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.