AKT Questions

1. A taxi driver re-attends your surgery. A urine sample taken one week before shows a positive test for metabolites of morphine verifying his story of drug misuse. He would like to go on to Buprenorphine (Subutex) as he hopes to detoxify quickly after a period of stabilisation. You agree. What is the single most common side effect of this regime?

a ) Respiratory depression
b ) Drowsiness
c ) Abdominal Pain
d ) Acute opiate withdrawal
e ) Depression

Answer: D

In patients taking a high level of opiates, Buprenorphine may precipitate withdrawal effects due to its partial antagonist activity on mu opioid receptors. It is for this reason that it is very safe in overdose, rarely causing typical opioid symptoms such as respiratory depression, drowsiness or abdominal pain and vomiting. These symptoms are more typically seen with Methadone, Lofexidine and Naltrexone respectively. Buprenorphine may however be implicated in respiratory depression if combined with alcohol or benzodiazepines.

2. A 23 year old man presents with a five day history of right lower lumbar pain with no obvious trigger factor, no radiation and no other symptoms. On examination, you find right lower lumbar paraspinal tenderness and reduced lumbar movements. Which is the single best evidence-based management plan?

a ) Acupuncture
b ) Staying active
c ) Back exercises
d ) Epidural injection
e ) Lumbar support

Answer: B

"Clinical Evidence" indicates that, for acute low back pain, advice to stay active and non steroidal anti inflammatory drugs are beneficial. Back exercises are unlikely to be beneficial and acupuncture, epidural steroid injection and lumbar support are of unknown effectiveness.

3. A woman has terminal pancreatic cancer and is on a syringe driver containing diamorphine in water. Her pain is very well controlled; but she has distressing respiratory secretions and is also very restless. Which two of the following could best be added to her syringe driver to control these symptoms?

a ) Cyclizine
b ) Dexamethasone
c ) Hyoscine hydrobromide
d ) Levomepromazine
e ) Metoclopramide
f ) Prochlorperazine

Answer: C & D

Hyoscine is very effective at controlling secretions in its hydrobromide form, whereas in its butylbromide form it is valuable for relief of bowel colic. It has some sedative effects but these would probably not be sufficient to control the woman’s restlessness. Levomepromazine would be ideal for this. Cyclizine and metoclopramide are useful anti emetics but cyclizine is particularly liable to precipitate with diamorphine. Dexamethasone can be given in a syringe driver to reduce cerebral oedema

4. A 49 year old man presents with a five week history of epigastric pain after meals. It is sometimes awakening him in the night. He has also been vomiting and is sure he has lost weight. On examination, you find epigastric tenderness, with no mass nor peritonism. An FBC is normal. Which is the single most appropriate investigation?

a ) Abdominal ultrasound
b ) Barium meal
c ) Serum amylase estimation
d ) Helicobacter pylori test
e ) Upper GI endoscopy

Answer: E

SIGN and NICE both recommend upper gastrointestinal endoscopy as the investigation of choice in dyspepsia with alarm symptoms (persistent vomiting, anorexia, weight loss, gastrointestinal blood loss or epigastric mass).

5. A 45 year old woman presents with tiredness, lethargy, dry skin constipation and weight gain. Of the following, which is the single most likely additional clinical feature that may be present?

a ) Carpal tunnel syndrome
b ) Proptosis
c ) Amenorrhoea
d ) Pre-tibial myxoedema
e ) Delirium

Answer: A

In Hypothyroidism mucopolysaccharide deposition can occur throughout the body affecting all organ systems. Pre-tibial myxoedema (swellings above the lateral malleoli) occurs in Graves Disease (overactive thyroid). Altered mental state can occur with depression and dementia and rarely myxoedematous coma. Other autoimmune diseases such as pernicious anaemia can be associated with hypothyroidism. Iron and folate deficiencies can occur with microcytic anaemias and macrocytosis.