Wednesday 31 December 2008

AKT Questions

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