1. A 70 year old patient with metastatic lung cancer is being treated with a slow release morphine preparation for pain relief. Which one of the following is a recognised side effect of this treatment?
a ) Hyperthermia
b ) Urinary retention
c ) Convulsions
d ) Jaundice
e ) Excess salivation
Answer: B
Side effects of morphine salts include hypothermia and dry mouth among many others. Morphine has an effect on the muscle of the urinary tract, causing the sphincter to contract. This may lead to urinary retention.
2. OPTIONS:
a ) Agitated depression
b ) Alzheimers dementia
c ) Anxiety disorder
d ) Bi-polar disorder
e ) Psychotic state
f ) Multi-infarct dementia
g ) Personality disorder
INSTRUCTION: For each clinical scenario below, select the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A 38 year old woman attends the surgery. She is tense and agitated with feelings of impending doom. She describes a lump in her throat, is prone to palpitations and has tingling in her hands. She finds it difficult to pinpoint why she feels like this.
The Correct answer is c.
2 . A 19 year old student attends the surgery accompanied by a friend. She is withdrawn and pre-occupied. On questioning, her friend says she has been under a lot of stress recently with exams. She has commented that residents of a neighbouring flat are listening to what she is thinking.
The Correct answer is e.
3 . A 60 year old man attends the surgery with his wife. He is over bearing and euphoric. He has a history of depression. His wife comments that he has been socialising and drinking more than usual. He is spending outwith his financial means and has great plans for a bizarre business venture.
The Correct answer is d.
Anxiety is a normal response to an unusual or stressful event; it is the psychological component of the "flight or fight" response. Anxiety is considered abnormal when it is excessively severe or it occurs in the absence of a stressful event or it impairs social, physical or occupational functioning.A psychosis is any major mental disorder of organic or emotional origin that is marked by a derangement of personality and loss of contact with reality. A psychosis is characterised by loss of insight into the fact that one is mentally ill, usually as part of a more general disturbance of the normal relationship between reality and imagination, fact and fantasy. The two most important symptoms of a psychotic disorder are hallucinations and delusions.Bipolar affective disorder is a condition where there are periodic swings of mood periods of months or years between manic episodes and depressed episodes
3. A 72 year old man has metastatic cancer of the prostate gland but has been doing quite well.. For the past two days, he has had low back pain which is worse when he moves but with no radiation. He increased his dose of co-codamol 30/500 two days ago. His wife has just phoned to say he cannot get out of bed and is unable to empty his bladder. He is constipated and his bowels last opened three days ago. You perform a rectal examination and find his rectum is empty and notice that he has poor anal tone. Which is the single most appropriate course of action?
a ) Arrange for hospital specialist review today
b ) Arrange an urgent domiciliary physiotherapy assessment
c ) Arrange for the District Nurse to come and catheterise him
d ) Change his co-codamol to morphine
e ) Prescribe a laxative
Answer: A
This man has probably developed spinal cord compression which is often preceded by back pain. His constipation is a result of this rather than an increase in his codeine intake. He needs urgent assessment and may respond well to radiotherapy if this can be arranged urgently (Oxford Textbook of GP suggests within 24-48 hours of onset of neurological signs.) A high dose of dexamethasone 16mg/day will help reduce compression prior to radiotherapy. Once paralysed less than 5% of patients will walk again.
4. A 45 year old man, with a long history of ear infections, states that his left ear has been discharging continuously over the last three months. His hearing has worsened and he has experienced dizziness. There is a feeling of fullness in the ear. In addition, there is an ache behind the ear, especially at night. On examination, there is a faecal smelling discharge and granulation tissue can be seen. What is the single most likely diagnosis?
a ) Chronic otitis media
b ) Tympanosclerosis
c ) Chronic otitis externa
d ) Cholesteatoma
e ) Middle ear osteoma
Answer: D
The history is strongly suggestive of cholesteatoma, the principle cause of which is recurring ear infections. Cholesteatoma consists of squamous epithelium that is trapped in the middle ear or mastoid. It is slow growing and causes destruction of bone. This results in a conductive deafness. Facial nerve damage can occur. Rarely, erosion of the cranial bone occurs with resultant meningitis.
5. OPTIONS:
a ) Amotivational syndrome
b ) Cardiovascular collapse
c ) Hallucinations
d ) Perforation of nasal septum
e ) Renal failure
f ) Seizures
g ) Tinnitus
INSTRUCTION: Match the following scenarios of drug misuse with the most likely above side effect. Each option can be used once, more than once or not at all.
1 . A 48 year old man who self-harms using coproxamol.
The Correct answer is b.
2 . A 42 year old woman who has been smoking cannabis “for years”.
The Correct answer is a.
3 . A 34 year old doctor who has been abusing benzodiazepines for over a year, but stopped yesterday.
The Correct answer is f
Coproxamol in self harm can cause hepatic failure. In addition, the dextropropoxyphene component, and its metabolites are cardiotoxic and can cause dysrhythmias and cardiovascular collapse Patients showing disinterest in work, family and friends may be suffering from the long term effects of cannabis abuse (amotivational syndrome). Sudden withdrawal from benzodiazepines can elicit seizures. Benzodiazepines are a relatively common drug of abuse in medics.
6. A 55 year old man has had ulcerative colitis for 20 years. It is usually well controlled on mesalazine 4g daily. Having developed recent back pain, he has been taking ibuprofen 400mg three times a day (which was prescribed for his wife). For the past week, he has had an increase in the frequency of his bowel motions which now occur four times a day and are more liquid than usual. He has had no rectal bleeding or fever. What is the single most appropriate drug adjustment to make?
a ) Add loperamide
b ) Add oral prednisolone
c ) Add rectal prednisolone
d ) Increase mesalazine
e ) Stop ibuprofen
Answer: E
NSAIDs are noted for precipitating a relapse in inflammatory bowel disease and should be avoided. Loperamide is of use as a maintenance treatment; but has no place in the management of a relapse such as is described here. Prednisolone is useful in bringing more severe symptoms under control (e.g. more than four motions per day with rectal bleeding and systemic upset). In such a case, a dose of 40mg daily is recommended in combination with a rectal preparation. There should be a gradual reduction over a period of eight weeks as a rapid withdrawal often results in a relapse. The maximum dose of mesalazine is 4g daily and there is nothing to be gained by increasing this.
Friday 28 November 2008
Tuesday 25 November 2008
AKT Questions
1. A 25 year old Russian immigrant presents with a low-grade pyrexia, generalised lymphadenopathy and a symmetrical maculopapular rash. The rash involves the scalp, palms of the hands and soles of the feet. He was also concerned about a shallow ulcerated patch on his groin but this now seems to be resolving. What is the single most likely diagnosis?
a ) Chancroid
b ) Herpes genitalis
c ) Lymphogranuloma venereum
d ) Rubella
e ) Secondary syphilis
Answer: E
Although Syphilis can be co-existent with HIV infection the symptoms described are classical of secondary syphilis. STDs appear to be very common in the former Soviet block at present. Chancroid - Haemophilus ducreyi, the microbial agent of chancroid, used to be probably the most common cause of genital ulcers in many parts of the world. However, the pattern of genital ulcer disease (GUD) is changing. Lymphogranuloma venereum is a sexually transmitted disease caused by the invasive Chlamydia trachomatis.. LGV is primarily an infection of lymphatics and lymph nodes. It gains entrance through breaks in the skin, or it can cross the epithelial cell layer of mucous membranes. A rash is not typical. The classical exanthems are not associated with genital ulceration.
2. A 50 year old man presents with reflux-type symptoms for the first time. On questioning, he has had no haematemesis nor melaena, no weight loss and no difficulty swallowing. He has taken bendroflumethiazide 2.5mgs daily for hypertension for the last two years and amlodipine was added four months ago. He states that he drinks less than 10 units of alcohol per week. His BP today is116/70. You decide on an intervention strategy and will review him in four weeks. Which one of the following actions is the most appropriate, at this point in time?
a ) Commence triple therapy
b ) Commence lansoprazole 30mg daily
c ) Cease bendroflumethiazide
d ) Commence gaviscon advance 8 tablets daily
e ) Cease amlodipine
Answer: E
NICE Guideline 17 outlines a stepwise approach to management. If there are no alarm signs, one should initially review suspect medication and address lifestyle precipitants before commencing antacids/PPIs or initiating investigations. Calcium antagonists can commonly cause dyspepsia.
3. 32-year-old male solicitor attends after experiencing two episodes of severe and debilitating headache in the last two days. On both occasions, he developed a rapid-onset, severe headache focused around his left eye, which became noticeably red and watery. Each time the headache lasted for one hour before resolving. He took no analgesia. He felt nauseated by the intensity of the pain, but experienced no visual disturbance or other neurological symptoms. He smokes 15 cigarettes a day and drinks 10 units of alcohol per week. He has no residual symptoms, and clinical examination is normal. Which one of the following treatments would be the licensed drug of choice to be taken at the onset of any subsequent attack?
a ) Dispersible Aspirin 900mg orally
b ) Ergotamine 2mg suppository per rectum
c ) Sumatriptan 6mg injection subcutaneously
d ) Verapamil 80mg tablet orally
e ) Zolmitriptan 5mg orodispersible tablet
Answer: C
This is classic Cluster Headache. It is five times commoner in males than females, and affects smokers more than non-smokers. Sumatriptan by s/c injection is the treatment of choice, and the only triptan licensed for this indication. Verapamil and ergotamine are recognised for prophylaxis only. Cluster Headache rarely responds to standard analgesia.
a ) Chancroid
b ) Herpes genitalis
c ) Lymphogranuloma venereum
d ) Rubella
e ) Secondary syphilis
Answer: E
Although Syphilis can be co-existent with HIV infection the symptoms described are classical of secondary syphilis. STDs appear to be very common in the former Soviet block at present. Chancroid - Haemophilus ducreyi, the microbial agent of chancroid, used to be probably the most common cause of genital ulcers in many parts of the world. However, the pattern of genital ulcer disease (GUD) is changing. Lymphogranuloma venereum is a sexually transmitted disease caused by the invasive Chlamydia trachomatis.. LGV is primarily an infection of lymphatics and lymph nodes. It gains entrance through breaks in the skin, or it can cross the epithelial cell layer of mucous membranes. A rash is not typical. The classical exanthems are not associated with genital ulceration.
2. A 50 year old man presents with reflux-type symptoms for the first time. On questioning, he has had no haematemesis nor melaena, no weight loss and no difficulty swallowing. He has taken bendroflumethiazide 2.5mgs daily for hypertension for the last two years and amlodipine was added four months ago. He states that he drinks less than 10 units of alcohol per week. His BP today is116/70. You decide on an intervention strategy and will review him in four weeks. Which one of the following actions is the most appropriate, at this point in time?
a ) Commence triple therapy
b ) Commence lansoprazole 30mg daily
c ) Cease bendroflumethiazide
d ) Commence gaviscon advance 8 tablets daily
e ) Cease amlodipine
Answer: E
NICE Guideline 17 outlines a stepwise approach to management. If there are no alarm signs, one should initially review suspect medication and address lifestyle precipitants before commencing antacids/PPIs or initiating investigations. Calcium antagonists can commonly cause dyspepsia.
3. 32-year-old male solicitor attends after experiencing two episodes of severe and debilitating headache in the last two days. On both occasions, he developed a rapid-onset, severe headache focused around his left eye, which became noticeably red and watery. Each time the headache lasted for one hour before resolving. He took no analgesia. He felt nauseated by the intensity of the pain, but experienced no visual disturbance or other neurological symptoms. He smokes 15 cigarettes a day and drinks 10 units of alcohol per week. He has no residual symptoms, and clinical examination is normal. Which one of the following treatments would be the licensed drug of choice to be taken at the onset of any subsequent attack?
a ) Dispersible Aspirin 900mg orally
b ) Ergotamine 2mg suppository per rectum
c ) Sumatriptan 6mg injection subcutaneously
d ) Verapamil 80mg tablet orally
e ) Zolmitriptan 5mg orodispersible tablet
Answer: C
This is classic Cluster Headache. It is five times commoner in males than females, and affects smokers more than non-smokers. Sumatriptan by s/c injection is the treatment of choice, and the only triptan licensed for this indication. Verapamil and ergotamine are recognised for prophylaxis only. Cluster Headache rarely responds to standard analgesia.
Monday 24 November 2008
AKT Questions
1. OPTIONS:
a ) Candidiasis
b ) Chlamydia
c ) Gonorrhoea
d ) HIV
e ) Herpes simplex
f ) Scabies
g ) Syphilis
INSTRUCTION: Genital infection presents in general practice in a variety of ways. Sexually transmitted infection can lead to significant morbidity and needs to be managed appropriately in primary care. For each of the following patients below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A 31 year old woman attends with a history of a febrile illness for five days followed by development of severe pain in the vulval area. Examination reveals numerous small ulcers. There is bilateral inguinal lyphadenopathy. She has been in a stable monogamous relationship for two years.
The Correct answer is e.
2 . A 22 year old man presents with a painful right knee, sore eyes and dysuria after an episode of unprotected intercourse with a new partner two weeks previously.
The Correct answer is b.
3 . A 35 year old homosexual man presents with a non itchy maculopapular rash on the palms of his hands and the soles of his feet, three months after a holiday in Brighton.
The Correct answer is g.
Herpes simplex can occur months or years into a stable relationship. Sexually acquired reactive arthritis (SARA) should be thought of in a patient who ‘can’t see, can’t pee and can’t bend the knee’. Chlamydia is the cause in 70% of cases. Secondary Syphilis is the great mimicker, and presents in a variety of ways, at least four weeks after the infective episode. Commonly it presents as a non itchy maculopapular rash affecting the palms and soles.
2. A 67 year old woman, who had chemotherapy two years ago, has metastatic breast carcinoma. During the past three weeks, she has become increasingly weak, tired and thirsty. She has had some nausea, is constipated and has lost her appetite. She has generalised aches and pains and has been a little confused. Which single biochemical abnormality is most likely to be implicated?
a ) Hypercalcaemia
b ) Hypocalcaemia
c ) Hypokalaemia
d ) Hypermagnesaemia
e ) Hypomagnesaemia
Answer: A
Hypercalcaemia usually has a non-specific presentation and includes the symptoms described exhibited by the patient. About 40% of breast tumours are liable to result in this especially where there is bone spread. Hypocalcaemia and hypokalaemia are both associated with tetany and there is no direct link with malignancy. Hypomagnesaemia is occasionally associated with cisplatin chemotherapy. Hypermagnesaemia is a rare condition found in neonates – again with no malignant association.
3. A 36 year old woman presents in the middle of a surgery with an acute flare up of her asthma symptoms. She complains of feeling more breathless and wheezy. Which one of the following signs, on its own, would prompt you to have her admitted as an emergency to hospital?
a ) Peak flow is reduced to 60% of her usual
b ) Resting pulse rate is 100/min
c ) Pulse oximetry shows SpO2 to be 90%
d ) Respiratory rate is 20/min
e ) Wheeze present throughout both lung fields
Answer: C
Immediate hospital admission is necessary if signs of life threatening asthma are present – peak flow <33% of best/predicted, SpO2 <92%, silent chest, cyanosis, feeble respiratory effort, bradycardia, dysrhythmia, hypotension, exhaustion, confusion, coma.
4. A 30 year old woman complains of frequent headaches. She describes a unilateral, throbbing headache associated with photophobia and nausea which can last more than 24hrs. For the last three months, the headaches have occurred at least once a week. She has been taking paracetamol but this has not helped. She has asthma and uses salbutamol and belcometasone inhalers. She has no other significant past medical history. Examination is normal. She asks for medication to help prevent her headaches occurring. Which is the single most appropriate drug?
a ) Co-codamol
b ) Pizotifen
c ) Propranolol
d ) Rizatriptan
e ) Topiramate
Answer: B
Co-codamol and Rizatriptan are used in the treatment of acute migraine but not for prevention. Overuse of both of these can lead to an increase in headache frequency. Propranolol is contraindicated in asthma and Topiramate should only be prescribed under specialist supervision for migraine.
5. A 25 year old woman comes to see you complaining of having had a bad cough for six days. She is coughing up green phlegm. She has no chest pain. She smokes 20/day. On examination, she is apyrexial and her chest is clear. She has no significant past history and is not on regular medication. She has tried taking regular paracetamol but now thinks she needs an antibiotic to help “clear this up”. What is the single most appropriate initial way to manage this patient according to current guidelines?
a ) Organise a Chest X Ray
b ) Prescribe an antibiotic
c ) Prescribe codeine linctus
d ) Send a sputum sample for culture
e ) Treat conservatively
Answer: E
There is no evidence to suggest that the use of an antibiotic/cough bottle/sputum sample/CXR for non-pneumonic lower respiratory tract infections in previously well adults is useful.
a ) Candidiasis
b ) Chlamydia
c ) Gonorrhoea
d ) HIV
e ) Herpes simplex
f ) Scabies
g ) Syphilis
INSTRUCTION: Genital infection presents in general practice in a variety of ways. Sexually transmitted infection can lead to significant morbidity and needs to be managed appropriately in primary care. For each of the following patients below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A 31 year old woman attends with a history of a febrile illness for five days followed by development of severe pain in the vulval area. Examination reveals numerous small ulcers. There is bilateral inguinal lyphadenopathy. She has been in a stable monogamous relationship for two years.
The Correct answer is e.
2 . A 22 year old man presents with a painful right knee, sore eyes and dysuria after an episode of unprotected intercourse with a new partner two weeks previously.
The Correct answer is b.
3 . A 35 year old homosexual man presents with a non itchy maculopapular rash on the palms of his hands and the soles of his feet, three months after a holiday in Brighton.
The Correct answer is g.
Herpes simplex can occur months or years into a stable relationship. Sexually acquired reactive arthritis (SARA) should be thought of in a patient who ‘can’t see, can’t pee and can’t bend the knee’. Chlamydia is the cause in 70% of cases. Secondary Syphilis is the great mimicker, and presents in a variety of ways, at least four weeks after the infective episode. Commonly it presents as a non itchy maculopapular rash affecting the palms and soles.
2. A 67 year old woman, who had chemotherapy two years ago, has metastatic breast carcinoma. During the past three weeks, she has become increasingly weak, tired and thirsty. She has had some nausea, is constipated and has lost her appetite. She has generalised aches and pains and has been a little confused. Which single biochemical abnormality is most likely to be implicated?
a ) Hypercalcaemia
b ) Hypocalcaemia
c ) Hypokalaemia
d ) Hypermagnesaemia
e ) Hypomagnesaemia
Answer: A
Hypercalcaemia usually has a non-specific presentation and includes the symptoms described exhibited by the patient. About 40% of breast tumours are liable to result in this especially where there is bone spread. Hypocalcaemia and hypokalaemia are both associated with tetany and there is no direct link with malignancy. Hypomagnesaemia is occasionally associated with cisplatin chemotherapy. Hypermagnesaemia is a rare condition found in neonates – again with no malignant association.
3. A 36 year old woman presents in the middle of a surgery with an acute flare up of her asthma symptoms. She complains of feeling more breathless and wheezy. Which one of the following signs, on its own, would prompt you to have her admitted as an emergency to hospital?
a ) Peak flow is reduced to 60% of her usual
b ) Resting pulse rate is 100/min
c ) Pulse oximetry shows SpO2 to be 90%
d ) Respiratory rate is 20/min
e ) Wheeze present throughout both lung fields
Answer: C
Immediate hospital admission is necessary if signs of life threatening asthma are present – peak flow <33% of best/predicted, SpO2 <92%, silent chest, cyanosis, feeble respiratory effort, bradycardia, dysrhythmia, hypotension, exhaustion, confusion, coma.
4. A 30 year old woman complains of frequent headaches. She describes a unilateral, throbbing headache associated with photophobia and nausea which can last more than 24hrs. For the last three months, the headaches have occurred at least once a week. She has been taking paracetamol but this has not helped. She has asthma and uses salbutamol and belcometasone inhalers. She has no other significant past medical history. Examination is normal. She asks for medication to help prevent her headaches occurring. Which is the single most appropriate drug?
a ) Co-codamol
b ) Pizotifen
c ) Propranolol
d ) Rizatriptan
e ) Topiramate
Answer: B
Co-codamol and Rizatriptan are used in the treatment of acute migraine but not for prevention. Overuse of both of these can lead to an increase in headache frequency. Propranolol is contraindicated in asthma and Topiramate should only be prescribed under specialist supervision for migraine.
5. A 25 year old woman comes to see you complaining of having had a bad cough for six days. She is coughing up green phlegm. She has no chest pain. She smokes 20/day. On examination, she is apyrexial and her chest is clear. She has no significant past history and is not on regular medication. She has tried taking regular paracetamol but now thinks she needs an antibiotic to help “clear this up”. What is the single most appropriate initial way to manage this patient according to current guidelines?
a ) Organise a Chest X Ray
b ) Prescribe an antibiotic
c ) Prescribe codeine linctus
d ) Send a sputum sample for culture
e ) Treat conservatively
Answer: E
There is no evidence to suggest that the use of an antibiotic/cough bottle/sputum sample/CXR for non-pneumonic lower respiratory tract infections in previously well adults is useful.
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