AKT questions

1. The Centor criteria are used to predict the likelihood of Group A beta-haemolytic streptococcal infection in patients presenting with acute sore throat. It may therefore be a useful tool in helping to determine whether or not such patients require an antibiotic prescription.Which ONE of the following is NOT one of the Centor criteria? Select ONE option only.

A. Absence of cough
B. Cough
C. Fever
D. Tender anterior cervical lymphadenopathy
E. Tonsillar exudate

Answer: B

The Centor criteria are:• Absence of cough• Fever• Tender anterior cervical lymphadenopathy• Tonsillar exudate. The presence of all four criteria has only a 40% positive predictive value for Group A beta-haemolytic streptococcal sore throat. However, the absence of all four criteria has an 80% negative predictive value.NICE have published guidelines incorporating the Centor criteria to guide antibiotic prescribing in patients presenting with acute sore throat.

2. An 82 year-old man presents with a three day history of sore throat and cough. He has type 2 diabetes. On examination he is apyrexial with no tonsillar exudate or cervical lymphadenopathy. His chest is clear on auscultation.Which is the SINGLE most appropriate intervention for this patient? Select ONE option only.

A. Delayed antibiotic prescription
B. Immediate antibiotic prescription
C. Admit to the acute medical unit
D. Prescribe simple analgesia
E. Reassure

Answer: B

Current NICE guidance recommends that an immediate prescription of antibiotics is appropriate for any patient aged over 80 years old with an acute cough and one of:
• Hospitalisation in the previous year
• Diabetes
• History of congestive heart failure
• Current use of oral steroids

Other patients should be offered an immediate antibiotic prescription if they:
• Are systemically unwell
• Have signs or symptoms of serious underlying infection
• Have co-morbidity increasing the risk of complications (e.g. significant heart, lung, renal, liver or neuromuscular disease, immunosuppression
• Are young children who were born prematurely

3. A 6 year-old boy attends the surgery with his mother. He complains of a runny nose, persistent sneezing and a sore throat, which all started yesterday. He is otherwise well with no other past medical history. You diagnose acute rhinosinusitis and decide not to prescribe an antibiotic.Approximately how long would you expect this patient’s illness to last? Select ONE option only.

A. 5 days
B. 7 days
C. 10 days
D. 14 days
E. 18 days

Answer: E

The average length of illness in acute rhinosinusitis is 2½ weeks. For all antibiotic prescribing strategies it is recommended that patients receive information about the natural course of the illness including the average duration of symptoms to expect.
Average duration of illness:
• Acute otitis media – 4 days
• Acute sore throat (including pharyngitis and tonsillitis) – 1 week
• Common cold – 1½ weeks
• Acute rhinosinusitis – 2½ weeks
• Acute cough (including bronchitis) – 3 weeks

4. A 21 year-old man presents with a ten day history of headache, malaise, myalgia, fever and dry cough. On examination his temperature is 38.7°C and his respiratory rate is 28/min. On auscultation of his chest there is reduced air entry and crackles and wheeze at the left base. Which SINGLE organism is the most likely cause of this patient’s symptoms? Select ONE option only.

A. Haemophilus influenzae
B. Legionella pneumophilia
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
E. Streptococcus pneumoniae

Answer: C

Mycoplasma pneumoniae:is implicated in approximately 6% of pneumonias in the UK. It primarily affects children and young adults. It often presents with atypical symptoms and signs. It is characterised by an influenza-like respiratory illness of gradual onset with headache, malaise, fever and cough. Doxycycline, alone or combined with amoxicillin is the treatment of choice.
Haemophilus influenzae :is a common cause of pneumonia in children and is frequently found in the phlegm of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).
Legionella pneumophilia: presents as an atypical pneumonia, however it is less common than Mycoplasma pneumoniae. Three epidemiological patterns are recognised:• In previously fit individuals living in an institution in which, for example, the shower or cooling system are contaminated• In immunocompromised and elderly male smokers• Sporadic. Erythromycin is the treatment of choice.
Staphylococcus aureus: is a rare cause of community-acquired pneumonia, but may occur as a secondary infection following a viral illness. It should therefore be considered during influenza epidemics or if the patient presents with a history suggesting recent pneumonia.
Streptococcus pneumoniae: is the commonest cause of community acquired pneumonia, accounting for approximately one third of all pneumonias in which an organism is identifiable. Typically it presents acutely over two to three days with dirty brown sputum. Amoxicillin is the treatment of choice.

5. A 16 month old baby boy is brought to the urgent care centre late at night by his parents. They describe a three day history of fever, runny nose and cough. Over the last 12 hours his cough has become much louder and his voice has become hoarse. On examination his temperature is 38.9°C and his respiratory rate is 30/min. There is no intercostal recession.What is the SINGLE most appropriate immediate management for this patient? Select ONE option only.

A. Oral amoxicillin
B. Oral dexametasone
C. Oxygen
D. Nebulised adrenaline
E. Nebulised salbutamol

Answer: B

This scenario describes a typical case of croup. Parainfluenza viruses account for the majority of cases. Single doses of dexametasone or budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Steam inhalation is no longer routinely recommended to parents due to the potential risk of steam burn injuries.The British National Formulary (BNF) has a useful section on the back few pages regarding ‘Medical Emergencies in the Community’ which outlines management of specific conditions including drug dosages. The dosage of dexametasone syrup is calculated by age and weight.Nebulised adrenaline may be useful in severe croup where there are marked signs of respiratory distress. The child should be transferred to hospital immediately if signs of respiratory distress are present.

6. This is the threshold criterion for confusion.

A. Less than 70 mmHg
B. Less than 80 mmHg
C. Less than 90 mm Hg
D. Less than 100 mmHg
E. 20/min or more
F. 25/min or more
G. 30/min or more
H. Mental test score of 7 or less
I. Mental test score of 8 or less
J. Mental test score of 9 or less

Answer: I

7. This is the threshold criterion for systolic blood pressure.

A. Less than 70 mmHg
B. Less than 80 mmHg
C. Less than 90 mm Hg
D. Less than 100 mmHg
E. 20/min or more
F. 25/min or more
G. 30/min or more
H. Mental test score of 7 or less
I. Mental test score of 8 or less
J. Mental test score of 9 or less

Answer: C

8. This is the threshold criterion for respiratory rate.

A. Less than 70 mmHg
B. Less than 80 mmHg
C. Less than 90 mm Hg
D. Less than 100 mmHg
E. 20/min or more
F. 25/min or more
G. 30/min or more
H. Mental test score of 7 or less
I. Mental test score of 8 or less
J. Mental test score of 9 or less

Answer: I