AKT Questions

1. Arrythmias: Concerning the above ECG and the list of available options.

a. Atrial Flutter
b. Ventricular Fibrillation
c. Premature Atrial Complex
d. 2nd Degree AV Block
e. Complete Heart Block
f. Mobitz type I
What abnormal rhythm is represented by the ECQ tracing above?


Answer: D

This is 2nd degree AV block (Mobitz II). It is almost always a disease of the distal conduction system. It is characterised by intermittently nonconducted P waves not preceded by PR prolongation and not followed by PR shortening. It is important as it may progress to Complete Heart Block

2. Depression: The NICE guidelines 2006 recommend one particular package of computerised Cognitive Behavioural Therapy (CBT) for the treatment of depression. Which package is this?

A.Beating the Blues
B. COPE
C. FearFighter
D. OCFighter
E. Overcoming Depression

Answer: A

NICE has made the following recommendations about the use of computerised cognitive behavioural therapy (CCBT) to treat depression and anxiety. It recommends using: 1. Beating the Blues for people with mild and moderate depression. 2. FearFighter for people with panic and phobia.

3. Pelvic Inflammatory Disease: Which ONE of the following is the most common causative organism implicated in Pelvic Inflammatory Disease (PID) in the UK?

A. Candida Albicans
B. Chlamydia trachomatis
C. Human Papilloma Virus
D. Mycoplasma genitalium
E Neisseria gonorrhoeae

Answer: B

The most common organism to cause PID in the UK is Chlamydia trachomatis (in at least 50%). Gonorrhoea (Neisseria gonorrhoea) is also a fairly common cause. Both may occur together, but in at least 20% of patients with PID no definite cause is found.

4. Whooping Cough: Which ONE of the following most closely matches the incubation period for Whooping Cough?

A. 0 - 5 days
B. 15 - 30 days
C. 5 - 15 days
D. > 30 days
E. none of the above

Answer: C

The incubation period of whooping cough (bordetella pertusis) - the time between contracting the infection and the appearance of the main symptoms - can vary from 5 to 15 days or even longer (as long as 20 days).

5. Intracranial Malignancy: A 57 year old gentleman well know to you presents to your clinic complaining of increasing headaches. He has an inoperable end-stage primary glioblastoma with raised intracranial pressure. What would you prescribe to help with his pain?

A. Amitryptilline
B. Dexamethasone
C. Paracetamol
D. Tramadol
E. Voltarol

Answer: B

In a palliative care setting such as this, short courses of high dose corticosteroids are often effective in reducing the oedema and raised intracranial pressure of brain malignancies.

6. Identification Of Heart Sounds: In which ONE of the following pathologies might you hear an opening snap after the second heart sound?

A. Aortic Regurgitation
B. Aortic Regurgitation
C. Aortic Stenosis
D. Mitral Stenosis
E. Patent Foramen Ovale

Answer: D

In Mitral Stenosis, an opening snap, which is an additional high pitched sound, may be heard after the A2 (aortic) component of the second heart sound. In individuals with mitral stenosis the pressure in the left ventricle can drop rapidly leading to forceful opening of the valve and hence the opening snap.

7. Osteoporosis: Which ONE of the following is NOT a risk factor for the development of osteoporosis?

A. Below Average BMI
B. Coeliac Disease
C. Female sex
D. High dietary salt intake
E. Hyperthyroidism

Answer: D

Whilst the WHO recognises limiting salt intake as part of a 'healthy lifestyle' and together with a number of other measures in attempting to delay or prevent the development of Osteoporosis, there is no definitve evidence that salt is a risk factor for Osteoporosis. Na-induced calciuria has been well documented and provides a physiological basis for the proposed role of dietary Na (or salt) as a risk factor for osteoporosis. However, the evidence is based primarily on acute salt-loading studies, and there are insufficient data on the effects of high salt intake on net Ca retention to predict long-term effects on bone health. Whilst a randomized longitudinal study of different sodium intake in two groups could clarify the role of sodium in bone mass, research to date has failed to confirm high dietary salt intake as a risk factor in the development of osteoporosis.

8. Breast Pathology: For each of the following scenarios select the most likely diagnosis.

a. Ductal carcinoma in-situ
b. Fibroadenoma
c. Benign mammary dysplasia
d. Phyllodes tumour
e. Duct ectasia
f. Fat necrosis
g. Carcinoma of the breast
h. Paget's disease of the nipple

1. A 42 year old woman presents with a firm palpable mass in her left breast. She has noticed the size has increased rapidly over the past 3 months and she has become concerned. There is no involvemnt or discharge from the nipple. Some tenderness over the left breast is noted with shiny, almost translucent skin, and the size is estimated at 5x8x10 cm.
Answer: D

Phyllodes tumours are rare, predominantly benign (around 90%), tumours that account for only about 1% of tumours of the breast. It is typically moveable with a smooth texture and relatively large in size (around 5cm). It is interesting to note it tends to involve the left breast more commonly than the right.

2. A 52 year old woman presents with a tender small but firm lump in her left breast. There is evidence of recent injury with overlying bruising and tenderness. Coarse calcification is noted on mammography and fat globules on excision biopsy.
Answer: E

3. A 57 year old lady with known intraductal breast carcinoma presents following left mastectomy with discharge of the nipple on that side accompanied by itching and flaking.
Answer: H

The incidence of Paget's diseae of the breast is around 4% of cases of female breast cancer. This syndrome presents as eczematoid skin changes such as redness and mild flaking of the nipple skin. As Paget's advances, symptoms may include tingling, itching, increased sensitivity, burning, and pain. There may also be discharge from the nipple. Most cases are associated with invasive breast cancer and some cases occur following mastectomy (as in this scenario) even if there is no breast tissue present. You should also note that it may also involve the aereolar skin in addition to the nipple.

9. Pathogenic Organisms: For each of the following clinical infections select the MOST LIKELY pathogenic organism from the list of available options.

a. Mycoplasma Pneumoniae
b. Haemophilus Influenzae
c. Staphylococcus Aureus
d. Bacteroides Fragilis
e. Polymicrobial
f. Escherichia Coli

1. A 23 year old woman with Crohn's disease and an associated perirectal abscess.
Answer: E
2. A 45 year old smoker with Community Acquired pneumonia
Answer:B
3. A 60 year old male with a Urinary Tract Infection.
Answer: F
4. A 68 year old gentleman with Bacterial Endocarditis
Answer: C

A variety of risk factors are associated with abcess development, these include Crohn's disease, radiation fibrosis, carcinoma and trauma. A perirectal abscess is usually an aerobic and anaerobic polymicrobial infection. Bacteroides Fragilis is the predominant anaerobe and other common bacteria include Escherichia Coli, Proteus, Bacteroides and Streptococcus. This is not to be confused with a perianal abscess which is easily palpable, not accompanied by fever or a raised white cell count unless concomitant with an immunosupressed state.
The most likely pathogen in community acquired pneumonia is streptococcus pneumoniae, however it is not offered as an option - haemophilus influenzae being the next most likely pathogen and therefore the correct choice. You should always remember that up to 13% of community acquired pneuomnia is viral in origin.
As with females, the usual route of inoculation in males is with gram-negative aerobic bacilli from the gut, with Escherichia coli being the most common offending organism. In males aged 3 months to 50 years. The incidence of UTI in men approaches that of women only in men older than 60 years.
Most cases of endocarditis are caused by a select group of organisms. Gram-positive bacteria, particularly alpha-haemolytic streptococci, staphylococcus aureus and coagualse-negative staphylococci are the most common. Enterococci are a rare cause but are often resistant to antibitotic treatment. Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella species (HACEK organisms) are particularly common in neonates and immunocompromised children. A patient may have typical clinical and/or echocardiographical findings of endocarditis but have persistently negative blood cultures. In this instance there may have been recent antibiotic therapy or infection with a fastidious organism.

10. Raynaud's Phenomenon: The most common cause of Raynaud's Phenomenon is?

A. Idiopathic
B. Rheumatoid arthritis
C. Scleroderma
D. Systemic Lupus Erythematosus
E. Through the use of vibrating tools or machinery

Answer: A

90% of cases of Raynaud's phenomenon are idiopathic.