Lutonics Not Lunatics

AKT questions

2010-05-01T13:27:00.001-07:00

1. A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following:
Blood group: A Rhesus negative

What is the most appropriate management regarding her rhesus status?ia

A.A Give first dose of anti-D at 28 weeksia

B.A No action required unless antenatal vaginal blood lossia

C.A Give first dose of anti-D as soon as possibleia

D.A Give anti-D just prior to deliveryia

E.A No action requiredia
Rhesus negative woman - anti-D at 28 + 34 weeks
NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks
Antenatal care: timetable

NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. They recommend:
• 10 antenatal visits in the first pregnancy if uncomplicated
• 7 antenatal visits in subsequent pregnancies if uncomplicated
• women do not need to be seen by a consultant if the pregnancy is uncomplicated

Gestation Purpose of visit
8 - 12 weeks (ideally < 10 weeks) Booking visit
• general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
• BP, urine dipstick, check BMI
Booking bloods/urine
• FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
• hepatitis B, syphilis, rubella
• HIV test is offered to all women
• urine culture to detect asymptomatic bacteriuria
10 - 13 weeks Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks Down's syndrome screening including nuchal scan
16 weeks Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
18 - 20+6 weeks Anomaly scan
25 weeks (only if primip) Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 11 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip) Routine care as above
34 weeks Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women
Information on labour and birth plan
36 weeks Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, 'baby-blues'
38 weeks Routine care as above
40 weeks (only if primip) Routine care as above
Discussion about options for prolonged pregnancy
41 weeks Routine care as above
Discuss labour plans and possibility of induction

2. A 21-year-old female is seen in the first seizure clinic in the outpatient department. A decision is made not to start her on anti-epileptic medication. What restrictions on driving should she be informed about?ia

A.A No restrictions but inform DVLAia

B.A No restrictions, no need to inform DVLA if not on medicationia

C.A Cannot drive for 1 month from date of seizureia

D.A Cannot drive for 6 months from date of seizureia

E.A Cannot drive for 1 year from date of seizureia
Patients cannot drive for 1 year following a seizure

DVLA: neurological disorders

The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating to drivers of heavy goods vehicles tend to be much stricter

Specific rules
• first seizure - 1 year off driving
• stroke or TIA - 1 month off driving
• multiple TIAs over short period of times - 3 months off driving
• craniotomy - 1 year off driving*
• narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'

Syncope
• simple faint: no restriction
• unexplained, low risk of recurrence: 4 weeks off
• explained and treated: 4 weeks off
• unexplained: 6 months off

*if the tumour is a benign meningioma and there is no seizure history, licence can be reconsidered 6 months after surgery if remains seizure free

3. A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. After discussing treatment options he elects not to be cardioverted. If the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer?ia
A.A Aspirinia
B.A Warfarin, target INR 2-3ia
C.A No anticoagulationia
D.A Warfarin, target INR 3-4ia
E.A Warfarin, target INR 2-3 for six months then aspirinia
Young AF, no TIA or risk factors, just give aspirin

Atrial fibrillation: anticoagulation

The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006

The guidelines suggest a stroke risk stratification approach when determining how to anticoagulate a patient, as detailed below:

Low risk - annual risk of stroke = 1%
• age < 65 years with no moderate or high risk factors
• use aspirin

Moderate risk - annual risk of stroke = 4%
• age > 65 years with no high risk factors, or:
• age < 75 years with diabetes, hypertension or vascular disease (ischaemic heart disease or peripheral arterial disease)
• use aspirin or warfarin depending on individual circumstances

High risk - annual risk of stroke = 8-12%
• age > 75 years with diabetes, hypertension or vascular disease (ischaemic heart disease or peripheral arterial disease)
• previous TIA, ischaemic stroke or thromboembolic event
• valve disease, heart failure or impaired left ventricular function
• use warfarin
4. An 18-year-old female presents to her GP as she has missed one of her Microgynon 30 pills yesterday morning. She has taken Microgynon for the past 2 years and is currently 4 days into a packet of pills. She had sexual intercourse last night and is unsure what to do. What is the correct management?ia

A.A Advise condom use for next 7 daysia

B.A Perform a pregnancy testia

C.A Omit pill break at end of packia

D.A No action neededia

E.A Emergency contraception should be offeredia
For further information please consult the link to the FFPRHC guidelines
Combined oral contraceptive pill: missed pill

The advice from the Faculty of Family Planning and Reproductive Health Care has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol

If 1 or 2 pills missed (at any time in the cycle)
• take a pill as soon as possible and then continue taking pills daily, one each day
• no additional contraceptive protection needed

If 3 or more pills missed
• take a pill as soon as possible and then continue taking pills daily, one each day
• the women should use condoms or abstain from sex until she has taken pills for 7 days in a row
• if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
• if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
• if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off

5. Which one of the following products is 'blacklisted' under Part XVIIIA of the Drug Tariff and hence cannot be dispensed on the NHS?ia

A.A Juvela gluten-free breadia

B.A Clozapineia

C.A Farley's Soya Formulaia

D.A EpiPenia

E.A Topical minoxidilia

Part XVIIIA of the Drug Tariff - The Blacklist

Theoretically any food, drug, toiletry or cosmetic may be prescribed on an NHS prescription unless the product is listed in Part XVIIIA of the Drug Tariff ('the blacklist’).

Medical devices (appliances) can only be prescribed on NHS prescriptions if the product is listed in Part IX of the Drug Tariff.

If a proprietary product is listed in ‘the blacklist’, it cannot be dispensed on the NHS. The only exception to this is if the prescription is issued using a generic name and the generic name is not itself included in the blacklist.

Some examples of 'blacklisted' products:
• Propecia (finasteride for male-pattern alopecia)
• Regaine (topical minoxidil for male-pattern alopecia)
• Calpol (see above, paracetamol suspension may be prescribed)

The Selected List

Part XVIIIB of the Drug Tariff lists items that may only be prescribed for the patient groups and for the purpose listed in the Drug Tariff. Prescribers must endorse prescriptions for these products ‘SLS’. This section covers the prescription of phosphodiesterase type-5 inhibitors.

For example:
• Niferex Elixir 30ml Paediatric Dropper Bottle - infants born prematurely - prophylaxis in treatment of iron deficiency
• sildenafil - only if treated prior to September 1998 or if has one of the following conditions: diabetes mellitus, Parkinson's disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, spinal cord injury, renal failure treated with dialysis or transplant, prostatectomy or radical pelvic surgery
6. A 62-year-old man presents with insomnia and lethargy. He has no other systemic symptoms of note. Routine clinical examination reveals a palpable mass in the right lower quadrant of the abdomen, which doesn't move with respiration and is non-pulsatile. What is the most appropriate management?ia

A.A Blood screen including LFTs, U&Esia

B.A Urgent referral to local urological serviceia

C.A Ultrasound abdomenia

D.A Urgent referral to local colorectal serviceia

E.A Routine referral to general surgical clinicia
Colorectal cancer: referral guidelines

NICE recommend the following patients are referred urgently (i.e. within 2 weeks) to colorectal services for investigation:
• patients > 40 years old, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more
• patients > 60 years old, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms
• patients > 60 years old, with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
• any patient presenting with a right lower abdominal mass consistent with involvement of the large bowel
• any patient with a palpable rectal mass
• unexplained iron deficiency anaemia in men or non-menstruating women (Hb < 11 g/dl in men, < 10 g/dl in women)
8. A 57-year-old female presents due to problems with urine leakage over the past six months. She describes frequent voiding and not always being able to get to the toilet in time. She denies losing urine when coughing or sneezing. What is the most appropriate initial treatment?ia

A.A Trial of oxybutyninia

B.A Bladder retrainingia

C.A Regular toiletingia

D.A Pelvic floor muscle trainingia

E.A Topical oestrogen creamia
Urinary incontinence - first-line treatment:
• urge incontinence: bladder retraining
• stress incontinence: pelvic floor muscle training

Urinary incontinence

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the UK population. It is more common in elderly females. NICE released guidance on the management of UI in 2006

Causes
• overactive bladder (OAB)/urge incontinence: due to detrusor over activity
• stress incontinence: leaking small amounts when coughing or laughing
• mixed incontinence: both urge and stress
• overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

Initial investigation
• bladder diaries should be completed for a minimum of 3 days
• urine dipstick and culture

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
• bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
• bladder stabilising drugs: immediate release oxybutynin is first-line
• surgical management: e.g. sacral nerve stimulation

If stress incontinence is predominant:
• pelvic floor muscle training (for a minimum of 3 months)
• surgical procedures: e.g. retropubic mid-urethral tape procedures

9. A 55-year-old man is admitted following an anterior myocardial infarction. Which of the following drugs is least likely to reduce mortality in the long-term?ia

A.A Atorvastatinia

B.A Atenololia

C.A Ramiprilia

D.A Aspirinia

E.A Isosorbide mononitrateia
Isosorbide mononitrate may be important in managing symptoms yet it has no proven mortality benefit following a myocardial infarction
Myocardial infarction: secondary prevention

NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2007. Some key points are listed below

All patients should be offered the following drugs:
• ACE inhibitor
• beta-blocker
• aspirin
• statin

Clopidogrel
• after an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks
• after a non-ST segment elevation myocardial infarction clopidogrel should be given for the first 12 months

Aldosterone antagonists
• patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3–14 days of the MI, preferably after ACE inhibitor therapy
10. A 54-year-old man presents with a variety of physical symptoms that have been present for the past 9 years. Numerous investigations and review by a variety of specialties have indicated no organic basis for his symptoms. This is an example of:ia

A.A Munchausen's syndromeia

B.A Hypochondrial disorderia

C.A Dissociative disorderia

D.A Somatisation disorderia

E.A Conversion disorderia
Unexplained symptoms
• Somatisation = Symptoms
• hypoChondria = Cancer
Somatisation disorder is the correct answer as the patient is concerned about persistent, unexplained symptoms rather than an underlying diagnosis such as cancer (hypochondrial disorder). Munchausen's syndrome describes the intentional production of symptoms, for example self poisoning
Unexplained symptoms

There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:

Somatisation disorder
• multiple physical SYMPTOMS present for at least 2 years
• patient refuses to accept reassurance or negative test results

Hypochondrial disorder
• persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
• patient again refuses to accept reassurance or negative test results

Conversion disorder
• typically involve loss of motor or sensory function
• some patients may experience secondary gain from loss of function
• patients may be indifferent to their apparent disorder

Dissociative disorder
• dissociation is a process of 'separating off' certain memories from normal consciousness
• in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor
• dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

Munchausen's syndrome
• also known as factitious disorder
• the intentional production of physical or psychological symptoms

Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other

11. A 2-month-old boy is brought to the afternoon surgery by his mother. Since the morning he has been taking reduced feeds and has been 'not his usual self'. On examination the baby appears well but has a low-grade temperature of 38.1ºC. What is the most appropriate management?ia

A.A Advise regarding antipyretics, to see if not settlingia

B.A IM benzylpenicillinia

C.A Advise regarding antipyretics, booked appointment for next dayia

D.A Admit to hospitalia

E.A Empirical amoxicillin for 7 daysia
Any child less than 3 months old with a temperature > 38ºC is regarded as a 'red' feature in the new NICE guidelines, warranting urgent referral to a paediatrician. Although many experienced GPs may choose not to strictly follow such advice it is important to be aware of recent guidelines for the AKT exam
Feverish illness in children

The 2007 Feverish illness in children guidelines by NICE introduced a 'traffic light' for risk stratification of children under the age of 5 years presenting with a fever. It should be noted that these guidelines only apply 'until a clinical diagnosis of the underlying condition has been made'. A link to the guidelines is provided but some key points are listed below.

Assessment

The following should be recorded in all febrile children:
• temperature
• heart rate
• respiratory rate
• capillary refill time

Signs of dehydration (reduced skin turgor, cool extremities etc) should also be looked for

Measuring temperature should be done with an electronic thermometer in the axilla if the child is < 4 weeks or with an electronic/chemical dot thermometer
in the axilla or an infra-red tympanic thermometer.

Risk stratification

Please see the link for the complete table, below is a modified version
Green – low risk Amber – intermediate risk Red – high risk
• Normal colour
• Responds normally to social cues
• Normal cry
• Not dehydrated

• No amber or red signs • Pallor reported by parent/carer

• Not responding normally to social cues
• Wakes only with prolonged stimulation
• Decreased activity
• Not smiling

• Nasal flaring
• Tachypnoea:
- RR > 50 breaths/minute age 6–12 months
- RR > 40 breaths/minute age > 12 months
• Oxygen saturation = 95% in air
• Crackles

• Dry mucous membrane
• Poor feeding in infants
• CRT = 3 seconds
• Reduced urine output
• Fever for = 5 days
• Swelling of a limb or joint
• Non-weight bearing/not using an extremity
• A new lump > 2 cm • Pale/mottled/ashen/blue
• No response to social cues
• Appears ill to a healthcare professional
• Unable to rouse
• Weak, high-pitched or continuous cry

• Grunting
• Tachypnoea:
- RR > 60 breaths/minute
• Moderate or severe
chest indrawing

• Reduced skin turgor
• Age 0–3 months, temperature > 38°C
• Age 3–6 months, temperature > 39°C

• Non-blanching rash
• Bulging fontanelle
• Neck stiffness
• Status epilepticus
• Focal neurological signs
• Focal seizures
• Bile-stained vomiting

Management

If green:
• Child can be managed at home with appropriate care advice, including when to seek further help

If amber:
• provide parents with a safety net or refer to a paediatric specialist for further assessment
• a safety net includes verbal or written information on warning symptoms and how
further healthcare can be accessed, a follow-up appointment, liaison with other healthcare professionals, e.g. out-of-hours providers, for further follow-up

If red:
• refer child urgently to a paediatric specialist

Other key points include
• oral antibiotics should not be prescribed to children with fever without apparent source
• if a pneumonia is suspected but the child is not going to be referred to hospital then a chest x-ray does not need to be routinely performed.

12. A 67-year-old man with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he be prescribed for breakthrough pain?ia

A.A 5 mgia

B.A 10 mgia

C.A 15 mgia

D.A 20 mgia

E.A 30 mgia
Breakthrough dose = 1/6th of daily morphine dose
The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg
Palliative care prescribing: pain

SIGN issued guidance on the control of pain in adults with cancer in 2008

Selected points
• the breakthrough dose of morphine is one-sixth the daily dose of morphine
• all patients who receive opioids should be prescribed a laxative
• opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
• metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Conversion between opioids
From To
Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 5

From To
Oral morphine Oral oxycodone Divide by 2

The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately equivalent to one '25 mcg/hour' patch, therefore product literature should be consulted
From To
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5

13. What are funnel plots primarily used for?ia

A.A Demonstrate the heterogeneity of a meta-analysisia

B.A Demonstrate the existence of publication bias in meta-analysesia

C.A Provide a graphical representation of the relative risk results in a case-control studyia

D.A Provide a graphical representation of the relative risk results in a cohort studyia

E.A Provide a graphical representation of the probability of a patient experiencing a particular adverse effectia
Funnel plots - show publication bias in meta-analyses

Funnel plot

A funnel plot is primarily used to demonstrate the existence of publication bias in meta-analyses. Funnel plots are usually drawn with treatment effects on the horizontal axis and study size on the vertical axis.

Interpretation
• a symmetrical, inverted funnel shape indicates that publication bias is unlikely
• conversely, an asymmetrical funnel indicates a relationship between treatment effect and study size. This indicates either publication bias or a systematic difference between smaller and larger studies (‘small study effects’)
14. A 19-year-old male with a history of asthma presents to the surgery due to shortness of breath. On examination his peak expiratory flow is 270 l/min (usual 600 l/min). Pulse is 96 bpm and the respiratory rate is 24 / min. Examination of the chest reveals a bilateral expiratory wheeze but is otherwise unremarkable. What is the most appropriate management?ia

A.A Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to A&E via ambulanceia

B.A Nebulised salbutamol + advise to double inhaled steroids + allow home if settles with follow-up reviewia

C.A Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to medical team via ambulanceia

D.A Oxygen + nebulised salbutamol + prednisolone and review following treatmentia

E.A Nebulised salbutamol + prednisolone + allow home if settles with follow-up reviewia
Whilst his respiratory rate is consistent with a 'moderate' exacerbation his peak flow, less than 50% of usual, means he should be treated as for a 'severe' exacerbation. The British Thoracic Society give specific recommendations on dealing with acute asthma in primary care - please see the link
Asthma: assessment and management in primary care

Patients with acute severe asthma are stratified into moderate, severe or life-threatening
Moderate Severe Life-threatening
• PEFR > 50% best or predicted
• Speech normal
• RR < 25 / min
• Pulse < 110 bpm • PEFR 33 - 50% best or predicted
• Can't complete sentences
• RR > 25/min
• Pulse > 110 bpm • PEFR < 33% best or predicted
• Oxygen sats < 92%
• Silent chest, cyanosis or feeble respiratory effort
• Bradycardia, dysrhythmia or hypotension
• Exhaustion, confusion or coma

Management of moderate asthma
• beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
• if PEFR between 50-75% then prednisolone 40-50mg

Management of severe asthma
• consider admission
• oxygen 40-60%
• beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
• prednisolone 40-50mg
• if no response then admit

Management of life-threatening asthma
• arrange immediate admission (999 call)
• oxygen 40-60%
• nebulised beta 2 agonists such as salbutamol, and ipratropium
• prednisolone 40-50mg or IV hydrocortisone 100mg
15. A 17-year-old female presents with recurrent attacks of collapse. These episodes typically occur without warning and have occurred whilst she was running for a bus. There is no significant past medical history and the only family history of note is that her father died suddenly when he was 38-years-old. What is the likely cause?ia

A.A Vaso-vagal attacksia

B.A Anxietyia

C.A Epilepsyia

D.A Cardiac syncopeia

E.A Malingeringia
Sudden death, unusual collapse in young person - ? HOCM
This is a rather vague question. However, a family history of sudden death should make you think of conditions such as hypertrophic obstructive cardiomyopathy
HOCM: features

Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins

Features
• dyspnoea, angina, syncope
• sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure
• jerky pulse, large 'a' waves, double apex beat
• ejection systolic murmur: increases with Valsalva manoeuvre and decreases on squatting

Associations
• Friedreich's ataxia
• WPW

Echo
• systolic anterior motion (SAM) of the anterior mitral valve leaflet
• asymmetric hypertrophy (ASH)
• mitral regurgitation

ECG
• LVH
• progressive T wave inversion
• deep Q waves
16. A 72-year-old woman presents with polyuria and polydipsia. Investigations reveal the following:
Fasting glucose 4.5 mmol/l
Calcium 2.88 mmol/l
Phosphate 0.75 mmol/l
Parathyroid hormone 6 pmol/L (normal range = 0.8 - 8.5)

What is the most likely underlying diagnosis?ia

A.A Myelomaia

B.A Sarcoidosisia

C.A Primary hyperparathyroidismia

D.A Vitamin D excessia

E.A Osteomalaciaia
The PTH level in primary hyperparathyroidism may be normal
Despite a raised calcium level the parathyroid hormone level is inappropriately normal. This points towards a diagnosis of primary hyperparathyroidism and the other causes would lead to a suppression of parathyroid hormone
Primary hyperparathyroidism

In postgraduate exams primary hyperparathyroidism is stereotypically seen in elderly females with an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is most commonly due to a solitary adenoma

Causes of primary hyperparathyroidism
• 80%: solitary adenoma
• 15%: hyperplasia
• 4%: multiple adenoma
• 1%: carcinoma

Features - 'bones, stones, abdominal groans and psychic moans'
• polydipsia, polyuria
• peptic ulceration/constipation/pancreatitis
• bone pain/fracture
• renal stones
• depression
• hypertension

Associations
• hypertension
• multiple endocrine neoplasia: MEN I and II

Investigations
• raised calcium, low phosphate
• PTH may be raised or normal
• technetium-MIBI subtraction scan

Treatment
• total parathyroidectomy
17. A 58-year-old man with no past medical history of note is admitted to hospital with crushing central chest pain. ECG on arrival shows anterior ST elevation and he is subsequently thrombolysed with a good resolution of symptoms and ECG changes. Two months following discharge from hospital, which combination of drugs should he be taking?ia

A.A ACE inhibitor + beta-blocker + statin + aspirinia

B.A Spironolactone + beta-blocker + statin + aspirinia

C.A ACE inhibitor + beta-blocker + statin + aspirin + clopidogrelia

D.A ACE inhibitor + statin + aspirin + clopidogrelia

E.A Beta-blocker + statin + aspirin + clopidogrelia
The current guidance is to continue clopidogrel for 4 weeks following a ST-elevation myocardial infarction
Myocardial infarction: secondary prevention

NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2007. Some key points are listed below

All patients should be offered the following drugs:
• ACE inhibitor
• beta-blocker
• aspirin
• statin

Clopidogrel
• after an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks
• after a non-ST segment elevation myocardial infarction clopidogrel should be given for the first 12 months

Aldosterone antagonists
• patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3–14 days of the MI, preferably after ACE inhibitor therapy
18. A 19-year-old man presents with a compound fracture of his leg following a fall from scaffolding. Examination reveals soiling of the wound with mud. He is sure he has had five previous tetanus vaccinations. What is the most appropriate course of action to prevent the development of tetanus?ia

A.A Clean wound + intramuscular human tetanus immunoglobulinia

B.A Clean wound + tetanus vaccineia

C.A Clean wound + tetanus vaccine + intramuscular human tetanus immunoglobulinia

D.A Clean wound + tetanus vaccine + benzylpenicillinia

E.A Clean woundia
A soiled, compound fracture is regarded as high-risk for tetanus and intramuscular human tetanus immunoglobulin should be given
Tetanus: vaccination

The tetanus vaccine is a cell-free purified toxin that is given as part of a combined vaccine (e.g. combined with diphtheria and inactivated polio vaccine)

Tetanus vaccine is currently given in the UK as part of the routine immunisation schedule at:
• 2 months
• 3 months
• 4 months
• 3-5 years
• 13-18 years

This therefore provides 5 doses of tetanus-containing vaccine. Five doses is now considered to provide adequate long-term protection against tetanus.

Intramuscular human tetanus immunoglobulin should be given to patients with high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue) irrespective of whether 5 doses of tetanus vaccine have previously been given

If vaccination history is incomplete or unknown then a dose of tetanus vaccine should be given combined with intramuscular human tetanus immunoglobulin for high-risk wounds
.com - Terms and Conditions
19. A 56-year-old man is reviewed in the Cardiology outpatient clinic following a myocardial infarction one year previously. During his admission he was found to be hypertensive and diabetic. He complains that he has put on 5kg in weight in the past 6 months. Which of his medications may be contributing to his weight gain?ia

A.A Metforminia

B.A Losartania

C.A Clopidogrelia

D.A Gliclazideia

E.A Simvastatinia

Sulfonylureas

Sulfonylureas are oral hypoglycaemic drugs used in the management of type 2 diabetes mellitus. They work by increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present.

Common adverse effects
• hypoglycaemic episodes (more common with long acting preparations such as chlorpropamide)
• increased appetite and weight gain

Rarer adverse effects
• syndrome of inappropriate ADH secretion
• bone marrow suppression
• liver damage (cholestatic)
• photosensitivity
• peripheral neuropathy

Sulfonylureas should be avoided in breast feeding and pregnancy
20. A mother whose 14-year-old daughter had a history of glue ear when younger asks the practice manager for a copy of her medical records. Which one of the following statements governing access to medical records is incorrect?ia

A.A Doctors should withhold information they may feel is damaging to the patients physical or mental healthia

B.A Access to records should be given within 40 daysia

C.A Parents may request access to their children's recordsia

D.A Competent children may seek access to their recordsia

E.A Should be done without a feeia
A fee is normally charged for access to medical records
Access to medical records

A patients right to view their own medical records is governed by the 1998 Data Protection Act and the 1990 Access to Health Records Act

Key principles
• patients have a right to see what is written in their medical record
• competent children may seek access to their records
• parents may request access to their children's (< 16 years) records
• doctors should not release information they feel may damage a patients emotional or physical health
• access to information recorded during the previous 40 days must be given within 21 days, or in any other case 40 days
• a fee may be charged
21. A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal metastases but until now has not had any significant problems with pain control. Unfortunately he is now getting regular back pain despite taking paracetamol 1g qds. Neurological examination is unremarkable. What is the most appropriate next step?ia

A.A Switch to co-codamol 30/500ia

B.A Refer for radiotherapyia

C.A Add oral bisphosphonateia

D.A Add diclofenacia

E.A Add dexamethasoneia
Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates have a role in managing bony pain but these are not first-line treatments
Palliative care prescribing: pain

SIGN issued guidance on the control of pain in adults with cancer in 2008

Selected points
• the breakthrough dose of morphine is one-sixth the daily dose of morphine
• all patients who receive opioids should be prescribed a laxative
• opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
• metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Conversion between opioids
From To
Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 5

From To
Oral morphine Oral oxycodone Divide by 2

The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately equivalent to one '25 mcg/hour' patch, therefore product literature should be consulted
From To
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5
22. Theme: Theme: Consultation modelsia
A. Heron
B. Byrne and Long
C. Berne
D. Fraser
E. Neighbour
F. Balint
G. Stott and Davis
H. Helman's folk model
I. Pendleton

For each of the following tasks select the consultation model most associated with itia
1. Safety netting

The correct answer is Neighbour
2. Handing over

The correct answer is Neighbour
3. Considering other problems

The correct answer is Pendleton

Consultation models

Calgary-Cambridge observation guide- Kurtz and Silverman - 1996
• initiating the session
• gathering information
• building the relationship
• giving information, explaining and planning
• closing the session

Stewart - patient-centred clinical method - 1995. 2003
• exploring both the disease and the illness experience
• understanding the whole person
• finding common ground
• incorporating prevention and health promotion
• enhancing the doctor-patient relationship
• being realistic (with time and resources)

Pendleton - The Consultation: an Approach to Learning and Teaching - 1984, 2003
• define the reason for the patient's attendance (ideas, concerns and expectations)
• consider other problems
• with the patient, choose an appropriate action for each problem
• achieve a shared understanding of the problems with the patient
• involve the patient in the management and encourage him/her to accept appropriate responsibility
• use time and resources appropriately
• establish or maintain a relationship with the patient which helps to achieve the other tasks

Fraser - Areas of competence - 1992
• interviewing and history-taking
• physical examination
• diagnosis and problem-solving
• patient management
• relating to patients
• anticipatory care
• record keeping

Neighbour - The Inner Consultation - five checkpoint model - 1987
• connecting
• summarising
• handing over
• safety netting
• housekeeping

Tuckett - meeting of two experts - 1985
• the consultation is a meeting between two experts
• doctors are experts in medicine
• patients are experts in their own illnesses
• shared understanding is the aim
• doctors should seek to understand the patient's beliefs
• doctors should address explanations in terms of the patient's belief system

Stott and Davis - Exceptional potential of the consultation - 1979
• management of presenting problems
• management of continuing problems
• modification of help-seeking behaviour
• opportunistic health promotion
23. A 23-year-old man presents as he is concerned about recent hair loss. Examination reveals the following:ia

What is the most likely diagnosis?

A.A Telogen effluviumia

B.A Alopecia areataia

C.A Tinea capitisia

D.A Male-pattern baldnessia

E.A Discoid lupus erythematousia

Alopecia areata

Alopecia areata is a presumed autoimmune condition causing localised, well demarcated patches of hair loss. At the edge of the hair loss, there may be small, broken 'exclamation mark' hairs

Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually. Careful explanation is therefore sufficient in many patients. Other treatment options include:
• topical or intralesional corticosteroids
• topical minoxidil
• phototherapy
• dithranol
• contact immunotherapy
24. Which one of the following is the most common ocular manifestation of rheumatoid arthritis?ia

A.A Scleritisia

B.A Episcleritisia

C.A Keratoconjunctivitis siccaia

D.A Corneal ulcerationia

E.A Keratitisia
Keratoconjunctivitis sicca is characterised by dry, burning and gritty eyes caused by decreased tear production
Rheumatoid arthritis: ocular manifestations

Ocular manifestations of rheumatoid arthritis are common, with 25% of patients having eye problems

Ocular manifestations
• keratoconjunctivitis sicca (most common)
• episcleritis (erythema)
• scleritis (erythema and pain)
• corneal ulceration
• keratitis

Iatrogenic
• steroid-induced cataracts
• chloroquine retinopathy
25. A 78-year-old women is discharged following a fractured neck of femur. On review she is making good progress but consideration is given to secondary prevention of further fractures. What is the most suitable management?ia

A.A Arrange DEXA scan + start strontium ranelate if T-score < -2.5 SDia

B.A Start oral bisphosphonateia

C.A Arrange DEXA scan + start oral bisphosphonate if T-score < -1.0 SDia

D.A Arrange DEXA scan + start hormone replacement therapy if T-score < -2.5 SDia

E.A Arrange DEXA scan + start oral bisphosphonate if T-score < -1.5 SDia
NICE guidelines support starting a bisphosphonate without waiting for a DEXA scan in such scenarios
Osteoporosis: secondary prevention

NICE guidelines were updated in 2008 on the secondary prevention of osteoporotic fractures in postmenopausal women.

Key points include
• treatment is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of – 2.5 SD or below). In women aged 75 years or older, a DEXA scan may not be required 'if the responsible clinician considers it to be clinically inappropriate or unfeasible'
• vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
• alendronate is first-line
• around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate (see treatment criteria below)
• strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates (see treatment criteria below)

Treatment criteria for patients not taking alendronate

Unfortunately, a number of complicated treatment cut-off tables have been produced in the latest guidelines for patients who do not tolerate alendronate

Risk factors (for use in the tables below)
• parental history of hip fracture
• alcohol intake of 4 or more units
• rheumatoid arthritis

T-scores (SD) at (or below) which risedronate or etidronate is recommended when alendronate cannot be taken
Age (years) No risk factors 1 risk factor 2 risk factors
50–54 Not indicated – 3.0 – 2.5
55–59 – 3.0 – 3.0 – 2.5
60–64 – 3.0 – 3.0 – 2.5
65–69 – 3.0 – 2.5 – 2.5
70 or older – 2.5 – 2.5 – 2.5

T-scores (SD) at (or below) which strontium ranelate or raloxifene is recommended when alendronate and either risedronate or etidronate cannot be taken
Age (years) No risk factors 1 risk factor 2 risk factors
50–54 Not indicated – 3.5 – 3.5
55–59 – 4.0 – 3.5 – 3.5
60–64 – 4.0 – 3.5 – 3.5
65–69 – 4.0 – 3.5 – 3.0
70–74 – 3.0 – 3.0 – 2.5
75 or older – 3.0 – 2.5 – 2.5

Supplementary notes on treatment

Bisphosphonates
• alendronate, risedronate and etidronate are all licensed for the prevention and treatment of post-menopausal and glucocorticoid-induced osteoporosis
• all three have been shown to reduce the risk of both vertebral and non-vertebral fractures although alendronate, risedronate may be superior to etidronate in preventing hip fractures
• ibandronate is a once-monthly oral bisphosphonate

Vitamin D and calcium
• poor evidence base to suggest reduced fracture rates in the general population at risk of osteoporotic fractures - may reduce rates in frail, housebound patients

Raloxifene - selective oestrogen receptor modulator (SERM)
• has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fractures
• has been shown to increase bone density in the spine and proximal femur
• may worsen menopausal symptoms
• increased risk of thromboembolic events
• may decrease risk of breast cancer

Strontium ranelate
• 'dual action bone agent' - increases deposition of new bone by osteoblasts and reduces the resorption of bone by osteoclasts
• strong evidence base, may be second-line treatment in near future
• increased risk of thromboembolic events

Teriparatide
• recombinant form of parathyroid hormone
• very effective at increasing bone mineral density but role in the management of osteoporosis yet to be clearly defined

Hormone replacement therapy
• has been shown to reduce the incidence of vertebral fracture and non-vertebral fractures
• due to concerns about increased rates of cardiovascular disease and breast cancer it is no longer recommended for primary or secondary prevention of osteoporosis unless the woman is suffering from vasomotor symptoms

Hip protectors
• evidence to suggest significantly reduce hip fractures in nursing home patients
• compliance is a problem

Falls risk assessment
• no evidence to suggest reduced fracture rates
• however, do reduce rate of falls and should be considered in management of high risk patients
26. A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?ia

A.A Hyperarousalia

B.A Emotional numbingia

C.A Nightmaresia

D.A Loss of inhibitionsia

E.A Avoidanceia

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example a major disaster or childhood sexual abuse. It encompasses what became known as 'shell shock' following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month

Features
• re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
• avoidance: avoiding people, situations or circumstances resembling or associated with the event
• hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
• emotional numbing – lack of ability to experience feelings, feeling detached
from other people
• depression
• drug or alcohol misuse
• anger
• unexplained physical symptoms

Management
• following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
• watchful waiting may be used for mild symptoms lasting less than 4 weeks
• trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
• drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended
27. A 7-year-old girl is brought to surgery due to a sore throat. She has a temperature of 39.2ºC and is not eating due to the pain, although she is tolerating fluids. The tonsils are covered in exudate bilaterally. Examination of the ears is unremarkable. Other than supportive treatment, what is the most appropriate management?ia

A.A Erythromycin for 10 daysia

B.A Amoxicillin for 7 daysia

C.A Antibiotics are not indicatedia

D.A Phenoxymethylpenicillin for 10 daysia

E.A Phenoxymethylpenicillin for 5 daysia
This girl has marked systemic upset and should be treated with antibiotics. A 7 or 10 day course of antibiotics is appropriate to ensure eradication of possible Streptococcus infection. Phenoxymethylpenicillin is the first-line antibiotic choice in the BNF
Sore throat

Sore throat encompasses pharyngitis, tonsillitis, laryngitis

Clinical Knowledge Summaries recommend:
• throat swabs and rapid antigen tests should not be carried out routinely in patients with a sore throat

Management
• paracetamol or ibuprofen for pain relief
• antibiotics are not routinely indicated

NICE indications for antibiotics
• features of marked systemic upset secondary to the acute sore throat
• unilateral peritonsillitis
• a history of rheumatic fever
• an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)

If antibiotics are indicated then either phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic) should be given. Either a 7 or 10 day course should be given

28. In accordance with recent NICE guidelines on urinary tract infection in children, which one of the following patients would not require a urine sample to be obtained?ia

A.A 4-year-old with a 5 day history of urinary frequencyia

B.A 2-year-old who has a persistent pyrexia after 48 hours of antibiotic treatment for otitis mediaia

C.A 16-month-old complaining of abdominal painia

D.A 2-month-old who is feeding poorly and vomitingia

E.A 3-year-old with a temperature of 37.7ºC who is well and has no obvious focus of infectionia
The 3-year-old most probably has a non-specific viral infection. There is no indication at the current time to check for a urinary tract infection
Urinary tract infection in children: features, diagnosis and management

Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood

Presentation in childhood depends on age:
• infants: poor feeding, vomiting, irritability
• younger children: abdominal pain, fever, dysuria
• older children: dysuria, frequency, haematuria
• features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness

NICE guidelines for checking urine sample in a child
• if there are any symptoms or signs suggestive or a UTI
• with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
• with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)

Urine collection method
• clean catch is preferable
• if not possible then urine collection pads should be used
• cotton wool balls, gauze and sanitary towels are not suitable
• invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible

Management
• infants less than 3 months old should be referred immediately to a paediatrician
• children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
• children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
• antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
29. A 31-year-old woman presents as she has noted an offensive, fishy vaginal discharge. She describes a grey, watery discharge. What is the most likely diagnosis?ia

A.A Trichomonas vaginalisia

B.A Candidaia

C.A Chlamydiaia

D.A Bacterial vaginosisia

E.A Physiological dischargeia

Vaginal discharge

Vaginal discharge is a common presenting symptom and is not always pathological

Common causes
• physiological
• Candida
• Trichomonas vaginalis
• bacterial vaginosis

Less common causes
• whilst cervical infections such as Chlamydia and Gonorrhoea can cause a vaginal discharge this is rarely the presenting symptoms
• ectropion
• foreign body
• cervical cancer

Key features of the common causes are listed below
Condition Key features
Candida 'Cottage cheese' discharge
Vulvitis
Itch
Trichomonas vaginalis Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Bacterial vaginosis Offensive, thin, white/grey, 'fishy' discharge
30. A 52-year-old woman with a history of hypothyroidism presents with lethargy and a sore tongue. Blood tests are reported as follows:
Hb 10.7 g/dl
MCV 121 fl
Plt 177 * 109/l
WBC 5.4 * 109/l

Further tests are ordered:
Vitamin B12 64 ng/l (200-900 ng/l)
Folic acid 7.2 nmol/l (> 3.0 nmol/l)

Antibodies to intrinsic factor are also found. What is the most appropriate management?ia

A.A 1 mg of IM hydroxocobalamin once every 3 monthsia

B.A 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 monthsia

C.A 1 mg of IM hydroxocobalamin once every 2 months + folic acid 5mg odia

D.A Give folic acid 5mg od one week then recheck bloodsia

E.A 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months + folic acid 5mg odia

Vitamin B12 deficiency
sqweqwesf erwrewfsdfs adasd dhe
Vitamin B12 is mainly used in the body for red blood cell development and also maintenance of the nervous system. It is absorbed after binding to intrinsic factor (secreted from parietal cells in the stomach) and is actively absorbed in the terminal ileum. A small of vitamin B12 is passively absorbed without being bound to intrinsic factor.

Causes of vitamin B12 deficiency
• pernicious anaemia
• post gastrectomy
• poor diet
• disorders of terminal ileum (site of absorption): Crohn's, blind-loop etc

Features of vitamin B12 deficiency
• macrocytic anaemia
• sore tongue and mouth
• neurological symptoms: e.g. Ataxia
• neuropsychiatric symptoms: e.g. Mood disturbances

Management
• if no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months
• if a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord
31. Which one of the following statements regarding appraisal is incorrect?ia

A.A The appraiser may be a non-principalia

B.A Formal training is required to become an appraiseria

C.A It is compulsoryia

D.A The average time commitment for appraisal is a minimum of 4.5 to 6.5 hoursia

E.A Practices are responsible for funding locum coveria
Primary care trusts are responsible for funding locum cover to compensate for time lost to appraisals
Appraisal
sqweqwesf erwrewfsdfs adasd dhe
Appraisal has been a requirement for GPs since 2002. It is meant to be a formative process identifying development needs rather than performance management.

Appraisal will eventually provide a regular, structured system for recording progress
towards revalidation and identifying development needs

The appraiser should be another GP (principal or non-principal), who will
have been properly trained in appraisal. Typically the average time commitment for appraisal is a minimum of 4.5 to 6.5 hours. This includes between 2 and 4 hours for preparation. Primary Care Trusts should provide funds for locum cover to compensate for this time

The content of appraisal is based on the core headings set out in the GMC’s
Good Medical Practice document:
• good clinical care
• maintaining good medical practice
• relationships with patients
• working with colleagues
• teaching and training
• probity
• health
32. A 24-year-old woman who is 14 weeks pregnant presents with a severe migraine. She has a long history of migraine and stopped propranolol prophylaxis when she found out she was pregnant. Unfortunately the headache has not responded to paracetamol 1g. What is the most appropriate next step?ia

A.A Ergotamineia

B.A Nasal zolmitriptania

C.A Ibuprofen 400mgia

D.A Almotriptan 12.5mgia

E.A Codeine 30mgia

Migraine: pregnancy, contraception and other hormonal factors
sqweqwesf erwrewfsdfs adasd dhe
SIGN produced guidelines in 2008 on the management of migraine, the following is selected highlights:

Migraine during pregnancy
• paracetamol 1g is first-line
• aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester

Migraine and the combined oral contraceptive (COC) pill
• if patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)

Migraine and hormone replacement therapy (HRT)
• safe to prescribe HRT for patients with a history of migraine but it may make migraines worse
33. A 64-year-old man with a history of Parkinson's disease is reviewed in clinic and a decision has been made to start him on cabergoline. Which one of the following adverse effects is most strongly associated with this drug?ia

A.A Optic neuritisia

B.A Transient rise in liver function testsia

C.A Pulmonary fibrosisia

D.A Renal failureia

E.A Thrombocytopeniaia

Parkinson's disease: management
sqweqwesf erwrewfsdfs adasd dhe
Currently accepted practice in the management of patients with Parkinson's disease (PD) is to delay treatment until the onset of disabling symptoms and then to introduce a dopamine receptor agonist. If the patient is elderly, levodopa is sometimes used as an initial treatment

Dopamine receptor agonists
• e.g. bromocriptine, ropinirole, cabergoline, apomorphine
• ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide*) have been associated with pulmonary, retroperitoneal and cardiac fibrosis. The Committee on Safety of Medicines advice that an ESR, creatinine and chest x-ray should be obtained prior to treatment and patients should be closely monitored

Levodopa
• usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of levodopa to dopamine
• reduced effectiveness with time (usually by 2 years)
• unwanted effects: dyskinesia, 'on-off' effect
• no use in neuroleptic induced parkinsonism

MAO-B (Monoamine Oxidase-B) inhibitors
• e.g. selegiline
• inhibits the breakdown of dopamine secreted by the dopaminergic neurons

Amantadine
• mechanism is not fully understood, probably increases dopamine release and inhibits its uptake at dopaminergic synapses

COMT (Catechol-O-Methyl Transferase) inhibitors
• e.g. entacapone
• COMT is an enzyme involved in the breakdown of dopamine, and hence may be used as an adjunct to levodopa therapy
• used in established PD

Antimuscarinics
• block cholinergic receptors
• now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson's disease
• help tremor and rigidity
• e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)

*pergolide was withdrawn from the US market in March 2007 due to concern regarding increased incidence of valvular dysfunction
35. A 24-year-old woman who is 18 weeks pregnant presents to surgery. Earlier on in the morning she came into contact with a child who has chickenpox. She is unsure if she had the condition herself as a child. What is the most appropriate action?ia

A.A Advise her to present within 24 hours of the rash developing for consideration of IV acicloviria

B.A Reassure her that there is no risk of fetal complications at this point in pregnancyia

C.A Give varicella immunoglobulinia

D.A Check varicella antibodiesia

E.A Prescribe oral acicloviria
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
Chickenpox exposure in pregnancy
sqweqwesf erwrewfsdfs adasd dhe
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome

Fetal varicella syndrome (FVS)
• risk of FVS following maternal varicella exposure is around 1-2% if occurs before 20 weeks gestation
• studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks. The risk in the first trimester is thought to be less (around 0.5-1%)
• features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

Management of chickenpox exposure
• if there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
• if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
• consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash
36. A 41-year-old woman is investigated for hot flushes and night sweats. Bloods show a significantly raised FSH level and her symptoms are attributed to the menopause. Following discussions with the patient she elects to have hormone replacement treatment. What is the most significant risk of failing to prescribe a combined oestrogen-progestogen preparation rather than an oestrogen-only preparation?ia

A.A Increased risk of venous thromboembolismia

B.A Increased risk of ovarian canceria

C.A Increased risk of endometrial canceria

D.A Increased risk of breast canceria

E.A Increased risk of colorectal canceria
HRT: unopposed oestrogen increases risk of endometrial cancer

Hormone replacement therapy: adverse effects
sqweqwesf erwrewfsdfs adasd dhe
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Side-effects
• nausea
• breast tenderness
• fluid retention and weight gain

Potential complications
• increased risk of breast cancer: increased by the addition of a progestogen
• increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely
• increased risk of venous thromboembolism: increased by the addition of a progestogen

Breast cancer
• in the Women's Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
• the increased risk relates to duration of use
• breast cancer incidence is higher in women using combined preparations compared to oestrogen-only preparations
• the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
37. A 54-year-old man with a history of type 2 diabetes mellitus and benign prostatic hyperplasia is referred to dermatology due to a number of lesions over his shin. On examination symmetrical, erythematous, tender, nodules are found. The lesions have started to heal without scarring. What is the most likely diagnosis?ia

A.A Necrobiosis lipoidica diabeticorumia

B.A Erythema nodosumia

C.A Pyoderma gangrenosumia

D.A Syphilisia

E.A Pretibial myxoedemaia

Shin lesions
sqweqwesf erwrewfsdfs adasd dhe
The differential diagnosis of shin lesions includes the following conditions:
• erythema nodosum
• pretibial myxoedema
• pyoderma gangrenosum
• necrobiosis lipoidica diabeticorum

Below are the characteristic features:

Erythema nodosum
• symmetrical, erythematous, tender, nodules which heal without scarring
• most common causes are streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill)

Pretibial myxoedema
• symmetrical, erythematous lesions seen in Graves' disease
• shiny, orange peel skin

Pyoderma gangrenosum
• initially small red papule
• later deep, red, necrotic ulcers with a violaceous border
• idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders

Necrobiosis lipoidica diabeticorum
• shiny, painless areas of yellow/red skin typically on the shin of diabetics
• often associated with telangiectasia
38. A 22-year-old woman who is an immigrant from Malawi presents for review as she thinks she is pregnant. This is confirmed with a positive pregnancy test. She is known to be HIV positive. Which one of the following should not be part of the management plan to ensure an optimal outcome?ia

A.A Oral zidovudine for the newborn until 6 weeks of ageia

B.A Maternal antiretroviral therapyia

C.A Encourage breast feedingia

D.A Intrapartum zidovudine infusionia

E.A Elective caesarean sectionia
The 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen
HIV and pregnancy
sqweqwesf erwrewfsdfs adasd dhe
With the increased incidence of HIV infection amongst the heterosexual population there is an increasing number of HIV positive women giving birth in the UK. In London the incidence may be as high as 0.4% of pregnant women. The aim of treating HIV positive women during pregnancy is to minimise harm to both the mother and fetus, and to reduce the chance of vertical transmission.

Factors which reduce vertical transmission (from 25-30% to 2%)
• maternal antiretroviral therapy
• mode of delivery (caesarean section)
• neonatal antiretroviral therapy
• infant feeding (bottle feeding)

Screening
• NICE guidelines recommend offering HIV screening to all pregnant women

Antiretroviral therapy
• all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
• if women are not currently taking antiretroviral therapy it is usually commenced between 28 and 32 weeks of gestation and should be continued intrapartum

Mode of delivery
• elective caesarean section*
• a zidovudine infusion should be started four hours before beginning the caesarean section

Neonatal antiretroviral therapy
• zidovudine is usually administered orally to the neonate for four to six weeks

Infant feeding
• in the UK all women should be advised not to breast feed

*the 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen
39. Which one of the following statements regarding the link between intrauterine devices (IUDs) and ectopic pregnancies is correct?ia

A.A The percentage of pregnancies that are ectopic is increased and the absolute number is increasedia

B.A The percentage of pregnancies that are ectopic is increased but the absolute number is decreasedia

C.A Having an intrauterine device has no effect on the rate of ectopic pregnanciesia

D.A The percentage of pregnancies that are ectopic is decreased and the absolute number is decreasedia

E.A The percentage of pregnancies that are ectopic is decreased but the absolute number is increasedia
IUCD - the percentage of pregnancies that are ectopic is increased but the absolute number is decreased

Intrauterine contraceptive devices
sqweqwesf erwrewfsdfs adasd dhe
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia

Effectiveness
• both the IUD and IUS are more than 99% effective

Mode of action
• IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
• IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening

Counselling
• IUD is effective immediately following insertion
• IUS can be relied upon after 7 days

Potential problems
• IUDs make periods heavier, longer and more painful
• the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
• uterine perforation during insertion: less than 1 in 1,000 risk
• the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
• infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
• expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
40. At what age would the average child acquire the ability to crawl?ia

A.A 6 monthsia

B.A 9 monthsia

C.A 12 monthsia

D.A 18 monthsia

E.A 2 yearsia

Developmental milestones: gross motor
sqweqwesf erwrewfsdfs adasd dhe
The table below summarises the major gross motor developmental milestones
Age Milestone
3 months Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
6 months Lying on abdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back
9 months Sits without support (Refer at 12 months)
Pulls to standing
Crawls
12 months Cruises
Walks with one hand held
15 months Walks unsupported (Refer at 18 months)
18 months Squats to pick up a toy
2 years Runs
Walks upstairs and downstairs holding on to rail
3 years Rides a tricycle using pedals
Walks up stairs without holding on to rail
4 years Hops on one leg

Notes
• the majority of children crawl on all fours before walking but some children 'bottom-shuffle'. This is a normal variant and runs in families
41. An 8-year-old boy is reviewed in clinic due to nocturnal enuresis. Of the following options, what is the most appropriate initial management strategy?ia

A.A Enuresis alarmia

B.A Trial of oral desmopressinia

C.A Trial of imipramineia

D.A Trial of intranasal desmopressinia

E.A Restrict fluids in the eveningia
A reward based system may also be used as a first line treatment in enuresis. Restricting fluids is not recommended advice - Clinical Knowledge Summaries suggest: 'Do not restrict fluids. The child should have about eight drinks a day, spaced out throughout the day, the last one about 1 hour before bed.'
Nocturnal enuresis
sqweqwesf erwrewfsdfs adasd dhe
The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the 'involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract'

Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)

Management
• dip urine for protein and sugar, send for culture (helps exclude diabetes mellitus and UTI)
• explanation, reassurance and education (e.g. avoid punitive measures)
• star charts are useful (the child earns a star for a dry night)
• if star charts fail then alarms which awake the child following a wetting episode may be tried
42. With reference to the Quality and Outcomes Framework (QOF), which component is responsible for the second highest number of points?ia

A.A Child health surveillanceia

B.A Clinical indicatorsia

C.A Organisationalia

D.A Additional servicesia

E.A Patient experienceia

Quality and Outcomes Framework
sqweqwesf erwrewfsdfs adasd dhe
The Quality and Outcomes Framework (QOF) is the annual reward and incentive programme detailing GP practice achievement results. It was introduced as part of the new General Medical Services (GMS) to incentivise not only the management of chronic disease such as diabetes but also to improve the organisation of the practice and patient experience

Other points
• for clinical indicators the value of a point is determined by the prevalence of that condition in the practice
• participation in the QOF is voluntary
• 5% of practices should be visited at random to help prevent fraud. The PCT visiting team will normally consist of a PCT management representative, a GP and a patient representative

The table below shows the four key areas on which the QOF is based
Clinical indicators 655 points Standards linked to the care of patients suffering from chronic diseases
Organisational 181 points Standards relating to records and information, communicating with patients, education and training, medicines management and clinical and practice management
Additional services 36 points Covering cervical screening, child health surveillance, maternity services and contraceptive services
Patient experience 108 points Based on patient surveys and length of consultations

20 points are also awarded for holistic care. The calculation is complicated but is basically awarded on the basis of overall achievement in the clinical domain

Patients may be 'exception reported' in the following situations:
• patients who have been recorded as refusing to attend review who have been invited on at least three occasions during the preceding 12 months
• patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances e.g. terminal illness, extreme frailty
• patients newly diagnosed within the practice or who have recently registered with the practice, who should have measurements made within 3 months and delivery of clinical standards within 9 months e.g. blood pressure or cholesterol measurements within target levels
• patients who are on maximum tolerated doses of medication whose treatment remain sub-optimal
• patients for whom prescribing a medication is not clinically appropriate e.g. those who have an allergy, another contraindication or have experienced an adverse reaction
• where a patient has not tolerated medication
• where a patient does not agree to investigation or treatment (informed dissent), and this has been recorded in their medical records
• where the patient has a supervening condition which makes treatment of their condition inappropriate e.g. cholesterol reduction where the patient has liver disease
• where an investigative service or secondary care service is unavailable
43. A home visit is requested by the husband of a 71-year-old woman who is 'off her legs'. On arriving the patient states that since mid-morning her left arm has felt weak and a degree of facial asymmetry is noted when she smiles. She is normally fit and well other than a past history of hypertension for which she takes ramipril. What is the most appropriate action?ia

A.A Arrange same-day medical admissionia

B.A Dial 999 for emergency admissionia

C.A Arrange review at rapid access TIA clinicia

D.A Arrange review at rapid access TIA clinic + give aspirin 300 mgia

E.A Dial 999 for emergency admission + give aspirin 300 mgia
This lady is most likely having a stroke, nowadays rightly recognised as a medical emergency. Aspirin should only be given once a haemorrhagic stroke has been excluded
Stroke: management
sqweqwesf erwrewfsdfs adasd dhe
The Royal College of Physicians (RCP) published guidelines on the diagnosis and management of patients following a stroke in 2004

Selected points relating to the management of acute stroke include:
• blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
• blood pressure should not be lowered in the acute phase unless there are complications e.g. hypertensive encephalopathy
• aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
• with regards to atrial fibrillation, the RCP state: 'anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke'
• if the cholesterol is > 3.5 mmol/l patients should be commence on a statin

Thrombolysis

Thrombolysis should only be given if:
• it is administered within 3 hours of onset of stroke symptoms (unless as part of a clinical trial)
• haemorrhage has been definitively excluded (i.e. imaging has been performed)

Alteplase is currently recommended by NICE
44. A meta-analysis is performed examining whether giving patients who've recently had a myocardial infarction a new dietary supplement prevents a further attack. The meta-analysis consists of four randomised controlled trials and is summarised below:ia

What is the most appropriate interpretation of the data?

A.A There is publication bias in studies looking into this questionia

B.A There is a non-significant trend that taking the supplement reduces the chance of a further myocardial infarctionsia

C.A There is a non-significant trend towards no benefit from taking the supplement in terms of reducing further myocardial infarctionsia

D.A Taking the supplement reduces the chance of a further myocardial infarctionsia

E.A Taking the supplement increases the chance of a further myocardial infarctionia
The meta-analysis of the results, represented by the diamond, is clear from the no effect line (odds ratio of 1) and shows a signficant increase in the chance of a further myocardial infarction.
Forest plots
sqweqwesf erwrewfsdfs adasd dhe
Forest plots are usually found in meta-analyses and provide a graphical representation of the strength of evidence of the constituent trials.

The name of the trials is listed down the left hand side, usually in chronological order. On the right side the results of the studies are shown as squares centred on the point estimate of the result of each trial. The size of the square is proportional to the size of the trial. The line running through the line shows the confidence interval, usually at 95%. Beneath the individual trials is the summary result (i.e. The result of the meta-analysis) represented by a diamond.

haematuria

2010-04-22T12:44:00.000-07:00

1. A 53-year-old man attends as a new patient to your practice. He has no previous past medical history and is not taking any regular medication. As part of his new patient check, the following results are obtained:

Urinalysis Blood++

Mid-stream urine (MSU) Negative

Blood pressure 112/68 mmHg

Urea and electrolytes Normal

Which ONE of the following options is the most appropriate INITIAL management for this patient? Select ONE option only.

A. Check prostate-specific antigen (PSA)
B. Re-check urinalysis in 2 weeks
C. Referral for renal ultrasound scan
D. Routine referral to renal physician
E. Urgent referral to urological surgeon

answer: E

Regarding the management of suspected urological cancer:

•Male or female adult patients of any age who present with painless macroscopic haematuria should be referred urgently.
•In male or female patients with symptoms suggestive of a urinary infection who also present with macroscopic haematuria, investigations should be undertaken to diagnose and treat the infection before consideration of referral. If infection is not confirmed the patient should be referred urgently.
•In all adult patients 40 years of age and older who present with recurrent or persistent urinary tract infection associated with haematuria, an urgent referral should be made.
•In patients under 50 years of age with microscopic haematuria, the urine should be tested for proteinuria and serum creatinine levels measured. Those with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made.
•In patients 50 years of age and older who are found to have unexplained microscopic haematuria, an urgent referral should be made.
Any patient with an abdominal mass identified clinically or on imaging that is thought to be arising from the urinary tract should be referred urgently.

Urgent referral to urological surgeon

AKT revision: Knee problems

2010-03-19T01:42:00.000-07:00

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

2010-03-19T01:20:00.000-07:00

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

2010-03-19T01:13:00.000-07:00

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

2010-03-19T01:03:00.000-07:00

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).

AKT revision - hepatitis

2010-03-18T01:51:00.000-07:00

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

2010-03-18T01:34:00.000-07:00

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

2010-03-18T01:21:00.000-07:00

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

AKT Revision

2010-03-08T00:42:00.000-08:00

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

2010-03-08T00:20:00.000-08:00

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.

AKT

2010-02-27T18:49:00.000-08:00

1. You are teaching a group of medical students basic clinical skills. Which one of the following statements is true?

A. Extrapyramidal syndromes characteristically produce an upper motor neurone pattern
B. Fasciculation of the tongue is an upper motor neurone feature of motor neurone disease
C. Lesions of peripheral nerves are usually upper motor neurone in type
D. Lower motor neurone lesions cause ankle clonus
E. Upgoing plantar responses and absent ankle jerks imply both upper and lower motor neurone lesions

Answer: E

This seemingly incompatible combination seen in conditions in which both upper and lower motor neurone lesions are present. These include advanced B12 deficiency and perhaps most commonly combined lumbar spondylosis and cervical myelopathy. While MND could, at least in theory, produce this pattern, it would not be characteristic. Remember that upper motor neurone lesions (that is lesions above the dorsal column cell or cranial nerve nucleus involve the pyramidal (corticospinal) tracts and produce spastic tone, increased reflexes, a characteristic pattern of weakness and sometimes ankle clonus. Plantar responses will be extensor. In contrast lower motor neurone lesions produce a flaccid tone, reduced reflexes and sometimes muscle fasciculation.

2. A right-handed male actor aged 66 presents with gradual deterioration of clarity in his speech. He has no problems with his teeth, pains in his mouth or associated neurological problems. Which is the single most likely site of his problem?

A. Bilateral upper motor neurone lesion of cranial nerves 1X and X
B. Left hemisphere

C. Lower motor neurone lesion of cranial nerves 1X and X
D. Midbrain
E. Right hemisphere

Answer: C

Motor neurone disease features high on the differential diagnosis here and careful assessment should be made of this patient’s swallowing and respiratory function. Dominant hemispheric lesions would be expected to produce dysphasia (not as in this case a dysarthria) and since the 1X and X nerve nuclei are below the level of the midbrain, a lesion at this site would not produce a LMN weakness. A bilateral corticospinal lesion, however, will produce (so called) ‘Pseudobulbar palsy’—the commonest causes of which are motor neurone disease and cerebrovascular disease. These are almost inevitably associated with other neuropsychiatric signs such as bilateral spasticity and emotional lability.

3. A 66-year-old man, known to have motor neurone disease presents with the gradual onset of breathlessness. Which is the single most helpful measure of respiratory function? [Show

A. Forced expiratory volume in 1 second (FEV1)
B. Forced vital capacity (FVC)
C. Forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)
D. Oxygen saturation
E. Peak flow rate

Answer: B

Patients with MND may have weakness of the intercostal muscles and the diaphragm. Symptoms may vary from breathlessness to orthopnoea (the latter especially if there is diaphragmatic involvement). More non-specific symptoms include daytime drowsiness due to changes in sleep pattern caused by hypercapnia—this, as in other causes of hypercapnia, may produce a morning headache.FEV1 is an important measure but is of most use in obstructive airways disease. While the FEV1/FVC would probably show a restrictive pattern in MND, the information gained from the combination is of less use than the FVC alone. The FVC (or more correctly the VC) not only indicates severity but is also easy to measure serially. Oxygen saturation alone, while relevant, may be expected to be fairly normal even in relatively advanced disease due to the shape of the oxygen dissociation curve. Peak flow is not relevant in this context.

4. A man with motor neurone disease is prescribed riluzole for motor neurone disease. You see the patient regularly and have a ‘shared care’ arrangement for monitoring the therapy. Which one of the following blood tests requires regular monitoring? [Show Discussion]

A. Fasting glucose
B. Full blood count
C. Liver function
D. Renal function
E. Thyroid function

Answer: C

Assuming normal baseline hepatic function, LFTs should be checked every month for 3 months, every 3 months for a further 9 months and every year thereafter.

5. A male patient has type 2 respiratory failure secondary to advanced motor neurone disease. When discussing options with him which is the single most appropriate initial way of delivering respiratory support should he wish to stay at home? [Show Discussion]

A. Endotracheal tube
B. Iron lung
C. Mask
D. Non-invasive ventilation
E. Tracheostomy

Answer: D

These portable devices are available via specialized respiratory units and prolong life. Further details of these (and other palliative measures) from the motor neurone disease association. http://www.mndassociation.org/

6. Which one of the following statements is true when considering a peripheral neuropathy

A. Examination should include testing from distally to proximally in the legs
B. Feet and hands are usually equally affected
C. Hyper-reflexia is characteristic
D. Hypertension is among the common causes
E. Joint position sense is usually absent if there is disturbance of pinprick sensation

Answer: A

There are many causes of peripheral neuropathy (alcohol and diabetes being two of the most common). Testing is best done for a given modality by first comparing the feet with (say) the upper leg which is likely to be normal. If there is a reproducible difference, it is then helpful to go from distal to proximal to see where sensation changes. The legs are usually affected before the hands and if anything hyporeflexia would be the norm. Hypertension is not a recognized cause and joint position sense loss would characteristically be a dorsal column problem.

7. The photograph below illustrates a previously fit middle-aged man who is recovering from a problem which started acutely 3 weeks before. Which one of the statements below is true? (See Figure 1)

A. He has a left-sided lower motor neurone weakness
B. He has a right-sided lower motor neurone weakness
C. He has a left-sided upper motor neurone weakness
D. He has a right-sided upper motor neurone weakness

Answer: A

This is most likely to be due to a Bell’s palsy. If this were an upper motor neurone weakness, the eye would not have been so obviously affected due to bilateral innervations. He does not require imaging or for that matter neurological referral unless atypical. If the weakness is prolonged (or recovery incomplete), the patient may benefit from assessment in a specialist facial nerve clinic.

AKT

2010-02-15T09:49:00.000-08:00

1. A 59 year-old woman with rheumatoid arthritis requires antibiotic prophylaxis for recurrent urinary tract infections. She is currently taking methotrexate on a weekly basis.Which is the SINGLE LEAST appropriate antibiotic to prescribe for this patient? Select ONE option only.

A. Cefalexin
B. Ciprofloxacin
C. Co-amoxiclav
D. Nitrofurantoin
E. Trimethoprim

Answer: E

The BNF states that the excretion of methotrexate is possibly reduced by ciprofloxacin, which increases the risk of methotrexate toxicity. However, this is not as significant as the methotrexate-trimethoprim interaction.There is a risk of cholestatic jaundice with co-amoxiclav, and it would therefore be less suitable for prolonged use in any patient with a history of liver disease.The most serious complication of methotrexate therapy is bone marrow suppression, and hence the need for regular blood monitoring with a full blood count. The concomitant use of an anti-folate drug (e.g. trimethoprim) increases the risk of bone marrow suppression, and should therefore be avoided, especially for prolonged treatment courses.

2. A 30 year-old man presents with an eight month history of low back pain and stiffness which is worse in the mornings. He has a long history of bilateral heel pain.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]

A. Ankylosing spondylitis
B. Osteoarthritis
C. Psoriatic arthritis
D. Reactive arthritis
E. Rheumatoid arthritis

Answer: A

The history of stiffness suggests an inflammatory condition in this patient. Ankylosing spondylitis is more common in young men. There may be a positive family history, and there is a strong association with HLA B27. Extra-articular manifestations include Anterior uveitis, Apical lung fibrosis, AV heart block, Aortic regurgitation and aortitis, Amyloidosis, Achilles tendonitis and plantar fasciitis.This would be the main differential diagnosis here, as psoriatic arthritis can present with a spondyloarthropathy or sacroiliitis.It would be unusual for symptoms to continue for eight months with a reactive arthritis, and there would be usually be a preceding history of (typically) a gastrointestinal infection.

3. A 15 year-old boy presents with a two month history of fever and a painful, red swelling just above his left knee. There is no history of trauma.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Ewing’s sarcoma
B. Juvenile idiopathic arthritis
C. Osgood-Schlatter’s disease
D. Osteomyelitis
E. Reactive arthritis

Answer: A

This is a rare but important diagnosis not to miss. It accounts for 2% of all childhood cancers. It is more common in males and typically presents in children and young adults aged 5-20 years. It may mimic an infective process, but red flag symptoms of fever, persistent pain (including nocturnal and rest pain) and persistent localised swelling should prompt an urgent referral to exclude a malignant lesion.Juvenile idiopathic arthritis refers to the onset of arthritis in a patient under the age of 16, which lasts for more than three months. If there are associated systemic features (e.g. fever, rash, lymphadenopathy), then it is referred to as Still’s disease.Osgood-Schlatter’s disease is an overuse condition which presents with pain (often bilateral) and tenderness over the tibial tuberosity, usually around the time of the pubertal growth spurt. Symptoms improve with rest. There should be no red flag symptoms present.Osteomyelitis would be unlikely in the absence of trauma, although can occur (e.g. from haematogenous spread).

4. A 38 year-old man presents having recently joined your practice. He is currently taking bendroflumethiazide for hypertension. He complains of recurrent episodic swelling and pain in his right ankle over the last three years. The practice nurse elicited the following clinical information at a new patient check yesterday:BMI 34.6BP 144/90Smoking status Ex-smokerAlcohol intake 40 units per weekUrinalysis Protein 1+Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]

A. Gout
B. Osteoarthritis
C. Psoriatic arthritis
D. Reiter’s syndrome
E. Rheumatoid arthritis

Answer: A

The combination of alcohol excess and use of bendroflumethiazide make gout the most likely diagnosis here. Most cases of gout are idiopathic, but identifiable causes include: increased purine levels (e.g. diet and alcohol), decreased urate excretion (e.g. renal failure) and drugs (e.g. thiazide and loop diuretics). Common sites of involvement include the metatarsophalangeal joint (MTPJ) of the big toe, the ankle joint and the finger joints. Factors precipitating acute attacks of gout include dehydration, alcohol, trauma and infection.Osteoarthritis would be unlikely in a 38 year-old patient.The asymmetrical oligoarthropathy subtype of psoriatic arthritis would be the main differential diagnosis here. However, this is less common than gout, and therefore less likely.Reiter’s syndrome is a triad of urethritis, conjunctivitis and seronegative arthritis. There is an association with HLA B27 and it usually occurs following a genital or gastrointestinal infection (e.g. chlamydia, gonorrhoea, shigella or campylobacter).Rheumatoid arthritis typically presents as a symmetrical polyarthropathy with morning stiffness affecting the small joints of the hands and feet. It affects women more commonly than men.

5. A 22 year-old woman presents to an out of hours GP after slipping on a wet pavement. She complains of pain in her right ankle.According to the Ottawa ankle rules, which SINGLE clinical finding indicates the need for an ankle x-ray? Select ONE option only. [Show Discussion]

A. Bony tenderness over the anterior tip of the medial malleolus
B. Bony tenderness over the posterior tip of the lateral malleolus
C. Inability to dorsiflex the ankle
D. Inability to plantarflex the ankle
E. Swelling over the lateral malleolus

Answer: B

The Ottawa rules clearly state the indications for a plain film x-ray of the ankle, foot and knee.An ankle x-ray is required only if there is pain in the malleolar area, associated with any of the following:
• Pain on palpation over the posterior tip/edge of the lateral malleolus
• Pain on palpation over the posterior tip/edge of the medial malleolus
• Inability to weight bear
The Ottawa rules can be found at www.gp-training.net

6. A 56 year-old woman presents complaining of thoracic back pain. A plain film x-ray of her thoracic spine confirms a vertebral wedge fracture at T10. Her GP requests a DEXA scan to assess bone mineral density.Which SINGLE result would confirm a diagnosis of osteoporosis in this patient? Select ONE option only. [Show Discussion]

A. T score of -2.6
B. T score of -2.1
C. T score of +1.7
D. Z score of -1.3
E. Z score of +2.2

Answer: A

Bone mineral density (BMD) is usually expressed as the number of standard deviations (SD) from the young adult mean. This is known as the T score. Normal bone density is within 1 SD of the young adult mean (i.e. T score > -1). Osteopenia is defined by a T score between -1 and -2.5. Osteoporosis is defined as a T score < -2.5. BMD can also be expressed as the number of standard deviations from the age-related mean. This is the Z score, which enables a patient's risk to be compared to other patients of the same age

7. A 67 year-old man complains of aches and pains in his lower back and pelvis. The pain is constant and worse at night. Investigations including blood tests and a lumbar spine x-ray are requested. The lumbar spine x-ray reveals characteristic changes of Paget’s disease.Which is the SINGLE MOST likely bone profile result to be expected in Paget’s disease? Select ONE option only. [Show Discussion]

A. Low serum calcium, normal alkaline phosphatase
B. Normal serum calcium, normal alkaline phosphatase
C. Normal serum calcium, raised alkaline phosphatase
D. Raised serum calcium, normal alkaline phosphatase
E. Raised serum calcium, raised alkaline phosphatase

Answer: C

In Paget’s disease, the classical biochemical finding is an elevated alkaline phosphatase with a normal serum calcium. This reflects an increase in osteoclastic activity and bone turnover. Mild hypercalcaemia can occasionally be found if the patient has been immobile for a prolonged period.

AKT

2010-02-15T09:35:00.000-08:00

1. A 34 year-old woman complains of tingling and numbness in her right hand for the past three weeks which is keeping her awake at night. The numbness is worst in the thumb, with some radiation to the right elbow.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Cervical spondylosis
B. De Quervain’s tenosynovitis
C. Median nerve entrapment
D. Multiple sclerosis
E. Ulnar nerve entrapment

Answer: C

This is a typical history of carpal tunnel syndrome which is due to median nerve entrapment in the carpal tunnel at the wrist. Symptoms are worst at night, and pain and parasthesia can extend proximally in to the elbow and shoulder in some cases which may cause some confusion or difficulty with diagnosis. Tinel’s and Phalen’s tests are useful examination tools to help confirm the diagnosis, although they can often be negative in the presence of otherwise classical symptoms. In Tinel’s test, tapping over the carpal tunnel causes tingling in the distribution of the median nerve (thumb and radial two and a half fingers). In Phalen’s test, symptoms are elicited by forcible palmar flexion of the wrist causes venous engorgement of the carpal tunnel.Cervical spondylosis is common in the elderly, but would be unlikely in a 34 year-old patient.De Quervain’s tenosynovitis is an overuse condition. It is characterised by localised tenderness over the extensor and abductor tendon sheaths of the thumb.The most common site of ulnar nerve entrapment is at the elbow, and this typically causes parasthesia and/or weakness in the ring and little fingers.

2. A 62 year-old woman presents with pain and stiffness in both shoulders for the last four weeks. Her symptoms are worse in the mornings, and she also admits to low mood and recent-onset headaches.

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: H

The history of morning stiffness points towards this being an inflammatory condition, and in this age group polymyalgia rheumatica is common. It may be associated with other systemic and non-specific features such as malaise, anorexia, low-grade fever, weight loss and depression. The history of headaches raises the possibility of associated temporal arteritis, and this requires urgent further assessment.

3. A 56 year-old man presents with bilateral shoulder pain and weakness for the last three months. He has noticed increasing difficulty in lifting himself out of his armchair at home. Investigations reveal a raised C reactive protein and creatine kinase. [Show Discussion]

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: I

The history of objective weakness here suggests a possible muscular problem. In polymyositis the limb girdle or proximal muscles are most severely affected, but typically their bulk is preserved beyond that expected from their weakness. Raised C reactive protein and creatine kinase levels reflect the acute and chronic inflammation of skeletal muscle which occur in this condition.

4. A 44 year-old woman presents with pain in all of her joints for the last four months. Her symptoms are worse in the shoulders and hips. On examination she has multiple sites of tenderness including over both trapezius muscles. [Show Discussion]

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: B

Fibromyalgia is characterised by chronic widespread pain (for more than three months) and the presence of at least 11 out of 18 specified ‘tender points’.

AKT

2010-02-15T09:29:00.000-08:00

1. A 52 year-old woman presents with an itchy rash on both wrists for the last three months. (See Figure 1) What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Contact dermatitis
B. Lichen planus
C. Pityriasis rosea
D. Psoriasis
E. Tinea corporis

Answer: B

This picture demonstrates the typical appearance of shiny, flat-topped, violaceous (purple/mauve colour) polygonal papules on the flexural aspects of the wrists which occur in lichen planus. There may be a fine white lace-like pattern on the surface which are called Wickham’s striae. Mucosal membranes including the genitalia may be affected, and treatment usually involves potent topical steroids. The aetiology is thought to be auto-immune.Pityriasis rosea typically presents with a scaly rash that is normally flat or only slightly raised. It is more common in children and young adults and usually affects the trunk predominantly. Human herpes viruses 6 and 7 may be implicated in the aetiology.Chronic extensor plaque psoriasis typically affects the elbow, knees, umbilicus, scalp and natal cleft. Other less common variants of psoriasis can occur, including a flexural type.Tinea corporis has typically a more scaly and annular appearance would be expected with a fungal infection.

AKT questions, nMRCGP exam

2010-02-07T07:08:00.000-08:00

1. Your practice nurse asks for your advice about a 66-year-old woman with a venous ulcer. Her ankle brachial pressure index (ABPI) is normal. Which one of the following interventions has been shown to increase healing of her ulcer? [Show Discussion]

A. Antibiotics
B. Exposure to air
C. Four-layer compression bandaging
D. Larvae
E. Non-occlusive dressings

Answer: C

four-layer compression bandaging (DOI: 10.1136/bmj.b1344) is a systematic review and meta-analysis of two forms of compression bandages (four-layer bandage and short-stretch bandage) in the treatment of venous leg ulcers. It concludes that the four-layer bandage significantly reduced the time to healing (hazard ratio = 1.31, 95% confidence interval = 1.09 to 1.58). Short-stretch bandages are useful in patients who are mobile and should be replaced daily. Although the four-layer bandage system is effective, its bulkiness may lead to non-adherence in some patients. It is designed to be left in place for several days, so its use is limited in highly exuding ulcers because dressings may need to be changed more often. Therefore, although four-layer bandages may improve healing overall, the choice of compression bandage should reflect the patient’s specific needs and circumstances. Of the other alternatives, antibiotics are of limited value unless there is cellulitis. Dressings are normally occlusive as ulcers heal better in a moist environment. Larvae have been shown to improve debridement (which is possibly an important component of healing) but not healing itself.

2. Your health care assistant asks for your advice on carrying out an ABPI on a patient with leg ulceration. Which one of the following pieces of advice below is appropriate?

A. The ABPI represents the highest recorded systolic pressure recorded in the two arms over the highest recorded systolic pressure in the affected leg
B. The ABPI represents the highest recorded systolic pressure recorded in the affected leg over the systolic pressure in the ipsilateral arm
C. The ABPI represents the highest recorded systolic pressure recorded in the affected leg over the highest recorded systolic pressure in either arm
D. The ABPI represents the highest recorded systolic pressure recorded in the ipsilateral arm over the systolic pressure in the affected leg

Answer: C

ABPI1 = P1/Pa—where ABPI1 represents the ABPI for a leg, P1 represents the highest pressure obtained from the ankle vessels in that leg and Pa is the highest brachial pressure in the two arms

3. Your practice nurse asks for your advice about a female patient of 67 years with severe, weeping varicose eczema that appears to be infected. Along with antibiotics and emollients, which is the single most appropriate management plan? [Show Discussion]

A. Emollients alone
B. Potassium permanganate (1 : 10 000)
C. Topical steroid (weak)
D. Topical steroid (potent)
E. Topical steroid (potent) + potassium permanganate (1 : 10 000)
F. Topical steroid (weak) + potassium permanganate (1 : 10 000)

Answer: E

potent topical steroids are likely to be needed for up to a month before stepping down. Potassium permanganate (1 : 10 000) is useful in moist weeping eczema and in usually prescribed as 'tablets' to be diluted in water (e.g. 'Permitabs'). It is particularly important to be aware that some of these patients have a contact sensitivity to the treatment itself ('MIMS' has a useful table of potential sensitizers in various preparations). Furthermore, these patients will usually require long-term emollients once the acute flare has settled.

4. At a patient group meeting in your practice, there is interest in screening for abdominal aortic aneurysm (AAA) following the tragic demise of the chairman from a ruptured aneurysm. Which one of the following statements is correct?

A. AAA is as common in women as in men
B. Computerized tomography is the screening method of choice
C. The usual threshold for intervention is 7 cm
D. Four percent of men older than 65 years will have an AAA
E. Women are to be screened from 2009 by the NHS

Answer: D

4% of men will have this condition. The NHS screening programme (which is being gradually implemented) is for men older than 65 years in whom the condition is much more common.

5. An 18 month old girl is brought to the surgery by her mother who is concerned regarding her development. On examination, she is able to crawl but is unable to stand unaided. She can hold a book and turn several pages but is not yet able to turn the pages singly. She has a vocabulary of 25 words but is unable to use two or three word phrases.Which is the SINGLE best description of this patient’s development? Select ONE option only.
A. Fine motor delay
B. Global developmental delay
C. Gross motor delay
D. Isolated speech delay
E. Normal development

Answer: C

At 18 months, a child with normal gross motor development will be able to walk well carrying a toy, and be able to walk up and down stairs with help. Building a tower of three cubes or turning pages of a book, two or three at a time would demonstrate normal fine motor development at this age. A child with normal speech development at 18 months will chatter continuously during play and use between six and twenty recognizsable words.Signs of abnormal development at 18 months include inability to stand or walk, no pincer grip, no spontaneous vocalizsation, and inability to recogniszee simple commands.

6. A 6 year old boy attends the community paediatric clinic with his parents. They are concerned that he is currently struggling academically at school. He is reading and writing at a level below that of his 4 year old brother. Cognitive testing reveals an intelligence quotient (IQ) of 54.Which SINGLE description best describes this patient’s intellectual ability? Select ONE option only.

A. Normal intelligence
B. Mild learning disability
C. Moderate learning disability
D. Severe learning disability
E. Profound learning disability

Answer: B

An IQ of 54 is consistent with a mild learning disability (LD).
Normal, >70
Mild LD, 50-–69
Moderate LD, 35-–49
Severe LD, 20-–34
Profound LD, < 20

IQ testing does not assess functional ability and may be affected by communication difficulties. Children with mild LD are often identified after starting school, whilst while those with moderate LD will require significant support at school. Patients with severe LD will often develop simple speech only, and those with profound LD may not develop speech at all

7. An 18 month old girl is brought to the surgery by her parents who are worried that her development has regressed over the last 2 months. She had normal developmental milestones up until the age of 15 months. However, she is now unable to walk and can only crawl. Her first words have become unrecognisable and she is now only able to babble. She has had two seizures in the last month.

A. Asperger’s syndrome
B. Cerebral palsy
C. Conduct disorder
D. Down’s syndrome
E. Dyslexia
F. Fetal alcohol syndrome
G. Fragile X syndrome
H. Gilles de la Tourette syndrome
I. Obsessive compulsive disorder
J. Rett syndrome

Answer: J

Rett syndrome is a sporadic neurodevelopmental syndrome seen almost exclusively in girls aged 17-–18 months. It is characterizsed by developmental regression following a period of normal childhood development. There is a subsequent rapid deterioration in symptoms including seizures and dementia.

8. A 14 year old boy is reviewed in the community paediatric clinic. He has a moderate learning disability. On examination, it is noted that he has a prominent forehead, large ears and large testes. His height and weight are both on the 50th centile for his age.

A. Asperger’s syndrome
B. Cerebral palsy
C. Conduct disorder
D. Down’s syndrome
E. Dyslexia
F. Fetal alcohol syndrome
G. Fragile X syndrome
H. Gilles de la Tourette syndrome
I. Obsessive compulsive disorder
J. Rett syndrome

Answer: G

Fragile X syndrome is characterizsed by developmental delay, mild to moderate learning disability and phenotypical features including long face, prominent forehead, large ears and large jaw. Post-pubertal boys typically have macro-orchidism.

AKT questions, nMRCGP exam

2010-02-07T06:36:00.000-08:00

1. Which one of the following statements is true when assessing a teenager who has self harmed?

A. Assessing how the patient feels about the consequences of his / her actions is essential
B. A doctor centred approach is preferable
C. Questioning on suicidal ideation makes it more likely that a future attempt at self harm will occur
D. The severity of a self harming episode is approximately proportional to the suicidal intent
E. The presence of a suicide note is reassuring

Answer: A

The consultation should be patient centred and it is essential to enquire about thoughts of future self harm. It does not make matters worse for the future. The presence of plans prior to the attempt or a suicide note are concerning

2. Which one of the following statements regarding treatment of young people is true?

A. A 15 year old girl wishing to commence the oral contraceptive should always have parental consent
B. Gillick / Fraser competence only applies to contraceptive issues
C. Once a child is deemed to be Gillick / Fraser competent this competence applies to all future forms of medical treatment.
D. If a 15 year old is deemed Gillick / Fraser competent this judgement confers to them the right to accept treatment
E. The parents of a 17 year old girl with severe anorexia nervosa have the right to over-ride her decision to refuse feeding even though she is deemed competent

Answer: D

Gillick / Fraser competence confers the right of a 15 year old to accept treatment but not necessarily the right to refuse (except in Scotland where competent minors have an independent right to consent to or refuse treatment under the age of legal capacity). Answers 1-3 are clearly false. Regarding answer 5: - GMC Guidance – Young People refusing consent: In England, Wales and Northern Ireland, the law on parents overriding young people’s competent refusal is complex.You should seek legal advice if you think treatment is in the best interests of a competent young person who refuses.

AKT questions, nMRCGP exam

2010-02-07T06:02:00.000-08:00

1. Assuming Fraser competence (where applicable) which one of the following situations is generally regarded as acceptable in law?

A. A 17 year old girl appearing in a pornographic film
B. Sexual intercourse between a 20 year old male and 15 year old female
C. Sexual intercourse between a 20 year old female and 15 year old male
D. Sexual intercourse between a 15 year old boy and 14 year old girl
E. Sexual intercourse between a 15 year old girl and 12 year old boy

Answer: D

There is specific protection in law for young people under the age of 18 regarding pornographic activity. Whilst sex under the age of 16 is regarded as criminal activity by the Crown Prosecution Service action is unlikely if both parties are of a similar age.

2. A healthy 16 year old girl consults you regarding the sequelae of chlamydial infection. Which one of the following statemtents is true? [Show Discussion]

A. It is a common cause of ectopic pregnancy
B. It is a common cause of pneumonia
C. 90% of infected females will develop pelvic inflammatory disease if untreated
D. 50% of patients with pelvic inflammatory disease due to Chlamydia will develop infertility
E. The risk of pelvic inflammatory disease is greatest after the first chlamydial infection

Answer: A

43% ectopic pregnancies are due to Chlamydia. It is a rare cause of pneumonia. If untreated up to 40% of women develop PID. Of which 20% have fertility problems. The risk of PID increases with subsequent infections

3. A healthy 16 year old girl consults you regarding the sequelae of chlamydial infection. Which one of the following statemtents is true?

A. A 19 year old nurse with vaginal discharge who thinks she has Chlamydia
B. A 15 year old student who is on the COC
C. A 17 year old girl with severe learning difficulties
D. A 20 year old homeless person with no contact details
E. A 26 year old girl who’s boyfriend has recently found out he has chlamydia

Answer: B

This patient is eligible if competent.

4. Jenny is 19 and has to come to you asking for you to fill in her health insurance form for work. She was screened for chlamydia two months ago but the test was negative. Which of the following is the correct advice about the information that you can give her insurance company?

A. You can disclose that she has had the test but not the result
B. You can disclose the test and the result
C. You can always disclose the result if it was positive
D. You can disclose the result if it was negative
E. You should not disclose that the test has been done despite the result being negative

Answer: E

BMA guidance states that information should not be revealed about whether an applicant for insurance has undertaken tests for STIs – not should any negative results be disclosed. In addition doctors should not reveal information about an isolated incident of an STI that has no long term health implications or even multiple episodes of non serious STIs.

5. Sasha comes to see you after having been told that her Chlamydia screening test was positive and asks about the potential complications. Which one of the following options is the least likely complication?

A. Fitz Hugh Curtis Syndrome
B. Chronic Pelvic Pain
C. Ectopic pregnancy
D. Tubal infertility
E. Bartholinitis

Answer: E

This is rare

6. The parents of a 14 year old boy consult you regarding their son’s behaviour. Which one of the options below is most likely to indicate an underlying psychiatric illness?

A. Aggressive behaviour accompanied by mood swings
B. Covert alcohol consumption
C. Feeling irritable for several weeks
D. A diet consisting solely of junk food
E. School truancy

Answer: C

7. A 17 year old boy presents alone with anxiety and agitation. On examination he appears dishevelled and appears to be distracted. His answers are monosyllabic and he feels that he is being persecuted by the media. He denies illicit drug taking. The single most likely diagnosis is:

A. Anxiety
B. Bipolar disorder
C. Depression
D. Personality disorder
E. Schizophrenia

Answer: E

Schizophrenia. There is evidence of psychosis in this patient and he needs urgent assessment by CAMHS. Bipolar disorder could produce a psychosis but is less common in this age group as could illicit drug abuse

8. Which one of the options below makes school refusal more likely than school truancy in a 16 year old boy?

A. Hiding school absence from parents
B. Nonchalance despite poor academic achievements
C. Somatic symptoms
D. Staying away from home during truancy
E. Stealing

Answer: C

School refusers tend to be sensitive , sometimes bullied children who may have a background of unhappiness. Somatic symptoms (eg abdominal pain) would be common associations. School truants on the other hand are more likely to come from poor, sometimes dysfunctional backgrounds and to have anti social tendencies.

9. A 14 year old boy presents with features of mild depression. Pending an opinion from the Child and Adolescent Mental Health Services (CAHMS) which one of the following courses of action would be most appropriate? [Show Discussion]

A. Amitriptylene
B. Fluoxetine
C. Imipramine
D. No prescription
E. Zopiclone

Answer: D

Because of the tendency to do more harm than good anti-depressants should not be used first line in adolescents with mild depression. Zopiclone (which is not an anti-depressant) would be inappropriate in this age group.

10. You are consulted by the parents of a four year old boy. He appears to be hyperactive, impulsive and he is unable to focus his attention but his parents say that this is relatively mild and only in certain situations. They are concerned that he might have ADHD. Assuming that you will review the patient which is the single most appropriate initial course of action?

A. Prescribe methylphenidate
B. Prescribe atomoxine
C. Refer to child psychiatrist
D. Refer to health visitor
E. Refer to paediatrician

Answer: D

Bearing in mind that the symptoms are mild either this or possibly referral to a parent-training / education programme (if available). Do not initiate methylphenidate or atomoxine in primary care although they may be prescribed under shared agreements with secondary care

AKT questions

2010-01-28T00:48:00.000-08:00

1. A 19-year-old man attends complaining of a rash on his penis for the last 3 months. (See Figure 1) What is the SINGLE most appropriate intervention for this patient? Select ONE option only.

A. Cryotherapy
B. Prescribe oral aciclovir
C. Prescribe topical podophyllotoxin (Warticon)
D. Reassure
E. Refer to genitourinary medicine clinic

Answer: D

This picture shows the typical appearance of pearly penile papules. They are common, occurring in up to 20% of men and present as flesh-coloured, smooth, rounded papules predominantly around the coronal margin of the glans. They are often arranged in parallel rows or concentric rings. They are not sexually -transmitted.Pearly penile papules may be mistaken for warts by both patients and clinicians.No treatment is necessary, although if cosmesis is a problem for the patient, then cryotherapy may be tried.Aciclovir is the treatment of choice for genital herpes which typically presents acutely with very painful ulcers.Cryotherapy and topical podophyllotoxin are both treatment options for genital warts. Podophyllotoxin cannot be used in pregnant or breastfeeding women.

2. Which ONE of the following is NOT associated with an increased risk of developing penile intraepithelial neoplasia? Select ONE option only. [Show Discussion]

A. Atopic dermatitis
B. Chronic infection with human papilloma virus (HPV)
C. Lichen sclerosus
D. Smoking
E. Uncircumcised males

Answer: A

Penile intraepithelial neoplasia (PIN) is associated with:

• Chronic infection with human papilloma virus (HPV)

• Chronic skin disease, especially lichen sclerosus and lichen planus

• Smoking

• ImmunosuppressionIf untreated,

PIN is associated with the development of invasive squamous cell carcinoma.www.dermnet.nz

3. In which ONE of the following situations can phosphodiesterase type-5 inhibitors such as sildenafil (Viagra) be prescribed on an National Health Service (NHS) prescription rather than on a private prescription? Select ONE option only.

A. In men aged 60 years or over
B. In men with chronic kidney disease stage 3 (CKD 3)
C. In men with hypogonadism
D. In men with hypothyroidism
E. In men with Parkinson’s disease

Answer: E

Phosphodiesterase type-5 inhibitors are not prescribable under the NHS, except to treat erectile dysfunction in men who:

• Have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, or spinal cord injury

• Are receiving dialysis for renal failure

• Have had radical pelvic surgery, prostatectomy (including transurethral resection of the prostate), or kidney transplant

• Were receiving Caverject®, Erecnos®, MUSE®, Viagra® or Viridal® for erectile dysfunction, at the expense of the NHS, on 14 September 1998

• Are suffering severe distress as a result of impotence (prescribed in specialist centres only)www.bnf.org.uk

4. A 23-year-old man attends complaining of difficulty getting an erection since starting a new relationship 4 months ago. He has already tried sildenafil (Viagra) which he had bought on the internet, but this has not helped. On examination, he has bilateral gynaecomastia, small testes and scanty axillary and pubic hair. His recent blood tests reveal the following:Testosterone 6 nmol/l (11–36 nmol/l)Luteinising hormone (LH) 27 IU/l (0.5–9 IU/l)Follicle stimulating hormone (FSH) 19 IU/l (1–8 IU/l)Which is the single MOST appropriate initial intervention for this patient? Select ONE option only. [Show Discussion]

A. Refer to clinical geneticist
B. Refer to endocrinologist
C. Refer to neurologist
D. Refer to psychosexual counsellor
E. Refer to urological surgeon

Answer: A

This scenario describes the typical phenotypical appearance of a patient with Klinefelter’s syndrome (47 XXY). It is the most common cause of male hypogonadism and infertility, affecting approximately 1 in 600 to 1 in 800 live births.It is characterizsed by hypergonadotrophic hypogonadism (raised gonadotrophins and low testosterone) and usually remains undiagnosed until adulthood.Referral to an endocrinologist would be required for advice regarding hormonal treatment;, however, the most appropriate initial referral would be to a clinical geneticist for genetic counselling and testing to confirm the diagnosis. They would be able to advise him regarding longer-term implications, including fertility issues (azoospermia) and risk of male breast cancer.

5. A 56-year-old man attends the surgery complaining of inability to maintain an erection during intercourse for the last 3 months. He describes normal early morning erections. On examination, his blood pressure is 150/84 mmHg and his body mass index (BMI) is 32. Physical examination is otherwise unremarkable.What is the SINGLE most likely underlying diagnosis in this patient? Select ONE option only.

A. Depression
B. Hypertension
C. Parkinson’s disease
D. Spinal cord injury
E. Type 2 diabetes

Answer: A

A good quality early morning erection makes an organic cause of erectile dysfunction unlikely

6. Which ONE of the following drugs does NOT cause erectile dysfunction? Select ONE option only.

A. Bendroflumethiazide
B. Chlorpromazine
C. Nifedipine
D. Sildenafil
E. spironolactone

Answer: D

Sildenafil is the generic name for Viagra, a phosphodiesterase-5 inhibitor which is used to treat erectile dysfunction. All of the other drugs listed can cause erectile dysfunction.Other commonly used classes of drugs which may cause erectile dysfunction include:• Anti-cholinergics• Anti-depressants• Anti-histamines• Anti-hypertensives• Anti-psychotics• Tranquilisers

7. A 58-year-old man attends complaining of inability to get an adequate erection for the last 5 months. He asks whether you would be able to prescribe him Viagra (sildenafil).Which ONE of the following would be a CONTRAINDICATION to the use of a phosphodiesterase type-5 inhibitor such as Viagra in this patient? Select ONE option only. [Show Discussion]

A. Current blood pressure of 178/96 mmHg
B. Current diagnosis of angina pectoris
C. Currently taking bisoprolol
D. Currently taking isosorbide mononitrate
E. Currently taking warfarin

Answer: D

Phosphodiesterase type-5 inhibitors are contra-indicated in patients receiving nitrates, in patients in whom vasodilation or sexual activity are inadvisable, or in patients with a previous history of non-arteritic anterior ischaemic optic neuropathy.In the absence of information, manufacturers contra-indicate these drugs in hypotension (avoid if systolic blood pressure below 90 mmHg), recent stroke, unstable angina, and myocardial infarction.www.bnf.org.uk

AKT questions/ nMRCGP questions

2010-01-28T00:40:00.000-08:00

1. A 56-year-old man is seen in the urgent care centre with vomiting and severe left-sided loin pain radiating to his left groin. On examination, his temperature is 37.6°C and he has left-sided loin tenderness. Urinalysis reveals blood+++ and protein++. A diagnosis of renal colic is suspected.In addition to an anti-emetic, which is the single MOST appropriate intervention for this patient? Select ONE option only.

A. Intramuscular codeine phosphate
B. Intramuscular diamorphine
C. Intramuscular diclofenac
D. Intramuscular pethidine
E. Rectal diclofenac

Answer: C

Intramuscular diclofenac 75 mg is the treatment of choice in acute renal colic. An opioid (e.g. pethidine or diamorphine) should be considered if diclofenac is contraindicated or is insufficient to control the pain.An anti-emetic should be administered for nausea and vomiting, particularly if an injectable opioid is given.

2. A 7-year-old boy is brought to the surgery by his father with a 2 week history of headache, rash and intermittent abdominal and joint pains. Urinalysis reveals blood++++ and protein+.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Acute leukaemia
B. Henoch–Schönlein purpura
C. Idiopathic thrombocytopenia
D. Post-streptococcal glomerulonephritis
E. Urinary tract infection

Answer: B

Henoch–-Schönlein purpura (HSP) is a vasculitis which most typically affects young children aged 3 to –8 years old. It is more common in boys. There is usually a preceding infective trigger such as a respiratory tract infection.There may be gastro-intestinal, joint and renal manifestations. There is haematuria and proteinuria in 70%, although this is often asymptomatic. More serious complications are rare. HSP is usually self-limiting and does no’t normally require any specific treatment.There is usually a preceding history of sore throat in post-streptococcal glomerulonephritis, and a rash would not normally be expected.

3. A 53-year-old man attends as a new patient to your practice. He has no previous past medical history and is not taking any regular medication. As part of his new patient check, the following results are obtained:Urinalysis Blood++Mid-stream urine (MSU) NegativeBlood pressure 112/68 mmHgUrea and electrolytes NormalWhich ONE of the following options is the most appropriate INITIAL management for this patient? Select ONE option only. [Show Discussion]

A. Check prostate-specific antigen (PSA)
B. Re-check urinalysis in 2 weeks
C. Referral for renal ultrasound scan
D. Routine referral to renal physician
E. Urgent referral to urological surgeon

Answer: E

Regarding the management of suspected urological cancer:
• Male or female adult patients of any age who present with painless macroscopic haematuria should be referred urgently.
• In male or female patients with symptoms suggestive of a urinary infection who also present with macroscopic haematuria, investigations should be undertaken to diagnose and treat the infection before consideration of referral. If infection is not confirmed the patient should be referred urgently.
• In all adult patients 40 years of age and older who present with recurrent or persistent urinary tract infection associated with haematuria, an urgent referral should be made.
• In patients under 50 years of age with microscopic haematuria, the urine should be tested for proteinuria and serum creatinine levels measured. Those with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made.
• In patients 50 years of age and older who are found to have unexplained microscopic haematuria, an urgent referral should be made.Any patient with an abdominal mass identified clinically or on imaging that is thought to be arising from the urinary tract should be referred urgently.

2010-01-27T01:02:00.000-08:00

1. Doctors must notify the Proper Office of the local authority (which is usually the consultant in communicable disease control) when attending a patient suspected of suffering from certain diseases.Which ONE of the following conditions is NOT a notifiable disease? Select ONE option only.

A. Cholera
B. Human Immunodeficiency Virus (HIV)
C. Mumps
D. Tuberculosis
E. Whooping cough

Answer: B

The statutory requirement for the notification of certain infectious diseases came into being towards the end of the 19th century. The list of diseases has been increased over the decades and now stands at about 30.The prime purpose of the notifications system is speed in detecting possible outbreaks and epidemics. Accuracy of diagnosis is secondary, and since 1968 clinical suspicion of a notifiable infection is all that is required.The full list of notifiable diseases can be found on the Health Protection Agency website at www.hpa.org.uk

2. A 54 year-old woman attends complaining of intermittent blurred vision in her left eye for the last two weeks. She is currently taking treatment for pulmonary tuberculosis. On examination the visual acuity is 6/9 in the right eye and 6/18 in the left eye.Which SINGLE drug is the most likely cause of this patient’s symptoms? Select ONE option only. [Show Discussion]

A. Ethambutol
B. Isoniazid
C. Pyrazinamide
D. Rifampicin
E. Streptomycin

Answer: A

Visual acuity should always be tested before ethambutol is used, since its side-effects are largely confined to visual disturbances in the form of loss of acuity, colour blindness and restriction of visual fields.These toxic effects are more common where excessive dosage is used or if the patient’s renal function is impaired.The earliest features of ocular toxicity are subjective and patients should be advised to discontinue therapy immediately if they develop deterioration in vision and promptly seek further advice.Early discontinuation of the drug is almost always followed by recovery of eyesight.www.bnf.org.ukIsoniazid, rifampicin and pyrazinamide are associated with liver toxicity, and therefore hepatic function should be checked before treatment with these drugs. Those with pre-existing liver disease or alcohol dependence should have frequent checks particularly in the first two months.Streptomycin is now rarely used in the UK except for resistant organisms.

3. Which ONE of the following statements represents the standard regime for treatment of tuberculosis in the UK? Select ONE option only. [Show Discussion]

A. 4 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 1 month
B. 4 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 2 months
C. 6 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 1 month
D. 4 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 2 months
E. 6 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 3 months

Answer: E

Initial phase treatment should be continued for two months, whilst continuous phase treatment is continued for a further four months.Longer treatment is necessary if there are complications of meningitis or spinal cord involvement, and for resistant organisms which may also require modification of the regimen.

4. In which ONE of the following situations should a BCG vaccination be offered to a newborn baby? Select ONE option only.
A. Born in an area with tuberculosis (TB) notification rate greater than 20 per 100,000 population
B. Born in an area with TB notification rate greater than 40 per 100,000 population
C. Family history of TB in previous 5 years
D. Family history of TB in previous 10 years
E. Family history of TB in previous 15 years

Answer: B

Primary care organisations with a high incidence of TB should consider vaccinating all neonates.www.nice.org.uk

AKT questions

2010-01-27T00:40:00.000-08:00

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

2010-01-25T00:38:00.000-08:00

1. A 26-year-old man presents with a rash over his right arm and elbow for the past 4 months. It is not itchy. What is the SINGLE MOST likely underlying cause for this patient’s rash? Select ONE option only.

A. Alcohol excess
B. Coeliac disease
C. Human immunodeficiency virus (HIV) infection
D. Hyperthyroidism
E. Hypogonadism

Answer: A

This picture shows eruptive xanthomata which characteristically arise on the buttocks, elbows and knees. They typically occur in hypertriglyceridaemia and uncontrolled diabetes mellitus. Alcohol excess is a common cause of hypertriglyceridaemia.Coeliac disease may be associated with dermatitis herpetiformis – —a blistering rash which tends to affect extensor surfaces. It is typically very itchy.HIV infection per se would not cause this rash, but some anti-retroviral drugs used in the management of HIV infection can cause dyslipidaemia as a side- effect. This rash may be mistaken for molluscum contagiosum which can occur in HIV and acquired immune deficiency syndrome (AIDS).

2. In the assessment of cardiovascular disease risk, if the patient is a man of South Indian origin, by what factor is his risk increased?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: B

3. In the assessment of cardiovascular disease risk, if the patient has ONE first-degree relative with a history of premature coronary heart disease, by what factor is their risk increased?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: C

4. In the assessment of cardiovascular disease risk, if the patient has TWO OR MORE first-degree relatives with a history of premature coronary heart disease, by what factor is their risk increased?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: D

NICE clinical guideline 67 (May 2008) Lipid Modification gives full details of how to assess and calculate cardiovascular disease risk.

5. In the treatment of hyperlipidaemia, statin therapy should be discontinued if serum transaminases are raised by more than what factor above the upper limit of normal?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: F

6.
In the treatment of hyperlipidaemia, statin therapy should be discontinued if myopathy is suspected and creatine kinase is elevated by more than what factor above the upper limit of normal? [Show Discussion]

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: J

The BNF has an excellent section on lipid-regulating drugs, including the use of statins (HMG CoA reductase inhibitors), their cautions and side-effects.Caution should be exercised when prescribing statins to those with liver disease and/or a history of alcohol excess.Hypothyroidism should be adequately treated before assessing the need for lipid-regulating treatment. Treating hypothyroidism can potentially correct the dyslipidaemia. In addition, hypothyroidism increases the risk of myositis with concomitant lipid-regulating therapy.

2010-01-25T00:23:00.000-08:00

1. According to current National Institute of Clinical Excellence (NICE) guidance, metformin should be stopped (due to lactic acidosis) when the estimated glomerular filtration rate falls below what level? Select ONE option only

A. 25 ml/min/1.73 m2
B. 30 ml/min/1.73 m2
C. 40 ml/min/1.73 m2
D. 45 ml/min/1.73 m2
E. 50 ml/min/1.73 m2

Answer:: B

See NICE guideline 66 (May 2008) Type 2 Ddiabetes: the management of type 2 diabetes.

2. A 49-year-old man attends for a repeat prescription of insulin, which has recently been started by his consultant diabetologist. His latest HbA1c is 10.2%. He currently works as a taxi driver.What is the SINGLE MOST appropriate advice to give to this patient regarding his work?

A. He can continue driving without any restrictions
B. He should inform the Driver and Vehicle Licensing Agency (DVLA) and can then continue driving without any restrictions
C. He should inform the DVLA and await further assessment from one of their medical advisors
D. He should inform the DVLA and can continue driving once his insulin dose is stable
E. He should inform the DVLA and must stop driving immediately

Answer: E

The DVLA recognizses two groups of licence holder – —Group 1 (for car and motorcycle drivers) and Group 2 (for taxi, lorry and bus drivers).Patients with insulin-treated diabetes and a Group 1 licence must be able to recognizse the warning symptoms of hypoglycaemia before being granted either a one1, two 2 or three 3 year licence.Patients with insulin-treated diabetes and a Group 2 licence are barred by law from driving.www.dft.gov.uk/dvla/medical.

3. A 74-year-old woman with type 2 diabetes presents with a swelling on her left thigh for the last 3 months. She was started on insulin 6 months ago and always uses her left thigh as an insulin injection site. On examination, a small soft mass is felt underneath the skin. There is no overlying erythema.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Acanthosis nigricans
B. Cellulitis
C. Insulinoma
D. Lipid hypertrophy
E. Necrobiosis lipoidica

Answer: D

The most likely diagnosis is lipid hypertrophy. The history that this patient has not been rotating injection sites. All patients starting insulin are advised to vary the site of injection to reduce the risk of this complication.Cellulitis is more common in those with diabetes, although there are no features to suggest it as a diagnosis here.An insulinoma is an insulin-secreting pancreatic tumour.Acanthosis nigricans is a rare skin condition which can be associated with insulin resistance and diabetes. It causes papillomatous hyperplasia of the dermis with hyperpigmentation – —commonly in the axilla, groin and neck creases.Necrobiosis lipoidica is a skin condition closely associated with diabetes. Initially, there are dusky red nodules on the shin which later become flat, irregular and yellow–-brown. Small-vessel damage in the dermis is thought to be implicated in its aetiology. It is more common in young and middle-aged women.

AKT Questions

2010-01-24T08:34:00.000-08:00

1. A 41-year-old man has recently attended the surgery for fasting blood tests, including an oral glucose tolerance test, as part of his annual hypertension review. The following results are received:Fasting plasma glucose 5.9 mmol/l2 hour plasma glucose 9.6 mmol/lSerum total cholesterol 5.6 mmol/l (3.0–5.3 mmol/l)Serum triglycerides 2.2 mmol/l (0.5–2.0 mmol/l)Whati is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Diabetes mellitus
B. Impaired fasting glycaemia
C. Impaired glucose tolerance
D. Metabolic syndrome
E. Normal glycaemic control

Answer: C

Diabetes mellitus is defined by:• Fasting glucose greater than or equal to 7.0 mmol/lL and• 2 hour glucose greater than or equal to11.1 mmol/lL
Impaired fasting glycaemia is defined by:• Fasting glucose greater than or equal to6.1 and less than < 7.0 mmol/lL and• 2 hour glucose < less than 7.8 mmol/lL
Impaired glucose tolerance is defined by:• Fasting glucose < less than 7.0 mmol/Ll and• 2 hour glucose greater than or equal to7.8 and < less than 11.1 mmol/lLThe
metabolic syndrome is a condition characterizsed by at least three of the following clinical features:• Central obesity• Elevated triglyceride• Low HDL cholesterol• Raised blood pressure• Raised fasting plasma glucoseNormal glycaemic control is defined by:• Fasting glucose less than or equal to 6.0 mmol/lL and• 2 hour glucose < less than 7.8 mmol/lL

AKT questions

2009-09-15T03:13:00.000-07:00

1. A 43 year old woman presents with an episode ofsevere pain in her upper abdomen of one hours duration and one vomit. She has had three previous episodes one of which woke her at night and lasted for two hours. She is now asymptomatic. She has tenderness on inspiration in her right upper quadrant.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: H

Chest pain in primary care is sometimes straight forward but can be one of the most challenging tests of decision making in Primary Care. Generally speaking there is limited use made of the Troponins (specific and sensitive for myocardial damage) and the D Dimer (sensitive but too non specific). Too often the results of the latter are telephoned through to a hapless out of hours doctor who has no clinical details to guide him! Although I might occasionally do a Troponin T (for instance in an elderly person with co-morbidity, full safety netting and reliable social support) I would only do so after a full clinical assessment, ECG and in the knowledge that an MI was clinically unlikely. I would take personal responsibility for checking the result.Biliary pain (case 1) is occasionally confused with cardiac pain, as is the characteristic L sided pain of the stressed executive (case 2). Such a patient will often end up with an exercise test for his own reassurance but, since this is not totally specific or sensitive may be superseded by cardiac CT in the future.

2. A 48 year old sales manager with no medical history presents following a medical by a private insurer. The examining doctor was concerned about his left sided chest pain which came on at variable times, was sharp in quality and which the patient associated with stress. A full biochemical screen and ECG at the medical were normal

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

3. A 70 year old patient telephones to tell you that he has had severe retrosternal pain for 30 minutes and has vomited once. His wife has told him that he looks dreadful

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: B

Myocardial infarction is the likely cause of the problems encountered by Case 3. There is no mileage in delaying admission these days but it important that the patient (or representative) is spoken to directly. If there is an aspirin in the house he should be advised to take it.

4. A 25 year old woman presents with R sided chest pain which has occurred in conjunction with an URTI. Clinically she is normotensive with a pulse rate of 90 regular, some chest wall tenderness and reproduction of pain on thoracic spine rotation. She takes the contraceptive pill.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

The young lady in case 4 is clinically unlikely to have a pulmonary embolus (but this should be considered) and a D Dimer of course could well be a distractor in the presence of a URTI. She is most likely to have pulled an intercostal muscle coughing.

5. A 40 year old police cadet was thumped in the ribs three days before during unarmed combat training. He has L sided chest pain worse on breathing and moving but has been able to work. Apart from rib tenderness clinical examination is unremarkable, he is normotensive and his oxygen saturations are 98% on air

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

The policeman in case 5 does not need further investigation (the most worrying consequence of his injuries is a tension pneumothorax which in this scenario is unlikely – A&E doctors may argue with this but it is unlikely to change management in primary care).

6. A 43 year old labourer presents with a short episode of severe thoracic spine pain earlier in the day which settled after 40 minutes or so. He had a previous episode the week before. On examination he looks well, BP 90/60, pulse 100 regularly and he has a soft early diastolic murmur.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: B

Case 6 is seriously ill. Check the BP in both arms (it may be different), insert a venflon if you have one and stay with the patient until the ambulance arrives. He probably has an aortic dissection (has he got Marfan.s syndrome?) and your action could be life-saving.

7. A 58 year old French teacher has a persistent cough and a niggling R sided chest pain. She smoked 20 cigarettes a day until 3 years ago

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I.Refer to the Rapid access chest pain clinic

Answer: F

I would be concerned that case 7 had a carcinoma of the bronchus and would order a Chest X-Ray. If this was normal I would review her and, if not settling either repeat or perform spirometry.

8. Arthur – an 80 year old Type 11 diabetic has tightness in his chest which occurs on walking 100 yards on the flat or on emotion – especially after eating. He has not experienced the pain at rest and when he stops it settles after 5-6 minutes

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: I

Arthur (case 8) probably has chronic stable angina and should be referred to the Rapid Access Chest pain clinic. Age is not a bar to effective treatment and, while he is waiting it would be sensible to check his lipids,Hb and electrolytes as well as a resting ECG .It would be reasonable to commence symptomatic treatment (eg Nitrate) as well as commencing Aspirin and a Statin – if not already taking them.

A 60 year old man has an anterior myocardial infarction treated acutely by Percutaneous Intervention (PCI) with stents and made an uneventful recovery.

9.
Which one of the following statements is true: [Show Discussion]

A. Aspirin needs to be given for 5 years and then stopped
B. Clopidogrel should be given for a year.
C. He should not be given ACE inhibitors if his creatinine is over 120mmol/l
D. He only needs a statin if his total cholesterol is more than 5.0 mmol/l
E. He doesn’t need a B Blocker unless he has a pulse persistently greater than 80

Answer: B

Current recommendations are that with stents clopidogrel continues for a year. Some cardiologists would advocate longer – but the evidence is not yet available. This is a fast moving field! Aspirin, B Blockers , statins (whatever the cholesterol)and possibly ACEI should be permanent. He needs his creatinine monitoring carefully.

Dermatology

2009-09-09T01:01:00.000-07:00

1. This elderly patient with a history of chronic sun exposure presented with some rough areas of skin on his forehead. This was an incidental finding. The single most likely diagnosis is?

A. Actinic keratoses
B. Metastases
C. Pyogenic granulomata
D. Seborrhoeic keratoses
E. Viral warts

Answer: A

These are chronic sun-related changes that may progress in time to squamous cell carcinomas. In the absence of significant induration, cryotherapy would be an appropriate treatment. Alternatives include topical diclofenac gel (e.g. 'Solareze').

dermatology

2009-09-09T00:58:00.000-07:00

1. This elderly patient presented incidentally with the lesion below that had been slowly enlarging for several months. What is the single most likely diagnosis? A. Actinic keratosis
B. Amelanotic melanoma
C. Cystic basal cell carcinoma
D. Pyogenic granuloma
E. Squamous cell carcinoma

Answer: C

this is a cystic basal cell carcinoma. Variants on the classical 'rolled edge' in basal cell neoplasms are common. Variants include this one as well as superficial spreading variants—which can be mistaken for a patch of eczema. The site is an important clue however and this, bearing in mind the age of the patient, should be referred.

AKT questions

2009-09-09T00:25:00.000-07:00

1. A 60-year-old man presents with pain between his neck and his right shoulder for 2 weeks following strenuous gardening, worse on moving. When asked, he points to the posterior aspect of the painful site. He has no symptoms below the elbow and is otherwise well. The single most likely cause of his pain is?

A. Acromioclavicular joint arthritis
B. Capsulitis of his shoulder
C. Cervical myelopathy
D. Cervical spondylosis
E. Rotator cuff tear

Answer: D

cervical spondylosis. This question really brings out the point that the site of pain around the shoulder will rapidly eliminate certain diagnoses. Acromioclavicular joint pain tends to be on top of the shoulder while neck pain characteristically radiates from its origin over the trapezius muscle. If there is significant disc disease, there is likely to be a problem below the elbow. Cervical myelopathy implies spinal cord involvement—in which case there may be a mild spastic paraparesis (possibly with an 'inverted supinator' signifying a UMN lesion around C5/6). Glenohumeral pain may be diffuse but is characteristically felt at the top of the arm.

2. A 50-year-old female patient presents with pain around her shoulder that is felt mainly in her upper arm. Which one of the following signs does not require early referral?

A. Fever and joint erythema
B. Horner’s syndrome
C. Inability to abduct and externally rotate following trauma
D. Muscle wasting around the scapula
E. Reduction in all directions of movement

Answer: E

reduction in all directions of movement. In the presence of fever and joint erythema, sepsis (although uncommon) should be considered. Nocturnal wakening is characteristic in both capsulitis of the shoulder and rotator cuff tears and (unlike back pain) is not a red flag in this context. Severe pain immediately following trauma suggests dislocation. The rounded contour of the shoulder will disappear in the commonest (anterior) dislocation and the patient will resist abduction and external rotation. Reduction in all directions of movement simply implies a 'capsular' cause of the pain—be it arthritic or a capsulitis. Muscle wasting around the scapula may mean a 'brachial neuritis'—a curious condition of unknown aetiology while Horner’s syndrome could indicate the presence of a Pancoast’s tumour.

3. Which one of the following statements below makes a meniscal tear more likely than alternative diagnoses? [Show Discussion]

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.

4. 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? [Show Discussion]

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.

5. 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? [Show Discussion]

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.

6.
A patient aged 60 years presents with this lesion on the dorsum of her forearm It has been present for around a month and enlarged rapidly over that time. What is the single most likely diagnosis?

A. Dermatofibroma
B. Keratoacanthoma
C. Melanoma
D. Nodular basal cell carcinoma
E. Pyogenic granuloma

Answer: B

This should be referred urgently for excision (surgically or by curettage) since the rate of growth is alarming and shave biopsy can look histologically very like squamous cell carcinoma. The lesion is benign and characteristically occurs in an older population on sun-exposed sites. It has a keratinous centre.

2009-02-08T06:40:00.000-08:00

1.A 23 year old nurse presents with nocturnal cough and wheeze. She has smoked 10 cigarettes daily for 6 years and is clinically well with a pulse rate of 70 beats per minute, respiratory rate 15 per minute and no chest signs. She has previously been well. Which one of the options below would be of most use in confirming her diagnosis? [Show Discussion]

A. Arterial blood gases
B. Chest X-Ray
C. Serial peak flow readings
D. Pulse oximetry
E. Spirometry

Answer: C

The distinction between asthma and COPD is made by considering the history and if necessary further investigations such as spirometry. Furthermore, despite the fact that she smokes, COPD is much more likely in patients over 35. This is a typical history for asthma. The fact that she is well when she sees you the next day and has no apparent abnormalities should not dissuade you from making this diagnosis. She should of course be discouraged from smoking.ABGs (even if they could be done in primary care) are inappropriate and likely to be normal, as is pulse oximetry – certainly during the daytime. In this setting (especially in a young woman) CXR is unlikely to be helpful – although if she does not respond to treatment should be considered. Bearing in mind that asthma is reversible airways obstruction spirometry may be normal – depending on whether it is don at a time when there is bronchospasm. Serial PFR is helpful on two countsa) A variability of 20% (usually lowest early in the morning or after trigger) is virtually diagnostic if the patient’s technique is adequate. It is important that the morning reading is done as soon as possible after rising and that the evening is around 5pm.b) It allows patients to self monitor in the future and play an active part in their ongoing management

AKT Exam Questions

2009-02-08T04:06:00.000-08:00

Theme: All the patients have recently been discharged from hospital. Match the patient scenarios below to a chosen option

1. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a knee replacement on Diclofenac 50mg tds as well as her other medications.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: B

Stop the Diclofenac which has dangerous interactions with Warfarin and could potentially exacerbate renal problems in association with Ramipril.

2. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a chest infection on Erythromycin 500mg qds as well as her other medications

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Erythromycin potentiates the action of warfarin but is presumably essential for whatever reason. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.

3. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a UTI on Ciprofloxacin 500mg bd as well as her other medications

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Ciprofloxacin potentiates the action of warfarin but is presumably essential. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.

4. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She was admitted with a fall and is continuing to do so.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Persistent falls contra-indicate Warfarin. IN this case it is important however to exclude arrthymias (especially bradycardias with bisoprolol) and postural hypotension.

5. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She complains of insomnia and falls. The hospital have prescribed Mirtazepine 30mg at night for significant depression.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: A

Assuming she is depressed, she may get better given time with mirtazepine. She requires careful cardiovascular assessment however – including postural blood pressures.

Theme – Prescribing for the Elderly

6. A 78 year old woman with longstanding hypertension consults you with marked ankle oedema. Her current medication is:- Ramipril 5mg daily; Amlodipine 5mg daily; Aspirin 75mg daily; Simvastatin 40mg daily and Lactulose 15ml at night. You can find no evidence of heart failure and her urine is negative. Her blood pressure is 140/78. Which one immediate intervention is most likely to help her?

A. Addition of Bendroflumethazide 5mg daily
B. Addition of Furosemide 40mg daily
C. Addition of Bumetamide 1mg daily
D. Stopping Amlodipine
E. Stopping Aspirin
F. Stopping Simvastatin

Answer: D

Stop Amlodipine. Despite its many benefits in this age group Amlodipine is a common cause of ankle oedema.

7. A 70 year old man presents to you as a new patient. He informs you that since a stroke two years ago he has suffered from dizziness and increasing difficulty mobilising. Initial recovery was good. His repeat prescriptions (from previous GP) are:- Ramipril 10mg daily; Indapamide 1.5mg daily; Aspirin 75mg daily; Atorvastatin 40mg daily; Furosemide 40mg daily; Prochlorperazine 5mg daily. Which focussed examinations below are most likely to lead to a management plan?

A. Cranial nerves and cerebellum
B. Mental state and reflexes
C. Muscle power and blood pressure
D. Postural blood pressure and gait
E. Pyramidal tracts and joint position sense

Answer: d

Postural blood pressure and gait. Regrettably this is not an uncommon scenario – inappropriate drug regimes find their way on to repeat prescribing systems (in this case a thiazide and loop diuretic which have synergistic actions) Consequences are treated symptomatically (in this case with a phenothiazine) which can itself cause Parkinsonism

AKT Questions:

2009-02-02T07:48:00.000-08:00

Theme – Endoscopy The following patients all have gastrointestinal symptoms. Initial management should include one of the options below. Each option may be used once, more than once or not at all:-

1. A man of 48 who has a history of endoscopically proven duodenal ulceration five years ago for which he received H. Pylori eradication but was lost to follow up. He has recurrent dyspepsia but no red flag symptoms

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: D

In these circumstances H. Pylori should be rechecked in the first instance (breath test or Stool antigen) and either PPI or eradication depending on the result.

2. 39 year old female nurse who has typical symptoms of reflux. Her body mass index is 35 and she had an initial response to two months high dose proton pump inhibitor.

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: D

This patient should have lifestyle advice, H pylori testing and eradication if positive (even though her symptoms may initially get worse). If negative it would be reasonable to give a proton pump inhibitor as required but review her.

3. A man of 57 with recent onset persistent dyspepsia but no other "red flags".

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: C

He should also have a blood screen and helicobacter testing.

4. A woman of 70 with recent onset of difficulty in swallowing

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: B

This would be an indication for a "two week" referral.

5. A woman of 70 who takes diclofenac and is found to have a haemoglobin of 9.0 with an iron deficient picture

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy.

Answer: C

If the endoscopy does not explain the anaemia she should have a colonoscopy.

AKT Questions

2009-02-02T05:35:00.000-08:00

1. 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.

2. Although hypothyroidism can cause vocal changes, hoarseness which is worse in the morning is likely to be associated with GORD. Obesity predisposes to GORD. Hoarseness, dysphagia and other motor symptoms are most likely to be caused by motor neurone disease (amyotrophic lateral sclerosis). Neck surgery can result in recurrent laryngeal nerve palsy in 1-2% of cases.

3. A double-blind, randomised, placebo-controlled trial, conducted in primary care, of a new drug for stroke prevention shows statistical and clinical evidence that the drug is superior to placebo in preventing stroke. In deciding whether or not to use this new drug, which one of the following statistics is most useful?

a ) NNK (Number Needed to Know)
b ) NNT (Number Needed to Treat)
c ) RRR (Relative Risk Reduction)
d ) CER (Control Event Rate)
e ) RRI (Relative Risk Increase)

Answer: B

The NNT (Number Needed to Treat) calculates the number of patients a clinician needs to treat in order to prevent one additional adverse outcome.

4. “The expanding use of qualitative research methodology has allowed us to gain knowledge about the characteristics, complexities and interrelationships of phenomena such as an individual’s experiences, emotions, beliefs and motives” (David Silverman, 2004). By applying this methodology in the primary care setting, we can obtain a greater understanding of the patients’ perspective and use this to improve patient health, the health care system and health service delivery. Which one of the following terms would you most associate with Qualitative rather than Quantitative research?

a ) Purposive sampling
b ) Controlled trials
c ) Randomisation
d ) Confidence interval
e ) Double blind

Answer: A

The randomised double blind controlled trial is the gold standard in quantitative research. Prospective studies can be used in Quantitative and Qualitative studies. Confidence intervals are used in statistics in relation to numeric data in Quantitative research. Purposive sampling is a sampling method used in Qualitative Research and is the selection of the most productive sample to answer the research question.

5. Your Practice Manager, of 10 years standing, has been off work for the last six months, with a diagnosis of Multiple Sclerosis. She contacts the Partners and asks if she can have a meeting and this is agreed. During the meeting, she confirms the diagnosis, stating that she realises the consequences of her physical impairment and its effect on her employability. Her mood and behaviour are entirely normal. She states that she is having some difficulties with normal day-to-day activities such as climbing stairs, doing housework, going shopping etc. She states that she wishes to return to work, as she is confident she can carry out all her previous management duties. She realises that getting to her upstairs office could be problematical and a whole day’s work could be overtiring. As her employer, which two management decisions would be most appropriate?

a ) Take her back as Practice Manager on a flexible, part-time basis
b ) Enforce her to take early ill-health retirement
c ) Revamp her working place environment
d ) Take her back as a Telephonist on a flexible ,part-time basis
e ) Take her back as Practice Manager only on a full time basis
f ) Tell her to keep getting sickness certificates from her Doctor
g ) Terminate her employment

The correct answers are, a, c.

Discrimination occurs against a disabled person if an employer treats someone less favourably than others who do not have a disability. The employer has a duty to look at whether there are any reasonable adjustments that can help the disabled person return to work (e.g. Changing hours, changing the local work place environment). The Disability Discrimination Act (2005) extends the definition of discrimination to people with progressive conditions such as Cancer, Multiple Sclerosis, and H.I.V.

AKT Questions

2009-02-02T04:01:00.000-08:00

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.

2009-02-02T02:50:00.000-08:00

1. Following prostatic biopsy, a 65 year old man, with spinal pain, has been confirmed as suffering from prostatic carcinoma. You are asked to prescribe him Goserelin, every 12 weeks and Cyproterone for three weeks. He asks you the reasons for having this combined therapy. The addition of the anti-androgen reduces the risk of which one of the following side effects of the gonadorelin analogue?

a ) Injection-site reaction
b ) Tumour ’flare’
c ) Hair loss
d ) Mood change
e ) Peripheral oedema

Answer: B

During the initial stage (1-2 weeks) of using Goserelin, increased production of testosterone may be associated with progression of prostate cancer. In susceptible patients, this tumour ‘flare’ may cause spinal cord compression, ureteric obstruction or increased bone pain. To reduce this risk, anti-androgen treatment (eg. Cyproterone) should be started three days before the Goserelin and continued for three weeks. The other recognised side-effects quoted will not be affected by this short term use of the anti- androgen.

2. In the process of critically appraising a randomised controlled trial (RCT), which one of the following terms is used to describe the generalisability of the trial results to your own defined patient population?

a ) Heterogeneity
b ) Reproducibility
c ) Significance
d ) External validity
e ) Positive predictive value

Answer: D

In assessments of the validity of studies of healthcare interventions, selection bias refers to systematic differences between comparison groups in prognosis or responsiveness to treatment. Random allocation with adequate concealment of allocation protects against selection bias. Other means of selecting who receives the intervention of interest, particularly leaving it up to the providers and recipients of care, are more prone to bias because decisions about care can be related to prognosis and responsiveness to treatment.
Selection bias is sometimes used to describe a systematic error in reviews due to how studies are selected for inclusion. Publication bias is an example of this type of selection bias.
Selection bias, confusingly, is also sometimes used to describe a systematic difference in characteristics between those who are selected for study and those who are not. This affects the generalisability (external validity) of a study but not its (internal) validity.

3. Your new registrar is keen to utilise her Information Management & Technology skills to enhance the care of her patients. Which one of the following is an online clinical decision support system specifically for general practitioners?

a ) MEDLINE
b ) PRODIGY
c ) NeLH
d ) OMNI
e ) EMIS
f ) VISION

Answer: B

PRODIGY is an online clinical decision support system for general practitioners. MEDLINE and OMNI are medical web-based information systems. NeLH provides access to the best current knowledge available for improving healthcare, clinical practice and patient choice. EMIS and VAMP VISION are practice based computer systems.

AKT Questions

2009-02-02T02:24:00.000-08:00

1. You are reading a research paper regarding a new blood test that can be used to screen for colorectal cancer. It shows the following data:

Cancer present Cancer absent Total no. of cases
Blood test positive 80 40 120
Blood test negative 20 60 80
Total no. of cases 100 100 200

What is the specificity of this new test?

a ) 20%
b ) 33%
c ) 60%
d ) 66%
e ) 75%
f ) 80%

Answer: C

Specificity is a measure of how well the test identifies those who do not have disease as not having disease (60%). Sensitivity is a measure of how well the test identifies those with disease as having disease (80%). The positive predictive value indicates how many people with a positive result have the disease (66%). The negative predictive value indicates how many people with a negative result do not have the disease (75%).

2. OPTIONS:

a ) Vitreous haemorrhage
b ) Proliferative retinopathy
c ) Macular degeneration
d ) Papilloedema
e ) Retinal vein occlusion
f ) Retinitis pigmentosa
g ) Optic neuritis

INSTRUCTION: For each of the patients below, select the fundal condition above that is most likely to be consistent with their symptoms and signs. Each option can be used once, more than once or not at all.

A. A 72 year old woman is a heavy smoker. She complains of increasing difficulty in recognising peoples’ faces and is having difficulty reading. She has been frightened by seeing a dark shape just as she wakens up. She says that her Venetian blinds appear wavy. Her assisted acuity is 6/18 bilaterally .Her BP is 170/100.

The Correct answer is c.
B . A 17 year old man has noticed that his vision has been poor in the evenings for the last six months, and this has resulted in him tripping up frequently. His acuity is 6/6 bilaterally. He has been told that a grandparent and a great-grandparent went blind in their 50’s.

The Correct answer is f.
C. A 56 year old HGV driver describes difficulty reversing his vehicle. He has given it some minor scrapes, and thinks there may be something wrong with his vision. He has been troubled by severe headaches for weeks. His acuity is 6/6 bilaterally. Visual field testing reveals a homonymous hemianopia.

The Correct answer is d.

50% of intracranial tumours have focal neurology at presentation.

new AKT Questions

2009-01-31T15:00:00.000-08:00

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.

AKT Questins

2009-01-26T06:16:00.000-08:00

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.

AKT Questions

2009-01-09T03:00:00.000-08:00

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

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 contactsâ€™, 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 Cowâ€™s milk protein intolerance

B Gastroenteritis

C Gastro-oesophageal reflux

D Hiatus hernia

E Hirschprungâ€™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.

B Correct answer
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.

H Correct answer
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.

G Correct answer
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

J Correct answer
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.

F Correct answer
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.

I Correct answer
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

AKT Questions

2009-01-08T16:52:00.001-08:00

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.

AKT Questions

2009-01-08T15:02:00.000-08:00

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.

AKT Questions

2009-01-07T03:28:00.000-08:00

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.

AKT Questions

2008-12-31T04:02:00.000-08:00

1. A 60 year old Partner in the Practice is persistently late in starting his surgeries. On at least three occasions, you have thought that you have smelled alcohol on his breath. During a consultation eight weeks ago, a patient alleges that the Partner concerned had said that he would refer her to a consultant, yet she has not received any word about it. You cannot see any reference to the referral in the computer record. What is the single most appropriate course of action?

a ) Meet him suggesting a Partnership meeting
b ) Report him to GMC
c ) Adopt a wait and observe policy
d ) Meet him privately and in isolation
e ) Report him to his Appraiser

Anse: A

This is a difficult management situation to deal with in real life. It is thus, a difficult scenario to be confronted with in a question format, as opinion and emphasis may not fully fit into right or wrong categories. However, it is included to stimulate thought.First and foremost, you must protect patients from risk of harm posed by a colleague’s conduct, performance or health. You must, however, have sufficient evidence before proceeding and must not act maliciously.As there are concerns over a number of fronts, it would be inappropriate to do nothing. Under the Age Discrimination Act, 2006, one cannot discriminate against anyone on the basis of age. Whilst risking relationship problems, it is important to be totally open and transparent, and approach the issues in an up-front, yet fair and conciliatory, manner with the person concerned. It is important to have colleagues also present so that responsibilities are shared and a plan of action jointly agreed.

2. A 65 year old patient, who has ischaemic heart disease and polymyalgia rheumatica, has symptoms of dyspepsia. He is on the multiple medications below. Which one of these is the least likely cause of his dyspepsia?

a ) Amlodipine
b ) Diclofenac
c ) Aspirin
d ) Bisoprolol
e ) Prednisolone

Answer: D

Amlodipine can commonly cause abdominal pain, nausea and GI upset. NSAIDs, aspirin and prednisolone are common causes of dyspepsia.

3. OPTIONS:

a ) Diverticular disease
b ) Endometriosis
c ) Interstitial cystitis
d ) Irritable bowel syndrome
e ) Follicular ovarian cyst
f ) Pelvic inflammatory disease
g ) Piriformis syndrome

INSTRUCTION: Pelvic pain is a common presentation in women. Select the single most likely diagnosis above for each of the clinical presentations below. Each option can be used once, more than once or not at all.

A. A 27 year old nulliparous woman presents with symptoms of dysmenorrhoea, dyspareunia and lower abdominal pain which is usually cyclical in nature. Diagnosis was confirmed on laparoscopy.

The Correct answer is b.
B . A 31 year old woman presents with lower abdominal pain and a bloating sensation. She suffers from mild flatulence and altered bowel habit. Her periods are heavy but the symptoms are unrelated to her menstrual cycle.

The Correct answer is d.
C . A 29 year old woman presents with abdominal bloating and a sharp severe transient left sided pain. She is not sexually active but has not had a period for three months. Pregnancy test is negative. Pelvic examination suggests a swelling in the left iliac fossa.

The Correct answer is e.

Endometriosis is characterised by ectopic endometrial tissue, which can cause dysmenorrhoea, dyspareunia, pelvic pain, and subfertility. Diagnosis is made by laparoscopy. Most endometrial deposits are found in the pelvis (ovaries, peritoneum, uterosacral ligaments, pouch of Douglas, and rectovaginal septum). Extrapelvic deposits, including those in the umbilicus and diaphragm, are rare. Irritable bowel syndrome (IBS) is a chronic non-inflammatory condition characterised by abdominal pain, altered bowel habit (diarrhoea or constipation), and abdominal bloating, but with no identifiable structural or biochemical disorder. Symptom based criteria, such as the Manning, the Rome I and the Rome II aid diagnosis but their main use is in defining populations in clinical trials. The most common type of simple ovarian cyst is the graafian follicle cyst, follicular cyst, or dentigerous cyst. This type can form when ovulation doesn't occur, and a follicle doesn't rupture or release its egg but instead grows until it becomes a cyst, or when a mature follicle involutes (collapses on itself). It can grow to about 2.3 inches in diameter. It is thin-walled and filled with clear fluid. Its rupture can create sharp, severe pain. Piriformis syndrome has remained a controversial diagnosis since its initial description in 1928. It is usually caused by a neuritis of the proximal sciatic nerve. The piriformis muscle can either irritate or compress the proximal sciatic nerve due to spasm and/or contracture.

4. A 65 year old woman has been on Lithium Carbonate for 10 years with good effect. Due to mild hypertension she was started on bendroflumethiazide 2.5mg. Six months later she went on holiday for two weeks to southern Europe. Three days before leaving she developed diarrhoea with watery stools every few hours and abdominal pain. She vomited once and remained nauseous. Two days after her return home, she attends you as she still has diarrhoea and nausea and is having some difficulty walking. You notice that her speech is a little slurred. She has a mild fever (37.6oC). Which one of the following investigations is the most appropriate?

a ) Check a stool sample for infection
b ) Check serum lithium level
c ) Check thyroid function
d ) Check urea and electrolytes
e ) Check white cell count

Answer: B

Lithium has a narrow therapeutic:toxic ratio. Sodium imbalance and dehydration are common precipitants of toxicity. This woman is at added risk of this because of the thiazide diuretic which would probably have best been avoided in the management of her hypertension. Patients on Lithium should be counselled about the risks of dehydration.

5. A 68 year old retired railway worker has Chronic Heart Failure (CHF) secondary to Ischaemic Heart Disease. He is already on an Angiotensin Converting Enzyme (ACE) inhibitor and his symptoms of exertional dyspnoea are well controlled. According to best evidence, which one of the following should you consider adding to his medication in order to reduce his risk of mortality due to CHF?

a ) Atorvastatin
b ) Bisoprolol
c ) Flecainide
d ) Furosemide
e ) Isosorbide mononitrate

Answer: B

Few drugs have been shown to reduce mortality in cardiac failure. They include Spironolactone, ACE inhibitors, and Beta blockers. Beta blockers reduce mortality in moderate as well as severe heart failure, and in all age groups, including the elderly. The evidence for loop diuretics is controversial

6. A 60 year old man, who worked underground in the coal industry for 30 years, has noticed a progressive deterioration in his hearing over several years. He relates that he had his adenoids removed as a child because of ear infections. He has had a hearing test organised by his former Trades Union. He brings the audiometry printout to you for your advice. It shows a loss of 60Db at a frequency of 4kHZ in both ears. What single most likely condition does this illustrate?

a ) Chronic otitis media
b ) Presbycusis
c ) Acoustic neuroma
d ) Noise-induced deafness
e ) Otosclerosis

Answer: D

The loss at 4kHz is characteristic of noise- induced deafness. As the deafness worsens, the loss can extend into the 8kHz frequency. The loss is typically sensori-neural

7. A four year old girl is brought along by her mother because of concerns about her increasing need for her reliever inhaler. Her current preventative treatment is 200mcg inhaled beclometasone metered dose inhaler (MDI) twice daily. Over the last 4-6 weeks she has required her salbutamol MDI at least three times per week, often overnight. There is no evidence of acute respiratory infection. She is using a spacer device, and her technique and compliance are good. According to the current British Thoracic Society/SIGN Guideline on Asthma, which one of the following interventions is the next management step?

a ) Add inhaled ipratropium bromide 20mcg t.d.s.
b ) Add inhaled salmeterol 50mcg b.d.
c ) Add inhaled sodium cromoglicate 10mg q.d.s.
d ) Add oral montelukast 4mg o.d
e ) Increase inhaled beclometasone dose to 400mcg b.d.

Answer: D

At presentation, this child is at Management Step 2, whereby she is using regular standard-dose inhaled corticosteroid, plus as-required inhaled short-acting ß2 agonist. To gain improved control, she must move up to Step 3, which for children between two and five years of age, requires the addition of an oral leukotriene receptor antagonist. Currently, only montelukast is licenced for use in this age group. It should be noted that Step 3 for adults and children over 5 is significantly different.

9. A 42 year old man, who regularly consumes 60 units of alcohol a week, presents to you asking for detoxification. He has never before been through alcohol detoxification and expresses a wish for a home- based programme. He is referred to the Community Alcohol Service which agrees that he is a suitable candidate and you are asked to prescribe Chlordiazepoxide. On Day 2 of his programme you receive a phone call from his alcohol worker telling you that he has started to have visual and tactile hallucinations, is disorientated and aggressive and has a temperature of 38.5 degrees C. She asks your advice. What is the single most appropriate next step?

a ) Arrange for a nurse to give intramuscular haloperidol today.
b ) Arrange for a nurse to give intramuscular thiamine today
c ) Arrange for a hospital physician to see him today
d ) Arrange for a psychiatrist to see him today
e ) Arrange for a higher oral dose of Chlordiazepoxide today

Answer: C

What is described here is Delirium Tremens. An acute infection could present in a similar way and needs to be excluded. However, a fever is a symptom of DTs. Untreated Delirium Tremens carries a mortality of up to 5%. Although some psychiatrists will admit patients with DTs, cases are generally treated by the acute medical service because there is often a coexisting medical condition such as pancreatitis, pneumonia or other infection. Haloperidol is an anti psychotic drug but has no place in the community management of alcohol induced psychotic symptoms. Although Diazepam is a benzodiazepine, it has a greater potential for misuse than Chlordiazepoxide and is the benzodiazepine most frequently associated with alcohol related fatalities. Thiamine is prescribed in potential or actual Korsakov’s syndrome

10. OPTIONS:

a ) Asperger’s syndrome
b ) Autism
c ) Cerebral palsy
d ) Cri du Chat
e ) Down’s syndrome
f ) Edward’s syndrome
g ) Fragile X syndrome

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

A . A three year old boy is brought to you by his worried grandmother. He used to go to nursery, but his mum stopped taking him because it was too demanding for him. His speech is poor. Gran says that he prefers his own company. When he gets stressed he bangs his head on the wall. He has a normal physical appearance.

The Correct answer is b.
2 . A five year old girl is having a difficult time making friends at school. At the recent parents’ night, the teacher described her as capable, but lacking in imagination, and a bit eccentric. She has only a few topics of conversation which interest her, including airports. She has a normal physical appearance.

The Correct answer is a.
3 . A 15 months old baby is referred to you by the health visitor. He has developmental delay. He is a poor sleeper. You examine him. He has some facial asymmetry. He moves all limbs normally. You note that he has enlarged testicles. He appears quite aggressive towards you.

The Correct answer i G

Developmental delay and school problems are common presentations for learning disabilities in primary care. GPs should recognise the common presentations and features in order to initiate appropriate specialist referral for formal diagnosis and management. Macroorchidism (enlarged testicles) is a common feature in males with learning disability; but it is particularly common in fragile X syndrome

AKT Questions

2008-11-28T03:32:00.000-08:00

1. A 70 year old patient with metastatic lung cancer is being treated with a slow release morphine preparation for pain relief. Which one of the following is a recognised side effect of this treatment?

a ) Hyperthermia
b ) Urinary retention
c ) Convulsions
d ) Jaundice
e ) Excess salivation

Answer: B

Side effects of morphine salts include hypothermia and dry mouth among many others. Morphine has an effect on the muscle of the urinary tract, causing the sphincter to contract. This may lead to urinary retention.

2. OPTIONS:
a ) Agitated depression
b ) Alzheimers dementia
c ) Anxiety disorder
d ) Bi-polar disorder
e ) Psychotic state
f ) Multi-infarct dementia
g ) Personality disorder

INSTRUCTION: For each clinical scenario below, select the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.

1 . A 38 year old woman attends the surgery. She is tense and agitated with feelings of impending doom. She describes a lump in her throat, is prone to palpitations and has tingling in her hands. She finds it difficult to pinpoint why she feels like this.
The Correct answer is c.

2 . A 19 year old student attends the surgery accompanied by a friend. She is withdrawn and pre-occupied. On questioning, her friend says she has been under a lot of stress recently with exams. She has commented that residents of a neighbouring flat are listening to what she is thinking.
The Correct answer is e.

3 . A 60 year old man attends the surgery with his wife. He is over bearing and euphoric. He has a history of depression. His wife comments that he has been socialising and drinking more than usual. He is spending outwith his financial means and has great plans for a bizarre business venture.
The Correct answer is d.

Anxiety is a normal response to an unusual or stressful event; it is the psychological component of the "flight or fight" response. Anxiety is considered abnormal when it is excessively severe or it occurs in the absence of a stressful event or it impairs social, physical or occupational functioning.A psychosis is any major mental disorder of organic or emotional origin that is marked by a derangement of personality and loss of contact with reality. A psychosis is characterised by loss of insight into the fact that one is mentally ill, usually as part of a more general disturbance of the normal relationship between reality and imagination, fact and fantasy. The two most important symptoms of a psychotic disorder are hallucinations and delusions.Bipolar affective disorder is a condition where there are periodic swings of mood periods of months or years between manic episodes and depressed episodes

3. A 72 year old man has metastatic cancer of the prostate gland but has been doing quite well.. For the past two days, he has had low back pain which is worse when he moves but with no radiation. He increased his dose of co-codamol 30/500 two days ago. His wife has just phoned to say he cannot get out of bed and is unable to empty his bladder. He is constipated and his bowels last opened three days ago. You perform a rectal examination and find his rectum is empty and notice that he has poor anal tone. Which is the single most appropriate course of action?

a ) Arrange for hospital specialist review today
b ) Arrange an urgent domiciliary physiotherapy assessment
c ) Arrange for the District Nurse to come and catheterise him
d ) Change his co-codamol to morphine
e ) Prescribe a laxative

Answer: A

This man has probably developed spinal cord compression which is often preceded by back pain. His constipation is a result of this rather than an increase in his codeine intake. He needs urgent assessment and may respond well to radiotherapy if this can be arranged urgently (Oxford Textbook of GP suggests within 24-48 hours of onset of neurological signs.) A high dose of dexamethasone 16mg/day will help reduce compression prior to radiotherapy. Once paralysed less than 5% of patients will walk again.

4. A 45 year old man, with a long history of ear infections, states that his left ear has been discharging continuously over the last three months. His hearing has worsened and he has experienced dizziness. There is a feeling of fullness in the ear. In addition, there is an ache behind the ear, especially at night. On examination, there is a faecal smelling discharge and granulation tissue can be seen. What is the single most likely diagnosis?

a ) Chronic otitis media
b ) Tympanosclerosis
c ) Chronic otitis externa
d ) Cholesteatoma
e ) Middle ear osteoma

Answer: D

The history is strongly suggestive of cholesteatoma, the principle cause of which is recurring ear infections. Cholesteatoma consists of squamous epithelium that is trapped in the middle ear or mastoid. It is slow growing and causes destruction of bone. This results in a conductive deafness. Facial nerve damage can occur. Rarely, erosion of the cranial bone occurs with resultant meningitis.

5. OPTIONS:
a ) Amotivational syndrome
b ) Cardiovascular collapse
c ) Hallucinations
d ) Perforation of nasal septum
e ) Renal failure
f ) Seizures
g ) Tinnitus

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

1 . A 48 year old man who self-harms using coproxamol.
The Correct answer is b.

2 . A 42 year old woman who has been smoking cannabis “for years”.
The Correct answer is a.

3 . A 34 year old doctor who has been abusing benzodiazepines for over a year, but stopped yesterday.
The Correct answer is f

Coproxamol in self harm can cause hepatic failure. In addition, the dextropropoxyphene component, and its metabolites are cardiotoxic and can cause dysrhythmias and cardiovascular collapse Patients showing disinterest in work, family and friends may be suffering from the long term effects of cannabis abuse (amotivational syndrome). Sudden withdrawal from benzodiazepines can elicit seizures. Benzodiazepines are a relatively common drug of abuse in medics.

6. A 55 year old man has had ulcerative colitis for 20 years. It is usually well controlled on mesalazine 4g daily. Having developed recent back pain, he has been taking ibuprofen 400mg three times a day (which was prescribed for his wife). For the past week, he has had an increase in the frequency of his bowel motions which now occur four times a day and are more liquid than usual. He has had no rectal bleeding or fever. What is the single most appropriate drug adjustment to make?

a ) Add loperamide
b ) Add oral prednisolone
c ) Add rectal prednisolone
d ) Increase mesalazine
e ) Stop ibuprofen

Answer: E

NSAIDs are noted for precipitating a relapse in inflammatory bowel disease and should be avoided. Loperamide is of use as a maintenance treatment; but has no place in the management of a relapse such as is described here. Prednisolone is useful in bringing more severe symptoms under control (e.g. more than four motions per day with rectal bleeding and systemic upset). In such a case, a dose of 40mg daily is recommended in combination with a rectal preparation. There should be a gradual reduction over a period of eight weeks as a rapid withdrawal often results in a relapse. The maximum dose of mesalazine is 4g daily and there is nothing to be gained by increasing this.

AKT Questions

2008-11-25T14:00:00.000-08:00

1. A 25 year old Russian immigrant presents with a low-grade pyrexia, generalised lymphadenopathy and a symmetrical maculopapular rash. The rash involves the scalp, palms of the hands and soles of the feet. He was also concerned about a shallow ulcerated patch on his groin but this now seems to be resolving. What is the single most likely diagnosis?

a ) Chancroid
b ) Herpes genitalis
c ) Lymphogranuloma venereum
d ) Rubella
e ) Secondary syphilis

Answer: E

Although Syphilis can be co-existent with HIV infection the symptoms described are classical of secondary syphilis. STDs appear to be very common in the former Soviet block at present. Chancroid - Haemophilus ducreyi, the microbial agent of chancroid, used to be probably the most common cause of genital ulcers in many parts of the world. However, the pattern of genital ulcer disease (GUD) is changing. Lymphogranuloma venereum is a sexually transmitted disease caused by the invasive Chlamydia trachomatis.. LGV is primarily an infection of lymphatics and lymph nodes. It gains entrance through breaks in the skin, or it can cross the epithelial cell layer of mucous membranes. A rash is not typical. The classical exanthems are not associated with genital ulceration.

2. A 50 year old man presents with reflux-type symptoms for the first time. On questioning, he has had no haematemesis nor melaena, no weight loss and no difficulty swallowing. He has taken bendroflumethiazide 2.5mgs daily for hypertension for the last two years and amlodipine was added four months ago. He states that he drinks less than 10 units of alcohol per week. His BP today is116/70. You decide on an intervention strategy and will review him in four weeks. Which one of the following actions is the most appropriate, at this point in time?

a ) Commence triple therapy
b ) Commence lansoprazole 30mg daily
c ) Cease bendroflumethiazide
d ) Commence gaviscon advance 8 tablets daily
e ) Cease amlodipine

Answer: E

NICE Guideline 17 outlines a stepwise approach to management. If there are no alarm signs, one should initially review suspect medication and address lifestyle precipitants before commencing antacids/PPIs or initiating investigations. Calcium antagonists can commonly cause dyspepsia.

3. 32-year-old male solicitor attends after experiencing two episodes of severe and debilitating headache in the last two days. On both occasions, he developed a rapid-onset, severe headache focused around his left eye, which became noticeably red and watery. Each time the headache lasted for one hour before resolving. He took no analgesia. He felt nauseated by the intensity of the pain, but experienced no visual disturbance or other neurological symptoms. He smokes 15 cigarettes a day and drinks 10 units of alcohol per week. He has no residual symptoms, and clinical examination is normal. Which one of the following treatments would be the licensed drug of choice to be taken at the onset of any subsequent attack?

a ) Dispersible Aspirin 900mg orally
b ) Ergotamine 2mg suppository per rectum
c ) Sumatriptan 6mg injection subcutaneously
d ) Verapamil 80mg tablet orally
e ) Zolmitriptan 5mg orodispersible tablet

Answer: C

This is classic Cluster Headache. It is five times commoner in males than females, and affects smokers more than non-smokers. Sumatriptan by s/c injection is the treatment of choice, and the only triptan licensed for this indication. Verapamil and ergotamine are recognised for prophylaxis only. Cluster Headache rarely responds to standard analgesia.

AKT Questions

2008-11-24T13:04:00.000-08:00

1. OPTIONS:

a ) Candidiasis
b ) Chlamydia
c ) Gonorrhoea
d ) HIV
e ) Herpes simplex
f ) Scabies
g ) Syphilis

INSTRUCTION: Genital infection presents in general practice in a variety of ways. Sexually transmitted infection can lead to significant morbidity and needs to be managed appropriately in primary care. For each of the following patients below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.

1 . A 31 year old woman attends with a history of a febrile illness for five days followed by development of severe pain in the vulval area. Examination reveals numerous small ulcers. There is bilateral inguinal lyphadenopathy. She has been in a stable monogamous relationship for two years.

The Correct answer is e.
2 . A 22 year old man presents with a painful right knee, sore eyes and dysuria after an episode of unprotected intercourse with a new partner two weeks previously.

The Correct answer is b.
3 . A 35 year old homosexual man presents with a non itchy maculopapular rash on the palms of his hands and the soles of his feet, three months after a holiday in Brighton.
The Correct answer is g.

Herpes simplex can occur months or years into a stable relationship. Sexually acquired reactive arthritis (SARA) should be thought of in a patient who ‘can’t see, can’t pee and can’t bend the knee’. Chlamydia is the cause in 70% of cases. Secondary Syphilis is the great mimicker, and presents in a variety of ways, at least four weeks after the infective episode. Commonly it presents as a non itchy maculopapular rash affecting the palms and soles.

2. A 67 year old woman, who had chemotherapy two years ago, has metastatic breast carcinoma. During the past three weeks, she has become increasingly weak, tired and thirsty. She has had some nausea, is constipated and has lost her appetite. She has generalised aches and pains and has been a little confused. Which single biochemical abnormality is most likely to be implicated?

a ) Hypercalcaemia
b ) Hypocalcaemia
c ) Hypokalaemia
d ) Hypermagnesaemia
e ) Hypomagnesaemia

Answer: A

Hypercalcaemia usually has a non-specific presentation and includes the symptoms described exhibited by the patient. About 40% of breast tumours are liable to result in this especially where there is bone spread. Hypocalcaemia and hypokalaemia are both associated with tetany and there is no direct link with malignancy. Hypomagnesaemia is occasionally associated with cisplatin chemotherapy. Hypermagnesaemia is a rare condition found in neonates – again with no malignant association.

3. A 36 year old woman presents in the middle of a surgery with an acute flare up of her asthma symptoms. She complains of feeling more breathless and wheezy. Which one of the following signs, on its own, would prompt you to have her admitted as an emergency to hospital?

a ) Peak flow is reduced to 60% of her usual
b ) Resting pulse rate is 100/min
c ) Pulse oximetry shows SpO2 to be 90%
d ) Respiratory rate is 20/min
e ) Wheeze present throughout both lung fields

Answer: C

Immediate hospital admission is necessary if signs of life threatening asthma are present – peak flow <33% of best/predicted, SpO2 <92%, silent chest, cyanosis, feeble respiratory effort, bradycardia, dysrhythmia, hypotension, exhaustion, confusion, coma.

4. A 30 year old woman complains of frequent headaches. She describes a unilateral, throbbing headache associated with photophobia and nausea which can last more than 24hrs. For the last three months, the headaches have occurred at least once a week. She has been taking paracetamol but this has not helped. She has asthma and uses salbutamol and belcometasone inhalers. She has no other significant past medical history. Examination is normal. She asks for medication to help prevent her headaches occurring. Which is the single most appropriate drug?

a ) Co-codamol
b ) Pizotifen
c ) Propranolol
d ) Rizatriptan
e ) Topiramate

Answer: B

Co-codamol and Rizatriptan are used in the treatment of acute migraine but not for prevention. Overuse of both of these can lead to an increase in headache frequency. Propranolol is contraindicated in asthma and Topiramate should only be prescribed under specialist supervision for migraine.

5. A 25 year old woman comes to see you complaining of having had a bad cough for six days. She is coughing up green phlegm. She has no chest pain. She smokes 20/day. On examination, she is apyrexial and her chest is clear. She has no significant past history and is not on regular medication. She has tried taking regular paracetamol but now thinks she needs an antibiotic to help “clear this up”. What is the single most appropriate initial way to manage this patient according to current guidelines?

a ) Organise a Chest X Ray
b ) Prescribe an antibiotic
c ) Prescribe codeine linctus
d ) Send a sputum sample for culture
e ) Treat conservatively

Answer: E

There is no evidence to suggest that the use of an antibiotic/cough bottle/sputum sample/CXR for non-pneumonic lower respiratory tract infections in previously well adults is useful.

AKT Questions

2008-10-14T06:12:00.000-07:00

1. OPTIONS:
a ) Colorectal carcinoma
b ) Endometrial carcinoma
c ) Liver carcinoma
d ) Oesophageal carcinoma
e ) Ovarian carcinoma
f ) Pancreatic carcinoma
g ) Small bowel carcinoma

INSTRUCTION: For each patient below, choose the most likely diagnosis from the list above. Each option may be used once, more than once or not at all.

1 . A 60 year old woman presents with a three month history of anorexia and epigastric discomfort. Over this time, she has lost 5kgs in weight. She is now experiencing some difficulty swallowing and has vomited after meals. On examination, the abdomen seems non tender and no masses are felt; weight loss is evident.
The Correct answer is d.

2 . A 60 year old woman presents with abdominal pain and distension. She has been vomiting. She tells you that, about eight weeks ago, her bowel had become much more loose and frequent. On examination, the whole abdomen is tender and distended, with no masses felt; bowel sounds are high pitched.
The Correct answer is a.

3 . A 60 year old woman presents with a six month history of non-specific abdominal pain and bloating. She was treated for irritable bowel with no improvement. On examination, the whole abdomen is tender, especially over the caecum, with no masses felt. Pelvic examination suggests a fullness in the right fornix.
The Correct answer is e.

The alarm signs associated with oesophageal and gastric cancer are dysphagia, anorexia, vomiting and weight loss.
Patients over 50 years with any of the following for more than 6 weeks should be referred urgently for investigation of colorectal cancer:
• Rectal bleeding with change in bowel habit
• Rectal bleeding without anal symptoms
• Palpable abdominal mass
• Intestinal obstruction Retrospective studies show that women with ovarian cancer present with non specific symptoms including abdominal pain and bloating, changes in bowel habit, urinary and/or pelvic symptoms. Many have been misdiagnosed as irritable bowel.

2. OPTIONS:
a ) Amoxicillin
b ) Beclometasone inhaler
c ) Ipratropium inhaler
d ) Montelukast
e ) Prednisolone
f ) Salbutamol inhaler
g ) Salmeterol inhaler

INSTRUCTION: For each of the following patients, choose the single most appropriate drug treatment from the above list. Each option may be used once, more than once or not at all.

1 . A six year old girl is brought to see you in the surgery. Mum has noticed that she has been coughing more over the last three months since a really bad cold. Some nights she disturbs other family members with her coughing. Examination is unremarkable. She keeps well otherwise and is on no other medication.
The Correct answer is f.

2 . A 67 year old man presents to the out of hours service with a two day history of increasing shortness of breath and cough. He is coughing up clear sputum but this is not new as he tells you he is a smoker. He has no other associated symptoms. He doesn’t feel his usual inhalers are helping but all he can tell you is that he has a blue one and a brown one. He is getting SOB getting washed and dressed but can still manage. He is apyrexial, pulse 88/min, respiratory rate 18/min, chest is wheezy.
The Correct answer is e.

3 . A 26 year old man, who has had asthma since childhood, has noticed he is more wheezy recently. Usually he would rarely use his reliever inhaler but in the last month he has used it 1-2 times a day. He also uses a beclometasone inhaler and has doubled the dose of this himself to a total of 800mcg a day but feels his symptoms have not improved much. He has no other significant past medical history. Examination is normal.
The Correct answer is g.

A trial of a bronchodilator can help confirm how likely a diagnosis of asthma is. He has non purulent sputum so an antibiotic is unnecessary but oral prednisolone is recommended for an acute flare up of breathlessness affecting activities of daily living. A trial of a long acting beta 2 agonist is recommended in adults if they have inadequate symptom control with inhaled steroids at doses between 200-800mcg/day (beclometasone).

3. In patients with a diagnosis of moderately severe Chronic Obstructive Airways Disease (COPD), which one of the following treatments has been shown in a systematic review to reduce mortality?
a ) Antibiot. ics in COPD exacerbations
b ) Cardioselective beta blockers for up to 12 weeks
c ) Carbocisteine for up to 12 weeks
d ) Inhaled steroids for at least two years
e ) Daily anticholinergic therapy for more than one month

answer: A

In COPD exacerbations, with increased cough and sputum purulence, antibiotics, regardless of choice, reduce the risk of short-term mortality by 77%. Therefore their use is supported in those who are moderately to severely ill.

4. OPTIONS:
a ) Acute rotator cuff tear
b ) Adhesive capsulitis
c ) Cervical spondylosis
d ) Gout
e ) Herpes zoster
f ) Pneumothorax
g ) Polymyalgia rheumatica
INSTRUCTION: For each patient below with shoulder pain, select the single most likely diagnosis above. Each option may be used once, more than once or not at all.

1 . A 63 year old woman has a one week history of pain in the left shoulder in a C4 distribution It is unpleasant and burning in character, and unrelated to exertion. She has a full range of neck and shoulder movement.
The Correct answer is e.

2 . A 70 year old woman has a two week history of pain and stiffness in both shoulders, occurring during the night, and easing off somewhat an hour after getting up. She has found that Ibuprofen helps.
The Correct answer is g.

3 . A 35 year old man suddenly develops left shoulder pain, worse on inspiration, after a fit of coughing several days ago. He has an excellent range of shoulder movement.
The Correct answer is f.

5. OPTIONS:
a ) Dermovate ointment
b ) Emollient
c ) Hydrocortisone cream
d ) Oral antibiotic
e ) Potassium permanganate wet wraps
f ) Oral antifungal
g ) Topical tar based product

INSTRUCTION: For each scenario below, choose the single most appropriate treatment from the above options. Each option can be used once, more than once or not at all.

1 . An infant of six months is brought to you with a severe nappy rash. Having consulted the health visitor, mum has tried an antifungal cream, with no effect. You note that the rash spares the skin flexures.
The Correct answer is c.

2 . A 53 year old smoker attends with intensely itchy hands. Examination reveals pustular lesions on the palms of the hands and the soles of the feet. You think this is palmoplantar pustulosis.
The Correct answer is a.

3 . A one year old child presents with an exudative, weeping eczema.
The Correct answer is e.

6. A 65 year old man presents with a three month history of dyspnoea and ankle oedema. On examination, he has a regular pulse of 108/minute, BP 140/90 and bilateral basal crepitations. Which one of the following tests would aid your decision in referring for echocardiography?

a ) Brain natriuretic peptide (BNP)
b ) Cholesterol (Cho)
c ) Creatinine Kinase (CK)
d ) Lactose Dehydrogenase (LDH)
e ) Troponins T and I

answer: A

Brain natriuretic peptide or NT pro- BNP and/or ECG should be recorded to indicate the need for echocardiography in patients with suspected CHF. There are local variations in the availability of BNP testing.

7. A 73 year old man attends with poor urinary stream, urinary hesitancy and nocturia. He was assessed by urology and the diagnosis was made of benign prostatic hypertrophy. You decide to start finasteride. Which one of the following is a known side-effect of this drug?

a ) Baldness
b ) Ejaculation disorders
c ) Increased libido
d ) Increased PSA level
e ) Priapism

answer: B

Anti-androgens, such as Finasteride, cause ejaculation disorders and reduce libido. A low strength of Finasteride is used to treat male-pattern baldness. Anti-androgens reduce the level of prostate cancer markers.

8. A 48 year old woman presents with a 24 hour history of a painful red eye, lacrimation, photophobia and blurred vision. Her visual acuity is 6/18 in the affected eye, and 6/6 in the other. Fluorescein shows a central patch of irregular uptake of stain. Which one of the following is the most likely diagnosis?
a ) Acute iritis
b ) Bacterial conjunctivitis
c ) Blepharitis
d ) Dendritic corneal ulcer
e ) Episcleritis

Answer: D

Dendritic ulcer is caused by herpes simplex virus, requires treatment with acyclovir 3% eye ointment, and should be referred immediately for ophthalmological assessment. Use of steroid drops can result in massive ulceration and blindness.

AKT Questions

2008-10-05T10:30:00.000-07:00

1. A taxi driver re-attends your surgery. A urine sample taken one week before shows a positive test for metabolites of morphine verifying his story of drug misuse. He would like to go on to Buprenorphine (Subutex) as he hopes to detoxify quickly after a period of stabilisation. You agree. What is the single most common side effect of this regime?

a ) Respiratory depression
b ) Drowsiness
c ) Abdominal Pain
d ) Acute opiate withdrawal
e ) Depression

Answer: D

In patients taking a high level of opiates, Buprenorphine may precipitate withdrawal effects due to its partial antagonist activity on mu opioid receptors. It is for this reason that it is very safe in overdose, rarely causing typical opioid symptoms such as respiratory depression, drowsiness or abdominal pain and vomiting. These symptoms are more typically seen with Methadone, Lofexidine and Naltrexone respectively. Buprenorphine may however be implicated in respiratory depression if combined with alcohol or benzodiazepines.

2. A 23 year old man presents with a five day history of right lower lumbar pain with no obvious trigger factor, no radiation and no other symptoms. On examination, you find right lower lumbar paraspinal tenderness and reduced lumbar movements. Which is the single best evidence-based management plan?

a ) Acupuncture
b ) Staying active
c ) Back exercises
d ) Epidural injection
e ) Lumbar support

Answer: B

"Clinical Evidence" indicates that, for acute low back pain, advice to stay active and non steroidal anti inflammatory drugs are beneficial. Back exercises are unlikely to be beneficial and acupuncture, epidural steroid injection and lumbar support are of unknown effectiveness.

3. A woman has terminal pancreatic cancer and is on a syringe driver containing diamorphine in water. Her pain is very well controlled; but she has distressing respiratory secretions and is also very restless. Which two of the following could best be added to her syringe driver to control these symptoms?

a ) Cyclizine
b ) Dexamethasone
c ) Hyoscine hydrobromide
d ) Levomepromazine
e ) Metoclopramide
f ) Prochlorperazine

Answer: C & D

Hyoscine is very effective at controlling secretions in its hydrobromide form, whereas in its butylbromide form it is valuable for relief of bowel colic. It has some sedative effects but these would probably not be sufficient to control the woman’s restlessness. Levomepromazine would be ideal for this. Cyclizine and metoclopramide are useful anti emetics but cyclizine is particularly liable to precipitate with diamorphine. Dexamethasone can be given in a syringe driver to reduce cerebral oedema

4. A 49 year old man presents with a five week history of epigastric pain after meals. It is sometimes awakening him in the night. He has also been vomiting and is sure he has lost weight. On examination, you find epigastric tenderness, with no mass nor peritonism. An FBC is normal. Which is the single most appropriate investigation?

a ) Abdominal ultrasound
b ) Barium meal
c ) Serum amylase estimation
d ) Helicobacter pylori test
e ) Upper GI endoscopy

Answer: E

SIGN and NICE both recommend upper gastrointestinal endoscopy as the investigation of choice in dyspepsia with alarm symptoms (persistent vomiting, anorexia, weight loss, gastrointestinal blood loss or epigastric mass).

5. A 45 year old woman presents with tiredness, lethargy, dry skin constipation and weight gain. Of the following, which is the single most likely additional clinical feature that may be present?

a ) Carpal tunnel syndrome
b ) Proptosis
c ) Amenorrhoea
d ) Pre-tibial myxoedema
e ) Delirium

Answer: A

In Hypothyroidism mucopolysaccharide deposition can occur throughout the body affecting all organ systems. Pre-tibial myxoedema (swellings above the lateral malleoli) occurs in Graves Disease (overactive thyroid). Altered mental state can occur with depression and dementia and rarely myxoedematous coma. Other autoimmune diseases such as pernicious anaemia can be associated with hypothyroidism. Iron and folate deficiencies can occur with microcytic anaemias and macrocytosis.

AKT Psychiatry

2008-10-03T06:12:00.000-07:00

1. A 33-year-old man comes for review of his depression. He has now been taking citalopram for 12 weeks with minimal effect on his symptoms. It is decided to switch him to venlafaxine. How should this be done?

A. 2 week period of overlapping the drugs
B. Withdraw citalopram with the commencement of venlafaxine once citalopram has been stopped
C. Wait 1 week after withdrawing citalopram before commencing venlafaxine
D. Wait 2 weeks after withdrawing citalopram before commencing venlafaxine
E. 1 week period of overlapping the drugs

Answer: B

The following is based on the Clinical Knowledge Summaries depression guidelinesSwitching from one SSRI to another SSRI
the first SSRI should be withdrawn before the second is started
if switching from fluoxetine then leave a gap of 4-7 days as it has a long half-life
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- exceptions include fluoxetine (should be withdrawn prior to TCAs being started) and clomipramine (should not be given with a SSRI)Switching from a SSRI to venlafaxine
withdraw the SSRI
start venlafaxine the next day (unless fluoxetine - wait 4-7 days as above)

2. A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?

A. Hyperarousal
B. Emotional numbing
C. Nightmares
D. Loss of inhibitions
E. Avoidance

Answer: D

Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example a major disaster or childhood sexual abuse. It encompasses what became known as 'shell shock' following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one monthFeatures
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing lack of ability to experience feelings, feeling detached
from other people
depression
drug or alcohol misuse
anger
unexplained physical symptoms
Management
following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
watchful waiting may be used for mild symptoms lasting less than 4 weeks
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended

3. A 24-year-old male is admitted to the Emergency Department complaining of severe abdominal pain. On examination he is shivering and rolling around the trolley. He has previously been investigated for abdominal pain and no cause has been found. He states that unless he is given morphine for the pain he will kill himself. This is an example of:

A. Hypochondrial disorder
B. Conversion disorder
C. Malingering
D. Munchausen's syndrome
E. Somatisation disorder

Answr: C

Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Conversion disorder
typically involve loss of motor or sensory function
some patients may experience secondary gain from loss of function
patients may be indifferent to their apparent disorder
Dissociative disorder
dissociation is a process of 'separating off' certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Munchausen's syndrome
also known as factitious disorder
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

4. Which one of the following statements regarding cognitive behavioural therapy is incorrect?

A. May be useful in the management of generalised anxiety disorder
B. Can be used for patients already taking antidepressants
C. Usually consists of one to two hour sessions once per week
D. Should be completed within 4 months
E. Patients usually get around 35-40 hours in total

Answer: E

Main points
useful in the management of depression and anxiety disorders
usually consists of one to two hour sessions once per week
should be completed within 4 months
patients usually get around 16-20 hours in total

5. Which one of the following is not a first-rank symptom of schizophrenia?

A. Thought broadcasting
B. Visual hallucinations
C. Thought withdrawal
D. Delusional perceptions
E. Auditory hallucinations

Schneider's first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient's behaviour
Thought disorder*:
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.
Other features of schizophrenia include
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
*occasionally referred to as thought alienation

AKT Questions

2008-10-02T23:30:00.000-07:00

1. Arrythmias: Concerning the above ECG and the list of available options.

a. Atrial Flutter
b. Ventricular Fibrillation
c. Premature Atrial Complex
d. 2nd Degree AV Block
e. Complete Heart Block
f. Mobitz type I
What abnormal rhythm is represented by the ECQ tracing above?

Answer: D

This is 2nd degree AV block (Mobitz II). It is almost always a disease of the distal conduction system. It is characterised by intermittently nonconducted P waves not preceded by PR prolongation and not followed by PR shortening. It is important as it may progress to Complete Heart Block

2. Depression: The NICE guidelines 2006 recommend one particular package of computerised Cognitive Behavioural Therapy (CBT) for the treatment of depression. Which package is this?

A.Beating the Blues
B. COPE
C. FearFighter
D. OCFighter
E. Overcoming Depression

Answer: A

NICE has made the following recommendations about the use of computerised cognitive behavioural therapy (CCBT) to treat depression and anxiety. It recommends using: 1. Beating the Blues for people with mild and moderate depression. 2. FearFighter for people with panic and phobia.

3. Pelvic Inflammatory Disease: Which ONE of the following is the most common causative organism implicated in Pelvic Inflammatory Disease (PID) in the UK?

A. Candida Albicans
B. Chlamydia trachomatis
C. Human Papilloma Virus
D. Mycoplasma genitalium
E Neisseria gonorrhoeae

Answer: B

The most common organism to cause PID in the UK is Chlamydia trachomatis (in at least 50%). Gonorrhoea (Neisseria gonorrhoea) is also a fairly common cause. Both may occur together, but in at least 20% of patients with PID no definite cause is found.

4. Whooping Cough: Which ONE of the following most closely matches the incubation period for Whooping Cough?

A. 0 - 5 days
B. 15 - 30 days
C. 5 - 15 days
D. > 30 days
E. none of the above

Answer: C

The incubation period of whooping cough (bordetella pertusis) - the time between contracting the infection and the appearance of the main symptoms - can vary from 5 to 15 days or even longer (as long as 20 days).

5. Intracranial Malignancy: A 57 year old gentleman well know to you presents to your clinic complaining of increasing headaches. He has an inoperable end-stage primary glioblastoma with raised intracranial pressure. What would you prescribe to help with his pain?

A. Amitryptilline
B. Dexamethasone
C. Paracetamol
D. Tramadol
E. Voltarol

Answer: B

In a palliative care setting such as this, short courses of high dose corticosteroids are often effective in reducing the oedema and raised intracranial pressure of brain malignancies.

6. Identification Of Heart Sounds: In which ONE of the following pathologies might you hear an opening snap after the second heart sound?

A. Aortic Regurgitation
B. Aortic Regurgitation
C. Aortic Stenosis
D. Mitral Stenosis
E. Patent Foramen Ovale

Answer: D

In Mitral Stenosis, an opening snap, which is an additional high pitched sound, may be heard after the A2 (aortic) component of the second heart sound. In individuals with mitral stenosis the pressure in the left ventricle can drop rapidly leading to forceful opening of the valve and hence the opening snap.

7. Osteoporosis: Which ONE of the following is NOT a risk factor for the development of osteoporosis?

A. Below Average BMI
B. Coeliac Disease
C. Female sex
D. High dietary salt intake
E. Hyperthyroidism

Answer: D

Whilst the WHO recognises limiting salt intake as part of a 'healthy lifestyle' and together with a number of other measures in attempting to delay or prevent the development of Osteoporosis, there is no definitve evidence that salt is a risk factor for Osteoporosis. Na-induced calciuria has been well documented and provides a physiological basis for the proposed role of dietary Na (or salt) as a risk factor for osteoporosis. However, the evidence is based primarily on acute salt-loading studies, and there are insufficient data on the effects of high salt intake on net Ca retention to predict long-term effects on bone health. Whilst a randomized longitudinal study of different sodium intake in two groups could clarify the role of sodium in bone mass, research to date has failed to confirm high dietary salt intake as a risk factor in the development of osteoporosis.

8. Breast Pathology: For each of the following scenarios select the most likely diagnosis.

a. Ductal carcinoma in-situ
b. Fibroadenoma
c. Benign mammary dysplasia
d. Phyllodes tumour
e. Duct ectasia
f. Fat necrosis
g. Carcinoma of the breast
h. Paget's disease of the nipple

1. A 42 year old woman presents with a firm palpable mass in her left breast. She has noticed the size has increased rapidly over the past 3 months and she has become concerned. There is no involvemnt or discharge from the nipple. Some tenderness over the left breast is noted with shiny, almost translucent skin, and the size is estimated at 5x8x10 cm.
Answer: D

Phyllodes tumours are rare, predominantly benign (around 90%), tumours that account for only about 1% of tumours of the breast. It is typically moveable with a smooth texture and relatively large in size (around 5cm). It is interesting to note it tends to involve the left breast more commonly than the right.

2. A 52 year old woman presents with a tender small but firm lump in her left breast. There is evidence of recent injury with overlying bruising and tenderness. Coarse calcification is noted on mammography and fat globules on excision biopsy.
Answer: E

3. A 57 year old lady with known intraductal breast carcinoma presents following left mastectomy with discharge of the nipple on that side accompanied by itching and flaking.
Answer: H

The incidence of Paget's diseae of the breast is around 4% of cases of female breast cancer. This syndrome presents as eczematoid skin changes such as redness and mild flaking of the nipple skin. As Paget's advances, symptoms may include tingling, itching, increased sensitivity, burning, and pain. There may also be discharge from the nipple. Most cases are associated with invasive breast cancer and some cases occur following mastectomy (as in this scenario) even if there is no breast tissue present. You should also note that it may also involve the aereolar skin in addition to the nipple.

9. Pathogenic Organisms: For each of the following clinical infections select the MOST LIKELY pathogenic organism from the list of available options.

a. Mycoplasma Pneumoniae
b. Haemophilus Influenzae
c. Staphylococcus Aureus
d. Bacteroides Fragilis
e. Polymicrobial
f. Escherichia Coli

1. A 23 year old woman with Crohn's disease and an associated perirectal abscess.
Answer: E
2. A 45 year old smoker with Community Acquired pneumonia
Answer:B
3. A 60 year old male with a Urinary Tract Infection.
Answer: F
4. A 68 year old gentleman with Bacterial Endocarditis
Answer: C

A variety of risk factors are associated with abcess development, these include Crohn's disease, radiation fibrosis, carcinoma and trauma. A perirectal abscess is usually an aerobic and anaerobic polymicrobial infection. Bacteroides Fragilis is the predominant anaerobe and other common bacteria include Escherichia Coli, Proteus, Bacteroides and Streptococcus. This is not to be confused with a perianal abscess which is easily palpable, not accompanied by fever or a raised white cell count unless concomitant with an immunosupressed state.
The most likely pathogen in community acquired pneumonia is streptococcus pneumoniae, however it is not offered as an option - haemophilus influenzae being the next most likely pathogen and therefore the correct choice. You should always remember that up to 13% of community acquired pneuomnia is viral in origin.
As with females, the usual route of inoculation in males is with gram-negative aerobic bacilli from the gut, with Escherichia coli being the most common offending organism. In males aged 3 months to 50 years. The incidence of UTI in men approaches that of women only in men older than 60 years.
Most cases of endocarditis are caused by a select group of organisms. Gram-positive bacteria, particularly alpha-haemolytic streptococci, staphylococcus aureus and coagualse-negative staphylococci are the most common. Enterococci are a rare cause but are often resistant to antibitotic treatment. Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella species (HACEK organisms) are particularly common in neonates and immunocompromised children. A patient may have typical clinical and/or echocardiographical findings of endocarditis but have persistently negative blood cultures. In this instance there may have been recent antibiotic therapy or infection with a fastidious organism.

10. Raynaud's Phenomenon: The most common cause of Raynaud's Phenomenon is?

A. Idiopathic
B. Rheumatoid arthritis
C. Scleroderma
D. Systemic Lupus Erythematosus
E. Through the use of vibrating tools or machinery

Answer: A

90% of cases of Raynaud's phenomenon are idiopathic.

AKT Questions

2008-10-02T23:10:00.000-07:00

1. William is 7 years old. He has taken Sodium Valproate for control of absence seizures since diagnosed at the age of 4 years. He has had no known seizures in the past year, and is otherwise well and coping with school socially and academically. At what point should you consider withdrawing Sodium Valproate?

a ) If he has less than three fits per year.
b ) If he has no nocturnal fits for two years.
c ) When he reaches puberty.
d ) If he remains fit-free for a further year.
e ) When he is considering taking driving

Answer: D

2. A 62 year old man falls down the stairs and sustains a hip fracture. A DEXA scan confirms osteoporosis (Femoral neck T <2.5).>

a ) Alendronate
b ) Alendronate + Calcium + Vitamin D
c ) Calcium + Vitamin D
d ) Raloxiphene + Calcium+Vitamin D
e ) Raloxiphene

Answer: B

Grade A evidence exists for the use of Alendronate, Calcium and vitamin D in the treatment of osteoporosis. Primary or idiopathic osteoporosis is much more common than secondary osteoporosis, and has its onset in the 7th or 8th decade. Secondary osteoporosis should be considered and investigated in younger age groups. An holistic approach should be taken to prevention of falls in the elderly, and before considering pharmacoprophylaxis, it is important to remember alcohol abuse, smoking, and immobility as contributors to osteoporosis.

3. A 22 year old woman presents complaining of diffuse muscle and deep bone pain. She says she is sweating profusely. This has come on suddenly. Observing her, she is yawning constantly and is tremulous and agitated. Her pupils are dilated. She is apyrexial. Her chest is clear. She has a tachycardia. Abdominal examination is normal. Surgery urinalysis is negative. She does not smell of alcohol. She denies any drug misuse. What is the single most likely diagnosis?

a ) Diabetic ketoacidosis
b ) Pelvic inflammatory disease
c ) Urinary tract infection
d ) Hyperthyroidism
e ) Acute opiate withdrawal

Answer: E

Although these are all features of a heightened adrenergic reaction – deep bone pain and yawning are typical of opiate withdrawal. Other symptoms of withdrawal can include dilated pupils, diarrhoea, goose bumps, sweating, agitation and tremor.

AKT Questions

2008-10-02T22:55:00.000-07:00

1. A 52 year old woman presents with unpleasant tingling in the right thumb, forefinger and middle finger. The sensation wakens her at night. She finds that shaking her wrist gives some relief. On examination, there is thenar eminence wasting. Her symptoms are reproduced by tapping on the volar aspect of her wrist. Which single treatment is likely to be beneficial?

a ) Oral loop diuretic
b ) Oral non steroidal anti-inflammatory
c ) Steroid injection into the wrist
d ) Topical non steroidal anti-inflammatory
e ) Oral pyridoxine

Answer: C

Clinical Evidence" reports that, for carpal tunnel syndrome, steroid injection and systemic corticosteroid therapy are likely to be beneficial. Non-steroidal anti-inflammatories and pyridoxine are of unknown effectiveness and diuretics are unlikely to be beneficial.

2. A 25 year old man attends with a history of constant itch and mild discomfort in his left ear. Examination reveals an erythematous rash of the ear canal. He also has a large, chronic tympanic membrane perforation. Which single treatment should be avoided in this case?

a ) Clotrimazole ear drops
b ) Flumetasone and clioquinol ear drops
c ) Hydrocortisone and gentamicin ear drops
d ) Aluminium acetate ear drops
e ) Prednisolone ear drops

Answer: C

Otitis externa causes itch and discomfort. A precipitant should be sought, e.g. swimming, skin conditions etc. Treatment of the inflammation is by topical corticosteroids. If bacterial infection is suspected, corticosteroid drops containing antibiotics may be used. However, those containing aminoglycosides are contraindicated in chronic tympanic perforation (due to risk of absorption and ototoxicity) unless initiated by a specialist.

3. A 36 year-old female hairdresser attends complaining of an intensely itchy rash affecting her wrists and hands. This has developed over the last seven days. On examination, there is a symmetrical eruption of small (less than 5mm), discrete, flat-topped, violet-coloured papules affecting the palmar surface of both wrists. There are also some small translucent papules on the palms themselves. Closer inspection of the surface of the lesions on the wrists reveals some whitish lines. On direct questioning, she admits that she has felt some discomfort in her mouth when eating for the last couple of days. On inspection of the buccal mucosa, you notice some faint, lacy, white lines and a few shallow erosions. Which is the single most likely diagnosis?

a ) Atopic eczema
b ) Hand, Foot and Mouth Disease
c ) Irritant Contact Dermatitis
d ) Lichen Planus
e ) Pompholyx

Answer: D

Lichen planus (LP) is an intensely itchy eruption of essentially unknown aetiology which is commonest between the ages of 20-50 years. The white lines are known as Wickham's Striae, and although not always seen, are good indicators of LP. If palms and soles are involved, the classic 'violaceous' colour is lost, and the lesions are translucent. Most cases resolve spontaneously within 12 months. Treatment is with high potency steroids, or occasionally oral steroids.

AKT Questions

2008-10-02T22:23:00.000-07:00

1. A 60 year old Caucasian woman, not normally prone to headaches, describes the gradual onset of worsening pain over the left side of her head, during the last five days. It is jabbing in nature and is aggravated by combing her hair. She has also noticed pain in the jaw when eating or talking. She has no rash. What is the single most likely diagnosis?

a ) Acute closed-angle glaucoma
b ) Migraine
c ) Retinal artery occlusion
d ) Temporal arteritis
e ) Trigeminal neuralgia

Answer: D

Temporal arteritis is 4-6 times more common in women than in men. It affects mainly those over the age of 50 – increasing with age. Jaw claudication occurs in approximately 65% of patients with temporal arteritis. Prompt treatment with oral steroids is required as more than 50% of untreated patients will get visual loss.

2. A patient presents to you in the surgery with several articles about his condition which he has taken from the internet. He wishes your opinion about the scientific robustness of these studies. You agree to read them in your spare time and report back to him. Which one of the following methods would you weight most highly in basing your opinion?

a ) Case control study
b ) Cohort study
c ) Expert opinion
d ) Meta-analysis
e ) Randomised control study

Answer: D

Meta-analysis is the systematic review of Randomised Control Trials. This is the highest level of evidence.

Levels of Evidence

Level
1++
High quality meta analysis, systemic review of RCTs, or RCTs with a very low risk of bias
1+
Well conducted meta analysis, systemic review of RCTs, or RCTs with a low risk of bias
1-
Meta analysis, systemic reviews of RCTs, or RCTs with a high risk of bias
2++
High quality systemic reviews of case-control or cohort studies.

High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is casual.
2+
Well conducted case control or cohort study with a low risk of confounding, bias, or chance and a moderate probability that the relationship is casual.
2-
Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not casual.
3
Non-analytical studies, e.g. case report, case series
4
Expert opinion

Grades Of Recommendation

Grade
A
At least one meta analysis, systemic review, or RCT rated as 1++, and directly applicable to the target population: or

A systemic review of RCTs or a body of evidence consisting principally of studies rated as 1+ , directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+
C
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or

Extrapolation of evidence from studies rated as 2+

3. OPTIONS:
a ) Adrenal Carcinoma
b ) Colonic Carcinoma
c ) Gastric Carcinoma
d ) Hodgkin’s Lymphoma
e ) Pancreatic Carcinoma
f ) Prostatic Carcinoma
g ) TesticularTeratoma
INSTRUCTION: For each of the patients below, choose the most likely underlying diagnosis from the list above. All are malignant diseases which may metastasise. Each option may be used once, more than once or not at all.

1 . A 72 year old man presents with fatigue and weight loss. There is no dysphagia nor post prandial fullness. His appetite has been poorer and bowel motions have become more frequent and loose. Abdominal examination reveals no masses. There is some tenderness in his RIF. Hb. is 9.2g/l and serum ferritin 15. Faecal Occult Blood test is positive.
The Correct answer is b.

2 . A 66 year old man presents with reduced appetite and weight loss over a three month period. He has felt nauseated with a feeling of epigastric fullness .There is no dysphagia. He has had no abdominal pain. He has noticed that his urine is dark and bowel motions are pale. On examination, he appears icteric. His abdomen reveals no masses; there is slight discomfort in the epigasrium.
The Correct answer is e.

3 . A 47 year old man relates that for the last two months he has experienced right sided abdominal and back pain. He is eating normally and has noted no weight loss. His bowels may be a little looser. He feels profoundly weak. He sweats a lot. On examination, there are no abdominal masses; there is tenderness in the right flank. He has quite marked acne vulgaris. BP 170/106. Urinalysis is negative. Hb is 14.2g/l. U & Es show hypokalaemia and hypernatraemia.
The Correct answer is a.

The symptoms of cancer of the colon differ according to the part of the colon affected and the type of tumour, but pain is common to all types. Unexplained weakness and anaemia are characteristic of right colonic carcinoma whilst a change in bowel habit feature in left colonic carcinoma. In Pancreatic carcinoma the classic symptoms are - weight loss, abdominal pain, loss of appetite, jaundice, nausea and vomiting, weakness, fatigue, diarrheoa, indigestion, back pain, clay-colored stools. Adrenocortical carcinomas are typically bulky, greater that 1.5 cm in diameter and invade locally with early spread to the liver, regional lymph nodes and the lungs. Half the tumours are physiologically active with hypercortisolism and/or excessive androgen production.

4. A 37 year old man presents thinking he may have caught Chlamydia through sexual contact with his partner. You agree to test him for infection. Which is the single most appropriate sample to send to the laboratory?

a ) A first void urine sample
b ) A midstream urine sample
c ) An early morning urine sample
d ) A semen sample
e ) A twenty four hour urine sample

Answer: A

SIGN no.42 on Management of Genital Chlamydia trachomatis infection states that the sample of choice for men or women is first void urine. The main alternative in women is an endocervical swab. A urethral swab in men is no more sensitive than first void urine and causes discomfort. The recommended test is a nucleic acid amplification test in which a ligase chain reaction or polymerase chain reaction amplifies the DNA. This test has almost 100% sensitivity, compared with 60-80% for antigen detection.

5. OPTIONS:
a ) Cardiac arrhythmia
b ) Parkinson’s disease
c ) Epilepsy
d ) Intermittent delirium
e ) Myopathy
f ) Meniere’s disease
g ) Transient ischaemic attack
INSTRUCTION: Each of the following patients has had an unwitnessed fall in the past week. Choose the single most likely cause from the above list. Each option can be used once, more than once or not at all.

1 . An 83 year old woman, on long term treatment for temporal arteritis, says she got no warning of the fall and just collapsed. She did not lose consciousness. When seen, her HR was 80/min and regular. BP 150/90 sitting and 148/88 standing. Her limbs showed poor musculature and strength -especially her thighs.
The Correct answer is e.

2 . An 80 year old man has suffered from hypertension for many years. He takes Aspirin. Perindopril and Atorvastatin. He says he felt slightly dizzy at the time of the fall. He also says that recently he has been walking much more slowly and has tripped on a number of occasions. He did not lose consciousness. On examination, his HR was 68/min. BP 120/78 sitting and 100/60 standing. His limbs showed no weakness but appeared very rigid.
The Correct answer is b.

3 . An 85 year-old woman has had hypertension for 20 years. She takes Enalapril and Simvastatin. Her husband thought she seemed confused immediately after the fall but her speech was difficult to make out. She was back to normal within an hour. On examination, HR 88/m and regular. BP160/100 sitting and 160/96 standing. Her limbs showed normal power.
The Correct answer is g.

Falls are usually multifactorial, and are caused by a combination of environmental factors and factors intrinsic to the patient. Long – term steroids can cause significant muscle wasting. Previously undiagnosed Parkinson’s Disease should be kept in line as a cause of an unexplained falls.

AKT Questions

2008-10-02T21:11:00.000-07:00

1. You are visiting a 73 year old woman who has been living with her son for the last three months, following frequent falls in her own home and then a subsequent diagnosis of vascular dementia. He is worried as he thinks his mum has been getting more forgetful, irritable and argumentative especially over the last 6-8 weeks. He asks if medication might help settle her. He says she forgets to change her clothes some days and says she has eaten when she hasn't. When asked about this, she becomes abusive, agitated and shouts at her son. She states that she wishes to return home as she misses her privacy and her friends, before breaking down in tears. She has no additional relevant past medical history or medication. Which one of the following drugs would treat this patient most appropriately?

a ) Amitriptyline
b ) Diazepam
c ) Donepezil
d ) Citalopram
e ) Risperidone

Answer: D

Vascular dementia is the second commonest dementia affecting older people. It is important to remember that those with dementia may also develop depression. Depression in older people can often cause forgetfulness along with a change in mood –and should be considered in this case. Adapting to life changes and having to accept a loss of independence because of ill health can be triggers for depression. An SSRI is preferred to a tricyclic due to the latter's increased side effect profile. Benzodiazepines should be avoided when possible in the elderly due to the risk of ataxia and falls. Donepezil is indicated for use in Alzheimer's disease but not vascular dementia. Risperidone should be avoided in the elderly due to the increased risk of cerebrovascular disease.

2. Baby Josh was born at 32 weeks gestation and has made good progress. He is now six months old and presents with a 24 hour history of clear nasal discharge and a wheezy cough. On examination, his temperature is 37oC. He is grunting with nasal flaring. Auscultation of his chest reveals bilateral fine inspiratory crackles. Which single management option is most appropriate?

a ) High flow rate oxygen
b ) Nebulised budesonide
c ) Nebulised ipratropium
d ) Nebulised ribavirin
e ) Nebulised salbutamol

Answer: A

Expert consensus suggests that nasal flaring and grunting is one of several indications for acute paediatric referral of babies with bronchiolitis. The need for high flow oxygen implies that admission is required. There is evidence that prematurity is a risk factor for severe disease.

3. You are asked to visit a 36 yr old man who lives in residential care and is significantly learning disabled. Over the last four days, the staff reported that he has gradually been getting more agitated and restless. He has been shouting out and hasn't been eating as much as usual. The staff are not sure when his bowels last moved but his pads have been wet as usual and there is no foul smell from his urine. He is totally unable to give a history himself. Examination is difficult as he is shouting and won't remain still. He is apyrexial, his chest is clear and, although his abdomen is soft, you think he might be tender there. He has cerebral palsy but no other significant history. His medication history is not significant. Which of the following would be the single best treatment to prescribe?

a ) Amoxicillin
b ) Diazepam
c ) Haloperidol
d ) Mebeverine
e ) Movicol

Answer: E

Common conditions, like constipation, can present atypically, often with a change in behaviour, in patients with learning disabilities due to difficulties with communication. One should avoid rushing in with psychotropic medication.

4. You receive a chest x-ray report for a 62 year old woman who has had a recent chest infection. Although there is no abnormality of the cardio-respiratory system, the film is reported as showing "severe osteopenia of the thoracic spine". The woman became menopausal at age 48, smoked until her early 60's and has a body mass index of 27. There is no other past medical or family history of relevance. In confirming or excluding a diagnosis of osteoporosis, what is the single most appropriate investigation?

a ) Dual-Energy X-ray Absorptiometry (DEXA) scan of AP spine and hip
b ) Plain x-ray of lateral spine and proximal femur
c ) Quantitative ultrasound (QUS)of heel
d ) Quantitative computed tomography(QCT) of spine
e ) Markers of bone turnover (calcium, phosphate , alkaline phosphatase)

Answer: A

Assessment of bone density from plain radiographs is not accurate, and, although severe osteopenia on plain films correlates reasonably with low bone mineral density (BMD) measured by DEXA, there is a wide overlap. There is evidence that QUS of the heel can predict fractures of the hip and spine independently of BMD. However, QUS results are difficult to extrapolate from one instrument to another. QCT has been reliably used to measure BMD, especially of the spine. It does, however, deliver high doses of radiation and the scanners are costly. Biochemical markers of bone turnover have no role in the diagnosis of osteoporosis, or in the selection of patients for BMD measurement. Treatment should not be instituted on the basis of plain film findings alone. When plain films are interpreted as ''severe osteopenia'' it is appropriate to suggest referral for DEXA. BMD should normally be measured by DEXA scanning performed on two sites, preferably anteroposterior spine and hip.

5. OPTIONS:
a ) Acute asthma
b ) Epiglottitis
c ) Laryngomalacia
d ) Pertussis
e ) Post viral wheeze
f ) RSV bronchiolitis
g ) Viral laryngotracheobronchitis (croup)
INSTRUCTION: For each child below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.

1 . An 18 month-old boy who has been coryzal, with mild pyrexia on and off for the preceding 36 hours, is brought to the emergency morning surgery. Overnight he has developed noisy inspiration and hoarseness, both of which are most dramatic when crying, but which settle easily at rest. You note a barking, 'sea lion' cough. Chest examination reveals only transmitted upper airways sounds.
The Correct answer is g.

2 . A five month-old boy has been coryzal and sneezy for a day or two. He now has a dry cough and increasing breathlessness which is limiting his feeding. On examination, he is tachycardic and tachypnoeic, with nasal flaring. Chest examination reveals intercostal recession and widespread wheeze, but no focal signs or crepitations.
The Correct answer is f.

3 . A 10 year-old girl has had a persistent, spasmodic cough since developing a 'cold' four weeks earlier. She has vigorous bouts of violent coughing which are worse at night, and which make her face 'go blue', or in some cases, makes her vomit. Her breathing seems normal in between bouts of coughing. Chest examination is essentially normal.
The Correct answer is d.

The peak incidence of croup is in the second year of life, and most cases are safely managed at home. The harsh stridor and barking cough are typical features. Respiratory syncitial virus (RSV) bronchiolitis is the most common lower respiratory tract infection of infancy. Those under six months are most at risk of respiratory failure. The child in this scenario should be admitted for supportive treatment. Immunisation reduces the risk of, but does not fully prevent, pertussis (whooping cough) in all cases. Not all cases have the classic inspiratory "whoop", and symptoms can persist for a number of months after the initial coryzal illness.

6. A 55 year old man has problems with impotence. In the treatment of erectile dysfunction, which one of the following has clear evidence of effectiveness?

a ) Ginseng
b ) Papaverine
c ) Tadalafil
d ) Vacuum devices
e ) Yohimbine

Answer: C

ED has many causes and all of the above options have been used in its treatment. However, of the options presented, only PDEIs such as tadalafil have clear evidence of effectiveness for the treatment of ED.

7. A 45 year old woman had her last cervical smear ten years ago. Her recent cervical smear, taken two weeks ago, has been reported as showing moderate dyskaryosis consistent with CIN 2. Which is the single most appropriate course of action?

a ) Repeat smear immediately
b ) Arrange routine colposcopy
c ) Repeat smear in three years
d ) Repeat smear in six months
e ) Arrange urgent colposcopy

Answer: B

Moderate dyskaryosis is abnormal and equivalent to CIN 2. HPV changes are also present in <1%. Routine referral to a colposcopy clinic is appropriate for excision/biopsy of the lesion.

8. A 35 year old former Accountant, who remains a daily Crack Cocaine user, has agreed to attend you every 3-4 months for support and health check monitoring. He has never injected and is HIV negative. Which two of the following should be included in your examination?

a ) Checking his FBC
b ) Taking his BP
c ) Checking for proteinuria
d ) Monitoring his peak flow rate
e ) Checking for glycosuria
f ) Carrying out fundoscopy

Answer: B & D

Chronic cocaine use commonly results in cardiovascular disease, raised BP, stroke, seizures, and lung disease.

9. A 17 year old man presents in a morning surgery with several hours of acute left testicular pain. He is unsure if there are urinary symptoms, but there is no history of injury. On examination, the left testicle is very tender. Clinical examination is otherwise unhelpful. Which is the single best course of action?

a ) Arrange an outpatient department ultrasound of the testes
b ) Arrange to review at the end of the evening surgery
c ) Arrange for admission via urology
d ) Check bloods for levels of AFP and ßhCG
e ) Prescribe ciprofloxacin

answer: C

Acute testicular pain can be difficult to manage in primary care. In this case, the differential is between epididymo-orchitis and testicular torsion. Diagnostic signs are not sufficiently sensitive. Torsion is commoner in adolescents and orchitis in those who are older/sexually active. The treatment of torsion is time-sensitive and requires urgent Doppler ultrasound assessment. The only safe course of action is to admit as an emergency via urology.

10. OPTIONS:
a ) Anorexia nervosa
b ) Anxiety
c ) Binge eating disorder
d ) Bulimia nervosa
e ) Depression
f ) Munchaushen syndrome
g ) Personality disorder
INSTRUCTION: For each of the patients below, choose the most likely mental health diagnosis above? Each option may be used once, more than once or not at all.

1 . A 26 year old woman, with a BMI of 25, is a frequent attender at the surgery. Her last period was three weeks ago. She is a vegan and is obsessed with what she eats. She has been like this since her early teens. She tends to isolate herself from others. She has made several suicide attempts. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is g.

2 . A 36 year old woman, with a BMI of 21, had her last period three weeks ago. She makes frequent visits to her dentist because of caries. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is d.

3 . A 17 year old woman, with a BMI of 14, had her last period a year ago. She attends the gym for four hours a day. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is a.

It is obviously important to distinguish between different eating disorders and other mental health problems that may present in a similar way. It is also important to be aware that a request for laxatives is not as straightforward as it may at first appear. Bulimics manage to maintain a normal BMI. Vomiting may show itself in dental caries due to the gastric acid's attack on dental enamel. Diarrhoea may be common in bulimic patients. Even though Anorexics may have similar behaviour patterns, they always have a low BMI and are often amenorrhoeic. Patients with a binge eating disorder eat vast quantities of food and are often obese as they do not compensate for their eating by inducing vomiting.

11. A 60 year old smoker, who is on treatment for hypertension and ischaemic heart disease, presents with a cough for the last six weeks. In considering a management plan for him, which one of the following statements, about cough, would you feel is most valid?

a ) ACE-inhibitor related cough is dose related
b ) Chronic cough related to smoking is not dose related
c ) GORD-associated cough may occur in the absence of GI symptoms
d ) Viral-induced cough responds to over-the-counter remedies
e ) Rhinosinusitis is rarely associated with

Answer: C

ACE-inhibitor cough is not dose related and onset can be more than a year after starting treatment. One of the commonest causes of persistent cough is smoking, which appears to be dose-related. Although patients may report subjective benefit from OTC cough remedies, there is no evidence for their efficacy. Rhinosinusitis is a common cause of cough. Spirometry is mandatory in the investigation of chronic cough.

12. OPTIONS:
a ) Erythema migrans
b ) Granuloma annulare
c ) Impetigo
d ) Palmoplantar pustulosis
e ) Pitted keratolysis
f ) Tinea pedis
g ) Varicella zoster
INSTRUCTION: For each of the following patients, select the single most appropriate diagnosis from the list above. Each option can be used once, more than once or not at all.

1 . A three year-old girl is brought from nursery school by her mother. Over the last 24 hours, she has developed a cluster of small pustules on her right face. Some of these have evolved into fragile blisters which are easily burst, leaving a golden crusted appearance. She is otherwise well. The Correct answer is c.

2 . A 42 year-old male Scout leader attends because he has noticed a gradually enlarging, pink, annular lesion on his left buttock. He thinks he may have been bitten by something during a camping expedition in rural Wales three weeks ago. It has not responded to topical Clotrimazole cream as suggested by his pharmacist
The Correct answer is a.

3 . A 25 year-old male fitness instructor consults with a complaint of excessive and embarrassing foot odour over the last year or so. On removing his training shoes and socks, you note a pungent odour and a thickening and whitening of the skin on the plantar aspect of his heels and forefoot. Multiple punched out erosions are noted on the affected skin.
The Correct answer is e.

Case 1, Impetigo, pages 517-523 Click here Case 2, Erythema Migrans, pages 267-272 Click here Case 3, Pitted Keratolysis, page 416 Click here

13. A man is 58 years old. One year ago, he began to have some difficulty swallowing and developed fasciculation of his tongue. His voice has become progressively weaker and he is now only able to communicate by writing. Which is the single most likely diagnosis?

a ) Dystrophia Myotonica
b ) Motor Neurone Disease
c ) Multiple Sclerosis
d ) Myaethenia Gravis
e ) Paraneoplastic Syndrome

Answer: B

The man has a bulbar palsy causing dysphonia, dysarthria and dysphagia. Each of the conditions listed may be associated with these; however only in Motor Neurone Disease is there fasciculation. He has loss of function of the lower motor neurones of the brainstem motor nuclei resulting in weakness of the tongue, facial muscles and the muscles involved in chewing and swallowing.

14. A 36 year old man presents with a short history of lethargy, weight loss, thirst and passing copious amounts of urine. Your provisional diagnosis would best be confirmed by which one of the following results?

a ) Glycosuria of 3+
b ) Random blood glucose of >10mmol/l
c ) HbA1c =6%
d ) Fasting blood glucose of >7mmol/l
e ) Post prandial blood glucose of >9mmol/l

Answer: D

15. OPTIONS:
a ) Absence seizure
b ) Febrile seizure
c ) Infantile spasms (West's syndrome)
d ) Myoclonic epilepsy
e ) Pseudoseizure
f ) Breath-holding
INSTRUCTION: For each patient below, choose the single most likely diagnosis above. Each option may be used once, more than once or not at all.

1 . A four month old baby develops tonic spasms, especially flexionally, that occur in runs every 5–10 seconds. The child is otherwise well.
The Correct answer is c.

2 . A two year old child is noted by his mother to be having staring spells, with fluttering of his eyelids, lasting a few seconds at a time.
The Correct answer is a.

3 . A five year old child develops sudden involuntary spasm of a group of muscles with symmetrical repetitive jerking. There is no loss of consciousness.
The Correct answer is d.

West's syndrome starts in first year of life. Runs of tonic spasms occur every 5-10 seconds. It is associated with loss of vision and social interaction. Most commonly one gets flexion spasms ("salaam" spasms). Myoclonic epilepsy is the sudden involuntary spasm of a muscle or a group of muscles. Lennox-Gastaut is a severe form (starts age 2-6y) with intractable seizures.

16. A 24 year old man with Down's syndrome visits you with his mum. He states that he is well but his mum has noticed a change in him. For the last few months, he has been much more lethargic than usual, is participating less at his day centre and wants to spend longer in bed sleeping. She has also noticed he has gained more weight and clothes he wore about four months ago no longer fit. Which one of the following is the most likely cause of his symptoms?

a ) Addison's disease
b ) Cushing's syndrome
c ) Hypercalcaemia
d ) Hypothyroidism
e ) Type 2 diabetes mellitus

Answer: D

Down's syndrome is a common cause of learning disability, with the average GP having 1 in 1000 patients with this syndrome. Hypothyroidism is often not routinely screened for in Down's syndrome; but is much more common than in the general population. There is an increased incidence of type 1 diabetes which presents in early childhood; but there is no increased incidence of type 2 diabetes associated with Down's syndrome. Down's syndrome is also associated with congenital heart disease, congenital GIT abnormalities, atlanto-axial instability, Alzheimer's disease, leukaemia, deafness, and cataracts.

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