Orthopaedics — Bone Lesions and Chronic Joint Disease, NMC MBBS licence examination syllabus (Nepal Medical Council).
NMC-style practice questions written for this site. They are not past questions, and no past paper has been reproduced.
A 15-year-old has had pain in the lower thigh for two months. It wakes him at night. There is a firm, tender swelling above the knee. He recalls being kicked during a football match around the time the pain started. What is the most appropriate next step?
Answer: Image the bone and refer urgently. Night pain with a firm swelling does not fit a mechanical pattern, and the remembered injury explains when the pain was noticed rather than why it has persisted and grown. Both infection and a primary bone tumour are possible at this age, and neither is excluded at the bedside.
A 68-year-old woman has a lesion in the femur found after a fracture sustained while stepping off a kerb. Which is the most useful early step?
Answer: Look for a primary elsewhere — examine the breast and the chest, and consider myeloma. In this age group a secondary deposit is far more likely than a primary bone tumour, and a fracture from trivial force indicates the bone was already weakened.
A 45-year-old woman reports stiffness in both hands lasting about two hours each morning, easing as the day goes on. The knuckles are swollen. How does this pattern differ from osteoarthritis, and why does it matter?
Answer: Prolonged morning stiffness that eases with movement is the inflammatory pattern; osteoarthritis gives brief stiffness and pain that worsens with use. It matters because inflammatory arthritis needs disease-suppressing treatment started early — delay costs joint function permanently.
A 60-year-old man with a history of gout presents with a single hot, swollen, exquisitely tender knee and a fever. He says it feels like his previous attacks. What is the safest approach?
Answer: Treat as septic arthritis until proven otherwise and aspirate the joint for microscopy and culture. A history of gout makes crystals likely but does not exclude infection, and a patient with gout can also have a septic joint. Cartilage is destroyed within days if infection is missed.
Why is the question "does the pain wake you at night?" more useful than asking how severe the pain is?
Answer: Severity does not distinguish the causes — mechanical pain can be severe. What distinguishes them is behaviour: mechanical pain eases with rest, so pain present at rest or waking a patient from sleep does not fit that pattern and needs explaining rather than treating.
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