AKT questions

1. A 60-year-old man presents with pain between his neck and his right shoulder for 2 weeks following strenuous gardening, worse on moving. When asked, he points to the posterior aspect of the painful site. He has no symptoms below the elbow and is otherwise well. The single most likely cause of his pain is?

A. Acromioclavicular joint arthritis
B. Capsulitis of his shoulder
C. Cervical myelopathy
D. Cervical spondylosis
E. Rotator cuff tear

Answer: D

cervical spondylosis. This question really brings out the point that the site of pain around the shoulder will rapidly eliminate certain diagnoses. Acromioclavicular joint pain tends to be on top of the shoulder while neck pain characteristically radiates from its origin over the trapezius muscle. If there is significant disc disease, there is likely to be a problem below the elbow. Cervical myelopathy implies spinal cord involvement—in which case there may be a mild spastic paraparesis (possibly with an 'inverted supinator' signifying a UMN lesion around C5/6). Glenohumeral pain may be diffuse but is characteristically felt at the top of the arm.

2. A 50-year-old female patient presents with pain around her shoulder that is felt mainly in her upper arm. Which one of the following signs does not require early referral?

A. Fever and joint erythema
B. Horner’s syndrome
C. Inability to abduct and externally rotate following trauma
D. Muscle wasting around the scapula
E. Reduction in all directions of movement

Answer: E

reduction in all directions of movement. In the presence of fever and joint erythema, sepsis (although uncommon) should be considered. Nocturnal wakening is characteristic in both capsulitis of the shoulder and rotator cuff tears and (unlike back pain) is not a red flag in this context. Severe pain immediately following trauma suggests dislocation. The rounded contour of the shoulder will disappear in the commonest (anterior) dislocation and the patient will resist abduction and external rotation. Reduction in all directions of movement simply implies a 'capsular' cause of the pain—be it arthritic or a capsulitis. Muscle wasting around the scapula may mean a 'brachial neuritis'—a curious condition of unknown aetiology while Horner’s syndrome could indicate the presence of a Pancoast’s tumour.

3. Which one of the following statements below makes a meniscal tear more likely than alternative diagnoses? [Show Discussion]

A. A hot, red and painful knee
B. Immediate swelling after injury
C. Increased laxity on the anterior draw test
D. Joint line tenderness
E. Presence of an effusion

Answer: D

joint line tenderness is the most sensitive test of meniscal damage. Typically, any effusion will be worse the morning after the injury (unless there is associated cruciate damage). A hot, red painful knee could be septic. The anterior draw sign is a test for anterior cruciate damage—as is a Lachmann test.

4. A 68-year-old man with a history of hypertension and chronic kidney disease (eGFR 47) presents with an acutely swollen right knee that occurred spontaneously. He takes ramipril and bendroflumethazide for hypertension. His temperature is normal. If practical, which is the single most specific test? [Show Discussion]

A. Erythrocyte sedimentation rate
B. Fluid aspiration for crystals
C. Serum calcium
D. Serum urate
E. X-ray

Answer: B

fluid aspiration for crystals. The most likely diagnosis in this scenario is acute gout. After initial treatment (probably with colchicines in view of his CKD), it is important to arrange a serum urate. This may be normal even in the presence of gout.

5. A 14-year-old female student presents with painful knees on stairs and following sport. She is a first team netball player. Which of the options below is the single most useful piece of initial advice? [Show Discussion]

A. Glucosamine
B. Non-steroidal anti-inflammatory drugs
C. Physiotherapy
D. Refer for arthroscopy
E. Stop all sport

Answer: C

physiotherapy. This is a common scenario that causes much distress both for the patient and her parents. Such patients are often female and high sporting achievers. PFJ symptoms may be due to malalignment, muscular imbalance or overuse and there may be an associated patellar tendinitis. While stopping all sport would almost certainly alleviate the problem, it is not always popular in this group of patients.

6.
A patient aged 60 years presents with this lesion on the dorsum of her forearm It has been present for around a month and enlarged rapidly over that time. What is the single most likely diagnosis?

A. Dermatofibroma
B. Keratoacanthoma
C. Melanoma
D. Nodular basal cell carcinoma
E. Pyogenic granuloma

Answer: B

This should be referred urgently for excision (surgically or by curettage) since the rate of growth is alarming and shave biopsy can look histologically very like squamous cell carcinoma. The lesion is benign and characteristically occurs in an older population on sun-exposed sites. It has a keratinous centre.