AKT Questions

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.