Musculoskeletal, Dermatology & ENT

A 55-year-old man wakes with an exquisitely painful, hot, swollen first metatarsophalangeal joint. He has had similar episodes before. What is the most appropriate acute treatment?

• AA course of oral prednisolone for six weeks
• BIntravenous flucloxacillin
• CAn NSAID or colchicine✓
• DStart allopurinol immediately

Answer: Acute gout is treated with an NSAID, colchicine or a short course of oral corticosteroid, chosen according to comorbidities and preference. Allopurinol is not usually started during an acute attack — NICE advises starting urate-lowering therapy two to four weeks after a flare has settled, though it can be started during a flare if flares are frequent — and it is continued if the patient is already taking it.

A 72-year-old woman fractures her wrist after a fall from standing. Her DEXA scan shows a T-score of −2.8 at the hip. What is the diagnosis and first-line treatment?

• AOsteopenia; lifestyle advice only
• BOsteoporosis; oral alendronate with calcium and vitamin D✓
• COsteoporosis; hormone replacement therapy as first choice
• DOsteomalacia; high-dose vitamin D alone

Answer: A T-score of −2.5 or below defines osteoporosis, and a fragility fracture makes treatment clearly indicated. Oral bisphosphonates such as alendronate are first-line, with calcium and vitamin D if intake is inadequate.

A 45-year-old man has a hot, swollen, very painful knee that he cannot move, with a fever of 38.5°C. What is the most important initial investigation?

• AA plain X-ray of the knee to look for joint destruction or fracture
• BSerum uric acid and inflammatory markers to confirm acute gout
• CAn MRI scan of the knee to assess the cartilage and ligaments
• DJoint aspiration for Gram stain, culture and crystals before starting antibiotics✓

Answer: A hot, swollen joint with fever is septic arthritis until proven otherwise. The joint must be aspirated for microscopy, culture and crystals before antibiotics are started, then intravenous antibiotics such as flucloxacillin are given while awaiting results.

A 25-year-old falls on an outstretched hand and has tenderness in the anatomical snuffbox. The initial X-rays are normal. What should be done?

• ADischarge with reassurance and simple analgesia, since a normal X-ray excludes a fracture
• BRefer for surgical fixation immediately
• CApply a supportive bandage and analgesia, and review only if the pain persists beyond a fortnight
• DImmobilise the wrist and repeat imaging in 10 to 14 days, or arrange MRI✓

Answer: Scaphoid fractures are often invisible on the first X-ray, and a missed fracture risks avascular necrosis and non-union. Snuffbox tenderness is treated as a fracture: immobilise and repeat imaging, or use MRI to confirm early.

A 50-year-old woman has a pigmented lesion on her back that has grown over three months, has an irregular border and contains two colours. What is the most appropriate action?

• AUrgent two-week-wait referral to dermatology for suspected melanoma✓
• BRemove it in primary care with a shave excision and send the specimen for histology
• CPrescribe a topical steroid and review
• DReassure and review in six months

Answer: Asymmetry, border irregularity, colour variation, a diameter over 6 mm and evolution are the ABCDE warning signs of melanoma; a lesion scoring highly on the weighted checklist needs urgent referral, and suspected melanomas are not excised in primary care.

A 4-year-old has had two days of ear pain and fever, with a red bulging eardrum. He is otherwise well and drinking. What is the most appropriate management?

• AAnalgesia with advice that most cases resolve in three days, and a back-up antibiotic prescription if it does not settle✓
• BEar syringing in the surgery to relieve the pressure behind the drum, followed by antibiotic ear drops
• CImmediate admission for intravenous antibiotics, since a bulging drum means the infection is severe
• DReferral to ENT for grommets, since a bulging drum at this age indicates glue ear that will need drainage

Answer: Most acute otitis media resolves without antibiotics within three days. NICE recommends analgesia and a no-antibiotic or back-up prescribing strategy for children who are systemically well, with immediate antibiotics reserved for those who are unwell, under two with bilateral infection, or have otorrhoea.

A 35-year-old woman has a nosebleed that has continued for ten minutes. What is the correct first-aid advice?

• ASit up, lean forward and pinch the soft part of the nose firmly for 10 to 15 minutes✓
• BLie flat with the head tilted back so that the blood drains away from the nostrils and clots more quickly
• CPack the bleeding nostril tightly with cotton wool, lie down and rest quietly until the bleeding has stopped completely
• DApply firm pressure to the bony bridge of the nose for two minutes, then release and check whether the bleeding has stopped

Answer: Leaning forward stops blood running down the throat, and firm continuous pressure on the soft, fleshy part of the nose for 10 to 15 minutes compresses the bleeding vessels in Little's area. Tilting the head back is wrong, and pressure on the bony bridge does nothing.

A 6-year-old has a small patch of golden-crusted, non-bullous impetigo on the chin and is otherwise well. What does NICE recommend as first-line treatment?

• AOral flucloxacillin for seven days
• BOral aciclovir
• CTopical clotrimazole
• DHydrogen peroxide 1% cream✓

Answer: For localised non-bullous impetigo in a well patient, NICE recommends hydrogen peroxide 1% cream first, with a topical antibiotic (fusidic acid) if unsuitable or ineffective, and oral flucloxacillin only for widespread or bullous disease.

A 30-year-old woman has symmetrical swelling and stiffness of the small joints of her hands, worse in the morning for over an hour, for the past three months. What is the most likely diagnosis?

• ARheumatoid arthritis✓
• BGout of the small joints
• COsteoarthritis of the hands
• DPsoriatic arthritis affecting the spine only

Answer: Symmetrical small-joint polyarthritis with prolonged morning stiffness is characteristic of rheumatoid arthritis, which needs early referral for disease-modifying treatment. Osteoarthritis causes short-lived stiffness and affects the distal joints.

A 75-year-old woman has a new headache, scalp tenderness and jaw pain on chewing. Her ESR is 85. What is the immediate treatment?

• AA triptan for migraine, taken at the onset of each headache
• BHigh-dose prednisolone immediately, without waiting for the temporal artery biopsy✓
• CIbuprofen and review in a fortnight, with a referral to rheumatology if the headache persists after that
• DAntibiotics for sinusitis, which explains the raised ESR and the facial pain

Answer: Giant cell arteritis threatens sight; steroids are started as soon as it is suspected, and the biopsy is arranged within two weeks because the artery stays abnormal for some days after treatment begins.

A 6-year-old has an itchy, red, weeping rash in the creases of the elbows and knees that comes and goes. What is the first-line treatment?

• ARegular emollients with a mild topical corticosteroid for flares✓
• BAn antifungal cream applied twice a day until the rash has gone completely
• CAvoiding all soap and washing until the skin has settled
• DOral antibiotics for a month to clear the infection in the skin

Answer: Atopic eczema is managed with liberal emollients and step-up topical steroids during flares; soap substitutes are used rather than avoiding washing altogether.

A 40-year-old man has sudden hearing loss in one ear with no pain or discharge. What should happen?

• AAntibiotic drops and review in two weeks, since otitis externa is the most likely cause
• BReassurance that it will resolve on its own within a few weeks without any treatment at all
• CEar syringing to remove wax, since impacted wax is the commonest cause of sudden hearing loss in adults
• DUrgent same-day referral to ENT, since sudden sensorineural hearing loss is an emergency✓

Answer: Sudden sensorineural hearing loss needs urgent assessment and treatment with steroids within days for the best chance of recovery; wax and infection cause conductive loss and are usually apparent on examination.