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.