AKT Questions

1. A 26-year-old woman presents having slipped off of a kerb 15 minutes earlier and twisted her left ankle while running for a bus. She has been helped to the surgery by two friends, who are supporting her on each side. She states that, although she was able to weight-bear immediately after the accident, she is now unable to do so because of the pain. She is a normally fit and healthy woman. According to the Ottawa Ankle and Foot Rules, which one of the following examination findings, in this case, is an immediate indication for onward referral for x-ray of the ankle?

a ) Bone tenderness over the anterior edge of the lateral malleolus
b ) Bone tenderness over the posterior edge of the lateral malleolus
c ) Bruising and tenderness over the anterior talofibular ligament
d ) Inability to weight-bear on the affected ankle at the time of examination
e ) Pain over the dorsal ligaments on resisted dorsiflexion of the foot

Answer: B

Findings other than B are present in soft tissue injury and do not obligate radiological assessment. Inability to weight-bear immediately after the injury, rather than at the time of examination (by which time soft tissue swelling contributes to the pain), is suspicious of a fracture and indicates an X-ray. The Ottawa Ankle and Foot Rules are not validated for use in those under 18 years of age. Their use can reduce the need for X-rays by around 25% and are readily applied to the primary care setting. See reference for full details of 'the Rules'.

2. A trainer relates to his registrar how, over the years, he has written down ideas, memories, connections, or emotions – the patient who gives a gift, the relative who is bereaved, the colleague who inspires. The audience is the writer himself. What single adjective best describes this form of writing?

a ) Analytical
b ) Biographical
c ) Creative
d ) Historical
e ) Reflective

Answer: E

3. OPTIONS:

a ) Acute closed-angle glaucoma
b ) Bacterial conjunctivitis
c ) Episcleritis
d ) Keratitis
e ) Orbital cellulitis
f ) Scleritis
g ) Subconjunctival haemorrhage

INSTRUCTION: For each patient with a painful red eye, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.


A . A 26 year old man, with no significant past history, presents to you with a three day history of increasing pain and redness of his left eye. He has been unable to wear his contact lenses due to the pain. He has blurred vision and is photophobic in this eye. On examination, he has pericorneal redness of the eye. His pupil reacts normally to light. Insertion of fluorescein reveals an irregular green patch on his cornea.

The Correct answer is d.
B . A 78 year old woman with dementia is visited urgently by you. She is unable to give a history but the nursing home staff report that she has become increasingly distressed and has vomited twice. She is moaning and rocking back and forth holding her head. While examining her, you notice her right eye is red while the left is normal. The redness is around the cornea and the pupil is unreactive to light. Insertion of fluorescein reveals no staining.

The Correct answer is a.
C . A 32 year old woman presents with an acutely painful red right eye and blurred vision. She has had recent swollen joints and takes a non steroidal anti-inflammatory. On examination, she is distressed with the pain and there is marked vasodilation of the vessels all over the white of her eye and it has a bluish appearance. Visual acuity in the right eye is 6/18. Insertion of fluorescein reveals no staining.

The Correct answer is f.

Keratitis can cause ulceration of the cornea which can be sight threatening due to scarring if not treated rapidly. If suspected, an immediate ophthalmology referral is necessary. Acute closed-angle glaucoma necessitates immediate ophthalmology assessment to avoid loss of sight. Symptoms may be preceded by warning haloes and on examination the cornea will be oedematous and appear hazy. Scleritis is often associated with connective tissue diseases. It is very painful and requires urgent ophthalmology assessment as systemic treatment may be required. Without treatment, permanent loss of vision may occur in the affected eye or even perforation of the globe. In posterior scleritis the sclera may look normal. Therefore any rheumatoid patient with a very painful eye should be referred for further assessment. Episcleritis is much less serious and usually affects only part of the eye and is less painful. It can be treated using NSAIDs.

4. OPTIONS:

a ) Amyotrophic lateral sclerosis
b ) Cerebrovascular accident
c ) Gastro-oesophageal reflux
d ) Hypoparathyroidism
e ) Hypothyroidism
f ) Laryngeal carcinoma
g ) Recurrent laryngeal nerve palsy

INSTRUCTION: For each of the patients below, choose the most likely cause of hoarseness above. Each option can be used once, more than once or not at all.

A . A 37 year old woman with a BMI of 34 has a history of dyspepsia. She is presenting with hoarseness which is worse in the morning.

The Correct answer is c.
B . A 68 year old man describes difficulty swallowing over the last few months. He is experiencing difficulties walking. He now presents with hoarseness.

The Correct answer is a.
C . A 53 year old woman, who underwent thyroid surgery four weeks ago, is now presenting with hoarseness.

The Correct answer is g.