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
Wednesday 31 December 2008
Friday 28 November 2008
AKT Questions
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.
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.
Tuesday 25 November 2008
AKT Questions
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.
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.
Monday 24 November 2008
AKT Questions
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.
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.
Tuesday 14 October 2008
AKT Questions
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.
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.
Sunday 5 October 2008
AKT Questions
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.
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.
Friday 3 October 2008
AKT Psychiatry
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
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
Thursday 2 October 2008
AKT Questions
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
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.
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
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.
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
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.
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
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.
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.
Wednesday 24 September 2008
AKT Questions
1. A 30 year old woman presents complaining of infrequent, scanty periods, weight gain, acne and excessive hair growth. You arrange some biochemical tests. In confirming your provisional diagnosis, which is the single most useful test?
a ) Fasting glucose
b ) Fasting lipid profile
c ) Free testosterone
d ) LH/FSH ratio
e ) Prolactin
Answer: C
An international consensus definition of PCOS has been published, which defines PCOS as having at least two of the following criteria: reduced or no ovulation; clinical and/or biochemical signs of excessive secretion of androgens; and/or polycystic ovaries (the presence of at least 12 follicles measuring 2–9 mm in diameter, an ovarian volume in excess of 10 ml, or both). Although the other tests can be useful, raised androgen levels are the most useful blood test in primary causes of Polycystic Ovarian Syndrome.
2. OPTIONS:
a ) Bacterial vaginosis
b ) Chlamydia trachomatis
c ) Gonorrhoea
d ) Herpes genitalis
e ) Syphilis
f ) Trichomonas vaginalis
g ) Vulvovaginal candidiasis
INSTRUCTION:
Choose the single most likely underlying gynaecological diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A sexually active 30 year old woman presents with a frothy vaginal discharge, abnormal vaginal odour, dyspareunia, and mild vulval itching. Vaginal examination reveals a ‘strawberry cervix’. A swab and smear test showed flagellated protozoa on microscopy.
The Correct answer is f.
2 . A 22 year old woman attends for a routine cervical smear test. She has no symptoms. On examination the nurse notes some mild mucopurulent discharge at the cervix and takes a swab. The swab shows gram negative diplococci.
The Correct answer is c.
3 . A sexually active 48 year old woman presents with symptoms of polyuria, polydipsia and recent weight loss. She has a BMI of 31. She has noticed a vaginal itch and some whitish discharge. Examination reveals a very red vulva and confirms a copious white discharge.
The Correct answer is g.
Trichomonas vaginalis is often an incidental finding, perhaps on a cervical cytology report. It may be carried by women for months or even years. It is almost exclusively a sexually transmissible infection. Refer to Genito-urinary Medicine if you find / suspect it. Be aware of the possibility of co-existing infections. Trichomonas vaginalis is a flagellated protozoan which lives in the vagina, urethra, foreskin and the paraurethral glands. Gonococci are Gram negative intra-cellular diplococci. They are spread by direct innoculation of secretions from one mucous membrane to another (urethra, endocervix, rectum, pharynx, and conjunctiva). Non-sexual transmission is exceptional – there is no evidence that it is caught from toilet seats. Vulvovaginal candidiasis - 80% are Candida albicans Non albicans species (e.g. C glabrata) account for the rest. 10 to 20% of women harbour candida species without symptoms (and no treatment may be needed if found).Typical symptoms are vulval or vaginal itch/soreness, external dysuria, dyspareunia and vaginal discharge. The pH of the discharge is 4 to 4.5 i.e. normal. (If higher, think of Bacterial vaginosis or Trichomonas vaginalis)
3. You see a 77 year old man who has been attending for review of his blood pressure. You have checked his blood pressure on two occasions over the previous two months and again today. The readings have been 170/80, 174/76 and today 180/78. His only medication is allopurinol which he has been taking for years for gout. He is an otherwise well man who has a healthy lifestyle and after giving him advice relating to this you would like to offer him treatment. According to current evidence, which is the most appropriate drug to initiate treatment?
a ) Amlodipine
b ) Bendroflumethiazide
c ) Doxazosin
d ) Losartan
e ) Ramipril
Answer: A
Isolated systolic hypertension is a sustained systolic pressure =140mmHg and a diastolic <90mmhg.>140 and/or diastolic >90) and those with isolated systolic hypertension should be treated as they will benefit from the reduction in risk of cardiovascular disease just as much, or more than, younger people. Current recommendations are that in patients more than 55 years a thiazide or a calcium channel blocker should be the first choice with an ACE inhibitor being added to the initial choice if needed. In this case, a thiazide is contraindicated in gout.
4. A 75 year old widow who has previously been well, and who has been commenced on Bendroflumethiazide for essential hypertension. Which one of the following biochemical abnormalities is she most at risk of developing?
a ) Hypoalbuminaemia
b ) Hypocalcaemia
c ) Hypogammaglobulinaemia
d ) Hypokalaemia
e ) Hypouricaemia
Answer: D
Other side effects of Bendroflumethazide include hypomagnesaemia, hyponatraemia, hypochloraemic alkalosis, hyperuricaemia, gout and hyperglycaemia. The likelihood of adverse effects in the elderly is increased by polypharmacy.
5. A 60 year old woman seeks your advice two weeks after coronary artery bypass grafting. She is an ex- smoker and her BMI is 30. Her husband died of a myocardial infarction several years previously and she is anxious to avoid a similar fate. For which one of the following interventions is there evidence to suggest that her all-cause mortality could be reduced by about a third?
a ) Avoidance of heavy lifting
b ) Cognitive behavioural therapy.
c ) Exercise
d ) Limitation of alcohol to 14 units per week.
e ) Weight reduction to a BMI of 24.
Answer: C
There is good evidence that exercise training should be a core element of cardiac rehabilitation programmes, and there is increasing recognition that it reduces morbidity as well as mortality in men and women of all ages with previous MI, revascularisation or angina. Exercise-only rehabilitation reduces mortality by 27%.
6. A patient has depression. He is employed as an accountant and he has been off work for 14 weeks. After how many weeks of sickness absence is he entitled to claim incapacity benefit?
a ) 4 weeks
b ) 13 weeks
c ) 20 weeks
d ) 28 weeks
e ) 52 weeks
Answer: D
The most common causes of sick note requests are back pain, depression and work place stress. If the patient is employed, they are entitled to statutory sick pay which lasts for a maximum of 28 weeks. At 28 weeks, incapacity benefit can then be claimed.
7. OPTIONS:
a ) Agitated depression
b ) Alzheimer’s disease
c ) Frontal lobe dementia
d ) Lewy body dementia
e ) Parkinson’s Disease
f ) Toxic confusional state
g ) Vascular dementia
INSTRUCTION: For each of the following patients with mental disturbance, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.
1 . A 70 year old woman with a six month history of fluctuating cognitive impairment associated with visual hallucinations and a tremor.
. The Correct answer is d.
2 . A 79 year old woman with a six day history of fluctuating consciousness level, impaired memory and visual hallucinations -all of acute onset
The Correct answer is f.
3 . An 86 year old woman with a six month history of sexual disinhibition, cognitive impairment and a change of personality.
The Correct answer is C
As management and prognosis of these states differs in many respects, it is obviously important to make an accurate diagnosis and not assume that all problems presenting with confusion represent dementia.
a ) Fasting glucose
b ) Fasting lipid profile
c ) Free testosterone
d ) LH/FSH ratio
e ) Prolactin
Answer: C
An international consensus definition of PCOS has been published, which defines PCOS as having at least two of the following criteria: reduced or no ovulation; clinical and/or biochemical signs of excessive secretion of androgens; and/or polycystic ovaries (the presence of at least 12 follicles measuring 2–9 mm in diameter, an ovarian volume in excess of 10 ml, or both). Although the other tests can be useful, raised androgen levels are the most useful blood test in primary causes of Polycystic Ovarian Syndrome.
2. OPTIONS:
a ) Bacterial vaginosis
b ) Chlamydia trachomatis
c ) Gonorrhoea
d ) Herpes genitalis
e ) Syphilis
f ) Trichomonas vaginalis
g ) Vulvovaginal candidiasis
INSTRUCTION:
Choose the single most likely underlying gynaecological diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A sexually active 30 year old woman presents with a frothy vaginal discharge, abnormal vaginal odour, dyspareunia, and mild vulval itching. Vaginal examination reveals a ‘strawberry cervix’. A swab and smear test showed flagellated protozoa on microscopy.
The Correct answer is f.
2 . A 22 year old woman attends for a routine cervical smear test. She has no symptoms. On examination the nurse notes some mild mucopurulent discharge at the cervix and takes a swab. The swab shows gram negative diplococci.
The Correct answer is c.
3 . A sexually active 48 year old woman presents with symptoms of polyuria, polydipsia and recent weight loss. She has a BMI of 31. She has noticed a vaginal itch and some whitish discharge. Examination reveals a very red vulva and confirms a copious white discharge.
The Correct answer is g.
Trichomonas vaginalis is often an incidental finding, perhaps on a cervical cytology report. It may be carried by women for months or even years. It is almost exclusively a sexually transmissible infection. Refer to Genito-urinary Medicine if you find / suspect it. Be aware of the possibility of co-existing infections. Trichomonas vaginalis is a flagellated protozoan which lives in the vagina, urethra, foreskin and the paraurethral glands. Gonococci are Gram negative intra-cellular diplococci. They are spread by direct innoculation of secretions from one mucous membrane to another (urethra, endocervix, rectum, pharynx, and conjunctiva). Non-sexual transmission is exceptional – there is no evidence that it is caught from toilet seats. Vulvovaginal candidiasis - 80% are Candida albicans Non albicans species (e.g. C glabrata) account for the rest. 10 to 20% of women harbour candida species without symptoms (and no treatment may be needed if found).Typical symptoms are vulval or vaginal itch/soreness, external dysuria, dyspareunia and vaginal discharge. The pH of the discharge is 4 to 4.5 i.e. normal. (If higher, think of Bacterial vaginosis or Trichomonas vaginalis)
3. You see a 77 year old man who has been attending for review of his blood pressure. You have checked his blood pressure on two occasions over the previous two months and again today. The readings have been 170/80, 174/76 and today 180/78. His only medication is allopurinol which he has been taking for years for gout. He is an otherwise well man who has a healthy lifestyle and after giving him advice relating to this you would like to offer him treatment. According to current evidence, which is the most appropriate drug to initiate treatment?
a ) Amlodipine
b ) Bendroflumethiazide
c ) Doxazosin
d ) Losartan
e ) Ramipril
Answer: A
Isolated systolic hypertension is a sustained systolic pressure =140mmHg and a diastolic <90mmhg.>140 and/or diastolic >90) and those with isolated systolic hypertension should be treated as they will benefit from the reduction in risk of cardiovascular disease just as much, or more than, younger people. Current recommendations are that in patients more than 55 years a thiazide or a calcium channel blocker should be the first choice with an ACE inhibitor being added to the initial choice if needed. In this case, a thiazide is contraindicated in gout.
4. A 75 year old widow who has previously been well, and who has been commenced on Bendroflumethiazide for essential hypertension. Which one of the following biochemical abnormalities is she most at risk of developing?
a ) Hypoalbuminaemia
b ) Hypocalcaemia
c ) Hypogammaglobulinaemia
d ) Hypokalaemia
e ) Hypouricaemia
Answer: D
Other side effects of Bendroflumethazide include hypomagnesaemia, hyponatraemia, hypochloraemic alkalosis, hyperuricaemia, gout and hyperglycaemia. The likelihood of adverse effects in the elderly is increased by polypharmacy.
5. A 60 year old woman seeks your advice two weeks after coronary artery bypass grafting. She is an ex- smoker and her BMI is 30. Her husband died of a myocardial infarction several years previously and she is anxious to avoid a similar fate. For which one of the following interventions is there evidence to suggest that her all-cause mortality could be reduced by about a third?
a ) Avoidance of heavy lifting
b ) Cognitive behavioural therapy.
c ) Exercise
d ) Limitation of alcohol to 14 units per week.
e ) Weight reduction to a BMI of 24.
Answer: C
There is good evidence that exercise training should be a core element of cardiac rehabilitation programmes, and there is increasing recognition that it reduces morbidity as well as mortality in men and women of all ages with previous MI, revascularisation or angina. Exercise-only rehabilitation reduces mortality by 27%.
6. A patient has depression. He is employed as an accountant and he has been off work for 14 weeks. After how many weeks of sickness absence is he entitled to claim incapacity benefit?
a ) 4 weeks
b ) 13 weeks
c ) 20 weeks
d ) 28 weeks
e ) 52 weeks
Answer: D
The most common causes of sick note requests are back pain, depression and work place stress. If the patient is employed, they are entitled to statutory sick pay which lasts for a maximum of 28 weeks. At 28 weeks, incapacity benefit can then be claimed.
7. OPTIONS:
a ) Agitated depression
b ) Alzheimer’s disease
c ) Frontal lobe dementia
d ) Lewy body dementia
e ) Parkinson’s Disease
f ) Toxic confusional state
g ) Vascular dementia
INSTRUCTION: For each of the following patients with mental disturbance, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.
1 . A 70 year old woman with a six month history of fluctuating cognitive impairment associated with visual hallucinations and a tremor.
. The Correct answer is d.
2 . A 79 year old woman with a six day history of fluctuating consciousness level, impaired memory and visual hallucinations -all of acute onset
The Correct answer is f.
3 . An 86 year old woman with a six month history of sexual disinhibition, cognitive impairment and a change of personality.
The Correct answer is C
As management and prognosis of these states differs in many respects, it is obviously important to make an accurate diagnosis and not assume that all problems presenting with confusion represent dementia.
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