more AKT questions

1. OPTIONS:

a ) Can never drive again after episode
b ) Can continue to drive after episode
c ) Cannot drive for one month after episode
d ) Cannot drive for 12 months after episode
e ) Cannot drive for 24 hours after episode
f ) Cannot drive for 6 months after episode
g ) Cannot drive for 24 months after episode

INSTRUCTION: According to current driving regulations from the Driver and Vehicle Licensing Agency (DVLA), choose the single most appropriate answer from the above list for each of the following. Each option may be used once, more than once or not at all.

A. A 72 year old man presents with a one hour history of complete loss of power in his left hand which occurred two days previously. The symptoms have now completely resolved and he has been well since. There were no associated symptoms. He has no significant medical history and is on no regular medication. He regularly drives to visit his wife in a nursing home.

The Correct answer is c.
B . A 21 year old woman describes an episode of loss of consciousness the previous day. She was standing at work, felt hot and then was aware of everything starting to go black. The next thing she remembers was lying on the ground. Her friend says she went very pale and dropped to the ground. Her limbs were twitching. She came round fully recovered in less than five minutes. She has been well since. She has a car for personal use.

The Correct answer is b.
C. A 24 year old man presents with an episode of collapse that happened that morning at home. He says he was getting ready for work and felt fine. He then found himself lying on the bedroom floor with no memory of falling. He felt exhausted, his muscles ached all over, and he had wet himself. He thinks he must have been on the floor for some time. He has no significant past history and is on no medication. His job involves driving a car.

The Correct answer is d.

After a TIA or stroke, patients may drive after a minimum of one month providing there is no residual neurological deficit at this point and they are clinically well. There is no need to stop driving after a simple faint. After an initial diagnosis of epilepsy, a licence is revoked for a year with a medical assessment at the end of this time.

2. A 70 year old woman, with spirometry confirmed COPD without reversibility, is attending the nurse- led COPD clinic. She complains to the nurse of gradually increasing breathlessness on minimal exertion, orthopnoea and fatigue. She is not feverish or complaining of increased coloured sputum. The practice nurse wants to try Tiotropium but feels something else might be amiss. She asks you to attend. You carry out a cardio-respiratory examination and find a few bilateral basal crepitations and pitting oedema of both ankles. Which single initial investigation would be most appropriate?

a ) Brain natriuretic peptide(BNP)
b ) Echocardiography
c ) 24 hour ECG
d ) Repeat spirometry
e ) Urinalysis

Answer: E

In this situation, initial basic investigations such as urinalysis and eGFR should be carried out first as renal failure symptoms are similar to those of chronic heart failure. Since the diagnosis of chronic heart failure is often incorrect when based on clinical symptoms and signs alone, confirmation by echocardiography is now a requirement of the Quality Outcomes Framework of the new GMS contract. It is also a recommendation made by SIGN even for the frail elderly. However, the presence of a normal Brain natriuretic peptide (BNP) blood test (if available locally) and a normal ECG will make the diagnosis of chronic heart failure unlikely

3. OPTIONS:

a ) Osteoarthrtitis
b ) Gout
c ) Haemarthrosis
d ) Pseudogout
e ) Trauma
f ) Septic arthritis
g ) Rheumatoid arthritis

INSTRUCTION: Choose the single most likely diagnosis above for each clinical scenario presented below. Each option can be used once, more than once or not at all.

A. A 60 year old man presents with an acutely painful first metatarsophalyngeal joint on his right foot which has been grumbling on for a week since he was on holiday In Tenerife.

The Correct answer is b.
B. A 75 year old woman, with known osteoarthritis, requests a home visit as she has awoken to find her left knee acutely painful, red and swollen. She complains of nausea. On examination, the knee is hot and swollen with restricted movement. Her pulse is 110. Temp 37.0.

The Correct answer is f.
C . A 43 year old diabetic patient hobbles into the surgery complaining of a two day history of increasing swelling and redness of her left ankle. She cannot remember injuring it. She can weightbear with difficulty. The joint is hot and swollen. She has a mild pyrexia of 37.8 C

The Correct answer is f.

Septic arthritis has a case fatality of around 11%. Delayed or inadequate diagnosis leads to joint damage. Patients with a short history of a hot swollen and tender joint (joints) should be regarded as having septic arthritis until proven otherwise, even in the absence of fever.

4. With reference to the Medicines and Healthcare products Regulatory Agency (MHRA) 'Yellow Card Scheme' for reporting adverse drug reactions (ADRs), which one of the following statements is correct?

a ) ADRs of any severity should be reported for new, black triangle drugs or vaccines
b ) An ADR report should be submitted only when causality between a drug and an adverse reaction is certain
c ) Herbal remedies are excluded from the ADR scheme
d ) Only a designated Healthcare Professional can report an ADR
e ) Patient consent is required before submitting an ADR report on their behalf

Answer: A

Causality does not have to be proven – suspicion is enough. Herbal remedies are included in the scheme. Anyone, patients included, may file a report. Patient consent is not required as no patient-specific personal information is required.

5. A 39 year old woman presents with a six month history of prolonged and heavy menstruation. She feels a heaviness in her lower abdomen. She has had two first trimester miscarriages in the previous 18 months. LMP was three weeks ago. Her last ultrasound scan was suspicious of a bulky uterus. There is no weight loss .She has a borderline low haemoglobin and low ferritin levels. She has had only moderate symptomatic relief from tranexamic acid and mefenamic acid. What is the single most likely diagnosis?

a ) Adenomyosis
b ) Endometrial carcinoma
c ) Myometrial fibroids
d ) Cervical carcinoma
e ) Endometrial polyp

Answer: C

Fibroids (uterine leiomyomas) are benign tumours of the smooth muscle cells of the uterus. Women with fibroids can be asymptomatic or may present with menorrhagia (30%), pelvic pain with or without dysmenorrhoea or pressure symptoms (34%), infertility (27%), and recurrent pregnancy loss (3%). Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue within the myometrium. The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively).

6. A research project looking at the management of moderate hypertension divides its subjects into two groups. Group A, with 1776 subjects, receives anti-hypertensive medication. Group B, with 1800 subjects, receives a placebo. After five years the risk of a stroke in Group A is 12%, while in group B it is 20%. What is the Number Needed to Treat (NNT) to prevent one extra stroke?

a ) 2.00
b ) 1.25
c ) 8.00
d ) 12.50
e ) 58.00

Anser: D

NNT is the reciprocal of the absolute risk reduction. For patients with moderate hypertension, receiving placebo treatments, about 20% would be expected to have a stroke over the next five years. This risk is reduced to 12% with antihypertensive drugs. This results in an absolute risk reduction of 0.20-0.12=0.08. The reciprocal of this number is 12.5 - implying that a doctor would need to treat about 12.5 moderately hypertensive patients for five years before he or she could expect to prevent one extra stroke.

7. OPTIONS:

a ) Dental caries
b ) Furuncle
c ) Nasopharyngeal carcinoma
d ) Otitis externa
e ) Otitis media
f ) Ramsay Hunt syndrome
g ) Temporomandibular joint dysfunction

INSTRUCTION: Match the following scenarios with the most likely diagnosis above. Each option can be used once, more than once or not at all.


1 . A 78 year old man with dysphagia and earache.

The Correct answer is c.
2 . A 75 year old man with facial weakness, a focal rash and earache.

The Correct answer is f.
3 . A 45 year old woman with earache worsened by eating and yawning.

The Correct answer is g.

In older patients, a diagnosis of dysphagia is often due to neurological causes such as a CVA. Earache is not a common feature of stroke. Earache with dysphagia suggests the presence of a nasopharyngeal carcinoma. Facial weakness in this age group can suggest stroke. However, in the context of a rash in the external auditory canal and earache, the most likely unifying diagnosis is Ramsay Hunt syndrome. In an adult with earache worsened by eating, dental caries is a possibility. The fact that the symptoms are worsened by yawning makes temporomandibular joint dysfunction more likely.

8. A 55 year old man, who is a heavy smoker, and has a history of hypertension, is seen on an emergency home visit. On examination, his blood pressure is 180/110 with an irregular pulse of 90 bpm. There is no evidence of cardiac failure. He has a mild expressive dysphasia with a left hemiparesis. According to his wife these symptoms have been present for more than 12 hours. He denies any headache and is fully conscious and orientated. With regard to the gold standard, what is the single most appropriate referral plan?

a ) Refer urgently for a neurology appointment (1-2 days).
b ) Refer as an emergency to the nearest hospital.
c ) Refer to a TIA clinic within 1 week.
d ) Refer as an emergency to the nearest stroke unit.
e ) Refer to the stroke clinic within 1 week

Answer: D

All patients with acute stroke should ideally be admitted to a multidisciplinary stroke unit as soon as possible. All patients with acute stroke should undergo CT brain scanning within 24 hours. Stroke outcome is significantly better when patients are treated in an organised stroke unit compared to either general hospital care or organised care at home. High blood pressure should not normally be lowered in the acute phase of stroke. Aspirin should be given as soon as possible after the onset of stroke symptoms once a diagnosis of primary haemorrhage has been excluded (by CT scanning). Following a TIA, the risk of stroke is approximately 7 times greater than the risk in the general population, especially in the first few weeks. Patients should be assessed and investigated in a specialist clinic within 7 days.