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.