AKT Questions

1. You are visiting a 73 year old woman who has been living with her son for the last three months, following frequent falls in her own home and then a subsequent diagnosis of vascular dementia. He is worried as he thinks his mum has been getting more forgetful, irritable and argumentative especially over the last 6-8 weeks. He asks if medication might help settle her. He says she forgets to change her clothes some days and says she has eaten when she hasn't. When asked about this, she becomes abusive, agitated and shouts at her son. She states that she wishes to return home as she misses her privacy and her friends, before breaking down in tears. She has no additional relevant past medical history or medication. Which one of the following drugs would treat this patient most appropriately?

a ) Amitriptyline
b ) Diazepam
c ) Donepezil
d ) Citalopram
e ) Risperidone

Answer: D

Vascular dementia is the second commonest dementia affecting older people. It is important to remember that those with dementia may also develop depression. Depression in older people can often cause forgetfulness along with a change in mood –and should be considered in this case. Adapting to life changes and having to accept a loss of independence because of ill health can be triggers for depression. An SSRI is preferred to a tricyclic due to the latter's increased side effect profile. Benzodiazepines should be avoided when possible in the elderly due to the risk of ataxia and falls. Donepezil is indicated for use in Alzheimer's disease but not vascular dementia. Risperidone should be avoided in the elderly due to the increased risk of cerebrovascular disease.

2. Baby Josh was born at 32 weeks gestation and has made good progress. He is now six months old and presents with a 24 hour history of clear nasal discharge and a wheezy cough. On examination, his temperature is 37oC. He is grunting with nasal flaring. Auscultation of his chest reveals bilateral fine inspiratory crackles. Which single management option is most appropriate?

a ) High flow rate oxygen
b ) Nebulised budesonide
c ) Nebulised ipratropium
d ) Nebulised ribavirin
e ) Nebulised salbutamol

Answer: A

Expert consensus suggests that nasal flaring and grunting is one of several indications for acute paediatric referral of babies with bronchiolitis. The need for high flow oxygen implies that admission is required. There is evidence that prematurity is a risk factor for severe disease.

3. You are asked to visit a 36 yr old man who lives in residential care and is significantly learning disabled. Over the last four days, the staff reported that he has gradually been getting more agitated and restless. He has been shouting out and hasn't been eating as much as usual. The staff are not sure when his bowels last moved but his pads have been wet as usual and there is no foul smell from his urine. He is totally unable to give a history himself. Examination is difficult as he is shouting and won't remain still. He is apyrexial, his chest is clear and, although his abdomen is soft, you think he might be tender there. He has cerebral palsy but no other significant history. His medication history is not significant. Which of the following would be the single best treatment to prescribe?

a ) Amoxicillin
b ) Diazepam
c ) Haloperidol
d ) Mebeverine
e ) Movicol

Answer: E

Common conditions, like constipation, can present atypically, often with a change in behaviour, in patients with learning disabilities due to difficulties with communication. One should avoid rushing in with psychotropic medication.

4. You receive a chest x-ray report for a 62 year old woman who has had a recent chest infection. Although there is no abnormality of the cardio-respiratory system, the film is reported as showing "severe osteopenia of the thoracic spine". The woman became menopausal at age 48, smoked until her early 60's and has a body mass index of 27. There is no other past medical or family history of relevance. In confirming or excluding a diagnosis of osteoporosis, what is the single most appropriate investigation?

a ) Dual-Energy X-ray Absorptiometry (DEXA) scan of AP spine and hip
b ) Plain x-ray of lateral spine and proximal femur
c ) Quantitative ultrasound (QUS)of heel
d ) Quantitative computed tomography(QCT) of spine
e ) Markers of bone turnover (calcium, phosphate , alkaline phosphatase)

Answer: A

Assessment of bone density from plain radiographs is not accurate, and, although severe osteopenia on plain films correlates reasonably with low bone mineral density (BMD) measured by DEXA, there is a wide overlap. There is evidence that QUS of the heel can predict fractures of the hip and spine independently of BMD. However, QUS results are difficult to extrapolate from one instrument to another. QCT has been reliably used to measure BMD, especially of the spine. It does, however, deliver high doses of radiation and the scanners are costly. Biochemical markers of bone turnover have no role in the diagnosis of osteoporosis, or in the selection of patients for BMD measurement. Treatment should not be instituted on the basis of plain film findings alone. When plain films are interpreted as ''severe osteopenia'' it is appropriate to suggest referral for DEXA. BMD should normally be measured by DEXA scanning performed on two sites, preferably anteroposterior spine and hip.

5. OPTIONS:
a ) Acute asthma
b ) Epiglottitis
c ) Laryngomalacia
d ) Pertussis
e ) Post viral wheeze
f ) RSV bronchiolitis
g ) Viral laryngotracheobronchitis (croup)
INSTRUCTION: For each child below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.

1 . An 18 month-old boy who has been coryzal, with mild pyrexia on and off for the preceding 36 hours, is brought to the emergency morning surgery. Overnight he has developed noisy inspiration and hoarseness, both of which are most dramatic when crying, but which settle easily at rest. You note a barking, 'sea lion' cough. Chest examination reveals only transmitted upper airways sounds.
The Correct answer is g.

2 . A five month-old boy has been coryzal and sneezy for a day or two. He now has a dry cough and increasing breathlessness which is limiting his feeding. On examination, he is tachycardic and tachypnoeic, with nasal flaring. Chest examination reveals intercostal recession and widespread wheeze, but no focal signs or crepitations.
The Correct answer is f.

3 . A 10 year-old girl has had a persistent, spasmodic cough since developing a 'cold' four weeks earlier. She has vigorous bouts of violent coughing which are worse at night, and which make her face 'go blue', or in some cases, makes her vomit. Her breathing seems normal in between bouts of coughing. Chest examination is essentially normal.
The Correct answer is d.

The peak incidence of croup is in the second year of life, and most cases are safely managed at home. The harsh stridor and barking cough are typical features. Respiratory syncitial virus (RSV) bronchiolitis is the most common lower respiratory tract infection of infancy. Those under six months are most at risk of respiratory failure. The child in this scenario should be admitted for supportive treatment. Immunisation reduces the risk of, but does not fully prevent, pertussis (whooping cough) in all cases. Not all cases have the classic inspiratory "whoop", and symptoms can persist for a number of months after the initial coryzal illness.

6. A 55 year old man has problems with impotence. In the treatment of erectile dysfunction, which one of the following has clear evidence of effectiveness?

a ) Ginseng
b ) Papaverine
c ) Tadalafil
d ) Vacuum devices
e ) Yohimbine

Answer: C

ED has many causes and all of the above options have been used in its treatment. However, of the options presented, only PDEIs such as tadalafil have clear evidence of effectiveness for the treatment of ED.

7. A 45 year old woman had her last cervical smear ten years ago. Her recent cervical smear, taken two weeks ago, has been reported as showing moderate dyskaryosis consistent with CIN 2. Which is the single most appropriate course of action?

a ) Repeat smear immediately
b ) Arrange routine colposcopy
c ) Repeat smear in three years
d ) Repeat smear in six months
e ) Arrange urgent colposcopy

Answer: B

Moderate dyskaryosis is abnormal and equivalent to CIN 2. HPV changes are also present in <1%. Routine referral to a colposcopy clinic is appropriate for excision/biopsy of the lesion.

8. A 35 year old former Accountant, who remains a daily Crack Cocaine user, has agreed to attend you every 3-4 months for support and health check monitoring. He has never injected and is HIV negative. Which two of the following should be included in your examination?

a ) Checking his FBC
b ) Taking his BP
c ) Checking for proteinuria
d ) Monitoring his peak flow rate
e ) Checking for glycosuria
f ) Carrying out fundoscopy

Answer: B & D

Chronic cocaine use commonly results in cardiovascular disease, raised BP, stroke, seizures, and lung disease.

9. A 17 year old man presents in a morning surgery with several hours of acute left testicular pain. He is unsure if there are urinary symptoms, but there is no history of injury. On examination, the left testicle is very tender. Clinical examination is otherwise unhelpful. Which is the single best course of action?

a ) Arrange an outpatient department ultrasound of the testes
b ) Arrange to review at the end of the evening surgery
c ) Arrange for admission via urology
d ) Check bloods for levels of AFP and ßhCG
e ) Prescribe ciprofloxacin

answer: C

Acute testicular pain can be difficult to manage in primary care. In this case, the differential is between epididymo-orchitis and testicular torsion. Diagnostic signs are not sufficiently sensitive. Torsion is commoner in adolescents and orchitis in those who are older/sexually active. The treatment of torsion is time-sensitive and requires urgent Doppler ultrasound assessment. The only safe course of action is to admit as an emergency via urology.

10. OPTIONS:
a ) Anorexia nervosa
b ) Anxiety
c ) Binge eating disorder
d ) Bulimia nervosa
e ) Depression
f ) Munchaushen syndrome
g ) Personality disorder
INSTRUCTION: For each of the patients below, choose the most likely mental health diagnosis above? Each option may be used once, more than once or not at all.

1 . A 26 year old woman, with a BMI of 25, is a frequent attender at the surgery. Her last period was three weeks ago. She is a vegan and is obsessed with what she eats. She has been like this since her early teens. She tends to isolate herself from others. She has made several suicide attempts. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is g.

2 . A 36 year old woman, with a BMI of 21, had her last period three weeks ago. She makes frequent visits to her dentist because of caries. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is d.

3 . A 17 year old woman, with a BMI of 14, had her last period a year ago. She attends the gym for four hours a day. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is a.

It is obviously important to distinguish between different eating disorders and other mental health problems that may present in a similar way. It is also important to be aware that a request for laxatives is not as straightforward as it may at first appear. Bulimics manage to maintain a normal BMI. Vomiting may show itself in dental caries due to the gastric acid's attack on dental enamel. Diarrhoea may be common in bulimic patients. Even though Anorexics may have similar behaviour patterns, they always have a low BMI and are often amenorrhoeic. Patients with a binge eating disorder eat vast quantities of food and are often obese as they do not compensate for their eating by inducing vomiting.

11. A 60 year old smoker, who is on treatment for hypertension and ischaemic heart disease, presents with a cough for the last six weeks. In considering a management plan for him, which one of the following statements, about cough, would you feel is most valid?

a ) ACE-inhibitor related cough is dose related
b ) Chronic cough related to smoking is not dose related
c ) GORD-associated cough may occur in the absence of GI symptoms
d ) Viral-induced cough responds to over-the-counter remedies
e ) Rhinosinusitis is rarely associated with

Answer: C

ACE-inhibitor cough is not dose related and onset can be more than a year after starting treatment. One of the commonest causes of persistent cough is smoking, which appears to be dose-related. Although patients may report subjective benefit from OTC cough remedies, there is no evidence for their efficacy. Rhinosinusitis is a common cause of cough. Spirometry is mandatory in the investigation of chronic cough.

12. OPTIONS:
a ) Erythema migrans
b ) Granuloma annulare
c ) Impetigo
d ) Palmoplantar pustulosis
e ) Pitted keratolysis
f ) Tinea pedis
g ) Varicella zoster
INSTRUCTION: For each of the following patients, select the single most appropriate diagnosis from the list above. Each option can be used once, more than once or not at all.

1 . A three year-old girl is brought from nursery school by her mother. Over the last 24 hours, she has developed a cluster of small pustules on her right face. Some of these have evolved into fragile blisters which are easily burst, leaving a golden crusted appearance. She is otherwise well. The Correct answer is c.

2 . A 42 year-old male Scout leader attends because he has noticed a gradually enlarging, pink, annular lesion on his left buttock. He thinks he may have been bitten by something during a camping expedition in rural Wales three weeks ago. It has not responded to topical Clotrimazole cream as suggested by his pharmacist
The Correct answer is a.

3 . A 25 year-old male fitness instructor consults with a complaint of excessive and embarrassing foot odour over the last year or so. On removing his training shoes and socks, you note a pungent odour and a thickening and whitening of the skin on the plantar aspect of his heels and forefoot. Multiple punched out erosions are noted on the affected skin.
The Correct answer is e.

Case 1, Impetigo, pages 517-523 Click here Case 2, Erythema Migrans, pages 267-272 Click here Case 3, Pitted Keratolysis, page 416 Click here

13. A man is 58 years old. One year ago, he began to have some difficulty swallowing and developed fasciculation of his tongue. His voice has become progressively weaker and he is now only able to communicate by writing. Which is the single most likely diagnosis?

a ) Dystrophia Myotonica
b ) Motor Neurone Disease
c ) Multiple Sclerosis
d ) Myaethenia Gravis
e ) Paraneoplastic Syndrome

Answer: B

The man has a bulbar palsy causing dysphonia, dysarthria and dysphagia. Each of the conditions listed may be associated with these; however only in Motor Neurone Disease is there fasciculation. He has loss of function of the lower motor neurones of the brainstem motor nuclei resulting in weakness of the tongue, facial muscles and the muscles involved in chewing and swallowing.

14. A 36 year old man presents with a short history of lethargy, weight loss, thirst and passing copious amounts of urine. Your provisional diagnosis would best be confirmed by which one of the following results?

a ) Glycosuria of 3+
b ) Random blood glucose of >10mmol/l
c ) HbA1c =6%
d ) Fasting blood glucose of >7mmol/l
e ) Post prandial blood glucose of >9mmol/l

Answer: D

15. OPTIONS:
a ) Absence seizure
b ) Febrile seizure
c ) Infantile spasms (West's syndrome)
d ) Myoclonic epilepsy
e ) Pseudoseizure
f ) Breath-holding
INSTRUCTION: For each patient below, choose the single most likely diagnosis above. Each option may be used once, more than once or not at all.

1 . A four month old baby develops tonic spasms, especially flexionally, that occur in runs every 5–10 seconds. The child is otherwise well.
The Correct answer is c.

2 . A two year old child is noted by his mother to be having staring spells, with fluttering of his eyelids, lasting a few seconds at a time.
The Correct answer is a.

3 . A five year old child develops sudden involuntary spasm of a group of muscles with symmetrical repetitive jerking. There is no loss of consciousness.
The Correct answer is d.

West's syndrome starts in first year of life. Runs of tonic spasms occur every 5-10 seconds. It is associated with loss of vision and social interaction. Most commonly one gets flexion spasms ("salaam" spasms). Myoclonic epilepsy is the sudden involuntary spasm of a muscle or a group of muscles. Lennox-Gastaut is a severe form (starts age 2-6y) with intractable seizures.

16. A 24 year old man with Down's syndrome visits you with his mum. He states that he is well but his mum has noticed a change in him. For the last few months, he has been much more lethargic than usual, is participating less at his day centre and wants to spend longer in bed sleeping. She has also noticed he has gained more weight and clothes he wore about four months ago no longer fit. Which one of the following is the most likely cause of his symptoms?

a ) Addison's disease
b ) Cushing's syndrome
c ) Hypercalcaemia
d ) Hypothyroidism
e ) Type 2 diabetes mellitus

Answer: D

Down's syndrome is a common cause of learning disability, with the average GP having 1 in 1000 patients with this syndrome. Hypothyroidism is often not routinely screened for in Down's syndrome; but is much more common than in the general population. There is an increased incidence of type 1 diabetes which presents in early childhood; but there is no increased incidence of type 2 diabetes associated with Down's syndrome. Down's syndrome is also associated with congenital heart disease, congenital GIT abnormalities, atlanto-axial instability, Alzheimer's disease, leukaemia, deafness, and cataracts.