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