Hydrocoele
EXPLANATION:
Hydrocoeles can be differentiated from other testicular lumps as they are not separate to testis and
transilluminate
When assessing scrotal lumps, it is important to determine whether the mass is separate or continuous
with the testis, and whether it is solid or cystic in nature.
A hydrocoele is a collection of fluid in the tunica vaginalis surrounding the testis, and as such is cystic or
fluctuant in nature, and would not be distinguishable from the testis itself. Therefore this is the correct
answer in this scenario. While a benign diagnosis in itself, hydrocoeles can often be secondary to testicular
tumors, which should be ruled out with an ultrasound scan.
Testicular tumours would naturally be continuous with the testis, although may be distinct and irregular in
nature. They would not be cystic or transilluminate, however, may also present with a secondary
hydrocoele.
Varicocoeles and epididymal cysts would be separate to the testis on examination.
Sperm granulomas are small lumps caused by the collection of sperm, usually in the context of a
vasectomy. They can occur at the site where the vas deferens is tied off, in the epididymis or the testis
itself.
SCROTAL SWELLING
Condition Notes
Inguinal hernia If inguinoscrotal swelling; cannot 'get above it' on examination
Cough impulse may be present
May be reducible
Testicular tumours Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo- Often history of dysuria and urethral discharge
orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Condition Notes
Infections with other gram negative organisms may be associated with
underlying structural abnormality
Epidiymal cysts Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to 'get above the lump' on examination
Hydrocele Non painful, soft fluctuant swelling
Often possible to 'get above it' on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Testicular torsion Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed
Varicocele Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility
Management
 Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high
ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
 Torsion is commonest in young teenagers and the history in older children can be difficult to elicit.
Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular
fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch.
 Varicoceles are usually managed conservatively. If there are concerns about testicular function of
infertility then surgery or radiological management can be considered.
 Epididymal cysts can be excised using a scrotal approach
 Hydroceles are managed differently in children where the underlying pathology is a patent processus
vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In
adults a scrotal approach is preferred and the hydrocele sac excised or plicated.
Q-32
A 25-year-old male presents to the general practitioner (GP) with testicular swelling. He describes a
'squidgy' feel to the top of his left testicle. He denies any pain and reports no problems with urination or
achieving erections.
The GP refers the patient for an ultrasound. The report states:

'Mild left sided varicocoele. Right testis normal. No other abnormalities detected'.
What is the next best step in the management of this patient?
A. Reassure and observe

B. Recommend semen cryopreservation
C. Laparoscopic repair of the varicocoele
D. Open repair of the varicocoele
E. Percutaneous embolisation of the varicocoele
ANSWER:
A. Reassure and observe
EXPLANATION:
Mild varcicoeles do not need intervention and can be managed conservatively
In adult males with subclinical or Grade I (mild) varicocoeles, reassurance and observation is the
appropriate measure to take. Therefore in this patient, the alternative option are inappropriate at this
stage.
When considering Grade II or III varicocoeles, management depends on whether fertility is a concern and
whether the patient is symptomatic.
Grade II or III varicocoele Management

Asymptomatic and normal semen Semen analysis every 1-
parameters 2yrs
Symptomatic or abnormal semen Surgery
parameters
Varicocoele treatment has a success rate of approximately 90%.
Please see Q-2 for Scrotal Problems

Q-33
A 47-year-old-man books a routine appointment to discuss his weight. He reports putting on more weight
in recent years and asks for your help. He has recently been suffering with pains in both his knees and x-
rays have shown signs of degenerative change. He is classified at high diabetes risk based on his HbA1c
but not does take any medication for this. He also has well controlled hypertension. He has previously
tried joining a gym but reports his knee pain has gotten so bad that he finds it difficult to do any exercise.
He has previously tried weight watchers but did not find it useful. He has not previously been referred to a
dietician.
His current weight is 148kg with a height of 1.7m, giving him a body mass index (BMI) of 51.2kg/m².
A. Refer to a dietitian
B. Prescribe a trial or orlistat
C. Refer to a local exercise programme for weight loss
D. Refer for consideration of bariatric surgery
E. Refer to a psychologist for behavioural intervention
ANSWER:
D. Refer for consideration of bariatric surgery
EXPLANATION:
Consider bariatric surgery as a first-line option for adults with a BMI >50
Obesity is a growing problem and it is important that general practitioners are familiar with referral
options and treatment thresholds. NICE guidelines suggest that anyone with a BMI over 50kg/m² should
be considered for bariatric surgery as a first line intervention.
Orlistat may be used if the waiting list for surgery is long but this person is likely to need support from tier
three obesity management services.
Given his reluctance to engage in exercise due to his knee pain it is unlikely that he will lose a significant
amount of weight through exercise alone.
A dietitian referral may be appropriate at a lower BMI but is unlikely to be sufficient here.
Psychology input may be helpful and is often undertaken prior to weight loss surgery, however this would
be be organised within a tier three obesity management service.
Please see Q-25 for Obesity: Bariatric Surgery
Q-34
A 60 year-old gentleman is called into your surgery after a blood test shows a raised prostate specific
antigen level (PSA). He asks if this means he has cancer. Approximately how many men with a raised PSA
have prostate cancer?
A. 2/3
B. 1/2
C. 1/3
D. 1/50
E. 1/10
ANSWER:
C. 1/3
EXPLANATION:
The prostate specific antigen (PSA) blood test is a screening test for prostate cancer, but it is not very
specific, with only about a third of patients with a raised level being found to have prostate cancer. It is
important to counsel patients about this prior to undergoing the test - a useful patient information leaflet
can be found on the NHS Cancer Screening website at the link below.
Source: http:www.cancerscreening.nhs.uk/prostate/prostate-patient-info-sheet.pdf
PROSTATE CANCER: PSA TESTING

Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and malignant prostate
epithelial cells. It has become an important tumour marker but much controversy still exists regarding its
usefulness as a screening tool.
The NHS Prostate Cancer Risk Management Programme (PCRMP) has published updated guidelines in 2009
on how to handle requests for PSA testing in asymptomatic men. A recent European trial (ERSPC) showed a
statistically significant reduction in the rate of death prostate cancer by 20% in men aged 55 to 69 years but
this was associated with a high risk of over-diagnosis and over-treatment. Having reviewed this and other
data the National Screening Committee have decided not to introduce a prostate cancer screening
programme yet but rather allow men to make an informed choice.
Age-adjusted upper limits for PSA were recommended by the PCRMP:
Age PSA level (ng/ml)

50-59 years 3.0
60-69 years 4.0
> 70 years 5.0
However, NICE Clinical Knowledge Summaries currently suggest a different cut-off:

 men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE
 note this is a lower threshold than the PCRMP 60-69 years limits recommended above
PSA levels may also be raised by*:

 benign prostatic hyperplasia (BPH)
 prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month
after treatment)
 ejaculation (ideally not in the previous 48 hours)
 vigorous exercise (ideally not in the previous 48 hours)
 urinary retention
 instrumentation of the urinary tract
Poor specificity and sensitivity

 around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20
ng/ml this rises to 60% of men
 around 20% with prostate cancer have a normal PSA
 various methods are used to try and add greater meaning to a PSA level including age-adjusted upper
limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time)
*whether digital rectal examination actually causes a rise in PSA levels is a matter of debate
Q-35
Which one of the following statements regarding male circumcision is correct?
A. Circumcision should always be performed under a general anaesthetic

B. It is available on the NHS in areas with a high Jewish or Islamic population
C. Increases the risk of penile cancer
D. Reduces the rate of HIV transmission
E. All infants with hypospadias should be circumcised before the age of 1 year
ANSWER:
D. Reduces the rate of HIV transmission
EXPLANATION:
CIRCUMCISION
Circumcision has been performed in a variety of cultures for thousands of years. Today it is mainly people of
the Jewish and Islamic faith who undergo circumcision for religious/cultural reasons. Circumcision for
religious or cultural reasons is not available on the NHS.
The medical benefits of routine circumcision remain controversial although some evidence has emerged that
it:
 reduces the risk of penile cancer
 reduces the risk of UTI
 reduces the risk of acquiring sexually transmitted infections including HIV
Medical indications for circumcision

 phimosis
 recurrent balanitis
 balanitis xerotica obliterans
 paraphimosis
It is important to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair.
Circumcision may be performed under a local or general anaesthetic.
Q-36
Roger is a 50-year-old man who has a friend recently diagnosed with bowel cancer. He has heard about
the faecal occult blood screening program but has read in the news about a new program involving a
scope. He asks you for more information. Which of the following is the correct guidance?
A. New program for men & women for one off colonoscopy at age 55
B. New program for men & women for one off sigmoidoscopy at age 55
C. New program for men & women for one off sigmoidoscopy at age 60
D. New program for men & women for one off sigmoidoscopy at age 65
E. New program for men for one off sigmoidoscopy at age 55
ANSWER:
B. New program for men & women for one off sigmoidoscopy at age 55
EXPLANATION:
The correct answer is option 2 - a one off sigmoidoscopy for men and women aged 55.
NHS bowel scope screening is a new addition to the bowel cancer screening. This involves a gradual roll
out across the UK of a one off sigmoidoscopy offered to all men and women at the age of 55.
For every 300 people screened using this screening program, it stops two from getting bowel cancer and
saves one life from bowel cancer.
The program is still being rolled out and as of 2015, approximately two-thirds of the UK is offering this
screening program with plans for all the UK to be taking part by 2018.
AKT report Jan 2015 - 'After AKT 22, we fed back on lack of knowledge around some national screening
programmes.'
Q-37
Which one of the following statements regarding the NHS Breast Screening Programme is correct?
A. Women are given a 'triple assessment' at each screening cycle

B. It is targeted at women aged 40-70 years
C. Women with a family history of cervical cancer should be offered more regular and/or earlier
screening
D. Women are screened every 3 years
E. Women over the age of 70 years are not eligible for screening
ANSWER:
D. Women are screened every 3 years
EXPLANATION:
Please see Q-27 for Breast Cancer: Screening
Q-38
You are working in a GP practice, and you are performing a face-to-face medications review upon a 64-
year-old man with a diagnosis of erectile dysfunction. He has been prescribed sildenafil, which he says
works well for the condition. He wishes to continue using the drug.
What is the maximum number of tablets you can prescribe for this patient each month, on the NHS?
A. Nil - ongoing supplies should be purchased privately

B. 2 tablets per month
C. 6 tablets per month
D. 2 tablets per month, writing a private script for any extra he wishes
E. As many tablets as the patient says he requires
ANSWER:
E. As many tablets as the patient says he requires
EXPLANATION:
There's now no limit to the number of generic sildenafil that can be prescribed to NHS patients with
erectile dysfunction
Previously, the prescription of sildenafil was restricted to patients suffering specific medical causes of
erectile dysfunction. The medication was prescribed under the Selected List System (SLS) scheme of the
Drug Tariff, with patients limited to four tablets per month.
These restrictions have since been removed and sildenafil can be prescribed to any patient with erectile
dysfunction. Official NICE guidance is now that GPs should assess monthly quantities on an 'individual
basis'. Unfortunately, old habits mean many patients are incorrectly restricted to four tablets a month.
(Note that the BNF does stipulate, however, that sildenafil should be used a maximum of once daily).
Q-39
Which one of the following is most associated with male infertility?
A. Sodium valproate therapy

B. Benign prostatic hyperplasia
C. Varicoceles
D. Epididymal cysts
E. Hydroceles
ANSWER:
C. Varicoceles
EXPLANATION:
Varicoceles may be associated with infertility
Please see Q-9 for Varicocele
Q-40
A 33-year-old man presents with a one day history of pain and swelling in the right testicle. Around four
weeks ago he returned from a holiday in Spain but reports no dysuria or urethral discharge. On
examination he has a tender, swollen right testicle. On examination the heart rate is 84/min and his
temperature is 37.1ºC. What is the most appropriate management?
A. IM ceftriaxone stat + oral doxycyline for 2 weeks

B. Oral doxycycline + metronidazole for 2 weeks
C. Oral trimethopim for 2 weeks
D. Oral azithromycin stat dose
E. Oral ciprofloxacin for 2 weeks
ANSWER:
A. IM ceftriaxone stat + oral doxycyline for 2 weeks
EXPLANATION:
EPIDIDYMO-ORCHITIS
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is
most commonly caused by local spread of infections from the genital tract (such as Chlamydia trachomatis
and Neisseria gonorrhoeae) or the bladder.
The most important differential diagnosis is testicular torsion. This needs to be excluded urgently to
prevent ischaemia of the testicle.
Features
 unilateral testicular pain and swelling
 urethral discharge may be present, but urethritis is often asymptomatic
 factors suggesting testicular torsion include patients < 20 years, severe pain and an acute onset
Management
 the British Association for Sexual Health and HIV (BASHH) produced guidelines in 2010
 if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose, plus
doxycycline 100mg by mouth twice daily for 10-14 days
 further investigations following treatment are recommended to exclude any underlying structural
abnormalities
Q-41
A 43-year-old man presents with severe, episodic pain in his right loin region. Urine dipstick is positive for
blood and you suspect a diagnosis of ureteric colic. At the current time he does not require admission. You
prescribe oral naproxen and arrange a non-contrast CT scan. Which one of the following types of
medication may also be beneficial in this scenario?
A. Nitrate
B. Benzodiazepine
C. Alpha-adrenergic blocker
D. Beta-blocker
E. Corticosteroid
ANSWER:
C. Alpha-adrenergic blocker
EXPLANATION:
Calcium channel blockers are also sometimes used to aid the spontaneous passage of the stone.
RENAL STONES: MANAGEMENT

The British Association of Urological Surgeons (BAUS) published guidelines in 2018 on the management of
acute ureteric/renal colic.
Initial management of renal colic

Medication
 the BAUS recommend an NSAID as the analgesia of choice for renal colic
 whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain
NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing
 the CKS guidelines suggest for patients who require admission: 'Administer a parenteral analgesic (such
as intramuscular diclofenac) for rapid relief of severe pain'
 BAUS no longer endorse the use of alpha-adrenergic blockers to aid ureteric stone passage routinely.
They do however acknowledge a recently published meta-analysis advocates the use of α-blockers for
patients amenable to conservative management, with greatest benefit amongst those with larger stones
Initial investigations
 urine dipstick and culture
 serum creatinine and electrolytes: check renal function
 FBC / CRP: look for associated infection
 calcium/urate: look for underlying causes
 also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis
Imaging
 BAUS now recommend that non-contrast CT KUB should be performed on all patients, within 14 hours of
admission
 if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should
be performed. In the case of an uncertain diagnosis, this is to exclude other diagnoses such as ruptured
abdominal aortic aneurysm
 CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95%
 ultrasound still has a role but given the wider availability of CT now and greater accurary it is no longer
recommend first-line. The sensitivity of ultrasound for stones is around 45% and specificity is around
90%
Management of renal stones

Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases.
Most renal stones measuring less than 5mm in maximum diameter will typically pass within 4 weeks of
symptom onset. More intensive and urgent treatment is indicated in the presence of ureteric obstruction,
renal developmental abnormality such as horseshoe kidney and previous renal transplant. Ureteric
obstruction due to stones together with infection is a surgical emergency and the system must be
decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric
stent placement.
In the non-emergency setting, the preferred options for treatment of stone disease include extra corporeal
shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, open surgery remains an option for
selected cases. However, minimally invasive options are the most popular first-line treatment.
Shockwave lithotripsy
 A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress
lead to stone fragmentation. The passage of shock waves can result in the development of solid organ
injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The
procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards.
Ureteroscopy
 A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in
individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In
most cases a stent is left in situ for 4 weeks after the procedure.
Percutaneous nephrolithotomy
 In this procedure, access is gained to the renal collecting system. Once access is achieved, intra corporeal
lithotripsy or stone fragmentation is performed and stone fragments removed.
Therapeutic selection
Disease Option
Stone burden of less than 2cm in aggregate Lithotripsy
Stone burden of less than 2cm in pregnant females Ureteroscopy
Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy
Ureteric calculi less than 5mm Manage expectantly
PREVENTION OF RENAL STONES

Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
 high fluid intake
 low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a
normocalcaemic diet)
 thiazides diuretics (increase distal tubular calcium resorption)
Oxalate stones
 cholestyramine reduces urinary oxalate secretion
 pyridoxine reduces urinary oxalate secretion
Uric acid stones

 allopurinol
 urinary alkalinization e.g. oral bicarbonate
Q-42
A 64-year-old women attends oncology clinic following a diagnosis of oestrogen receptor (ER) positive
breast cancer. Her consultant decides to commence treatment with anastrozole, an aromatase inhibitor.
Of the following, which is a potential complication associated with this treatment?
A. Endometrial cancer
B. Hypercalcaemia
C. Ischaemic heart disease
D. Osteoporosis
E. Venous thromboembolism
ANSWER:
D. Osteoporosis
EXPLANATION:
Aromatase inhibitors (e.g. anastrozole) may cause osteoporosis
In the management of oestrogen receptor (ER) positive breast cancer, two classes of oral anti-oestrogen
drugs are predominantly used.
Aromatase inhibitors (AIs) such as anastrozole and letrozole reduce peripheral oestrogen synthesis. This
accounts for the majority of oestrogen synthesis in post-menopausal women, and therefore aromatase
inhibitors are used in this group.
The major adverse effect of aromatase inhibitors is osteoporosis. In postmenopausal women, aromatase
inhibitors increase bone loss at a rate of 1- 3%/year. Bone mineral density should be checked both prior to
commencing and throughout treatment.
AIs are not associated with any of the other side effects listed.
The other class of anti-oestrogen medications is Selective oEstrogen Receptor Modulators (SERM), such as
tamoxifen. This is used to treat both pre- and post-menopausal women with ER positive breast cancer.
Adverse effects include venous thromboembolism, endometrial cancer, cerebral ischaemia and
hypertriglyceridaemia.
Please see Q-8 for Anti-Oestrogen Drugs
Q-43
A worried gentleman comes to your surgery because he took part in the routine bowel cancer screening
program and has been found to have a positive faecal occult blood test (FOBt) result. He asks if this means
he has bowel cancer. Approximately what percentage of patients who have a positive FOBt go on to have
bowel cancer detected at colonoscopy?
A. 0.5%
B. 2%
C. 10%
D. 50%
E. 75%
ANSWER:
C. 10%
EXPLANATION:
The ability to discuss NHS screening programmes with patients is required by the RCGP curriculum under
the statement on 'Healthy people, promoting health and preventing disease.'
Men and women aged 60-74 are offered routine screening for bowel cancer using the faecal occult blood
test (FOBt) every two years. Approximately 2% of patients will have a positive screening results and will be
invited to colonoscopy; approximately 10% of those invited will be found to have bowel cancer (it should
be noted around 25% of patients decline colonoscopy).
Source: NHS Cancer Screening Programmes website

http:www.cancerscreening.nhs.uk/bowel/outcome-flowchart.pdf
Q-44
A 58-year-old woman is referred to breast clinic with a hard painless lump in her left breast. She is
eventually diagnosed with breast cancer. She undergoes a series of tests and her clinician decides to
prescribe anastrozole.
Which of the following side effects should she be warned about before this medication is prescribed?
A. Deep vein thrombosis

B. Endometrial cancer
C. Osteoporosis
D. Urinary incontinence
E. Vaginal bleeding
ANSWER:
C. Osteoporosis
EXPLANATION:
Aromatase inhibitors (e.g. anastrozole) may cause osteoporosis
Her breast cancer is ER-positive, meaning that it is responsive to oestrogen (about 80% of all breast
cancers are). In postmenopausal women, this can be targeted with aromatase inhibitors such as
anastrozole.
The most important side effect of this hormonal treatment is osteoporosis. Women should have their bone
mineral density formally assessed at the beginning of treatment and at regular intervals thereafter.
Deep vein thrombosis, endometrial cancer, and vaginal bleeding are both side effects of another common
drug used to treat breast cancer (tamoxifen).
Anastrozole has not been linked to urinary incontinence.
Please see Q-8 for Anti-Oestrogen Drugs
Q-45
The mother of a 2-month-old boy comes to surgery as she has noticed a soft lump in his right groin area.
There is no antenatal or postnatal history of note. He is breast feeding well and is opening his bowels
regularly. On examination you note a 1 cm swelling in the right inguinal region which is reducible and
disappears on laying him flat. Scrotal examination is normal. What is the most appropriate action?
A. Refer to paediatric surgery

B. Refer to orthotics for fitting of a Pavlik harness
C. Reassure mother + ask her to return if not resolved by 6 months
D. Reassure mother + ask her to return if not resolved by 12 months
E. Reassure mother + ask her to return if not resolved by 2 years
ANSWER:
A. Refer to paediatric surgery
EXPLANATION:
Congenital inguinal hernias have a high rate of complications and should be repaired promptly once
identified.
ABDOMINAL WALL HERNIAS
The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the
wall of the cavity that normally contains it.
Risk factors for abdominal wall hernias include:

 obesity
 ascites
 increasing age
 surgical wounds
Features
 palpable lump
 cough impulse
 pain
 obstruction: more common in femoral hernias
 strangulation: may compromise the bowel blood supply leading to infarction
Types of abdominal wall hernias:
Type of hernia Details

Inguinal hernia Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of
patients are male; men have around a 25% lifetime risk of developing an
inguinal hernia.
Above and medial to pubic tubercle
Strangulation is rare
Femoral hernia Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required
Umbilical hernia Symmetrical bulge under the umbilicus
Paraumbilical hernia Asymmetrical bulge - half the sac is covered by skin of the abdomen
directly above or below the umbilicus
Epigastric hernia Lump in the midline between umbilicus and the xiphisternum
Most common in men aged 20-30 years
Incisional hernia May occur in up to 10% of abdominal operations
Spigelian hernia Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the
rectus abdominis muscle medially and the semilunar line laterally)
Obturator hernia A hernia which passes through the obturator foramen. More common in
females and typical presents with bowel obstruction
Richter hernia A rare type of hernia where only the antimesenteric border of the bowel
herniates through the fascial defect
Richter's hernia can present with strangulation without symptoms of
obstruction
Abdominal wall hernias in children:

Congenital inguinal Indirect hernias resulting from a patent processus vaginalis
hernia Occur in around 1% of term babies. More common in premature babies
and boys
60% are right sided, 10% are bilaterally
Should be surgically repaired soon after diagnosis as at risk of incarceration
Infantile umbilical Symmetrical bulge under the umbilicus
hernia More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
Complications are rare
Q-46
You see consulting with a 25-year-old patient over the phone who is having problems with his erections.
He is normally fit and well, doesn't smoke and drinks 10-12 units of alcohol a week. He has had a girlfriend
for 5 years but this issue is starting to affect their relationship.
You go on to take a full psychosexual history before offering him some advice.
What history findings from the list below would suggest an organic rather than a psychogenic cause for his
problem?
A. A sudden onset
B. Self stimulated or waking erections
C. A normal libido
D. Premature ejaculation
E. Relationship problems
ANSWER:
C. A normal libido
EXPLANATION:
Having a normal libido is suggestive of an organic cause of ED
organic, psychogenic and mixed. It can also be caused by certain drugs.
Symptoms which suggest a psychogenic cause include:

 Sudden onset.
 Early collapse of erection.
 Self-stimulated or waking erections.
 Premature ejaculation or inability to ejaculate.
 Problems or changes in a relationship.
 Major life events.
 Psychological problems.
Symptoms that suggest an organic cause include:

 Gradual onset.
 Normal ejaculation.
 Normal libido (except hypogonadal men).
 Risk factor in medical history (cardiovascular, endocrine or neurological).
 Operations, radiotherapy, or trauma to the pelvis or scrotum.
 A current drug recognised as associated with ED.
 Smoking, high alcohol consumption, use of recreational or bodybuilding drugs.
Therefore, the only correct answer is option 3.
Q-47
Nigel is a 53-year-old gentleman with a background of prostate cancer who underwent a complete
prostatectomy 3 months ago. You have been asked to perform a PSA level after 3 months for routine
surveillance. The result shows a PSA level of 2 ng/ml (normal upper range for his age group is 3.9 ng/ml).
How would you manage this result?
A. Urgent referral to oncology

B. Repeat PSA in 6 months
C. Repeat PSA in 3 months
D. Reassurance as within normal range
E. Repeat PSA in 1 month
ANSWER:
A. Urgent referral to oncology
EXPLANATION:
Following a complete prostatectomy, the PSA level should be 'undetectable' which is defined usually as a
value less than 0.2ng/ml. Therefore following 3 months a value of 2 (albeit within the normal range for
patients who have not had treatment) would be considered a significantly elevated value and would,
therefore, warrant urgent referral to oncology for further investigation.
References:
Prostate Cancer Foundation - THE ROLE OF PSA
http://www.pcf.org/site/c.leJRIROrEpH/b.5837041/k.8FFF/TheRoleofPSA.htm
The American Cancer Society - Following PSA levels during and after treatment
http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-p-s-a-levels-after-
treatment
Please see Q-34 for Prostate Cancer: PSA Testing
Q-48
You are reviewing a 48-year-old man who has come to see you with erectile dysfunction (ED). This has
slowly been getting worse for the last 3 years and it is causing relationship problems with his wife. He is
normally fit and well.
An examination of his cardiovascular system is normal, his blood pressure is 138/87 mmHg. His body mass
index (BMI) is within normal range and examination of his genitalia is normal.
You decide to run some blood tests including HbA1c level and lipids.
Which other blood test/tests should be included in this initial screen?
A. Thyroid function tests (TFTs)

B. Testosterone level
C. Follicle stimulating hormone (FSH) and leuteinising hormone (LH)
D. Cortisol level
E. Prolactin level
ANSWER:
B. Testosterone level
EXPLANATION:
All men with ED should have their testosterone level checked
Expert opinion is that men presenting with erectile dysfunction should be screened for underlying
diabetes, cardiovascular disease (CVD), and hypogonadism, as this will provide an opportunity to
intervene (including lifestyle modifications) and improve both the erectile dysfunction and cardiovascular
health.
A glucose and lipid profile is recommended for all men with a new presentation of erectile dysfunction,
due to the strong association of erectile dysfunction with CVD and diabetes.
Therefore, the other test that should be included is a testosterone level for all men presenting with erectile
dysfunction to screen for hypogonadism. The correct answer is, therefore, option 2.
The advice of the British Society for Sexual Medicine (BSSM) is that testosterone screening is pragmatic in
light of the fact that testosterone deficiency is reversible and can have a negative impact on
phosphodiesterase-5 inhibitor efficacy. They advise that men with consistently low total serum
testosterone levels (less than 12 nmol/l) may benefit from up to a 6 months trial of testosterone
replacement therapy for erectile dysfunction.
If the free testosterone is low or borderline the correct management is to repeat the testosterone
measurement, and measure follicle-stimulating hormone (FSH), luteinising hormone (LH), and prolactin
levels. If these are abnormal you should consider referral to endocrinology.
A PSA is recommended in men with an abnormal digital rectal examination or in men >50 years who are at
greater risk of prostate cancer or you are considering testosterone replacement.
Cortisol and thyroid function tests are not recommended when assessing a patient with ED unless they
have symptoms of thyroid, Cushing's or Addison's disease.
Q-49
Which one of the following statements regarding varicoceles is correct?
A. Over 80% occur on the left side

B. All patients should be offered surgery to prevent infertility
C. Around 5% of patients have an underlying testicular cancer
D. They are more common in pre-pubertal males
E. Having a varicocele is a risk factor for deep vein thrombosis
ANSWER:
A. Over 80% occur on the left side
EXPLANATION:
Q-50
You review a 58-year-old man, who is concerned about his risk of abdominal aortic aneurysm (AAA), as his
father recently died of a ruptured AAA. He has a body mass index of 30kg/m² and a 30 pack-year smoking
history. His blood pressure in clinic is 142/93 mmHg. He is provided with a leaflet of information regarding
AAA screening.
Which of the following is correct regarding this screening?
A. Due to his risk factors he will be offered screening at age 60

B. He will be invited for 5-yearly abdominal ultrasounds starting at age 65
C. He will be invited for one-off abdominal ultrasound at aged 65
D. He will be invited for yearly abdominal ultrasounds from age 75
E. He will be invited for a one-off abdominal ultrasound at age 75
ANSWER:
C. He will be invited for one-off abdominal ultrasound at aged 65
EXPLANATION:
Screening for an abdominal aortic aneurysm consists of a single abdominal ultrasound for males aged 65
All men, regardless of risk factors, receive an invitation at age 65 for abdominal aortic aneurysm screening
consisting of a single ultrasound. If an aneurysm is detected, further follow-up will be arranged.
Please see Q-10 for Abdominal Aortic Aneurysm: Screening and Management of Unruptured Aneurysms
Q-51-53
Theme: Abdominal pain
A. Alcoholic hepatitis
B. Acute cholecystitis
C. Duodenal ulcer
D. Gastric ulcer
E. Biliary colic
F. Ruptured abdominal acute aneurysm
G. Acute pancreatitis
H. Gastroenteritis
I. Diverticulitis
J. Intestinal obstruction
Q-51
A 49-year-old woman presents with pain in the right upper quadrant. This has been occurring for the past
3 months and is often precipitated by a heavy meal. When the pain comes it is typically lasts around 1-2
hours. Clinical examination is unremarkable other than mild tenderness in the right upper quadrant.
ANSWER:
E. Biliary colic
Q-52
A 37-year-old attends surgery due to a one day history of severe central abdominal pain radiating through
to the back. He has vomited several times and is guarding on examination. Parotitis and spider naevi are
also noted.
ANSWER:
EXPLANATION:
Parotitis and spider naevi suggest excessive alcohol intake which is one of the most common causes of acute
pancreatitis.
Q-53
A 72-year-old woman who takes regular laxatives comes to surgery. Over the past two days she has
developed progressively worse pain in the left lower quadrant. On examination she has a low-grade
pyrexia and is tender on the left side of the abdomen
ANSWER:
I. Diverticulitis
ABDOMINAL PAIN
The table below gives characteristic exam question features for conditions causing abdominal pain. Unusual
and 'medical' causes of abdominal pain should also be remembered:
 myocardial infarction
 diabetic ketoacidosis
 pneumonia
 acute intermittent porphyria
 lead poisoning

Peptic ulcer Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by
disease eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis,
melena etc)
Appendicitis Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing's sign: more pain in RIF than LIF when palpating LIF
Acute Usually due to alcohol or gallstones
pancreatitis Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's
sign) is described but rare
Biliary colic Pain in the RUQ radiating to the back and interscapular region, may be following a
fatty meal. Slight misnomer as the pain may persist for hours
Obstructive jaundice may cause pale stools and dark urine
It is sometimes taught that patients are female, forties, fat and fair although this is
obviously a generalisation
Acute History of gallstones symptoms (see above)
cholecystitis Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy's sign positive (arrest of inspiration on palpation of the RUQ)
Diverticulitis Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white cells
Abdominal Severe central abdominal pain radiating to the back
aortic aneurysm Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent
severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease
Intestinal History of malignancy/previous operations
obstruction Vomiting
Not opened bowels recently
'Tinkling' bowel sounds
Diagram showing stereotypical areas where particular conditions present. The diagram is not exhaustive and only lists
the more common conditions seen in clinical practice. Note how pain from renal causes such as renal/ureteric colic and
pyelonephritis may radiate and move from the loins towards the suprapubic area.
Q-54-56
Theme: Scrotal problems
A. Varicocele
B. Testicular cancer
C. Epididymo-orchitis
D. Epididymal cyst
E. Inguinal hernia
F. Hydrocele
G. Femoral hernia
H. Hydatid of Morgagni
I. Fournier's gangrene
J. Cardiac failure
For each of the following scenarios please select the most likely diagnosis:
Q-54
A 31-year-old man presents as he and his partner have been having problems conceiving. On examination
there is a diffuse lumpy swelling on the left side of his scrotum. This is not painful and the testicle, which
can be felt separately, is normal.
ANSWER:
A. Varicocele
Q-55
A 44-year-old man notices a pea-sized lump on his right testicle. On examination a discrete soft mass can
be felt posterior to the right testicle.
ANSWER:
D. Epididymal cyst
Q-56
A 75-year-old man presents with a swelling in his right scrotum. On examination a large, non-tender
swelling is found in the scrotum. You cannot palpate above the swelling during the examination.
ANSWER:
E. Inguinal hernia
EXPLANATION:
A hydrocele is less likely as you cannot 'get above' the swelling on examination.
Q-57-59
Theme: Venous thromboembolism prophylaxis
A. 5 days
B. 7 days
C. 8-9 days
D. 14 days
E. 21 days
F. 28 days
G. 36-42 days
H. 56 days
I. No post-procedure prophylaxis required
For each of the following conditions/procedures please select the required duration of venous
thromboembolism prophylaxis after the procedure. It has been decided to use low-molecular weight
heparin as the patient cannot take aspirin.
Q-57
Elective hip replacement
ANSWER:
F. 28 days
Q-58
Elective knee replacement
ANSWER:
D. 14 days
Q-59
Hip fracture
ANSWER:
F. 28 days
Please see Q-18 for Venous Thromboembolism: Prophylaxis in Patients Admitted to Hospital
Q-60
A 43-year-old Jewish lady presented to her GP requesting screening for breast cancer. She denied any
symptoms, and breast examination was unremarkable. She reported that her maternal aunt suffered from
breast cancer, first diagnosed at 45 years. What would be the most appropriate action with regards to
further investigation?
A. Refer to secondary care for early screening

B. Refer urgently to be seen in breast clinic
C. Do nothing as the patient does not meet criteria for screening at present
D. Explain that the NHS screening programme is being expanded to start at 47 years and she should come
back to request screening then
E. Advise that the screening programme starts at age 40 and she should already have received an
invitation
ANSWER:
A. Refer to secondary care for early screening
EXPLANATION:
Family history of Jewish ancestry and breast cancer - refer to secondary care
As outlined in the extensive list below, there are certain criteria that warrant early referral to secondary
care. A history of breast cancer in a first or degree relative, combined with a Jewish ancestry, is one of
them. In this case, a patient should be referred to secondary care.
The current presentation does not warrant an urgent referral.
Whilst the NHS Screening programme is being expanded to start at 47, this woman has grounds to be
referred earlier
Q-61
A 55-year-old patient comes to see you to discuss his high cholesterol and his HbA1c, which is in the pre-
diabetic range. This has come off the back of an NHS health check, for which he received an invitation in
the post. He jokes that he wished he hadn't taken it up because he had felt well before and now he has
two new problems!
What other screening test might he soon receive an invitation from the NHS for?
A. Prostate specific antigen (PSA) blood test for prostate cancer

B. Bowel scope for bowel cancer
C. Eye test for glaucoma
D. Ultrasound for abdominal aortic aneurysm (AAA)
E. Home test kit (FIT/FOB) for bowel cancer
ANSWER:
B. Bowel scope for bowel cancer
EXPLANATION:
Screening for bowel cancer using sigmoidoscopy is being rolled out as part of the NHS screening program
Bowel screening using flexible sigmoidoscopy is currently being rolled out (not yet done in all parts of the
UK). This is a one-off test at age 55. It runs in parallel with the existing home test kit (FIT/FOB) screening
which is sent out 2-yearly to patients aged 60-74. PSA testing is not part of the routine NHS screening
program, though patients can request it from the GP. AAA screening is offered to men at the age of 65.
The NHS website advises everyone should have an eye test every 2 years which should include checks for
glaucoma, but this is not part of the NHS screening program.
Q-62
Which one of the following statements regarding congenital inguinal hernias is correct?
A. They should be managed conservatively

B. Result from the premature closure of the processus vaginalis
C. They are more common in girls
D. The incidence in newborns is 0.1-0.2%
E. They are more common on the right side
ANSWER:
E. They are more common on the right side
EXPLANATION:
Please see Q-45 for Abdominal Wall Hernias
Q-63
What is the lifetime risk of developing colorectal cancer in the United Kingdom?
A. 1%
B. 2%
C. 5%
D. 10%
E. 15%
ANSWER:
C. 5%
EXPLANATION:
Colorectal cancer is the third most common cancer in the UK, with approximately 30,000 new cases in
England and Wales per year
Q-64
A 72-year-old man presents to surgery. Whilst walking back from a friends house he slipped on some ice
and fell backwards, landing on his right arm and banging his head on the kerb in the process. His past
medical history includes atrial fibrillation for which he takes bisoprolol and warfarin. A routine INR taken
four days ago was 2.2. There are no signs of any external injury to his right arm or scalp. What is the most
appropriate course of action with relation to his head injury?
A. Refer the patient to hospital for a CT head scan to be performed within 8 hours
B. Give standard head injury advice
C. Admit for 24 hours of observation
D. Admit for 8 hours of observation
E. Give standard head injury advice + advise he stops warfarin for 5 days
ANSWER:
A. Refer the patient to hospital for a CT head scan to be performed within 8 hours
EXPLANATION:
Patients who've had a head injury and are on warfarin need to have a CT scan, regardless of whether they
have risk factors for an intracranial injury. NICE state:
For patients (adults and children) who have sustained a head injury with no other indications for a CT head
scan and who are having warfarin treatment, perform a CT head scan within 8 hours of the injury. A
provisional written radiology report should be made available within 1 hour of the scan being performed.
HEAD INJURY: NICE GUIDANCE ON INVESTIGATION

NICE has strict and clear guidance regarding which adult patients are safe to discharge and which need
further CT head imaging. The latter group are also divided into two further cohorts, those who require an
immediate CT head and those requiring CT head within 8 hours of injury:
CT head immediately
 GCS < 13 on initial assessment
 GCS < 15 at 2 hours post-injury
 suspected open or depressed skull fracture.
 any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear
or nose, Battle's sign).
 post-traumatic seizure.
 focal neurological deficit.
 more than 1 episode of vomiting
CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have
experienced some loss of consciousness or amnesia since the injury:
 age 65 years or older
 any history of bleeding or clotting disorders
 dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected
from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
 more than 30 minutes' retrograde amnesia of events immediately before the head injury
If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan,
perform a CT head scan within 8 hours of the injury.
Q-65-67
Theme: Abdominal pain
A. Myocardial infarction
B. Colorectal cancer
C. Duodenal ulcer
D. Gastric ulcer
E. Biliary colic
F. Ruptured abdominal aortic aneurysm
H. Toxic megacolon
I. Diverticulitis
Q-65
A 65-year-old man with a history of ischaemic heart disease presents with sudden onset central
abdominal pain radiating to his back. He is clammy and short of breath.
ANSWER:
F. Ruptured abdominal aortic aneurysm
Q-66
A 34-year-old man who drinks 21 units of alcohol per week presents with episodic epigastric pain that is
relieved by eating.
ANSWER:
C. Duodenal ulcer
Q-67
A 40-year-old woman with a history of Crohn's disease presents with abdominal pain and distension. She
describes constipation for the past 4 days.
ANSWER:
Please see Q-51-53 for Abdominal Pain
Q-68
Which one of the following statements regarding testicular cancer is correct?
A. Fragile X syndrome is a risk factor

B. Gynaecomastia is seen in the majority of men
C. Seminomas have a better prognosis than teratomas
D. Afro-Caribbean ethnicity is a risk factor
E. May present as a varicocele in up to 10% of patients
ANSWER:
C. Seminomas have a better prognosis than teratomas
EXPLANATION:
TESTICULAR CANCER
Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of
testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into:
 seminomas
 non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma
Non-germ cell tumours include Leydig cell tumours and sarcomas.
The peak incidence for teratomas is 25 years and seminomas is 35 years. Risk factors include:
 infertility (increases risk by a factor of 3)
 cryptorchidism
 family history
 Klinefelter's syndrome
 mumps orchitis
Features
 a painless lump is the most common presenting symptom
 pain may also be present in a minority of men
 other possible features include hydrocele, gynaecomastia
 AFP is elevated in around 60% of germ cell tumours
 LDH is elevated in around 40% of germ cell tumours
 seminomas: hCG may be elevated in around 20%
Diagnosis
 ultrasound is first-line
Management
 treatment depends on whether the tumour is a seminoma or a non-seminoma
 orchidectomy
 chemotherapy and radiotherapy may be given depending on staging and tumour type
Prognosis is generally excellent

 5 year survival for seminomas is around 95% if Stage I
 5 year survival for teratomas is around 85% if Stage I
Q-69
You see a 52-year-old gentleman with a personal problem. He has been having problems with erections
for the last 12 months. It has slowly got worse. He rarely comes to the doctor and has no past medical
history.
What is the most common organic cause of this symptom?
A. Central neurogenic causes

B. Vascular causes
C. Peripheral neurogenic causes
D. Hormonal causes
E. Structural/anatomical causes
ANSWER:
B. Vascular causes
EXPLANATION:
Of organic causes of erectile dysfunction, vascular causes are the most common
Organic causes include vasculogenic, neurogenic (either central or peripheral), structural or hormonal.
Psychogenic causes can be broadly split into generalised or situational.
By far the most common cause of organic ED is vasculogenic causes. This includes cardiovascular disease
(CVD), hypertension, hyperlipidaemia, diabetes mellitus, smoking, and major pelvic surgery.
Therefore, the risk factors for erectile dysfunction are similar to those for CVD and include obesity,
diabetes, dyslipidaemia, metabolic syndrome, hypertension, endothelial dysfunction, and lifestyle factors
(such as lack of exercise and smoking). When assessing a man with ED you, therefore, need to screen him
for CVD as well as taking a thorough psychosexual history.
Q-70
A 71-year-old man is undergoing medical treatment for benign prostatic hyperplasia. He presents to his
GP with new-onset nocturnal enuresis. Urinalysis is clear, rectal examination shows an enlarged but
smooth prostate. He has no neurological signs. A post voiding bladder scan shows 250ml residual volume.
He is referred to urology for his suspected chronic urinary retention. Ultrasound shows bilateral
hydronephrosis and mildly abnormal renal function tests. He is not keen to undergo surgery. What is the
most appropriate initial long-term management?
A. Suprapubic catheter
B. Long term urinary catheter
C. Intermittent self-catheterisation
D. Three-way catheter
E. Cystectomy and ileal conduit
ANSWER:
C. Intermittent self-catheterisation
EXPLANATION:
Patients with chronic urinary retention should be taught intermittent self catheterisation before a long
term catheter is offered.
Cystectomy is a surgical procedure and so the patient is unlikely to want this and is not indicated for
urinary retention. Three-way catheters are used for irrigation of the bladder in patients experiencing
haematuria, however, are inappropriate as a long-term measure. Suprapubic catheters and long-term
urinary catheters are both options, however, it would be least restrictive to give the patient education and
a trial of intermittent self-catheterisation. It is also associated with fewer UTIs and other complications
than long-term catheters.
Please see Q-21 for Benign Prostatic Hyperplasia
Q-71
You are reviewing a 72-year-old gentleman over the phone who is troubled with erectile dysfunction. He
is newly registered to your practice but says that he has hypertension, angina and a tablet for his 'water-
works'.
He reads out his list of medications which include: aspirin, losartan, atorvastatin, tamsulosin, bisoprolol
and amlodipine. His doctor started a new tablet 3 months ago but he is not sure which one it was. Since
then his erections have been worse.
Which tablet is most likely to be the culprit for his symptoms?
A. Losartan
B. Atorvastatin
C. Tamsulosin
D. Bisoprolol
E. Amlodipine
ANSWER:
D. Bisoprolol
EXPLANATION:
Beta-blockers are a common drug cause of ED
Erectile dysfunction (ED) is listed in the BNF as being 'uncommon' for amlodipine. For beta-blockers, the
BNF lists ED as being 'common or very common'.
Q-72
Tina is a 25-year-old woman who presents with breast tenderness bilaterally prior to her period. She also
notices that her breasts feel more lumpier. The pain is extremely uncomfortable and she would like to
know what she can do about this. As she has recently finished her period, there is no pain on palpation of
her breasts, and there are no palpable lumps.
What is the first-line treatment for Tina?
A. Codeine
B. Cerazette
C. Vitamin E
D. A supportive bra
E. Evening primrose oil
ANSWER:
D. A supportive bra
EXPLANATION:
A supportive bra and simple analgesia is the first-line treatment for cyclical mastalgia
Cyclical mastalgia is breast pain related to the hormonal changes during the menstrual cycle.
According to NICE guidelines, first-line treatments include a supportive bra and simple analgesia.
Simple analgesia includes paracetamol and NSAIDs. Codeine is not recommended.
Cerazette is a progesterone-only contraceptive pill. It can sometimes make breast tenderness worse.
Vitamin E and primrose oil are not recommended as per NICE guidelines.
CYCLICAL MASTALGIA
Benign cyclical mastalgia is a common cause of breast pain in younger females.
Clinical features
 It varies in intensity according to the phase of the menstrual cycle
 Cyclical mastalgia is not usually associated with point tenderness of the chest wall (more likely to be
Tietze's syndrome).
 The underlying cause is difficult to pinpoint, examination should focus on identifying focal lesions (such
as cysts) that may be treated to provide symptomatic benefit.
Management
 Women should be advised to wear a supportive bra
 Conservative treatments include standard oral and topical analgesia
 flaxseed oil and evening primrose oil are sometimes used but neither are recommended by NICE Clinical
Knowledge Summaries
 If the pain has not responded to conservative measures after 3 months, and is affecting the quality of life
or sleep, then referral should be considered
o Hormonal agents such as bromocriptine and danazol may be more effective. However, many women
discontinue these therapies due to adverse effects.
Q-73
A 56-year-old lady initially presented with a hard painless lump in her left breast and was recently
diagnosed with invasive ductal carcinoma following a core biopsy. Her last menstrual period was over 7
years ago and she has no history of ovarian/endometrial cancer. Hormone receptor studies from the
biopsy came back as:
Oestrogen receptor (ER) positive

Progesterone receptor (PR) positive
Her-2 receptor (HER-2) negative
She had left mastectomy and axillary node clearance followed by radiotherapy. She is seen in breast clinic
1 month later and is making a good recovery, with no signs of recurrence.
What mode of hormonal therapy should she be offered?
A. None
B. Tamoxifen for 5 years
C. Trastuzumab
D. Anastrozole
E. Tamoxifen for 10 years
ANSWER:
D. Anastrozole
EXPLANATION:
Adjuvant hormonal therapy for ER +ve breast cancer: anastrozole in post-menopausal women
Anastrozole is an aromatase inhibitor that reduces peripheral oestrogen synthesis. This is important as
aromatisation accounts for the majority of oestrogen production in post-menopausal women and
therefore anastrozole is used for ER +ve breast cancer in this group.
BREAST CANCER: MANAGEMENT

The management of breast cancer depends on the staging, tumour type and patient background. It may
involve any of the following:
 surgery
 radiotherapy
 hormone therapy
 biological therapy
 chemotherapy
Surgery
The vast majority of patients who have breast cancer diagnosed will be offered surgery. An exception may
be a very frail, elderly lady with metastatic disease who may be better managed with hormonal therapy.
Prior to surgery, the presence/absence of axillary lymphadenopathy determines management:

 women with no palpable axillary lymphadenopathy at presentation should have a pre-operative axillary
ultrasound before their primary surgery
o if positive then they should have a sentinel node biopsy to assess the nodal burden
 in patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node
clearance is indicated at primary surgery
o this may lead to arm lymphedema and functional arm impairment
Depending on the characteristics of the tumour women either have a wide-local excision or a mastectomy.
Around two-thirds of tumours can be removed with a wide-local excision. The table below lists some of the
factors determining which operation is offered:
Mastectomy Wide Local Excision

Multifocal tumour Solitary lesion
Central tumour Peripheral tumour
Large lesion in small breast Small lesion in large breast
DCIS > 4cm DCIS < 4cm
Women should be offered breast reconstruction to achieve a cosmetically suitable result regardless of the
type of operation they have. For women who've had a mastectomy this may be done at the initial operation
or at a later date.
Radiotherapy
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce
the risk of recurrence by around two-thirds. For women who've had a mastectomy radiotherapy is offered
for T3-T4 tumours and for those with four or more positive axillary nodes
Hormonal therapy
Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this
was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal
women. In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*.
This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal
women and therefore anastrozole is used for ER +ve breast cancer in this group.
Important side-effects of tamoxifen include an increased risk of endometrial cancer, venous

thromboembolism and menopausal symptoms.
Biological therapy
The most common type of biological therapy used for breast cancer is trastuzumab (Herceptin). It is only
useful in the 20-25% of tumours that are HER2 positive.
Trastuzumab cannot be used in patients with a history of heart disorders.
Chemotherapy
Cytotoxic therapy may be used either prior to surgery ('neoadjuvanant' chemotherapy) to downstage a
primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node
disease - FEC-D is used in this situation.
Q-74
You see an 18-year-old man with a scrotal swelling on the left-hand side. He noticed it about 4 weeks ago
but it has not gone away. He has no pain or any other symptoms. He is otherwise fit and well although he
smokes 10 cigarettes a day.
On examination, he has a small scrotal swelling (approximately 2cm in diameter) when he is standing up
which is separate and superior to the left testicle and feels like swollen veins. When he lies down you
can't feel the swelling anymore. Both testes are the same size.
You diagnose a varicocele and discuss this with the patient.
A. 90% of varicoceles appear on the right

B. Scrotal or groin pain is common with a varicocele
C. Varicoceles are not associated with abnormal semen parameters
D. Varicoceles occur in about 15% of adolescent boys and men
E. A left-sided varicocele alone is rare and should be referred to a urologist
ANSWER:
D. Varicoceles occur in about 15% of adolescent boys and men
EXPLANATION:
Varicoceles occur in about 15% of adolescent boys and men
Varicoceles occur in about 15% of adolescent boys and men. Therefore, option 4 is correct.
90% of varicoceles appear on the left. Therefore, option 1 is incorrect.
Scrotal or groin pain is uncommon. In fact, less than 3% of men with a varicocele have pain or dragging or
heavy sensations in the scrotum. Therefore, option 2 is wrong.
Approximately one in four men with abnormal semen parameters will have a varicocele, and 40% of men
presenting with infertility have a varicocele. Therefore, option 3 is incorrect.
A right-sided varicocele alone is rare and should be referred to a urologist. Therefore, option 5 is wrong.
Q-75
A 40-year-old man attends his General Practice to discuss a friend who recently died of a ruptured
abdominal aortic aneurysm (AAA). He asks what screening programmes there are currently available for
the condition.
Which of the following is correct?
A. Abdominal ultrasound scan aged 65 and then every 5 years

B. Single abdominal CT scan aged 65
C. Abdominal CT scan aged 65 and then every 3 years
D. Single abdominal ultrasound aged 65
E. No current screening programme in place
ANSWER:
D. Single abdominal ultrasound aged 65
EXPLANATION:
Screening for an abdominal aortic aneurysm consists of a single abdominal ultrasound for males aged 65
In England, abdominal aortic aneurysm screening (AAA) is offered to men during the year they turn 65.
If normal (<3cm) the patient will require no further future scans as the chances of developing a AAA after
65 years old is small.
Q-76
A 55-year-old accountant presents to surgery requesting a sick note following an open repair of an
inguinal hernia. According to Department of Work and Pensions advice, when should he be able to return
to work?
A. After 5 days
B. After 7 days
C. After 1 - 2 weeks
D. After 2 - 3 weeks
E. After 3 - 4 weeks
ANSWER:
D. After 2 - 3 weeks
EXPLANATION:
Inguinal hernia repair: back to work after 2-3 weeks if open, 1-2 weeks if laparoscopic
Please see Q-5 for Inguinal Hernia
Q-77
You are the duty doctor in a busy GP practice. You see a 32-year-old lady as an emergency with severe
rectal pain. She gave birth 10 days ago to a healthy baby girl. It was her first birth and was complicated by
a long labour, forceps delivery, and an episiotomy.
She has been recovering well at home but is finding it very hard to sit down due to pain in her perineum.
She is bleeding vaginally but this is settling. Her main complaint is a severe rectal pain, particularly when
she is opening her bowels. She has also noticed that there is bright red blood on the tissue when she
wipes. The pain continues in her rectum for approximately 30 minutes after she has opened her bowels.
On examination, her abdomen is soft and non-tender. Her episiotomy wound is healing well and her anus
looks normal externally. Her observations are normal.
The most likely diagnosis is:
A. Retained products of conception

B. Haemorrhoids
C. Anal fissure
D. Episiotomy wound infection
E. Rectal prolapse
ANSWER:
C. Anal fissure
EXPLANATION:
An anal fissure is the most likely diagnosis for a lady who has recently given birth, who has painful, bright
red rectal bleeding
The diagnosis here is an anal fissure. Childbirth is a risk factor for an anal fissure due to the pushing and
pressure on the perineum. Patients complain of pain (which can be very severe) and bleeding when
passing stools. This pain can continue for some time after having the bowels open. Therefore, option 3 is
correct.
She is reporting a number of normal symptoms post-childbirth, such as pain when sitting and vaginal
bleeding. Both of these symptoms will settle.
The history does not fit with retained products of conception as the patient would be unwell and have
offensive vaginal discharge. Therefore, option 1 is incorrect.
Haemorrhoids typically present with bright red, painless rectal bleeding. They can be painful but are rarely
painful when internal (this patient has a normal anus on examination). Therefore, option 2 is incorrect.
A rectal prolapse would be obvious on examination as you would see it outside of the anus. Therefore,
option 5 is wrong.
An episiotomy wound infection can be painful. The patient may feel systemically unwell and the wound
will look red and possibly be oozing. This is not the case here so option 4 is wrong.
ANAL FISSURE
Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for
less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
Risk factors
 constipation
 inflammatory bowel disease
 sexually transmitted infections e.g. HIV, syphilis, herpes
Features
 painful, bright red, rectal bleeding
 around 90% of anal fissures occur on the posterior midline.
o if the fissures are found in alternative locations then other underlying causes should be considered
e.g. Crohn's disease
Management of an acute anal fissure (< 6 weeks)

 dietary advice: high-fibre diet with high fluid intake
 bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
 lubricants such as petroleum jelly may be tried before defecation
 topical anaesthetics
 analgesia
 topical steroids do not provide significant relief
Management of a chronic anal fissure (> 6 weeks)

 the above techniques should be continued
 topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
 if topical GTN is not effective after 8 weeks then secondary care referral should be considered for
surgery (sphincterotomy) or botulinum toxin
Q-78
A 44-year-old woman is diagnosed with breast cancer. She has no past medical history of note, is pre-
menopausal and has no family history of breast or ovarian cancer. Staging suggests early disease and she
has a wide-local excision followed by whole-breast radiotherapy. Pathology results show that the tumour
is oestrogen receptor positive, HER2 negative. Which one of the following adjuvant treatments is she most
likely to be offered?
A. Anastrozole
B. Letrozole
C. Tamoxifen
D. Trastuzumab (Herceptin)
E. Cytotoxic therapy with epirubicin, cyclophosphamide and fluorouracil
ANSWER:
C. Tamoxifen
EXPLANATION:
Tamoxifen is used as the women is pre-menopausal. There is ongoing debate about whether therapy
should be for 5 years or longer.
Please see Q-73 for Breast Cancer: Management
Q-79
A 79-year-old complains of lower urinary tract symptoms. Which one of the following statements
regarding benign prostatic hyperplasia is incorrect?
A. Goserelin is licensed for refractory cases
B. Side-effects of 5 alpha-reductase inhibitors include ejaculation disorders and gynaecomastia
C. Possible presentations include recurrent urinary tract infection
D. 5 alpha-reductase inhibitors typically decrease the prostate specific antigen level
E. More common in black men
ANSWER:
A. Goserelin is licensed for refractory cases
EXPLANATION:
Goserelin (Zoladex) is not used in the management of benign prostatic hyperplasia
Q-80
A 60-year-old man presents with lower urinary tract symptoms and is offered a PSA test. According to NHS
guidelines, which one of the following could interfere with the PSA level?
A. Vigorous exercise in the past 48 hours

B. Poorly controlled diabetes mellitus
C. Smoking in the past 48 hours
D. Current constipation
E. Drinking more than 4 units of alcohol in the past 48 hours
ANSWER:
A. Vigorous exercise in the past 48 hours
EXPLANATION:
Q-81
A 54-year-old woman is reviewed in clinic. She has recently been diagnosed with superficial
thrombophlebitis of the long saphenous vein after being referred for an ultrasound scan after a deep vein
thrombosis was suspected.
Her past medical history includes morbid obesity and knee osteoarthritis that has resulted in her having
reduced mobility.
What is the most appropriate next step?
A. Topical NSAID for 2 weeks

B. Consult a haematologist re: warfarin for 3 months
C. Topical heparinoid for 2 weeks
D. Consult a haematologist re: low-molecular weight heparin for 30 days
E. Consult a haematologist re: low-molecular weight heparin for 3 months
ANSWER:
D. Consult a haematologist re: low-molecular weight heparin for 30 days
EXPLANATION:
Clinical Knowledge Summaries advise that when patient's present with superficial thrombophlebitis we
should identify patients at an increased risk of developing a deep vein thrombosis:
A person's risk should be judged by considering the size and number of risk factors present. Particular
importance should be given to people with:
Thrombophlebitis that extends near where an affected superficial vein joins a deep vein, for example
where the long saphenous vein joins the femoral vein at the groin.
Reduced mobility.
Thrombophlebitisnotassociated with varicose veins.
Past history of DVT or pulmonary embolism (PE).
This patient is at an increased risk because of her reduced mobility.
SUPERFICIAL THROMBOPHLEBITIS
Superficial thrombophlebitis, as the name suggests describes the inflammation associated with thrombosis
of one of the superficial veins, usually the long saphenous vein of the leg. This process is usually non-
infective in nature but secondary bacterial infection may rarely occur resulting in septic thrombophlebitis.
Around 20% with superficial thrombophlebitis will have an underlying deep vein thrombosis (DVT) at
presentation and 3-4% of patients will progress to a DVT if untreated. The risk of DVT is partly linked to the
length of vein affected - an inflammed vein > 5 cm is more likely to have an associated DVT.
Management
There are currently a variety of treatment approaches to superficial thrombophlebitis. Traditionally NSAIDs
have been used, with topical NSAIDs for limited and mild disease and oral NSAIDs for more severe disease.
Topical heparinoids have also be used in the management of superficial thrombophlebitis.
A Cochrane review however found topical NSAIDs and heparinoids have no significant benefit in terms of
reducing extension or progression to DVT. Oral NSAIDs were however shown to reduce the risk of extension
by 67%.
Compression stockings are also used. Remember that the ankle-brachial pressure index (ABPI) should be
measured before prescribing compression stockings, particularly if using class 2 or above stockings.
One of the major changes to the management of superficial thrombophlebitis is the increased use of low-
molecular weight heparin. This has been shown to reduce extension and transformation to DVT. SIGN
produced guidelines in 2010:
Patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should
have an ultrasound scan to exclude concurrent DVT.
 Patients with superficial thrombophlebitis should have anti-embolism stockings and can be considered for
treatment with prophylactic doses of LMWH for up to 30 days or fondaparinux for 45 days.
 If LMWH is contraindicated, 8-12 days of oral NSAIDS should be offered.
Patients with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be
considered for therapeutic anticoagulation for 6-12 weeks.
This may be a significant departure from our current practice - the majority of patients with superficial
thrombophlebitis (i.e. those affecting the long saphenous vein) should be referred for an ultrasound scan.
Q-82
A 16-year-old girl presents with a 3 month history of breast pain. She describes a dull ache in both breasts
which occurs in the 2 weeks before her period is due. She is otherwise fit and well with has no other
medical conditions. She is not sexually active.
Examination reveals no breast lumps or overlying skin changes.
What is the next most appropriate step in management?
A. Refer urgently to a breast specialist

B. Commence a 7-day course of antibiotics
C. Commence the combined oral contraceptive pill
D. Commence the progesterone-only pill
E. Advice on a supportive bra and simple analgesia
ANSWER:
E. Advice on a supportive bra and simple analgesia
EXPLANATION:
Cyclical breast pain is common affecting up to two-thirds of women, usually starting two weeks before the
onset of the menstrual period. In the absence of other features of breast cancer (such as a breast lump or
overlying nipple or skin changes), breast pain is not associated with breast cancer. Referral to a breast
specialist can be considered if the pain is severe enough to affect quality of life or sleep and does not
respond to first-line treatment after 3 months, however there is no indication for referral in this case.
There is no evidence for antibiotics in the treatment of cyclical breast pain.
Current NICE CKS guidance advises against either the combined oral contraceptive pill or progesterone-
only pill in the treatment of cyclical breast pain as there limited evidence of effectiveness compared to
placebo.
First-line management for cyclical breast pain is advice on a supportive bra and simple analgesia. This is
based on expert consensus which states that as long as malignancy has been excluded as a cause, most
cases of cyclical breast pain can be managed with conservative management and a watchful-waiting
approach.
Please see Q-72 for Cyclical Mastalgia

Q-83
You see a 65-year-old man who has right sided scrotal swelling which appeared suddenly 2 weeks ago. He
says that it is uncomfortable and painful. He has no other relevant past medical history. He smokes 20
cigarettes a day.
On examination, he has what feels like a varicocele in his right scrotum. He has a swelling which feels like
veins. It is separate from his right testicle and situated above it. The swelling is palpable when standing
and lying down.
You discuss the fact that you think this is a varicocele with the patient. Which statement below is correct?
A. 90% of varicoceles occur on the right hand side

B. Varicoceles are not associated with infertility
C. This patient requires urgent referral to a urologist
D. This patient requires referral if his symptoms do not settle within 1 month
E. All left sided varicoceles should have an ultrasound to look for an underlying tumour
ANSWER:
C. This patient requires urgent referral to a urologist
EXPLANATION:
A solitary right-sided varicocele requires urgent referral to a urologist
About 90% of varicoceles occur on the left side because of the difference in drainage routes of the right
and left spermatic veins. Therefore, option 1 is wrong.
A solitary right-sided varicocele requires urgent referral to a urologist. Therefore, option 3 is correct and
NICE state that we should not routinely refer men with a left-sided varicocele for ultrasonography to look
for an underlying tumour. Therefore, option 5 is wrong.
Q-84
Which one of the following may be used to monitor patients with colorectal cancer?
A. CA-125
B. Carcinoembryonic antigen
C. Alpha-fetoprotein
D. CA 19-9
E. CA 15-3
ANSWER:
B. Carcinoembryonic antigen
EXPLANATION:
Carcinoembryonic antigen may be used to monitor for recurrence in patients post-operatively or to assess
response to treatment in patients with metastatic disease
Q-85
A patient is started on finasteride for the treatment of benign prostatic hyperplasia. How long should the
patient be told that treatment may take to be effective?
A. Within 8 hours of taking the tablet

B. Within 3 days
C. Up to 7 days
D. Up to 4 weeks
E. Up to 6 months
ANSWER:
E. Up to 6 months
EXPLANATION:
Finasteride treatment of BPH may take 6 months before results are seen
Q-86
A 25-year-old female presents to surgery with a 2 week history of painless rectal bleeding. Inspection of
perineum and rectal examination is unremarkable. Proctoscopy reveals haemorrhoidal cushions at the left
lateral and right anterior position. What is the most important component of management?
A. Sitz baths
B. Topical nitrate
C. Fibre supplementation
D. Improving anal hygiene
E. Application of lubricant prior to defecation
ANSWER:
C. Fibre supplementation
EXPLANATION:
Fibre supplementation has been shown to be as effective as injection sclerotherapy in some studies
HAEMORRHOIDS
Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal
vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3
o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are said to exist when they become enlarged,
congested and symptomatic
Clinical features
 painless rectal bleeding is the most common symptom
 pruritus
 pain: usually not significant unless piles are thrombosed
 soiling may occur with third or forth degree piles
Types of haemorrhoids
External
 originate below the dentate line
 prone to thrombosis, may be painful
Internal
 originate above the dentate line
 do not generally cause pain
Grading of internal haemorrhoids
Grade I Do not prolapse out of the anal canal

Grade II Prolapse on defecation but reduce spontaneously
Grade III Can be manually reduced
Grade IV Cannot be reduced
Management
 soften stools: increase dietary fibre and fluid intake
 topical local anaesthetics and steroids may be used to help symptoms
 outpatient treatments: rubber band ligation is superior to injection sclerotherapy
 surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
 newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Acutely thrombosed external haemorrhoids

 typically present with significant pain
 examination reveals a purplish, oedematous, tender subcutaneous perianal mass
 if patient presents within 72 hours then referral should be considered for excision. Otherwise patients
can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10
days
Q-87
A 52-year-old man is seen in genitourinary medicine (GUM) clinic with a five day history of a swollen,
tender and erythematous glans penis. He is unable to fully retract his foreskin and is experiencing pain on
urination. He is not sexually active. This is his fourth presentation for balanitis in the last 12 months. On
each occasion he has tested negative for sexually transmitted infections and bacterial infections and has
been managed successfully with saline baths and topical clotrimazole. His past medical history is
remarkable for diabetes mellitus.
After treating this acute episode with saline baths and topical clotrimazole, what is the most appropriate
next step in management?
A. Nystatin cream
B. One week course of oral flucloxacillin
C. Prophylactic oral fluconazole
D. Prophylactic topical hydrocortisone
E. Refer for circumcision
ANSWER:
E. Refer for circumcision
EXPLANATION:
Recurrent balanitis is an indication for circumcision
Balanitis is inflammation of the glans penis. This can be due to sexually transmitted infection, dermatitis,
bacterial infection, or in this case an opportunistic fungal infection (Candida) that is likely secondary to the
patient's diabetes.
Acute infections are managed with saline baths and treatment of the underlying cause. In most cases,
topical treatment is recommended:
Sexually transmitted infection: appropriate treatment of the infection
Dermatitis: topical hydrocortisone
Candida: topical clotrimazole or miconazole or nystatin cream
Bacterial infection: flucloxacillin or erythromycin or metronidazole according to sensitivity
In cases of recurrent balanitis, the most appropriate treatment is circumcision, which will prevent the
condition from recurring.
Please see Q-35 for Circumcision
Q-88-90
Theme: Suture removal
A. 2 days
B. 4 days
C. 8 days
D. 12 days
E. 16 days
F. 21 days
For each one of the following locations please select the optimal time to remove the sutures. Assume the
patient has had a small skin lesion removed in primary care and has no relevant medical history.
Q-88
Back
ANSWER:
D. 12 days
Q-89
Face
ANSWER:
B. 4 days
Q-90
Scalp
ANSWER:
C. 8 days
MINOR SURGERY
Local anaesthetic (LA)
Lidocaine is the most widely used LA. It has a rapid onset of action and anaesthesia lasts for around 1 hour.
 the maximum safe dose is 3mg/kg. The BNF states 200mg (or 500mg if given in solutions containing
adrenaline), which equates to 3mg/kg for a 66kg patient. This is the equivalent of 20ml of 1% solution or
10ml of 2% solution
 lidocaine is available pre-mixed with adrenaline. This increases the duration of action of lidocaine and
reduces blood loss secondary to vasoconstriction. It must never be used near extremities due to the risk
of ischaemia
Suture material
Non-absorbable Absorbable
Silk Vicryl
Novafil Dexon
Prolene PDS
Ethilon
Non-absorbable sutures are normally removed after 7-14 days, depending on the location. Absorbable
sutures normally disappear after 7-10 days. Removal times for non-absorbable sutures are shown below:
Area Removal time (days)

Face 3-5
Scalp, limbs, chest 7 - 10
Hand, foot, back 10 - 14
Q-91
A 65-year-old man presents with lower urinary tract symptoms. For the past few months, he has had
problems with urinary urgency and has had several episodes of incontinence when he could not reach the
toilet in time. He describes good urinary flow with no hesitancy or straining. Urinalysis and prostate
examination are unremarkable.
Which one of the following medications is most likely to help alleviate his symptoms?
A. Alpha blocker
B. Antimuscarinic
C. 5-alpha reductase inhibitor
D. Loop diuretic
E. Desmopressin
ANSWER:
B. Antimuscarinic
EXPLANATION:
Antimuscarinic drugs are useful in patients with an overactive bladder
This patient has symptoms of an overactive bladder. Conservative measures should be discussed and
bladder training offered.
Examples of suitable antimuscarinic drugs include oxybutynin, tolterodine and darifenacin.
LOWER URINARY TRACT SYMPTOMS IN MEN

Lower urinary tract symptoms (LUTS) in men are very common and are present in the majority of men aged
> 50 years. They are most commonly secondary to benign prostatic hyperplasia but other causes should be
considered including prostate cancer.
It is useful to classify the symptoms into 3 broad groups.
Voiding Storage Post-micturition

Hesitancy Urgency Post-micturition dribbling
Poor or intermittent stream Frequency Sensation of incomplete emptying
Straining Nocturia
Incomplete emptying Urinary incontinence
Terminal dribbling
Examination
 urinalysis: exclude infection, check for haematuria
 digital rectal examination: size and consistency of prostate
 a PSA test may be indicated, but the patient should be properly counselled first
It is useful to get the patient to complete the following to guide management:

 urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and
nocturnal polyuria.
 International Prostate Symptom Score (IPSS): assess the impact on the patient's life. This classifies the
symptoms as mild, moderate or severe
Management
Predominately voiding symptoms
 conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and
containment products
 if 'moderate' or 'severe' symptoms offer an alpha-blocker
 if the prostate is enlarged and the patient is 'considered at high risk of progression' then a 5-alpha
reductase inhibitor should be offered
 if the patient has an enlarged prostate and 'moderate' or 'severe' symptoms offer both an alpha-blocker
and 5-alpha reductase inhibitor
 if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a
antimuscarinic (anticholinergic) drug may be added
Predominately overactive bladder

 conservative measures include moderating fluid intake
 bladder retraining should be offered
 antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate
release), tolterodine (immediate release), or darifenacin (once daily preparation)
 mirabegron may be considered if first-line drugs fail
Nocturia
 advise about moderating fluid intake at night
 furosemide 40mg in late afternoon may be considered
 desmopressin may also be helpful
Q-92
You are reviewing a 38-year-old man that you saw last week with an anal fissure caused by constipation
and straining. He has no systemic symptoms and is otherwise well. He has been using the lidocaine
ointment (which you prescribed last week) before every stool but he is still troubled by severe rectal pain
when he has his bowels open. He is still passing bright red blood with every stool. The pain continues to
burn for 30 minutes after each stool. His stools are now soft as he is taking regular lactulose and has
modified his diet.
The next option for this man is:
A. Refer routinely to a colorectal surgeon

B. Refer urgently to a colorectal surgeon
C. Prescribe topical GTN ointment for 6-8 weeks and review if still not healed
D. Prescribe topical diltiazem 2%
E. Prescribe hydrocortisone ointment for 7 days
ANSWER:
C. Prescribe topical GTN ointment for 6-8 weeks and review if still not healed
EXPLANATION:
Anal fissure - topical glyceryl trinitrate
This patient has an anal fissure which has not settled for one week and the use of lidocaine ointment. The
next step is to consider prescribing rectal glyceryl trinitrate (GTN) 0.4% ointment (provided there are no
contraindications) to relieve pain and aid healing. Advise the person to use it twice a day for 6–8 weeks.
Therefore, the correct answer is option 3.
He does not need a referral to the colorectal surgeons at this point as he has no symptoms of a serious
underlying pathology. If the GTN does not work after 6-8 weeks you could consider referring him to the
surgeons. Therefore, options 1 and 2 are wrong.
Topical diltiazem is occasionally prescribed following specialist advice. Therefore, option 4 is wrong.
Hydrocortisone ointment is not a recommended treatment for an anal fissure. Therefore, option 5 is
wrong.
Please see Q-77 for Anal Fissure
Q-93
A 62-year-old man is called for review after a positive faecal occult blood test done as part of the national
screening programme. During counselling for colonoscopy he asks what percentage of patients with a
positive faecal occult blood test have colorectal cancer. What is the most accurate answer?
A. 0.5 - 2%
B. 5 - 15%
C. 20 - 30%
D. 30 - 50%
E. 55 - 75%
ANSWER:
B. 5 - 15%
EXPLANATION:
Colorectal cancer screening - PPV of FOB = 5 - 15%
There is also a 30-45% chance of having an adenoma with a positive faecal occult blood test
Q-94
A 62-year-old lady, Agatha, reports that her older sister has just been diagnosed with breast cancer after
having her mammogram done as part of the national screening programme. Agatha says that she has had
her mammogram today and the results were normal.
When will Agatha's next mammogram be due?
A. 2 years
B. 1 year
C. 5 years
D. 3 years
E. No need for further mammograms after 62
ANSWER:
D. 3 years
EXPLANATION:
Breast cancer screening is available to women aged 50- 70 years and is done every 3 years in the UK. There
are plans to extend this to women aged 47-73 years by the end of 2016. Women aged 40-50 who have a
high risk of breast cancer may be offered 2 yearly screening.
After AKT 22, we fed back on lack of knowledge around some national screening programmes. Although
GPs are not always involved in making referrals when abnormalities are found, candidates should be
aware of the relevant pathways and procedures following abnormal screening results.
Q-95
A 22-year-old model presents with an 8 week history of a painless lump in her right breast which has not
changed in size and persists with each menstrual cycle. She is very worried as her best friend recently died
of cervical cancer. Of note, her maternal great aunt had breast cancer in her 60s. She is otherwise fit and
well however given her family history, she is expecting to be referred urgently. On examination, there is a
pea-size, smooth, slightly fluctuant lump in the right breast (upper outer quadrant). What would be the
recommended management?
A. Urgent breast referral (within 2 weeks)

B. Consider a non-urgent referral
C. Referral for genetic testing
D. Reassure patient that the lump is definitely benign so no need for any referral
E. Book patient to minor surgery clinic for fine needle aspiration as this is definitely a cyst
ANSWER:
B. Consider a non-urgent referral
EXPLANATION:
A woman < 30 years of age presenting with an unexplained breast lump with or without pain does not
meet 2WW criteria but can be considered for a non-urgent referral
The patient is likely to have a benign breast lesion given her age and seemingly reassuring clinical
examination however nothing is definite; it would be appropriate to consider a non-urgent referral to the
breast clinic (as she is worried too). Her family history of breast cancer is not significant as you can see
below.
NICE CKS - Breast Cancer (Managing Family History)
'Refer people to secondary care who have:

 One first-degree female relative diagnosed with breast cancer under the age of 40 years.
 One first-degree male relative diagnosed with breast cancer at any age.
 One first-degree relative with bilateral breast cancer where the first primary was diagnosed under the
age of 50 years.
 Two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast
cancer at any age.
 One first-degree or second-degree relative diagnosed with breast cancer at any age and one first-
degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a
first-degree relative).
 Three first-degree or second-degree relatives diagnosed with breast cancer at any age.'
BREAST CANCER: REFERRAL

NICE published referral guidelines for suspected breast cancer in 2015 (our emphasis):
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast
cancer if they are:
 aged 30 and over and have an unexplained breast lump with or without pain or
 aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other
changes of concern
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in
people:
 with skin changes that suggest breast cancer or
 aged 30 and over with an unexplained lump in the axilla
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.
Q-96
Which one of the following is not an indication for circumcision?
A. Phimosis
B. Paraphimosis
C. Recurrent balanitis
D. Balanitis xerotica obliterans
E. Peyronie's disease
ANSWER:
E. Peyronie’s disease
EXPLANATION:
Q-97
A 53-year-old man who has no past history of note requests a PSA test. One of his father's friends has
recently been diagnosed with prostate cancer. What is the most appropriate action?
A. Perform a digital rectal examination and refer him to urology so he can be counselled regarding the
PSA test
B. Tell him that you can appreciate his concern but reassure that at his age he is at very low risk
C. Advise him that a national screening programme was started in 2009 and he will be called at the age of
60 years for a test
D. Give him a patient information leaflet with details of the PSA test and allow him to make the choice
E. Offer to perform a digital rectal examination but advise him that the PSA test is not recommended in
younger asymptomatic men
ANSWER:
D. Give him a patient information leaflet with details of the PSA test and allow him to make the choice
EXPLANATION:
Q-98
A 44-year-old man attends for counselling with regards to a vasectomy. Which one of the following
statements is true regarding vasectomy?
A. Vasectomy is effective immediately

B. Female sterilisation is more effective
C. Two negative semen samples should be obtained at 2 and 4 weeks before other contraceptive
methods are stopped
D. Chronic testicular pain is seen in more than 5% of patients
E. Sexual intercourse should be avoided for one month to reduce the chance of a sperm granuloma
ANSWER:
D. Chronic testicular pain is seen in more than 5% of patients
EXPLANATION:
Please see Q-28 for Vasectomy
Q-99
Which one of the following statements regarding lidocaine is correct?
A. Preparations mixed with adrenaline should not be used for minor surgery involving the finger
B. The maximum dose of lidocaine is 5mg/kg
C. The anaesthetic effect usual wears off after 15-20 minutes
D. Is contraindicated in patients with a history of ventricular tachycardia
E. Preparations mixed with adrenaline are more likely to cause blood loss
ANSWER:
A. Preparations mixed with adrenaline should not be used for minor surgery involving the finger
EXPLANATION:
Please see Q-90 for Minor Surgery
Q-100
A 42-year-old man presents with a lump in his right scrotum. This has been present for 3 weeks. It is not
painful and he does not have any urinary symptoms. His weight is stable.
On examination, he has a 3mm smooth lump above and separate to his testicle. It is non-tender and
mobile.
What is the likely diagnosis?
A. Epididymal cyst
B. Hydrocoele
C. Lymph node
D. Teratoma
E. Varicocele
ANSWER:
A. Epididymal cyst
EXPLANATION:
The description of this lump makes it likely to be an epididymal cyst. The patient does not seem to have
any symptoms with the lump. This is not a testicular lump so cannot be a teratoma. A hydrocoele is a
swelling of the hemi-scrotum. There are no lymph nodes in the scrotum. A varicocele typically feels like a
'bag of worms' and is more common on the left side. An ultrasound scan of the scrotum can be used to
confirm the suspicion of an epididymal cyst.
Q-101
A 60-year-old man is worried about his risk of developing colorectal cancer. Following the introduction of
the national screening programme how often is such a patient offered a faecal immunochemical test
(FIT)?
A. Every year
B. Every two years
C. Every three years
D. Every five years
E. On one occasion at the age of 65
ANSWER:
B. Every two years
EXPLANATION:
Q-102-104
Theme: Breast disorders
A. Lipoma
B. Paget's disease of the breast
C. Breast cancer
D. Sebaceous cysts
E. Fibroadenoma
F. Fibroadenosis
G. Duct papilloma
H. Breast abscess
I. Fat necrosis
For each one of the following please select the most appropriate answer:
Q-102
A 49-year-old woman presents with a tender lump around the areola associated with a green nipple
discharge.
ANSWER:
Q-103
An obese woman presents with an irregular lump on the lateral aspect of her right breast associated with
skin tethering. Biopsy excludes a malignant cause.
ANSWER:
I. Fat necrosis
Q-104
A 41-year-old woman presents with a two-month history of pain and an irregular fixed lump in her left
breast.
ANSWER:
C. Breast cancer
EXPLANATION:
A short history (e.g. a few days) of pain and a lump would make you consider another diagnosis such as a
breast abscess but the combination of a persistent lump spanning at least one menstrual cycle and the
irregularity point to a diagnosis of cancer.
Please see Q-11-13 for Breast Disorders
Q-105
You are discussing an elevated PSA result with one of your patients, a 62-year-old man with a PSA level of
10.2 ng/ml.
What next step is the urologist most likely to recommend?
A. Prostatectomy
B. Cystoscopy with prostate biopsy
C. Staging CT scan
D. Multiparametric MRI
E. TRUS-guided biopsy
ANSWER:
D. Multiparametric MRI
EXPLANATION:
Multiparametric MRI has replaced TRUS biopsy as the first-line investigation in suspected prostate cancer
The 2019 NICE guidelines made changes to how suspected prostate cancer is investigated in secondary
care. Previously a TRUS-guided biopsy would be used first-line to clarify the diagnosis, as around two-
thirds of such patients will not have prostate cancer.
NICE state the following:
Offer multiparametric MRI as the first-line investigation for people with suspected clinically localised
prostate cancer. Report the results using a 5‑point Likert scale.
PROSTATE CANCER: INVESTIGATION

The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS)
biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric
MRI as a first-line investigation.
Complications of TRUS biopsy:

 sepsis: 1% of cases
 pain: lasting >= 2 weeks in 15% and severe in 7%
 fever: 5%
 haematuria and rectal bleeding
Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate
cancer.
 the results are reported using a 5‑point Likert scale
If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered
If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a
biopsy.
Q-106
You are working in a GP practice, and a 42-year-old female presents with unilateral blood stained nipple
discharge. She is otherwise well. On examination, you can't feel any breast lumps or axillary
lymphadenopathy and she has no changes to her nipple of the skin of the breast.
What is the most likely cause?
A. Duct ectasia
B. Breast abscess
C. Duct papilloma
D. Menopause
E. Galactocele
ANSWER:
C. Duct papilloma
EXPLANATION:
Blood stained discharge is most likely to be associated with a papiloma
In this scenario, unilateral blood stained discharge is likely to be associated with a duct papilloma. This is a
small harmless growth in one of the breast ducts, often behind the nipple. It does have malignant
potential and so is often removed.
Duct ectasia will often present with green-brown discharge and an abscess with puss discharging from the
nipple. The latter will also be associated with red, swollen, warm skin of the breast.
Hormonal changes in the menopause can cause nipple discharge. However, this will be bilateral and a
clear-white colour.
A galactocele develops due to a clogged milk duct, often when the woman is postpartum. The resulting
discharge is milky-creamy in nature.
NIPPLE DISCHARGE
Causes of nipple discharge

Physiological During breast feeding
Galactorrhoea Commonest cause may be response to emotional events, drugs such as
histamine receptor antagonists are also implicated
Hyperprolactinaemia  Commonest type of pituitary tumour
 Microadenomas <1cm in diameter
 Macroadenomas >1cm in diameter
 Pressure on optic chiasm may cause bitemporal hemianopia
Mammary duct  Dilatation breast ducts.

ectasia  Most common in menopausal women
 Discharge typically thick and green in colour
 Most common in smokers
Carcinoma  Often blood stained

 May be underlying mass or axillary lymphadenopathy
Intraductal  Commoner in younger patients

papilloma  May cause blood stained discharge
 There is usually no palpable lump
Assessment of patients
 Examine breast and determine whether there is mass lesion present
 All mass lesions should undergo Triple assessment.
Reporting of investigations
Where a mass lesion is suspected or investigations are requested these are prefixed using a system that
denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below:
1 No abnormality
2 Abnormality with benign features
3 Indeterminate probably benign
4 Indeterminate probably malignant
5 Malignant
Management of non malignant nipple discharge

 Exclude endocrine disease
 Nipple cytology unhelpful
 Smoking cessation advice for duct ectasia
 For duct ectasia with severe symptoms, total duct excision may be warranted.
Q-107
Which ONE of the following patients would be eligible for the abdominal aortic aneurysm (AAA)
screening?
A. 70-year-old female with hypercholesterolaemia

B. 55-year-old obese male with type 2 diabetes
C. 65-year-old male with no significant past medical history or family history
D. 45-year-old male with a longstanding history of alcohol and substance misuse
E. 80-year-old female with hypertension
ANSWER:
C. 65-year-old male with no significant past medical history or family history
EXPLANATION:
AAA screening is offered to:
 Men => 65 years of age
 Men and women with a strong family history of AAA
All of the other options do not fit the AAA screening eligibility criteria.
Q-108
A 55-year-old man with a history of gallstone disease presents with a two day history of pain in the right
upper quadrant. He has feels 'like I have flu' and his wife reports he has had a fever for the past day. On
examination his temperature is 38.1ºC, blood pressure 100/60 mmHg, pulse 102/min and he is tender in
the right upper quadrant. His sclera have a yellow-tinge. What is the most likely diagnosis?
A. Pancreatic cancer
B. Biliary colic
C. Ascending cholangitis
D. Acute cholecystitis
E. Acute viral hepatitis
ANSWER:
C. Ascending cholangitis
EXPLANATION:
Charcot's cholangitis triad: fever, jaundice and right upper quadrant pain
This patient has Charcot's triad (right upper quadrant pain, fever and jaundice), which is classically linked
to ascending cholangitis. The systemic upset and jaundice are less typical of acute cholecystitis.
ASCENDING CHOLANGITIS
Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common
predisposing factor is gallstones.
Charcot's triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
 fever is the most common feature, seen in 90% of patients
 RUQ pain 70%
 jaundice 60%
 hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make
Reynolds' pentad)
Other features
 raised inflammatory markers
Management
 intravenous antibiotics
 endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
Q-109
A 33-year-old presents to surgery with suspected renal colic. His pain is controlled with oral naproxen and
he does not require admission. What is the most appropriate imaging modality to investigate his
symptoms?
A. Non-contrast CT
B. Micturating cystourethrogram
C. Intravenous urography
D. MRI
E. KUB x-ray
ANSWER:
A. Non-contrast CT
EXPLANATION:
Many GPs now have direct access to non-contrast CT.
Please see Q-41 for Renal Stones: Management
Q-110
A 56-year-old gentleman with no lower urinary tract symptoms requests a prostate-specific antigen (PSA)
for a 'prostate check-up'. What percentage of men with a raised PSA will be found to have prostate
cancer?
A. 66%
B. 50%
C. 25%
D. 33%
E. 10%
ANSWER:
D. 33%
EXPLANATION:
A raised PSA may be due to a variety of non-malignant causes. These include:
 Benign prostatic hyperplasia
 Prostatitis, urinary tract infection
 Ejaculation or vigorous exercise in past 48 hours
Patients who are asymptomatic must be adequately counselled regarding the implications of a raised PSA
result. This is a useful patient information leaflet:
http://www.cancerscreening.nhs.uk/prostate/
Q-111-113
Theme: Anorectal disorders
A. Fistula in ano
B. Fissure in ano
C. Ischiorectal fossa abscess
D. Haemorrhoids
E. Crohn's disease
F. Internal rectal prolapse
G. Solitary rectal ulcer
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than
once or not at all.
Q-111
A 23-year-old man presents with a three week history of painless rectal bleeding. The bleeding typically
occurs post defecation and blood is noted in the toilet pan and on paper when he wipes himself. He is
otherwise well and his bowel habit is regular, though recently he has been slightly constipated.
ANSWER:
D. Haemorrhoids
EXPLANATION:
Post defecatory rectal bleeding that is noted in the toilet pan and on toilet paper is often haemorrhoidal in
nature. In this age group detailed colonic assessments are not required provided that digital rectal
examination (and ideally proctoscopy) are concordant with this diagnosis.
Q-112
34-year-old lady presents with a long history of chronic constipation and occasional episodic rectal
bleeding. Abdominal examination is unremarkable, on digital rectal examination she has an indurated
ulcer located anteriorly approximately 4cm from the dentate line.
ANSWER:
G. Solitary rectal ulcer
EXPLANATION:
Solitary rectal ulcers are well documented in patients with chronic constipation and repeated straining. Their
exact aetiology is not well understood. Biopsy of these lesions is mandatory and the histological
appearances are usually diagnostic and exclude malignancy. Treatment is usually directed at correcting the
reason for the underlying constipation.
Q-113
A 23-year-old lady presents with a one week history of painful rectal bleeding that typically occurs in
association with the passage of the stool and is also noted on wiping the anus afterwards. Examination of
the anorectum is impossible due to pain. However, external inspection reveals a midline sentinel skin tag.
ANSWER:
B. Fissure in ano
EXPLANATION:
Fissure in ano is a common cause of painful rectal bleeding. Examination of the anorectum (which must be
performed) is often best deferred until the fissure is less painful and hopefully healed. The external
appearance of a sentinel skin tag together with this history is strongly suggestive of the diagnosis. Whilst
posteriorly sited fissures are often related to the passage of hard stool, those located anteriorly or if multiple
are strongly suggestive of underlying organic disease and merit endoscopy.
ANORECTAL DISORDERS
Location: 3, 7, 11 o'clock position
Internal or external
Haemorrhoids Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy
Fissure in ano Location: midline 6 (posterior midline 90%) and 12 o'clock position. Distal to the
dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae
Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile
Location: 3, 7, 11 o'clock position
Internal or external
Haemorrhoids Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy
Ano rectal E.coli, staph aureus
abscess Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
Anal fistula Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Goodsalls
rule determines location
Rectal Associated with childbirth and rectal intussceception. May be internal or external
prolapse
Pruritus ani Systemic and local causes
Anal neoplasm Squamous cell carcinoma commonest unlike adenocarcinoma in rectum
Solitary rectal Associated with chronic straining and constipation. Histology shows mucosal
ulcer thickening, lamina propria replaced with collagen and smooth muscle
(fibromuscular obliteration)
Q-114
You are consulting with a 38-year-old man over the phone. He is normally fit and well with no family
history. He does not smoke and drinks 15-20 units of wine a week. He has been having issues with erectile
dysfunction for the last 6 months which is gradually getting worse. You suggest that he should come in for
an examination and blood tests. You briefly discuss some treatment options.
He would like to know what treatment is available for this symptom that he can buy over the counter
(OTC)?
A. There are no OTC treatments, he would need a prescription

B. Alprostadil gel
C. Sildenafil (Viagra®)
D. Tadalafil (Cialis®)
E. Avanafil (Spedra®) 100mg tablets
ANSWER:
C. Sildenafil (Viagra®)
EXPLANATION:
Sildenafil can be purchased OTC
Treatment of erectile dysfunction (ED) includes lifestyle modifications along with treating cardiovascular
risk factors. We should also prescribe a PDE-5 inhibitor regardless of suspected cause for erectile
dysfunction (provided there are no contraindications).
Sildenafil 50mg (Viagra®) is the only phosphodiesterase inhibitor (PDE5) that can be purchased over the
counter. Therefore, option 3 is the only correct answer.
Furthermore, generic sildenafil can be prescribed without restriction on the NHS.

However, Viagra®, tadalafil (Cialis®), vardenafil (Levitra®), and avanafil (Spedra®) and alprostadil are not
prescribable on an NHS prescription except for men who have certain chronic health conditions (eg
diabetes).
Q-115
A 33-year-old pregnant woman presents with pruritus ani. Which one of the following statements
regarding haemorrhoids is incorrect?
A. Painless rectal bleeding is the most common symptom

B. Haemorrhoidal tissue is part of the normal anatomy
C. Internal haemorrhoids do not generally cause pain
D. Soiling may be seen
E. Usually occur at the 1 o'clock, 5 o'clock and 9 o'clock position
ANSWER:
E. Usually occur at the 1 o'clock, 5 o'clock and 9 o'clock position
EXPLANATION:
Haemorrhoids usually occur at the 3 o'clock, 7 o'clock and 11 o'clock position
Please see Q-86 for Haemorrhoids
Q-116
A 68-year-old man who has never been screened for abdominal aortic aneurysm (AAA) wishes to be
included in the NHS screening programme for AAA.
He denies having recent abdominal or back pain. He does not have any long term medical condition and is
not on any long term medication. He has never smoked and his family history is negative for AAA.
He is offered an aortic ultrasound which reveals an abdominal aorta diameter of 5.7 cm.
Based on the information above, which of the following should be done for this patient?
A. Admit him to the emergency department immediately

B. Allow him to go home as abdominal aorta diameter is considered normal, no further scans required
C. Allow him to go home and come for another ultrasound scan after 1 year
D. Refer him to be seen by a vascular specialist within 2 weeks
E. Refer him to be seen by a vascular specialist within 12 weeks
ANSWER:
D. Refer him to be seen by a vascular specialist within 2 weeks
EXPLANATION:
People with an abdominal aorta diameter of 5.5 cm or larger should be seen by a vascular specialist within
2 weeks of diagnosis
Refer people with an abdominal aorta diameter of 5.5 cm or larger to a regional vascular service, to be
seen within 2 weeks of diagnosis [NICE 2018].
Refer people with an abdominal aorta diameter of 3–5.4 cm to a regional vascular service, to be seen
within 12 weeks of diagnosis.[NICE 2018].
Repeat scan every year for people with an abdominal aorta diameter of 3cm to 4.4cm.
The patient does not need to be admitted to the emergency department as he is clinically well.
Q-117
A 24-year-old man presents due to severe pain when defecating for the past 2 weeks. He has occasionally
noted some blood on the toilet paper when wiping himself. On examination a tear is seen on the posterior
midline of the anal verge. Which one of the following should not be recommended as a treatment option?
A. Bulk-forming laxatives
B. Application of lubricant prior to defecation
C. Topical steroids
D. Dietary advice
E. Paracetamol
ANSWER:
C. Topical steroids
EXPLANATION:
Topical steroids have been shown in studies to be of little benefit in treating anal fissures
Q-118
You have a consultation booked with Mrs Parr, an elderly woman who has recently been diagnosed with
bowel cancer. She says she had never submitted the home test kits for the NHS bowel cancer screening
program as she didn't like the idea of it and she'd had no symptoms so she didn't think she was at risk. Her
husband who attends with her has also never taken part in the screening program and now wonders if he
can be screened. He is aged 76.
What should you tell him?
A. He is no longer eligible for bowel cancer screening within the NHS screening program
B. He is eligible for screening if he develops symptoms of bowel cancer
C. He can self-refer for one-off bowel scope screening
D. He can self-refer for home test kit
E. Home test kits will be sent out every 2 years, submit test within the screening program
ANSWER:
D. He can self-refer for home test kit
EXPLANATION:
Patients aged over 74 can self-refer for bowel screening
No longer eligible for bowel cancer screening within the NHS screening program. Incorrect, home test kits
are sent out every 2 years to all patients aged 60-74, after this age patients can request a kit every 2 years
by self referral (helpline number on NHS website).
Eligible for screening if develops symptoms of bowel cancer. Incorrect, screening by definition is for
asymptomatic patients, if patients develop symptoms they should be formally investigated eg. as per NICE
suspected cancer guidelines.
He can self-refer for one-off bowel scope screening. Incorrect, in areas where bowel scope screening has
been rolled out, patients can self refer up to the age of 60.
He can self-refer for home test kit. Correct answer, home test kits are sent out every 2 years to all patients
aged 60-74, after this age patients can request a kit every 2 years by self-referral (helpline number on NHS
website).
Home test kits will be sent out every 2 years, submit test within the screening program. Incorrect, he is
now outside of the age group that routinely get sent kits every 2 years (60-74) but he can self-refer by
calling the number on the NHS website.
Q-119
A 34-year-old male is admitted with central abdominal pain radiating through to the back and vomiting.
The following results are obtained:
Amylase 1,245 u/dl
Which one of the following medications is most likely to be responsible?
A. Phenytoin
B. Sodium valproate
C. Metoclopramide
D. Sumatriptan
E. Pizotifen
ANSWER:
B. Sodium valproate
EXPLANATION:
Sodium valproate induced pancreatitis is more common in young adults and tends to occur within the first
few months of treatment. Asymptomatic elevation of the amylase level is seen in up to 10% of patients
ACUTE PANCREATITIS: CAUSES
The vast majority of cases in the UK are caused by gallstones and alcohol.
Popular mnemonic is GET SMASHED

Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids,
sodium valproate)
CT from a patient with acute pancreatitis. Note the diffuse parenchymal enlargement with oedema and indistinct
margins.
*pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine
Q-120
A 53-year-old gentleman has contacted the GP surgery enquiring about a screening test for bowel cancer.
He has read from the newspaper that one-off flexible sigmoidoscopy is now offered to patients in addition
to faecal occult blood test under the NHS bowel screening problem. He is otherwise fit and well with no
abdominal symptoms. There is no family of bowel cancer.
At what age are people offered this test, if any?
A. 45
B. 50
C. 55
D. 60
E. 65
ANSWER:
C. 55
EXPLANATION:
One-off flexible sigmoidoscopy at age 55 aims to detect and treat polyps, reducing future risk of colorectal
cancer
In addition to faecal occult blood screening, one-off flexible sigmoidoscopy screening was introduced to
areas of England in 2013 to people aged 55 years. If polyps are identified during sigmoidoscopy, these are
biopsied and the rest of the bowel is examined by colonoscopy.
Q-121
You see a 60-year-old man who has right sided scrotal swelling which appeared suddenly last week and is
painful. He has no other relevant past medical history.
On examination, he has what feels like a varicocele in his right scrotum. He has a swelling which feels like
a 'bag of worms' and is above his right testicle. It remains there when he lies down.
You discuss the fact that you think he has a varicocele with the patient. Which statement below is correct?
A. About 90% of varicoceles occur on the left side

B. Scrotal or groin pain is common with a varicocele
C. A left-sided varicocele alone is rare and should be referred to a urologist
D. Varicoceles are not associated with abnormal semen parameters
E. Varicoceles occur in 30% of adolescent boys and adult men
ANSWER:
A. About 90% of varicoceles occur on the left side
EXPLANATION:
About 90% of varicoceles occur on the left side
About 90% of varicoceles occur on the left side. Therefore, option 1 is correct.
Scrotal or groin pain is uncommon. In fact, less than 3% of men with a varicocele have pain or dragging or
heavy sensations in the scrotum. Therefore, option 2 is wrong.
A right-sided varicocele alone is rare and should be referred to a urologist. Therefore, option 3 is wrong.
Varicoceles occur in about 15% of adolescent boys and men. Therefore, option 5 is incorrect.
Q-122
Sarah, a 27-year-old female, recently gave birth to a healthy baby boy with whom she has been managing
to breastfeed. Since breastfeeding for four weeks, Sarah presents to her GP with a sore, inflamed, right
breast.
On examination, the GP notes the inflammation and a raised temperature, 38.1ºC.
The GP diagnoses mastitis as prescribes medication and encourages her to continue breastfeeding.
What is the most common organism causing this condition?
A. Escherichia coli
B. Streptococcus pneumoniae
C. Streptococcus pyogenes
D. Streptococcus mutans
E. Staphylococcus aureus
ANSWER:
E. Staphylococcus aureus
EXPLANATION:
The most common organism causing mastitis is Staphylococcus aureus
Mastitis is inflammation of the breast, commonly occurring in breastfeeding women. Patients often
present with pain and redness of breast and fever.
Flucloxacillin is the first line antibiotic management as the commonest causative organism of mastitis is
Staphylococcus aureus. If patient is penicillin allergic, then erythromycin is second line.
If patient is not responding to the antibiotics then a sample of the breast milk is sent for microscopy,
culture, and antibiotic sensitivity. Other causes of mastitis include Streptococcus species, Escherichia coli
and fungal causes such as Candida.
MASTITIS
Mastitis affects around 1 in 10 breastfeeding women.
Management
The first-line management of mastitis is to continue breastfeeding.
The BNF advises treating 'if systemically unwell, if nipple fissure present, if symptoms do not improve after
12-24 hours of effective milk removal of if culture indicates infection'. The first-line antibiotic is flucloxacillin
for 10-14 days, reflecting the fact that the most common organism causing infective mastitis is
Staphylococcus aureus. Breastfeeding or expressing should continue during treatment.
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
Q-123
A 66-year-old comes for review. He had a prosthetic aortic valve replacement five years ago for which he
is warfarinised. Over the past three months he has been complaining of fatigue and a full blood count was
requested:
Hb 10.3 g/dl
MCV 68 fl
Plt 356 * 109/l
WBC 5.2 * 109/l
Blood film Hypochromia
INR 3.0
An upper GI endoscopy was reported as normal. What is the most appropriate next investigation?
A. Transthoracic echocardiogram
B. Colonoscopy
C. Three sets of blood cultures
D. Transoesophageal echocardiogram
E. Reticulocyte count
ANSWER:
B. Colonoscopy
EXPLANATION:
Any patient of this age with an unexplained microcytic anaemia should have a lower gastrointestinal tract
investigation to exclude colorectal cancer
Please see Q-7 for Colorectal Cancer: Referral Guidelines
Q-124
Bilkis is a 31-year-old woman who has presented with cyclical breast pain.
Which of the following should be recommended first line?
A. A supportive bra
B. Codeine
C. Evening primrose oil
D. Progestogen-only pill
E. Reduce caffeine intake
ANSWER:
A. A supportive bra
EXPLANATION:
A supportive bra and simple analgesia are the first-line treatment for cyclical mastalgia
This patient is presenting with cyclical mastalgia. First-line management includes a supportive bra and
simple analgesia such as paracetamol, ibuprofen or topical NSAIDS.
Codeine would not be used first line.
There is insufficient good-quality evidence to recommend reducing caffeine or taking the progestogen-only
pill.
A systematic review demonstrated that evening primrose oil is no more effective than placebo.
Q-125
Which one of the following statements regarding hydroceles is correct?
A. Communicating hydroceles are found in more than 3% of newborn males

B. The vast majority occur on the right hand side
C. In younger children are often secondary to a varicocele
D. With hydroceles you usually cannot get above the swelling on examination
E. Are associated with infertility
ANSWER:
A. Communicating hydroceles are found in more than 3% of newborn males
EXPLANATION:
Q-126
You see a 28-year-old male patient with erectile dysfunction. He is normally fit and well and takes no
regular medications. He does not smoke and drinks minimal alcohol.
You go on to take a more detailed history of his problem and take a full psychosexual history.
What history findings from the list below would be suggestive of a psychogenic cause rather than an
organic cause for his problem?
A. A history of premature ejaculation

B. A gradual onset of symptoms
C. A history of pelvic trauma
D. The absence of self stimulated and morning erections
E. Normal libido
ANSWER:
A. A history of premature ejaculation
EXPLANATION:
History of premature ejaculation is suggestive of a psychogenic cause of ED

 Sudden onset.

 Gradual onset.
Q-127
A 31-year-old man returns for review. He was diagnosed with an anal fissure around 7 weeks ago and has
tried dietary modification, laxatives and topical anaesthetic with little benefit. What is the most
appropriate next step?
A. Oral bisacodyl
B. Oral calcium channel blocker
C. Topical steroid
D. Buccal glyceryl trinitrate prior to defecation
E. Topical glyceryl trinitrate
ANSWER:
E. Topical glyceryl trinitrate
EXPLANATION:
Anal fissure - topical glyceryl trinitrate
Q-128
A woman presents to surgery. Her 52-year-old mother has recently been diagnosed with breast cancer.
She is concerned about her own risk and wonders if she needs 'genetic tests'. There is no other history of
breast cancer in the family. Which one of the following facts should prompt referral to secondary care?
A. An aunt with endometrial cancer

B. Her mother's cancer being ER (oestrogen receptor) positive
C. Jewish ancestry
D. Her mother's cancer being HER2 (oestrogen receptor) positive
E. Her mother having metastases at the time of diagnosis
ANSWER:
C. Jewish ancestry
EXPLANATION:
Ovarian cancer, rather than endometrial, is associated with familial breast cancer.
Q-129
A 60-year-old man receives a bowel cancer screening kit in the post for the first time. He is asymptomatic
with an unremarkable medical history and family history. In the next 10 years, how often will he be
invited for screening?
A. Annually
B. Every 2 years
C. Every 3 years
D. Every 5 years
E. Every 6 years
ANSWER:
B. Every 2 years
EXPLANATION:
Bowel cancer screening = every 2 years between the ages 60 to 74 years
Bowel cancer screening is every 2 years between the ages 60 to 74 years

Q-130
A 60-year-old man is investigated for intermittent claudication. He is referred to the local vascular unit
and a diagnosis of peripheral arterial disease is made. His blood pressure is 128/78 mmHg and his fasting
cholesterol 3.8 mmol/l. Following recent NICE guidelines which of the following medications should he be
taking?
A. Aspirin + statin + ACE inhibitor
B. Aspirin + statin
C. Clopidogrel
D. Aspirin
E. Clopidogrel + statin
ANSWER:
E. Clopidogrel + statin
EXPLANATION:
As this patient has established cardiovascular disease he should be taking a statin, regardless of the
baseline cholesterol. The 2010 NICE guidelines on clopidogrel changed the previous advice that all patients
with established cardiovascular disease should be taking aspirin, unless there is a contraindication. NICE
propose that clopidogrel is now used first-line following an ischaemic stroke and also in peripheral arterial
disease.
PERIPHERAL ARTERIAL DISEASE: MANAGEMENT

Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help
to quit smoking.
Comorbidities should be treated, including

 hypertension
 obesity
As with any patient who has established cardiovascular disease, all patients should be taking a statin.
Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that clopidogrel
should be used first-line in patients with peripheral arterial disease in preference to aspirin.
Exercise training has been shown to have significant benefits. NICE recommend a supervised exercise
programme for all patients with peripheral arterial disease prior to other interventions.
Severe PAD or critical limb ischaemia may be treated by:

 angioplasty
 stenting
 bypass surgery
Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other
interventions such as angioplasty of bypass surgery.
Drugs licensed for use in peripheral arterial disease (PAD) include:

 naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life
 cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not
recommended by NICE
Q-131
You receive a fax through from urology. One of your patients with a raised PSA recently underwent a
prostatic biopsy. The report reads as follows:
Adenocarcinoma prostate, Gleason 3+4
Which one of the following statements regarding the Gleason score is incorrect?
A. Grades the glandular architecture seen on histology following hollow needle biopsy
B. The Gleason grade ranges from 1 to 5
C. The Gleason score ranges from 2 to 10
D. The lower the Gleason score the worse the prognosis
E. Used to predict prognosis in patients with prostatic cancer
ANSWER:
D. The lower the Gleason score the worse the prognosis
EXPLANATION:
PROSTATE CANCER: PROGNOSIS
The Gleason score is used to predict prognosis in patients with prostatic cancer. The grading system is based
on the glandular architecture seen on histology following hollow needle biopsy
The most prevalent and the second most prevalent pattern seen are added to obtain a Gleason score. The
Gleason grade ranges from 1 to 5 meaning the Gleason score ranges from 2 to 10 (i.e. two values added)
The higher the Gleason score the worse the prognosis
Q-132
You see an 18-year-old male patient who is concerned about his erections. He started having issues 6
months ago. He is normally fit and well with no past medical history. He denies any illicit drug use and
does not smoke. He drinks occasionally at the weekends. He lives with his mum and dad and has just
started a new relationship with a girl from college.
What history finding from the list below would suggest a psychogenic cause rather than an organic cause
for his erections?
A. Gradual onset of symptoms

B. Use of recreational drugs
C. Normal libido
D. Previous trauma to the pelvis
E. The presence of self stimulated or morning erections
ANSWER:
E. The presence of self stimulated or morning erections
EXPLANATION:
The presence of good quality spontaneous or self-stimulated erections suggests a psychogenic cause of ED
 Sudden onset.

 Gradual onset.
Therefore, the only correct answer is option 5. All the other history findings are suggestive of an organic
cause of ED.
Q-133
A thirteen-year-old girl is brought in by her mother with a one year history of activity-related low back
pain. She sometimes has to stop during sports activities at school but is usually able to continue after a
few minutes rest. She has no red flag symptoms and neurological examination of the lower limbs is
normal.
On examination you notice a curvature of her spine and diagnose scoliosis and plan to refer her to the
local paediatric orthopaedic department.
Which investigation would be diagnostic of her condition?
A. MRI lumbosacral spine

B. X-ray lumbosacral spine
C. CT lumbosacral spine
D. X-ray whole spine
E. No investigation necessary
ANSWER:
E. No investigation necessary
EXPLANATION:
Scoliosis is a clinical diagnosis and does not in itself necessitate further investigations/imaging
Scoliosis is a clinical diagnosis based upon examination findings and whilst X-rays and MRIs can be helpful
in guiding the management, they are not mandatory diagnostically. Therefore no investigation is the
correct answer.
CT scanning would not be indicated as it is a high dose of radiation for a young person.
MRI is not an ideal imaging tool for looking at bones but would be indicated in a young person with back
pain if you were expecting nerve or spinal cord pathology.
X-ray of the whole spine is a significant dose of radiation and whilst x-ray lumbosacral spine would be
more targeted, it is still unnecessary diagnostically.
DISEASES AFFECTING THE VERTEBRAL COLUMN
Ankylosing  Chronic inflammatory disorder affecting the axial skeleton

spondylitis  Sacro-ilitis is a usually visible in plain films
 Up to 20% of those who are HLA B27 positive will develop the condition
 Affected articulations develop bony or fibrous changes
 Typical spinal features include loss of the lumbar lordosis and progressive
kyphosis of the cervico-thoracic spine
Scheuermann's  Epiphysitis of the vertebral joints is the main pathological process

disease  Predominantly affects adolescents
 Symptoms include back pain and stiffness
 X-ray changes include epiphyseal plate disturbance and anterior wedging
 Clinical features include progressive kyphosis (at least 3 vertebrae must
be involved)
 Minor cases may be managed with physiotherapy and analgesia, more
severe cases may require bracing or surgical stabilisation
Scoliosis  Consists of curvature of the spine in the coronal plane

 Divisible into structural and non structural, the latter being commonest in
adolescent females who develop minor postural changes only. Postural
scoliosis will typically disappear on manoeuvres such as bending forwards
 Structural scoliosis affects > 1 vertebral body and is divisible into
idiopathic, congential and neuromuscular in origin. It is not correctable
by alterations in posture
 Within structural scoliosis, idiopathic is the most common type
 Severe, or progressive structural disease is often managed surgically with
bilateral rod stabilisation of the spine
Spina bifida  Non fusion of the vertebral arches during embryonic development
 Three categories; myelomeningocele, spina bifida occulta and
meningocele
 Myelomeningocele is the most severe type with associated neurological
defects that may persist in spite of anatomical closure of the defect
 Up to 10% of the population may have spina bifida occulta, in this
condition the skin and tissues (but not not bones) may develop over the
distal cord. The site may be identifiable by a birth mark or hair patch
 The incidence of the condition is reduced by use of folic acid
supplements during pregnancy
Spondylolysis  Congenital or acquired deficiency of the pars interarticularis of the neural

arch of a particular vertebral body, usually affects L4/ L5
 May be asymptomatic and affects up to 5% of the population
 Spondylolysis is the commonest cause of spondylolisthesis in children
 Asymptomatic cases do not require treatment
Spondylolisthesis  This occurs when one vertebra is displaced relative to its immediate
inferior vertebral body
 May occur as a result of stress fracture or spondylolysis
 Traumatic cases may show the classic 'Scotty Dog' appearance on plain
films
 Treatment depends upon the extent of deformity and associated
neurological symptoms, minor cases may be actively monitored.
Individuals with radicular symptoms or signs will usually require spinal
decompression and stabilisation
Q-134
A 73-year-old woman presents with episodic confusion and headaches for the past week. She has a
history of alcohol excess and a background of atrial fibrillation and type 2 diabetes mellitus. Her daughter
reports that she has been having frequent spells of confusion over the past few days. Last year she was
assessed for frequent falls. Her current medications include bisoprolol, metformin and warfarin.
Neurological examination is unremarkable and her blood sugar is 6.7 mmol/l. What is the most likely
diagnosis?
A. Korsakoff's syndrome
B. Wernicke's encephalopathy
C. Extradural haematoma
D. Subarachnoid haemorrhage
E. Subdural haematoma
ANSWER:
E. Subdural haematoma
EXPLANATION:
Fluctuating confusion/consciousness? - subdural haematoma
This patient has a number of risk factors for a subdural haematoma including old age, alcoholism and
anticoagulation. Korsakoff's syndrome and Wernicke's encephalopathy do not usually cause headaches.
HEAD INJURY: TYPES OF TRAUMATIC BRAIN INJURY
Basics
 primary brain injury may be focal (contusion/haematoma) or diffuse (diffuse axonal injury)
 diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption
and tearing of axons
 intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may occur
adjacent to (coup) or contralateral (contre-coup) to the side of impact
 secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial
herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted
following trauma rendering the brain more susceptible to blood flow changes and hypoxia
 the Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event
Type of injury Notes

Extradural Bleeding into the space between the dura mater and the skull. Often results from
(epidural) acceleration-deceleration trauma or a blow to the side of the head. The majority of
haematoma epidural haematomas occur in the temporal region where skull fractures cause a
rupture of the middle meningeal artery.
Features
 features of raised intracranial pressure

 some patients may exhibit a lucid interval
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around the
haematoma frontal and parietal lobes.
Risk factors include old age, alcoholism and anticoagulation.
Slower onset of symptoms than a epidural haematoma. There may be fluctuating

confusion/consciousness
Subarachnoid Classically causes a sudden occipital headache. Usually occurs spontaneously in the
haemorrhage context of a ruptured cerebral aneurysm but may be seen in association with other
injuries when a patient has sustained a traumatic brain injury
Image gallery
Extradural (epidural) haematoma:

Subdural haematoma
Subarachnoid haemorrhage
Q-135
You review a 65-year-old man in surgery. He has had a diagnosis of benign prostatic hypertrophy for 5
years. This is treated with tamsulosin (alpha blocker) and finasteride (5-alpha reductase inhibitor), which
until recently had been keeping his symptoms well controlled. He presents with 3 months of worsening
symptoms of poor flow, hesitancy, nocturia, weight loss and back pain. You request a prostate-specific
antigen blood test. The result is 2.8ng/mL - normal for his age range. What is the most likely diagnosis?
A. Urinary tract infection

B. Treatment-resistant benign prostatic hyperplasia
C. Spinal cord compression
D. Prostate cancer
E. Prostatitis
ANSWER:
D. Prostate cancer
EXPLANATION:
The answer here is prostate cancer. This patient has known BPH which was well controlled on medication.
He presents with new lower urinary tract symptoms, coupled with red flags features of weight loss and
back pain. His PSA is normal however he is on finasteride which is known to reduce PSA levels. The 3-
month duration of symptoms and weight loss are not in keeping with a diagnosis of a urinary tract
infection. Treatment-resistant BPH is unlikely after 5 years of successful treatment and would not give red
flag features. Spinal cord compression can cause urinary symptoms of either incontinence or retention,
unlikely to cause nocturia or flow issues. Prostatitis is not the answer as there is no systemic upset or
pelvic pain noted. This is usually a painful condition, can be acute or chronic in nature and associated with
frequency and dysuria, pelvic/ lower back/genital pain.
(AKT feedback report October 2016)
Q-136
A 45-year old gentleman presents to your surgery with a 6 month history of inability to achieve an
erection. He has a background of obesity and ischaemic heart disease. He takes ramipril and amlodipine
and has no known drug allergies. You explore his history, examine him and decide to perform some blood
tests. Which of the following tests should be performed in every man presenting with erectile
dysfunction?
A. Serum lipids, fasting plasma glucose and serum testosterone

B. Serum lipids, fasting plasma glucose, serum testosterone and prostate specific antigen
C. Serum lipids and fasting plasma glucose
D. Fasting plasma glucose and prostate specific antigen
E. Fasting plasma glucose and serum testosterone
ANSWER:
A. Serum lipids, fasting plasma glucose and serum testosterone
EXPLANATION:
NICE clinical knowledge summaries states that in all men lipids and fasting glucose should be measured to
calculate the 10-year cardiovascular risk and also free testosterone between 9 and 11am. If free
testosterone is low or borderline then the test should be repeated, and follicle-stimulating hormone,
luteinizing hormone and prolactin should be measured. Abnormalities should prompt referral to
endocrinology.
October 2015 AKT report: 'Several areas of mens health caused difficulty, including management of
erectile dysfunction and effects of treatment for prostate conditions.'
Q-137
You are reviewing a 35-year-old patient over the phone who you saw 2 weeks ago with erectile
dysfunction (ED). You arranged some blood tests which have come back abnormal. His HbA1c and lipid
profile are both normal but his total testosterone level is low at 9 nmol/l (normal is >12 nmol/l).
What is the correct management of this patient?
A. Refer him to endocrinology

B. Trial testosterone replacement gel for 6 months
C. Trial sildenafil and repeat his testosterone level in 3 months
D. Repeat the testosterone level
E. Repeat the testosterone level and check follicle stimulating hormone (FSH), luteinising hormone (LH),
and prolactin level
ANSWER:
E. Repeat the testosterone level and check follicle stimulating hormone (FSH), luteinising hormone (LH), and
prolactin level
EXPLANATION:
In a man with ED if the testosterone level is low the correct management is to repeat the test and check
FSH, LH, and prolactin levels
In a man with ED if the testosterone level is low the correct management is to repeat the test and check
FSH, LH, and prolactin levels. You should then consider referral to endocrinology if these are abnormal.
Therefore, option 5 is the only correct answer.
Hyperprolactinaemia is a cause of ED. FSH and LH are raised in primary hypogonadism.
The advice of the British Society for Sexual Medicine (BSSM) is that testosterone screening is pragmatic in
light of the fact that testosterone deficiency is reversible and can have a negative impact on
phosphodiesterase-5 inhibitor efficacy. They advise that men with consistently low total serum
testosterone levels (less than 12 nmol/l) may benefit from up to a 6 months trial of testosterone
replacement therapy for erectile dysfunction.
Q-138
You see a 52-year-old man with a problem with his penis. For the last few months, he has noticed that his
glans-penis and foreskin are red and swollen. He is unable to retract his foreskin. He also complains of
slight dysuria.
On examination, he has redness of the glans penis, which extends onto the skin of the shaft of the penis.
There is no obvious discharge.
You suspect this patient has non-specific dermatitis causing balanitis. What treatment should you
recommend?
A. Prescribe topical hydrocortisone 1% cream or ointment once a day and oral flucloxacillin (500 mg four
times a day) for 7 days
B. Prescribe topical hydrocortisone 1% once daily and an imidazole cream
C. No treatment necessary, advise daily cleaning under the foreskin with lukewarm water, followed by
gentle drying
D. Prescribe an imidazole cream
E. Prescribe oral flucloxacillin (500 mg four times a day) for 7 days
ANSWER:
B. Prescribe topical hydrocortisone 1% once daily and an imidazole cream
EXPLANATION:
A patient with non-specific dermatitis causing balanitis should be treated first line with topical
hydrocortisone 1% once daily and an imidazole cream
A patient with non-specific dermatitis causing balanitis should be treated first line with topical
hydrocortisone 1% once daily and an imidazole cream (clotrimazole 1%, miconazole 2%, or econazole 1%).
Therefore, option 2 is correct.
Patients should also be advised to clean under the foreskin daily with lukewarm water, followed by gentle
drying. Other advice includes not using soap or other irritants and possible prescribing an emollient.
However, he would still need a prescription for a steroid and imidazole cream as above. Therefore, option
3 is wrong.
Topical hydrocortisone with oral flucloxacillin is wrong. Therefore, option 1 is wrong.
Imidazole cream alone is also wrong. Therefore, option 4 is wrong.
Oral flucloxacillin is used if there is a suspected streptococcal infection. A bacterial infection is likely to
look more severe, the patient might feel more unwell and there would be a discharge. Therefore, option 5
is wrong.
Please see Q-6 for Balanitis
Q-139
You review a 9-month-old who has parents of Jamaican origin. His parents have noticed a small swelling
around his umbilicus. He is a well child who is on the 50th centile. On examination you note a small,
reducible umbilical hernia which is less than 1 cm in size. What is the most appropriate management?
A. Contact the local Child Protection Officer

B. Admit to paediatrics
C. Reassure the parents that the vast majority resolve by the age of 4-5 years
D. Refer to paediatric surgeon
E. Refer to a paediatrician for a sweat test
ANSWER:
C. Reassure the parents that the vast majority resolve by the age of 4-5 years
EXPLANATION:
Congenital hernias
 inguinal: repair ASAP
 umbilical: manage conservatively
This little boy has an umbilical hernia. The vast majority are managed conservatively as usually (>90%)
resolve spontaneously.
Q-140
A 61-year-old woman presents with abdominal discomfort, bloating and change in bowel habit to looser,
more frequent stools. She has been aware of these symptoms since the death of her husband 2 months
ago. Her daughter has suggested she has irritable bowel syndrome and she is requesting treatment for
this. How should you manage her?
A. Start an antispasmodic agent
B. Prescribe loperamide as and when required
C. 2 week referral to secondary care
D. Arrange bloods and request an abdominal ultrasound scan
E. Start low dose sertraline and review
ANSWER:
C. 2 week referral to secondary care
EXPLANATION:
This lady has presented with a red flag symptom of change in bowel habit to loose stool persisting more
than 6 weeks in a person over 60 years of age. She should be counselled about the possibility of an
underlying malignancy and referred under the 2-week rule to secondary care for further investigations to
exclude an underlying bowel cancer.
Q-141
A 62-year-old comedian presents with a 6 week history of urinary incontinence exacerbated by coughing
and laughing. She denies drinking excessive caffeine or experiencing frequency or dysuria. Observations
and clinical examination are unremarkable. Urine dipstick demonstrates non-visible haematuria but is
negative for leucocytes and nitrites. Her recent bloods are below:
Date: Yesterday
Hb 120 g/l
Platelets 200 x 109/l
WBC 14 x 109/l
U&E All normal
LFT All normal
Clotting All normal
What would be the recommended management?
A. Repeat urine dip in 2 weeks and if the non-visible haematuria persists, refer to urology urgently
B. Routine referral to urology
C. Trial of Pelvic floor exercises
D. Urgent referral to urology (to be seen within 2 weeks)
E. Trial of oxybutynin
ANSWER:
D. Urgent referral to urology (to be seen within 2 weeks)
EXPLANATION:
A patient >= 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white
cell count on a blood test should be referred using the suspected cancer pathway (within 2 weeks) to
exclude bladder cancer
This patient is >= 60 years of age with unexplained non-visible haematuria and a raised WCC so should be
referred under the suspected cancer pathway.
BLADDER CANCER
Bladder cancer is the second most common urological cancer. It most commonly affects males aged
between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5
fold increased risk of the disease. Exposure to hydrocarbons such as 2-Naphthylamine increases the risk.
Although rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a
common cause of squamous cell carcinomas, in those countries where the disease is endemic.
Benign tumours
Benign tumours of the bladder including inverted urothelial papilloma and nephrogenic adenoma are
uncommon.
Bladder malignancies
 Transitional cell carcinoma (>90% of cases)
 Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
 Adenocarcinoma (2%)
Transitional cell carcinomas may arise as solitary lesions, or may be multifocal, owing to the effect of 'field
change' within the urothelium. Up to 70% of TCC's will have a papillary growth pattern. These tumours are
usually superficial in location and accordingly have a better prognosis. The remaining tumours show either
mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local
invasion and may be of higher grade, the prognosis is therefore worse. Those with T3 disease or worse have
a 30% (or higher) risk of regional or distant lymph node metastasis.
TNM Staging
Stage Description
T0 No evidence of tumour
Ta Non invasive papillary carcinoma
T1 Tumour invades sub epithelial connective tissue
T2a Tumor invades superficial muscularis propria (inner half)
T2b Tumor invades deep muscularis propria (outer half)
T3 Tumour extends to perivesical fat
T4 Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina
T4a Invasion of uterus, prostate or bowel
T4b Invasion of pelvic sidewall or abdominal wall
N0 No nodal disease
N1 Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac,
or presacral lymph node)
N2 Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external
iliac, or presacral lymph node metastasis)
Stage Description
N3 Lymph node metastasis to the common iliac lymph nodes
M0 No distant metastasis
M1 Distant disease
Presentation
Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental
microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once
infection excluded).
Staging
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information
relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT
scanning. Nodes of uncertain significance may be investigated using PET CT.
Treatment
Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher
grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered
either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.
Prognosis
T1 90%
T2 60%
T3 35%
T4a 10-25%
Any T, N1-N2 30%
Q-142
A 50-year-old woman presents with right-sided medial thigh pain for the past week. There has been no
change in her bowels. On examination you noticed a grape sized lump below and lateral to the right pubic
tubercle which is difficult to reduce. What is the most likely diagnosis?
A. Inguinal hernia
B. Richter hernia
C. Spigelian hernia
D. Obturator hernia
E. Femoral hernia
ANSWER:
E. Femoral hernia
EXPLANATION:

Q-143
Which one of the following clinical features would not warrant an urgent referral (i.e. within 2 weeks) to
local colorectal services?
A. Unexplained iron-deficiency anaemia in a 62-year-old male

B. 62-year-old female with a 3 month history of rectal bleeding
C. Palpable rectal mass in a 36-year-old female
D. 48-year-old female with a 8 week history of rectal bleeding and increased stool frequency
E. A 57-year-old woman with a 7 week history of passing looser stools than normal
ANSWER:
E. A 57-year-old woman with a 7 week history of passing looser stools than normal
EXPLANATION:
Q-144
You see a 17-year-old boy with a scrotal swelling. He noticed the left side swelling about 2 months ago
following a rugby match. He describes the lump as soft and located above his testicle. He has no pain or
discomfort with it but is very anxious about what it might be. His cousin had testicular cancer at 25.
On examination, he has a soft 2cm swelling which is separate from and located above his left testicle. It
feels like a 'bag of worms'.
Given the likely diagnosis, which statement below is correct?
A. Less than 3% of men with this condition have pain

B. This condition occurs bilaterally in 50% of men
C. This condition occurs in about 30% of adolescent boys and men
D. About 90% of these swellings occur on the right side
E. This condition is not associated with infertility
ANSWER:
A. Less than 3% of men with this condition have pain
EXPLANATION:
Less than 3% of men with a varicocele have pain
The most likely diagnosis here is a varicocele. Varicoceles generally become noticeable at puberty due to
testicular growth and increased testicular blood flow.
The correct statement is option 1; less than 3% of men with a varicocele have pain.
Bilateral varicoceles occur in approximately 10% of men. Therefore, option 2 is wrong.
Varicoceles occur in about 15% of adolescent boys and men. Therefore, option 3 is wrong.
About 90% of varicoceles occur on the left side because of the difference in drainage routes of the right
and left spermatic veins. Therefore, option 4 is wrong.
Q-145
A 48-year-old female attends for an appointment with her GP as she has been experiencing some green-
brown coloured nipple discharge. She is otherwise well and denies any other changes to her breasts. She
has had 3 children which she has breastfed and isn't on any hormonal contraception. What is the most
common cause of brown-green nipple discharge?
A. Breast cancer
B. Duct ectasia
C. Prolactinoma
D. Fat necrosis of the breast
E. Paget's disease of the breast
ANSWER:
B. Duct ectasia
EXPLANATION:
Brown-green nipple discharge is most commonly associated with duct ectasia.
Brown-green nipple discharge is often associated with duct ectasia. This is a condition often found in
women around the menopause and occurs due to a dilation of the milk duct as a result of ageing. This may
or may not be associated with a small lump right under the nipple.
Breast cancer can sometimes present with nipple discharge, however, this is likely to be bloody and
coming from one nipple. A prolactinoma is a benign pituitary tumour which produces prolactin. As a result,
there is bilateral lactation, often a cream colour discharge.
Fat necrosis of the breast often occurs due to blunt trauma to the breast, as a result, a hard lump may be
felt, but there is no associated nipple discharge. Paget's disease of the nipple often presents with a change
in the skin of the nipple and areola. There is often no associated nipple discharge.
Please see Q-106 for Nipple Discharge
Q-146
A 62-year-old man presents with insomnia and lethargy. He has no other systemic symptoms of note.
Routine clinical examination reveals a palpable mass in the right lower quadrant of the abdomen, which
doesn't move with respiration and is non-pulsatile. What is the most appropriate management?
A. Blood screen including LFTs, U&Es

B. Urgent referral to local urological service
C. Ultrasound abdomen
D. Urgent referral to local colorectal service
E. Routine referral to general surgical clinic
ANSWER:
D. Urgent referral to local colorectal service
EXPLANATION:
Q-147
A 56 year old man presents with new onset erectile dysfunction. He is generally well, in a stable
relationship and is on no regular medication. Examination is unremarkable. Which of the following is
recommended as an initial work up?
A. Testosterone, lipids, fasting glucose

B. Testosterone, prolactin, fasting glucose, liver function tests (LFTs)
C. Lipids, fasting glucose, LFTs
D. Prolactin, lipids, fasting glucose
E. LFTs, fasting glucose, testosterone
ANSWER:
A. Testosterone, lipids, fasting glucose
EXPLANATION:
Q-148
A woman is concerned about her risk of breast cancer. Which one of the following scenarios should
prompt a referral to the local breast services:
A. A woman whose mother was diagnosed with breast cancer aged 46 years
B. A woman whose sister has been diagnosed with HER2 positive breast cancer aged 51 years
C. A woman whose father has been diagnosed with breast cancer aged 56 years
D. A woman who has two grandmothers who were diagnosed with breast cancer at the ages of 66 years
and 61 years
E. A woman who has a mother diagnosed with breast cancer aged 62 years and a maternal aunt
diagnosed with cervical cancer aged 34-years
ANSWER:
C. A woman whose father has been diagnosed with breast cancer aged 56 years
EXPLANATION:
Q-149
Which one of the following scenarios would not warrant an urgent referral to the local breast service
according to NICE guidelines?
A. 38-year-old woman with an unexplained lump in her left axilla. Lymphadenopathy can be felt on
examination. Breast examination is normal
B. 34-year-old female with a 4 week history of a new breast lump. Benign in nature on examination
C. 55-year-old female with new breast lump. Benign in nature on examination
D. 28-year-old female with a 8 week history of a new breast lump. Benign in nature on examination
E. 53-year-old female with a unilateral bloody nipple discharge
ANSWER:
D. 28-year-old female with a 8 week history of a new breast lump. Benign in nature on examination
EXPLANATION:
NICE guidelines suggest a cut-off age of 30 years when a woman has an unexplained breast lump with or
without pain. As this 28-year-old is below this cut-off she should be referred non-urgently to the local
breast services.
Please see Q-95 for Breast Cancer: Referral
Q-150
A 67-year-old man has been treated for prostate cancer. He is receiving 3 monthly injections of a
gonadorelin analogue. He comes to see you because he is experiencing troublesome hot flushes. What
does NICE recommend as a treatment for this?
A. Gabapentin
B. Fluoxetine
C. Citalopram
D. Cyproterone acetate
E. Clonidine
ANSWER:
EXPLANATION:
NICE recommends cyproterone acetate for the management of hot flushes in men undergoing hormonal
treatment for prostate cancer. None of the other medications are recommended. (AKT feedback report
October 2016)
PROSTATE CANCER: MANAGEMENT

Localised prostate cancer (T1/T2)
Treatment depends on life expectancy and patient choice. Options include:
 conservative: active monitoring & watchful waiting
 radical prostatectomy
 radiotherapy: external beam and brachytherapy
Localised advanced prostate cancer (T3/T4)

Options include:
 hormonal therapy: see below
 radical prostatectomy: erectile dysfunction is a common complication
 radiotherapy: external beam and brachytherapy. Patients are at increased risk of bladder, colon, and
rectal cancer following radiotherapy for prostate cancer
Metastatic prostate cancer disease - hormonal therapy
Synthetic GnRH agonist
 e.g. Goserelin (Zoladex)
 cover initially with anti-androgen to prevent rise in testosterone
Anti-androgen
 cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes
Orchidectomy
Q-151
A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of
the following is it most important to co-prescribe for the first three weeks of treatment?
A. Tamoxifen
B. Lansoprazole
C. Allopurinol
E. Tamsulosin
ANSWER:
EXPLANATION:
Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin
analogues due to the risk of tumour flare. This phenomenon is secondary to initial stimulation of
luteinising hormone release by the pituitary gland resulting in increased testosterone levels.
The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.
Please see Q-150 for Prostate Cancer: Management
Q-152
A digital rectal examination and PSA test should be offered to which of the following patients?
A. A 63-year-old man with poor appetite and type 2 diabetes

B. A 53-year-old man with change in bowel habit to looser stools
C. A 62-year-old man with unexplained lower back pain
D. A 65-year-old man with erectile dysfunction and angina (taking GTN, bisoprolol, aspirin and
simvastatin)
E. A 56-year-old man with 1 urinary tract infection
ANSWER:
C. A 62-year-old man with unexplained lower back pain
EXPLANATION:
NICE recommend offering a PR and PSA test to men with any of the following unexplained symptoms:
 erectile dysfunction
 haematuria
 lower back pain
 bone pain
 weight loss, especially in the elderly.
Prior to doing a PSA, a urine dipstick/MSU should be done to exclude infection. After treatment for a UTI,
PSA should not be tested for 1 month.
If the age specific PSA is high or increasing, with a normal PR examination, refer urgently even if the
patient is asymptomatic.
In an asymptomatic patient with a PSA at the upper limit of normal, repeat PSA after 1-3 months. If the
PSA is increasing, an urgent referral should be sent
Source: NICE referral guidelines for suspected cancer
Please see Q-1 for Prostate Cancer: Features
Q-153
The NHS runs several screening programs to detect diseases at an early, treatable stage. Which of the
following conditions does the NHS currently offer routine screening for?
A. Glaucoma
B. Prostate cancer
C. Ovarian cancer
D. Congenital adrenal hyperplasia
E. Abdominal aortic aneurysm
ANSWER:
E. Abdominal aortic aneurysm
EXPLANATION:
The NHS runs several screening programmes - currently all men are invited to be screened for abdominal
aortic aneurysm (AAA) by ultrasound scan the year they turn 65.
The UK National Screening Committee assesses evidence to recommend which conditions should be
screened for. Conditions currently undergoing review but not yet routinely screened for include prostate
cancer, glaucoma and congenital adrenal hyperplasia, amongst others.
It should be noted that the NHS currently advises a Prostate cancer 'risk management' programme as
opposed to a screening programme - men can request screening with a PSA test after receiving counselling
about it, but they are not routinely invited for screening.
Sources:
http:legacy.screening.nhs.uk/screening-recommendations.php
https:www.gov.uk/topic/population-screening-programmes
ABDOMINAL AORTIC ANEURYSM
Abdominal aortic aneurysms occur primarily as a result of the failure of elastic proteins within the
extracellular matrix. Aneurysms typically represent dilation of all layers of the arterial wall. Most aneurysms
are caused by degenerative disease. After the age of 50 years the normal diameter of the infrarenal aorta is
1.5cm in females and 1.7cm in males. Diameters of 3cm and greater, are considered aneurysmal. The
pathophysiology involved in the development of aneurysms is complex and the primary event is loss of the
intima with loss of elastic fibres from the media. This process is associated with, and potentiated by,
increased proteolytic activity and lymphocytic infiltration.
Major risk factors for the development of aneurysms include smoking and hypertension. Rare but important
causes include syphilis and connective tissues diseases such as Ehlers Danlos type 1 and Marfans syndrome.
Q-154
A 57-year-old woman with a recent diagnosis of breast cancer is found to be positive for a BRCA1
mutation on genetic screening. She has a strong family history of breast cancer, with both her mother and
aunt receiving treatment for the condition at a young age.
She is concerned that she may have passed the gene onto her son and daughter. She is also concerned
that her sister may have the gene, given her family history.
In counselling this lady, which of the following is the most appropriate statement with regards to the risk
of her family inheriting the BRCA1 gene?
A. Sister and daughter have a 50% chance of inheriting the gene while her son has a 25% risk
B. Both children and her sister have a 25% chance of inheriting the gene
C. Both children and her sister have a 50% chance of inheriting the gene
D. Both children have 25% chance of inheriting the gene while her sister has a 50% chance
E. Both children and her sister have a 100% chance of inheriting the gene
ANSWER:
C. Both children and her sister have a 50% chance of inheriting the gene
EXPLANATION:
There is a 50/50 chance of siblings and children of BRCA1 carrier to also have the gene
While BRCA1 and 2 mutations only account for 5-10% of breast cancers, it is reasonable to suspect a
genetic component when there is a strong family history of any form of malignancy. BRCA gene mutations
are almost always heterozygous and are inherited in an autosomal dominant fashion. As such, having one
parent with the mutation results in a 50% chance of that gene being passed on to a child.
1) Gender differences in inheritance can only occur if the mutation in question is X or Y linked, which is not
the case with BRCA1. Additionally, if this would the case, it could not be a 25% risk for the son.
2) A 25% risk is only possible of a causative mutation is autosomal recessive, and then it would only be
true for the development of the condition. The risk of inheriting a faulty gene is still 50%, which is what the
question is asking.
3) is correct
4) As for 2, it is only possible to have a 25% risk in the context of autosomal recessive mutations.
5) It would only be possible to have a 100% risk for everyone if both the patient and her mother were
homozygous for the BRCA1 mutation, and her father was at least a carrier. As the vast majority of BRCA1
mutations are homozygous, this is an unlikely scenario.
BREAST CANCER: RISK FACTORS
Predisposing factors
 BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
 1st degree relative premenopausal relative with breast cancer (e.g. mother)
 nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
 early menarche, late menopause
 combined hormone replacement therapy (relative risk increase * 1.023/year of use), combined oral
contraceptive use
 past breast cancer
 not breastfeeding
 ionising radiation
 p53 gene mutations
 obesity
 previous surgery for benign disease (?more follow-up, scar hides lump)
Q-155
A 79-year-old woman develops a leg ulcer just above the right medial malleolus. You are considering
referring her for compression bandaging. She is not diabetic. Following SIGN guidelines, what is the
minimum ankle-brachial pressure index (ABPI) that she must have to ensure compression bandaging is
safe?
A. 0.7
B. 0.8
C. 0.9
D. 1.0
E. 1.1
ANSWER:
B. 0.8
EXPLANATION:
SIGN state the following:
Compression therapy may be safely used in leg ulcer patients with ABPI>=0.8.
ANKLE-BRACHIAL PRESSURE INDEX

The ankle-brachial pressure index (ABPI) is the ratio of the systolic blood pressure in the lower leg to that in
the arms. Lower blood pressure in the legs (result in a ABPI < 1) is an indicator of peripheral arterial disease
(PAD). ABPI is therefore useful in evaluating patients with suspected PAD, for example a male smoker who
presents with intermittent claudication.
It is also important to determine the ABPI in patients with leg ulcers. Venous ulcers are often treated with
compression bandaging. Doing this in a patient with PAD could however be harmful as it would further
restrict the blood supply to the foot. ABPIs should therefore always be measured in patients with leg ulcers.
Interpretation of ABPI
 > 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
 1.0 - 1.2: normal
 0.9 - 1.0: acceptable
 < 0.9: likely PAD. Values < 0.5 indicate severe disease which should be referred urgently
The ABPI is a good test, values less than 0.90 have been shown to have a sensitivity of 90% and a specificity
of 98%* for PAD.
Compression bandaging is generally considered acceptable if the ABPI >= 0.8.
*Yao ST, Hobbs JT, Irvine WT. Ankle systolic pressure measurements in arterial disease affecting the lower
extremities. Br J Surg. Sep 1969;56(9):676-9.
Q-156
A GP receives notification from the Abdominal Aortic Aneurysm Screening program that one of his
patients has been found to have an aneurysm measuring 6.5cm in diameter. What should happen next?
A. No action needed
B. Re-scan in 3 months
C. Re-scan in 12 months
D. Follow-up with screening programme Nurse Specialist
E. Refer to Vascular Outpatients
ANSWER:
E. Refer to Vascular Outpatients
EXPLANATION:
Knowledge about NHS screening programmes is required by the RCGP curriculum under the statement on
'Healthy people, promoting health and preventing disease.' All men are invited to be screened for
abdominal aortic aneurysm (AAA) by ultrasound scan at the age of 65 - evidence shows this reduces
premature deaths from ruptured AAA by as much as 50%.
The patient is discharged from the screening programme if the aortic diameter is normal. Small and
medium AAAs are followed up with appointments with a Nurse Specialist from the screening programme
and regular surveillance scans. If a large AAA (>5.5 cm diameter) is found, the patient should be referred
to Vascular Outpatients to be seen within 2 weeks. The patient will be referred from the screening
programme, but the GP is also contacted urgently to provide additional information to complete the
referral eg. Past Medical History. If surgery is indicated, the patient should be operated on within 8 weeks
of the referral.
Please see Q-153 for Abdominal Aortic Aneurysm
Q-157
A 24-year-old man presents with rectal bleeding and a 'sharp, stinging' pain on defecation. This has been
present for the past two weeks. He has a tendency towards constipation and notices that when he wipes
himself fresh blood is often on the paper. Rectal examination is limited due to pain but no external
abnormalities are seen. What is the most likely diagnosis?
A. Internal haemorrhoids
B. Anal carcinoma
C. Rectal polyp
D. Anogenital herpes
E. Anal fissure
ANSWER:
E. Anal fissure
EXPLANATION:
The combination of pain and bleeding is very characteristic of anal fissures. Pain is a feature of
thrombosed external haemorrhoids but is unusual with internal haemorrhoids. Superficial anal fissures
may be difficult to see on examination.
Q-158
You see a 75-year-old patient with diabetes, hypertension, and chronic kidney disease (CKD). He had an
anterior myocardial infarction (MI) 2 months ago for which he had a stent. He is having his annual review
when he mentions that he has suffered from erectile dysfunction for the last 2 years. He says that it came
on gradually and that he now never has erections anymore, in any situation. He has been married for 45
years and this is having an effect on his relationship with his wife.
His blood pressure today is 135/85 mmHg. Recent blood tests reveal that his blood glucose levels are well
controlled on oral medications and his CKD is stable. He takes regular exercise.
He would really like some treatment to help with his erections.
What is the recommended first-line treatment for this gentleman?
A. Sildenafil
B. Tadalafil and lifestyle advice
C. A vacuum erection device along with lifestyle advice
D. Lifestyle advice only
E. Caverject® intracavernous injection
ANSWER:
C. A vacuum erection device along with lifestyle advice
EXPLANATION:
Vacuum erection devices are recommended as first-line treatment in those who can't/won't take a PDE-5
inhibitor
According to the NICE clinical knowledge summary (CKS) guidelines, phosphodiesterase (PDE-5) inhibitors,
such as sildenafil and tadalafil are recommended first-line treatment for men with erectile dysfunction
(ED) unless there are contraindications. A history of a stroke or MI in the last 6/12 is a contraindication for
all PDE-5 inhibitors. Therefore, they are not suitable for this patient and options 1 and 2 are incorrect.
The most common organic cause of erectile dysfunction (ED) is vasculogenic causes such as cardiovascular
disease (CVD). Therefore, the same risk factors and lifestyle factors apply as for CVD. Erectile dysfunction
usually responds well to a combination of lifestyle changes and drug treatment. Advise, where applicable,
that he should lose weight (important), stop smoking, reduce alcohol consumption, and increase exercise.
Lifestyle changes and risk factor modification must precede or accompany treatment. However, this
patient seems to have good control of his risk factors and already takes regular exercise. He also wants
treatment so option 4 is not correct.
As per the NICE CKS guidelines on erectile dysfunction, vacuum erection devices are recommended as first-
line treatment in well-informed older men with infrequent sexual intercourse and comorbidity requiring
non-invasive, drug-free management of erectile dysfunction. They are reported to be highly effective with
variable satisfaction. Therefore, option 3 is correct.
An intracavernous injection would be a 2nd line option for men following pelvic trauma or spinal cord
injury. Therefore, option 5 is incorrect.
Q-159
A 66-year-old lady presents to you with frequency, urge and pain when passing urine. This is her fifth
urinary tract infection (UTI) within the space of six months. She has been treated with antibiotics each
time, and whilst the symptoms do get better with this, they return fairly soon after. You dip her urine
today which shows 3+ leucocytes, 1+ nitrite and 1+ protein. She is otherwise fit and well with no
significant past medical history. What is the most appropriate action with regards to further investigation?
A. Non-urgent referral for investigation of suspected bladder cancer

B. Treat the UTI and take no further action
C. Send urine for microscopy and take no further action until the result of this is received
D. No further investigation - urinary tract infections are common in older women
E. Perform routine blood tests including a full blood count and renal profile and wait for the results
before referring to secondary care
ANSWER:
A. Non-urgent referral for investigation of suspected bladder cancer
EXPLANATION:
>= 60 with recurrent or persistent UTI - non-urgent referral for suspected bladder cancer
The NICE guidelines were updated in 2015 to include new criteria for non-urgent referral for suspected
bladder cancer in patients presenting with recurrent or persistent unexplained urinary tract infections
(UTI).
Whilst you can request microscopy and treat the UTI, you are no closer to explaining the high frequency of
UTIs. This is also not explained simply by older age and female gender. Whilst you can do blood tests, this
should not delay referral.
The NICE guidelines indicate that an urgent referral is not necessarily required in this scenario.
Please see Q-141 for Bladder Cancer
Q-160
A 23-year-old man presents with a 2-week history of a new right sided painless scrotal swelling. On
examination, there is a soft non-tender right sided scrotal swelling that transilluminates with a pen torch
and on palpation of the testicle you can feel an irregular, hard swelling. There is no erythema and the
patient is afebrile. What is the most appropriate management option?
A. Reassure
B. Perform bloods for tumour markers including alpha fetoprotein and human chorionic gonadotrophin
C. Refer for urgent scrotal ultrasound
D. Refer for non urgent ultrasound
E. Refer for routine urology outpatient review
ANSWER:
C. Refer for urgent scrotal ultrasound
EXPLANATION:
The first-line investigation of a testicular mass is an ultrasound
A new hydrocele may be the first sign of a testicular malignancy. Patients in their 20s and 30s are at
highest risk of testicular malignancy. According to NICE- new hydroceles in males aged 20-40 years old
must be investigated by way of urgent scrotal ultrasound. Reassuring this patient is therefore not an
appropriate management option, nor is requesting a routine ultrasound or outpatient review as this
would cause a delay in investigation and possible diagnosis of malignancy. Blood tests to look for tumour
markers may be an appropriate investigation later following identification of suspected testicular
malignancy.
(AKT feedback report October 2016) Source NICE CKS: Scrotal Swellings
Please see Q-68 for Testicular Cancer
Q-161
What is the maximum safe volume of lidocaine 1% that may be used during minor surgery on an adult
weighing approximately 66kg?
A. 10 ml
B. 30 ml
C. 50 ml
D. 20 ml
E. 5 ml
ANSWER:
D. 20 ml
EXPLANATION:
The maximum dose of 1% lidocaine for a 66kg person is 20ml
Please see Q-90 for Minor Surgery

Q-162
You see a 25-year-old man with a left-sided varicocele, which he has had for 10 years. It does not cause
him any problems or discomfort and it hasn't increased in size.
He has been trying for a baby with his girlfriend for 6 months without success. He is wondering whether it
might have something to do with his scrotal swelling?
A. Surgery for varicoceles is a form of fertility treatment

B. Surgery for varicoceles improves spontaneous pregnancy rates
C. There is no link between the size of the varicocele and the chance of infertility
D. Abnormal sperm production with a low FSH is consistent with impaired spermatogenesis
E. Nearly two-thirds of men who have a varicocele have no difficulty in fathering children
ANSWER:
E. Nearly two-thirds of men who have a varicocele have no difficulty in fathering children
EXPLANATION:
Nearly two-thirds of men who have a varicocele have no difficulty in fathering children
NICE recommends that men should not be offered surgery for varicoceles as a form of fertility treatment
because it does not improve pregnancy rates. Therefore, option 1 and 3 are incorrect.
Although varicoceles may be associated with fertility problems, nearly two-thirds of men who have a
varicocele have no difficulty in fathering children. Therefore, option 5 is correct.
Only larger varicoceles, which are typically easily palpable, have been clearly associated with infertility.
Abnormal sperm production with an elevated FSH is consistent with impaired spermatogenesis. Therefore,
option 4 is wrong.
Q-163
You see a 24-year-old man in your morning clinic. He is complaining of a problem with his penis. He has
noticed some lesions on his glans penis for the last few days and stinging when he passes urine. You take a
sexual history and he states that he has had sex with two women in the last 3 months, both times with
inconsistent condom use. He also says that he has sticky, itchy eyes and a painful and swollen left knee.
On examination, he has a well-demarcated erythematous plaque with a ragged white border on his penis.
What is the name of the lesion on his penis?
A. Zoon's balanitis
B. Circinate balanitis
C. Erythroplasia of Queyrat
D. Squamous cell carcinoma
E. Lichen sclerosis
ANSWER:
B. Circinate balanitis
EXPLANATION:
Circinate balanitis is the most likely diagnosis in a man with chronic balanitis who has Reiter's syndrome
and has a well-demarcated erythematous plaque with a ragged white border on his penis
Circinate balanitis is the most likely diagnosis in a man who has Reiter's syndrome and has a well-
demarcated erythematous plaque with a ragged white border on his penis. This man has the classic triad
of Reiter's syndrome: urethritis, arthritis, and conjunctivitis. He has had unprotected sex and has acquired
a sexually transmitted infection. This has led to the development of Circinate balanitis. He needs to be
seen at the sexual health clinic and the rheumatology clinic. The correct answer is, therefore, 2.
Zoon's balanitis is a benign condition of uncertain origin affecting uncircumcised men. It may be secondary
to other conditions such as lichen sclerosus or erythroplasia of Queyrat. It presents with orange-red lesions
with pinpoint redder spots on the glans and adjacent areas of the foreskin in uncircumcised men.
Erythroplasia of Queyrat is an in-situ squamous cell carcinoma. It presents with single or multiple plaques
with a red, velvety appearance and is often asymptomatic. Therefore, option 3 is wrong.
With a squamous cell carcinoma, lesions may be papillary or flat. Papillary lesions usually appear on the
glans which eventually becomes necrotic and ulcerated. Flat lesions usually ulcerate early. Squamous cell
carcinoma may arise on the background of lichen planus or lichen sclerosus. This is not the history here so
option 4 is also wrong.
Lichen sclerosis is the most likely diagnosis in an uncircumcised man, who has developed a tight white ring
around the tip of the foreskin and phimosis. This is not the case here, therefore option 5 is wrong.
Please see Q-6 for Balanitis
Q-164
A 30-year-old breastfeeding mother presents to GP with a 3-day history of a left inflamed nipple. There is
mild tenderness around the nipple but she is continuing to breastfeed. She is afebrile and vital signs are
within normal range.
What do you tell her?
A. Prescribe a course of flucloxacillin

B. Refer to hospital
C. Prescribe topical antibiotic
D. Recommend her to breastfeed with the unaffected breast
E. Advise the lady to keep breastfeeding normally
ANSWER:
E. Advise the lady to keep breastfeeding normally
EXPLANATION:
First-line management of mastitis is to continue breastfeeding
NICE guidelines advise women to continue breastfeeding if possible. Antibiotics can be prescribed if there
are systemic features, if there is a fissure present and if symptoms persist (for over 12 hours) despite
effective milk removal. Referral, in this case, is not indicated. Although topical antibiotics can sometimes
be used they are not stipulated in the guidelines.
Please see Q-122 for Mastitis
Q-165
Which of the following is not known to cause acute pancreatitis?
A. Hypocalcaemia
B. Hypothermia
C. Mumps
D. Hypertriglyceridaemia
E. Steroids
ANSWER:
A. Hypocalcaemia
EXPLANATION:
Hypercalcaemia, not hypocalcaemia is a recognised cause of acute pancreatitis
Please see Q-119 for Acute Pancreatitis: Causes
Q-166
You see a 28-year-old man who has a left-sided scrotal swelling. He has had it since he was 18 when he
initially presented to another GP who reassured him it was nothing to worry about. It does not cause him
any problems, he has no pain and it has not grown at all. It is approximately 2cm, soft and located above
his left testicle.
He is normally fit and well, although he is currently struggling to conceive a child with his wife.
You examine him and believe that he has a left-sided varicocele. It is only palpable when he is standing.
What percentage of men presenting with infertility have a varicocele?
A. <5%
B. 10%
C. 25%
D. 40%
E. 50%
ANSWER:
D. 40%
EXPLANATION:
40% of men presenting with infertility have a varicocele
presenting with infertility have a varicocele. Therefore, option 4 is correct.
Q-167
Which one of the following scenarios is the most common presentation of testicular cancer?
A. Painful testicular lump in a 56-year-old man

B. Painless testicular lump in a 27-year-old man
C. Painless testicular lump in a 43-year-old man
D. Painful testicular lump in a 25-year-old man
E. Painful testicular lump associated with dysuria in a 38-year-old man
ANSWER:
B. Painless testicular lump in a 27-year-old man
EXPLANATION:
Please see Q-68 for Testicular Cancer
Q-168
A 60-year-old man presents with a 3-month history of perineal and lower back pain associated with
urinary frequency, dysuria and poor urinary flow. He presents now because over the last week he has had
some discomfort when he ejaculates. Rectal examination reveals a smooth, normal sized but tender
prostate gland. What is the most likely diagnosis?
A. Urethritis
B. Chronic prostatitis
C. Benign prostatic hyperplasia
D. Acute prostatitis
E. Prostatic abscess
ANSWER:
B. Chronic prostatitis
EXPLANATION:
This patient has chronic prostatitis. It is chronic as he has symptoms of at least 3 months duration. There
may be pain in the perineum, abdomen, lower back, inguinal region, scrotum, testis or penis.There may
also be lower urinary tract symptoms or symptoms of sexual dysfunction such as erectile dysfunction,
premature ejaculation, discomfort on ejaculation or decreased libido. Urethritis would not give lower
urinary tract symptoms and perineal pain. Benign prostatic hyperplasia is painless, with a smooth and
enlarged prostate on examination in combination with lower urinary tract symptoms. A prostatic abscess
may be suspected in patients with persistent perineal pain and continued or recurrent urinary tract
infections despite antibiotic therapy- often the prostate is enlarged on examination.
(AKT feedback report October 2016) Source: NICE CKS Chronic Prostatitis.
CHRONIC PROSTATITIS
A prolonged course of a quinolone is often recommended. There has been some debate as to whether
prostatic massage has improved outcomes, though no conclusive data published to date.
Q-169
You are consulting with a 26-year-old male patient who has a personal problem. He is normally fit and
well and rarely sees the doctor. He has been having problems with his erections and it is now having a
negative impact on his relationship with his girlfriend of 8 months.
What history findings would suggest that this patient needs a referral to urology rather than primary care
management?
A. A sudden onset of symptoms

B. A low testosterone level
C. Presence of self stimulated or waking erections
D. A history of always having had difficultly achieving an erection
E. History of premature ejaculation
ANSWER:
D. A history of always having had difficultly achieving an erection
EXPLANATION:
For a young patient who has always had difficulty achieving an erection, referral to urology is appropriate
Options 1, 3 and five are suggestive of a psychogenic cause of ED but do not warrant referral to urology.
Therefore, they are incorrect.
Option 2 suggests hypogonadism and warrants referral to endocrinology (not urology). Therefore, this
option is incorrect.
Patients that warrant referral to urology include:

 Young men who have always had difficulty in obtaining or maintaining an erection.
 Men with a history of trauma (for example to the genital area, pelvis, or spine).
 Abnormality of the penis or testicles is found on examination.
Therefore, option 4 is the correct answer.

Q-170
A 65-year-old woman presents with painful, red skin on the inside of her thigh. This has developed over
the past 4-5 days and has not happened before. She is normally fit and well and no past medical history of
note other than depression. On examination she has erythematous, tender skin on the medial aspect of
her right thigh consistent with the long saphenous vein. The vein is palpable and cord-like. There is no
associated swelling of the right calf and no history of chest pain or dyspnoea. Heart rate is 84/min and her
temperature is 37.0ºC. What is the most appropriate management?
A. Prescribe an oral NSAID

B. Prescribe a topical NSAID
C. Refer for an ultrasound scan
D. Prescribe a topical heparinoid
E. Prescribe an oral NSAID and oral flucloxacillin
ANSWER:
C. Refer for an ultrasound scan
EXPLANATION:
SIGN recommend referring patients with long saphenous vein superficial thrombophlebitis for an
ultrasound scan to exclude an underlying DVT
Please see Q-81 for Superficial Thrombophlebitis
Q-171
Stacey is a 23-year-old woman with a diagnosis of cyclical mastalgia.
When would you expect her breast pain to be at its worst?
A. Around menses
B. During the follicular phase
C. During the luteal phase
D. In winter
E. No variation
ANSWER:
A. Around menses
EXPLANATION:
Cyclical mastalgia varies with intensity according to the phase of the menstrual cycle
Cyclical mastalgia is usually worst around the time of menstruation.
It begins in the luteal phase and gradually worsens until menstruation, after which it improves (the
follicular phase).
It is related to hormone changes and is not affected by the seasons.

Q-172
A 34-year-old man presents to an emergency surgery with abdominal pain. This started earlier on in the
day and is getting progressively worse. The pain is located on his left flank and radiates down into his
groin. He has had no similar pain previously and is normally fit and well. Examination reveals a man who is
flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management?
A. Oral ciprofloxacin
B. IM diclofenac 75 mg
C. Oral co-amoxiclav and metronidazole
D. IM morphine 5 mg
E. IM diclofenac 75 mg + start bendroflumethiazide to prevent further episodes
ANSWER:
B. IM diclofenac 75 mg
EXPLANATION:
Guidelines continue to recommend the use of IM diclofenac in the acute management of renal colic
This man may need to be referred acutely to the surgeons for pain relief and investigations to exclude
obstruction. It would not be suitable to start bendroflumethiazide in the initial phase of the first episode
Please see Q-41 for Renal Stones: Management
Q-173
A Jewish family attend their GP with their newly born son to discuss circumcision and whether there are
any medical contraindications to circumcision on religious grounds.
Which of the following congenital conditions would constitute such a contraindication?
A. Horseshoe kidney
B. Hypospadias
C. Phimosis
D. Balanitis xerotica obliterans
E. Imperforate anus
ANSWER:
B. Hypospadias
EXPLANATION:
Hypospadias is a contraindication to circumcision in infancy as the foreskin is used in the repair
The only condition here which would directly impact a circumcision is hypospadias as the foreskin is used
(if present) to perform the repair and in the process a circumcision is done. Therefore this is the only
condition which would contraindicate a routine circumcision for religious grounds as it would mean a
repair of the hypospadias would require grafting from elsewhere in the body. Both balanitis xerotica
obliterans and phimosis are indications for circumcision and are the two most common reasons why
children in the UK have medical circumcisions. A horseshoe kidney and an imperforate anus would have no
impact on circumcision for religious grounds and would not be a contraindication.
Q-174
Yvonne is a 74-year-old lady who comes to see you regarding breast screening. She was previously having
mammograms regularly but has learnt that screening for breast cancer stops at 73. She asks if she can still
continue to have NHS screening mammograms?
A. No, but she can have a private referral

B. No, mammograms are not effective above 70
C. No, she should self-monitor and see her GP if symptoms develop
D. Yes, she will be offered regular ultrasound screening above 70
E. Yes, she can self-refer
ANSWER:
E. Yes, she can self-refer
EXPLANATION:
The breast screening program in the NHS is being expanded to include women aged 47-73 years. Above
this age, women can continue to have screening by self-referring themselves.
Therefore the correct answer is 5.
Option 1, 2 and 3 is incorrect as she can continue to have screening if she self-refers.
Option 4 is incorrect as screening is with mammograms not ultrasound scans.
AKT report Jan 2015 - 'After AKT 22, we fed back on lack of knowledge around some national screening
programs.'

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SURGICAL AND MUSCULO SKELETAL PROBLEMS

It is these components which form the triceps reflex arc.

UPPER LIMB ANATOMY

Erb-Duchenne palsy ('waiter's tip')

LOWER BACK PAIN: PROLAPSED DISC

Site of compression Features

A. Only active movement limited + internal rotation most affected

Features typically develop over days

Associations* (idiopathic in the majority)

*there is scanty evidence to support a link with repetitive use

OSTEOPOROSIS: ASSESSING RISK

Methods of risk assessment

Interpreting the results of FRAX

When should we reassess a patient's risk?

A. Lumbar spine x-ray

LOWER BACK PAIN

The table below indicates some specific causes of LBP:

May be acute or chronic

Bone sarcoma include:

Malignant Fibrous Histiocytoma

A. Suprapubic pain is the most common symptom

Transient synovitis Typical age group = 2-10 years

 hip pain: develops progressively over a few weeks

Slipped upper Typical age group = 10-15 years

 knee or distal thigh pain is common

Perthes disease - bilateral disease

Slipped upper femoral epiphysis - left side

A. Arterial duplex scan

Spinal stenosis is diagnosed with an MRI lumbar spine.

Nerve conduction studies are for peripheral neuropathy.

LUMBAR SPINAL STENOSIS

What is the most likely diagnosis?

What is the most appropriate management?

LOWER BACK PAIN: INVESTIGATION AND MANAGEMENT

NSAIDs are now first-line for back pain

Advice to people with low back pain

Other possible treatments

Which statement regarding non-specific lower back pain is correct?

A. Paracetamol +/- codeine is first line for analgesia

Therefore, option 4 is wrong.

Please see Q-6 for Lower Back Pain

A. Manipulation and progressive casting starting after 3 months

Most commonly idiopathic. Associations include:

*reference: BMJ 2010; 340:c355: Current management of clubfoot. Bridgens J, Kiely N

What is the most likely cause of Tim's pain?

A. Common peroneal nerve

 symptoms are similar to lateral epicondylitis making it difficult to

Cubital tunnel Due to the compression of the ulnar nerve.

 initially intermittent tingling in the 4th and 5th finger

Please see Q-8 for Hip Problems in Children

A. Following a hip replacement patients should avoid crossing their legs

OSTEOARTHRITIS: JOINT REPLACEMENT

EMG is rarely used as it is difficult to perform.

Please see Q-6 for Lower Back Pain

Please see Q-16 for Elbow Pain

Please see Q-2 for Lower Back Pain: Prolapsed Disc

A. Order an x-ray of her hips and lumbar spine

There is no such thing as a Birmingham Hip Score tool.