SURGERY & ORTHO MCQs

Q-1 prostate and hence don't cause obstructive symptoms early

A digital rectal examination and PSA test should be offered on. Possible features include:
to which of the following patients? • bladder outlet obstruction: hesitancy, urinary retention
• haematuria, haematospermia
A. A 63-year-old man with poor appetite and type 2 • pain: back, perineal or testicular
diabetes • digital rectal examination: asymmetrical, hard, nodular
B. A 53-year-old man with change in bowel habit to looser enlargement with loss of median sulcus
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:
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 Isotope bone scan (using technetium-99m labelled diphosphonates which
be tested for 1 month. 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
If the age specific PSA is high or increasing, with a normal PR keeping with multiple osteoblastic metastasis.
examination, refer urgently even if the patient is
asymptomatic. Q-2
A 62-year-old man is called for review after a positive faecal
In an asymptomatic patient with a PSA at the upper limit of occult blood test done as part of the national screening
normal, repeat PSA after 1-3 months. If the PSA is increasing, programme. During counselling for colonoscopy he asks
an urgent referral should be sent what percentage of patients with a positive faecal occult
Source: NICE referral guidelines for suspected cancer blood test have colorectal cancer. What is the most accurate
answer?
PROSTATE CANCER: FEATURES
Prostate cancer is now the most common cancer in adult A. 0.5 - 2%
males in the UK and is the second most common cause of B. 5 - 15%
death due to cancer in men after lung cancer. C. 20 - 30%
D. 30 - 50%
Risk factors E. 55 - 75%
• increasing age
• obesity ANSWER:
• Afro-Caribbean ethnicity 5 - 15%
• family history: around 5-10% of cases have a strong family
history EXPLANATION:
Colorectal cancer screening - PPV of FOB = 5 - 15%
Localised prostate cancer is often asymptomatic. This is partly There is also a 30-45% chance of having an adenoma with a
because cancers tend to develop in the periphery of the positive faecal occult blood test
COLORECTAL CANCER: SCREENING It is important to exclude hypospadias prior to circumcision as
Overview the foreskin may be used in surgical repair. Circumcision may
• most cancers develop from adenomatous polyps. be performed under a local or general anaesthetic.
Screening for colorectal cancer has been shown to reduce
mortality by 16% Q-4 THROUGH Q-6
• the NHS now has a national screening programme Theme: Venous thromboembolism prophylaxis
offering screening every 2 years to all men and women
aged 60 to 74 years in England, 50 to 74 years in Scotland. A. 5 days
IPatients aged over 74 years may request screening B. 7 days
• eligible patients are sent faecal occult blood (FOB) tests C. 8-9 days
through the post D. 10-14 days
• patients with abnormal results are offered a colonoscopy E. 15-21 days
F. 28-35 days
At colonoscopy, approximately: G. 36-42 days
• 5 out of 10 patients will have a normal exam H. 43-54 days
• 4 out of 10 patients will be found to have polyps which I. No post-procedure prophylaxis required
may be removed due to their premalignant potential
• 1 out of 10 patients will be found to have cancer For each of the following conditions/procedures please
select the required duration of venous thromboembolism
Q-3 prophylaxis after the procedure:
Which one of the following statements regarding male
circumcision is correct? Q-4
Elective hip replacement
A. Circumcision should always be performed under a
general anaesthetic ANSWER:
B. It is available on the NHS in areas with a high Jewish or 28-35 days
Islamic population
C. Increases the risk of penile cancer Q-5
D. Reduces the rate of HIV transmission Elective knee replacement
E. All infants with hypospadias should be circumcised
before the age of 1 year ANSWER:
10-14 days
ANSWER:
Reduces the rate of HIV transmission Q-6
Hip fracture
EXPLANATION:
CIRCUMCISION ANSWER:
Circumcision has been performed in a variety of cultures for 28-35 days
thousands of years. Today it is mainly people of the Jewish
and Islamic faith who undergo circumcision for EXPLANATION Q-4 THROUGH Q-6:
religious/cultural reasons. Circumcision for religious or VENOUS THROMBOEMBOLISM: PROPHYLAXIS IN PATIENTS
cultural reasons is not available on the NHS. ADMITTED TO HOSPITAL
Venous thromboembolism (VTE) still accounts for a significant
The medical benefits of routine circumcision remain proportion of avoidable hospital deaths. In an effort to tackle
controversial although some evidence has emerged that it: this problem NICE produced guidelines in 2010.
• reduces the risk of penile cancer
• reduces the risk of UTI Before admission
• reduces the risk of acquiring sexually transmitted • advise women to consider stopping oestrogen-containing
infections including HIV oral contraception or HRT 4 weeks before surgery.
• assess the risks and benefits of stopping antiplatelet
Medical indications for circumcision therapy 1 week before surgery.
• phimosis
The following patients are deemed at risk of VTE
• recurrent balanitis
Medical patients
• balanitis xerotica obliterans
• if mobility significantly reduced for >= 3 days or
• paraphimosis
• if expected to have ongoing reduced mobility relative to
normal state plus any VTE risk factor (see below)
 Procedure Length of prophylaxis
Surgical patients and patients with trauma Elective hip 28-35 days
• if total anaesthetic + surgical time > 90 minutes or Elective knee 10-14 days
• if surgery involves pelvis or lower limb and total Hip fracture 28-35 days
anaesthetic + surgical time > 60 minutes or
• if acute surgical admission with inflammatory or intra- Q-7
abdominal condition or A 62-year-old man with no significant past medical history
• if expected to have significant reduction in mobility or presents with a right sided groin lump which he noticed
• if any VTE risk factor present (see below) whilst having a shower. It has been present for 2 weeks and
disappears when he lies down. It never causes him any
VTE risk factors discomfort and there are no other gastrointestinal
• active cancer or cancer treatment symptoms of note. Examination reveals an small reducible
• age > 60 years swelling in the right groin. What is the most appropriate
• critical care admission management?
• dehydration
• known thrombophilias A. Refer for fitting of a truss
• obesity (BMI > 30 kg/m2) B. Refer to vascular surgeon
• one or more significant medical comorbidities (for C. Routine referral for surgical repair
example: heart disease; metabolic, endocrine or D. Advise no action as it will probably improve with time
respiratory pathologies; acute infectious diseases; E. Fast-track referral to colorectal service
inflammatory conditions)
• personal history or first-degree relative with a history of ANSWER:
VTE Routine referral for surgical repair
• use of HRT
EXPLANATION:
• use of oestrogen-containing contraceptive therapy
This patient has an asymptomatic inguinal hernia. Studies
• varicose veins with phlebitis
looking at conservative management tend to find that many
patients become symptomatic and eventually have surgery
In-patient VTE prophylaxis
anyway. As this patient is medically fit most clinicians would
As a general rule pharmacological VTE prophylaxis is used for
refer for surgical repair.
medical patients unless there is a contraindication.
Inguinal hernias do not resolve spontaneously.
For surgical patients mechanical VTE prophylaxis is offered for
patients at risk. Pharmacological VTE prophylaxis is also given
A number of PCTs have begun to put asymptomatic inguinal
for if the risk of major bleeding is low.
hernias on the 'low clinical priority' list. Whilst this may be
reasonable for older patients who are 'not bothered' by their
Pharmacological VTE prophylaxis options:
condition it is debatable how feasible such a blanket policy is
• fondaparinux sodium
for all patients.
• low molecular weight heparin (LMWH)
• unfractionated heparin (UFH) (for patients with renal INGUINAL HERNIA
failure) Inguinal hernias account for 75% of abdominal wall hernias.
Around 95% of patients are male; men have around a 25%
Mechanical VTE prophylaxis options: lifetime risk of developing an inguinal hernia.
• anti-embolism stockings (thigh or knee length)
• foot impulse devices Features
• intermittent pneumatic compression devices (thigh or • groin lump: disappears on pressure or when the patient
knee length) lies down
• discomfort and ache: often worse with activity, severe
Post-procedure VTE prophylaxis pain is uncommon
For certain procedures pharmacological VTE prophylaxis is • strangulation is rare
recommended for all patients, using one of the following:
• dabigatran, started 14 hours after surgery Whilst traditional textbooks describe the anatomical
• fondaparinux, started 6 hours after surgery differences between indirect (hernia through the inguinal
• LMWH, started 6-12 hours after surgery canal) and direct hernias (through the posterior wall of the
• rivaroxaban, started 6-10 hours after surgery. inguinal canal) this is of no relevance to the clinical
• apixaban management.
Management
• the clinical consensus is currently to treat medically fit ANSWER:
patients even if they are asymptomatic Diverticulitis
• a hernia truss may be an option for patients not fit for
surgery but probably has little role in other patients EXPLANATION Q-8 THROUGH 10:
• mesh repair is associated with the lowest recurrence rate ABDOMINAL PAIN
The table below gives characteristic exam question features
The Department for Work and Pensions recommend that for conditions causing abdominal pain. Unusual and 'medical'
following an open repair patients return to non-manual work causes of abdominal pain should also be remembered:
after 2-3 weeks and following laparoscopic repair after 1-2 • myocardial infarction
weeks • diabetic ketoacidosis
• pneumonia
Complications • acute intermittent porphyria
• early: bruising, wound infection • lead poisoning
• late: chronic pain, recurrence
Condition Characteristic exam feature
Q-8 THROUGH 10 Peptic ulcer Duodenal ulcers: more common than gastric ulcers,
Theme: Abdominal pain disease epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be
A. Alcoholic hepatitis seen (haematemesis, melena etc)
B. Acute cholecystitis
Appendicitis Pain initial in the central abdomen before localising to the
C. Duodenal ulcer right iliac fossa
D. Gastric ulcer Anorexia is common
E. Biliary colic Tachycardia, low-grade pyrexia, tenderness in RIF
F. Ruptured abdominal acute aneurysm Rovsing's sign: more pain in RIF than LIF when palpating
G. Acute pancreatitis LIF
H. Gastroenteritis Acute pancreatitis Usually due to alcohol or gallstones
I. Diverticulitis Severe epigastric pain
Vomiting is common
J. Intestinal obstruction
Examination may reveal tenderness, ileus and low-grade
fever
For each one of the following scenarios please select the Periumbilical discolouration (Cullen's sign) and flank
most likely diagnosis: discolouration (Grey-Turner's sign) is described but rare
Biliary colic Pain in the RUQ radiating to the back and interscapular
Q-8 region, may be following a fatty meal. Slight misnomer as
A 49-year-old woman presents with pain in the right upper the pain may persist for hours
quadrant. This has been occurring for the past 3 months and Obstructive jaundice may cause pale stools and dark urine
is often precipitated by a heavy meal. When the pain comes It is sometimes taught that patients are female, forties, fat
it is typically lasts around 1-2 hours. Clinical examination is and fair although this is obviously a generalisation
unremarkable other than mild tenderness in the right upper Acute cholecystitis History of gallstones symptoms (see above)
Continuous RUQ pain
quadrant.
Fever, raised inflammatory markers and white cells
ANSWER: Murphy's sign positive (arrest of inspiration on palpation
of the RUQ)
Biliary colic
Diverticulitis Colicky pain typically in the LLQ
Q-9 Fever, raised inflammatory markers and white cells
A 37-year-old attends surgery due to a one day history of Abdominal aortic Severe central abdominal pain radiating to the back
severe central abdominal pain radiating through to the back. aneurysm Presentation may be catastrophic (e.g. Sudden collapse) or
sub-acute (persistent severe central abdominal pain with
He has vomited several times and is guarding on
developing shock)
examination. Parotitis and spider naevi are also noted. Patients may have a history of cardiovascular disease
Intestinal History of malignancy/previous operations
ANSWER:
obstruction Vomiting
Acute pancreatitis Not opened bowels recently
'Tinkling' bowel sounds
Q-10
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.
 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 Symmetrical bulge under the umbilicus
hernia
Paraumbilical Asymmetrical bulge - half the sac is covered by skin of the
hernia abdomen directly above or below the umbilicus
Epigastric Lump in the midline between umbilicus and the
hernia xiphisternum
Diagram showing stereotypical areas where particular conditions present. The Most common in men aged 20-30 years
diagram is not exhaustive and only lists the more common conditions seen in
Incisional May occur in up to 10% of abdominal operations
clinical practice. Note how pain from renal causes such as renal/ureteric colic and
hernia
pyelonephritis may radiate and move from the loins towards the suprapubic area.
Spigelian hernia Also known as lateral ventral hernia
Rare and seen in older patients
Q-11
A hernia through the spigelian fascia (the aponeurotic layer
A 50-year-old woman presents with right-sided medial thigh between the rectus abdominis muscle medially and the
pain for the past week. There has been no change in her semilunar line laterally)
bowels. On examination you noticed a grape sized lump Obturator A hernia which passes through the obturator foramen. More
below and lateral to the right pubic tubercle which is difficult hernia common in females and typical presents with bowel
to reduce. What is the most likely diagnosis? obstruction
Richter hernia A rare type of hernia where only the antimesenteric border
A. Inguinal hernia of the bowel herniates through the fascial defect
B. Richter hernia
C. Spigelian hernia Abdominal wall hernias in children:
D. Obturator hernia
E. Femoral hernia Type of hernia Details
Congenital inguinal Indirect hernias resulting from a patent processus
ANSWER: hernia vaginalis
Occur in around 1% of term babies. More common in
Femoral hernia
premature babies and boys
60% are right sided, 10% are bilaterally
EXPLANATION: Should be surgically repaired soon after diagnosis as
ABDOMINAL WALL HERNIAS at risk of incarceration
The classical surgical definition of a hernia is the protrusion of Infantile umbilical Symmetrical bulge under the umbilicus
an organ or the fascia of an organ through the wall of the hernia More common in premature and Afro-Caribbean
cavity that normally contains it. babies
The vast majority resolve without intervention before
the age of 4-5 years
Risk factors for abdominal wall hernias include:
Complications are rare
• obesity
• ascites
Q-12
• increasing age
Rina is an orthopaedic SHO working in a paediatric
• surgical wounds orthopaedic outpatient clinic. She receives a number of GP
referrals regarding limb development in children. Which of
Features
the following is a normal variant in a child and can be
• palpable lump referred back to the GP with expectant management?
• cough impulse
• pain A. Genu valgus in a 1-year-old
• obstruction: more common in femoral hernias B. Genu varum in a 5-year-old child
• strangulation: may compromise the bowel blood supply C. Right knee pain in a growing child aged 10 years old
leading to infarction D. Femoral anteversion aged 12 years old
E. Flat feet aged 2 years old
ANSWER: Mode of
Flat feet aged 2 years old Diagnosis presentation Treatment Radiology
Limitation to occurring then (like a melting
EXPLANATION: internal rotation is percutaneous ice cream cone)
Many orthopaedic outpatient referrals from general practice usually seen. Knee pinning of the hip The Southwick
pain is usually may be required. angle gives
are normal variants. The key features of normal variants are
present 2 months indication of
that they are always symmetrical, painless and improve with prior to hip disease severity
age. slipping. Bilateral
in 20%.
From birth till about 2 years of age, genu varum (bow legs) is
a normal variant. Referral should be considered if genu Q-13
varum is asymmetrical or persists beyond 3 years of age and A 45-year old gentleman presents to your surgery with a 6
vitamin D deficiency is an important differential if the genu month history of inability to achieve an erection. He has a
varum is severe. Genu Valgus (knock knees) is a normal background of obesity and ischaemic heart disease. He takes
variant between 3- 6 years of age and again vitamin D ramipril and amlodipine and has no known drug allergies.
deficiency should be considered if the valgus is severe or You explore his history, examine him and decide to perform
persists. Flat feet is a normal variant until age 3. Most flat some blood tests. Which of the following tests should be
feet resolve by age 8 years as the foot arch starts to develop performed in every man presenting with erectile
from around 3 years of age. Arches should appear when dysfunction?
asking the infant to stand on their tip toes, and the foot
should also be flexible and painless. Painful rigid flat feet A. Serum lipids, fasting plasma glucose and serum
should always be referred and may suggest tarsal coalition. testosterone
B. Serum lipids, fasting plasma glucose, serum testosterone
There are 3 main causes of in-toeing- metatarsus adductus and prostate specific antigen
(congenital foot deformity), internal tibial torsion (feet C. Serum lipids and fasting plasma glucose
internally rotated) and femoral anteversion (feet and knees D. Fasting plasma glucose and prostate specific antigen
internally rotated). The vast majority resolve by around 8 E. Fasting plasma glucose and serum testosterone
years of age.
ANSWER:
PAEDIATRIC ORTHOPAEDICS Serum lipids, fasting plasma glucose and serum testosterone

Mode of EXPLANATION:
Diagnosis presentation Treatment Radiology
NICE clinical knowledge summaries states that in all men
Developmental Usually diagnosed Splints and Initially no
lipids and fasting glucose should be measured to calculate
dysplasia of the in infancy by harnesses or obvious change
hip screening tests. traction. In later on plain films
the 10-year cardiovascular risk and also free testosterone
May be bilateral, years osteotomy and and USS gives between 9 and 11am. If free testosterone is low or borderline
when disease is hip realignment best resolution then the test should be repeated, and follicle-stimulating
unilateral there procedures may be until 3 months of hormone, luteinizing hormone and prolactin should be
may be leg length needed. In arthritis a age. On plain measured. Abnormalities should prompt referral to
inequality. As joint replacement films Shentons endocrinology.
disease progresses may be needed. line should form
child may limp However, this is best a smooth arc
and then early deferred if possible October 2015 AKT report: 'Several areas of mens health
onset arthritis. as it will almost caused difficulty, including management of erectile
More common in certainly require dysfunction and effects of treatment for prostate conditions.'
extended breech revision
babies. ERECTILE DYSFUNCTION
Perthes Disease Hip pain (may be Remove pressure X-rays will show As part of assessment for erectile dysfunction Clinical
referred to the from joint to allow flattened femoral knowledge Summaries (CKS) recommend that all men have
knee) usually normal head. Eventually
their 10-year cardiovascular risk calculated by measuring lipid
occurring between development. in untreated
5 and 12 years of Physiotherapy. cases the and fasting glucose serum levels.
age. Bilateral Usually self-limiting femoral head will
disease in 20%. if diagnosed and fragment. Free testosterone should also be measured in the morning
treated promptly. between 9 and 11am. If free testosterone is low or borderline,
Slipped upper Typically seen in Bed rest and non- X-rays will show it should be repeated along with follicle-stimulating hormone,
femoral obese male weight bearing. Aim the femoral head luteinizing hormone and prolactin levels. If any of these are
epiphysis adolescents. Pain to avoid avascular displaced and abnormal refer to endocrinology for further assessment.
is often referred to necrosis. If severe falling
the knee. slippage or risk of it inferolaterally
Opinion on testosterone measurement differs between some
experts but CKS advises universal measurement of EXPLANATION Q-14 THROUGH 16:
testosterone in men with erectile dysfunction as LEVELS OF EVIDENCE
recommended by the British Society for Sexual Medicine and The level of evidence refers to the study design used by
the European Association of Urology. investigators to minimise bias.

Source: Clinical Knowledge Summaries - Erectile Dysfunction Level of Source

(last revised December 2014). evidence
I Evidence obtained from systematic review of all relevant
Q-14 THROUGH 16 randomised controlled trials
Theme: Levels of evidence II Evidence derived from at least one properly designed
randomised controlled trial
A. I III Evidence derived from well designed pseudo-randomised
controlled trials (e.g. alternate allocation) or historical controls
B. II
IV Evidence derived from case series or case reports
C. III
D. IV V Panel or expert opinion

E. V

Please select the level of evidence which is supplied by the Q-17

following. Each option may be used once, more than once or A 67-year-old man has been treated for prostate cancer. He
not at all. is receiving 3 monthly injections of a gonadorelin analogue.
He comes to see you because he is experiencing troublesome
Q-14 hot flushes. What does NICE recommend as a treatment for
One of the senior surgeons in the hospital advises as to the this?
best management of Merkel cell tumours of the skin in
which she has a special interest. A. Gabapentin
B. Fluoxetine
ANSWER: C. Citalopram
V D. Cyproterone acetate
E. Clonidine
EXPLANATION:
Personal expert opinion qualifies for level V evidence. ANSWER:
Cyproterone acetate
Q-15
A group of surgeons review a meta-analysis of a series of EXPLANATION:
randomised controlled trials on the Cochrane database and NICE recommends cyproterone acetate for the management
decide that one type of hip replacement is superior to of hot flushes in men undergoing hormonal treatment for
another. prostate cancer. None of the other medications are
recommended. (AKT feedback report October 2016)
ANSWER:
I PROSTATE CANCER: MANAGEMENT
Localised prostate cancer (T1/T2)
EXPLANATION: Treatment depends on life expectancy and patient choice.
A meta- analysis of more than one well designed trials will Options include:
typically represent level I evidence. It does, of course, depend • conservative: active monitoring & watchful waiting
on how well the trials were conducted and reported. • radical prostatectomy
• radiotherapy: external beam and brachytherapy
Q-16
A group of surgeons are trying to decide which type of mesh Localised advanced prostate cancer (T3/T4)
to use for incisional hernia repair. Their assimilated evidence
includes two case series and one randomised controlled trial. Options include:
• hormonal therapy: see below
ANSWER: • radical prostatectomy
II • radiotherapy: external beam and brachytherapy

EXPLANATION: Metastatic prostate cancer disease - hormonal therapy

Data which includes at least one RCT will usually qualify for Synthetic GnRH agonist
level II evidence.
• e.g. Goserelin (Zoladex) carcinoma and other rarer types of breast cancer are classified
• cover initially with anti-androgen to prevent rise in as 'Special Type'
testosterone Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Anti-androgen Lobular carcinoma-in-situ (LCIS)
• cyproterone acetate prevents DHT binding from
intracytoplasmic protein complexes Rarer types of breast cancer are shown in the following list.
These are classed as 'Special Type' but as noted previously
Orchidectomy remember that a relatively common type of breast cancer
(lobular) is also Special Type:
Q-18 • Medullary breast cancer
A 68-year-old woman has is assessed in the breast clinic after • Mucinous (mucoid or colloid) breast cancer
having an abnormal mammogram. Clinical exam of the • Tubular breast cancer
breast reveals a small fixed lump in the right breast. What is • Adenoid cystic carcinoma of the breast
the most common type of breast cancer? • Metaplastic breast cancer
• Lymphoma of the breast
A. Invasive lobular carcinoma • Basal type breast cancer
B. Inflammatory breast cancer • Phyllodes or cystosarcoma phyllodes
C. Invasive ductal carcinoma (no special type) • Papillary breast cancer
D. Paget's disease of the nipple
E. Tubular breast cancer Other types of breast cancer include the following (although
please note they may be associated with the underlying
ANSWER: lesions seen above, rather than completely separate
Invasive ductal carcinoma (no special type) subtypes):

EXPLANATION: Paget's disease of the nipple is an eczematoid change of the

Invasive ductal carcinoma (no special type) is the most nipple associated with an underlying breast malignancy and it
common type of breast cancer is present in 1-2% of patients with breast cancer. In half of
these patients, it is associated with an underlying mass lesion
BREAST CANCER: TYPES AND CLASSIFICATION and 90% of such patients will have an invasive carcinoma. 30%
The terminology surrounding breast cancer can sometimes be of patients without a mass lesion will still be found to have an
confusing and has changed over recent years. It is useful to underlying carcinoma. The remainder will have carcinoma in
start by considering basic breast anatomy 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-19
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

What is the most appropriate management?

Most breast cancers arise from duct tissue followed by lobular
tissue, described as ductal or lobular carcinoma respectively. A. Alpha-1 antagonist
These can be further subdivided as to whether the cancer B. 5 alpha-reductase inhibitor
hasn't spread beyond the local tissue (described as carcinoma- C. Non-urgent referral for transurethral resection of
in-situ) or has spread (described as invasive). Therefore, prostate
common breast cancer types include: D. Empirical treatment with ciprofloxacin for 2 weeks
Invasive ductal carcinoma. This is the most common type of E. Urgent referral to urology
breast cancer. To complicate matters further this has recently
been renamed 'No Special Type (NST)'. In contrast, lobular
ANSWER: Q-20
Alpha-1 antagonist A 25-year-old female presents to surgery with a 2 week
history of painless rectal bleeding. Inspection of perineum
EXPLANATION: and rectal examination is unremarkable. Proctoscopy
Alpha-1 antagonists are first-line in patients with benign reveals haemorrhoidal cushions at the left lateral and right
prostatic hyperplasia anterior position. What is the most important component of
management?
BENIGN PROSTATIC HYPERPLASIA
Benign prostatic hyperplasia (BPH) is a common condition A. Sitz baths
seen in older men. B. Topical nitrate
C. Fibre supplementation
Risk factors D. Improving anal hygiene
• age: around 50% of 50-year-old men will have evidence of E. Application of lubricant prior to defecation
BPH and 30% will have symptoms. Around 80% of 80-
year-old men have evidence of BPH Fibre supplementation has been shown to be as effective as
• ethnicity: black > white > Asian injection sclerotherapy in some studies

BPH typically presents with lower urinary tract symptoms ANSWER:

(LUTS), which may be categorised into: Fibre supplementation
• voiding symptoms (obstructive): weak or intermittent
urinary flow, straining, hesitancy, terminal dribbling and EXPLANATION:
incomplete emptying HAEMORRHOIDS
• storage symptoms (irritative) urgency, frequency, urgency Haemorrhoidal tissue is part of the normal anatomy which
incontinence and nocturia contributes to anal continence. These mucosal vascular
• post-micturition: dribbling cushions are found in the left lateral, right posterior and right
• complications: urinary tract infection, retention, anterior portions of the anal canal (3 o'clock, 7'o'clock and 11
obstructive uropathy o'clock respectively). Haemorrhoids are said to exist when
they become enlarged, congested and symptomatic
Management options
• watchful waiting Clinical features
• medication: alpha-1 antagonists, 5 alpha-reductase • painless rectal bleeding is the most common symptom
inhibitors. The use of combination therapy was supported • pruritus
by the Medical Therapy Of Prostatic Symptoms (MTOPS) • pain: usually not significant unless piles are thrombosed
trial • soiling may occur with third or forth degree piles
• surgery: transurethral resection of prostate (TURP)
Types of haemorrhoids
Alpha-1 antagonists e.g. tamsulosin, alfuzosin External
• decrease smooth muscle tone (prostate and bladder) • originate below the dentate line
• considered first-line, improve symptoms in around 70% of • prone to thrombosis, may be painful
men
• adverse effects: dizziness, postural hypotension, dry Internal
mouth, depression • originate above the dentate line
• do not generally cause pain
5 alpha-reductase inhibitors e.g. finasteride
• block the conversion of testosterone to Grading of internal haemorrhoids
dihydrotestosterone (DHT), which is known to induce BPH
Grade I Do not prolapse out of the anal canal
• unlike alpha-1 antagonists causes a reduction in prostate
Grade II Prolapse on defecation but reduce spontaneously
volume and hence may slow disease progression. This
however takes time and symptoms may not improve for 6 Grade III Can be manually reduced
months. They may also decrease PSA concentrations by Grade IV Cannot be reduced
up to 50%
• adverse effects: erectile dysfunction, reduced libido, Management
ejaculation problems, gynaecomastia • 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 Age-adjusted upper limits for PSA were recommended by the
• newer treatments: Doppler guided haemorrhoidal artery PCRMP:
ligation, stapled haemorrhoidopexy
Age PSA level (ng/ml)
Acutely thrombosed external haemorrhoids 50-59 years 3.0
• typically present with significant pain 60-69 years 4.0
• examination reveals a purplish, oedematous, tender > 70 years 5.0
subcutaneous perianal mass
• if patient presents within 72 hours then referral should be PSA levels may also be raised by*:
considered for excision. Otherwise patients can usually be • benign prostatic hyperplasia (BPH)
managed with stool softeners, ice packs and analgesia. • prostatitis and urinary tract infection (NICE recommend
Symptoms usually settle within 10 days to postpone the PSA test for at least 1 month after
treatment)
Q-21 • ejaculation (ideally not in the previous 48 hours)
A 56 year old gentleman with no lower urinary tract • vigorous exercise (ideally not in the previous 48 hours)
symptoms requests a prostate specific antigen (PSA) for a • urinary retention
'prostate check up'. What percentage of men with a raised • instrumentation of the urinary tract
PSA will be found to have prostate cancer?
Poor specificity and sensitivity
A. 66% • around 33% of men with a PSA of 4-10 ng/ml will be
B. 50% found to have prostate cancer. With a PSA of 10-20 ng/ml
C. 25% this rises to 60% of men
D. 33% • around 20% with prostate cancer have a normal PSA
E. 10% • various methods are used to try and add greater meaning
to a PSA level including age-adjusted upper limits and
ANSWER: monitoring change in PSA level with time (PSA velocity or
33% PSA doubling time)

EXPLANATION: *whether digital rectal examination actually causes a rise in

A raised PSA may be due to a variety of non-malignant PSA levels is a matter of debate
causes. These include:
• Benign prostatic hyperplasia Q-22 THROUGH 24
• Prostatitis, urinary tract infection Theme: Breast disorders
• Ejaculation or vigorous exercise in past 48 hours
A. Lipoma
Patients who are asymptomatic must be adequately B. Paget's disease of the breast
counselled regarding the implications of a raised PSA result. C. Breast cancer
This is a useful patient information leaflet: D. Sebaceous cysts
E. Fibroadenoma
PROSTATE CANCER: PSA TESTING F. Fibroadenosis
Prostate specific antigen (PSA) is a serine protease enzyme G. Duct papilloma
produced by normal and malignant prostate epithelial cells. It H. Breast abscess
has become an important tumour marker but much I. Fat necrosis
controversy still exists regarding its usefulness as a screening J. Mammary duct ectasia
tool.
For each one of the following please select the most
The NHS Prostate Cancer Risk Management Programme appropriate answer:
(PCRMP) has published updated guidelines in 2009 on how to
handle requests for PSA testing in asymptomatic men. A Q-22
recent European trial (ERSPC) showed a statistically significant A 49-year-old woman presents with a tender lump around
reduction in the rate of death prostate cancer by 20% in men the areola associated with a green nipple discharge.
aged 55 to 69 years but this was associated with a high risk of
over-diagnosis and over-treatment. Having reviewed this and ANSWER:
other data the National Screening Committee have decided Mammary duct ectasia
not to introduce a prostate cancer screening programme yet
but rather allow men to make an informed choice.
Q-23 Disorder Features
An obese woman presents with an irregular lump on the Initial inflammatory response, the lesion is
lateral aspect of her right breast associated with skin typical firm and round but may develop
tethering. Biopsy excludes a malignant cause. into a hard, irregular breast lump
Rare and may mimic breast cancer so
further investigation is always warranted
ANSWER:
Breast abscess More common in lactating women
Fat necrosis
Red, hot tender swelling

Q-24
Lipomas and sebaceous cysts may also develop around the
A 41-year-old woman presents with a two-month history of
breast tissue.
pain and an irregular fixed lump in her left breast.
Q-25
ANSWER:
A woman presents to surgery. Her 52-year-old mother has
Breast cancer
recently been diagnosed with breast cancer. She is
concerned about her own risk and wonders if she needs
EXPLANATION:
'genetic tests'. There is no other history of breast cancer in
the family. Which one of the following facts should prompt
EXPLANATION Q-22 THROUGH 24:
referral to secondary care?
A short history (e.g. a few days) of pain and a lump would
make you consider another diagnosis such as a breast abscess
A. An aunt with endometrial cancer
but the combination of a persistent lump spanning at least
B. Her mother's cancer being ER (oestrogen receptor)
one menstrual cycle and the irregularity point to a diagnosis
positive
of cancer.
C. Jewish ancestry
D. Her mother's cancer being HER2 (oestrogen receptor)
BREAST DISORDERS
positive
The table below describes some of the features seen in the
E. Her mother having metastases at the time of diagnosis
most common breast disorders:

Disorder Features ANSWER:

Fibroadenoma Common in women under the age of 30 Jewish ancestry
years
Often described as 'breast mice' due as EXPLANATION:
they are discrete, non-tender, highly mobile Ovarian cancer, rather than endometrial, is associated with
lumps familial breast cancer.
Fibroadenosis (fibrocystic Most common in middle-aged women
disease, benign mammary 'Lumpy' breasts which may be painful. BREAST CANCER: SCREENING
dysplasia) Symptoms may worsen prior to
The NHS Breast Screening Programme is being expanded to
menstruation
include women aged 47-73 years from the previous
Breast cancer Characteristically a hard, irregular lump.
There may be associated nipple inversion
parameter of 50-70 years. Women are offered a mammogram
or skin tethering every 3 years. After the age of 70 years women may still have
mammograms but are 'encouraged to make their own
Paget's disease of the breast - intraductal appointments'.
carcinoma associated with a reddening and
thickening (may resemble eczematous The effectiveness of breast screening is regularly debated
changes) of the nipple/areola
although it is currently thought that the NHS Breast Screening
Mammary duct ectasia Dilatation of the large breast ducts
Programme may save around 1,400 lives per year.
Most common around the menopause
May present with a tender lump around the
areola +/- a green nipple discharge Familial breast cancer
If ruptures may cause local inflammation,
sometimes referred to as 'plasma cell
NICE published guidelines on the management of familial
mastitis' breast cancer in 2013, giving guidelines on who needs referral.
Duct papilloma Local areas of epithelial proliferation in If the person concerned only has one first-degree or second-
large mammary ducts
degree relative diagnosed with breast cancer they do NOT
Hyperplastic lesions rather than malignant
or premalignant need to be referred unless any of the following are present in
May present with blood stained discharge the family history:
Fat necrosis More common in obese women with large • age of diagnosis < 40 years
breasts • bilateral breast cancer
May follow trivial or unnoticed trauma • male breast cancer
• ovarian cancer ANSWER:
• Jewish ancestry Women are screened every 3 years
• sarcoma in a relative younger than age 45 years
• glioma or childhood adrenal cortical carcinomas EXPLANATION:
• complicated patterns of multiple cancers at a young age Please see Q-25 for Breast Cancer: Screening
• paternal history of breast cancer (two or more relatives
on the father's side of the family) Q-28
A 44-year-old man attends for counselling with regards to a
Women who are at an increased risk of breast cancer due to vasectomy. Which one of the following statements is true
their family history may be offered screening from a younger regarding vasectomy?
age. The following patients should be referred to the breast
clinic for further assessment: A. Vasectomy is effective immediately
• one first-degree female relative diagnosed with breast B. Female sterilisation is more effective
cancer at younger than age 40 years, or C. Two negative semen samples should be obtained at 2
and 4 weeks before other contraceptive methods are
• one first-degree male relative diagnosed with breast
stopped
cancer at any age, or
D. Chronic testicular pain is seen in more than 5% of
• one first-degree relative with bilateral breast cancer
patients
where the first primary was diagnosed at younger than
E. Sexual intercourse should be avoided for one month to
age 50 years, or
reduce the chance of a sperm granuloma
• two first-degree relatives, or one first-degree and one
second-degree relative, diagnosed with breast cancer at ANSWER:
any age, or Chronic testicular pain is seen in more than 5% of patients
• one first-degree or second-degree relative diagnosed with
breast cancer at any age and one first-degree or second- EXPLANATION:
degree relative diagnosed with ovarian cancer at any age VASECTOMY
(one of these should be a first-degree relative), or Male sterilisation - vasectomy
• three first-degree or second-degree relatives diagnosed • failure rate: 1 per 2,000*
with breast cancer at any age • simple operation, can be done under LA (some GA), go
home after a couple of hours
Q-26 • doesn't work immediately
Which one of the following statements regarding congenital • semen analysis needs to be performed twice following a
inguinal hernias is correct? vasectomy before a man can have unprotected sex
(usually at 16 and 20 weeks)
A. They should be managed conservatively • complications: bruising, haematoma, infection, sperm
B. Result from the premature closure of the processus granuloma, chronic testicular pain (affects between 5-
vaginalis 30% men)
C. They are more common in girls • the success rate of vasectomy reversal is up to 55%, if
D. The incidence in newborns is 0.1-0.2% done within 10 years, and approximately 25% after more
E. They are more common on the right side than 10 years.

ANSWER: Q-29
They are more common on the right side Roger is a 50-year-old man who has a friend recently
diagnosed with bowel cancer. He has heard about the faecal
EXPLANATION: occult blood screening program but has read in the news
Please see Q-11 for Abdominal Wall Hernias about a new program involving a scope. He asks you for
more information. Which of the following is the correct
Q-27 guidance?
Which one of the following statements regarding the NHS
Breast Screening Programme is correct? A. New program for men & women for one off colonoscopy
at age 55
A. Women are given a 'triple assessment' at each screening B. New program for men & women for one off
cycle sigmoidoscopy at age 55
B. It is targeted at women aged 40-70 years C. New program for men & women for one off
C. Women with a family history of cervical cancer should sigmoidoscopy at age 60
be offered more regular and/or earlier screening D. New program for men & women for one off
D. Women are screened every 3 years sigmoidoscopy at age 65
E. Women over the age of 70 years are not eligible for E. New program for men for one off sigmoidoscopy at age
screening 55
ANSWER: • sexually transmitted infections e.g. HIV, syphilis, herpes
New program for men & women for one off sigmoidoscopy at
age 55 Features
• painful, bright red, rectal bleeding
EXPLANATION:
The correct answer is option 2 - a one off sigmoidoscopy for Management of an acute anal fissure (< 6 weeks)
men and women aged 55. • dietary advice: high-fibre diet with high fluid intake
• bulk-forming laxatives are first line - if not tolerated then
NHS bowel scope screening is a new addition to the bowel lactulose should be tried
cancer screening. This involves a gradual roll out across the • lubricants such as petroleum jelly may be tried before
UK of a one off sigmoidoscopy offered to all men and women defecation
at the age of 55. • topical anaesthetics
• -analgesia
For every 300 people screened using this screening program, • topical steroids do not provide significant relief
it stops two from getting bowel cancer and saves one life
from bowel cancer. Management of a chronic anal fissure (> 6 weeks)
• the above techniques should be continued
The program is still being rolled out and as of 2015,
• topical glyceryl trinitrate (GTN) is first line treatment for a
approximately two-thirds of the UK is offering this screening
chronic anal fissure
program with plans for all the UK to be taking part by 2018.
• if topical GTN is not effective after 8 weeks then
secondary referral should be considered for surgery or
AKT report Jan 2015 - 'After AKT 22, we fed back on lack of
botulinum toxin
knowledge around some national screening programmes.'
Q-31
Please see Q-2 for Colorectal Cancer: Screening
Which one of the following is most associated with male
infertility?
Q-30
A 24-year-old man presents due to severe pain when
A. Sodium valproate therapy
defecating for the past 2 weeks. He has occasionally noted
B. Benign prostatic hyperplasia
some blood on the toilet paper when wiping himself. On
C. Varicoceles
examination a tear is seen on the posterior midline of the
D. Epididymal cysts
anal verge. Which one of the following should not be
E. Hydroceles
recommended as a treatment option?
ANSWER:
A. Bulk-forming laxatives
Varicoceles
B. Application of lubricant prior to defecation
C. Topical steroids
EXPLANATION:
D. Dietary advice
Varicoceles may be associated with infertility
E. Paracetamol
SCROTAL PROBLEMS
ANSWER:
Topical steroids
Epididymal cysts
Epididymal cysts are the most common cause of scrotal
EXPLANATION:
swellings seen in primary care.
Topical steroids have been shown in studies to be of little
benefit in treating anal fissures
Features
• separate from the body of the testicle
ANAL FISSURE
• found posterior to the testicle
Anal fissures are longitudinal or elliptical tears of the
squamous lining of the distal anal canal. If present for less
Associated conditions
than 6 weeks they are defined as acute, and chronic if present
for more than 6 weeks. Around 90% of anal fissures occur on • polycystic kidney disease
the posterior midline • cystic fibrosis
• von Hippel-Lindau syndrome
Risk factors
• constipation Diagnosis may be confirmed by ultrasound.
• inflammatory bowel disease
Management is usually supportive but surgical removal or Management
sclerotherapy may be attempted for larger or symptomatic • usually conservative
cysts. • occasionally surgery is required if the patient is troubled
by pain. There is ongoing debate regarding the
Hydrocele effectiveness of surgery to treat infertility
A hydrocele describes the accumulation of fluid within the
tunica vaginalis. They can be divided into communicating and Q-32
non-communicating: A GP receives notification from the Abdominal Aortic
• communicating: caused by patency of the processus Aneurysm Screening program that one of his patients has
vaginalis allowing peritoneal fluid to drain down into the been found to have an aneurysm measuring 6.5cm in
scrotum. Communicating hydroceles are common in diameter. What should happen next?
newborn males (clinically apparent in 5-10%) and usually
resolve within the first few months of life A. No action needed
• non-communicating: caused by excessive fluid production B. Re-scan in 3 months
within the tunica vaginalis C. Re-scan in 12 months
D. Follow-up with screening programme Nurse Specialist
Hydroceles may develop secondary to: E. Refer to Vascular Outpatients
• epididymo-orchitis
• testicular torsion ANSWER:
• testicular tumours Refer to Vascular Outpatients

Features EXPLANATION:
• soft, non-tender swelling of the hemi-scrotum. Usually Knowledge about NHS screening programmes is required by
anterior to and below the testicle the RCGP curriculum under the statement on 'Healthy
• the swelling is confined to the scrotum, you can get people, promoting health and preventing disease.' All men
'above' the mass on examination are invited to be screened for abdominal aortic aneurysm
• transilluminates with a pen torch (AAA) by ultrasound scan at the age of 65 - evidence shows
• the testis may be difficult to palpate if the hydrocele is this reduces premature deaths from ruptured AAA by as
large much as 50%.

Diagnosis may be clinical but ultrasound is required if there is The patient is discharged from the screening programme if
any doubt about the diagnosis or if the underlying testis the aortic diameter is normal. Small and medium AAAs are
cannot be palpated. followed up with appointments with a Nurse Specialist from
the screening programme and regular surveillance scans. If a
Management large AAA (>5.5 cm diameter) is found, the patient should be
• infantile hydroceles are generally repaired if they do not referred to Vascular Outpatients to be seen within 2 weeks.
resolve spontaneously by the age of 1-2 years The patient will be referred from the screening programme,
• in adults a conservative approach may be taken but the GP is also contacted urgently to provide additional
depending on the severity of the presentation. Further information to complete the referral eg. Past Medical
investigation (e.g. ultrasound) is usually warranted History. If surgery is indicated, the patient should be
however to exclude any underlying cause such as a operated on within 8 weeks of the referral.
tumour
ABDOMINAL AORTIC ANEURYSM
Varicocele Abdominal aortic aneurysms occur primarily as a result of the
A varicocele is an abnormal enlargement of the testicular failure of elastic proteins within the extracellular matrix.
veins. They are usually asymptomatic but may be important as Aneurysms typically represent dilation of all layers of the
they are associated with infertility. arterial wall. Most aneurysms are caused by degenerative
disease. After the age of 50 years the normal diameter of the
Varicoceles are much more common on the left side (> 80%). infrarenal aorta is 1.5cm in females and 1.7cm in males.
Features: Diameters of 3cm and greater, are considered aneurysmal.
The pathophysiology involved in the development of
• classically described as a 'bag of worms'
aneurysms is complex and the primary event is loss of the
• subfertility
intima with loss of elastic fibres from the media. This process
is associated with, and potentiated by, increased proteolytic
Diagnosis
activity and lymphocytic infiltration.
• ultrasound with Doppler studies
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 ANSWER:
type 1 and Marfans syndrome. 28-year-old female with a 8 week history of a new breast
lump. Benign in nature on examination
Q-33
You review a 65-year-old man in surgery. He has had a EXPLANATION:
diagnosis of benign prostatic hypertrophy for 5 years. This is NICE guidelines suggest a cut-off age of 30 years when a
treated with tamsulosin (alpha blocker) and finasteride (5- woman has an unexplained breast lump with or without
alpha reductase inhibitor), which until recently had been pain. As this 28-year-old is below this cut-off she should be
keeping his symptoms well controlled. He presents with 3 referred non-urgently to the local breast services.
months of worsening symptoms of poor flow, hesitancy,
nocturia, weight loss and back pain. You request a prostate- BREAST CANCER: REFERRAL
specific antigen blood test. The result is 2.8ng/mL - normal NICE published referral guidelines for suspected breast cancer
for his age range. What is the most likely diagnosis? in 2015 (our emphasis):
A. Urinary tract infection Refer people using a suspected cancer pathway referral (for
B. Treatment-resistant benign prostatic hyperplasia an appointment within 2 weeks) for breast cancer if they are:
C. Spinal cord compression
• aged 30 and over and have an unexplained breast lump
D. Prostate cancer
with or without pain or
E. Prostatitis
• aged 50 and over with any of the following symptoms in
one nipple only: discharge, retraction or other changes of
ANSWER:
concern
Prostate cancer
EXPLANATION: Consider a suspected cancer pathway referral (for an
The answer here is prostate cancer. This patient has known appointment within 2 weeks) for breast cancer in people:
BPH which was well controlled on medication. He presents • with skin changes that suggest breast cancer or
with new lower urinary tract symptoms, coupled with red • aged 30 and over with an unexplained lump in the axilla
flags features of weight loss and back pain. His PSA is normal
however he is on finasteride which is known to reduce PSA Consider non-urgent referral in people aged under 30 with an
levels. The 3-month duration of symptoms and weight loss unexplained breast lump with or without pain.
are not in keeping with a diagnosis of a urinary tract
infection. Treatment-resistant BPH is unlikely after 5 years of Q-35 THROUGH 37
successful treatment and would not give red flag features. Theme: Anorectal disorders
Spinal cord compression can cause urinary symptoms of
either incontinence or retention, unlikely to cause nocturia or A. Fistula in ano
flow issues. Prostatitis is not the answer as there is no B. Fissure in ano
systemic upset or pelvic pain noted. This is usually a painful C. Ischiorectal fossa abscess
condition, can be acute or chronic in nature and associated D. Haemorrhoids
with frequency and dysuria, pelvic/ lower back/genital pain. E. Crohn's disease
(AKT feedback report October 2016) F. Internal rectal prolapse
G. Solitary rectal ulcer
Please see Q-19 for Benign Prostatic Hyperplasia
Q-34 Please select the most likely diagnosis for the scenario given.
Which one of the following scenarios would not warrant an Each option may be used once, more than once or not at all.
urgent referral to the local breast service according to NICE
guidelines? Q-35
A 23-year-old man presents with a three week history of
A. 38-year-old woman with an unexplained lump in her left
painless rectal bleeding. The bleeding typically occurs post
axilla. Lymphadenopathy can be felt on examination.
defecation and blood is noted in the toilet pan and on paper
Breast examination is normal
when he wipes himself. He is otherwise well and his bowel
B. 34-year-old female with a 4 week history of a new
habit is regular, though recently he has been slightly
breast lump. Benign in nature on examination
constipated.
C. 55-year-old female with new breast lump. Benign in
nature on examination
ANSWER:
D. 28-year-old female with a 8 week history of a new
Haemorrhoids
breast lump. Benign in nature on examination
E. 53-year-old female with a unilateral bloody nipple
discharge
EXPLANATION: Location: 3, 7, 11 o'clock position
Post defecatory rectal bleeding that is noted in the toilet pan Internal or external
and on toilet paper is often haemorroidal in nature. In this age Treatment: Conservative, Rubber band ligation,
Haemorrhoids Haemorrhoidectomy
group detailed colonic assessments are not required provided
that digital rectal examination (and ideally proctoscopy) are anal papillae

concordant with this diagnosis. Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile
Ano rectal E.coli, staph aureus
abscess Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
Q-36
Anal fistula Usually due to previous ano-rectal abscess
34-year-old lady presents with a long history of chronic
Intersphincteric, transsphincteric, suprasphincteric, and
constipation and occasional episodic rectal bleeding. extrasphincteric. Goodsalls rule determines location
Abdominal examination is unremarkable, on digital rectal
Rectal prolapse Associated with childbirth and rectal intussceception. May be
examination she has an indurated ulcer located anteriorly internal or external
approximately 4cm from the dentate line. Pruritus ani Systemic and local causes
Anal neoplasm Squamous cell carcinoma commonest unlike
ANSWER: adenocarcinoma in rectum
Solitary rectal ulcer Solitary rectal Associated with chronic straining and constipation. Histology
ulcer shows mucosal thickening, lamina propria replaced with
EXPLANATION: collagen and smooth muscle (fibromuscular obliteration)
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 Q-38
mandatory and the histological appearances are usually A 62-year-old man presents with lethargy. This has been
diagnostic and exclude malignancy. Treatment is usually getting worse over the past few months and is not
directed at correcting the reason for the underlying associated with any specific symptoms. A series of blood
constipation. tests are requested:

Q-37 Hb 12.3 g/l

A 23-year-old lady presents with a one week history of
MCV 82 fl
painful rectal bleeding that typically occurs in association
with the passage of the stool and is also noted on wiping the Platelets 233* 109/l

anus afterwards. Examination of the anorectum is WBC 6.4 * 109/l

impossible due to pain. However, external inspection reveals
Iron studies Normal
a midline sentinel skin tag.
Vitamin B12/folate Normal

ANSWER: CRP 6 mg/l

Fissure in ano TSH 2mU/l

EXPLANATION:
In keeping with NICE guidance, what is the most appropriate
Fissure in ano is a common cause of painful rectal bleeding.
next step?
Examination of the anorectum (which must be performed) is
often best deferred until the fissure is less painful and
A. Refer for a non-urgent colonoscopy
hopefully healed. The external appearance of a sentinel skin
B. Arrange a chest x-ray
tag together with this history is strongly suggestive of the
C. Offer faecal occult blood testing
diagnosis. Whilst posteriorly sited fissures are often related to
D. Dietary advice then repeat full blood count in 6 months
the passage of hard stool, those located anteriorly or if
E. Trial of vitamin B12 injections then repeat full blood
multiple are strongly suggestive of underlying organic disease
count in 6 months
and merit endoscopy.
ANSWER:
EXPLANATION Q-35 THROUGH 37:
Offer faecal occult blood testing
ANORECTAL DISORDERS
EXPLANATION:
Location: 3, 7, 11 o'clock position
Internal or external
NICE recommend faecal occult blood testing in this scenario,
Treatment: Conservative, Rubber band ligation, even in the absence of iron-deficiency.
Haemorrhoids Haemorrhoidectomy
Fissure in ano Location: midline 6 (posterior midline 90%) and 12 o'clock COLORECTAL CANCER: REFERRAL GUIDELINES
position. Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged
NICE updated their referral guidelines in 2015. The following EXPLANATION:
patients should be referred urgently (i.e. within 2 weeks) to Please see Q-25 for Breast Cancer: Screening
colorectal services for investigation:
• patients >= 40 years with unexplained weight loss AND Q-40
abdominal pain A 72-year-old man is diagnosed with prostate cancer and
• patients >= 50 years with unexplained rectal bleeding goserelin (Zoladex) is prescribed. Which one of the following
• patients >= 60 years with iron deficiency anaemia OR is it most important to co-prescribe for the first three weeks
change in bowel habit of treatment?
• tests show occult blood in their faeces (see below)
A. Tamoxifen
An urgent referral (within 2 weeks) should be 'considered' if: B. Lansoprazole
there is a rectal or abdominal mass C. Allopurinol
• there is an unexplained anal mass or anal ulceration D. Cyproterone acetate
• patients < 50 years with rectal bleeding AND any of the E. Tamsulosin
following unexplained symptoms/findings:
• -→ abdominal pain ANSWER:
• -→ change in bowel habit Cyproterone acetate
• -→ weight loss
EXPLANATION:
• -→ iron deficiency anaemia
Anti-androgen treatment such as cyproterone acetate should
be co-prescribed when starting gonadorelin analogues due
Faecal Occult Blood Testing (FOBT)
to the risk of tumour flare. This phenomenon is secondary to
initial stimulation of luteinising hormone release by the
This was one of the main changes in 2015. Remember that the
pituitary gland resulting in increased testosterone levels.
NHS now has a national screening programme offering
screening every 2 years to all men and women aged 60 to 74
The BNF advises starting cyproterone acetate 3 days before
years. Patients aged over 74 years may request screening.
the gonadorelin analogue.
In addition FOBT should be offered to:
Please see Q-17 for Prostate Cancer: Management
• patients >= 50 years with unexplained abdominal pain OR
weight loss
Q-41
• patients < 60 years with changes in their bowel habit OR
Nigel is a 53 year old gentleman with a background of
iron deficiency anaemia
prostate cancer who underwent a complete prostatectomy 3
• patients >= 60 years who have anaemia even in the
months ago. You have been asked to perform a PSA level
absence of iron deficiency
after 3 months for routine surveillance. The result shows a
PSA level of 2 ng/ml (normal upper range for his age group is
Q-39
3.9 ng/ml). How would you manage this result?
A woman is concerned about her risk of breast cancer.
Which one of the following scenarios should prompt a
A. Urgent referral to oncology
referral to the local breast services:
B. Repeat PSA in 6 months
C. Repeat PSA in 3 months
A. A woman whose mother was diagnosed with breast
D. Reassurance as within normal range
cancer aged 46 years
E. Repeat PSA in 1 month
B. A woman whose sister has been diagnosed with HER2
positive breast cancer aged 51 years
Following a complete prostatectomy the PSA level should be
C. A woman whose father has been diagnosed with breast
'undetectable' which is defined usually as a value less than
cancer aged 56 years
0.2ng/ml. Therefore following 3 months a value of 2 (albeit
D. A woman who has two grandmothers who were
within the normal range for patients who have not had
diagnosed with breast cancer at the ages of 66 years and
treatment) would be considered a significantly elevated
61 years
value and would therefore warrant urgent refrral to
E. A woman who has a mother diagnosed with breast
oncology for further investigation.
cancer aged 62 years and a maternal aunt diagnosed
with cervical cancer aged 34-years
ANSWER:
Urgent referral to oncology
ANSWER:
A woman whose father has been diagnosed with breast EXPLANATION:
cancer aged 56 years Please see Q-21 for Prostate Cancer: PSA Testing
Q-42 EXPLANATION:
A 56 year old man presents with new onset erectile Please see Q-22 THROUGH 24 for Breast Disorders
dysfunction. He is generally well, in a stable relationship and
is on no regular medication. Examination is unremarkable. Q-46
Which of the following is recommended as an initial work You are discussing an elevated PSA result with one of your
up? patients, a 62-year-old man with a PSA level of 7.2 ng/ml.
Which procedure is he most likely to have following referral
A. Testosterone, lipids, fasting glucose to a urologist?
B. Testosterone, prolactin, fasting glucose, liver function
tests (LFTs) A. Prostatectomy
C. Lipids, fasting glucose, LFTs B. Cystoscopy with prostate biopsy
D. Prolactin, lipids, fasting glucose C. Staging CT scan
E. LFTs, fasting glucose, testosterone D. MRI pelvis
E. TRUS-guided biopsy
ANSWER:
Testosterone, lipids, fasting glucose ANSWER:
TRUS-guided biopsy
EXPLANATION:
Please see Q-13 for Erectile Dysfunction EXPLANATION:
A TRUS-guided biopsy is need to clarify the diagnosis as
Q-43 THROUGH 45 around two-thirds of such patients will not have prostate
Theme: Breast disorders cancer.

A. Lipoma Please see Q-21 for Prostate Cancer: PSA Testing

B. Paget's disease of the breast
C. Breast cancer Q-47
D. Sebaceous cysts A 60-year-old man is worried about his risk of developing
E. Fibroadenoma colorectal cancer. Following the introduction of the national
F. Fibroadenosis screening programme how often is such a patient offered a
G. Duct papilloma faecal occult blood screening test?
H. Breast abscess
I. Fat necrosis A. Every year
J. Mammary duct ectasia B. Every two years
C. Every three years
For each one of the following please select the most D. Every five years
appropriate answer: E. On one occasion at the age of 65

Q-43 ANSWER:
A 72-year-old woman complains of 'eczema' on her left Every two years
nipple. On examination the areola is erythematous and
thickened. EXPLANATION:
Please see Q-2 for Colorectal Cancer: Screening
ANSWER:
Paget’s disease of the breast Q-48
A 65-year-old woman presents with painful, red skin on the
Q-44 inside of her thigh. This has developed over the past 4-5 days
A 26-year-old woman has noticed a discrete, non-tender and has not happened before. She is normally fit and well
lump which is highly mobile on examination. and no past medical history of note other than depression.
ANSWER: On examination she has erythematous, tender skin on the
Fibroadenoma medial aspect of her right thigh consistent with the long
saphenous vein. The vein is palpable and cord-like. There is
Q-45 no associated swelling of the right calf and no history of
A 35-year-old woman complains of 'lumpy' breasts. Her chest pain or dyspnoea. Heart rate is 84/min and her
symptoms are worse in the premenstrual period. temperature is 37.0ºC. What is the most appropriate
management?
ANSWER:
Fibroadenosis
A. Prescribe an oral NSAID • Patients with superficial thrombophlebitis should have
B. Prescribe a topical NSAID anti-embolism stockings and can be considered for
C. Refer for an ultrasound scan treatment with prophylactic doses of LMWH for up to 30
D. Prescribe a topical heparinoid days or fondaparinux for 45 days.
E. Prescribe an oral NSAID and oral flucloxacillin • If LMWH is contraindicated, 8-12 days of oral NSAIDS
should be offered.
ANSWER:
Refer for an ultrasound scan Patients with superficial thrombophlebitis at, or extending
towards, the sapheno-femoral junction can be considered for
EXPLANATION: therapeutic anticoagulation for 6-12 weeks.
SIGN recommend referring patients with long saphenous
vein superficial thrombophlebitis for an ultrasound scan to This may be a significant departure from our current practice -
exclude an underlying DVT the majority of patients with superficial thrombophlebitis (i.e.
those affecting the long saphenous vein) should be referred
SUPERFICIAL THROMBOPHLEBITIS for an ultrasound scan.
Superficial thrombophlebitis, as the name suggests describes
the inflammation associated with thrombosis of one of the Q-49
superficial veins, usually the long saphenous vein of the leg. A 55-year-old accountant presents to surgery requesting a
This process is usually non-infective in nature but secondary sick note following an open repair of an inguinal hernia.
bacterial infection may rarely occur resulting in septic According to Department of Work and Pensions advice,
thrombophlebitis. when should he be able to return to work?

Around 20% with superficial thrombophlebitis will have an A. After 5 days

underlying deep vein thrombosis (DVT) at presentation and 3- B. After 7 days
4% of patients will progress to a DVT if untreated. The risk of C. After 1 - 2 weeks
DVT is partly linked to the length of vein affected - an D. After 2 - 3 weeks
inflammed vein > 5 cm is more likely to have an associated E. After 3 - 4 weeks
DVT.
ANSWER:
Management After 2 - 3 weeks
There are currently a variety of treatment approaches to
superficial thrombophlebitis. Traditionally NSAIDs have been EXPLANATION:
used, with topical NSAIDs for limited and mild disease and oral Inguinal hernia repair: back to work after 2-3 weeks if open,
NSAIDs for more severe disease. 1-2 weeks if laparoscopic

Topical heparinoids have also be used in the management of Please see Q-7 for Inguinal Hernia
superficial thrombophlebitis.
Q-50 THROUGH 52
Theme: Abdominal pain
A Cochrane review however found topical NSAIDs and
heparinoids have no significant benefit in terms of reducing
A. Myocardial infarction
extension or progression to DVT. Oral NSAIDs were however
B. Colorectal cancer
shown to reduce the risk of extension by 67%.
C. Duodenal ulcer
D. Gastric ulcer
Compression stockings are also used. Remember that the
E. Biliary colic
ankle-brachial pressure index (ABPI) should be measured
F. Ruptured abdominal aortic aneurysm
before prescribing compression stockings, particularly if using
G. Acute pancreatitis
class 2 or above stockings.
H. Toxic megacolon
I. Diverticulitis
One of the major changes to the management of superficial
J. Intestinal obstruction
thrombophlebitis is the increased use of low-molecular weight
heparin. This has been shown to reduce extension and For each one of the following scenarios please select the
transformation to DVT. SIGN produced guidelines in 2010: most likely diagnosis:

Patients with clinical signs of superficial thrombophlebitis Q-50

affecting the proximal long saphenous vein should have an A 65-year-old man with a history of ischaemic heart disease
ultrasound scan to exclude concurrent DVT. presents with sudden onset central abdominal pain radiating
to his back. He is clammy and short of breath.
ANSWER: Q-55
Ruptured abdominal aneurysm You receive a fax through from urology. One of your patients
with a raised PSA recently underwent a prostatic biopsy. The
Q-51 report reads as follows:
A 34-year-old man who drinks 21 units of alcohol per week
presents with episodic epigastric pain that is relieved by Adenocarcinoma prostate, Gleason 3+4
eating.
Which one of the following statements regarding the
ANSWER: Gleason score is incorrect?
Duodenal ulcer
A. Grades the glandular architecture seen on histology
Q-52 following hollow needle biopsy
A 40-year-old woman with a history of Crohn's disease B. The Gleason grade ranges from 1 to 5
presents with abdominal pain and distension. She describes C. The Gleason score ranges from 2 to 10
constipation for the past 4 days. D. The lower the Gleason score the worse the prognosis
E. Used to predict prognosis in patients with prostatic
ANSWER: cancer
Intestinal obstruction
ANSWER:
EXPLANATION: The lower the Gleason score the worse the prognosis
Please see Q-8 THROUGH 10 for Abdominal Pain
EXPLANATION:
Q-53 PROSTATE CANCER: PROGNOSIS
A 64-year-old man who is asymptomatic requests a PSA test. The Gleason score is used to predict prognosis in patients with
What is the upper limit of normal for a man of this age? prostatic cancer. The grading system is based on the glandular
architecture seen on histology following hollow needle biopsy
A. 3.0 ng/ml
B. 3.5 ng/ml The most prevalent and the second most prevalent pattern
C. 4.0 ng/ml seen are added to obtain a Gleason score. The Gleason grade
D. 4.5 ng/ml ranges from 1 to 5 meaning the Gleason score ranges from 2
E. 5.0 ng/ml to 10 (i.e. two values added)

ANSWER: The higher the Gleason score the worse the prognosis
4.0 ng/ml
Q-56
EXPLANATION: Which one of the following scenarios is the most common
Please see Q-21 for Prostate Cancer: PSA Testing presentation of testicular cancer?

Q-54 A. Painful testicular lump in a 56-year-old man

What is the lifetime risk of developing colorectal cancer in B. Painless testicular lump in a 27-year-old man
the United Kingdom? C. Painless testicular lump in a 43-year-old man
D. Painful testicular lump in a 25-year-old man
A. 1% E. Painful testicular lump associated with dysuria in a 38-
B. 2% year-old man
C. 5%
D. 10% ANSWER:
E. 15% Painless testicular lump in a 27-year-old man

ANSWER: EXPLANATION:
5% TESTICULAR CANCER
Testicular cancer is the most common malignancy in men
EXPLANATION: aged 20-30 years. Around 95% of cases of testicular cancer are
Colorectal cancer is the third most common cancer in the UK, germ-cell tumours. Germ cell tumours may essentially be
with approximately 30,000 new cases in England and Wales divided into:
per year • seminomas
• non-seminomas: including embryonal, yolk sac, teratoma
Please see Q-2 for Colorectal Cancer: Screening and choriocarcinoma
 A. Start an antispasmodic agent
Non-germ cell tumours include Leydig cell tumours and B. Prescribe loperamide as and when required
sarcomas. C. 2 week referral to secondary care
D. Arrange bloods and request an abdominal ultrasound
The peak incidence for teratomas is 25 years and seminomas scan
is 35 years. Risk factors include: E. Start low dose sertraline and review
• cryptorchidism
• infertility ANSWER:
• family history 2 week referral to secondary care
• Klinefelter's syndrome
• mumps orchitis EXPLANATION:
This lady has presented with a red flag symptom of change in
Features bowel habit to loose stool persisting more than 6 weeks in a
• a painless lump is the most common presenting symptom person over 60 years of age. She should be counselled about
• pain may also be present in a minority of men the possibility of an underlying malignancy and referred
• other possible features include hydrocele, gynaecomastia under the 2-week rule to secondary care for further
investigations to exclude an underlying bowel cancer.
Diagnosis
• ultrasound is first-line Please see Q-38 for Colorectal Cancer: Referral Guidelines

Management Q-59
A 69-year-old man is started on tamsulosin for benign
• treatment depends on whether the tumour is a
prostatic hyperplasia. Which one of the following best
seminoma or a non-seminoma
describes the side-effects he may experience?
• orchidectomy
• chemotherapy and radiotherapy may be given depending
A. Urgency + insomnia
on staging and tumour type
B. Dizziness + postural hypotension
C. Urinary retention + nausea
Prognosis is generally excellent
D. Urgency + erectile dysfunction
• 5 year survival for seminomas is around 95% if Stage I
E. Erectile dysfunction + reduced libido
• 5 year survival for teratomas is around 85% if Stage I
ANSWER:
Q-57 Dizziness + postural hypotension
Which one of the following ethnic groups have an increased
incidence of prostate cancer? EXPLANATION:
Dizziness + postural hypotension
A. Afro-Caribbean
B. Ashkenazi Jews Please see Q-19 for Benign Prostatic Hyperplasia
C. Chinese
D. Indian subcontinent Q-60
E. White A 23-year-old man presents with a 2-week history of a new
right sided painless scrotal swelling. On examination, there is
ANSWER: a soft non-tender right sided scrotal swelling that
Afro-Caribbean transilluminates with a pen torch and on palpation of the
testicle you can feel an irregular, hard swelling. There is no
EXPLANATION: erythema and the patient is afebrile. What is the most
Prostate cancer - more common in the Afro-Caribbean appropriate management option?
population
Please see Q-1 for Prostate Cancer: Features A. Reassure
B. Perform bloods for tumour markers including alpha
Q-58 fetoprotein and human chorionic gonadotrophin
A 61-year-old woman presents with abdominal discomfort, C. Refer for urgent scrotal ultrasound
bloating and change in bowel habit to looser, more frequent D. Refer for non urgent ultrasound
stools. She has been aware of these symptoms since the E. Refer for routine urology outpatient review
death of her husband 2 months ago. Her daughter has
suggested she has irritable bowel syndrome and she is ANSWER:
requesting treatment for this. How should you manage her? Refer for urgent scrotal ultrasound
EXPLANATION: ANSWER:
A new hydrocele may be the first sign of a testicular Inguinal hernia
malignancy. Patients in their 20s and 30s are at highest risk
of testicular malignancy. According to NICE- new hydroceles EXPLANATION:
in males aged 20-40 years old must be investigated by way A hydrocele is less likely as you cannot 'get above' the swelling
of urgent scrotal ultrasound. Reassuring this patient is on examination.
therefore not an appropriate management option, nor is EXPLANATION Q-61 THROUGH 63:
requesting a routine ultrasound or outpatient review as this Please see Q-31 for Scrotal Problems
would cause a delay in investigation and possible diagnosis
of malignancy. Blood tests to look for tumour markers may Q-64
be an appropriate investigation later following identification A 73-year-old woman presents with episodic confusion and
of suspected testicular malignancy. headaches for the past week. She has a history of alcohol
excess and a background of atrial fibrillation and type 2
(AKT feedback report October 2016) Source NICE CKS: Scrotal diabetes mellitus. Her daughter reports that she has been
Swellings having frequent spells of confusion over the past few days.
Last year she was assessed for frequent falls. Her current
Please see Q-56 for Testicular Cancer medications include bisoprolol, metformin and warfarin.
Neurological examination is unremarkable and her blood
Q-61 THROUGH 63 sugar is 6.7 mmol/l. What is the most likely diagnosis?
Theme: Scrotal problems A. Korsakoff's syndrome
B. Wernicke's encephalopathy
A. Varicocele C. Extradural haematoma
B. Testicular cancer D. Subarachnoid haemorrhage
C. Epididymo-orchitis E. Subdural haematoma
D. Epididymal cyst
E. Inguinal hernia ANSWER:
F. Hydrocele Subdural hematoma
G. Femoral hernia
H. Hydatid of Morgagni EXPLANATION:
I. Fournier's gangrene Fluctuating confusion/consciousness? - subdural haematoma
J. Cardiac failure This patient has a number of risk factors for a subdural
haematoma including old age, alcoholism and
For each of the following scenarios please select the most anticoagulation. Korsakoff's syndrome and Wernicke's
likely diagnosis: encephalopathy do not usually cause headaches.
HEAD INJURY: TYPES OF TRAUMATIC BRAIN INJURY
Q-61 Basics
A 31-year-old man presents as he and his partner have been • primary brain injury may be focal (contusion/haematoma)
having problems conceiving. On examination there is a or diffuse (diffuse axonal injury)
diffuse lumpy swelling on the left side of his scrotum. This is • diffuse axonal injury occurs as a result of mechanical
not painful and the testicle, which can be felt separately, is shearing following deceleration, causing disruption and
normal. tearing of axons
• intra-cranial haematomas can be extradural, subdural or
ANSWER: intracerebral, while contusions may occur adjacent to
Varicocele (coup) or contralateral (contre-coup) to the side of impact
Q-62 • secondary brain injury occurs when cerebral oedema,
A 44-year-old man notices a pea-sized lump on his right ischaemia, infection, tonsillar or tentorial herniation
testicle. On examination a discrete soft mass can be felt exacerbates the original injury. The normal cerebral auto
posterior to the right testicle. regulatory processes are disrupted following trauma
rendering the brain more susceptible to blood flow
ANSWER: changes and hypoxia
Epididymal cyst • the Cushings reflex (hypertension and bradycardia) often
occurs late and is usually a pre terminal event
Q-63
A 75-year-old man presents with a swelling in his right Type of injury Notes
scrotum. On examination a large, non-tender swelling is Extradural Bleeding into the space between the dura mater and
found in the scrotum. You cannot palpate above the swelling (epidural) the skull. Often results from acceleration-deceleration
during the examination. haematoma trauma or a blow to the side of the head. The majority
of epidural haematomas occur in the temporal region
Type of injury Notes
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

haematoma commonly occur around the frontal and parietal lobes.

Risk factors include old age, alcoholism and

anticoagulation.
Subdural haematomas
Slower onset of symptoms than a epidural haematoma.
Subarachnoid Usually occurs spontaneously in the context of a
haemorrhage 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:

Subarachnoid haemorrhage
Q-65 Q-67
A 45-year-old man presents with a right sided scrotal An 85-year-old man is diagnosed with prostate
swelling. He describes this getting worse over the last 2 adenocarcinoma following prostatic biopsy. He is advised
weeks and comes to see you because it appears unsightly that conservative management is preferable because of his
and he has developed an unpleasant dragging sensation. On advanced age and relatively low Gleason score. What is the
examination of the patient lying flat, there is a tense, right lowest Gleason score that is indicative of malignancy?
sided varicocele. What is the most appropriate
management? A. 5
B. 6
A. Refer urgently to Urology C. 7
B. Consider delayed referral to Urology if the discomfort D. 8
worsens E. 9
C. Reassure the patient
D. Refer for an ultrasound scan of the testis ANSWER:
E. Refer to urology to consider ablative therapy 6

ANSWER: EXPLANATION:
Refer urgently to Urology The lowest Gleason score of prostate cancer found on biopsy
is 6
EXPLANATION: Prostate biopsies are given a Gleason grade from 1 to 5.
Rapidly developing varicoceles, solitary right sided
varicoceles and varicoceles that remain tense with the The overall Gleason score is comprised of the sum of the two
patient lying down especially if the patient are over 40 years most common histological patterns seen. The first number
of age are red flags for testicular tumours and these patients reflects the most common grade seen in all the samples. The
should be urgently referred to Urology to exclude cancer. As second number is the highest grade of the remaining tissue.
this patient has several red flags he needs an urgent referral.
The other options are not appropriate as they may lead to As such, the Gleason score can range from 2 to 10. However,
delays in diagnoses and appropriate management. as grades 1 and 2 are not used often in the histological
(AKT feedback report October 2016) Source NICE CKS appraisal of biopsy, the lowest score of cancer found on
Varicocele biopsy is 3+3 or 6.
Please see Q-31 for Scrotal Problems Prostate cancers with a score of 6 can be referred to as well-
differentiated or low-grade. They are often less aggressive
Q-66 and slower to grow and spread.
A 60 year-old gentleman is called into your surgery after a
blood test shows a raised prostate specific antigen level The higher the Gleason score, the more aggressive the cancer
(PSA). He asks if this means he has cancer. Approximately and the greater the risk for metastasis.
how many men with a raised PSA have prostate cancer?
Please see Q-55 for Prostate Cancer: Prognosis
A. 2/3
B. 1/2 Q-68
C. 1/3 Which one of the following statements regarding hydroceles
D. 1/50 is correct?
E. 1/10

ANSWER: A. Communicating hydroceles are found in more than 3%

1/3 of newborn males
B. The vast majority occur on the right hand side
EXPLANATION: C. In younger children are often secondary to a varicocele
The prostate specific antigen (PSA) blood test is a screening D. With hydroceles you usually cannot get above the
test for prostate cancer, but it is not very specific, with only swelling on examination
about a third of patients with a raised level being found to E. Are associated with infertility
have prostate cancer. It is important to counsel patients
about this prior to undergoing the test - a useful patient ANSWER:
information leaflet can be found on the NHS Cancer Communicating hydroceles are found in more than 3% of
Screening website at the link below. newborn males
EXPLANATION:
Please see Q-21 for Prostate Cancer: PSA Testing
Please see Q-31 for Scrotal Problems
Q-69 EXPLANATION Q-70 THROUGH 72:
Which one of the following clinical features would not MINOR SURGERY
warrant an urgent referral (i.e. within 2 weeks) to local Local anaesthetic (LA)
colorectal services? Lidocaine is the most widely used LA. It has a rapid onset of
action and anaesthesia lasts for around 1 hour.
A. Unexplained iron-deficiency anaemia in a 62-year-old the maximum safe dose is 3mg/kg. The BNF states 200mg (or
male 500mg if given in solutions containing adrenaline), which
B. 62-year-old female with a 3 month history of rectal equates to 3mg/kg for a 66kg patient. This is the equivalent of
bleeding 20ml of 1% solution or 10ml of 2% solution
C. Palpable rectal mass in a 36-year-old female lidocaine is available pre-mixed with adrenaline. This
D. 48-year-old female with a 8 week history of rectal increases the duration of action of lidocaine and reduces
bleeding and increased stool frequency blood loss secondary to vasoconstriction. It must never be
E. A 57-year-old woman with a 7 week history of passing used near extremities due to the risk of ischaemia
looser stools than normal
Suture material
ANSWER:
A 57-year-old woman with a 7 week history of passing looser Non-absorbable Absorbable
stools than normal Silk Vicryl
Novafil Dexon
EXPLANATION: Prolene PDS
Ethilon

Please see Q-38 for Colorectal Cancer: Referral Guidelines

Non-absorbable sutures are normally removed after 7-14
Q-70 THROUGH 72 days, depending on the location. Absorbable sutures normally
Theme: Suture removal disappear after 7-10 days. Removal times for non-absorbable
sutures are shown below:
A. 2 days
Area Removal time (days)
B. 4 days
Face 3-5
C. 8 days
D. 12 days Scalp, limbs, chest 7 - 10
E. 16 days Hand, foot, back 10 - 14
F. 21 days

For each one of the following locations please select the

optimal time to remove the sutures. Assume the patient has Q-73
had a small skin lesion removed in primary care and has no A 65-year-old man presents with lower urinary tract
relevant medical history. symptoms. For the past few months, he has had problems
with urinary urgency and has had several episodes of
Q-70 incontinence when he could not reach the toilet in time. He
Back describes good urinary flow with no hesitancy or straining.
Urinalysis and prostate examination are unremarkable.
ANSWER:
12 Which one of the following medications is most likely to help
alleviate his symptoms?
Q-71
Face A. Alpha blocker
B. Antimuscarinic
ANSWER: C. 5-alpha reductase inhibitor
4 D. Loop diuretic
E. Desmopressin
Q-72
Scalp ANSWER:
Antimuscarinic
ANSWER:
8 EXPLANATION:
Antimuscarinic drugs are useful in patients with an
overactive bladder
This patient has symptoms of an overactive bladder. • antimuscarinic drugs should be offered if symptoms
Conservative measures should be discussed and bladder persist. NICE recommend oxybutynin (immediate
training offered. release), tolterodine (immediate release), or darifenacin
(once daily preparation)
Examples of suitable antimuscarinic drugs include • mirabegron may be considered if first-line drugs fail
oxybutynin, tolterodine and darifenacin.
Nocturia
LOWER URINARY TRACT SYMPTOMS IN MEN • advise about moderating fluid intake at night
Lower urinary tract symptoms (LUTS) in men are very • furosemide 40mg in late afternoon may be considered
common and are present in the majority of men aged > 50 • desmopressin may also be helpful
years. They are most commonly secondary to benign prostatic
hyperplasia but other causes should be considered including Q-74
prostate cancer. A 44-year-old woman is diagnosed with breast cancer. She
has no past medical history of note, is pre-menopausal and
It is useful to classify the symptoms into 3 broad groups. has no family history of breast or ovarian cancer. Staging
suggests early disease and she has a wide-local excision
Voiding Storage Post-micturition followed by whole-breast radiotherapy. Pathology results
Hesitancy Urgency Post-micturition show that the tumour is oestrogen receptor positive, HER2
Poor or intermittent stream Frequency dribbling negative. Which one of the following adjuvant treatments is
Straining Nocturia Sensation of she most likely to be offered?
Incomplete emptying Urinary incontinence incomplete emptying
Terminal dribbling
A. Anastrozole
B. Letrozole
Examination
C. Tamoxifen
urinalysis: exclude infection, check for haematuria
D. Trastuzumab (Herceptin)
digital rectal examination: size and consistency of prostate
E. Cytotoxic therapy with epirubicin, cyclophosphamide
a PSA test may be indicated, but the patient should be
and fluorouracil
properly counselled first
ANSWER:
It is useful to get the patient to complete the following to
Tamoxifen
guide management:
• urinary frequency-volume chart: distinguish between
EXPLANATION:
urinary frequency, polyuria, nocturia, and nocturnal
Tamoxifen is used as the women is pre-menopausal. There is
polyuria.
ongoing debate about whether therapy should be for 5 years
• International Prostate Symptom Score (IPSS): assess the or longer.
impact on the patient's life. This classifies the symptoms
as mild, moderate or severe BREAST CANCER: MANAGEMENT
The management of breast cancer depends on the staging,
Management tumour type and patient background. It may involve any of
Predominately voiding symptoms the following:
• conservative measures include: pelvic floor muscle • surgery
training, bladder training, prudent fluid intake and
• radiotherapy
containment products
• hormone therapy
• if 'moderate' or 'severe' symptoms offer an alpha-blocker
• biological therapy
• if the prostate is enlarged and the patient is 'considered
• chemotherapy
at high risk of progression' then a 5-alpha reductase
inhibitor should be offered
Surgery
• if the patient has an enlarged prostate and 'moderate' or
The vast majority of patients who have breast cancer
'severe' symptoms offer both an alpha-blocker and 5-
diagnosed will be offered surgery. An exception may be a very
alpha reductase inhibitor
frail, elderly lady with metastatic disease who may be better
• if there are mixed symptoms of voiding and storage not managed with hormonal therapy.
responding to an alpha blocker then a antimuscarinic
(anticholinergic) drug may be added Depending on the characteristics of the tumour women either
have a wide-local excision or a mastectomy. Around two-
Predominately overactive bladder thirds of tumours can be removed with a wide-local excision.
• conservative measures include moderating fluid intake The table below lists some of the factors determining which
• bladder retraining should be offered operation is offered:
Mastectomy Wide Local Excision ANSWER:
Multifocal tumour Solitary lesion Grade III
Central tumour Peripheral tumour
Large lesion in small breast Small lesion in large breast EXPLANATION:
DCIS > 4cm DCIS < 4cm Please see Q-20 for Haemorrhoids

Women should be offered breast reconstruction to achieve a Q-76

cosmetically suitable result regardless of the type of operation What is the maximum safe volume of lidocaine 1% that may
they have. For women who've had a mastectomy this may be be used during minor surgery on an average sized adult?
done at the initial operation or at a later date.
A. 10 ml
Radiotherapy B. 30 ml
Whole breast radiotherapy is recommended after a woman C. 50 ml
has had a wide-local excision as this may reduce the risk of D. 20 ml
recurrence by around two-thirds. For women who've had a E. 5 ml
mastectomy radiotherapy is offered for T3-T4 tumours and for
those with four or more positive axillary nodes ANSWER:
20 ml
Hormonal therapy
Adjuvant hormonal therapy is offered if tumours are positive EXPLANATION:
for hormone receptors. For many years this was done using Please see Q-72 for Minor Surgery
tamoxifen for 5 years after diagnosis. Tamoxifen is still used in
pre- and peri-menopausal women. In post-menopausal Q-77
women, aromatase inhibitors such as anastrozole are used for Which one of the following statements regarding testicular
this purpose*. This is important as aromatisation accounts for cancer is correct?
the majority of oestrogen production in post-menopausal
women and therefore anastrozole is used for ER +ve breast A. Fragile X syndrome is a risk factor
cancer in this group. B. Gynaecomastia is seen in the majority of men
C. Seminomas have a better prognosis than teratomas
Important side-effects of tamoxifen include an increased risk D. Afro-Caribbean ethnicity is a risk factor
of endometrial cancer, venous thromboembolism and E. May present as a varicocele in up to 10% of patients
menopausal symptoms.
ANSWER:
Biological therapy Seminomas have a better prognosis than teratomas
The most common type of biological therapy used for breast
cancer is trastuzumab (Herceptin). It is only useful in the 20- EXPLANATION:
25% of tumours that are HER2 positive.
Please see Q-56 for Testicular Cancer
Trastuzumab cannot be used in patients with a history of
heart disorders. Q-78
A 79-year-old woman develops a leg ulcer just above the
Chemotherapy right medial malleolus. You are considering referring her for
Cytotoxic therapy may be used to either downstage a primary compression bandaging. She is not diabetic. Following SIGN
lesion or after surgery depending on the stage of the tumour, guidelines, what is the minimum ankle-brachial pressure
for example if there is axillary node disease. index (ABPI) that she must have to ensure compression
bandaging is safe?
Q-75
A 37-year-old man with a history of internal haemorrhoids A. 0.7
presents as his symptoms have recently flared. He now B. 0.8
describes piles which he has to manually reduce following C. 0.9
defecation. What grade of haemorrhoids does he have? D. 1.0
E. 1.1
A. Grading system does not apply to internal haemorrhoids
B. Grade I ANSWER:
C. Grade II 0.8
D. Grade III
E. Grade IV
EXPLANATION: Conditions currently undergoing review but not yet routinely
SIGN state the following: screened for include prostate cancer, glaucoma and
Compression therapy may be safely used in leg ulcer patients congenital adrenal hyperplasia, amongst others.
with ABPI>=0.8.
It should be noted that the NHS currently advises a Prostate
ANKLE-BRACHIAL PRESSURE INDEX cancer 'risk management' programme as opposed to a
The ankle-brachial pressure index (ABPI) is the ratio of the screening programme - men can request screening with a
systolic blood pressure in the lower leg to that in the arms. PSA test after receiving counselling about it, but they are not
Lower blood pressure in the legs (result in a ABPI < 1) is an routinely invited for screening.
indicator of peripheral arterial disease (PAD). ABPI is therefore
useful in evaluating patients with suspected PAD, for example Please see Q-32 for Abdominal Aortic Aneurysm
a male smoker who presents with intermittent claudication.
Q-80
It is also important to determine the ABPI in patients with leg A 37-year-old woman with a history of gallstones is listed to
ulcers. Venous ulcers are often treated with compression have a laparoscopic cholecystectomy in three months time.
bandaging. Doing this in a patient with PAD could however be She is currently prescribed Microgynon 30 (combined oral
harmful as it would further restrict the blood supply to the contraceptive pill). The patient asks for advice as she is
foot. ABPIs should therefore always be measured in patients aware that her contraceptive pill may increase the risk of
with leg ulcers. blood clots. What is the most appropriate advice in this
situation?
Interpretation of ABPI
• > 1.2: may indicate calcified, stiff arteries. This may be A. She is safe to continue taking Microgynon
seen with advanced age or PAD B. She should stop Microgynon 48 hours before the
• 1.0 - 1.2: normal procedure
• 0.9 - 1.0: acceptable C. She should stop Microgynon 7 days before the
• < 0.9: likely PAD. Values < 0.5 indicate severe disease procedure
which should be referred urgently D. She should stop Microgynon 28 days before the
procedure
The ABPI is a good test, values less than 0.90 have been E. She should stop Microgynon 3 months before the
shown to have a sensitivity of 90% and a specificity of 98%* procedure
for PAD.
ANSWER:
Compression bandaging is generally considered acceptable if She should stop Microgynon 28 days before the procedure
the ABPI >= 0.8.
EXPLANATION:
Q-79 Please see Q-6 for Venous Thromboembolism: Prophylaxis in
The NHS runs several screening programs to detect diseases Patients Admitted to Hospital
at an early, treatable stage. Which of the following
conditions does the NHS currently offer routine screening Q-81
for? A 54-year-old woman is reviewed in clinic. She has recently
been diagnosed with superficial thrombophlebitis of the long
A. Glaucoma saphenous vein after being referred for an ultrasound scan
B. Prostate cancer after a deep vein thrombosis was suspected. What is the
C. Ovarian cancer most appropriate treatment?
D. Congenital adrenal hyperplasia
E. Abdominal aortic aneurysm A. Topical NSAID for 2 weeks
B. Warfarin for 3 months
ANSWER: C. Topical heparinoid for 2 weeks
Abdominal aortic aneurysm D. Low-molecular weight heparin for 30 days
E. Low-molecular weight heparin for 10 days
EXPLANATION:
The NHS runs several screening programmes - currently all ANSWER:
men are invited to be screened for abdominal aortic Low-molecular weight heparin for 30 days
aneurysm (AAA) by ultrasound scan the year they turn 65.
EXPLANATION:
The UK National Screening Committee assesses evidence to Please see Q-48 for Superficial Thrombophlebitis
recommend which conditions should be screened for.
Q-82 ANSWER:
A 42-year-old man presents with a lump in his right scrotum. Yes, she can self-refer
This has been present for 3 weeks. It is not painful and he
does not have any urinary symptoms. His weight is stable. EXPLANATION:
The breast screening program in the NHS is being expanded
On examination, he has a 3mm smooth lump above and
to include women aged 47-73 years. Above this age, women
separate to his testicle. It is non-tender and mobile.
can continue to have screening by self-referring themselves.
What is the likely diagnosis?
Therefore the correct answer is 5.
A. Epididymal cyst
B. Hydrocoele Option 1, 2 and 3 is incorrect as she can continue to have
C. Lymph node screening if she self-refers.
D. Teratoma Option 4 is incorrect as screening is with mammograms not
E. Varicocele ultrasound scans.
ANSWER:
AKT report Jan 2015 - 'After AKT 22, we fed back on lack of
Epididymal cyst
knowledge around some national screening programs.'
EXPLANATION:
The description of this lump makes it likely to be an Please see Q-25 for Breast Cancer: Screening
epididymal cyst. The patient does not seem to have any
symptoms with the lump. This is not a testicular lump so Q-85
cannot be a teratoma. A hydrocoele is a swelling of the Which one of the following statements regarding lidocaine is
hemi-scrotum. There are no lymph nodes in the scrotum. A correct?
varicocele typically feels like a 'bag of worms' and is more
common on the left side. An ultrasound scan of the scrotum A. Preparations mixed with adrenaline should not be used
can be used to confirm the suspicion of an epididymal cyst. for minor surgery involving the finger
B. The maximum dose of lidocaine is 5mg/kg
Please see Q-31 for Scrotal Problems
C. The anaesthetic effect usual wears off after 15-20
Q-83 minutes
Which one of the following types of suture is absorbable? D. Is contraindicated in patients with a history of
ventricular tachycardia
A. Ethilon E. Preparations mixed with adrenaline are more likely to
B. Vicryl cause blood loss
C. Novafil
D. Prolene ANSWER:
E. Silk Preparations mixed with adrenaline should not be used for
minor surgery involving the finger
ANSWER:
Vicryl EXPLANATION:
Please see Q-72 for Minor Surgery
EXPLANATION: Q-86
Please see Q-72 for Minor Surgery A 60-year-old man presents with lower urinary tract
symptoms and is offered a PSA test. According to NHS
Q-84 guidelines, which one of the following could interfere with
Yvonne is a 74-year-old lady who comes to see you regarding the PSA level?
breast screening. She was previously having mammograms
regularly but has learnt that screening for breast cancer A. Vigorous exercise in the past 48 hours
stops at 73. She asks if she can still continue to have NHS B. Poorly controlled diabetes mellitus
screening mammograms? C. Smoking in the past 48 hours
D. Current constipation
A. No, but she can have a private referral E. Drinking more than 4 units of alcohol in the past 48
B. No, mammograms are not effective above 70 hours
C. No, she should self-monitor and see her GP if symptoms
ANSWER:
develop
Vigorous exercise in the past 48 hours
D. Yes, she will be offered regular ultrasound screening
above 70 EXPLANATION:
E. Yes, she can self-refer Please see Q-21 for Prostate Cancer: PSA Testing
Q-87 Q-89
A 62-year-old lady, Agatha, reports that her older sister has What is the failure rate of male sterilisation?
just been diagnosed with breast cancer after having her
mammogram done as part of the national screening A. 1 in 100
programme. Agatha says that she has had her mammogram B. 1 in 200
today and the results were normal. C. 1 in 300
D. 1 in 400
When will Agatha's next mammogram be due? E. 1 in 2,000
A. 2 years
B. 1 year ANSWER:
C. 5 years 1 in 2,000
D. 3 years
E. No need for further mammograms after 62 EXPLANATION:
Male sterilisation - failure rate = 1 in 2,000
ANSWER:
3 years Please see Q-28 for Vasectomy
EXPLANATION:
Breast cancer screening is available to women aged 50- 70 Q-90
years and is done every 3 years in the UK. There are plans to A 33-year-old man presents with a one day history of pain
extend this to women aged 47-73 years by the end of 2016. and swelling in the right testicle. Around four weeks ago he
Women aged 40-50 who have a high risk of breast cancer returned from a holiday in Spain but reports no dysuria or
may be offered 2 yearly screening. urethral discharge. On examination he has a tender, swollen
right testicle. On examination the heart rate is 84/min and
The January 2015 AKT feedback report stated: his temperature is 37.1ºC. What is the most appropriate
management?
After AKT 22, we fed back on lack of knowledge around some
national screening programmes. Although GPs are not A. IM ceftriaxone stat + oral doxycyline for 2 weeks
always involved in making referrals when abnormalities are B. Oral doxycycline + metronidazole for 2 weeks
found, candidates should be aware of the relevant pathways C. Oral trimethopim for 2 weeks
and procedures following abnormal screening results. D. Oral azithromycin stat dose
Please see Q-25 for Breast Cancer: Screening E. Oral ciprofloxacin for 2 weeks
Q-88 ANSWER:
A 72-year-old man is diagnosed with high-risk localised IM ceftriaxone stat + oral doxycyline for 2 weeks
prostate cancer. He opts for treatment by means of
androgen deprivation therapy and is commenced on the EXPLANATION:
luteinising hormone-releasing hormone (LHRH) agonist Epididymo-orchitis
Buserelin. What is the recommended duration of treatment
with LHRH agonist? Epididymo-orchitis describes an infection of the epididymis +/-
A. 3 years testes resulting in pain and swelling. It is most commonly
B. 3 months caused by local spread of infections from the genital tract
C. 12 months (such as Chlamydia trachomatis and Neisseria gonorrhoeae)
D. 2 years or the bladder.
E. 5 years
The most important differential diagnosis is testicular
ANSWER: torsion. This needs to be excluded urgently to prevent
3 years ischaemia of the testicle.
EXPLANATION:
The answer to this question is 3 years. This treatment works Features
by lowering levels of testosterone in the body so that it does • unilateral testicular pain and swelling
not fuel the growth of malignant prostate cells. Patients • urethral discharge may be present, but urethritis is often
should be informed about the side-effects of treatment, asymptomatic
particularly urinary and sexual dysfunction, loss of fertility, • factors suggesting testicular torsion include patients < 20
osteoporosis, fatigue and hot flushes. (AKT report October years, severe pain and an acute onset
2016) Source BNF prostate cancer Management
Please see Q-17 for Prostate Cancer: Management • the British Association for Sexual Health and HIV (BASHH)
produced guidelines in 2010
• if the organism is unknown BASHH recommend: A. There is no merit in differentiating between direct and
ceftriaxone 500mg intramuscularly single dose, plus indirect hernias prior to referral
doxycycline 100mg by mouth twice daily for 10-14 days B. Patients should be referred promptly due to the risk of
• further investigations following treatment are strangulation
recommended to exclude any underlying structural C. Symptoms are typically worse following exertion
abnormalities D. 95% of patients are male
E. Are the most common cause of abdominal wall hernias
Q-91
A 30-year-old man presents with a painless lump in his right ANSWER:
testicle. Which one of the following is most strongly Patients should be referred promptly due to the risk of
associated with testicular cancer? strangulation

A. Increasing age EXPLANATION:

B. Smoking Inguinal hernias rarely strangulate
C. Infertility
D. High maternal age Please see Q-7 for Inguinal Hernia
E. High paternal age
Q-94
ANSWER: A 79-year-old complains of lower urinary tract symptoms.
Infertility Which one of the following statements regarding benign
prostatic hyperplasia is incorrect?
EXPLANATION:
A. Goserelin is licensed for refractory cases
Please see Q-56 for Testicular Cancer B. Side-effects of 5 alpha-reductase inhibitors include
ejaculation disorders and gynaecomastia
Q-92 C. Possible presentations include recurrent urinary tract
You review a 9-month-old who has parents of Jamaican infection
origin. His parents have noticed a small swelling around his D. 5 alpha-reductase inhibitors typically decrease the
umbilicus. He is a well child who is on the 50th centile. On prostate specific antigen level
examination you note a small, reducible umbilical hernia E. More common in black men
which is less than 1 cm in size. What is the most appropriate
management? ANSWER:
Goserelin is licensed for refractory cases
A. Contact the local Child Protection Officer
B. Admit to paediatrics EXPLANATION:
C. Reassure the parents that the vast majority resolve by Goserelin (Zoladex) is not used in the management of benign
the age of 4-5 years prostatic hyperplasia
D. Refer to paediatric surgeon
E. Refer to a paediatrician for a sweat test Please see Q-19 for Benign Prostatic Hyperplasia

ANSWER: Q-95
Reassure the parents that the vast majority resolve by the age A 31-year-old man returns for review. He was diagnosed
of 4-5 years with an anal fissure around 7 weeks ago and has tried
dietary modification, laxatives and topical anaesthetic with
EXPLANATION: little benefit. What is the most appropriate next step?
Congenital hernias
• inguinal: repair ASAP A. Oral bisacodyl
• umbilical: manage conservatively B. Oral calcium channel blocker
This little boy has an umbilical hernia. The vast majority are C. Topical steroid
managed conservatively as usually (>90%) resolve D. Buccal glyceryl trinitrate prior to defecation
spontaneously. E. Topical glyceryl trinitrate

Please see Q-11 for Abdominal Wall Hernias ANSWER:

Topical glyceryl trinitrate
Q-93
Which one of the following statements regarding inguinal EXPLANATION:
hernias is not correct? Anal fissure - topical glyceryl trinitrate
Please see Q-30 for Anal Fissure Q-98
A 53-year-old man who has no past history of note requests
Q-96
a PSA test. One of his father's friends has recently been
A 66-year-old comes for review. He had a prosthetic aortic
diagnosed with prostate cancer. What is the most
valve replacement five years ago for which he is
appropriate action?
warfarinised. Over the past three months he has been
complaining of fatigue and a full blood count was requested:
A. Perform a digital rectal examination and refer him to
Hb 10.3 g/dl
urology so he can be counseled regarding the PSA test
B. Tell him that you can appreciate his concern but
MCV 68 fl
reassure that at his age he is at very low risk
Plt 356 * 109/l C. Advise him that a national screening programme was
WBC 5.2 * 109/l
started in 2009 and he will be called at the age of 60
years for a test
Blood film Hypochromia
D. Give him a patient information leaflet with details of the
INR 3.0 PSA test and allow him to make the choice
E. Offer to perform a digital rectal examination but advise
An upper GI endoscopy was reported as normal. What is the him that the PSA test is not recommended in younger
most appropriate next investigation? asymptomatic men
A. Transthoracic echocardiogram
B. Colonoscopy ANSWER:
C. Three sets of blood cultures Give him a patient information leaflet with details of the PSA
D. Transoesophageal echocardiogram test and allow him to make the choice
E. Reticulocyte count EXPLANATION:
ANSWER: Please see Q-21 for Prostate Cancer: PSA Testing
Colonoscopy Q-99
EXPLANATION: A worried gentleman comes to your surgery because he took
Any patient of this age with an unexplained microcytic part in the routine bowel cancer screening program and has
anaemia should have a lower gastrointestinal tract been found to have a positive faecal occult blood test (FOBt)
investigation to exclude colorectal cancer result. He asks if this means he has bowel cancer.
Approximately what percentage of patients who have a
Please see Q-38 for Colorectal Cancer: Referral Guidelines positive FOBt go on to have bowel cancer detected at
Q-97 colonoscopy?
The mother of a 2-month-old boy comes to surgery as she A. 0.5%
has noticed a soft lump in his right groin area. There is no B. 2%
antenatal or postnatal history of note. He is breast feeding C. 10%
well and is opening his bowels regularly. On examination D. 50%
you note a 1 cm swelling in the right inguinal region which is E. 75%
reducible and disappears on laying him flat. Scrotal
examination is normal. What is the most appropriate action? ANSWER:
10%
A. Refer to paediatric surgery EXPLANATION:
B. Refer to orthotics for fitting of a Pavlik harness The ability to discuss NHS screening programmes with
C. Reassure mother + ask her to return if not resolved by 6 patients is required by the RCGP curriculum under the
months statement on 'Healthy people, promoting health and
D. Reassure mother + ask her to return if not resolved by preventing disease.'
12 months
E. Reassure mother + ask her to return if not resolved by 2 Men and women aged 60-74 are offered routine screening
years for bowel cancer using the faecal occult blood test (FOBt)
every two years. Approximately 2% of patients will have a
ANSWER: positive screening results and will be invited to colonoscopy;
Refer to paediatric surgery approximately 10% of those invited will be found to have
bowel cancer (it should be noted around 25% of patients
EXPLANATION: decline colonoscopy).
Congenital inguinal hernias have a high rate of complications Please see Q-2 for Colorectal Cancer: Screening
and should be repaired promptly once identified.
Please see Q-11 for Abdominal Wall Hernias
Q-100 ANSWER:
A 24-year-old man presents with rectal bleeding and a Usually occur at the 1 o'clock, 5 o'clock and 9 o'clock position
'sharp, stinging' pain on defecation. This has been present
for the past two weeks. He has a tendency towards EXPLANATION:
constipation and notices that when he wipes himself fresh Haemorrhoids usually occur at the 3 o'clock, 7 o'clock and 11
blood is often on the paper. Rectal examination is limited o'clock position
due to pain but no external abnormalities are seen. What is
the most likely diagnosis? Please see Q-20 for Haemorrhoids

A. Internal haemorrhoids Q-103

B. Anal carcinoma Which one of the following statements regarding prostate
C. Rectal polyp specific antigen (PSA) testing is NOT true?
D. Anogenital herpes
E. Anal fissure A. Around a third of men with a PSA of 4-10 ng/ml will be
found to have prostate cancer
ANSWER: B. A PSA level of 3.8 ng/ml in a 55-year-old man is normal
Anal fissure C. Around 20% of patients diagnosed with prostate cancer
have a normal PSA
EXPLANATION: D. PSA levels rise following ejaculation
The combination of pain and bleeding is very characteristic E. Very high PSA levels (e.g. > 50 ng/ml) suggest metastatic
of anal fissures. Pain is a feature of thrombosed external disease
haemorrhoids but is unusual with internal haemorrhoids.
Superficial anal fissures may be difficult to see on ANSWER:
examination. A PSA level of 3.8 ng/ml in a 55-year-old man is normal

Please see Q-30 for Anal Fissure EXPLANATION:

Please see Q-21 for Prostate Cancer: PSA Testing
Q-101
Which one of the following statements regarding varicoceles Q-104
is correct? A 62-year-old man presents with insomnia and lethargy. He
has no other systemic symptoms of note. Routine clinical
A. Over 80% occur on the left side examination reveals a palpable mass in the right lower
B. All patients should be offered surgery to prevent quadrant of the abdomen, which doesn't move with
infertility respiration and is non-pulsatile. What is the most
C. Around 5% of patients have an underlying testicular appropriate management?
cancer
D. They are more common in pre-pubertal males A. Blood screen including LFTs, U&Es
E. Having a varicocele is a risk factor for deep vein B. Urgent referral to local urological service
thrombosis C. Ultrasound abdomen
D. Urgent referral to local colorectal service
ANSWER: E. Routine referral to general surgical clinic
Over 80% occur on the left side
ANSWER:
EXPLANATION: Urgent referral to local colorectal service
Please see Q-31 for Scrotal Problems
EXPLANATION:
Q-102 Please see Q-38 for Colorectal Cancer: Referral Guidelines
A 33-year-old pregnant woman presents with pruritus ani.
Which one of the following statements regarding Q-105
haemorrhoids is incorrect? Which one of the following is not an indication for
circumcision?
A. Painless rectal bleeding is the most common symptom
B. Haemorrhoidal tissue is part of the normal anatomy A. Phimosis
C. Internal haemorrhoids do not generally cause pain B. Paraphimosis
D. Soiling may be seen C. Recurrent balanitis
E. Usually occur at the 1 o'clock, 5 o'clock and 9 o'clock D. Balanitis xerotica obliterans
position E. Peyronie's disease
ANSWER: A. Refer the patient to hospital for a CT head scan to be
Peyronie’s disease performed within 8 hours
B. Give standard head injury advice
EXPLANATION: C. Admit for 24 hours of observation
Please see Q-3 for Circumcision D. Admit for 8 hours of observation
E. Give standard head injury advice + advise he stops
Q-106 warfarin for 5 days
Which one of the following may be used to monitor patients
with colorectal cancer? ANSWER:
Refer the patient to hospital for a CT head scan to be
A. CA-125 performed within 8 hours.
B. Carcinoembryonic antigen
C. Alpha-fetoprotein EXPLANATION:
D. CA 19-9 Patients who've had a head injury and are on warfarin need
E. CA 15-3 to have a CT scan, regardless of whether they have risk
factors for an intracranial injury. NICE state:
ANSWER:
Carcinoembryonic antigen For patients (adults and children) who have sustained a head
injury with no other indications for a CT head scan and who
EXPLANATION: are having warfarin treatment, perform a CT head scan
Carcinoembryonic antigen may be used to monitor for within 8 hours of the injury. A provisional written radiology
recurrence in patients post-operatively or to assess response report should be made available within 1 hour of the scan
to treatment in patients with metastatic disease being performed.

Please see Q-2 for Colorectal Cancer: Screening HEAD INJURY: NICE GUIDANCE ON INVESTIGATION
NICE has strict and clear guidance regarding which adult
Q-107 patients are safe to discharge and which need further CT head
A patient is started on finasteride for the treatment of imaging. The latter group are also divided into two further
benign prostatic hyperplasia. How long should the patient be cohorts, those who require an immediate CT head and those
told that treatment may take to be effective? requiring CT head within 8 hours of injury:

A. Within 8 hours of taking the tablet CT head immediately

B. Within 3 days • GCS < 13 on initial assessment
C. Up to 7 days • GCS < 15 at 2 hours post-injury
D. Up to 4 weeks • suspected open or depressed skull fracture.
E. Up to 6 months • any sign of basal skull fracture (haemotympanum, 'panda'
eyes, cerebrospinal fluid leakage from the ear or nose,
ANSWER: Battle's sign).
Up to 6 months • post-traumatic seizure.
• focal neurological deficit.
EXPLANATION: • more than 1 episode of vomiting
Finasteride treatment of BPH may take 6 months before
results are seen CT head scan within 8 hours of the head injury - for adults
with any of the following risk factors who have experienced
Please see Q-19 for Benign Prostatic Hyperplasia some loss of consciousness or amnesia since the injury:
• age 65 years or older
Q-108 • any history of bleeding or clotting disorders
A 72-year-old man presents to surgery. Whilst walking back
• dangerous mechanism of injury (a pedestrian or cyclist
from a friends house he slipped on some ice and fell
struck by a motor vehicle, an occupant ejected from a
backwards, landing on his right arm and banging his head on
motor vehicle or a fall from a height of greater than 1
the kerb in the process. His past medical history includes
metre or 5 stairs)
atrial fibrillation for which he takes bisoprolol and warfarin.
• more than 30 minutes' retrograde amnesia of events
A routine INR taken four days ago was 2.2. There are no
immediately before the head injury
signs of any external injury to his right arm or scalp. What is
the most appropriate course of action with relation to his
If a patient is on warfarin who have sustained a head injury
head injury?
with no other indications for a CT head scan, perform a CT
head scan within 8 hours of the injury.
Q-109 Drugs licensed for use in peripheral arterial disease (PAD)
A 60-year-old man is investigated for intermittent include:
claudication. He is referred to the local vascular unit and a • naftidrofuryl oxalate: vasodilator, sometimes used for
diagnosis of peripheral arterial disease is made. His blood patients with a poor quality of life
pressure is 128/78 mmHg and his fasting cholesterol 3.8 • cilostazol: phosphodiesterase III inhibitor with both
mmol/l. Following recent NICE guidelines which of the antiplatelet and vasodilator effects - not recommended
following medications should he be taking? by NICE

Aspirin + statin + ACE inhibitor Q-110 THROUGH 112

Aspirin + statin Theme: Abdominal swelling
Clopidogrel
Aspirin A. Irritable bowel syndrome
Clopidogrel + statin B. Endometrial cancer
C. Ovarian cancer
ANSWER: D. Pregnancy
Clopidogrel + statin E. Intestinal obstruction
F. Urinary retention
EXPLANATION: G. Ascites
As this patient has established cardiovascular disease he H. Gastric cancer
should be taking a statin, regardless of the baseline I. Colorectal cancer
cholesterol. The 2010 NICE guidelines on clopidogrel changed J. Bladder cancer
the previous advice that all patients with established
cardiovascular disease should be taking aspirin, unless there For each one of the following scenarios select the most likely
is a contraindication. NICE propose that clopidogrel is now diagnosis:
used first-line following an ischaemic stroke and also in
peripheral arterial disease. Q-110
62-year-old woman with a 3 month history of urinary
PERIPHERAL ARTERIAL DISEASE: MANAGEMENT symptoms, early satiety and a raised CA125
Peripheral arterial disease (PAD) is strongly linked to smoking.
Patients who still smoke should be given help to quit. ANSWER:
Ovarian cancer
Comorbidities should be treated, including
• hypertension EXPLANATION:
• diabetes mellitus Ovarian cancer tends to present late due to non-specific
• obesity symptoms

As with any patient who has established cardiovascular Q-111

disease, all patients should be taking a statin. In 2010 NICE 26-year-old female with a history of constipation, episodic
published guidance suggesting that clopidogrel should be abdominal pain and bloating.
used first-line in patients with peripheral arterial disease in
preference to aspirin. ANSWER:
Irritable bowel syndrome
Exercise training has been shown to have significant benefits.
NICE recommend a supervised exercise programme for all EXPLANATION:
patients with peripheral arterial disease prior to other These are classic symptoms of irritable bowel syndrome
interventions.
Q-112
Severe PAD or critical limb ischaemia may be treated by: 72-year-old woman with a history of congestive cardiac
• angioplasty failure. She reports having a poor appetite and feeling
• stenting bloated. She is admitted frequently to hospital with left
• bypass surgery ventricular failure due to poor compliance with medication

Amputation should be reserved for patients with critical limb ANSWER:

ischaemia who are not suitable for other interventions such as Ascites
angioplasty of bypass surgery.
EXPLANATION: Talipes equinovarus is twice as common in males than females
Patients with poorly controlled heart failure may develop and has an incidence of 1 per 1,000 births. Around 50% of
'cardiac cachexia', partly due to gut oedema cases are bilateral.

EXPLANATION Q-110 THROUGH 112: Most commonly idiopathic. Associations include:

Abdominal swelling • spina bifida
• cerebral palsy
The table below gives characteristic exam question features • Edward's syndrome (trisomy 18)
for conditions causing abdominal swelling • oligohydramnios
• arthrogryposis
Condition Characteristic exam feature
Pregnancy Young female
The diagnosis is clinical (the deformity is not passively
Amenorrhoea
correctable) and imaging is not normally needed.
Intestinal obstruction History of malignancy/previous operations
Vomiting
Not opened bowels recently Management*
'Tinkling' bowel sounds • in recent years there has been a move away from surgical
Ascites History of alcohol excess, cardiac failure intervention to more conservative methods such as the
Urinary retention History of prostate problems Ponseti method
Dullness to percussion around suprapubic area • the Ponseti method consists of manipulation and
Ovarian cancer Older female progressive casting which starts soon after birth. The
Pelvic pain deformity is usually corrected after 6-10 weeks. An
Urinary symptoms e.g. urgency Achilles tenotomy is required in around 85% of cases but
Raised CA125
this can usually be done under local anaesthetic
Early satiety, bloating
• night-time braces should be applied until the child is aged
4 years. The relapse rate is 15%
Q-113
Please look at the image below:
Q-114
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

QFracture is based on UK primary care data.

Which one of the following statements regarding this
condition is true?
ANSWER:
Is based on UK primary care data
A. The majority of cases are idiopathic
B. It is most commonly diagnosed at the six-week check
EXPLANATION:
C. It is bilateral in 80-90% of cases
OSTEOPOROSIS: ASSESSING RISK
D. The incidence is 5 per 1,000 live births
We worry about osteoporosis because of the increased risk of
E. X-rays should be performed to confirm the diagnosis
fragility fractures. So how do we assess which patients are at
risk and need further investigation?
ANSWER:
The majority of cases are idiopathic
NICE produced guidelines in 2012: Osteoporosis: assessing the
risk of fragility fracture. The following is based on those
EXPLANATION:
guidelines.
TALIPES EQUINOVARUS
Talipes equinovarus, or club foot, describes an inverted
They advise that all women aged >= 65 years and all men aged
(inward turning) and plantar flexed foot. It is usually
>= 75 years should be assessed. Younger patients should be
diagnosed on the newborn exam.
assessed in the presence of risk factors, such as:
• previous fragility fracture
• current use or frequent recent use of oral or systemic
glucocorticoid If the FRAX assessment was done without a bone mineral
• history of falls density (BMD) measurement the results (10-year risk of a
• family history of hip fracture fragility fracture) will be given and categorised automatically
• other causes of secondary osteoporosis into one of the following:
• low body mass index (BMI) (less than 18.5 kg/m²) • low risk: reassure and give lifestyle advice
• smoking • intermediate risk: offer BMD test
• alcohol intake of more than 14 units per week for women • high risk: offer bone protection treatment
and more than 21 units per week for men.
Therefore, with intermediate risk results FRAX will
Methods of risk assessment recommend that you arrange a BMD test to enable you to
NICE recommend using a clinical prediction tool such as FRAX more accurately determine whether the patient needs
or QFracture to assess a patients 10 year risk of developing a treatment
fracture. This is analogous to the cardiovascular risk tools such
as QRISK. If the FRAX assessment was done witha bone mineral density
(BMD) measurement the results (10-year risk of a fragility
FRAX fracture) will be given and categorised automatically into one
• estimates the 10-year risk of fragility fracture of the following:
• valid for patients aged 40-90 years • reassure
• based on international data so use not limited to UK • consider treatment
patients • strongly recommend treatment
• assesses the following factors: age, sex, weight, height,
previous fracture, parental fracture, current smoking, If you use QFracture instead patients are not automatically
glucocorticoids, rheumatoid arthritis, secondary categorised into low, intermediate or high risk. Instead the
osteoporosis, alcohol intake 'raw data' relating to the 10-year risk of any sustaining an
• bone mineral density (BMD) is optional, but clearly osteoporotic fracture. This data then needs to be interpreted
improves the accuracy of the results. NICE recommend alongside either local or national guidelines, taking into
arranging a DEXA scan if FRAX (without BMD) shows an account certain factors such as the patient's age.
intermediate result
When should we reassess a patient's risk?
QFracture NICE recommend that we recalculate a patient's risk (i.e.
• estimates the 10-year risk of fragility fracture repeat the FRAX/QFracture):
• developed in 2009 based on UK primary care dataset
• can be used for patients aged 30-99 years (this is stated • if the original calculated risk was in the region of the
on the QFracture website, but other sources give a figure intervention threshold for a proposed treatment and only
of 30-85 years) after a minimum of 2 years, or
• includes a larger group of risk factors e.g. cardiovascular • when there has been a change in the person's risk factors
disease, history of falls, chronic liver disease, rheumatoid
arthritis, type 2 diabetes and tricyclic antidepressants Q-115
A 46-year-old female presents with a burning sensation over
There are some situations where NICE recommend arranging the antero-lateral aspect of her right thigh. A diagnosis of
BMD assessment (i.e. a DEXA scan) rather than using one of meralgia paraesthetica is suspected. Which nerve is most
the clinical prediction tools: likely to be affected?
• before starting treatments that may have a rapid adverse
effect on bone density (for example, sex hormone A. Common peroneal nerve
deprivation for treatment for breast or prostate cancer). B. Anterior cutaneous nerve of thigh
C. Posterior cutaneous nerve of thigh
• in people aged under 40 years who have a major risk
D. Lateral cutaneous nerve of thigh
factor, such as history of multiple fragility fracture, major
E. Sciatic nerve
osteoporotic fracture, or current or recent use of high-
dose oral or high-dose systemic glucocorticoids (more
ANSWER:
than 7.5 mg prednisolone or equivalent per day for 3
Lateral cutaneous nerve of thigh
months or longer).
EXPLANATION:
Interpreting the results of FRAX
Burning thigh pain - ? meralgia paraesthetica - lateral
Once we've decided that we need to do a risk assessment
cutaneous nerve of thigh compression
using FRAX and have entered all the data we are left with
results to interpret.
MERALGIA PARAESTHETICA Q-117
Basics A 64-year-old woman who is known to have rheumatoid
• caused by compression of lateral cutaneous nerve of arthritis presents with pain in her right ring finger when she
thigh flexes it. On one occasion she reports it became 'stuck'.
• typically burning sensation over antero-lateral aspect of Clinical examination is unremarkable other than a palpable
thigh nodule at the base of the finger. What is the most likely
diagnosis?
Q-116
What is the first-line treatment for Morton's neuroma? A. Swan-neck deformity
B. Dupuytren's contracture
A. Avoid high heels + supinatory insoles + NSAIDs C. Trigger finger
B. Avoid high heels + supinatory insoles D. Mallet finger
C. Avoid high heels + physiotherapy E. Boutonniere deformity
D. Avoid high heels + NSAIDs
E. Avoid high heels + metatarsal pads ANSWER:
Trigger finger
ANSWER:
Avoid high heels + metatarsal pads EXPLANATION:
TRIGGER FINGER
EXPLANATION: Trigger finger is a common condition associated with
Clinical Knowledge Summaries do not recommend the abnormal flexion of the digits. It is thought to be caused by a
routine use of NSAIDs for patients with Morton's neuroma disparity between the size of the tendon and pulleys through
which they pass. In simple terms the tendon becomes 'stuck'
MORTON'S NEUROMA and cannot pass smoothly through the pulley.
Morton's neuroma is a benign neuroma affecting the
intermetatarsal plantar nerve, most commonly in the third Associations* (idiopathic in the majority)
inter-metatarsophalangeal space. The female to male ratio is • more common in women than men
around 4:1. • rheumatoid arthritis
• diabetes mellitus
Features
• forefoot pain, most commonly in the third inter- Features
metatarsophalangeal space • more common in the thumb, middle, or ring finger
• worse on walking. May be described as a shooting or • initially stiffness and snapping ('trigger') when extending a
burning pain. Patients may feel they have a pebble in flexed digit
their shoe • a nodule may be felt at the base of the affected finger
• Mulder's click: one hand tries to hold the neuroma
between the finger and thumb. The other hand squeezes Management
the metatarsals together. A click may be heard as the • steroid injection is successful in the majority of patients.
neuroma moves between the metatarsal heads A finger splint may be applied afterwards
• there may be loss of sensation distally in the toes • surgery should be reserved for patients who have not
responded to steroid injections
Diagnosis is usually clinical although ultrasound may be
helpful in confirming the diagnosis *there is scanty evidence to support a link with repetitive use

Management Q-118
• avoid high-heels A 23-year-old canoeist presents with pain in the right distal
• metatarsal pad dorsoradial forearm, around 5-10 cm from the wrist joint. On
• CKS recommends referral if symptoms persist for > 3 examination the area is slightly erythematous and swollen.
months despite footwear modifications and the use of Crepitus can be felt when the patient moves his right hand.
metatarsal pads What is the most likely diagnosis?
• orthotists may give the patient a metatarsal dome
orthotic A. Carpo-metacarpal osteoarthritis
• other secondary care options include corticosteroid B. Carpal tunnel syndrome
injection and neurectomy of the involved interdigital C. De Quervain's tenosynovitis
nerve and neuroma D. Intersection syndrome
E. Ganglion cyst
ANSWER: ANSWER:
De Quervain's tenosynovitis Use the FRAX tool

EXPLANATION: EXPLANATION:
INTERSECTION SYNDROME Please see Q-114 for Osteoporosis: Assessing Risk
Intersection syndrome is a tenosynovitis caused by
inflammation where the abductor pollicis longus and extensor Q-120
pollicis brevis muscles cross over (or intersect) the tendons of An 11-year-old boy comes to see you in clinic with left hip
the extensor carpi radialis longus and the extensor carpi pain. He is a very keen runner. His mum tells you that he has
radialis brevis. an intermittent limp and his gait has altered over the past
few weeks.
Features
• intersection syndrome is commonly misdiagnosed as de On examination, the left leg is externally rotated and
Quervain's tenosynovitis shortened. He has reduced internal rotation and an antalgic
• pain in the distal dorsoradial forearm, around 5-10 cm gait.
proximal of the wrist joint
• swelling and erythema may be seen What is the likely diagnosis?

Intersection syndrome is commonly seen in skiers, tennis A. Acute transient synovitis

players, weight lifters and canoeists. B. Osgood-Schlatter disease
C. Osteochondritis
Management D. Perthes disease
• NSAIDs E. Slipped upper femoral epiphysis
• steroid injection
ANSWER:
• physiotherapy
Slipped upper femoral epiphysis
• surgical treatment is rarely required
EXPLANATION:
Q-119
This boy has features in keeping with slipped upper femoral
A 55-year-old woman presents for review. Her mother has
epiphysis. This diagnosis can often be delayed resulting in
just been discharged after suffering a hip fracture. She is
worse prognosis and is an area of high medico-legal interest.
concerned that she may have 'inherited' osteoporosis and is
Patients present with hip pain (or sometimes referred knee
asking what she should do. She has no significant past
pain). This pain can be exacerbated by running. An altered
medical history of note, takes no regular medication and has
gait is reported and examination can reveal reduced internal
never sustained any fractures. She smokes around 20
rotation and external rotation whilst walking. Acute
cigarettes per day and drinks about 3-4 units of alcohol per
transient synovitis is usually a more acute presentation and
day.
is usually secondary to a viral infection is younger children.
Osgood-Schlatter's disease presents with knee pain.
What is the most appropriate course of action?
Osteochondritis most often presents with knee pain in
adolescents. Perthes disease usually affects younger children
A. Arrange bone mineral density measurement (DEXA scan)
and examination includes stiffness and reduced global range
B. Reassure her that assessment of fragility fracture risk
of motion.
does not need to be done until 65 years
C. Refer her to the genetics team for a risk assessment
HIP PROBLEMS IN CHILDREN
D. Start first-line bone protection (i.e. ensure
The table below provides a brief summary of the potential
calcium/vitamin D replete + oral bisphosphonate)
causes of hip problems in children
E. Use the FRAX tool
Condition Notes
This lady has a number of risk factors for developing
Development Often picked up on newborn examination
osteoporosis:
dysplasia of the Barlow's test, Ortolani's test are positive
• positive family history hip Unequal skin folds/leg length
• smoking
• excess alcohol intake Transient Typical age group = 2-10 years
synovitis Acute hip pain associated with viral infection
She should therefore have an immediate FRAX assessment, (irritable hip) Commonest cause of hip pain in children
rather than waiting until 65 years as we would for women Perthes disease Perthes disease is a degenerative condition affecting
without any relevant risk factors the hip joints of children, typically between the ages of
4-8 years. It is due to avascular necrosis of the femoral
Condition Notes Perthes disease - both femoral epiphyses show extensive destruction, the
acetabula are deformed
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 Perthes disease - bilateral disease

Slipped upper Typical age group = 10-15 years

femoral More common in obese children and boys
epiphysis 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
Slipped upper femoral epiphysis - left side

Juvenile Preferred to the older term juvenile chronic arthritis,

idiopathic describes arthritis occurring in someone who is less
arthritis (JIA) 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

Features of pauciarticular JIA

• joint pain and swelling: usually medium sized

joints e.g. knees, ankles, elbows
• limp Slipped upper femoral epiphysis - left side
• ANA may be positive in JIA - associated with
anterior uveitis Q-121
Which one of the following statements regarding trigger
Septic arthritis Acute hip pain associated with systemic upset e.g. finger is true?
pyrexia. Inability/severe limitation of affected joint
A. Steroid injection is an appropriate first-line treatment
Image gallery 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:
Steroid injection is an appropriate first-line treatment

EXPLANATION:
Please see Q-117 for Trigger Finger
Q-122 • try to encourage self-management
A 44-year-old man is diagnosed with lower back pain. This • stay physically active and exercise
has been present for around 2 weeks and there are no red
flags such as trauma or systemic symptoms. Clinical Analgesia
examination including neurological examination is • NSAIDS are now recommended first-line for patients with
unremarkable. You encourage him to remain active and give back pain. This follows studies that show paracetamol
him a 'back sheet' detailing some exercises he could do. He monotherapy is relatively ineffective for back pain
asks for analgesia to 'help him through the day'. What is the • proton pump inhibitors should be co-prescribed for
most appropriate initial medication? patients over the age of 45 years who are given NSAIDs
• NICE guidelines on neuropathic pain should be followed
A. Oral paracetamol for patients with sciatica
B. Oral codeine
C. Oral naproxen Other possible treatments
D. Topical ibuprofen • exercise programme: 'Consider a group exercise
E. Oral amitriptyline programme (biomechanical, aerobic, mindbody or a
combination of approaches) within the NHS for people '
ANSWER: • manual therapy (spinal manipulation, mobilisation or soft
Oral naproxen tissue techniques such as massage) 'but only as part of a
treatment package including exercise, with or without
EXPLANATION: psychological therapy.'
From the 2016 NICE guidelines: • radiofrequency denervation
1.2.17 Consider oral non-steroidal anti-inflammatory drugs • epidural injections of local anaesthetic and steroid for
(NSAIDs) for managing low back pain, taking into account acute and severe sciatica
potential differences in gastrointestinal, liver and cardio-
renal toxicity, and the person's risk factors, including age. Q-123 THROUGH 125
Theme: Lower back pain: prolapsed disc
1.2.18 When prescribing oral NSAIDs for low back pain, think
about appropriate clinical assessment, ongoing monitoring A. L2
of risk factors, and the use of gastroprotective treatment. B. L3
C. L4
1.2.19 Prescribe oral NSAIDs for low back pain at the lowest D. L5
effective dose for the shortest possible period of time. E. S1
F. S2
1.2.20 Consider weak opioids (with or without paracetamol) G. S3
for managing acute low back pain only if an NSAID is
contraindicated, not tolerated or has been ineffective. For each one of the following scenarios select the nerve root
which is most likely to be compressed:
1.2.21 Do not offer paracetamol alone for managing low
back pain. Q-123
A 52-year-old woman develops pain shooting down the
LOWER BACK PAIN: INVESTIGATION AND MANAGEMENT posterior aspect of the left leg. On examination she has
NICE updated their guidelines on the management of lower reduced sensation on the lateral aspect of the left foot and
back pain in 2016. They apply to patients with non-specific weakness of left foot plantar flexion.
lower back pain (i.e. not due to malignancy, infection, trauma
etc) ANSWER:
S1
NSAIDs are now first-line for back pain
Q-124
Investigation A 31-year-old man with sudden onset back pain radiating to
• lumbar spine x-ray should not be offered the anterior aspect of his right knee. Examination reveals an
• MRI should only be offered to patients with non-specific absent knee jerk with reduced sensation over the patella and
back pain 'only if the result is likely to change the medial aspect of his calf. The quadriceps are also noted
management' and to patients where malignancy, to be weak on the affected side.
infection, fracture, cauda equina or ankylosing spondylitis
is suspected ANSWER:
L4
Advice to people with low back pain
Q-125 ANSWER:
A 44-year-old man complains of pain radiating from his left Cubital tunnel syndrome
hip to foot for the past week. On examination all reflexes are
intact and the only positive finding is weak dorsiflexion of EXPLANATION:
the left big toe ELBOW PAIN
The table below details some of the characteristic features of
ANSWER: conditions causing elbow pain:
L5
EXPLANATION: Features
The clue here is normal reflexes - this excludes L3,L4 (knee)
and S1,S2 (ankle) • pain and tenderness localised to the
lateral epicondyle
EXPLANATION Q-123 THROUGH 125: • pain worse on resisted wrist extension
LOWER BACK PAIN: PROLAPSED DISC with the elbow extended or supination
A prolapsed lumbar disc usually produces clear dermatomal of the forearm with the elbow
leg pain associated with neurological deficits. extended
• episodes typically last between 6
Features months and 2 years. Patients tend to
• leg pain usually worse than back Lateral epicondylitis have acute pain for 6-12 weeks
• pain often worse when sitting (tennis elbow)
Medial epicondylitis Features
The table below demonstrates the expected features (golfer's elbow)
according to the level of compression:

Site of compression Features • pain and tenderness localised to the

medial epicondyle
L3 nerve root Sensory loss over anterior thigh
compression Weak quadriceps • pain is aggravated by wrist flexion and
Reduced knee reflex pronation
Positive femoral stretch test • symptoms may be accompanied by
L4 nerve root Sensory loss anterior aspect of knee numbness / tingling in the 4th and 5th
compression Weak quadriceps finger due to ulnar nerve involvement
Reduced knee reflex
Positive femoral stretch test Radial tunnel Most commonly due to compression of the
L5 nerve root Sensory loss dorsum of foot syndrome posterior interosseous branch of the radial nerve. It
compression Weakness in foot and big toe dorsiflexion is thought to be a result of overuse.
Reflexes intact
Positive sciatic nerve stretch test Features
S1 nerve root Sensory loss posterolateral aspect of leg and lateral
compression aspect of foot
Weakness in plantar flexion of foot • symptoms are similar to lateral
Reduced ankle reflex epicondylitis making it difficult to
Positive sciatic nerve stretch test diagnose
• however, the pain tends to be around 4-5
Management cm distal to the lateral epicondyle
• similar to that of other musculoskeletal lower back pain: • symptoms may be worsened by
analgesia, physiotherapy, exercises extending the elbow and pronating the
• if symptoms persist then referral for consideration of MRI forearm
is appropriate
Cubital tunnel Due to the compression of the ulnar nerve.
Q-126
syndrome
A 40-year-old woman complains of a permanent 'funny- Features
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 • initially intermittent tingling in the 4th
most likely diagnosis? and 5th finger

A. Cubital tunnel syndrome • may be worse when the elbow is resting

on a firm surface or flexed for extended
B. Lateral epicondylitis periods
C. Medial epicondylitis • later numbness in the 4th and 5th finger
D. Median nerve entrapment syndrome with associated weakness
E. Radial tunnel syndrome
 Features Q-129
A 68-year-old obese man presents with a one-day history of
• pain and tenderness localised to the progressively more severe lower back pain. There was no
lateral epicondyle obvious trigger. Abdominal examination is unremarkable.
• pain worse on resisted wrist extension Blood pressure is 90/60 mmHg and his pulse is 120 bpm
with the elbow extended or supination
of the forearm with the elbow ANSWER:
extended Leaking abdominal aortic aneurysm
• episodes typically last between 6
months and 2 years. Patients tend to EXPLANATION:
Lateral epicondylitis have acute pain for 6-12 weeks Whilst patients often suffer an acute haemodynamic collapse
(tennis elbow) a number of patients will have more sub-acute symptoms if
Olecranon bursitis Swelling over the posterior aspect of the elbow. the aneurysm is leaking prior to rupture.
There may be associated pain, warmth and
erythema. It typically affects middle-aged male EXPLANATION Q-127 THROUGH 129:
patients. LOWER BACK PAIN
Lower back pain (LBP) is one of the most common
Q-127 THROUGH 129 presentations seen in practice. Whilst the majority of
Theme: Lower back pain presentations will be of a non-specific muscular nature it is
worth keeping in mind possible causes which may need
A. Peripheral arterial disease specific treatment.
B. Prolapsed disc Red flags for lower back pain
C. Facet joint pain
• age < 20 years or > 50 years
D. Perforated duodenal ulcer
• history of previous malignancy
E. Leaking abdominal aortic aneurysm
• night pain
F. Pyelonephritis
• history of trauma
G. Ankylosing spondylitis
H. Rheumatoid arthritis • systemically unwell e.g. weight loss, fever
I. Crush fracture The table below indicates some specific causes of LBP:
J. Spinal stenosis
May be acute or chronic
Pain worse in the morning and on standing
For each one of the following scenarios please select the
On examination there may be pain over the facets.
most likely diagnosis: Facet joint The pain is typically worse on extension of the back
Spinal stenosis Usually gradual onset
Q-127 Unilateral or bilateral leg pain (with or without back
A 34-year-old man reports the sudden onset of back pain pain), numbness, and weakness which is worse on
after bending over to tie his shoe laces. There is tenderness walking. Resolves when sits down. Pain may be described
over the lumbar spine on examination and leaning back as 'aching', 'crawling'.
worsens the pain. Neurological examination and straight leg Relieved by sitting down, leaning forwards and crouching
down
raising is normal
Clinical examination is often normal
Requires MRI to confirm diagnosis
ANSWER:
Ankylosing Typically a young man who presents with lower back
Facet joint pain
spondylitis pain and stiffness
EXPLANATION: Stiffness is usually worse in morning and improves with
activity
Although patients often give a history of bending prior to disc
Peripheral arthritis (25%, more common if female)
prolapse the normal straight leg raising makes this diagnosis
Peripheral Pain on walking, relieved by rest
less likely. arterial disease Absent or weak foot pulses and other signs of limb
ischaemia
Q-128 Past history may include smoking and other vascular
A 76-year-old man reports pain is his buttocks when he diseases
walks the dog. The pain comes on after around 500 yards
and resolves when he stops. He has a past history of chronic Q-130
obstructive pulmonary disease and ischaemic heart disease. A 64-year-old female with a history of rheumatoid arthritis
Neurological examination is normal and the foot pulses are presents with increased difficulty in walking. On examination
difficult to feel in both feet there is weakness of ankle dorsiflexion and of the extensor
hallucis longus associated with loss of sensation on the
ANSWER: lateral aspect of the lower leg. What is the most likely
Peripheral arterial disease diagnosis?
A. Tibial nerve palsy • obesity
B. Obturator nerve palsy • developmental dysplasia of the hip
C. Common peroneal nerve palsy
D. Lateral cutaneous nerve palsy Features
E. Pudendal nerve palsy • chronic history of groin ache following exercise and
relieved by rest
ANSWER: • red flag features suggesting an alternative cause include
Common peroneal nerve palsy rest pain, night pain and morning stiffness > 2 hours
• the Oxford Hip Score is widely used to assess severity
EXPLANATION:
COMMON PERONEAL NERVE LESION Investigations
• NICE recommends that if the features are typical then a
The sciatic nerve divides into the tibial and common peroneal clinical diagnosis can be made
nerves. Injury often occurs at the neck of the fibula • otherwise plain x-rays are the first-line investigation

The most characteristic feature of a common peroneal nerve Management

lesion is foot drop • oral analgesia
• intra-articular injections: provide short-term benefit
Other features include:
• total hip replacement remains the definitive treatment
• weakness of foot dorsiflexion
• weakness of foot eversion Complications of total hip replacement
• weakness of extensor hallucis longus • venous thromboembolism
• sensory loss over the dorsum of the foot and the lower • intraoperative fracture
lateral part of the leg • nerve injury
• wasting of the anterior tibial and peroneal muscles
Reasons for revision of total hip replacement
Q-131 • aseptic loosening (most common reason)
A 73-year-old woman who has previously had a total hip
• pain
replacement (THR) presents for review due to pain on the
• dislocation
side of her prosthesis. What is the most common reason that
• infection
a revision operation would need to be performed in a
patient who has had a THR?
Q-132
ou review a middle-aged man with shoulder pain. He has
A. Aseptic loosening of the implant
limited movement of the right shoulder in all directions.
B. Autoimmune reaction to the implant
Which of the following clinical findings is most consistent
C. Infection
with a diagnosis of frozen shoulder (adhesive capsulitis)?
D. Fracture of the implant or surrounding bone
E. Implant passes expiry date
A. Only active movement limited + internal rotation most
affected
ANSWER:
B. Active and passive movement limited + abduction most
Aseptic loosening of the implant
affected
C. Active and passive movement limited + external rotation
EXPLANATION:
most affected
Aseptic loosening is the most common reason total hip
D. Active and passive movement limited + internal rotation
replacements need to be revised
most affected
Other common reasons for revision include pain and
E. Only active movement limited + external rotation most
dislocation
affected
OSTEOARTHRITIS OF THE HIP
ANSWER:
Osteoarthritis (OA) of the hip is the second most common
Active and passive movement limited + external rotation most
presentation of OA after the knee. It accounts for significant
affected
morbidity and total hip replacement is now one of the most
common operations performed in the developed world.
EXPLANATION:
ADHESIVE CAPSULITIS
Risk factors
Adhesive capsulitis (frozen shoulder) is a common cause of
• increasing age
shoulder pain. It is most common in middle-aged females. The
• female gender (twice as common)
aetiology of frozen shoulder is not fully understood.
 ANSWER:
Associations They may be a distal neurological deficit
• diabetes mellitus: up to 20% of diabetics may have an
episode of frozen shoulder EXPLANATION:
Please see Q-116 for Morton’s Neuroma
Features typically develop over days
external rotation is affected more than internal rotation or Q-135
abduction A 60-year-old woman presents with a swelling just proximal
both active and passive movement are affected to the nail bed on the left great toe. She has a history of
patients typically have a painful freezing phase, an adhesive osteoarthritis but is usually well.
phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years

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-133
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 What is the most likely diagnosis?
movement in the right knee. He is able to flex his right hip
fully but internal rotation is painful. What is the most likely A. Basal cell carcinoma
diagnosis? B. Epidermoid cyst
C. Orf
A. Transient synovitis D. Myxoid cyst
B. Perthes disease E. Rheumatoid nodule
C. Trochanteric bursitis
D. Medial collateral ligament strain ANSWER:
E. Slipped upper femoral epiphysis Myxoid cyst

ANSWER: EXPLANATION:
Slipped upper femoral epiphysis MYXOID CYST
Myxoid cysts (also known as mucous cysts) are benign
EXPLANATION: ganglion cysts usually found on the distal, dorsal aspect of the
Slipped upper femoral epiphysis - typically an overweight finger. There is usually osteoarthritis in the surrounding joint.
adolescent boy with knee / hip problems They are more common in middle-aged women.
This is a classic presentation of slipped upper femoral
epiphysis. The child's obesity is a strong clue. Q-136
You are performing a newborn examination. Which one of
Please see Q-120 for Hip Problems in Children the following best describes the clinical findings of a
clubfoot?
Q-134
Which one of the following statements regarding Morton's A. Inverted + plantar flexed foot which is not passively
neuroma is correct? correctable
B. Inverted + dorsiflexed foot + pes planus which is not
A. Occurs most commonly in the second inter- passively correctable
metatarsophalangeal space C. Inverted + plantar flexed foot + pes planus which is
B. They may be a distal neurological deficit passively correctable
C. They are more common in patients who have multiple D. Everted + dorsiflexed foot which is not passively
sclerosis correctable
D. Has malignant potential in around 1% of patients E. Inverted + plantar flexed foot which is passively
E. There is roughly equal incidence in males and females correctable
ANSWER: Q-139
Inverted + plantar flexed foot which is not passively A 35 year old lady has been experiencing intermittent pins
correctable and needles in her right hand for the past month. As part of
your neurological examination you attempt to elicit the
EXPLANATION: triceps reflex by placing the lady's arm across her chest and
Please see Q-113 for Talipes Equinovarus striking the triceps tendon with a tendon hammer. Which
nerve (and its nerve root) are you testing?
Q-137
A 30-year-old man attends complaining of pain on the inner A. Radial nerve C7
side of his right elbow and forearm since he built a bookcase B. Median nerve C6
at home 3 days ago. He is normally fit and well and on no C. Median nerve C7
regular medication. On examination you elicit some D. Ulnar nerve C5
tenderness of the medial elbow joint and the patient reports E. Radial nerve C6
discomfort felt in the elbow on resisted pronation of the
wrist. What is the likely diagnosis? ANSWER:
Radial nerve C7
A. Golfer's elbow
B. Tennis elbow EXPLANATION:
C. De Quervain's tenosynovitis The radial nerve innervates the triceps muscle. It is primarily
D. Radial tunnel syndrome derived from the C7 nerve root.
E. Olecranon bursitis
The radial nerve is the motor supply to the extensor
ANSWER: compartments of the upper arm.
Golfer’s elbow
The triceps muscle is the chief extensor of the forearm. Its
EXPLANATION: name derives from its three heads of origin; the long, lateral
Epicondylitis is caused by repeated strain leading to and medial heads. It attaches into the olecranon of the ulna.
inflammation of the common extensor tendon at the
epicondyle. It is these components which form the triceps reflex arc.
Golfer's elbow or medial epicondylitis produces tenderness
over the medial epicondyle and medial wrist pain on resisted UPPER LIMB ANATOMY
wrist pronation. The information below contains selected facts which
Tennis elbow or lateral epicondylitis produces tenderness commonly appear in examinations:
over the lateral epicondyle and lateral elbow pain on
resisted wrist extension. Typical
mechanism of
Please see Q-126 for Elbow Pain Nerve Motor Sensory injury & notes
Musculocutaneous Elbow flexion Lateral part of Isolated injury rare
Q-138 nerve (C5-C7) (supplies biceps the forearm - usually injured as
brachii) and part of brachial
Which one of the following statements regarding the FRAX
supination plexus injury
risk score is correct?
Axillary nerve Shoulder abduction Inferior Humeral neck
(C5,C6) (deltoid muscle) region of the fracture/dislocation
A. Estimates the 20-year risk of a patient sustaining a deltoid
fragility fracture muscle Results in flattened
B. A bone mineral density measurement within the past 12 deltoid
months is required Radial nerve (C5- Extension (forearm, Small area Humeral midshaft
C. Asks about the age of menopause for women C8) wrist, fingers, thumb) between the fracture
D. Can only be used for UK-based patients dorsal aspect
of the 1st and Palsy results in
E. Valid for patients aged 40-90 years
2nd wrist drop
metacarpals
ANSWER: Median nerve (C6, LOAF* muscles Palmar aspect Wrist lesion →
Valid for patients aged 40-90 years C8, T1) of lateral 3½ carpal tunnel
Features depend on fingers syndrome
EXPLANATION: the site of the lesion:
FRAX may be used for patients aged 40-90 years.

Please see Q-114 for Osteoporosis: Assessing Risk • wrist:

 Typical • as above, may be secondary to shoulder dystocia during
mechanism of birth. Also may be caused by a sudden upward jerk of the
Nerve Motor Sensory injury & notes hand
paralysis of • associated with Horner's syndrome
thenar
muscles,
opponens *LOAF muscles
pollicis • Lateral two lumbricals
• elbow: loss • Opponens pollis
of • Abductor pollis brevis
pronation • Flexor pollis brevis
of forearm
and weak
wrist
Q-140
flexion 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
Ulnar nerve (C8, Intrinsic hand Medial 1½ Medial epicondyle
T1) muscles except fingers fracture should continue. According to NICE guidelines how long
LOAF* should patients receive low-molecular weight heparin
Damage may result following an elective hip replacement?
Wrist flexion in a 'claw hand'
Long thoracic Serratus anterior Often during sport A. 7 days
nerve (C5-C7) e.g. following a B. 14 days
blow to the ribs. C. 4 weeks
Also possible
D. 2 months
complication of
mastectomy E. 3 months

Damage results in ANSWER:

a winged scapula 4 weeks

EXPLANATION:
Hip replacement: LMWH for 4 weeks

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
Diagram of the Brachial Plexus
• for hips the most common type of operation is a
Erb-Duchenne palsy ('waiter's tip') cemented hip replacement. A metal femoral component
is cemented into the femoral shaft. This is accompanied
• due to damage of the upper trunk of the brachial plexus
by a cemented acetabular polyethylene cup
(C5,C6)
• uncemented hip replacements are becoming increasingly
• may be secondary to shoulder dystocia during birth
popular, particularly in younger more active patients.
• the arm hangs by the side and is internally rotated, elbow
They are more expensive than conventional cemented hip
extended
replacements
• hip resurfacing is also sometimes used where a metal cap
Klumpke injury
is attached over the femoral head. This is often used in
• due to damage of the lower trunk of the brachial plexus
younger patients and has the advantage that the femoral
(C8, T1)
 neck is preserved which may be useful if conventional Q-142
arthroplasty is needed later in life A 56-year-old man complains of pain in his foot. You suspect
a diagnosis of Morton's neuroma.
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
Where is the pain most likely to be located?
Complications
• wound and joint infection A. Marker A
• thromboembolism: NICE recommend patients receive B. Marker B
low-molecular weight heparin for 4 weeks following a hip C. Marker C
replacement D. Marker D
E. Marker E
• dislocation
Q-141 ANSWER:
A 35-year-old man attends your surgery two days after being Marker B
struck on the lateral aspect of his right knee by the bumper
of a car travelling at low speed. He is able to walk, albeit EXPLANATION:
with an antalgic gait. However, he is unable to dorsiflex the Please see Q-116 for Morton’s Neuroma
ankle, evert the foot or extend his toes. There is loss of
sensation of the dorsum of the foot. Which structure is he Q-143
most likely to have damaged? A 50-year-old woman presents with pain in the right forefoot
for the past three months. The pain is described as a burning
A. Saphenous nerve which is brought on by walking. There is no history of trauma
B. Femoral nerve and the patient does not do any regular exercise. Her alcohol
C. Sciatic nerve intake is 28 units per week. On examination she complains
D. Common peroneal nerve of tenderness in the middle of the forefoot and her
E. Tibial nerve symptoms are recreated by squeezing the metatarsals
ANSWER: together. What is the most likely diagnosis?
Common peroneal nerve
A. Metatarsal stress fracture
EXPLANATION: B. Gout
The common peroneal nerve supplies the muscles of the C. Alcohol-related peripheral neuropathy
peroneal and anterior compartment of the leg and sensation D. Plantar fasciitis
to the dorsum of the foot. E. Morton's neuroma

It travels through the popliteal fossa, wrapping around the ANSWER:

head of the fibula (where it is sometimes palpable). Morton's neuroma

Habitual leg crossing, prolonged bed rest, hyperflexion of the EXPLANATION:

knee, pressure in obstetric stirrups and conditioning in ballet The examination findings would not support a diagnosis of
dancers are typical 'textbook' examples of scenarios where alcohol-related peripheral neuropathy.
peroneal neuropathy can occur as a result of nerve
compression against the head of the fibular. Transient Please see Q-116 for Morton’s Neuroma
trauma at this site (as in this scenario) can cause a
temporary neurapraxia, whereas prolonged or more severe Q-144
trauma can result in permanent foot drop. Which one of the following statements regarding adhesive
capsulitis (frozen shoulder) is correct?
Please see Q-130 for Common Peroneal Nerve Lesion
A. It is bilateral in around 40% of cases Q-147
B. Each episode typically lasts between 6 months and 2 A 33-year-old woman presents with back pain which radiates
years down her right leg. This came on suddenly when she was
C. Abduction is most severely affected bending down to pick up her child. On examination straight
D. It is most common in elderly patients (> 70 years of age) leg raising is limited to 30 degrees on the right hand side due
E. Early physiotherapy has been shown to resolve 60% of to shooting pains down her leg. Sensation is reduced on the
cases within 6 months dorsum of the right foot, particularly around the big toe and
foot dorsiflexion is also weak. The ankle and knee reflexes
ANSWER: appear intact. A diagnosis of disc prolapse is suspected.
Each episode typically lasts between 6 months and 2 years Which nerve root is most likely to be affected?
EXPLANATION: A. L2
Please see Q-132 for Adhesive Capsulitis B. L3
Q-145 C. L4
A 65-year-old man presents with bilateral leg pain that is D. L5
brought on by walking. His past medical history includes E. S1
peptic ulcer disease and osteoarthritis. He can typically walk ANSWER:
for around 5 minutes before it develops. The pain subsides L5
when he sits down. He has also noticed that leaning
forwards or crouching improves the pain. Musculoskeletal EXPLANATION:
and vascular examination of his lower limbs is L5 lesion features = loss of foot dorsiflexion + sensory loss
unremarkable. What is the most likely diagnosis? dorsum of the foot
Please see Q-123 THROUGH 125 for Lower Back Pain:
A. Inflammatory arachnoiditis
Prolapsed Disc
B. Peripheral arterial disease
C. Raised intracranial pressure Q-148
D. Spinal stenosis A 55-year-old man presents as he has noticed thickening of
E. Lumbar vertebral crush fracture the 'tendons' on both hands:

ANSWER:
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.

Please see Q-127 THROUGH 129 for Lower Back Pain Which one of the following is least associated with this
condition?
Q-146
A 50-year-old woman complains of pain in her right elbow. A. Positive family history
This has been present for the past four weeks and is maximal B. Phenytoin treatment
around 4-5cm distal from the lateral aspect of the elbow C. Manual labour
joint. The pain is made worse by extending the elbow and D. Alcoholic liver disease
pronating the forearm. What is the most likely diagnosis? E. Chronic kidney disease
ANSWER:
A. Lateral epicondylitis
Chronic kidney disease
B. Radial tunnel syndrome
C. De Quervain's tenosynovitis EXPLANATION:
D. Cubital tunnel syndrome Dupuytren's contracture is actually a thickening of the
E. Medial epicondylitis palmar fascia rather than the tendons
ANSWER: DUPUYTREN'S CONTRACTURE
Radial tunnel syndrome Dupuytren's contracture has a prevalence of about 5%. It is
more common in older male patients and around 60-70%
EXPLANATION:
have a positive family history
Please see Q-126 for Elbow Pain
Specific causes include: • wrist splints at night
• manual labour • surgical decompression (flexor retinaculum division)
• phenytoin treatment
Q-150
• alcoholic liver disease
You see a 42 year old man with a 6 day history of shooting
• trauma to the hand
pains down his left leg and a progressive numb sensation to
Q-149 his lateral foot and lower leg. He has no urinary or bowel
A 44-year-old woman presents with pain in her right hand symptoms. On examination he has intact sensation
and forearm which has been getting worse for the past few throughout but appears weaker to the lateral part of his
weeks. There is no history of trauma. The pain is lower leg and foot. He has weakness of ankle dorsiflexion
concentrated around the thumb and index finger and is and great toe extension. On examination he has a foot drop.
often worse at night. Shaking her hand seems to provide A rectal examination is unremarkable. In addition to
some relief. On examination there is weakness of the analgesia, what is the best management?
abductor pollicis brevis and reduced sensation to fine touch
A. Physiotherapy
at the index finger. What is the most likely diagnosis?
B. Urgent referral to the local spinal team
A. C6 entrapment neuropathy C. Review at 6 weeks
B. Thoracic outlet syndrome D. Advise attending the local emergency department
C. Carpal tunnel syndrome E. Reassurance
D. Cervical rib
ANSWER:
E. Pancoast's tumour
Urgent referral to the local spinal team
ANSWER:
EXPLANATION:
Carpal tunnel syndrome
Patients with progressive, persistent or severe neurological
EXPLANATION: deficit should be referred urgently to the local spinal team.
More proximal symptoms would be expected with a C6 More mild unilateral neurology associated with sciatica may
entrapment neuropathy e.g. weakness of the biceps muscle be monitored. If there is persistent neurological deficit at
or reduced biceps reflex. two weeks prompt referral is appropriate.

Patients with carpal tunnel syndrome often get relief from If there is suspicion of cauda equina syndrome they need to
shaking their hands and this may be an important clue in be admitted or attend the emergency department. Evidence
exam questions. of cauda equina syndrome would be severe or progressive
CARPAL TUNNEL SYNDROME bilateral neurological defecit, recent onset urinary retention
Carpal tunnel syndrome is caused by compression of median or urinary/ faecal incontinence, saddle anaesthesia or
nerve in the carpal tunnel. unexpected laxity of the anal sphincter. Other red flags
determine the need for urgent referral or admitting to
History hospital as per clinical judgement.
• pain/pins and needles in thumb, index, middle finger
Please see Q-122 for Lower Back Pain: Investigation and
• unusually the symptoms may 'ascend' proximally
Management
• patient shakes his hand to obtain relief, classically at night
Q-151
Examination
A 23-year-old female presents with a painless swelling on
• weakness of thumb abduction (abductor pollicis brevis)
the back of her wrist:
• 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
• rheumatoid arthritis
Electrophysiology
• motor + sensory: prolongation of the action potential
Treatment
• corticosteroid injection
Of the following options, what is the most appropriate Please see Q-131 for Osteoarthritis of the Hip
management?
Q-154
A. Check rheumatoid factor and refer to rheumatology A 40-year-old man presents with pain in his lower back and
B. Check full blood count 'sciatica' for the past three days. He describes bending down
C. Reassurance and review if not settling to pick up a washing machine when he felt 'something go'.
D. Inject with sclerosing agent He now has severe pain radiating from his back down the
E. Arrange ultrasound right leg. On examination he describes paraesthesia over the
anterior aspect of the right knee and the medial aspect of his
ANSWER: calf. Power is intact and the right knee reflex is diminished.
Reassurance and review if not settling The femoral stretch test is positive on the right side. Which
nerve root is most likely to be affected?
EXPLANATION:
GANGLION A. Common peroneal nerve
A ganglion presents as a 'cyst' arising from a joint or tendon B. Lateral cutaneous nerve of the thigh
sheath. They are most commonly seen around the back of the C. L5
wrist and are 3 times more common in women D. L3
E. L4
Ganglions often disappear spontaneously after several
months ANSWER:
L4
Q-152
A newborn baby is noted to have bilateral clubfoot. What is EXPLANATION:
the treatment of choice? Please see Q-123 THROUGH 125 for Lower Back Pain:
Prolapsed Disc
A. Manipulation and progressive casting starting after 3
months Q-155
B. Surgical correction at 1 year You see an 81-year-old lady with a history of diabetes,
C. Surgical correction at 6 months osteoarthritis and hypertension. She twisted her leg whilst
D. Manipulation and progressive casting starting soon after getting out of a car and developed increasing pain weight
birth bearing which has eased with simple analgesia. She also tells
E. Surgical correction at 3 months you she has a lump under her knee. On examination, she has
a 4cm non-tender lump just below the popliteal fossa which
ANSWER: becomes tense on extending the leg. She has full power
Manipulation and progressive casting starting soon after birth throughout. What is the most likely diagnosis?

EXPLANATION: A. Deep vein thrombosis

Please see Q-113 for Talipes Equinovarus B. Popliteal artery aneurysm
C. Sprain
Q-153 D. Baker's cyst
You are reviewing a patient who is complaining of hip pain. E. Ruptured head of gastrocnemius
You suspect a diagnosis of osteoarthritis. Which of the
following symptoms should prompt further investigations for ANSWER:
an alternative diagnosis? Baker's cyst
A. A 6-month history of symptoms
B. The patient being 59-years-old EXPLANATION:
C. A history of development dysplasia of the hip This describes the typical patient with a Baker's cyst. They
D. Morning stiffness lasting 4 hours are more likely to develop in patients with arthritis or gout
E. A body mass index of 33 kg/m² and following a minor trauma to the knee. Foucher's sign
describes the increase in tension of the Baker's cyst on
ANSWER: extension of the knee.
Morning stiffness lasting 4 hours
A DVT (deep vein thrombosis) needs to be considered
EXPLANATION:
because it can mimic a Baker's cyst. A DVT can also co-exist
Morning stiffness lasting > 2 hours may be an indication of
with a Baker's cyst and a low threshold for ultrasound should
inflammatory arthritis. This would warrant further
be considered.
investigations.
KNEE PROBLEMS: OLDER ADULTS ANSWER:
The table below summarises the key features of common Assess her using the FRAX tool
knee problems:
EXPLANATION:
Condition Key features Radiographs may show osteopenia but it is not possible to
Osteoarthritis of the Patient is typically > 50 years, often overweight determine the severity of osteopenia/osteoporosis
knee Pain may be severe accurately using this method alone. Calcium and phosphate
Intermittent swelling, crepitus and limitation of levels are normal in osteoporosis.
movement may occur
Infrapatellar bursitis Associated with kneeling There is no such thing as a Birmingham Hip Score tool.
(Clergyman's knee)
Prepatellar bursitis Associated with more upright kneeling Please see Q-114 for Osteoporosis: Assessing Risk
(Housemaid's knee)
Anterior cruciate May be caused by twisting of the knee - 'popping'
Q-157
ligament noise may have been noted
Rapid onset of knee effusion
A 45-year-old man presents with a three-month history of
Positive draw test posterior heel pain. This is generally worse on the mornings
Posterior cruciate May be caused by anterior force applied to the and after playing squash. On examination, his Achilles is
ligament proximal tibia (e.g. knee hitting dashboard during tender and thickened but there is no palpable gap or other
car accident) signs of rupture. You advise simple analgesia and refraining
Collateral ligament Tenderness over the affected ligament from exacerbating activities. What else may improve his
Knee effusion may be seen symptoms?
Meniscal lesion May be caused by twisting of the knee
Locking and giving-way are common feature A. Achilles tendon massage
Tender joint line B. Ankle rotation exercises
C. Ankle dorsiflexion stretches
D. Calf muscle concentric exercises
E. Calf muscle eccentric exercises

ANSWER:
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
Q-156 xanthomata)
A 70-year-old woman who has a strong family history of
fragility fractures secondary to osteoporosis presents as she Achilles tendinopathy (tendinitis)
is concerned about her own risk. What is the most Features
appropriate way to assess her risk? • gradual onset of posterior heel pain that is worse
following activity
A. Order an x-ray of her hips and lumbar spine • morning pain and stiffness are common
B. Assess her using the Birmingham Hip Score tool
• calf muscle eccentric exercises - this may be self-directed
C. Order a MRI of her hips and lumbar spine
or under the guidance of physiotherapy
D. Check her calcium and phosphate levels
E. Assess her using the FRAX tool
The management is typically supportive including simple
analgesia and reduction in precipitating activities.
Achilles tendon rupture Q-160
Achilles tendon rupture should be suspected if the person Which one of the following statements regarding slipped
describes the following whilst playing a sport or running; an upper femoral epiphysis is true?
audible 'pop' in the ankle, sudden onset significant pain in the
calf or ankle or the inability to walk or continue the sport. A. Suprapubic pain is the most common symptom
B. A chronic slip, with symptoms over weeks to months is
An examination should be conducted using Simmond's triad, the most common presentation
to help exclude Achilles tendon rupture. This can be C. Typical age group is 5-10 years
performed by asking the patient to lie prone with their feet D. More common in girls
over the edge of the bed. The examiner should look for an E. Bilateral in less than 5% of cases
abnormal angle of declination; Achilles tendon rupture may
lead to greater dorsiflexion of the injured foot compared to ANSWER:
the uninjured limb. They should also feel for a gap in the A chronic slip, with symptoms over weeks to months is the
tendon and gently squeeze the calf muscles if there is an most common presentation
acute rupture of the Achilles tendon the injured foot will stay
in the neutral position when the calf is squeezed. EXPLANATION:

An acute referral should be made to an orthopaedic specialist Please see Q-120 for Hip Problems in Children
following a suspected rupture.
Q-161
Q-158 Please look at the image of the toe below:
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

B. Arrange physiotherapy
C. Refer for duplex scan
D. Refer for MRI
E. Perform a myeloma screen
Which underlying condition is this appearance most
ANSWER: associated with?
Refer for MRI
A. Rheumatoid arthritis
EXPLANATION: B. Osteoarthritis
This presentation requires a MRI to confirm the diagnosis C. Diabetes mellitus
and exclude other causes D. Gout
E. Pseudogout
Please see Q-127 THROUGH 129 for Lower Back Pain
ANSWER:
Q-159 Osteoarthritis
Which one of the following is a risk factor for clubfoot?
EXPLANATION:
A. Spina bifida Please see Q-135 for Myxoid Cyst
B. Maternal diabetes mellitus
Q-162
C. Down's syndrome
A 45-year-old man presents with a painful swelling on the
D. Female gender
posterior aspect of his elbow. There is no history of trauma.
E. Polyhydramnios
On examination an erythematous tender swelling is noted.
What is the most likely diagnosis?
ANSWER:
Spina bifida A. Synovial cyst
B. Haemarthrosis
EXPLANATION: C. Septic arthritis
Please see Q-113 for Talipes Equinovarus D. Gout
E. Olecranon bursitis
ANSWER: ANSWER:
Olecranon bursitis Following a hip replacement patients should avoid crossing
their legs
EXPLANATION:
EXPLANATION:
Please see Q-126 for Elbow Pain This is to reduce the chance of dislocation.
Q-163
Which one of the following is not associated with carpal Please see Q-140 for Osteoarthritis: Joint Replacement
tunnel syndrome?
Q-166
A. Tinel's sign A 38-year-old woman develops lower back pain radiating
B. Compression of the median nerve down her right leg whilst performing DIY. She describes a
C. Wasting of the hypothenar eminence severe, sharp, stabbing pain which is worse on movement.
D. Flexion of the wrist reproduces symptoms Clinical examination reveals a positive straight leg raise test
E. Weakness of thumb abduction on the right-hand side. Appropriate analgesia is prescribed.
Of the following, what is the most suitable next-step in
ANSWER: management?
Wasting of the hypothenar eminence
A. Check ESR
EXPLANATION: B. Arrange physiotherapy
Please see Q-149 for Carpal Tunnel Syndrome C. Refer for MRI
D. Perform a vaginal examination
Q-164 E. Lumbar spine x-ray
You review a 57-year-old woman. She has read in the paper
about the risks of osteoporosis and wants advice on whether ANSWER:
she is at risk or not. She is fit and well, doesn't smoke and Arrange physiotherapy
drinks only 1-2 units of alcohol per week.
EXPLANATION:
At what age do NICE recommend that we start to assess This patient has symptoms consistent with a prolapsed disc.
women regarding their risk suffering a fragility fracture? Even if this is proven by a MRI scan it would not change the
initial management as the vast majority of patients improve
A. At the menopause with conservative treatment such as physiotherapy.
B. After the age of 55 years
C. After the age of 60 years Please see Q-123 THROUGH 125 for Lower Back Pain:
D. After the age of 65 years Prolapsed Disc
E. After the age of 70 years
Q-167
ANSWER: Which one of the following statements regarding the FRAX
After the age of 65 years tool for assessing the risk of fragility fractures is true?
EXPLANATION: A. The FRAX score can be calculated with or without a
DEXA scan result
Please see Q-114 for Osteoporosis: Assessing Risk B. Estimates the 5-year risk of having a fragility fracture
C. Only assesses the risk of developing a hip fracture
Q-165 D. Includes questions about ethnicity
Which one of the following statements regarding joint E. Cannot be used in patients older than 70-years
replacement surgery is correct?
ANSWER:
A. Following a hip replacement patients should avoid The FRAX score can be calculated with or without a DEXA scan
crossing their legs result
B. Hip resurfacing is now the most common type of hip
replacement operation performed in the UK EXPLANATION:
C. Patients should be encouraged to avoid using walking Please see Q-114 for Osteoporosis: Assessing Risk
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
Q-168 THROUGH 170 ANSWER:
Theme: Limping child Juvenile idiopathic arthritis

A. Septic arthritis EXPLANATION:

B. Perthes disease This is a typical presentation of pauciarticular juvenile
C. Transient synovitis idiopathic arthritis.
D. Osteochondritis dissecans
E. Juvenile idiopathic arthritis EXPLANATION Q-168 THROUGH 170:
F. Development dysplasia of the hip Please see Q-120 for Hip Problems in Children
G. Slipped upper femoral epiphysis
H. Metaphyseal dysplasia Q-171
I. Ewing's sarcoma A 59-year-old woman presents to surgery. She has arranged
J. Psoas abscess 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
For each one of the following presentations please select the neck. She is wondering what needs doing. You perform a
most likely diagnosis: general examination of the lady which is normal. What is the
most appropriate next step in management?
Q-168
6-year-old boy with a limp. His parents report that this has A. Prescribe a calcium and vitamin D supplement and
been getting steadily worse over the past few weeks. He repeat the DEXA in 3 years
complains of pain in the right groin/hip region. An x-ray B. Do a FRAX assessment
shows widening of the right hip joint space with flattening of C. Prescribe a calcium and vitamin D supplement and
the femoral head. repeat the DEXA in 12 months
D. Prescribe a calcium and vitamin D supplement +
ANSWER: alendronate
Perthes disease E. Refer to rheumatology

EXPLANATION: ANSWER:
Pointers to Perthes: Do a FRAX assessment
• gender: 5 times more common in boys
• age: typical presents in children aged 4-8 years EXPLANATION:
• x-ray findings The FRAX assessment is needed to assess this ladies true
fracture risk. The bone mineral density measurement is a
Q-169 part of this, albeit an important factor.
A 7-year-old boy is brought in by his mother. For the past
day he has felt generally unwell with a headache and Please see Q-114 for Osteoporosis: Assessing Risk
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:
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-170
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.