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.

AKT Questions

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

A. 4-year-old with a 5 day history of urinary frequency
B. 2-year-old who has a persistent pyrexia after 48 hours of antibiotic treatment for otitis media
C. 16-month-old complaining of abdominal pain
D. 2-month-old who is feeding poorly and vomiting

E. 3-year-old with a temperature of 37.7ºC who is well and has no obvious focus of infection

Answer: E

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

Presentation in childhood depends on age:

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

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

Urine collection method

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

Management
infants less than 3 months old should be referred immediately to a paediatrician
children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs

2. An 8-year-old boy is reviewed in clinic due to nocturnal enuresis. Of the following options, what is the most appropriate initial management strategy?
A. Enuresis alarm
B. Trial of oral desmopressin
C. Trial of imipramine
D. Trial of intranasal desmopressin
E. Discourage fluids at night


Answer: A

A reward based system may also be used as a first line treatment in enuresis. Restricting fluids is not recommended advice - Clinical Knowledge Summaries suggest: 'Do not restrict fluids. The child should have about eight drinks a day, spaced out throughout the day, the last one about 1 hour before bed.'
Nocturnal enuresis
The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the 'involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract'Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)Management
dip urine for protein and sugar, send for culture (helps exclude diabetes mellitus and UTI)
explanation, reassurance and education (e.g. avoid punitive measures)
star charts are useful (the child earns a star for a dry night)
if star charts fail then alarms which awake the child following a wetting episode may be tried

3. At what age would the average child acquire the ability to crawl?

A. 6 months
B. 9 months
C. 12 months
D. 18 months
E. 2 years


Answer: B

The table below summarises the major gross motor developmental milestones


Age - Milestone
3 months
Little or no head lag on being pulled to sitLying on abdomen, good head controlHeld sitting, lumbar curve
6 months
Lying on abdomen, arms extendedLying on back, lifts and grasps feetPulls self to sittingHeld sitting, back straightRolls front to back
9 months
Sits without support (Refer at 12 months)Pulls to standingCrawls
12 months
CruisesWalks with one hand held
15 months
Walks unsupported (Refer at 18 months)
18 months
Squats to pick up a toy
2 years
RunsWalks upstairs and downstairs holding on to rail
3 years
Rides a tricycle using pedalsWalks up stairs without holding on to rail
4 years
Hops on one leg

Notes
the majority of children crawl on all fours before walking but some children 'bottom-shuffle'. This is a normal variant and runs in families

4. A 9-year-old boy is brought to surgery as his asthma has been getting worse over the past 2 days. His mother is concerned that his breathing is getting worse and not responding to inhaled salbutamol as normal. Which one of the following is consistent with a life-threatening asthma attack?
A. Quiet breath sounds on auscultation
B. SpO2 of 94%

C. Heart rate of 120 bpm
D. Respiratory rate of 30 / minute
E. Peak flow 40% of predicted


Answer: A

Quiet breath sounds in a child with asthma is a worrying feature. Children with asthma normally have an obvious bilateral wheeze - the absence of this may suggest a life-threatening asthma attack

Asthma in children: assessment of acute attacks
The table below summarises the grading of asthma attacks in children between 2 and 5 years of age
Moderate attack
SpO2 > 92%No clinical features of severe asthma
Severe attack
SpO2 <> 130/minRespiratory rate > 50/minUse of accessory neck muscles
Life-threatening attack
SpO2 <92%Silent chestPoor respiratory effortAgitationAltered consciousnessCyanosis

The table below summarises the grading of asthma attacks in children greater than 5 years of age
Moderate attack
SpO2 > 92%PEF > 50% best or predictedNo clinical features ofsevere asthma
Severe attack
SpO2 <> 120/minRespiratory rate > 30/minUse of accessory neck muscles
Life-threatening attack
SpO2 < 92%PEF < 33% best or predictedSilent chestPoor respiratory effortAltered consciousnessCyanosis

Tuesday 23 September 2008

more AKT Questions

1. A Theatre nurse in the local hospital presented to you several weeks ago stating that he fell into an at-risk category for HIV infection. After counselling, you arrange a test. This has now come back positive. You discuss with him the physical and social implications of the condition and how it will be managed. He states very clearly that he does not wish his employer to know. You explain the difficulties this may place on your professional obligation to maintain patient confidentiality. In this regard, what is the single, most appropriate action to take?

a ) You ask him to inform the Occupational Health Dept.
b ) You inform, anonymously, the Occupational Health Dept.
c ) You agree to review the issue after an interval.
d ) You inform, openly, the Occupational Health Dept.
e ) You agree to disclose the issue to no-one.

Answer: D

If you know, or have good reason to believe, that a medical colleague or a health care worker who has, or may have, a serious communicable disease, is practising, or has practised, in a way which places patients at risk, you must inform an appropriate person in the health care worker's employing authority, for example an occupational health physician, or where appropriate, the relevant regulatory body.

2. OPTIONS:
a ) Autistic spectrum disorder
b ) Cerebral palsy
c ) Developmental dyspraxia
d ) Dyscalculia
e ) Dysgraphia
f ) Dyslexia
g ) Fragile X syndrome

INSTRUCTIONFor each of the patients below, select the single most likely diagnosis from the list above. Each option can be used once, more than once or not at all.

1 . A father consults you with his 8 year old son. He says that the boy has trouble putting thoughts on paper and writes with inappropriately sized and spaced letters. He has spelling difficulties although he seems to know verbally how to spell the words. He seems to have no difficulty reading. He is interested in sports and has lots of friends.
a . The Correct answer is e.

2 . A young couple attend the surgery to discuss their 6 year old son. They are clearly distressed and are finding their son difficult to cope with. He plays on his own and does not interact well with his peer group. He is not interested in stories and has a habit of repeating what is said.

a . The Correct answer is a.


3 . A young single mother brings her 9 year old son to your surgery. She has noticed that he is poor at games and is getting a hard time at school. He knocks into things and has difficulty with buttons when dressing. He has some difficulty with sounding words and has poor handwriting.

answer C

Sunday 7 September 2008

AKT questions

1. A young woman, who normally wears contact lenses, consults you wearing her glasses. The day before, she was clearing out a cupboard when she felt she had got dust into her left eye, and it became suddenly painful. It has not improved. You do a visual acuity test and it is 6/6 in both eyes with glasses. You stain her left cornea with Fluorescein and can clearly identify a tiny foreign body. There is no corneal staining otherwise. You decide to remove the foreign body (FB) with a cotton wool bud, after first inserting anaesthetic drops. The FB comes away very easily. You set out a management plan for her. Which two of the following should be included in that plan?

a ) Ask her to wear an eye pad for 24hours.
b ) Prescribe Chloramphenicol eye drops for five days
c ) Arrange a follow-up in 24 hours
d ) Prescribe Diclofenac eye drops as a first line painkiller
e ) Tell her she can reinsert her contact lenses in 24 hours time
f ) Arrange for her to see an ophthalmologist

Answer: B & C

Local anaesthetic eye drops act for about 15 minutes, so an eye pad to prevent injury is not required. Oral Paracetamol or Ibuprofen are the first line painkillers. She should not replace the contact lenses until 24 hours after the antibiotic course has been completed. Referral to an ophthalmologist is only indicated if your follow up reveals a problem

2. An obese 45 year old man, with hypertension and peptic ulcer disease, presents with difficulty walking. Examination reveals an acutely swollen, erythematous and tender metatarsophalangeal joint of the right big toe. What is the single best treatment option for him?

a ) Aspirin
b ) Colchicine
c ) Co-codamol
d ) Ibuprofen
e ) Allopurinol

Answer: B

Acute attacks of gout are usually treated with high doses of anti-inflammatory NSAIDs such as ibuprofen, diclofenac or naproxen unless contraindicated e.g. with peptic ulcer. Caution should be exercised in hypertension. Colchicine is probably as effective as NSAIDs and can be used if NSAIDs are contra-indicated. It can only be used as a very short course and up to a total of 6mg has been reached. The course should not be repeated within 3 days. Its use can be limited by the development of toxicity at higher doses. In renal failure, use of NSAIDs and colchicine can be problematic. Aspirin is not recommended in gout. Co-codamol does not confer the anti-inflammatory effect required. COX2s’ share the side effects of conventional NSAIDS and are not licensed for the treatment of gout. Allopurinol treatment is used in the long term treatment of gout but should not be used until three weeks after an acute attack.

3. A 20 year old woman, who has suffered from well controlled epilepsy for the last 10 years, tells you that she is contemplating a pregnancy. She takes Carbamazepine 1.2g daily. She has given up smoking and restricts herself to two units of alcohol per week. She has heard that there are vitamin supplements she can take. She wishes your advice on these. Which one of the following would you advise her to take?

a ) Calcium Folinate 15mg preconceptually and for the first trimester at least
b ) Folic Acid 5mg preconceptually and for the first trimester at least
c ) Ferrograd-Folic 105/350 preconceptually and for the first trimester at least
d ) Folic acid 400mcg preconceptually and for the first trimester at least
e ) Pyridoxine 50mg preconceptually and for the first trimester at least

Answer: B

There is an increased risk of neural tube defects with, in particular, Carbamazepine, Lamotrigine, Oxcarbazepine, Phenytoin and Valproate. A dose of Folic Acid 5mg is required along with individual counselling by a doctor. Combined preparations are not appropriate

4. A young woman, on Methadone maintenance, delivers a 3,500g baby and discharges herself from hospital after 24 hours. She is breastfeeding. On the third day postnatally, she phones and tells you the baby seems very irritable, has a high pitched cry and is breathing very rapidly. You visit them. Which one of the following actions is most appropriate?

a ) Ask the mother to stop breast feeding
b ) Admit the baby and mother to hospital
c ) Ask the Health Visitor to monitor and review
d ) Ask the mother to reduce the Methadone over the next four weeks
e ) Admit the baby to hospital

Answer: B

The baby is likely to be suffering from Neonatal Abstinence Syndrome due to Methadone withdrawal and would most safely be cared for in a paediatric unit. Mother should be encouraged to continue to take her usual dose of Methadone. She should also continue to breastfeed as the small amounts of drug in her breast milk will help the gradual reduction of Methadone levels in the baby’s blood. The mother is likely to have high levels of guilt and discussing these with a Counsellor or Health Visitor, at a later point, would be therapeutic.

5. OPTIONS:
a ) Aspirin
b ) Bendroflumethiazide
c ) Enalapril
d ) Gliclazide
e ) Metformin
f ) Nifedipine
g ) Simvastatin
INSTRUCTION: A 67 year old type 2 diabetic man is on the drugs listed above. At different stages, he develops various additional problems described below. Choose the single drug above most likely to be the cause of the problem. Each option can be used once, more than once or not at all.

1 . He develops an intractable dry cough without wheeze.
The Correct answer is c.

2 . He develops an inflamed joint which you think might be gout?
The Correct answer is b.

3 . He develops severe muscle pain.
The Correct answer is g.

6. A 25 year old woman is 28 weeks pregnant. She has a feeling of fullness in one breast and is fearful of breast cancer, from which an aunt suffered. Which single characteristic would warrant her referral to a breast clinic?

a ) Bilateral breast pain
b ) Bilateral breast nodularity
c ) Breast pain with fever
d ) Localised breast erythema
e ) Discrete breast mass

Answer: E

Women who should be referred include those with any new discrete lump, those with a new lump in a pre-existing area of nodularity those with a non-lactational abscess that does not settle after one course of antibiotics, those with a refilling or recurrent cyst and those with a unilateral axillary lymph node lump.

7. A 40 year old patient develops left sided facial weakness. On examination the paralysis is of lower motor neurone type. He asks what may be the cause. Apart from herpes virus infection, which one of the following is a common cause?

a ) Alcohol excess
b ) Dental caries
c ) Horner’s syndrome
d ) Middle ear disease
e ) Syphilis

Answer: D

This patient has Bell’s Palsy – a condition described 100 years ago by Sir Charles Bell. It is the most common cause of facial paralysis world wide. Its aetiology is usually unclear. There can be vascular, infectious, genetic and immunological causes.

8. OPTIONS:
a ) Carcinoma of colon
b ) Campylobacter
c ) Crohn’s disease
d ) Giardiasis
e ) Irritable bowel syndrome
f ) Laxative abuse
g ) Pseudomembranous colitis
INSTRUCTION: For each of the patients below, choose the most likely underlying diagnosis from the list above. Each answer can be used once, more than once or not at all.

1 . An 18 year old girl has been amenorrhoeic for six months. She has lost 5kgs and has developed loose stools, without bleeding, at least four times a day.
The Correct answer is f.

2 . A 22 year old student has returned from Russia with episodic loose stools and passing offensive wind.
The Correct answer is d.

3 . A 36 year old businessman has completed a two week course of cephalexin. He has now developed a fever, diarrhoea and cramping abdominal pain.
The Correct answer is g.

Laxative abuse is found to be the cause of chronic diarrhoea, after comprehensive investigations,in about 20% of patients. This may commonly occur with a history of an eating disorder. Giardiasis infection is suggested by watery stool with flatus++ (explosive diarrhoea). It is estimated that 95% of travellers to St Petersburg contract the disease. The treatment is metronidazole 2g for three days. Rapid response is diagnostic. Pseudomembranous colitis is due to an overgrowth in the colon of Clostridium difficile. There is a history of antibiotic usage.

9. OPTIONS:

a ) Body Temperature
b ) Full Blood Count
c ) Liver Function Tests
d ) Plasma Glucose
e ) Serum electrolytes
f ) Throat Swab
g ) Thyroid Function Tests

INSTRUCTION: For each patient below, with a potential psychotropic medication side effect, select the single most important confirmatory investigation, or examination, from the list above. Each option can be used once, more than once or not at all.

1 . A 72 year-old woman, in the local nursing home, who was started on Citalopram four weeks ago following a diagnosis of depression, has become increasingly confused over the last week. Today she seems drowsy, and a reliable staff member reports what appeared to be a short-lived seizure that morning.
The Correct answer is e.

2 . A 25 year-old man with resistant schizophrenia has been well controlled on Clozapine 400mg daily for 15 months. Over the last six weeks, he has been living with various family and friends after eviction from his flat. His attendance for reviews at the psychiatric clinic has been erratic. He presents with general malaise, a sore throat, and thinks he has “the 'flu”.
The Correct answer is b.

3 . A 19 year-old male schizophrenic, who lives with his parents, is being visited urgently at home. He has been well controlled since starting Flupentixol (Depixol) depot injections three months ago. On arrival, you find him to have a fluctuating level of consciousness, muscular rigidity, tachycardia and labile blood pressure.
The Correct answer is a.

10. A 26 year-old keen sportsman attends after being advised to do so by a local pharmacist. He has been told he has a fungal toenail infection, and has been using over-the-counter amorolfine lacquer for three months, with no change in the appearance of the nail. He has subungual hyperkeratosis and onycholysis of his right great toenail. Which single statement best reflects the advice you would give him?

a ) Fungal nail infection is trivial requiring no treatment
b ) Treatment can be commenced without confirmation of fungal infection
c ) First-line treatment should be oral
d ) All cases of nail dystrophy are fungal in origin
e ) First line treatment should be topical

Answer: C

Only around 50% of all cases of nail dystrophy are due to fungal infection, so treatment should not be commenced before mycological confirmation has been made. Tinea infection of the nail is almost always treated systemically. Topical applications such as amorolfine and ticonazole may be effective in treating very early onycomycosis. Fungal nail infection is not universally trivial: in the elderly the disease can give rise to complications such as cellulitis, and therefore further compromise the limb in those with diabetes or peripheral vascular disease. Complications can therefore be serious in some clinical situations.