Friday 19 March 2010

AKT revision: Knee problems

1. Which one of the following statements below makes a meniscal tear more likely than alternative diagnoses?

A. A hot, red and painful knee.
B. Immediate swelling after injury.
C. Increased laxity on the anterior draw test.
D. Joint line tenderness.
E. Presence of an effusion.

Answer: D

Joint line tenderness is the most sensitive test of meniscal damage. Typically, any effusion will be worse the morning after the injury (unless there is associated cruciate damage). A hot, red painful knee could be septic. The anterior draw sign is a test for anterior cruciate damage-as is a Lachmann test.


2.A 68-year-old man with a history of hypertension and chronic kidney disease (eGFR 47) presents with an acutely swollen right knee that occurred spontaneously. He takes ramipril and bendroflumethazide for hypertension. His temperature is normal. If practical, which is the single most specific test?

A. Erythrocyte sedimentation rate.
B. Fluid aspiration for crystals.
C. Serum calcium.
D. Serum urate.
E. X-ray.

Answer: B

Fluid aspiration for crystals. The most likely diagnosis in this scenario is acute gout. After initial treatment (probably with colchicines in view of his CKD), it is important to arrange a serum urate. This may be normal even in the presence of gout.

3. A 14-year-old female student presents with painful knees on stairs and following sport. She is a first team netball player. Which of the options below is the single most useful piece of initial advice?

A. Glucosamine
B. Non-steroidal anti-inflammatory drugs
C. Physiotherapy
D. Refer for arthroscopy
E. Stop all sport

Answer: C

physiotherapy. This is a common scenario that causes much distress both for the patient and her parents. Such patients are often female and high sporting achievers. PFJ symptoms may be due to malalignment, muscular imbalance or overuse and there may be an associated patellar tendinitis. While stopping all sport would almost certainly alleviate the problem, it is not always popular in this group of patients.

AKT revision: Ovarian cysts and cancer

1.Which one of the following statements is true about CA125?

A serum level greater than 100U/ml (NR <35 U/ml) makes a germ cell tumour the most likely diagnosis.
It is only raised if an epithelial ovarian tumour is present
It is an important parameter in the ovarian risk of malignancy index
The level is reduced if the patient has glycosuria
Women over 50 are screened with a serum CA125 every five years

Answer: C

The RMI combines Ultrasound findings, CA125 and menopausal status. CA125 is a non specific test and the most likely association is with epithelial tumours and not germ cell. Other tumours may cause it to be raised as may diabetes, CCF and liver disease

*The options below relate to referral patterns in women with issues relating to potential ovarian pathology. Each option may be used once, more than once or not at all. Indicate the single most appropriate answer for each patient.

2.A 56 year old woman complaining of bloating and a walnut sized adnexal swelling

A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission


Answer: C

3. A 30 year old asymptomatic Irish woman whose sister has breast cancer aged 35

A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission

Answer: B

for genetic counselling / testing.

4. A 3.5cm right sided cyst found on pelvic ultrasound in a 28 year old non pregnant woman

A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission

Answer: A

referral will however be necessary if this is still present on a repeat scan in 2-3 months.

5. A 40 year old asymptomatic Jewish woman whose aunt died from ovarian cancer

A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission

Answer: B

for genetic counselling / testing since there is a higher incidence of BRCA1 and BRCA2 mutations in this population.

AKT revision: breast conditions

1.A 28 year old develops a tender red quadrant on her right breast 10 days following the birth of her first child. Her temperature is 37.5 degrees, there is no fluctuance and she is breast feeding. Which one of the options below represents the single most appropriate management plan?

A. Avoid antibiotics since she is breast feeding
B. Co-amoxiclav and temporary cessation of breast feeding
C. Co-amoxiclav and continue breast feeding
D. Doxycycline temporary cessation of breast feeding
E. Doxycycline and continue breast feeding

Answer: C

Co-amoxiclav and continue feeding. Tetracyclines should generally be avoided if breast feeding (and in any case are unlikely to be helpful) and it is important that breast feeding continues.

2. Which one of the following female patients with a three day history requires urgent referral? They are all on day 24 of their menstrual cycles

A. A non pregnant 35 year old with tender lumpy breasts who presents with worsening tenderness on the right side.
B. A 28 year old woman with a non tender 2cm mobile lump. She is on the combined oral contraceptive pill and her grandmother developed breast cancer aged 60
C. A 30 year old with an eczematous eruption on both breasts
D. A non pregnant 35 year old with nodularity in her right breast. Her left breast is normal
E. A nulliparous 30 year old with bilateral serous discharge from both nipples.

Answer: D

Solitary asymmetrical nodularity should be triple assessed. All the other options require careful discussion with the patient and review - Option 1 probably has Benign Fibrocystic Change but should be reviewed after menstruation. Option 2 is most likely to have a fibroadenoma and although most GPs would refer her there is no clinical urgency unless there are additional risk factors (e.g. strong family history). Options 3 and 5 are unlikely to have serious pathology. It is however important not to mistake a unilateral eczematous eruption (which does not respond to topical treatment) for eczema since it may be a marker for an underlying carcinoma.

3. Which one of the following variables is the most important determinant of prognosis in Invasive ductal breast cancer?

A. Age of patient
B. Axillary lymph node positivity
C. Oestrogen receptor status
D. Site of tumour
E. Size of tumour

Answer: B

AKT revision: menopause and HRT

1.In a non hysterectomised woman, for which one of the following perimenopausal conditions is systemic HRT likely to be recommended?

A. Poor concentration
B. Depression
C. Flushes
D. Incontinence
E. Vaginal dryness

Answer: C

Although many experts would recommend HRT for vaginal dryness this can generally be achieved with topical preparations.

2. Which one of the following lifestyle interventions is most likely to be of help in a patient of 50 with troublesome vasomotor symptoms?

A. Coffee
B. Occasional Exercise
C. Red wine in moderation
D. Weight loss

Answer: D


3.When counselling a 48 year old perimenopausal woman regarding the menopause which one of the following statements regarding combined HRT is correct?

A. Continuous combined preparations are the treatment of choice at this age
B. It is the treatment of choice for established osteoporosis
C. Her risk of arterial disease is unlikely to be significantly increased
D. Persistent bleeding problems are usual
E. Treatment usually continues for up to ten years

Answer: C

Studies suggest a minor increase heart disease risk in women 10 yrs post menopause, and no increased stroke risk detectable in the first year of HRT use. At this age therefore (assuming a duration of treatment of 1-2 years) problems are unlikely.
Generally speaking continuous combined preparations would be given to women who have finished menstruating. Whilst HRT is useful in preventing osteoporosis in those at high risk it has no place in managing the condition. Although bleeding problems can occur initially they should settle after three months. The duration of treatment is for the shortest time possible (as a rule of thumb around 1-2 years).

Thursday 18 March 2010

AKT revision - hepatitis

1.You receive a clinic letter regarding a 57 year old man whom you had referred to the local hepatologist for further investigation of abnormal liver function tests. The consultant describes a diagnosis of chronic hepatitis in his clinic letter.
Which ONE of the following viruses is MOST LIKELY to be the cause of chronic hepatitis in this patient? Select ONE option only.

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E

Answer: C

Hepatitis A and E viruses cause an acute hepatitis and do not have a chronic infection state.
Approximately 2-5% of patients infected with hepatitis B virus (HBV) will develop a chronic hepatitis; however, almost 75% of patients infected with hepatitis C virus (HCV) will develop a chronic hepatitis.
Hepatitis D virus (HDV) requires the presence of HBV to replicate; therefore, HDV infection develops only in patients who are positive for hepatitis B surface antigen. The rate of progression to chronic hepatitis is approximately 70-80%. HDV is less common than HCV and therefore HCV would be the most likely cause of chronic hepatitis in this patient.

2.A 36 year old man was seen by your colleague last week with a 10 day history of abdominal pain following a recent family holiday in Africa. He is otherwise well in himself. You are the on-call GP in your surgery today and receive the following results:

Bilirubin 17 µmol/l (3-17 µmol/l)
Alanine aminotransferase 58 IU/l (0-35 IU/l)
Alkaline phosphatase 266 IU/l (30-300 IU/l)
Gamma glutamyl transpeptidase 32 IU/l (11-50 IU/l)
Hepatitis A IgM antibodies POSITIVE
Hepatitis A IgG antibodies NEGATIVE
What is the SINGLE MOST appropriate INITIAL management option for this patient? Select ONE option only.

A. Advice and reassurance
B. Arrange sexual contact tracing
C. Refer for abdominal ultrasound scan
D. Repeat hepatitis serology in three months
E. Routine referral to gastroenterology

Answer: A

The presence of hepatitis A IgM antibodies here indicates acute hepatitis A infection.
If hepatitis A IgG antibodies were present, this would indicate previous hepatitis A infection and these antibodies would be detectable lifelong.
Hepatitis A virus is transmitted faeco-orally through contacts or travel to an endemic area. It has an incubation period of 2-6 weeks and is usually a self-limiting illness. The risk of acute liver failure is very low (less than 0.1%) although this increases with age and in those with pre-existing liver disease. There is no chronic infection state and recovery from an acute infection induces lifelong immunity.

3. A 30 year old lady attends the surgery for preconception advice. She is newly married and is originally from China. She last had sexual intercourse with her husband 14 days ago and he has been abroad on a business trip since that time. He is due to return home today. You elucidate that her husband has chronic hepatitis B. She requests a blood test to determine her Hepatitis B status.
In order to reduce the immediate risk of transmission of disease, which ONE of the following is the most appropriate INITIAL management for this patient? Select ONE option only.

A. Advise the patient about 'safe sex', or to refrain from sexual intercourse
B. Arrange an 'accelerated schedule' preexposure immunisation
C. Arrange for passive immunisation with hepatitis B immunoglobulin (HBIG)
D. Arrange for routine pre-exposure immunisation
E. Arrange serological testing to confirm the patient's hepatitis B status

Answer: A

Ideally, the patient needs to undergo serological testing to ascertain her hepatitis B status.
In the interim, she either needs to practice 'safe sex' or refrain completely.
Both the vaccine and passive immunization with HBIG should be given as soon as possible-preferably within 12 hours, ideally within 24 hours, although it should be considered up to 1 week after exposure.
DoH: The Green Book
www.dh.gov.uk
www.britishlivertrust.org.uk
www.bnf.org

4.A 48 year old man attends the surgery for advice regarding travel vaccinations. After assessing his risks including specific travel destinations, you advise him to receive a hepatitis A vaccination.
Which ONE of the following statements regarding Hepatitis A vaccination is correct? Select ONE option only.

A. A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years
B. A single dose of hepatitis A vaccine confers immunity for up to 2 years
C. A single dose of hepatitis A vaccine confers immunity for up to 3 years
D. Hepatitis A is a live vaccine
E. Hepatitis A vaccine is administered subcutaneously

Answer: A

A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years. A single dose of hepatitis A vaccine confers immunity for up to 1 year. It is an inactivated vaccine and is administered intramuscularly.
www.bnf.org.uk
www.fitfortravel.nhs.uk

5. Which ONE of the following diseases is notifiable under the Public Health (Infectious Diseases) Regulations 1988? Select ONE option only.

A. Creutzfeldt-Jakob disease
B. Hepatitis A
C. HIV
D. Infectious mononucleosis
E. Syphilis

Answerr: B

AKT revision - sore throat

Below is a series of management options for patients who present to you with a sore throat. From the list of patients below select the single most appropriate management option. Each option may be used once, more than once, or not at all.

1. A 50 year old woman recently commenced on carbimazole for thyrotoxicosis presents with a sore throat and headache for one day. On examination her pharynx is red, her temperature 37.0 and she looks well.

A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days

Answer: D

This patient needs a full blood count the same day to exclude a carbimazole induced blood dyscrasia. If this is normal the decision on antibiotics can be made later.

2. A four year old child with a sore throat of two days duration. The family are due to go on holiday in three days. His throat looks red (but there are no exudates), he has mild cervical lymphadenopathy but there is no fever.

A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days

Answer: C

3. A 19 year old female student who presents with sore throat, fever, anterior and posterior cervical lymphadenopathy and who has a foul tonsillar exudate on examination.

A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days

Answer: F

She also needs a FBC and glandular fever screen since she could well have glandular fever. Amoxycillin is undesirable in this patient for two reasons:
1. She may develop a rash if she has glandular fever
2. It will interfere with the OCP if she is on it - which Penicillin V will not.


4. A 10 year old boy presents with his third attack of "tonsillitis". He has no cough. On examination he looks unwell, has tonsillar exudates, cervical lymphadenopathy and a temperature of 38.7 degrees centigrade.

A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days

Answer: F
see NICE guidance. He has four centor criteria. The recommended duration of antibiotics (if given) is 10 days

5. A two year old travelling person attends as an emergency. On examination she is snuffly but well, temperature 36.6 degrees C. Her throat is mildly injected.

A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days

Answer: D

There are no positive Centor criteria and management should be centred on parental education and the development of a shared management plan

AKT revision

1. Which one of the following features is not consistent with acute conjunctivitis?

A. Bilateral red eyes
B. Lymphadenopathy
C. Mild photophobia
D. Papillae under an everted upper lid
E. Reduced visual acuity

Answer: E

2.A 25 year old male patient (with no significant past medical history) presents with a painful red right eye. On examination his corrected visual acuity is 6/12 in the affected eye, the redness is concentrated around the cornea and his right pupil is smaller than his left. Which of the following options represents the single most likely diagnosis?

A. Allergic Conjunctivitis
B. Glaucoma
C. Iritis
D. Marginal keratitis
E. Viral conjunctivitis

Answer: C

This is unlikely to be acute conjunctivitis because of the pattern of injection "circumlimbal", the reduction in visual acuity and the pupilary change. In this age group acute glaucoma would be unlikely - especially in the absence of any ophthalmic history.

3. A two month year old boy presents acutely with his third episode of conjunctivitis. Both he and his mother are otherwise well. What is the the single most appropriate management plan whilst awaiting swabs?

A. No antibiotic treatment
B. Oral antibiotic treatment
C. Topical antibiotic treatment
D. Both oral and topical antibiotic treatment

Answer: A

The most likely cause is naso-lacrimal duct obstruction although it is essential to exclude Ophthalmia Neonatorum (notably from Chlamydia) with this story . If swabs are negative most cases of acute conjunctivitis will resolve without treatment and if the cause of the problem is duct obstruction gentle massage of the nose (cephalo caudally whilst feeding) is said to help.

4. Which one of the following statements is true about acute sinusitis in adults?

A. Antibiotics are usually indicated in the presence of a purulent discharge
B. Decongestants have been shown to be effective
C. Plain X-Ray of the paranasal sinuses is a useful investigation in primary care
D. Sinusitis is more likely if symptoms are not preceded by an URTI
E. Sinusitis is more likely if there is pain in the teeth than if there is not

Answer: C

Monday 8 March 2010

AKT Revision

1.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
A patient with ischaemic heart disease who has anaphylaxis to eggs.

True

There are very few contraindications to influenza vaccination which is also licensed in children. Generally speaking, it should be targeted to those with chronic disease and not (as in case 10) to the 'worried well'.

2. Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Chronic kidney disease stage four

False

3.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Diabetes (type 1)

False

4.

Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Healthy individual with multiple absences from work due to recurrent 'flu'

True
There are very few contraindications to influenza vaccination which is also licensed in children. Generally speaking, it should be targeted to those with chronic disease and not (as in case 10) to the 'worried well'.

5.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Lung cancer with bony metastases on chemotherapy

False

6.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Severe neutropoenia due to myelodysplasia

False

AKT revision

1. A 23-year-old woman who is 12 weeks into her first pregnancy has failed to stop smoking by simple means asks whether you can help. You would like to balance the patient’s needs against best available evidence. Which one of the following options would be most appropriate?

A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. arenicline

Answer: C

There is no evidence that acupuncture works, buproprion and varenicline are contraindicated in both pregnancy and breastfeeding. It would seem prudent to minimize the duration of exposure of the fetus to nicotine—thus nicotine lozenges would be preferable to the longer acting patches.

- The following patient, who has failed to stop smoking by simple means, asks whether you can help. You would like to balance the patient’s needs against best available evidence.

A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. Varenicline


2. A 17-year-old boy whose grandfather has just died of lung cancer, who is still at school and smokes 10 cigarettes per day. He seems motivated.

Answer: D

The initial options would be between nicotine lozenges and patches. Since he is still at school (and teachers tend to object to chewing gum), D would be preferable.

3. A 52-year-old man with a history of seizures who relapsed after stopping nicotine replacement therapy (NRT) 6 months before and would prefer to try something else.

Answer: E

Buproprion is contraindicated due to the seizures and there is no evidence for acupuncture. While NRT may be used again, it would be reasonable to go along with the patient’s wishes.

4. A 32-year-old woman who considers herself a 'social smoker' in that she smokes approximately 20 cigarettes per week

Answer: C

There is some evidence that even 'light' smokers can be helped by smoking cessation therapy. This is an important subgroup (12 % of smokers do not smoke daily).

5. A 60-year-old man with ischaemic heart disease and mild COPD who has quit successfully with varenicline but fears relapse.

Answer: E

Acupuncture has no evidence of efficacy and there is no evidence that buproprion prevents relapse. NRT is an option (but he has ischaemic heart disease) and there is evidence that varenicline will prevent relapse if prescribed for a further 3 months.

6.A 65-year-old woman who would like help to reduce her habit but who does not wish to stop completely at the moment.

Answer: C

There is evidence that if the requests of such patients are granted, then they are more likely to quit in the future. There is, however, no evidence of long-term health benefit from 'cutting down'. NRT is licensed for this use and the evidence is actually for nicotine chewing gum. The choice of lozenges rather than patches is therefore for this reason as well as preventing the double effect of a patch (long acting) and a cigarette.