1. A 50 year old man has a blood pressure of 158/88. He has no known atherosclerotic disease but is keen to prevent it. He asks if he should take aspirin. At which calculated absolute risk of a cardiovascular or cerebrovascular event is it appropriate to start aspirin 75mg?
a ) Greater than, or equal to, 10% over five years
b ) Greater than, or equal to, 10% over 10years
c ) Greater than, or equal to, 15% over five years
d ) Greater than, or equal to, 15% over 10 years
e ) Greater than ,or equal to, 20% over five years
f ) Greater than, or equal to, 20% over 10 years
Answer: F
Asymptomatic individuals, without established atherosclerotic disease, but with a calculated cardiovascular risk of more than, or equal to, 20% in 10 years, should be considered for aspirin 75mg daily.
2. A 40 year old woman presents with intermittent abdominal pain which she says is totally relieved by defaecation. Which one of the following symptoms would suggest further investigations are mandatory?
a ) Loose stools
b ) Blood in stools
c ) Feeling of incomplete evacuation
d ) Increased stool frequency
e ) Mucus in stools
Answer: B
According to the Manning Criteria for the diagnosis of irritable bowel syndrome, the diagnosis may be made if three or more of the following are present: abdominal pain, relief of pain with defecation, increased stool frequency with pain, looser stools with pain, mucus in stools and feeling of incomplete evacuation. If any of the following red flag symptoms are present a full GI work up is needed: being over 50 years old, having weight loss, blood in stools, anaemia or fever.
3. A 40 year old doctor, who has just returned from a six month sojourn in Central America, presents with a painless nodule of his right upper eyelid. It has been growing slowly over the last six weeks. What is the single most likely infected cause of the swelling?
a ) Leishmaniasis
b ) Leprosy
c ) Malaria
d ) Schistosomiasis
e ) Trypanosomiasis
Answer: A
He is presenting with a chalazion. With increasing international travel, it is important to take a travel history. Leishmaniasis is found in the rain forests of Central and Southern America. It can commonly present as an infected chalazion
4. A 54 year old man, with a moderate learning disability, is brought to see you by his carer. She states that his behaviour has been deteriorating over the last three weeks. He hasn’t been responding when spoken to and hasn’t been doing things when asked. He becomes aggressive when confronted. In particular, he has refused to turn down the volume on his TV and this is causing arguments with other residents. He has been well otherwise, with no change in eating or toilet habit. He has no relevant history or medication. He answers all questions with the response “I’m fine” but this is his usual. On examination, he is apyrexial, pulse and BP are normal. His chest and abdomen are normal. Which one of the following is the most likely diagnosis?
a ) Absence seizures
b ) Depression
c ) Ear wax
d ) Early onset dementia
e ) Urinary tract infection
Answer: C
Due to communication difficulties, people with learning disabilities may not complain of any sensory changes and, therefore, simple problems like a build up of ear wax can present in an unusual way. One must be alert to such atypical, and often simple, explanations.
5. OPTIONS:
a ) 2 weeks
b ) 4 weeks
c ) 6 weeks
d ) 8 weeks
e ) 12 weeks
f ) 26 weeks
g ) 52 weeks
INSTRUCTION: For each patient below who has had a Myocardial Infarction (MI), select the single most appropriate time scale above to fit their circumstances. Each option may be used once, more than once or not at all.
A. Mr A is 50 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. For how long after the event should he be advised to refrain from driving his car? (He does not hold a PSV or HGV licence)
The Correct answer is b.
B. Mrs B is 50 years old and has recently had an uncomplicated MI. This is her first cardiovascular event and she has made a straightforward recovery. She works as a dinner lady. This involves a lot of lifting and carrying of heavy pots and pans as well as supervision of children. She misses the company at work and is keen to get back to her own job. According to the British Heart Foundation when should she be advised that she may return to her work?
The Correct answer is e.
C. 3 . Mr C is 45 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. He is able to climb two flights of stairs without difficulty. His daughter has recently had a baby and he is keen to visit. This would involve a flight of three hours. How long after his MI do most airlines advise before he can fly?
The Correct answer is a.
Mrs B must be considered to be a heavy manual worker and as such should be advised to wait for three months before going back to her work. The British Heart Foundation has a useful leaflet on activity after an MI- Heart Information Series No7. Most airlines will not carry passengers for two weeks after an uncomplicated MI but will then do so if they can climb a flight of stairs without difficulty.
7. OPTIONS:
a ) Prostate cancer
b ) Bladder calculus
c ) Chronic prostatitis
d ) Urinary tract infection
e ) Urethritis
f ) Benign prostatic hypertrophy
g ) Urethral stricture
INSTRUCTION: Choose the single most likely option above for each of the scenarios below. Each option can be used once, more than once or not at all.
1 . A 58 year old patient, who has previously been catheterized and has undergone a T.U.R.P, complains of diminishing urine flow over a period of months. Rectal examination reveals no prostatic enlargement.
The Correct answer is g.
2 . A 65 year old patient presents with terminal dribbling, poor flow and hesitancy. Rectal examination reveals a smooth and symmetrical swelling. The surface is flattened and it is difficult to get the examining finger forward round each side.
The Correct answer is f.
3 . A 32 year old diabetic man presents with chronic, perineal pain of varying severity and frequency. It is exacerbated by sitting on a hard chair. He also describes low back pain extending down his left leg with bouts of fever and dysuria. Rectal examination reveals an enlarged, firm, and irregular prostate.
The Correct answer is c.
Prostate cancer is rare below the age of 50. Benign prostatic hypertrophy is a common condition in older men; it is unusual before 50 years of age and is most common between 60 and 70
8. A 67 year old woman, who is well known to you, has been diagnosed with Alzheimer’s disease and is in a care home. You are asked to see her because she has become aggressive and violent towards carers and other residents. Carers have followed NICE guidance on the management of aggression with no success. You manage to examine her and can find no obvious cause for her deterioration. You decide that she will need admission for further assessment in order to exclude other remediable causes for her agitation, and that it is justifiable to sedate her at this point. Which the single most appropriate drug for this purpose?
a ) IM haloperidol
b ) Oral diazepam
c ) Oral chlorpromazine
d ) IM lorazepam
e ) Oral lorazepam
Answr: E
Agitation and aggression should be managed by non-pharmacological methods where possible. The use of drugs is often unnecessary, and they can increase the risk of cerebrovascular events. If the risks have been considered and are justified, oral drugs are preferable to parenteral routes. Oral lorazepam, haloperidol or olanzapine in the lowest effective dose are the preferred drugs. Careful patient monitoring after sedation is mandatory.
10. A 23 year old man, who is a reformed intravenous drug misuser, was screened by the practice for blood borne viruses. He was found to be suffering from chronic Hepatitis C. He is accepted on to a treatment programme and is given pegylated Interferon and Ribavirin. He presents to you complaining of feeling extremely tired and not wanting to do anything. His appetite is poor and his bowel is looser than usual. He has lost weight. As a precaution you check his bloods. Which one of the following is the most likely diagnosis?
a ) Crohn’s disease
b ) Depression
c ) Gastric carcinoma
d ) Psychotic illness
e ) Renal failure
Answer: B
This combination of drugs has a very wide range of adverse side effects including effects on the liver, heart, kidney, gastrointestinal and haemopoietic systems. However, depression and flu-like symptoms are much more common.
Saturday 31 January 2009
Monday 26 January 2009
AKT Questins
1. As part of their annual review for hypertension, your patients have urea and electrolytes measured. Significant numbers are now coming back with evidence of chronic renal impairment. Which of the following statements about this condition are true? Select three statements only.
A. Most laboratories now provide a measurement of the patient’s true glomerular filtration rate (GFR) which is a definitive guide to renal function
B.Patients with eGFR > 60 ml/min per 1.73 m2 do not have renal impairment
C.An eGFR < 15 is the cut-off for stage 5 chronic renalimpairment, at which point patients should be considered for dialysis
D. A blood pressure treatment goal of < 125/75 is indicatedfor patients with proteinuria
E. A high-protein diet is required in patients with proteinuria to replace urinary losses
F. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with only one kidney
G. Patients with moderate-to-severe chronic renal impairment should follow a diet restricted in potassium
Answer: C,D,G
The result measured by laboratories is an estimated GFR (or eGFR), which assumes standard body surface area and race. Patients who have, for instance, had an amputation may receive erroneous results. An eGFR between 60 and 89 correlates with mild renal impairment. Stage 5 chronic kidney disease is defined as eGFR < 15. Low protein diet has been shown to reduce death rate in chronic renal disease. Patients with only one kidney are prone to renal impairment and should all be considered for ACE inhibitors.
A. Most laboratories now provide a measurement of the patient’s true glomerular filtration rate (GFR) which is a definitive guide to renal function
B.Patients with eGFR > 60 ml/min per 1.73 m2 do not have renal impairment
C.An eGFR < 15 is the cut-off for stage 5 chronic renalimpairment, at which point patients should be considered for dialysis
D. A blood pressure treatment goal of < 125/75 is indicatedfor patients with proteinuria
E. A high-protein diet is required in patients with proteinuria to replace urinary losses
F. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with only one kidney
G. Patients with moderate-to-severe chronic renal impairment should follow a diet restricted in potassium
Answer: C,D,G
The result measured by laboratories is an estimated GFR (or eGFR), which assumes standard body surface area and race. Patients who have, for instance, had an amputation may receive erroneous results. An eGFR between 60 and 89 correlates with mild renal impairment. Stage 5 chronic kidney disease is defined as eGFR < 15. Low protein diet has been shown to reduce death rate in chronic renal disease. Patients with only one kidney are prone to renal impairment and should all be considered for ACE inhibitors.
more free AKT questions
1. Which of the following statements about screening for colorectal cancer are true? Select three options only.
A. The presence of a latent phase with precancerous lesions makes colorectal cancer ideal for screening
B. Colonoscopy is the only screening method proven to reduce mortality
C. Of patients with colorectal cancer 90% have symptoms of rectal bleeding
D. Proposed national screening for colorectal cancer will target those aged 50-74 years
E. Flexible sigmoidoscopy in women of average risk picks up only 35% of cancers
F. Of patients with iron-deficient anaemia in general practice 11% were found to have gastrointestinal cancer
Answer: A,E, F
fecal occult blood testing isthe only screening method proven to cut death rates. the proposed screenig programme will start in 2010 an scren the age group 60-69 years. the CONCeRN study showed low sensitivity for colonoscopy in women of average risk. rectal bleeding occurs in less than 50% of colorectal cancer.
2. A patient with dyspepsia has recently had an upper gastrointestinal endoscopy. His histology comes back positive for Helicobacter pylori. Which of the following statements about the management of this situation are true? Select two answers only.
A. Serological testing is highly sensitive and specific
B. Resistance to metronidazole is common in inner city areas
C. Eradication therapy involves a combination of amoxicillin and a proton pump inhibitor
D. Serological testing can be repeated after 4 weeks to confirm eradication
E. Prescriptions for Heliclear (amoxicillin, clarithromycin and lansoprazole) treatment packs are charged three prescription charges
Answer: B, E
Breath esting, CLO testing and stol antigen tsts are senstive and senstive. eradication therapy involves high dose amoxicillin, clarithromycin and lansoprazol. serological testing tkes 6-12 months to retur to normal.
3. A 73-year-old mentions at a routine blood pressure check-up that he has to get up four or five times a night to go to the toilet. This is disturbing his wife to the point that he has moved into the spare room. Examination reveals a smooth enlarged prostate and you send blood for PSA (prostate-specific antigen) testing and a urine specimen for culture. This comes back clear and his PSA level is 3.6. Which of the following statements about his management is true?
A. He should be referred for a prostate biopsy
B. Transurethral resection of the prostate is the treatment of choice in this patient C. Finasteride will provide rapid relief from his symptoms with no risk of postural hypotension
D. Saw palmetto has been shown to have a placebo effect only
E. a-Blockers are the first-line treatment in this patient group
Answer: E
Surgery should be reserved for patients with bladder outflow obstruction or in those in whom medical therapy fails. Finasteride is effective but takes some weeks to work. Its mode of action is to shrink the prostate. Saw palmetto has been shown to be an effective treatment for prostatism.
4. A 56-year-old man presents with unprovoked, painless, macroscopic haematuria. Dipstick testing confirms the presence of blood but no leucocytes or nitrites. Which of the following may be a cause of these symptoms?
A. Renal colic
B. Beetroot consumption
C. Urinary tract infection
D. Bladder tumour
E. Renal trauma
F. all of the above.
Answe: D
Painless macroscopic haematuria should be considered to be the result of renal tract cancer until proven otherwise. A UTI would be associated with dysuria and leucocytes and nitrites. Beetroot may discolour the urine but would not affect dipstick results. Trauma and colic are associated with pain, although haematuria may be a sign of a coagulopathy.
A. The presence of a latent phase with precancerous lesions makes colorectal cancer ideal for screening
B. Colonoscopy is the only screening method proven to reduce mortality
C. Of patients with colorectal cancer 90% have symptoms of rectal bleeding
D. Proposed national screening for colorectal cancer will target those aged 50-74 years
E. Flexible sigmoidoscopy in women of average risk picks up only 35% of cancers
F. Of patients with iron-deficient anaemia in general practice 11% were found to have gastrointestinal cancer
Answer: A,E, F
fecal occult blood testing isthe only screening method proven to cut death rates. the proposed screenig programme will start in 2010 an scren the age group 60-69 years. the CONCeRN study showed low sensitivity for colonoscopy in women of average risk. rectal bleeding occurs in less than 50% of colorectal cancer.
2. A patient with dyspepsia has recently had an upper gastrointestinal endoscopy. His histology comes back positive for Helicobacter pylori. Which of the following statements about the management of this situation are true? Select two answers only.
A. Serological testing is highly sensitive and specific
B. Resistance to metronidazole is common in inner city areas
C. Eradication therapy involves a combination of amoxicillin and a proton pump inhibitor
D. Serological testing can be repeated after 4 weeks to confirm eradication
E. Prescriptions for Heliclear (amoxicillin, clarithromycin and lansoprazole) treatment packs are charged three prescription charges
Answer: B, E
Breath esting, CLO testing and stol antigen tsts are senstive and senstive. eradication therapy involves high dose amoxicillin, clarithromycin and lansoprazol. serological testing tkes 6-12 months to retur to normal.
3. A 73-year-old mentions at a routine blood pressure check-up that he has to get up four or five times a night to go to the toilet. This is disturbing his wife to the point that he has moved into the spare room. Examination reveals a smooth enlarged prostate and you send blood for PSA (prostate-specific antigen) testing and a urine specimen for culture. This comes back clear and his PSA level is 3.6. Which of the following statements about his management is true?
A. He should be referred for a prostate biopsy
B. Transurethral resection of the prostate is the treatment of choice in this patient C. Finasteride will provide rapid relief from his symptoms with no risk of postural hypotension
D. Saw palmetto has been shown to have a placebo effect only
E. a-Blockers are the first-line treatment in this patient group
Answer: E
Surgery should be reserved for patients with bladder outflow obstruction or in those in whom medical therapy fails. Finasteride is effective but takes some weeks to work. Its mode of action is to shrink the prostate. Saw palmetto has been shown to be an effective treatment for prostatism.
4. A 56-year-old man presents with unprovoked, painless, macroscopic haematuria. Dipstick testing confirms the presence of blood but no leucocytes or nitrites. Which of the following may be a cause of these symptoms?
A. Renal colic
B. Beetroot consumption
C. Urinary tract infection
D. Bladder tumour
E. Renal trauma
F. all of the above.
Answe: D
Painless macroscopic haematuria should be considered to be the result of renal tract cancer until proven otherwise. A UTI would be associated with dysuria and leucocytes and nitrites. Beetroot may discolour the urine but would not affect dipstick results. Trauma and colic are associated with pain, although haematuria may be a sign of a coagulopathy.
Friday 9 January 2009
AKT Questions
1. The following are notifiable diseases in England and Wales
a. acute encephalitis T
b. dysentery T
c. pulmonary tuberculosis T
d. chicken pox F
e. Kawasaki disease F
Bacterial: anthrax, diphtheria, leptosporosis, pertussis, plague, Brucellosis, tetanus, typhus, cholera, dysentery, food poisoning, paratyphoid fever, typhoid, leprosy, tuberculosis, meningitis, meningococcal infection, ophthalmia neonatorum, erysipelas, scarlet fever.
Viral: acute encephalitis, AIDS, hepatitis B, measles, mumps,rubella, poliomyelitis, rabies, varicella (encephalitis- chickenpox isn't) , yellow fever.
Protozoal: malaria.
Chicken pox is notifiable in Scotland.
2. Theme:Causes of deafness
A Acoustic neuroma
B Alport's syndrome
C Barotrauma
D Drug induced
E Hypothyroidism
F Meningitis
G Otitis media
H Paget's disease
I Pendred's syndrome
J Radiotherapy
K Stroke
Select the most likely cause of deafness in the following cases:
-A 75-year-old male presents as he has increasing problems with deafness. He suffers from Parkinson's disease and takes l-dopa therapy.On examination, he has a pill rolling tremor and reduced mobility. There is also enlargement of the skull.
Answer: H
Although this man has Parkinson's disease, the description of a large skull suggests Paget's disease as the cause of deafness as l-dopa does not cause deafness. Paget's causes enlargement of the bone in the inner ear which can be responsible for the conductive deafness
- A 20-year-old female presents with increasing deafness. She only takes the oral contraceptive pill. On examination, there is nil of note but urinalysis reveals blood ++ and protein++.
Answer: B
Alport's syndrome is an inherited condition associated with sensorineural deafness and renal dysfunction.
- A 54-year-old female presents with a two month history of increasing deafness in the left ear. She has a history of hypertension for which she takes lisinopril and amlodipine. On examination she has decreased hearing in the left ear both through air and bone and there is loss of the corneal reflex on the left side.
Answer: A
The sensorineural deafness suggests involvement of the VIII cranial nerve and the loss of corneal reflex indicates involvement of the V cranial nerve. This would occur in the posterior fossa of the brain and hence the likely lesion is an acoustic neuroma.
3. You have been informed by the local hospital that a 4-year-old patient from your practice has been admitted with definite meningococcal sepsis. There have not been any previous cases. You need to organise appropriate prophylaxis. Which of the following is the single most appropriate group to treat?
a. All family members
b. All family members and friends who have played with the child in the last 48 hours
c. All family members and children at the same nursery
d. All household members
e. All household members and children at the same nursery
Answer: D
This is a congenital abnormality, presenting as prolonged conjugated jaundice. A history of dark urine and pale stools might also be given. This requires urgent corrective surgery. A significant number of children operated on after 6 weeks of age develop chronic hepatic failure and some require liver transplantation.
In full-term babies, physiological jaundice is usually visible from day 2 or day 3, peaks at day 5, and has resolved by day 14. Treatment consists of ensuring adequate milk intake and ruling out any other causes (ie infection, rhesus or aBo incompatibility). If the bilirubin level is rising rapidly, phototherapy might be necessary but can usually be avoided if feeding issues are addressed early. Physiological jaundice in preterm infants starts sooner and usually lasts longer, up to 21 days.
A sudden onset of respiratory distress in a child of 18 months to 3 years should raise the suspicion of an inhaled foreign body. If there is a suggestive history and/or unilateral clinical signs it is an important diagnosis to rule out. Urgent paediatric assessment is required.
Many children aged under 3 years wheeze with viral infections. no treatment is usually necessary. a trial of salbutamol via inhaler and spacer can be given to children aged over 1 year if respiratory distress is severe or if there is a strong family history of atopy.
Recurrent lower respiratory tract infections and poor weight gain warrant further investigation. The most likely diagnosis in the white population is cystic fibrosis. Other pathologies such as immunodeficiencies, congenital lung abnormalities and rarer causes of bronchiectasis such as primary ciliary dyskinesia should be considered if cystic fibrosis tesing is negative.
Children with chronic neurological conditions often have gastrooesophageal reflux and are at high risk of recurrent aspiration. Fundoplication and gastrostomy feeds can help. Infections need to be treated early and aggressively because this is the main cause of mortality in this group of patients.
a. acute encephalitis T
b. dysentery T
c. pulmonary tuberculosis T
d. chicken pox F
e. Kawasaki disease F
Bacterial: anthrax, diphtheria, leptosporosis, pertussis, plague, Brucellosis, tetanus, typhus, cholera, dysentery, food poisoning, paratyphoid fever, typhoid, leprosy, tuberculosis, meningitis, meningococcal infection, ophthalmia neonatorum, erysipelas, scarlet fever.
Viral: acute encephalitis, AIDS, hepatitis B, measles, mumps,rubella, poliomyelitis, rabies, varicella (encephalitis- chickenpox isn't) , yellow fever.
Protozoal: malaria.
Chicken pox is notifiable in Scotland.
2. Theme:Causes of deafness
A Acoustic neuroma
B Alport's syndrome
C Barotrauma
D Drug induced
E Hypothyroidism
F Meningitis
G Otitis media
H Paget's disease
I Pendred's syndrome
J Radiotherapy
K Stroke
Select the most likely cause of deafness in the following cases:
-A 75-year-old male presents as he has increasing problems with deafness. He suffers from Parkinson's disease and takes l-dopa therapy.On examination, he has a pill rolling tremor and reduced mobility. There is also enlargement of the skull.
Answer: H
Although this man has Parkinson's disease, the description of a large skull suggests Paget's disease as the cause of deafness as l-dopa does not cause deafness. Paget's causes enlargement of the bone in the inner ear which can be responsible for the conductive deafness
- A 20-year-old female presents with increasing deafness. She only takes the oral contraceptive pill. On examination, there is nil of note but urinalysis reveals blood ++ and protein++.
Answer: B
Alport's syndrome is an inherited condition associated with sensorineural deafness and renal dysfunction.
- A 54-year-old female presents with a two month history of increasing deafness in the left ear. She has a history of hypertension for which she takes lisinopril and amlodipine. On examination she has decreased hearing in the left ear both through air and bone and there is loss of the corneal reflex on the left side.
Answer: A
The sensorineural deafness suggests involvement of the VIII cranial nerve and the loss of corneal reflex indicates involvement of the V cranial nerve. This would occur in the posterior fossa of the brain and hence the likely lesion is an acoustic neuroma.
3. You have been informed by the local hospital that a 4-year-old patient from your practice has been admitted with definite meningococcal sepsis. There have not been any previous cases. You need to organise appropriate prophylaxis. Which of the following is the single most appropriate group to treat?
a. All family members
b. All family members and friends who have played with the child in the last 48 hours
c. All family members and children at the same nursery
d. All household members
e. All household members and children at the same nursery
Answer: D
The following groups would be classed as close contacts and require prophylaxis:
people in the same household
people who have slept in the house during the 7 days prior to the onset of the illness
people who have spent several hours a day in the house inthe last 7 days
â€کKissing contacts’, ie boy/girlfriend
students sharing the same room or flat as the case
anyone who gave mouth-to-mouth resuscitation to the index case
Those attending the same childminder as the index case in the last 7 days.
Groups not requiring prophylaxis:
school, nursery or playgroup contacts
students on the same course or in the same hall of residence who are not in the above categories.
4. THEME: VOMITING
A Cow’s milk protein intolerance
B Gastroenteritis
C Gastro-oesophageal reflux
D Hiatus hernia
E Hirschprung’s disease
F Lactose intolerance
G Overfeeding
H Posseting
I Pyloric stenosis
J Reduced gastric motility
For each of the following clinical situations, choose the single most likely diagnosis from the list of options given above. Each option can be used once, more than once or not at all.
A 1-week-old baby is brought by his mother. He was born at home. Mum is concerned that he is vomiting and not feeding well. On questioning, his mother tells you that she cannot remember her child opening his bowels. On examination, the child appears grey, his abdomen is distended and firm. He vomits forcefully when you palpate his abdomen.
E Correct answer
Classically presents in the neonatal period with failure to pass meconium within 24 hours and features of obstruction. It is caused by aganglionosis of the distal bowel. If only a small segment of large bowel is affected children can present several years later with chronic constipation. diagnosis is made by rectal biopsy.
A 6-week-old baby is brought to see you with increasing vomiting. His mother reports that he feeds very well and is always hungry. Initially he vomited small amounts after some feeds. Over the last week, he has had large vomits after every feed. On examination, the baby is alert and hungry but appears to have lost weight.
I Correct answer
Caused by hypertrophy of the pyloric sphincter. Classically presents at 6 weeks with a preceding history of worsening vomiting as the pylorus becomes increasingly hypertrophied with use. Babies usually feed very well and are very hungry. Weight loss can be dramatic. Management includes stopping feeds, correction of electrolyte imbalance and surgical correction. The prognosis is very good.
A 6-week-old baby has a history of vomiting. His mother reports that from the age of 1 week her child has vomited after almost every feed. He is distressed when he vomits and if he is laid flat after a feed. He is thriving and examination is unremarkable.
C Correct answer
Common in infancy, due to relatively poor muscle tone. Symptoms improve with age. This is due to stronger muscle tone, introduction of dietary solids and a more upright posture for the baby. in severe cases there can be failure to thrive and feeding aversion because of the distress associated with feeds. there are several management options:
Keeping the child upright (no proved benefit)
Propping up the head of the bed (no proved benefit)
Thickening agents (proved benefit)
Antacids, eg Gaviscon (no proved benefit)
Ranitidine (proved benefit)
Omeprazole and domperidone, often used but not licensed.
A 6-week-old baby has a history of vomiting. His mother reports that he vomits after feeds, two or three times a day. He is described as a hungry baby. He takes 300 ml every 3 hours during the day, having seven feeds in 24 hours. His weight is above the 99th centile. Examination is otherwise unremarkable.
G Correct answer
Full-term babies normally require 150 ml/kg/day of milk. Particularly hungry babies might need more than this to settle them but volumes over 200 ml/kg/day are not recommended. Overfeeding is common and often results in vomiting.
An 8-month-old baby has a history of vomiting. She attends nursery 3 days per week. She has a 2-day history of vomiting after some feeds and the vomiting is worsening today. She is opening her bowels regularly and had one loose stool this morning. Examination is unremarkable, although she cries throughout.
B Correct answer
Mild, self-limiting episodes of gastroenteritis are common in this age group. Infants who attend nursery have twice the number of viral infections as those that do not.
5. THEME: JAUNDICE
A ABO incompatibility
B Biliary atresia
C Breast milk jaundice
D Galactosaemia
E Gilbert syndrome
F Hepatitis
G Hypothyroidism
H Physiological jaundice
I Rhesus incompatibility
J Sepsis
For each of the following clinical situations choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not all.
· A 20-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well and the baby’s mother has no concerns. On further questioning, she tells you that the baby’s urine is dark in colour and that the stools are the same colour as the baby’s nappy. Examination reveals no abnormality.
This is a congenital abnormality, presenting as prolonged conjugated jaundice. A history of dark urine and pale stools might also be given. This requires urgent corrective surgery. A significant number of children operated on after 6 weeks of age develop chronic hepatic failure and some require liver transplantation.
· A 10-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well. The jaundice was first noted on day 2 of life. The baby’s mother is concerned that her baby has a red rash in the nappy area and some small spots on the face. Examination reveals no other abnormalities.
C Correct answer
Babies who are breastfed are more likely to become jaundiced because they are taking less milk volume in the first 48 hours. The jaundice also takes longer to resolve than in formula-fed babies. This is not harmful and there is no need to stop breastfeeding.
·A 4-day-old baby is brought to your surgery by his father. He is concerned that the baby has not been feeding well for the past 24 hours. On examination, the baby is jaundiced and floppy and the heart rate is 160/minute. The father cannot give you any further history.
J Correct answer
Infection can present with jaundice in the neonatal period. Onset of jaundice in the first 24 hours of life warrants investigation for sepsis. After this time there are usually other symptoms and signs indicating infection, as in this case. In prolonged jaundice (visible after 14 days), an untreated infective cause (eg urinary tract infection) should be ruled out.
· A 6-day-old baby is brought to your surgery by her mother. She is the third baby in the family and the mother is concerned about her baby’s feeding. She describes her baby as sleepy and floppy and taking a long time to finish bottles. The mother says that the baby has been jaundiced since day 3 of life. On examination, the baby is jaundiced and floppy with a large fontanelle.
G Correct answer
Hypothyroidism can present in the neonatal period as jaundice, poor tone and poor feeding. examination is usually otherwise normal, although a large fontanelle and umbilical hernia may be features. Urgent investigation and treatment is necessary as mental retardation develops early and is irreversible. Screening for hypothyroidism is now part of the national neonatal screening programme, but the result would not be available at this stage. If there is clinical suspicion of hypothyroidism it is important to check the baby’s full thyroid function profile as the screening test only measures thyroid-stimulating hormone levels.
· You see a 6-day-old baby who is jaundiced. The baby was noted to be jaundiced on day 2 of life. Bilirubin levels were checked in the hospital and the baby did not require any treatment. Although he took a few days to start feeding, he is now breastfeeding well. The mother feels he is slightly less jaundiced than yesterday. Other than jaundice you can find no other abnormalities on examination.
In full-term babies, physiological jaundice is usually visible from day 2 or day 3, peaks at day 5, and has resolved by day 14. Treatment consists of ensuring adequate milk intake and ruling out any other causes (ie infection, rhesus or aBo incompatibility). If the bilirubin level is rising rapidly, phototherapy might be necessary but can usually be avoided if feeding issues are addressed early. Physiological jaundice in preterm infants starts sooner and usually lasts longer, up to 21 days.
6. THEME: WHEEZE
A Anaphylaxis
B Asthma
C Bronchiolitis
D Chronic lung disease
E Croup
F Cystic fibrosis
G Foreign body inhalation
H Primary ciliary dyskinesia
I Recurrent aspiration
J Virus-induced wheeze
For each of the following clinical situations, choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not at all.
· A 2-year-old child is brought to see you with sudden onset of wheeze and shortness of breath. The symptoms started when the child was at nursery this morning. She has been otherwise well. There is no significant past medical or family history. On examination, she is distressed, with mild subcostal recession; there is an audible wheeze. On auscultation, you can hear wheeze on the right side of the chest, with good air entry throughout.
A sudden onset of respiratory distress in a child of 18 months to 3 years should raise the suspicion of an inhaled foreign body. If there is a suggestive history and/or unilateral clinical signs it is an important diagnosis to rule out. Urgent paediatric assessment is required.
·A 20-month-old boy is brought to see you with respiratory distress. He has been unwell for 2 days with a runny nose, cough and reduced feeding. He is normally fit and well. On examination, the child is coryzal and has a temp of 38.1 °C. His respiratory rate is 32/minute, with mild subcostal recession. Wheeze can be heard throughout the chest with good air entry. He has a blanching maculopapular rash on his trunk
Many children aged under 3 years wheeze with viral infections. no treatment is usually necessary. a trial of salbutamol via inhaler and spacer can be given to children aged over 1 year if respiratory distress is severe or if there is a strong family history of atopy.
·A white 22-month-old boy is brought to see you by his mother. They have recently moved to the area. His mother tells you that he often needs antibiotics for his chest and that this is why she has brought him in now. On examination, the child is small and thin (weight and height are on 0.4th centile) with visible Harrison’s sulci. He has mild subcostal recession. Wheeze can be heard throughout the chest.
Recurrent lower respiratory tract infections and poor weight gain warrant further investigation. The most likely diagnosis in the white population is cystic fibrosis. Other pathologies such as immunodeficiencies, congenital lung abnormalities and rarer causes of bronchiectasis such as primary ciliary dyskinesia should be considered if cystic fibrosis tesing is negative.
·You are asked to visit a 3-year-old girl at home. She is not known to you but from her notes you see that she has diagnoses of cerebral palsy, kyphoscoliosis and severe gastro-oesophageal reflux. She is fed via a gastrostomy tube. She has symptoms of a moist cough and fever. On examination, she has a respiratory rate of 28/minute and wheeze and crepitations throughout the chest.
Children with chronic neurological conditions often have gastrooesophageal reflux and are at high risk of recurrent aspiration. Fundoplication and gastrostomy feeds can help. Infections need to be treated early and aggressively because this is the main cause of mortality in this group of patients.
· A 6-week-old baby is brought to see you with breathing difficulties. She was born at 33 weeks’ gestation and was discharged home 2 weeks ago. She has a 24-hour history of fast, noisy breathing and reduced feeding and the mother thinks that she might have stopped breathing just now in the waiting room. On examination, there is subcostal recession and wheeze is heard bilaterally.
C Correct answer
Bronchiolitis is a viral illness affecting infants aged under 1 year. It is predominantly caused by respiratory syncitial virus (rsv). Clinical features include respiratory distress, wheeze, coryzal symptoms, lowgrade temperature and reduced feeding. Treatment is supportive. Those under the age of 2 months, ex-premature babies and those with existing pathology (eg cardiac disease) are at particular risk and can develop apnoeas. Paluvizumab, a monoclonal antibody against rsv, is now available, though it is very expensive. It is currently offered to premature babies with significant lung disease and to some children with cardiac problems
Thursday 8 January 2009
AKT Questions
1. A 33- year-old woman presents with a 6-month history of a progressively painful area in the upper outer quadrant of her right breast. She has been on oral contraception intermittently for nearly 15 years. Clinically, there is as area of moderate nodularity in the right breast but no discrete lesion is palpable. Select the single most likely diagnosis from the list below?
A. benign breast change
B. breast carcinoma
C. fibroadenoma.
D. haematoma
E. mondor's disease.
Answer: A
Painful nodularity of the breast (unilateral or bilateral) is characteristic of benign breast change (sometimes referred to as "abnormalities of normal development and involution" or ANDI, "fibroadenosis" or "fibrocystic changes"). It affects 1/3 of all women and often causes anxiety in premenopausal women. The symptoms can be cyclical and evening primrose oil provides symptomatic relief.
2. Which of the following statements about Crohn's disease is true?
A. active disease should be treated initially with mesalazine
B. antimycobacterial therapies are an effective treatment if used early
C. anti-TNF-α therapy is associated with remission rates of 80%.
d. Crohn's disease only affects the colon
E. patients should be referred early for surgery.
Answer: B
Mesalazine is no better than placebo in the management of active disease. Its main use is in prevention of relapse after surgery. Infliximab is an effective anti-TNF-α therapy in up to 80% of cases, but only 24% are steroid free. Surgery should be reserved for patients who do not respond to steroids, Methotrexate or Infliximab. Antibiotics should only be used for septic complications and perianal disease. Crohn' disease can affect any part of the GI tract from the mouth to the anus.
A. benign breast change
B. breast carcinoma
C. fibroadenoma.
D. haematoma
E. mondor's disease.
Answer: A
Painful nodularity of the breast (unilateral or bilateral) is characteristic of benign breast change (sometimes referred to as "abnormalities of normal development and involution" or ANDI, "fibroadenosis" or "fibrocystic changes"). It affects 1/3 of all women and often causes anxiety in premenopausal women. The symptoms can be cyclical and evening primrose oil provides symptomatic relief.
2. Which of the following statements about Crohn's disease is true?
A. active disease should be treated initially with mesalazine
B. antimycobacterial therapies are an effective treatment if used early
C. anti-TNF-α therapy is associated with remission rates of 80%.
d. Crohn's disease only affects the colon
E. patients should be referred early for surgery.
Answer: B
Mesalazine is no better than placebo in the management of active disease. Its main use is in prevention of relapse after surgery. Infliximab is an effective anti-TNF-α therapy in up to 80% of cases, but only 24% are steroid free. Surgery should be reserved for patients who do not respond to steroids, Methotrexate or Infliximab. Antibiotics should only be used for septic complications and perianal disease. Crohn' disease can affect any part of the GI tract from the mouth to the anus.
AKT Questions
1. A 15 year old boy is brought in by his father. The father describes witnessing his son collapsing and becoming briefly unconscious during a game of football two days earlier. Which one of the following would be the most appropriate management in the surgery?
a ) FBC
b ) 12 lead ECG
c ) Reassurance
d ) Spirometry
e ) Urinalysis
Answer: B
Sudden death in the young during exertion can commonly be due to Long QT syndrome and may present with syncope and or palpitation prior to sudden death at a later date. It is increasingly recognised that non-competitive physical activity or even emotional upsets can be associated with arrhythmias and sudden death. A history such as this should, therefore, always prompt further cardiac investigation.
2. A 45 year old man (lifelong UK resident) presents with a three month history of cough, sweats, tiredness and weight loss. Despite these symptoms, he is managing all activities of daily living. He has recently moved into a flat with his new partner and her seven year old son having previously been homeless and living in hostels. He has no significant past medical or drug history. He had a chest X-ray carried out which suggested a diagnosis of active pulmonary TB. Risk assessment suggests that this is unlikely to be a multiple drug resistant strain. In infection control, which one of the following is the most appropriate statement?
a ) Wear a face mask when seeing him during the early weeks of treatment
b ) Screen close contacts only if they become symptomatic
c ) Admit him for commencement of treatment in isolation
d ) His BCG vaccinated partner should be screened
e ) The asymptomatic son should receive BCG vaccination immediately
Answer: D
Generally a face mask is unnecessary unless the patient has multiple drug resistant TB (MDR TB) in which case it is advisable until the patient is no longer infectious. All close contacts should be assessed and screened for asymptomatic disease. Once disease has been excluded BCG vaccination can be considered. Unless the patient is clinically unwell, hospital admission for tests or treatment should be avoided. Previous BCG vaccination cannot be assumed to give immunity for a close contact, particularly so if they could be HIV positive. All patients should have a risk assessment carried out for HIV and MDR Tuberculosis.
3. OPTIONS:
a ) Abdominal ultrasound
b ) Ankle brachial pressure index
c ) Exercise tolerance ECG
d ) Echocardiography
e ) 12 lead resting ECG
f ) 24 hour ambulatory blood pressure monitoring
g ) 24 hour ambulatory ECG monitoring
INSTRUCTION: From the above list, select the investigations most likely to confirm the clinical diagnosis for each of the following patients. Each option can be used once, more than once or not at all.
A . A 45 year-old woman presents with a three month history of feelings of thumping in the chest, associated with breathlessness. She is a non-smoker and drinks 30 units of alcohol weekly. Examination reveals a regular pulse, and a BP of 150/90.
The Correct answer is g.
B . A 50 year-old man has experienced a tight sensation in his chest for three weeks when walking uphill on the golf course, and after meals. He smokes 10 cigarettes daily. Examination is normal.
The Correct answer is c.
C. A 70 year-old man presents with two weeks’ vague lumbar backache. His past history is unremarkable apart from controlled hypertension, and he stopped smoking 20 years ago. His father died suddenly in his 60s, of an unknown cause. Examination reveals no abnormality except obesity.
The Correct answer is a.
Resting ECGs should be performed in patients with palpitations or chest pain, but a normal ECG does not exclude coronary artery disease. It also rarely picks up episodic arrhythmias. Abdominal aortic aneurysm should be considered as a cause of vague abdominal or back pain in the elderly.
4. A young woman, for whom you have been prescribing daily supervised Methadone 40mgs, tells you she is approximately 10 weeks pregnant. She relates that, about 20 minutes after taking her Methadone, she vomits it up. She then feels sweaty and agitated for the rest of the day. She asks if she could be given more Methadone to take later in the day. What is the single most appropriate action?
a ) Reduce her daily dose of Methadone
b ) Prescribe additional Methadone for a few weeks
c ) Report her to Social Services
d ) Arrange additional drug counselling
e ) Stop her Methadone
Answer: B
The main objective is to maintain drug taking stability during pregnancy as this is associated with a better outcome.
5. You examine a five year old child who has had a cough and runny nose for 48 hours. He has a temperature of 38oC. There are no significant focal signs. He is very active around your room, showing no signs of being unwell or distressed. With regard to his temperature, which one of the following is the best intervention?
a ) Tepid sponging
b ) Paracetamol
c ) No treatment
d ) Paracetamol with Ibuprofen
e ) Ibuprofen
Answer: C
Antipyretic therapy should not be used routinely with the sole aim of reducing body temperature in children with a fever who are otherwise well and not distressed. Discussion with the parent is clearly an important part of the management plan
6. A 25 year old woman with a diagnosis of chronic fatigue syndrome asks your opinion on various interventions which she has read about on the internet. Based on a systematic review of randomised controlled trials, which one of the following interventions has been shown to improve measures of fatigue and physical functioning?
a ) Antidepressants
b ) Hypnotherapy
c ) Galantamine
d ) Graded exercise
e ) Immunotherapy
Answer: D
7. OPTIONS:
a ) Bacterial vaginitis
b ) Breakthrough bleeding
c ) Cervical carcinoma
d ) Dysfunctional uterine bleeding
e ) Ectopic pregnancy
f ) Pelvic inflammatory disease
g ) Threatened abortion
INSTRUCTION: For each patient with vaginal bleeding or discharge, select the most likely single diagnosis. Each option can be used once, more than once or not at all.
A . A 26 year old woman attends complaining of recent onset of painful vaginal bleeding. Her period is two weeks late although she puts this down to a recent illness. On vaginal examination, she has some cervical excitation and on abdominal examination there is guarding and rebound tenderness in the left iliac fossa.
The Correct answer is e.
B. A 20 year old non-pregnant woman presents with a fever of 38C, bilateral lower abdominal pain and increased vaginal discharge. Abdominal examination reveals generalised tenderness with no rebound. Vaginal examination reveals cervical excitation with adnexal tenderness.
The Correct answer is f.
C . A 40 year old woman, with a previous regular period pattern, presents with a three month history of painless inter menstrual and post coital bleeding. She is a current smoker and has a past history of HPV. A pregnancy test is negative.
The Correct answer is c.
Always think of ectopic pregnancy in a sexually active woman with abdominal pain and bleeding. There is usually amenorrhoea but an ectopic may be present before a period is missed. Tubal colic causes abdominal pain which may precede vaginal bleeding. Blood loss may be dark (prune juice) or fresh. Symptoms may range from mild to severe (shock if rupture occurs). Early diagnosis is vital, immediate referral for assessment is required. Early diagnosis and treatment of pelvic infection is essential to minimise immediate and future complications (e.g. sepsis, pain, menorrhagia, dysmenorrhoea, infertility and ectopic pregnancy). Risk factors for cervical carcinoma include smoking and the Human Papilloma Virus. Overt carcinoma is rarely detected on a smear. Non menstrual bleeding (intermenstrual, postcoital) is the classic symptom and should always be investigated.
8. A 41 year old overweight type 2 diabetic with three children presents for review of contraception. She has a history of dysmenorrhoea and menorrhagia with iron deficiency anaemia. She is troubled by migraine with aura. Her mother suffered a fractured neck of femur and died from breast carcinoma. She does not wish sterilisation. Which one of the following methods would you recommend?
a ) Combined oral contraceptive (COC)
b ) Depomedroxyprogesterone acetate (DMPA)
c ) Intrauterine device (IUD)
d ) Intrauterine system (IUS)
e ) Norethisterone enantate
Answer: D
Migraine contraindicates the use of COC. The IUD can exacerbate menorrhagia. DMPA is associated with a small loss in bone mineral density, which is largely recovered after discontinuation, and it is recommended that it should be used with care in the over 40s. There is no evidence that an IUS causes weight gain, whereas DMPA use can be associated with a weight gain of up to 2-3kg in one year.
a ) FBC
b ) 12 lead ECG
c ) Reassurance
d ) Spirometry
e ) Urinalysis
Answer: B
Sudden death in the young during exertion can commonly be due to Long QT syndrome and may present with syncope and or palpitation prior to sudden death at a later date. It is increasingly recognised that non-competitive physical activity or even emotional upsets can be associated with arrhythmias and sudden death. A history such as this should, therefore, always prompt further cardiac investigation.
2. A 45 year old man (lifelong UK resident) presents with a three month history of cough, sweats, tiredness and weight loss. Despite these symptoms, he is managing all activities of daily living. He has recently moved into a flat with his new partner and her seven year old son having previously been homeless and living in hostels. He has no significant past medical or drug history. He had a chest X-ray carried out which suggested a diagnosis of active pulmonary TB. Risk assessment suggests that this is unlikely to be a multiple drug resistant strain. In infection control, which one of the following is the most appropriate statement?
a ) Wear a face mask when seeing him during the early weeks of treatment
b ) Screen close contacts only if they become symptomatic
c ) Admit him for commencement of treatment in isolation
d ) His BCG vaccinated partner should be screened
e ) The asymptomatic son should receive BCG vaccination immediately
Answer: D
Generally a face mask is unnecessary unless the patient has multiple drug resistant TB (MDR TB) in which case it is advisable until the patient is no longer infectious. All close contacts should be assessed and screened for asymptomatic disease. Once disease has been excluded BCG vaccination can be considered. Unless the patient is clinically unwell, hospital admission for tests or treatment should be avoided. Previous BCG vaccination cannot be assumed to give immunity for a close contact, particularly so if they could be HIV positive. All patients should have a risk assessment carried out for HIV and MDR Tuberculosis.
3. OPTIONS:
a ) Abdominal ultrasound
b ) Ankle brachial pressure index
c ) Exercise tolerance ECG
d ) Echocardiography
e ) 12 lead resting ECG
f ) 24 hour ambulatory blood pressure monitoring
g ) 24 hour ambulatory ECG monitoring
INSTRUCTION: From the above list, select the investigations most likely to confirm the clinical diagnosis for each of the following patients. Each option can be used once, more than once or not at all.
A . A 45 year-old woman presents with a three month history of feelings of thumping in the chest, associated with breathlessness. She is a non-smoker and drinks 30 units of alcohol weekly. Examination reveals a regular pulse, and a BP of 150/90.
The Correct answer is g.
B . A 50 year-old man has experienced a tight sensation in his chest for three weeks when walking uphill on the golf course, and after meals. He smokes 10 cigarettes daily. Examination is normal.
The Correct answer is c.
C. A 70 year-old man presents with two weeks’ vague lumbar backache. His past history is unremarkable apart from controlled hypertension, and he stopped smoking 20 years ago. His father died suddenly in his 60s, of an unknown cause. Examination reveals no abnormality except obesity.
The Correct answer is a.
Resting ECGs should be performed in patients with palpitations or chest pain, but a normal ECG does not exclude coronary artery disease. It also rarely picks up episodic arrhythmias. Abdominal aortic aneurysm should be considered as a cause of vague abdominal or back pain in the elderly.
4. A young woman, for whom you have been prescribing daily supervised Methadone 40mgs, tells you she is approximately 10 weeks pregnant. She relates that, about 20 minutes after taking her Methadone, she vomits it up. She then feels sweaty and agitated for the rest of the day. She asks if she could be given more Methadone to take later in the day. What is the single most appropriate action?
a ) Reduce her daily dose of Methadone
b ) Prescribe additional Methadone for a few weeks
c ) Report her to Social Services
d ) Arrange additional drug counselling
e ) Stop her Methadone
Answer: B
The main objective is to maintain drug taking stability during pregnancy as this is associated with a better outcome.
5. You examine a five year old child who has had a cough and runny nose for 48 hours. He has a temperature of 38oC. There are no significant focal signs. He is very active around your room, showing no signs of being unwell or distressed. With regard to his temperature, which one of the following is the best intervention?
a ) Tepid sponging
b ) Paracetamol
c ) No treatment
d ) Paracetamol with Ibuprofen
e ) Ibuprofen
Answer: C
Antipyretic therapy should not be used routinely with the sole aim of reducing body temperature in children with a fever who are otherwise well and not distressed. Discussion with the parent is clearly an important part of the management plan
6. A 25 year old woman with a diagnosis of chronic fatigue syndrome asks your opinion on various interventions which she has read about on the internet. Based on a systematic review of randomised controlled trials, which one of the following interventions has been shown to improve measures of fatigue and physical functioning?
a ) Antidepressants
b ) Hypnotherapy
c ) Galantamine
d ) Graded exercise
e ) Immunotherapy
Answer: D
7. OPTIONS:
a ) Bacterial vaginitis
b ) Breakthrough bleeding
c ) Cervical carcinoma
d ) Dysfunctional uterine bleeding
e ) Ectopic pregnancy
f ) Pelvic inflammatory disease
g ) Threatened abortion
INSTRUCTION: For each patient with vaginal bleeding or discharge, select the most likely single diagnosis. Each option can be used once, more than once or not at all.
A . A 26 year old woman attends complaining of recent onset of painful vaginal bleeding. Her period is two weeks late although she puts this down to a recent illness. On vaginal examination, she has some cervical excitation and on abdominal examination there is guarding and rebound tenderness in the left iliac fossa.
The Correct answer is e.
B. A 20 year old non-pregnant woman presents with a fever of 38C, bilateral lower abdominal pain and increased vaginal discharge. Abdominal examination reveals generalised tenderness with no rebound. Vaginal examination reveals cervical excitation with adnexal tenderness.
The Correct answer is f.
C . A 40 year old woman, with a previous regular period pattern, presents with a three month history of painless inter menstrual and post coital bleeding. She is a current smoker and has a past history of HPV. A pregnancy test is negative.
The Correct answer is c.
Always think of ectopic pregnancy in a sexually active woman with abdominal pain and bleeding. There is usually amenorrhoea but an ectopic may be present before a period is missed. Tubal colic causes abdominal pain which may precede vaginal bleeding. Blood loss may be dark (prune juice) or fresh. Symptoms may range from mild to severe (shock if rupture occurs). Early diagnosis is vital, immediate referral for assessment is required. Early diagnosis and treatment of pelvic infection is essential to minimise immediate and future complications (e.g. sepsis, pain, menorrhagia, dysmenorrhoea, infertility and ectopic pregnancy). Risk factors for cervical carcinoma include smoking and the Human Papilloma Virus. Overt carcinoma is rarely detected on a smear. Non menstrual bleeding (intermenstrual, postcoital) is the classic symptom and should always be investigated.
8. A 41 year old overweight type 2 diabetic with three children presents for review of contraception. She has a history of dysmenorrhoea and menorrhagia with iron deficiency anaemia. She is troubled by migraine with aura. Her mother suffered a fractured neck of femur and died from breast carcinoma. She does not wish sterilisation. Which one of the following methods would you recommend?
a ) Combined oral contraceptive (COC)
b ) Depomedroxyprogesterone acetate (DMPA)
c ) Intrauterine device (IUD)
d ) Intrauterine system (IUS)
e ) Norethisterone enantate
Answer: D
Migraine contraindicates the use of COC. The IUD can exacerbate menorrhagia. DMPA is associated with a small loss in bone mineral density, which is largely recovered after discontinuation, and it is recommended that it should be used with care in the over 40s. There is no evidence that an IUS causes weight gain, whereas DMPA use can be associated with a weight gain of up to 2-3kg in one year.
Wednesday 7 January 2009
AKT Questions
1. Which of the following statements about encompresis is true?
A. it cannot be diagnosed before the age of four.
B. it involves the voluntary passage of faeces.
C. it I particularly a common problem in lower socioeconomic groups.
D. it is best managed with a coercive approach to potty training.
E. it is more common in females.
Answer: A
Encompresis is the involuntary passage of fully formed faeces and is not a diagnosis that can be made before the age of four. It is an uncommon disorder but much more common in boys. Coercive potty training is likely to worsen the condition. Organic disorders such as Hirschprung's disease must be excluded before psychiatric management is considered. The treatment of choice includes behavioural management, such as the use of a start chart, along with parental counselling or family therapy to help modify hostile attitudes.
2. A 34-year-old man presents to his GP with a 6-month Hx of back pain with no recent Hx of trauma. There are no red flag symptoms. He works long hours as an IT technician. You see from the notes that he has presented in the past with intermittent episodes of back stiffness and occasional neck ache. He is otherwise fit and well, though he was treated with a steroid injection for plantar fascitis last year. On examination, he has no neurological signs but does have reduced range of movement in his cervical spine, particularly for extension. Which one of the following options is the most likely diagnosis?
A. ankylosing spondylitis
B. mechanical back pain
C. osteoarthritis
D. rheumatoid arthritis
E. wedge fracture
Answer: A
AS has prevalence of approximately 1 in 2200 and affects men twice as frequently as women. It tends to present n young men with morning back pain and stiffness. As progressive spinal fusion occurs there can be reduced spinal movement, with kyphosis and sacroiliac joint pain. It is associated with plantar fascitis, lung fibrosis, inflammatory bowel disease and amyloidosis. X-ray of the spine might show a "bamboo spine" with vertebral fusion. The diagnosis is associated with HLA-B27 positivity.
3. Which one of the following food items has the highest glycaemic index?
A. cucumber
B. oranges.
C. peanuts
D. potatoes
E. tomatoes
Answer: D
The GI index and nutrition are popular in the exam as this is important with regard to diabetes and also dieting. Foods with low GI give a smaller rise in blood glucose and are said to result in better glycaemic control in diabetes. Potatoes have a high GI, whereas cucumber has the lowest.
4. Which one of the following is true of psoriasis?
A. topical steroids should be the mainstay of treatment.
B. oral steroids cause pustular psoriasis
C. psoriatic arthropathy never occurs in the absence of a typical rash.
d. Methotrexate is only used to treat the arthropathy.
E. can be cured outright.
Answer: B
Topical steroids are used to treat psoriasis, but second line and for short periods. Oral steroids can produce dramatic pustular psoriasis. Psoriatic arthropathy can occur without skin changes but usually there are nail changes. Methotrexate is used to treat psoriasis without arthropathy and at this point in time the disease is not curable.
5. A 19-year old man has had perineal pain for the past 3 days and has developed fever. He also describes dysuria. On rectal examination he is found to have a tender boggy prostate gland. Which one of the following actions is the most appropriate next step?
A. an HIV test should be organised as soon as possible.
B. a urine sample should be obtained for culture.
C. antibiotics should be started only after any culture results are received.
D. rectal tissue should be swabbed and sent to the laboratory.
E. the prostate should be massaged to obtain Prostatic fluid for culture.
Answer: B
This patient has symptoms consistent with acute prostatitis. Fever, arthralgia, low abdominal pain and a urethral discharge are all common symptom. Diagnosis is made by urine culture. Prostatic massage should be avoided as it can allow the infection to disseminate and will be painful to the patient.
6. A 55-year-old patient has longstanding treated hypertension. He has had his eGFR measured on annual basis. Last year his eGFR was estimated at 54 ml/min/1.73m2. This year he has an unexplained fall in eGFR to 41 ml/min/1.73m2. He feels otherwise well. Which one of the following actions is the most appropriate?
A. arrange renal US and only refer to renal team if US is abnormal.
B. repeat eGFR in 6 months.
C. repeat eGFR in one year.
D. routine OP referral to the renal team.
E. urgent OP referral to the renal team
Answer: D
Patients who have an unexplained fall in eGFR might warrant routine referral to the renal team. An unexplained annual fall in eGFR of >15% is considered significant by the renal association. NICE guidelines also suggest referral for patients with a fall in eGFR. Those with at least a 5-ml/min unexplained fall in eGFR over one year (or less) should be referred. A renal US is also indicated in these patients.
7. A child has just registered with your practice because his family has moved to the area. He has recently been diagnosed with hereditary spherocytosis. Which one of the following statements about this condition is true?
A. it is X-linked recessive condition.
B. it is associated with aplastic crises
C. it is usually diagnosed incidentally in adulthood on routine blood testing
D. patients should be treated with vit. B12 supplementation.
E. there is usually no clinical signs.
Answer: B
Hereditary spherocytosis is an autosomal recessive condition that affects 1 in 5000 live births. It usually presents in childhood as jaundice or with aplastic crises, usually triggered by parvovirus infections. Most children receive folic acid supplementation. Splenomegaly is common. It is rarely diagnosed in adulthood.
A. it cannot be diagnosed before the age of four.
B. it involves the voluntary passage of faeces.
C. it I particularly a common problem in lower socioeconomic groups.
D. it is best managed with a coercive approach to potty training.
E. it is more common in females.
Answer: A
Encompresis is the involuntary passage of fully formed faeces and is not a diagnosis that can be made before the age of four. It is an uncommon disorder but much more common in boys. Coercive potty training is likely to worsen the condition. Organic disorders such as Hirschprung's disease must be excluded before psychiatric management is considered. The treatment of choice includes behavioural management, such as the use of a start chart, along with parental counselling or family therapy to help modify hostile attitudes.
2. A 34-year-old man presents to his GP with a 6-month Hx of back pain with no recent Hx of trauma. There are no red flag symptoms. He works long hours as an IT technician. You see from the notes that he has presented in the past with intermittent episodes of back stiffness and occasional neck ache. He is otherwise fit and well, though he was treated with a steroid injection for plantar fascitis last year. On examination, he has no neurological signs but does have reduced range of movement in his cervical spine, particularly for extension. Which one of the following options is the most likely diagnosis?
A. ankylosing spondylitis
B. mechanical back pain
C. osteoarthritis
D. rheumatoid arthritis
E. wedge fracture
Answer: A
AS has prevalence of approximately 1 in 2200 and affects men twice as frequently as women. It tends to present n young men with morning back pain and stiffness. As progressive spinal fusion occurs there can be reduced spinal movement, with kyphosis and sacroiliac joint pain. It is associated with plantar fascitis, lung fibrosis, inflammatory bowel disease and amyloidosis. X-ray of the spine might show a "bamboo spine" with vertebral fusion. The diagnosis is associated with HLA-B27 positivity.
3. Which one of the following food items has the highest glycaemic index?
A. cucumber
B. oranges.
C. peanuts
D. potatoes
E. tomatoes
Answer: D
The GI index and nutrition are popular in the exam as this is important with regard to diabetes and also dieting. Foods with low GI give a smaller rise in blood glucose and are said to result in better glycaemic control in diabetes. Potatoes have a high GI, whereas cucumber has the lowest.
4. Which one of the following is true of psoriasis?
A. topical steroids should be the mainstay of treatment.
B. oral steroids cause pustular psoriasis
C. psoriatic arthropathy never occurs in the absence of a typical rash.
d. Methotrexate is only used to treat the arthropathy.
E. can be cured outright.
Answer: B
Topical steroids are used to treat psoriasis, but second line and for short periods. Oral steroids can produce dramatic pustular psoriasis. Psoriatic arthropathy can occur without skin changes but usually there are nail changes. Methotrexate is used to treat psoriasis without arthropathy and at this point in time the disease is not curable.
5. A 19-year old man has had perineal pain for the past 3 days and has developed fever. He also describes dysuria. On rectal examination he is found to have a tender boggy prostate gland. Which one of the following actions is the most appropriate next step?
A. an HIV test should be organised as soon as possible.
B. a urine sample should be obtained for culture.
C. antibiotics should be started only after any culture results are received.
D. rectal tissue should be swabbed and sent to the laboratory.
E. the prostate should be massaged to obtain Prostatic fluid for culture.
Answer: B
This patient has symptoms consistent with acute prostatitis. Fever, arthralgia, low abdominal pain and a urethral discharge are all common symptom. Diagnosis is made by urine culture. Prostatic massage should be avoided as it can allow the infection to disseminate and will be painful to the patient.
6. A 55-year-old patient has longstanding treated hypertension. He has had his eGFR measured on annual basis. Last year his eGFR was estimated at 54 ml/min/1.73m2. This year he has an unexplained fall in eGFR to 41 ml/min/1.73m2. He feels otherwise well. Which one of the following actions is the most appropriate?
A. arrange renal US and only refer to renal team if US is abnormal.
B. repeat eGFR in 6 months.
C. repeat eGFR in one year.
D. routine OP referral to the renal team.
E. urgent OP referral to the renal team
Answer: D
Patients who have an unexplained fall in eGFR might warrant routine referral to the renal team. An unexplained annual fall in eGFR of >15% is considered significant by the renal association. NICE guidelines also suggest referral for patients with a fall in eGFR. Those with at least a 5-ml/min unexplained fall in eGFR over one year (or less) should be referred. A renal US is also indicated in these patients.
7. A child has just registered with your practice because his family has moved to the area. He has recently been diagnosed with hereditary spherocytosis. Which one of the following statements about this condition is true?
A. it is X-linked recessive condition.
B. it is associated with aplastic crises
C. it is usually diagnosed incidentally in adulthood on routine blood testing
D. patients should be treated with vit. B12 supplementation.
E. there is usually no clinical signs.
Answer: B
Hereditary spherocytosis is an autosomal recessive condition that affects 1 in 5000 live births. It usually presents in childhood as jaundice or with aplastic crises, usually triggered by parvovirus infections. Most children receive folic acid supplementation. Splenomegaly is common. It is rarely diagnosed in adulthood.
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