1. The district nurse asks you to review a 67 year-old woman with ulcerative colitis. She has been seeing the woman for treatment of a venous ulcer on the left leg. The nurse is concerned about a new ulcer which has developed rapidly on the right lower leg over a 10 day period. It started as a small, red 'bump' which very quickly broke down into a rapidly deepening and widening ulcer. The ulcer now measures 6cm in diameter, has a purple edge and appears to be undermining the surrounding skin. The patient tells you that it is incredibly painful. Which is the single most likely diagnosis?
a ) Erythema nodosum
b ) Necrobiosis lipoidica
c ) Pyoderma gangrenosum
d ) Squamous cell carcinoma
e ) Venous ulcer
Answer: C
Pyoderma gangrenosum often affects those with underlying diseases such as inflammatory bowel disease and rheumatoid arthritis. The pain, clinical appearance, and speed at which it develops are what sets it apart from more common lesions such as arterial and venous ulcers. There is no specific diagnostic test for PG, but incisional biopsy can help rule out other pathologies. Treatment is mainly through strong topical or oral steroids, but other immune-modulating drugs may be used for severe disease.
2. A mother asks you to visit her 16 year old son at home. All day he has been feverish, complaining of being sore all over and having a headache. He has vomited twice that afternoon but in the last hour he has become drowsy and is difficult to wake up. He is now moaning but is not making any other verbal response. He is very pale, his lips are cyanosed, his hands and feet are very cold to touch. His pulse is 130/min, respiratory rate is 30/min, temp 38.5 and his BP is 70/40. On further examination, he has neck stiffness. He has no significant medical or drug history. You arrange an emergency ambulance. Which one of the following would be the most appropriate immediate action?
a ) Withhold an antibiotic if causative organism unknown
b ) Administer oral penicillin immediately if able to swallow
c ) Administer IM benzylpenicillin immediately
d ) Withhold an antibiotic in the absence of a purpuric rash
e ) Administer IV erythromycin if penicillin allergic
Answer: C
The first priority in suspected meningitis in the community, where there is a possibility of meningococcal disease, is to organise transfer to hospital whether or not antibiotics are given. In meningococcal disease there may be signs of either meningitis or septicaemia or both and symptoms can progress rapidly within minutes, necessitating immediate hospitalisation. Parenteral benzylpenicillin is the drug of choice and will act much more rapidly than oral penicillin. Cefotaxime is the alternative if penicillin allergic (or chloramphenicol if clear history of previous anaphylaxis with penicillin).
3. A 17 year old woman attends asking for contraception for the first time. She says that she would prefer a non-oral option, as she forgets to take medication, but would be guided by you. She has no significant medical history. She is normotensive. Her BMI is 18. Which single best treatment would you advise?
a ) Transdermal Ethinylestradiol 20mcg/Norelgestromin150mcg/24hrs
b ) Oral Ethinylestradiol30mcg/Levonorgestrel 150 mcg
c ) Parenteral Medroxyprogesterone 150mg
d ) Oral Norethisterone 350mcg
e ) Intrauterine Levonorgestrel 20mcg/24hrs
Answer: E
Where non-compliance with oral therapy appears to be a significant issue, the progestogen-only intra-uterine device is the best option. There is also evidence that the frequency of pelvic inflammatory disease may be reduced with such a device in the youngest age groups who are most at risk. Transdermal patches should be restricted to women who are very unlikely to comply with oral therapy. Problems can arise with detachment. It is also more expensive. If compliance is likely to be good a monophasic combined pill is the best option – and 30mcg of oestrogen is appropriate for standard use, where no risk factors apply. One should try to avoid parenteral Medroxyprogesterone in adolescents as it causes a reduction in bone mineral density. The Progesterone only pill is suitable in older women with risk factors. It has a higher failure rate than combined preparations.
4. A 24 year old woman is waiting to see the practice nurse for her holiday vaccinations. About 15 minutes later, you hear the nurse shouting for help from her room. You find the patient collapsed on the floor. Apparently she had started to go red and complain of an itch following her injection. She then started coughing and slumped to the floor. On examination, she has stridor, is hypotensive and tachycardic. She has a blotchy red rash all over and reduced capillary refill. Which one of the following is the initial treatment of choice?
a ) Adrenaline (1 in 10 000) given IV
b ) Adrenaline (1 in 1000) given IM
c ) Chlorphenamine given IV
d ) Hydrocortisone given IV
e ) Salbutamol nebulised
Answer: B
The condition described is anaphylaxis. Management should start with ABC followed by administration of IM adrenaline (1 in 1000) repeated at five minute intervals as clinically necessary. Adrenaline for IV use is 1 in 10 000 and should only be used in special circumstances and is not generally considered necessary or safe in the community. Adrenaline should be followed by parenteral chlorphenamine and then hydrocortisone as per the Resuscitation Council UK Guidelines.
5. A four year old boy has been running a temperature for six days. On examination, he has bilateral conjunctival injection, dry cracked lips, erythema with swelling of his hands and feet, and cervical lymphadenopathy. Which is the single most likely diagnosis?
a ) Otitis media
b ) Kawasaki Disease
c ) Meningitis
d ) Tonsillitis
e ) Pneumonia
Answer: B
This child has four out of the five features seen in Kawasaki Disease; the fifth being a polymorphous rash, usually over the trunk. Atypical Kawasaki Disease can be diagnosed with fewer features. It is a disease of children predominantly younger than 5 years of age. It is more common in males.
6. Recognition and treatment of Insulin Resistance Syndrome (Syndrome X) has become very important due to its association with increased morbidity and mortality. Which one of the following is a feature of the Insulin Resistance Syndrome?
a ) Low LDL
b ) Low plasma insulin
c ) Low plasma triglycerides
d ) Low blood glucose
e ) Low HDL
Answer: E
Syndrome X is the association of insulin resistance with hyperinsulinaemia, central obesity, raised BP, hyperglycaemia and coronary artery disease. There is increased plasma triglycerides and reduced HDL. There is increased thrombogenic potential. Management revolves around lifestyle change with weight loss, exercise and management of hyperglycaemia, with oral medication or insulin. Hypertension and dyslipidaemias are treated as required. Insulin Resistance Syndrome, (Syn. Metabolic Syndrome, Syndrome X) is the association of insulin resistance with hyperinsulinaemia, central obesity, raised BP, hyperglycaemia and coronary artery disease.
7. A 28 year old married woman, who rarely attends the surgery, attends in an anxious state. She reports having had a single episode of unprotected vaginal intercourse with a work colleague during a business trip one week previously. No other unprotected mucosal exposure occurred. He was not from a known high risk area or group. She is now worried that she may have contracted HIV and wants to be certain that there is no risk of infecting her husband from this episode. Which one of the following would you advise?
a ) HIV testing now
b ) Post exposure prophylaxis
c ) No further action
d ) Chlamydia screening
e ) Psychological referral
Answer: D
PEPSE (Post exposure prophylaxis after sexual exposure) to HIV should be considered on a case by case basis within 72 hours of exposure. In most areas, a referral will be made to a GUM clinic but there may be expertise within general practice. GPs should not refrain from testing for HIV; but HIV serology may not become positive for six months after an exposure and so further testing will be required. It would be correct to offer testing for other sexually transmitted diseases such as Chlamydia.
8. A 67 year old man attends the surgery with his daughter. She feels that her father has some visual impairment. He seems more prone to bump in to things and is unaware of surrounding traffic when driving. He has no significant past medical history. You find his visual acuity to be mildly reduced at 6/9 in both eyes .On visual field testing, he appears to have lost peripheral vision in all directions in both eyes. He has not attended an optician for several years. What is the single most likely diagnosis?
a ) Cataract formation
b ) Diabetic retinopathy
c ) Primary open-angle glaucoma
d ) Macular degeneration
e ) Retinal detachment
Answer: C
In open angle (chronic simple) glaucoma the build up of pressure inside the eye is painless as well as slow. But, if it isn’t treated, as the optic nerve is gradually damaged, the field of vision is reduced, so that eventually only a small area of central vision remains (tunnel vision) before sight is lost completely. Most people do not notice any symptoms until they have some loss of vision and by this time the optic nerve may be damaged. This is why regular screening tests are important over the age of 40 and especially in people with a family history.
Tuesday 26 August 2008
Saturday 23 August 2008
AKT Questions
1. A 72 year old woman has stable angina. Her regular medications include simvastatin, which was increased to 40mg two months earlier. She presents with a complaint of tenderness and stiffness of the muscles in her neck, shoulders and low back. Her symptoms came on rather suddenly about four weeks previously. They have been worse in the mornings, and have been making it difficult to get out of bed or rise from a chair. She has had a feeling of general malaise, with little appetite, and some weight loss. Blood tests reveal a mild normocytic, normochromic anaemia, a mildly raised alkaline phosphatase (ALP), a normal creatine phosphokinase (CK), a low level positive rheumatoid factor, and an erythrocyte sedimentation rate (ESR) of 110 mm/hr. Which one of the following is the most likely diagnosis?
a ) Fibromyalgia
b ) Rheumatoid arthritis
c ) Polymyalgia rheumatica
d ) Statin-induced myositis
e ) Systemic lupus erythematosus
Answer: C
Polymyalgia rheumatica is a systemic illness with prominent constitutional and musculoskeletal symptoms. Diagnosis is entirely based on history, examination, non-specific evidence of inflammation on lab testing, and prompt response to treatment with corticosteroids
2. A 40 year old man complains of recent onset deafness. Audiogram shows a sensorineural hearing loss on the left side; the right side is within normal. Which one of the following is the most likely diagnosis?
a ) Acoustic neuroma
b ) Otitis media
c ) Otosclerosis
d ) Presbycusis
e ) Tympanosclerosis
Answer: A
Only presbycusis (ageing) and an acoustic neuroma cause sensorineural hearing loss. Of these, only acoustic neuroma causes unilateral sensorineural hearing loss in a man of 40.
3. A 60 year old ex miner with COPD and Ischaemic Heart Disease, is diagnosed with primary open-angle glaucoma by a Consultant. Without knowing his history, he has given you several treatment options to choose from. What is the single best treatment to start him on?
a ) Brimonidine eye drops
b ) Timolol eye drops
c ) Acetazolamide orally
d ) Latanoprost eye drops
e ) Carteolol eye drops
Answer: D
Eye drops are the preferred option, but are absorbed systemically. Timolol and Carteolol, being Betablockers, can exacerbate bronchospasm. Brimonidine, an adrenoceptor stimulant, can aggravate coronary insufficiency.Latanopost stands out as the best option as BNF list it as only a rare or very rare cause of chest pain and asthma.
4. A 48 year old man complains of a one week history of low back pain with radiation of pain down his right leg. He has been taking an over-the-counter paracetamol/codeine preparation .Which single new symptom would prompt you to refer him to secondary care for urgent assessment (within 24hrs)?
a ) Pain radiating down the left leg
b ) Paraesthesia over the lateral aspect of the right leg
c ) Pain is worse when lying flat
d ) Pain is worse with defaecation
e ) Urinary hesitancy and reduced frequency
Answer: E
Any symptoms suggestive of cauda equina syndrome require immediate referral (assessment within 24 hours). These include perineal anaesthesia, reduced anal sphincter tone, urinary retention, progressive motor weakness, or evidence of bilateral nerve root involvement.
5. A 28 year old woman comes to see you. She feels tired all the time, and has been seeing the health-visitor who suspects postnatal depression. She had a post-partum haemorrhage following the delivery of her first child two years ago. She has put on a stone in weight, is cold and amenorrhoeic. She is unhappy, but not depressed. She desperately wants to conceive, and has been trying for a year. You check a subfertility screen. She is not ovulating. Free T4 and TSH are both very low, as is Prolactin, LH and FSH. Which one of the following is the most likely diagnosis?
a ) Cushing’s syndrome
b ) Hypothyroidism
c ) Kallman’s syndrome
d ) Polycystic ovarian syndrome
e ) Sheehan’s syndrome
Answer: E
The symptoms could be consistent with hypothyroidism, but the panhypopituitarism shown in the bloods (in a woman who has secondary subfertility) is best explained by a postpartum haemorrhage which impairs pituitary function – Sheehan’s syndrome.
6. A 70 year old man describes to you that he has noticed the gradual onset of a tremor in his right hand. His wife has noticed that his handwriting is becoming smaller. He has also noticed that his balance is becoming poorer and he is walking much more slowly. He experiences dizziness when he rises suddenly from a chair. Examination reveals a coarse, rhythmical tremor of the right lower arm at rest. There is also increased rigidity of the arm. Because he is on treatment for hypertension you check his BP which is 160/100 sitting and 150/90 standing. He takes Enalapril 5mgs. What is the single most appropriate referral intervention?
a ) Refer to the Practice Nurse for BP monitoring
b ) Refer to a Specialist in Parkinson’s Disease
c ) Refer to a GPwSI in neurology
d ) Refer for a CT scan
e ) Refer to a Nurse Specialist in neurology
Answer: B
The diagnosis of Parkinson’s Disease should be made by a Specialist with expertise in the differential diagnosis of the condition. Treatment should not be commenced before referral.
7. If 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?
A. Stop and recommence 4 weeks after acute inflammation has settled
B. Reduce allopurinol to 100mg od until acute attack has settled
C. Stop and switch to colchicine prophylaxis
D. Stop and recommence 2 weeks after acute inflammation has settled
E. Continue allopurinol in current dose
Answer: E
Gout: management
Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)Acute management
NSAIDs
intra-articular steroid injection
colchicine has a slower onset of action. The main side-effect is diarrhoea
if the patient is already taking allopurinol it should be continued
Allopurinol prophylaxis - see indications below
allopurinol should not be started until 2 weeks after an acute attack has settled
initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 300 µmol/l
NSAID or colchicine cover should be used when starting allopurinol
Indications for allopurinol*
1. recurrent attacks - the British Society for Rheumatology recommend 'In uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attacks occur within 1 year'
2. tophi
3. renal disease
4. uric acid renal stones
5. prophylaxis if on cytotoxics or diuretics
*patients with Lesch-Nyhan syndrome often take allopurinol for life
a ) Fibromyalgia
b ) Rheumatoid arthritis
c ) Polymyalgia rheumatica
d ) Statin-induced myositis
e ) Systemic lupus erythematosus
Answer: C
Polymyalgia rheumatica is a systemic illness with prominent constitutional and musculoskeletal symptoms. Diagnosis is entirely based on history, examination, non-specific evidence of inflammation on lab testing, and prompt response to treatment with corticosteroids
2. A 40 year old man complains of recent onset deafness. Audiogram shows a sensorineural hearing loss on the left side; the right side is within normal. Which one of the following is the most likely diagnosis?
a ) Acoustic neuroma
b ) Otitis media
c ) Otosclerosis
d ) Presbycusis
e ) Tympanosclerosis
Answer: A
Only presbycusis (ageing) and an acoustic neuroma cause sensorineural hearing loss. Of these, only acoustic neuroma causes unilateral sensorineural hearing loss in a man of 40.
3. A 60 year old ex miner with COPD and Ischaemic Heart Disease, is diagnosed with primary open-angle glaucoma by a Consultant. Without knowing his history, he has given you several treatment options to choose from. What is the single best treatment to start him on?
a ) Brimonidine eye drops
b ) Timolol eye drops
c ) Acetazolamide orally
d ) Latanoprost eye drops
e ) Carteolol eye drops
Answer: D
Eye drops are the preferred option, but are absorbed systemically. Timolol and Carteolol, being Betablockers, can exacerbate bronchospasm. Brimonidine, an adrenoceptor stimulant, can aggravate coronary insufficiency.Latanopost stands out as the best option as BNF list it as only a rare or very rare cause of chest pain and asthma.
4. A 48 year old man complains of a one week history of low back pain with radiation of pain down his right leg. He has been taking an over-the-counter paracetamol/codeine preparation .Which single new symptom would prompt you to refer him to secondary care for urgent assessment (within 24hrs)?
a ) Pain radiating down the left leg
b ) Paraesthesia over the lateral aspect of the right leg
c ) Pain is worse when lying flat
d ) Pain is worse with defaecation
e ) Urinary hesitancy and reduced frequency
Answer: E
Any symptoms suggestive of cauda equina syndrome require immediate referral (assessment within 24 hours). These include perineal anaesthesia, reduced anal sphincter tone, urinary retention, progressive motor weakness, or evidence of bilateral nerve root involvement.
5. A 28 year old woman comes to see you. She feels tired all the time, and has been seeing the health-visitor who suspects postnatal depression. She had a post-partum haemorrhage following the delivery of her first child two years ago. She has put on a stone in weight, is cold and amenorrhoeic. She is unhappy, but not depressed. She desperately wants to conceive, and has been trying for a year. You check a subfertility screen. She is not ovulating. Free T4 and TSH are both very low, as is Prolactin, LH and FSH. Which one of the following is the most likely diagnosis?
a ) Cushing’s syndrome
b ) Hypothyroidism
c ) Kallman’s syndrome
d ) Polycystic ovarian syndrome
e ) Sheehan’s syndrome
Answer: E
The symptoms could be consistent with hypothyroidism, but the panhypopituitarism shown in the bloods (in a woman who has secondary subfertility) is best explained by a postpartum haemorrhage which impairs pituitary function – Sheehan’s syndrome.
6. A 70 year old man describes to you that he has noticed the gradual onset of a tremor in his right hand. His wife has noticed that his handwriting is becoming smaller. He has also noticed that his balance is becoming poorer and he is walking much more slowly. He experiences dizziness when he rises suddenly from a chair. Examination reveals a coarse, rhythmical tremor of the right lower arm at rest. There is also increased rigidity of the arm. Because he is on treatment for hypertension you check his BP which is 160/100 sitting and 150/90 standing. He takes Enalapril 5mgs. What is the single most appropriate referral intervention?
a ) Refer to the Practice Nurse for BP monitoring
b ) Refer to a Specialist in Parkinson’s Disease
c ) Refer to a GPwSI in neurology
d ) Refer for a CT scan
e ) Refer to a Nurse Specialist in neurology
Answer: B
The diagnosis of Parkinson’s Disease should be made by a Specialist with expertise in the differential diagnosis of the condition. Treatment should not be commenced before referral.
7. If 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?
A. Stop and recommence 4 weeks after acute inflammation has settled
B. Reduce allopurinol to 100mg od until acute attack has settled
C. Stop and switch to colchicine prophylaxis
D. Stop and recommence 2 weeks after acute inflammation has settled
E. Continue allopurinol in current dose
Answer: E
Gout: management
Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)Acute management
NSAIDs
intra-articular steroid injection
colchicine has a slower onset of action. The main side-effect is diarrhoea
if the patient is already taking allopurinol it should be continued
Allopurinol prophylaxis - see indications below
allopurinol should not be started until 2 weeks after an acute attack has settled
initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 300 µmol/l
NSAID or colchicine cover should be used when starting allopurinol
Indications for allopurinol*
1. recurrent attacks - the British Society for Rheumatology recommend 'In uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attacks occur within 1 year'
2. tophi
3. renal disease
4. uric acid renal stones
5. prophylaxis if on cytotoxics or diuretics
*patients with Lesch-Nyhan syndrome often take allopurinol for life
Friday 22 August 2008
AKT Qustions
1. A 22-year-old male blood donor is noted to have the following blood results:
Bilirubin 41 µmol/L
ALP 84 U/L
ALT 23 U/L
Albumin 41 g/L
Dipstick urinalys is normal
He has recently complained of coryzal symptoms and a non-productive cough. What is the most likely diagnosis?
A. Gilbert's syndrome
B. Dubin-Johnson syndrome
C. Rotor syndrome
D. Hepatitis C infection
E. Infectious mononucleosis
Answer: A
An isolated hyperbilirubinaemia in a 22-year-old male is likely to be secondary to Gilbert's syndrome. The normal dipstix urinalysis excludes Dubin-Johnson and Rotor syndrome as these both produce a conjugated bilirubinaemia. Viral infections are common triggers for a rise in the bilirubin in patients with Gilbert's
Gilbert's syndrome
Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronyl transferase. The prevalence is approximately 1-2% in the general population
Features:
unconjugated hyperbilinaemia (i.e. not in urine)
jaundice may only be seen during an intercurrent illness
Investigation and management
investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
no treatment required
*the exact mode of inheritance is still a matter of debate
2. Which one of the following steroid creams is the most potent?ia
A. Propaderm
B. Eumovate
C. Betnovate RD
D. Betnovate
E. Dermovate
answer: E
Use weakest steroid cream which controls patients symptomsThe table below shows topical steroids by potency
Very potent
Clobetasone propionate 0.05% (Dermovate)
Potent
Betamethasone dipropionate 0.025% (Propaderm)Betamethasone valerate 0.1% (Betnovate)
Moderate
Betamethasone valerate 0.025% (Betnovate RD)Clobetasone butyrate 0.05% (Eumovate)
Mild
Hydrocortisone 0.5-2.5%
Finger tip rule
1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of the flat of an adult hand
Area of skin Fingertip units per dose
Hand and fingers (front and back) 1.0
A foot (all over) 2.0
Front of chest and abdomen 7.0
Back and buttocks 7.0
Face and neck 2.5
An entire arm and hand 4.0
An entire leg and foot 8.0
Bilirubin 41 µmol/L
ALP 84 U/L
ALT 23 U/L
Albumin 41 g/L
Dipstick urinalys is normal
He has recently complained of coryzal symptoms and a non-productive cough. What is the most likely diagnosis?
A. Gilbert's syndrome
B. Dubin-Johnson syndrome
C. Rotor syndrome
D. Hepatitis C infection
E. Infectious mononucleosis
Answer: A
An isolated hyperbilirubinaemia in a 22-year-old male is likely to be secondary to Gilbert's syndrome. The normal dipstix urinalysis excludes Dubin-Johnson and Rotor syndrome as these both produce a conjugated bilirubinaemia. Viral infections are common triggers for a rise in the bilirubin in patients with Gilbert's
Gilbert's syndrome
Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronyl transferase. The prevalence is approximately 1-2% in the general population
Features:
unconjugated hyperbilinaemia (i.e. not in urine)
jaundice may only be seen during an intercurrent illness
Investigation and management
investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
no treatment required
*the exact mode of inheritance is still a matter of debate
2. Which one of the following steroid creams is the most potent?ia
A. Propaderm
B. Eumovate
C. Betnovate RD
D. Betnovate
E. Dermovate
answer: E
Use weakest steroid cream which controls patients symptomsThe table below shows topical steroids by potency
Very potent
Clobetasone propionate 0.05% (Dermovate)
Potent
Betamethasone dipropionate 0.025% (Propaderm)Betamethasone valerate 0.1% (Betnovate)
Moderate
Betamethasone valerate 0.025% (Betnovate RD)Clobetasone butyrate 0.05% (Eumovate)
Mild
Hydrocortisone 0.5-2.5%
Finger tip rule
1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of the flat of an adult hand
Area of skin Fingertip units per dose
Hand and fingers (front and back) 1.0
A foot (all over) 2.0
Front of chest and abdomen 7.0
Back and buttocks 7.0
Face and neck 2.5
An entire arm and hand 4.0
An entire leg and foot 8.0
Sunday 17 August 2008
AKT Questions
1. A 18-year-old female presents to her GP as she has missed one of her Microgynon 30pills yesterday morning. She has taken Microgynon for the past 2 years and is currently 4 days into a packet of pills. She had sexual intercourse last night and is unsure what to do. What is the correct management?
A. Advise condom use for next 7 days
B. Perform a pregnancy test
C. Omit pill break at end of pack
D. No action neededia
Answer: D
The advice from the Faculty of Family Planning and Reproductive Health Care has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 or 2 pills missed (at any time in the cycle)
• take a pill as soon as possible and then continue taking pills daily, one each day
• no additional contraceptive protection needed
If 3 or more pills missed
• take a pill as soon as possible and then continue taking pills daily, one each day
• the women should use condoms or abstain from sex until she has taken pills for 7 days in a row
• if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
• if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
• if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
2. A 21-year-old female is seen in the first seizure clinic in the outpatient department. A decision is made not to start her on anti-epileptic medication. What restrictions on driving should she be informed about?
A. No restrictions but inform DVLA
B. No restrictions, no need to inform DVLA if not on medication
C. Cannot drive for 1 month from date of seizure
D. Cannot drive for 6 months from date of seizure
E. Cannot drive for 1 year from date of seizure
Answer: E
Patients cannot drive for 1 year following a seizure
The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating to drivers of heavy goods vehicles tend to be much stricter
Specific rules
• first seizure - 1 year off driving
• stroke or TIA - 1 month off driving
• multiple TIAs over short period of times - 3 months off driving
• craniotomy - 1 year off driving*
• narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'
Syncope
• simple faint: no restriction
• unexplained, low risk or recurrence: 4 weeks off
• explained and treated: 4 weeks off
• unexplained: 6 months off
*if the tumour is a benign meningioma and there is no seizure history, licence can be reconsidered 6 months after surgery if remains seizure free
3. If 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?
A. Stop and recommence 4 weeks after acute inflammation has settled
B. Reduce allopurinol to 100mg od until acute attack has settled
C. Stop and switch to colchicine prophylaxis
D. Stop and recommence 2 weeks after acute inflammation has settled
E. Continue allopurinol in current dose
Answer: E
Gout: management
Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)Acute management:
A. Advise condom use for next 7 days
B. Perform a pregnancy test
C. Omit pill break at end of pack
D. No action neededia
Answer: D
The advice from the Faculty of Family Planning and Reproductive Health Care has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 or 2 pills missed (at any time in the cycle)
• take a pill as soon as possible and then continue taking pills daily, one each day
• no additional contraceptive protection needed
If 3 or more pills missed
• take a pill as soon as possible and then continue taking pills daily, one each day
• the women should use condoms or abstain from sex until she has taken pills for 7 days in a row
• if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
• if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
• if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
2. A 21-year-old female is seen in the first seizure clinic in the outpatient department. A decision is made not to start her on anti-epileptic medication. What restrictions on driving should she be informed about?
A. No restrictions but inform DVLA
B. No restrictions, no need to inform DVLA if not on medication
C. Cannot drive for 1 month from date of seizure
D. Cannot drive for 6 months from date of seizure
E. Cannot drive for 1 year from date of seizure
Answer: E
Patients cannot drive for 1 year following a seizure
The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating to drivers of heavy goods vehicles tend to be much stricter
Specific rules
• first seizure - 1 year off driving
• stroke or TIA - 1 month off driving
• multiple TIAs over short period of times - 3 months off driving
• craniotomy - 1 year off driving*
• narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'
Syncope
• simple faint: no restriction
• unexplained, low risk or recurrence: 4 weeks off
• explained and treated: 4 weeks off
• unexplained: 6 months off
*if the tumour is a benign meningioma and there is no seizure history, licence can be reconsidered 6 months after surgery if remains seizure free
3. If 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?
A. Stop and recommence 4 weeks after acute inflammation has settled
B. Reduce allopurinol to 100mg od until acute attack has settled
C. Stop and switch to colchicine prophylaxis
D. Stop and recommence 2 weeks after acute inflammation has settled
E. Continue allopurinol in current dose
Answer: E
Gout: management
Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)Acute management:
NSAIDs
intra-articular steroid injection
colchicine has a slower onset of action. The main side-effect is diarrhoea
if the patient is already taking allopurinol it should be continued.
Allopurinol prophylaxis - see indications below
allopurinol should not be started until 2 weeks after an acute attack has settled
initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 300 µmol/l
NSAID or colchicine cover should be used when starting allopurinol
Indications for allopurinol*
recurrent attacks - the British Society for Rheumatology recommend 'In uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attacks occur within 1 year'
tophi
renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics
*patients with Lesch-Nyhan syndrome often take allopurinol for life
4. A 2-month-old girl is brought to surgery with poor feeding and vomiting. Mother reports that her urine has a strong smell. A urinary tract infection is suspected. What is the most appropriate management?
A. Urine culture + empirical oral antibiotic therapy + ultrasound as soon as possible
B. Urine culture + empirical oral antibiotic therapy + outpatient referral to paediatrics
C. Urine culture + oral antibiotics based upon results + ultrasound within 6 weeks
D. Urine culture + empirical oral antibiotic therapy + ultrasound within 6 weeks
E. Refer immediately to hospital
Answer: E
Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood.
Presentation in childhood depends on age:
infants: poor feeding, vomiting, irritability
younger children: abdominal pain, fever, dysuria
older children: dysuria, frequency, haematuria
features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
NICE guidelines for checking urine sample in a child:
if there are any symptoms or signs suggestive or a UTI
with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
Urine collection method
clean catch is preferable
if not possible then urine collection pads should be used
cotton wool balls, gauze and sanitary towels are not suitable
invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
Management
infants less than 3 months old should be referred immediately to a paediatrician
children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
5. A 19-year-old male with a history of asthma presents to the surgery due to shortness of breath. On examination his peak flow is 250 l/min (usual 600 l/min). Pulse is 100 bpm and the respiratory rate is 24 / min. Examination of the chest reveals a bilateral expiratory wheeze but is otherwise unremarkable. What is the most appropriate management?
A. Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to A&E via ambulance
B. Nebulised salbutamol + advise to double inhaled steroids + allow home if settles with follow-up review
C. Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to medical team via ambulance
D. Oxygen + nebulised salbutamol + prednisolone and review following treatment
E. Nebulised salbutamol + prednisolone + allow home if settles with follow-up review
Answer: D
Whilst his respiratory rate is consistent with a 'moderate' exacerbation his peak flow, less than 50% of usual, means he should be treated as for a 'severe' exacerbation. The British Thoracic Society give specific recommendations on dealing with acute asthma in primary care
Asthma: assessment and management in primary care
Patients with acute severe asthma are stratified into moderate, severe or life-threatening
Moderate
• PEF > 50% best or predicted• Speech normal• RR <>
Severe
• PEF 33 - 50% best or predicted• Can't complete sentences• RR > 25/min• Pulse > 110 bpm
Life-threatening
• PEF <>
Management of moderate asthma
beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
if PEF between 50-75% then prednisolone 40-50mg
Management of severe asthma
consider admission
oxygen 40-60%
beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
prednisolone 40-50mg
if no response then admit
Management of life-threatening asthma
arrange immediate admission (999 call)
oxygen 40-60%
nebulised beta 2 agonists such as salbutamol, and ipratropium prednisolone 40-50mg or IV hydrocortisone 100mg
6. A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following:
Blood group: A Rhesus negative
What is the most appropriate management regarding her rhesus status?
A. Give first dose of anti-D at 28 weeks
B. No action required unless antenatal vaginal blood loss
C. Give first dose of anti-D as soon as possible
D. Give anti-D just prior to delivery
E. No action required
Answer: A
Rhesus negative woman - anti-D at 28 + 34 weeks
NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks
Antenatal care: timetable
NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. They recommend:
10 antenatal visits in the first pregnancy if uncomplicated
7 antenatal visits in subsequent pregnancies if uncomplicated
women do not need to be seen by a consultant if the pregnancy is uncomplicated
AKT Questions
1. A 57-year-old female presents due to problems with urine leakage over the past six months. She describes frequent voiding and not always being able to get to the toilet in time. She denies losing urine when coughing or sneezing. What is the most appropriate initial treatment?ia
A. Trial of oxybutynin
B. Bladder retraining
C. Regular toileting
D. Pelvic floor muscle training
E. Topical oestrogen cream
Answer: B
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the UK population. It is more common in elderly females. NICE released guidance on the management of UI in 2006
Causes:
A. Trial of oxybutynin
B. Bladder retraining
C. Regular toileting
D. Pelvic floor muscle training
E. Topical oestrogen cream
Answer: B
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the UK population. It is more common in elderly females. NICE released guidance on the management of UI in 2006
Causes:
1. overactive bladder (OAB)/urge incontinence: due to detrusor over activity.
2. stress incontinence: leaking small amounts when coughing or laughing
3. mixed incontinence: both urge and stress
4. overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation:
1. bladder diaries should be completed for a minimum of 3 days
2. urine dipstick and culture
Management depends on whether urge or stress UI is the predominant picture.
- If urge incontinence is predominant:
1. bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
2. bladder stabilising drugs: immediate release oxybutynin is first-line
3. surgical management: e.g. sacral nerve stimulation
If stress incontinence is
1. pelvic floor muscle training (for a minimum of 3 months)
2. surgical procedures: e.g. retropubic mid-urethral tape procedures
2. A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. If the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer the patient?
A. Aspirin
B. Warfarin, target INR 2-3
C. No anticoagulation
D. Warfarin, target INR 3-4
E. Warfarin, target INR 2-3 for six months then aspirin
Answer: A
- Young AF, no TIA or risk factors, just give aspirin
Atrial fibrillation: anticoagulation
The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006The guidelines suggest a stroke risk stratification approach when determining how to anticoagulate a patient, as detailed below:
Low risk - annual risk of stroke = 1%
age < color="#ff0000">use aspirin.
Moderate risk - annual risk of stroke = 4%
age > 65 years with no high risk factors, or:
age < color="#ff0000">use aspirin or warfarin depending on individual circumstances
High risk - annual risk of stroke = 8-12%
age > 75 years with diabetes, hypertension or vascular disease (ischaemic heart disease or peripheral arterial disease)
previous TIA, ischaemic stroke or thromboembolic event
valve disease, heart failure or impaired left ventricular functionuse warfarin
3. A 3-year-old boy is brought to the surgery with chickenpox. His mother wants advice regarding school exclusion. What is the most appropriate advice to give?
A. Should be excluded until 2 days after all lesions have scabbed over
B. Should be excluded until 5 days after skin lesions first appeared
C. Should be excluded until skin lesions have disappeared
D. School exclusion is not indicated
Answer B
Chickenpox school exclusion - 5 days after skin lesions first appeared
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion.
Chickenpox is highly infectious
spread via the respiratory route
can be caught from someone with shingles
infectivity = 4 days before rash, until all lesions scabbed over*
incubation period = 11-21 days.
Clinical features (tend to be more severe in older children/adults)
fever initially, itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
systemic upset is usually mild
Management is supportive
keep cool, trim nails
calamine lotion
school exclusion: current HPA advice is 5 days from start of skin eruption. They also state 'Traditionally children have been excluded until all lesions are crusted. However, transmission has never been reported beyond the fifth day of the rash.'
immunocompromised children and infants with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered
A common complication is secondary bacterial infection of the lesions.
Rare complications include
pneumonia, encephalitis (cerebellar involvement may be seen), disseminated haemorrhagic chickenpox, arthritis, nephritis and pancreatitis may very rarely be seen
*it is now thought that patients are no longer infectious 5 days after the rash has developed - see management regarding school exclusion
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