Tuesday 15 September 2009

AKT questions

1. A 43 year old woman presents with an episode ofsevere pain in her upper abdomen of one hours duration and one vomit. She has had three previous episodes one of which woke her at night and lasted for two hours. She is now asymptomatic. She has tenderness on inspiration in her right upper quadrant.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: H

Chest pain in primary care is sometimes straight forward but can be one of the most challenging tests of decision making in Primary Care. Generally speaking there is limited use made of the Troponins (specific and sensitive for myocardial damage) and the D Dimer (sensitive but too non specific). Too often the results of the latter are telephoned through to a hapless out of hours doctor who has no clinical details to guide him! Although I might occasionally do a Troponin T (for instance in an elderly person with co-morbidity, full safety netting and reliable social support) I would only do so after a full clinical assessment, ECG and in the knowledge that an MI was clinically unlikely. I would take personal responsibility for checking the result.Biliary pain (case 1) is occasionally confused with cardiac pain, as is the characteristic L sided pain of the stressed executive (case 2). Such a patient will often end up with an exercise test for his own reassurance but, since this is not totally specific or sensitive may be superseded by cardiac CT in the future.

2. A 48 year old sales manager with no medical history presents following a medical by a private insurer. The examining doctor was concerned about his left sided chest pain which came on at variable times, was sharp in quality and which the patient associated with stress. A full biochemical screen and ECG at the medical were normal

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

3. A 70 year old patient telephones to tell you that he has had severe retrosternal pain for 30 minutes and has vomited once. His wife has told him that he looks dreadful

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: B

Myocardial infarction is the likely cause of the problems encountered by Case 3. There is no mileage in delaying admission these days but it important that the patient (or representative) is spoken to directly. If there is an aspirin in the house he should be advised to take it.

4. A 25 year old woman presents with R sided chest pain which has occurred in conjunction with an URTI. Clinically she is normotensive with a pulse rate of 90 regular, some chest wall tenderness and reproduction of pain on thoracic spine rotation. She takes the contraceptive pill.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

The young lady in case 4 is clinically unlikely to have a pulmonary embolus (but this should be considered) and a D Dimer of course could well be a distractor in the presence of a URTI. She is most likely to have pulled an intercostal muscle coughing.

5. A 40 year old police cadet was thumped in the ribs three days before during unarmed combat training. He has L sided chest pain worse on breathing and moving but has been able to work. Apart from rib tenderness clinical examination is unremarkable, he is normotensive and his oxygen saturations are 98% on air

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

The policeman in case 5 does not need further investigation (the most worrying consequence of his injuries is a tension pneumothorax which in this scenario is unlikely – A&E doctors may argue with this but it is unlikely to change management in primary care).

6. A 43 year old labourer presents with a short episode of severe thoracic spine pain earlier in the day which settled after 40 minutes or so. He had a previous episode the week before. On examination he looks well, BP 90/60, pulse 100 regularly and he has a soft early diastolic murmur.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: B

Case 6 is seriously ill. Check the BP in both arms (it may be different), insert a venflon if you have one and stay with the patient until the ambulance arrives. He probably has an aortic dissection (has he got Marfan.s syndrome?) and your action could be life-saving.

7. A 58 year old French teacher has a persistent cough and a niggling R sided chest pain. She smoked 20 cigarettes a day until 3 years ago

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I.Refer to the Rapid access chest pain clinic

Answer: F

I would be concerned that case 7 had a carcinoma of the bronchus and would order a Chest X-Ray. If this was normal I would review her and, if not settling either repeat or perform spirometry.

8. Arthur – an 80 year old Type 11 diabetic has tightness in his chest which occurs on walking 100 yards on the flat or on emotion – especially after eating. He has not experienced the pain at rest and when he stops it settles after 5-6 minutes

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: I

Arthur (case 8) probably has chronic stable angina and should be referred to the Rapid Access Chest pain clinic. Age is not a bar to effective treatment and, while he is waiting it would be sensible to check his lipids,Hb and electrolytes as well as a resting ECG .It would be reasonable to commence symptomatic treatment (eg Nitrate) as well as commencing Aspirin and a Statin – if not already taking them.



A 60 year old man has an anterior myocardial infarction treated acutely by Percutaneous Intervention (PCI) with stents and made an uneventful recovery.

9.
Which one of the following statements is true: [Show Discussion]

A. Aspirin needs to be given for 5 years and then stopped
B. Clopidogrel should be given for a year.
C. He should not be given ACE inhibitors if his creatinine is over 120mmol/l
D. He only needs a statin if his total cholesterol is more than 5.0 mmol/l
E. He doesn’t need a B Blocker unless he has a pulse persistently greater than 80

Answer: B

Current recommendations are that with stents clopidogrel continues for a year. Some cardiologists would advocate longer – but the evidence is not yet available. This is a fast moving field! Aspirin, B Blockers , statins (whatever the cholesterol)and possibly ACEI should be permanent. He needs his creatinine monitoring carefully.

Wednesday 9 September 2009

Dermatology


1. This elderly patient with a history of chronic sun exposure presented with some rough areas of skin on his forehead. This was an incidental finding. The single most likely diagnosis is?


A. Actinic keratoses
B. Metastases
C. Pyogenic granulomata
D. Seborrhoeic keratoses
E. Viral warts


Answer: A


These are chronic sun-related changes that may progress in time to squamous cell carcinomas. In the absence of significant induration, cryotherapy would be an appropriate treatment. Alternatives include topical diclofenac gel (e.g. 'Solareze').

dermatology


1. This elderly patient presented incidentally with the lesion below that had been slowly enlarging for several months. What is the single most likely diagnosis? A. Actinic keratosis
B. Amelanotic melanoma
C. Cystic basal cell carcinoma
D. Pyogenic granuloma
E. Squamous cell carcinoma


Answer: C


this is a cystic basal cell carcinoma. Variants on the classical 'rolled edge' in basal cell neoplasms are common. Variants include this one as well as superficial spreading variants—which can be mistaken for a patch of eczema. The site is an important clue however and this, bearing in mind the age of the patient, should be referred.

AKT questions


1. A 60-year-old man presents with pain between his neck and his right shoulder for 2 weeks following strenuous gardening, worse on moving. When asked, he points to the posterior aspect of the painful site. He has no symptoms below the elbow and is otherwise well. The single most likely cause of his pain is?

A. Acromioclavicular joint arthritis
B. Capsulitis of his shoulder
C. Cervical myelopathy
D. Cervical spondylosis
E. Rotator cuff tear


Answer: D


cervical spondylosis. This question really brings out the point that the site of pain around the shoulder will rapidly eliminate certain diagnoses. Acromioclavicular joint pain tends to be on top of the shoulder while neck pain characteristically radiates from its origin over the trapezius muscle. If there is significant disc disease, there is likely to be a problem below the elbow. Cervical myelopathy implies spinal cord involvement—in which case there may be a mild spastic paraparesis (possibly with an 'inverted supinator' signifying a UMN lesion around C5/6). Glenohumeral pain may be diffuse but is characteristically felt at the top of the arm.


2. A 50-year-old female patient presents with pain around her shoulder that is felt mainly in her upper arm. Which one of the following signs does not require early referral?


A. Fever and joint erythema
B. Horner’s syndrome
C. Inability to abduct and externally rotate following trauma
D. Muscle wasting around the scapula
E. Reduction in all directions of movement


Answer: E


reduction in all directions of movement. In the presence of fever and joint erythema, sepsis (although uncommon) should be considered. Nocturnal wakening is characteristic in both capsulitis of the shoulder and rotator cuff tears and (unlike back pain) is not a red flag in this context. Severe pain immediately following trauma suggests dislocation. The rounded contour of the shoulder will disappear in the commonest (anterior) dislocation and the patient will resist abduction and external rotation. Reduction in all directions of movement simply implies a 'capsular' cause of the pain—be it arthritic or a capsulitis. Muscle wasting around the scapula may mean a 'brachial neuritis'—a curious condition of unknown aetiology while Horner’s syndrome could indicate the presence of a Pancoast’s tumour.


3. Which one of the following statements below makes a meniscal tear more likely than alternative diagnoses? [Show Discussion]

A. A hot, red and painful knee
B. Immediate swelling after injury
C. Increased laxity on the anterior draw test
D. Joint line tenderness
E. Presence of an effusion


Answer: D


joint line tenderness is the most sensitive test of meniscal damage. Typically, any effusion will be worse the morning after the injury (unless there is associated cruciate damage). A hot, red painful knee could be septic. The anterior draw sign is a test for anterior cruciate damage—as is a Lachmann test.


4. A 68-year-old man with a history of hypertension and chronic kidney disease (eGFR 47) presents with an acutely swollen right knee that occurred spontaneously. He takes ramipril and bendroflumethazide for hypertension. His temperature is normal. If practical, which is the single most specific test? [Show Discussion]

A. Erythrocyte sedimentation rate
B. Fluid aspiration for crystals
C. Serum calcium
D. Serum urate
E. X-ray


Answer: B


fluid aspiration for crystals. The most likely diagnosis in this scenario is acute gout. After initial treatment (probably with colchicines in view of his CKD), it is important to arrange a serum urate. This may be normal even in the presence of gout.


5. A 14-year-old female student presents with painful knees on stairs and following sport. She is a first team netball player. Which of the options below is the single most useful piece of initial advice? [Show Discussion]

A. Glucosamine
B. Non-steroidal anti-inflammatory drugs
C. Physiotherapy
D. Refer for arthroscopy
E. Stop all sport


Answer: C


physiotherapy. This is a common scenario that causes much distress both for the patient and her parents. Such patients are often female and high sporting achievers. PFJ symptoms may be due to malalignment, muscular imbalance or overuse and there may be an associated patellar tendinitis. While stopping all sport would almost certainly alleviate the problem, it is not always popular in this group of patients.


6.
A patient aged 60 years presents with this lesion on the dorsum of her forearm It has been present for around a month and enlarged rapidly over that time. What is the single most likely diagnosis?

A. Dermatofibroma
B. Keratoacanthoma
C. Melanoma
D. Nodular basal cell carcinoma
E. Pyogenic granuloma


Answer: B

This should be referred urgently for excision (surgically or by curettage) since the rate of growth is alarming and shave biopsy can look histologically very like squamous cell carcinoma. The lesion is benign and characteristically occurs in an older population on sun-exposed sites. It has a keratinous centre.

Sunday 8 February 2009

1.A 23 year old nurse presents with nocturnal cough and wheeze. She has smoked 10 cigarettes daily for 6 years and is clinically well with a pulse rate of 70 beats per minute, respiratory rate 15 per minute and no chest signs. She has previously been well. Which one of the options below would be of most use in confirming her diagnosis? [Show Discussion]

A. Arterial blood gases
B. Chest X-Ray
C. Serial peak flow readings
D. Pulse oximetry
E. Spirometry

Answer: C

The distinction between asthma and COPD is made by considering the history and if necessary further investigations such as spirometry. Furthermore, despite the fact that she smokes, COPD is much more likely in patients over 35. This is a typical history for asthma. The fact that she is well when she sees you the next day and has no apparent abnormalities should not dissuade you from making this diagnosis. She should of course be discouraged from smoking.ABGs (even if they could be done in primary care) are inappropriate and likely to be normal, as is pulse oximetry – certainly during the daytime. In this setting (especially in a young woman) CXR is unlikely to be helpful – although if she does not respond to treatment should be considered. Bearing in mind that asthma is reversible airways obstruction spirometry may be normal – depending on whether it is don at a time when there is bronchospasm. Serial PFR is helpful on two countsa) A variability of 20% (usually lowest early in the morning or after trigger) is virtually diagnostic if the patient’s technique is adequate. It is important that the morning reading is done as soon as possible after rising and that the evening is around 5pm.b) It allows patients to self monitor in the future and play an active part in their ongoing management

AKT Exam Questions

Theme: All the patients have recently been discharged from hospital. Match the patient scenarios below to a chosen option

1. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a knee replacement on Diclofenac 50mg tds as well as her other medications.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: B

Stop the Diclofenac which has dangerous interactions with Warfarin and could potentially exacerbate renal problems in association with Ramipril.

2. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a chest infection on Erythromycin 500mg qds as well as her other medications

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Erythromycin potentiates the action of warfarin but is presumably essential for whatever reason. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.

3. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a UTI on Ciprofloxacin 500mg bd as well as her other medications

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Ciprofloxacin potentiates the action of warfarin but is presumably essential. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.

4. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She was admitted with a fall and is continuing to do so.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Persistent falls contra-indicate Warfarin. IN this case it is important however to exclude arrthymias (especially bradycardias with bisoprolol) and postural hypotension.

5. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She complains of insomnia and falls. The hospital have prescribed Mirtazepine 30mg at night for significant depression.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: A

Assuming she is depressed, she may get better given time with mirtazepine. She requires careful cardiovascular assessment however – including postural blood pressures.

Theme – Prescribing for the Elderly

6. A 78 year old woman with longstanding hypertension consults you with marked ankle oedema. Her current medication is:- Ramipril 5mg daily; Amlodipine 5mg daily; Aspirin 75mg daily; Simvastatin 40mg daily and Lactulose 15ml at night. You can find no evidence of heart failure and her urine is negative. Her blood pressure is 140/78. Which one immediate intervention is most likely to help her?

A. Addition of Bendroflumethazide 5mg daily
B. Addition of Furosemide 40mg daily
C. Addition of Bumetamide 1mg daily
D. Stopping Amlodipine
E. Stopping Aspirin
F. Stopping Simvastatin

Answer: D

Stop Amlodipine. Despite its many benefits in this age group Amlodipine is a common cause of ankle oedema.

7. A 70 year old man presents to you as a new patient. He informs you that since a stroke two years ago he has suffered from dizziness and increasing difficulty mobilising. Initial recovery was good. His repeat prescriptions (from previous GP) are:- Ramipril 10mg daily; Indapamide 1.5mg daily; Aspirin 75mg daily; Atorvastatin 40mg daily; Furosemide 40mg daily; Prochlorperazine 5mg daily. Which focussed examinations below are most likely to lead to a management plan?

A. Cranial nerves and cerebellum
B. Mental state and reflexes
C. Muscle power and blood pressure
D. Postural blood pressure and gait
E. Pyramidal tracts and joint position sense

Answer: d

Postural blood pressure and gait. Regrettably this is not an uncommon scenario – inappropriate drug regimes find their way on to repeat prescribing systems (in this case a thiazide and loop diuretic which have synergistic actions) Consequences are treated symptomatically (in this case with a phenothiazine) which can itself cause Parkinsonism

Monday 2 February 2009

AKT Questions:

Theme – Endoscopy The following patients all have gastrointestinal symptoms. Initial management should include one of the options below. Each option may be used once, more than once or not at all:-

1. A man of 48 who has a history of endoscopically proven duodenal ulceration five years ago for which he received H. Pylori eradication but was lost to follow up. He has recurrent dyspepsia but no red flag symptoms

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: D


In these circumstances H. Pylori should be rechecked in the first instance (breath test or Stool antigen) and either PPI or eradication depending on the result.

2. 39 year old female nurse who has typical symptoms of reflux. Her body mass index is 35 and she had an initial response to two months high dose proton pump inhibitor.

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: D

This patient should have lifestyle advice, H pylori testing and eradication if positive (even though her symptoms may initially get worse). If negative it would be reasonable to give a proton pump inhibitor as required but review her.

3. A man of 57 with recent onset persistent dyspepsia but no other "red flags".

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: C

He should also have a blood screen and helicobacter testing.

4. A woman of 70 with recent onset of difficulty in swallowing

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy

Answer: B

This would be an indication for a "two week" referral.

5. A woman of 70 who takes diclofenac and is found to have a haemoglobin of 9.0 with an iron deficient picture

A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy.

Answer: C

If the endoscopy does not explain the anaemia she should have a colonoscopy.

AKT Questions

1. OPTIONS:

a ) Amyotrophic lateral sclerosis
b ) Cerebrovascular accident
c ) Gastro-oesophageal reflux
d ) Hypoparathyroidism
e ) Hypothyroidism
f ) Laryngeal carcinoma
g ) Recurrent laryngeal nerve palsy

INSTRUCTION: For each of the patients below, choose the most likely cause of hoarseness above. Each option can be used once, more than once or not at all.

A. A 37 year old woman with a BMI of 34 has a history of dyspepsia. She is presenting with hoarseness which is worse in the morning.

The Correct answer is c.
B . A 68 year old man describes difficulty swallowing over the last few months. He is experiencing difficulties walking. He now presents with hoarseness.

The Correct answer is a.
C . A 53 year old woman, who underwent thyroid surgery four weeks ago, is now presenting with hoarseness.

The Correct answer is g.

2. Although hypothyroidism can cause vocal changes, hoarseness which is worse in the morning is likely to be associated with GORD. Obesity predisposes to GORD. Hoarseness, dysphagia and other motor symptoms are most likely to be caused by motor neurone disease (amyotrophic lateral sclerosis). Neck surgery can result in recurrent laryngeal nerve palsy in 1-2% of cases.

3. A double-blind, randomised, placebo-controlled trial, conducted in primary care, of a new drug for stroke prevention shows statistical and clinical evidence that the drug is superior to placebo in preventing stroke. In deciding whether or not to use this new drug, which one of the following statistics is most useful?

a ) NNK (Number Needed to Know)
b ) NNT (Number Needed to Treat)
c ) RRR (Relative Risk Reduction)
d ) CER (Control Event Rate)
e ) RRI (Relative Risk Increase)

Answer: B

The NNT (Number Needed to Treat) calculates the number of patients a clinician needs to treat in order to prevent one additional adverse outcome.

4. “The expanding use of qualitative research methodology has allowed us to gain knowledge about the characteristics, complexities and interrelationships of phenomena such as an individual’s experiences, emotions, beliefs and motives” (David Silverman, 2004). By applying this methodology in the primary care setting, we can obtain a greater understanding of the patients’ perspective and use this to improve patient health, the health care system and health service delivery. Which one of the following terms would you most associate with Qualitative rather than Quantitative research?

a ) Purposive sampling
b ) Controlled trials
c ) Randomisation
d ) Confidence interval
e ) Double blind

Answer: A

The randomised double blind controlled trial is the gold standard in quantitative research. Prospective studies can be used in Quantitative and Qualitative studies. Confidence intervals are used in statistics in relation to numeric data in Quantitative research. Purposive sampling is a sampling method used in Qualitative Research and is the selection of the most productive sample to answer the research question.

5. Your Practice Manager, of 10 years standing, has been off work for the last six months, with a diagnosis of Multiple Sclerosis. She contacts the Partners and asks if she can have a meeting and this is agreed. During the meeting, she confirms the diagnosis, stating that she realises the consequences of her physical impairment and its effect on her employability. Her mood and behaviour are entirely normal. She states that she is having some difficulties with normal day-to-day activities such as climbing stairs, doing housework, going shopping etc. She states that she wishes to return to work, as she is confident she can carry out all her previous management duties. She realises that getting to her upstairs office could be problematical and a whole day’s work could be overtiring. As her employer, which two management decisions would be most appropriate?

a ) Take her back as Practice Manager on a flexible, part-time basis
b ) Enforce her to take early ill-health retirement
c ) Revamp her working place environment
d ) Take her back as a Telephonist on a flexible ,part-time basis
e ) Take her back as Practice Manager only on a full time basis
f ) Tell her to keep getting sickness certificates from her Doctor
g ) Terminate her employment

The correct answers are, a, c.

Discrimination occurs against a disabled person if an employer treats someone less favourably than others who do not have a disability. The employer has a duty to look at whether there are any reasonable adjustments that can help the disabled person return to work (e.g. Changing hours, changing the local work place environment). The Disability Discrimination Act (2005) extends the definition of discrimination to people with progressive conditions such as Cancer, Multiple Sclerosis, and H.I.V.

AKT Questions

1. A 26-year-old woman presents having slipped off of a kerb 15 minutes earlier and twisted her left ankle while running for a bus. She has been helped to the surgery by two friends, who are supporting her on each side. She states that, although she was able to weight-bear immediately after the accident, she is now unable to do so because of the pain. She is a normally fit and healthy woman. According to the Ottawa Ankle and Foot Rules, which one of the following examination findings, in this case, is an immediate indication for onward referral for x-ray of the ankle?

a ) Bone tenderness over the anterior edge of the lateral malleolus
b ) Bone tenderness over the posterior edge of the lateral malleolus
c ) Bruising and tenderness over the anterior talofibular ligament
d ) Inability to weight-bear on the affected ankle at the time of examination
e ) Pain over the dorsal ligaments on resisted dorsiflexion of the foot

Answer: B

Findings other than B are present in soft tissue injury and do not obligate radiological assessment. Inability to weight-bear immediately after the injury, rather than at the time of examination (by which time soft tissue swelling contributes to the pain), is suspicious of a fracture and indicates an X-ray. The Ottawa Ankle and Foot Rules are not validated for use in those under 18 years of age. Their use can reduce the need for X-rays by around 25% and are readily applied to the primary care setting. See reference for full details of 'the Rules'.

2. A trainer relates to his registrar how, over the years, he has written down ideas, memories, connections, or emotions – the patient who gives a gift, the relative who is bereaved, the colleague who inspires. The audience is the writer himself. What single adjective best describes this form of writing?

a ) Analytical
b ) Biographical
c ) Creative
d ) Historical
e ) Reflective

Answer: E

3. OPTIONS:

a ) Acute closed-angle glaucoma
b ) Bacterial conjunctivitis
c ) Episcleritis
d ) Keratitis
e ) Orbital cellulitis
f ) Scleritis
g ) Subconjunctival haemorrhage

INSTRUCTION: For each patient with a painful red eye, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.


A . A 26 year old man, with no significant past history, presents to you with a three day history of increasing pain and redness of his left eye. He has been unable to wear his contact lenses due to the pain. He has blurred vision and is photophobic in this eye. On examination, he has pericorneal redness of the eye. His pupil reacts normally to light. Insertion of fluorescein reveals an irregular green patch on his cornea.

The Correct answer is d.
B . A 78 year old woman with dementia is visited urgently by you. She is unable to give a history but the nursing home staff report that she has become increasingly distressed and has vomited twice. She is moaning and rocking back and forth holding her head. While examining her, you notice her right eye is red while the left is normal. The redness is around the cornea and the pupil is unreactive to light. Insertion of fluorescein reveals no staining.

The Correct answer is a.
C . A 32 year old woman presents with an acutely painful red right eye and blurred vision. She has had recent swollen joints and takes a non steroidal anti-inflammatory. On examination, she is distressed with the pain and there is marked vasodilation of the vessels all over the white of her eye and it has a bluish appearance. Visual acuity in the right eye is 6/18. Insertion of fluorescein reveals no staining.

The Correct answer is f.

Keratitis can cause ulceration of the cornea which can be sight threatening due to scarring if not treated rapidly. If suspected, an immediate ophthalmology referral is necessary. Acute closed-angle glaucoma necessitates immediate ophthalmology assessment to avoid loss of sight. Symptoms may be preceded by warning haloes and on examination the cornea will be oedematous and appear hazy. Scleritis is often associated with connective tissue diseases. It is very painful and requires urgent ophthalmology assessment as systemic treatment may be required. Without treatment, permanent loss of vision may occur in the affected eye or even perforation of the globe. In posterior scleritis the sclera may look normal. Therefore any rheumatoid patient with a very painful eye should be referred for further assessment. Episcleritis is much less serious and usually affects only part of the eye and is less painful. It can be treated using NSAIDs.

4. OPTIONS:

a ) Amyotrophic lateral sclerosis
b ) Cerebrovascular accident
c ) Gastro-oesophageal reflux
d ) Hypoparathyroidism
e ) Hypothyroidism
f ) Laryngeal carcinoma
g ) Recurrent laryngeal nerve palsy

INSTRUCTION: For each of the patients below, choose the most likely cause of hoarseness above. Each option can be used once, more than once or not at all.

A . A 37 year old woman with a BMI of 34 has a history of dyspepsia. She is presenting with hoarseness which is worse in the morning.

The Correct answer is c.
B . A 68 year old man describes difficulty swallowing over the last few months. He is experiencing difficulties walking. He now presents with hoarseness.

The Correct answer is a.
C . A 53 year old woman, who underwent thyroid surgery four weeks ago, is now presenting with hoarseness.

The Correct answer is g.
1. Following prostatic biopsy, a 65 year old man, with spinal pain, has been confirmed as suffering from prostatic carcinoma. You are asked to prescribe him Goserelin, every 12 weeks and Cyproterone for three weeks. He asks you the reasons for having this combined therapy. The addition of the anti-androgen reduces the risk of which one of the following side effects of the gonadorelin analogue?

a ) Injection-site reaction
b ) Tumour ’flare’
c ) Hair loss
d ) Mood change
e ) Peripheral oedema

Answer: B

During the initial stage (1-2 weeks) of using Goserelin, increased production of testosterone may be associated with progression of prostate cancer. In susceptible patients, this tumour ‘flare’ may cause spinal cord compression, ureteric obstruction or increased bone pain. To reduce this risk, anti-androgen treatment (eg. Cyproterone) should be started three days before the Goserelin and continued for three weeks. The other recognised side-effects quoted will not be affected by this short term use of the anti- androgen.

2. In the process of critically appraising a randomised controlled trial (RCT), which one of the following terms is used to describe the generalisability of the trial results to your own defined patient population?

a ) Heterogeneity
b ) Reproducibility
c ) Significance
d ) External validity
e ) Positive predictive value

Answer: D

In assessments of the validity of studies of healthcare interventions, selection bias refers to systematic differences between comparison groups in prognosis or responsiveness to treatment. Random allocation with adequate concealment of allocation protects against selection bias. Other means of selecting who receives the intervention of interest, particularly leaving it up to the providers and recipients of care, are more prone to bias because decisions about care can be related to prognosis and responsiveness to treatment.
Selection bias is sometimes used to describe a systematic error in reviews due to how studies are selected for inclusion. Publication bias is an example of this type of selection bias.
Selection bias, confusingly, is also sometimes used to describe a systematic difference in characteristics between those who are selected for study and those who are not. This affects the generalisability (external validity) of a study but not its (internal) validity.

3. Your new registrar is keen to utilise her Information Management & Technology skills to enhance the care of her patients. Which one of the following is an online clinical decision support system specifically for general practitioners?

a ) MEDLINE
b ) PRODIGY
c ) NeLH
d ) OMNI
e ) EMIS
f ) VISION

Answer: B

PRODIGY is an online clinical decision support system for general practitioners. MEDLINE and OMNI are medical web-based information systems. NeLH provides access to the best current knowledge available for improving healthcare, clinical practice and patient choice. EMIS and VAMP VISION are practice based computer systems.

AKT Questions

1. You are reading a research paper regarding a new blood test that can be used to screen for colorectal cancer. It shows the following data:

Cancer present Cancer absent Total no. of cases
Blood test positive 80 40 120
Blood test negative 20 60 80
Total no. of cases 100 100 200

What is the specificity of this new test?

a ) 20%
b ) 33%
c ) 60%
d ) 66%
e ) 75%
f ) 80%

Answer: C

Specificity is a measure of how well the test identifies those who do not have disease as not having disease (60%). Sensitivity is a measure of how well the test identifies those with disease as having disease (80%). The positive predictive value indicates how many people with a positive result have the disease (66%). The negative predictive value indicates how many people with a negative result do not have the disease (75%).

2. OPTIONS:

a ) Vitreous haemorrhage
b ) Proliferative retinopathy
c ) Macular degeneration
d ) Papilloedema
e ) Retinal vein occlusion
f ) Retinitis pigmentosa
g ) Optic neuritis

INSTRUCTION: For each of the patients below, select the fundal condition above that is most likely to be consistent with their symptoms and signs. Each option can be used once, more than once or not at all.


A. A 72 year old woman is a heavy smoker. She complains of increasing difficulty in recognising peoples’ faces and is having difficulty reading. She has been frightened by seeing a dark shape just as she wakens up. She says that her Venetian blinds appear wavy. Her assisted acuity is 6/18 bilaterally .Her BP is 170/100.

The Correct answer is c.
B . A 17 year old man has noticed that his vision has been poor in the evenings for the last six months, and this has resulted in him tripping up frequently. His acuity is 6/6 bilaterally. He has been told that a grandparent and a great-grandparent went blind in their 50’s.

The Correct answer is f.
C. A 56 year old HGV driver describes difficulty reversing his vehicle. He has given it some minor scrapes, and thinks there may be something wrong with his vision. He has been troubled by severe headaches for weeks. His acuity is 6/6 bilaterally. Visual field testing reveals a homonymous hemianopia.

The Correct answer is d.

50% of intracranial tumours have focal neurology at presentation.

Sunday 1 February 2009

more AKT questions

1. OPTIONS:

a ) Can never drive again after episode
b ) Can continue to drive after episode
c ) Cannot drive for one month after episode
d ) Cannot drive for 12 months after episode
e ) Cannot drive for 24 hours after episode
f ) Cannot drive for 6 months after episode
g ) Cannot drive for 24 months after episode

INSTRUCTION: According to current driving regulations from the Driver and Vehicle Licensing Agency (DVLA), choose the single most appropriate answer from the above list for each of the following. Each option may be used once, more than once or not at all.

A. A 72 year old man presents with a one hour history of complete loss of power in his left hand which occurred two days previously. The symptoms have now completely resolved and he has been well since. There were no associated symptoms. He has no significant medical history and is on no regular medication. He regularly drives to visit his wife in a nursing home.

The Correct answer is c.
B . A 21 year old woman describes an episode of loss of consciousness the previous day. She was standing at work, felt hot and then was aware of everything starting to go black. The next thing she remembers was lying on the ground. Her friend says she went very pale and dropped to the ground. Her limbs were twitching. She came round fully recovered in less than five minutes. She has been well since. She has a car for personal use.

The Correct answer is b.
C. A 24 year old man presents with an episode of collapse that happened that morning at home. He says he was getting ready for work and felt fine. He then found himself lying on the bedroom floor with no memory of falling. He felt exhausted, his muscles ached all over, and he had wet himself. He thinks he must have been on the floor for some time. He has no significant past history and is on no medication. His job involves driving a car.

The Correct answer is d.

After a TIA or stroke, patients may drive after a minimum of one month providing there is no residual neurological deficit at this point and they are clinically well. There is no need to stop driving after a simple faint. After an initial diagnosis of epilepsy, a licence is revoked for a year with a medical assessment at the end of this time.

2. A 70 year old woman, with spirometry confirmed COPD without reversibility, is attending the nurse- led COPD clinic. She complains to the nurse of gradually increasing breathlessness on minimal exertion, orthopnoea and fatigue. She is not feverish or complaining of increased coloured sputum. The practice nurse wants to try Tiotropium but feels something else might be amiss. She asks you to attend. You carry out a cardio-respiratory examination and find a few bilateral basal crepitations and pitting oedema of both ankles. Which single initial investigation would be most appropriate?

a ) Brain natriuretic peptide(BNP)
b ) Echocardiography
c ) 24 hour ECG
d ) Repeat spirometry
e ) Urinalysis

Answer: E

In this situation, initial basic investigations such as urinalysis and eGFR should be carried out first as renal failure symptoms are similar to those of chronic heart failure. Since the diagnosis of chronic heart failure is often incorrect when based on clinical symptoms and signs alone, confirmation by echocardiography is now a requirement of the Quality Outcomes Framework of the new GMS contract. It is also a recommendation made by SIGN even for the frail elderly. However, the presence of a normal Brain natriuretic peptide (BNP) blood test (if available locally) and a normal ECG will make the diagnosis of chronic heart failure unlikely

3. OPTIONS:

a ) Osteoarthrtitis
b ) Gout
c ) Haemarthrosis
d ) Pseudogout
e ) Trauma
f ) Septic arthritis
g ) Rheumatoid arthritis

INSTRUCTION: Choose the single most likely diagnosis above for each clinical scenario presented below. Each option can be used once, more than once or not at all.

A. A 60 year old man presents with an acutely painful first metatarsophalyngeal joint on his right foot which has been grumbling on for a week since he was on holiday In Tenerife.

The Correct answer is b.
B. A 75 year old woman, with known osteoarthritis, requests a home visit as she has awoken to find her left knee acutely painful, red and swollen. She complains of nausea. On examination, the knee is hot and swollen with restricted movement. Her pulse is 110. Temp 37.0.

The Correct answer is f.
C . A 43 year old diabetic patient hobbles into the surgery complaining of a two day history of increasing swelling and redness of her left ankle. She cannot remember injuring it. She can weightbear with difficulty. The joint is hot and swollen. She has a mild pyrexia of 37.8 C

The Correct answer is f.

Septic arthritis has a case fatality of around 11%. Delayed or inadequate diagnosis leads to joint damage. Patients with a short history of a hot swollen and tender joint (joints) should be regarded as having septic arthritis until proven otherwise, even in the absence of fever.

4. With reference to the Medicines and Healthcare products Regulatory Agency (MHRA) 'Yellow Card Scheme' for reporting adverse drug reactions (ADRs), which one of the following statements is correct?

a ) ADRs of any severity should be reported for new, black triangle drugs or vaccines
b ) An ADR report should be submitted only when causality between a drug and an adverse reaction is certain
c ) Herbal remedies are excluded from the ADR scheme
d ) Only a designated Healthcare Professional can report an ADR
e ) Patient consent is required before submitting an ADR report on their behalf

Answer: A

Causality does not have to be proven – suspicion is enough. Herbal remedies are included in the scheme. Anyone, patients included, may file a report. Patient consent is not required as no patient-specific personal information is required.

5. A 39 year old woman presents with a six month history of prolonged and heavy menstruation. She feels a heaviness in her lower abdomen. She has had two first trimester miscarriages in the previous 18 months. LMP was three weeks ago. Her last ultrasound scan was suspicious of a bulky uterus. There is no weight loss .She has a borderline low haemoglobin and low ferritin levels. She has had only moderate symptomatic relief from tranexamic acid and mefenamic acid. What is the single most likely diagnosis?

a ) Adenomyosis
b ) Endometrial carcinoma
c ) Myometrial fibroids
d ) Cervical carcinoma
e ) Endometrial polyp

Answer: C

Fibroids (uterine leiomyomas) are benign tumours of the smooth muscle cells of the uterus. Women with fibroids can be asymptomatic or may present with menorrhagia (30%), pelvic pain with or without dysmenorrhoea or pressure symptoms (34%), infertility (27%), and recurrent pregnancy loss (3%). Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue within the myometrium. The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively).

6. A research project looking at the management of moderate hypertension divides its subjects into two groups. Group A, with 1776 subjects, receives anti-hypertensive medication. Group B, with 1800 subjects, receives a placebo. After five years the risk of a stroke in Group A is 12%, while in group B it is 20%. What is the Number Needed to Treat (NNT) to prevent one extra stroke?

a ) 2.00
b ) 1.25
c ) 8.00
d ) 12.50
e ) 58.00

Anser: D

NNT is the reciprocal of the absolute risk reduction. For patients with moderate hypertension, receiving placebo treatments, about 20% would be expected to have a stroke over the next five years. This risk is reduced to 12% with antihypertensive drugs. This results in an absolute risk reduction of 0.20-0.12=0.08. The reciprocal of this number is 12.5 - implying that a doctor would need to treat about 12.5 moderately hypertensive patients for five years before he or she could expect to prevent one extra stroke.

7. OPTIONS:

a ) Dental caries
b ) Furuncle
c ) Nasopharyngeal carcinoma
d ) Otitis externa
e ) Otitis media
f ) Ramsay Hunt syndrome
g ) Temporomandibular joint dysfunction

INSTRUCTION: Match the following scenarios with the most likely diagnosis above. Each option can be used once, more than once or not at all.


1 . A 78 year old man with dysphagia and earache.

The Correct answer is c.
2 . A 75 year old man with facial weakness, a focal rash and earache.

The Correct answer is f.
3 . A 45 year old woman with earache worsened by eating and yawning.

The Correct answer is g.

In older patients, a diagnosis of dysphagia is often due to neurological causes such as a CVA. Earache is not a common feature of stroke. Earache with dysphagia suggests the presence of a nasopharyngeal carcinoma. Facial weakness in this age group can suggest stroke. However, in the context of a rash in the external auditory canal and earache, the most likely unifying diagnosis is Ramsay Hunt syndrome. In an adult with earache worsened by eating, dental caries is a possibility. The fact that the symptoms are worsened by yawning makes temporomandibular joint dysfunction more likely.

8. A 55 year old man, who is a heavy smoker, and has a history of hypertension, is seen on an emergency home visit. On examination, his blood pressure is 180/110 with an irregular pulse of 90 bpm. There is no evidence of cardiac failure. He has a mild expressive dysphasia with a left hemiparesis. According to his wife these symptoms have been present for more than 12 hours. He denies any headache and is fully conscious and orientated. With regard to the gold standard, what is the single most appropriate referral plan?

a ) Refer urgently for a neurology appointment (1-2 days).
b ) Refer as an emergency to the nearest hospital.
c ) Refer to a TIA clinic within 1 week.
d ) Refer as an emergency to the nearest stroke unit.
e ) Refer to the stroke clinic within 1 week

Answer: D

All patients with acute stroke should ideally be admitted to a multidisciplinary stroke unit as soon as possible. All patients with acute stroke should undergo CT brain scanning within 24 hours. Stroke outcome is significantly better when patients are treated in an organised stroke unit compared to either general hospital care or organised care at home. High blood pressure should not normally be lowered in the acute phase of stroke. Aspirin should be given as soon as possible after the onset of stroke symptoms once a diagnosis of primary haemorrhage has been excluded (by CT scanning). Following a TIA, the risk of stroke is approximately 7 times greater than the risk in the general population, especially in the first few weeks. Patients should be assessed and investigated in a specialist clinic within 7 days.

Saturday 31 January 2009

new AKT Questions

1. A 50 year old man has a blood pressure of 158/88. He has no known atherosclerotic disease but is keen to prevent it. He asks if he should take aspirin. At which calculated absolute risk of a cardiovascular or cerebrovascular event is it appropriate to start aspirin 75mg?

a ) Greater than, or equal to, 10% over five years
b ) Greater than, or equal to, 10% over 10years
c ) Greater than, or equal to, 15% over five years
d ) Greater than, or equal to, 15% over 10 years
e ) Greater than ,or equal to, 20% over five years
f ) Greater than, or equal to, 20% over 10 years

Answer: F

Asymptomatic individuals, without established atherosclerotic disease, but with a calculated cardiovascular risk of more than, or equal to, 20% in 10 years, should be considered for aspirin 75mg daily.

2. A 40 year old woman presents with intermittent abdominal pain which she says is totally relieved by defaecation. Which one of the following symptoms would suggest further investigations are mandatory?

a ) Loose stools
b ) Blood in stools
c ) Feeling of incomplete evacuation
d ) Increased stool frequency
e ) Mucus in stools

Answer: B

According to the Manning Criteria for the diagnosis of irritable bowel syndrome, the diagnosis may be made if three or more of the following are present: abdominal pain, relief of pain with defecation, increased stool frequency with pain, looser stools with pain, mucus in stools and feeling of incomplete evacuation. If any of the following red flag symptoms are present a full GI work up is needed: being over 50 years old, having weight loss, blood in stools, anaemia or fever.

3. A 40 year old doctor, who has just returned from a six month sojourn in Central America, presents with a painless nodule of his right upper eyelid. It has been growing slowly over the last six weeks. What is the single most likely infected cause of the swelling?

a ) Leishmaniasis
b ) Leprosy
c ) Malaria
d ) Schistosomiasis
e ) Trypanosomiasis

Answer: A

He is presenting with a chalazion. With increasing international travel, it is important to take a travel history. Leishmaniasis is found in the rain forests of Central and Southern America. It can commonly present as an infected chalazion

4. A 54 year old man, with a moderate learning disability, is brought to see you by his carer. She states that his behaviour has been deteriorating over the last three weeks. He hasn’t been responding when spoken to and hasn’t been doing things when asked. He becomes aggressive when confronted. In particular, he has refused to turn down the volume on his TV and this is causing arguments with other residents. He has been well otherwise, with no change in eating or toilet habit. He has no relevant history or medication. He answers all questions with the response “I’m fine” but this is his usual. On examination, he is apyrexial, pulse and BP are normal. His chest and abdomen are normal. Which one of the following is the most likely diagnosis?

a ) Absence seizures
b ) Depression
c ) Ear wax
d ) Early onset dementia
e ) Urinary tract infection

Answer: C

Due to communication difficulties, people with learning disabilities may not complain of any sensory changes and, therefore, simple problems like a build up of ear wax can present in an unusual way. One must be alert to such atypical, and often simple, explanations.

5. OPTIONS:
a ) 2 weeks
b ) 4 weeks
c ) 6 weeks
d ) 8 weeks
e ) 12 weeks
f ) 26 weeks
g ) 52 weeks

INSTRUCTION: For each patient below who has had a Myocardial Infarction (MI), select the single most appropriate time scale above to fit their circumstances. Each option may be used once, more than once or not at all.

A. Mr A is 50 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. For how long after the event should he be advised to refrain from driving his car? (He does not hold a PSV or HGV licence)

The Correct answer is b.
B. Mrs B is 50 years old and has recently had an uncomplicated MI. This is her first cardiovascular event and she has made a straightforward recovery. She works as a dinner lady. This involves a lot of lifting and carrying of heavy pots and pans as well as supervision of children. She misses the company at work and is keen to get back to her own job. According to the British Heart Foundation when should she be advised that she may return to her work?

The Correct answer is e.
C. 3 . Mr C is 45 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. He is able to climb two flights of stairs without difficulty. His daughter has recently had a baby and he is keen to visit. This would involve a flight of three hours. How long after his MI do most airlines advise before he can fly?

The Correct answer is a.

Mrs B must be considered to be a heavy manual worker and as such should be advised to wait for three months before going back to her work. The British Heart Foundation has a useful leaflet on activity after an MI- Heart Information Series No7. Most airlines will not carry passengers for two weeks after an uncomplicated MI but will then do so if they can climb a flight of stairs without difficulty.

7. OPTIONS:

a ) Prostate cancer
b ) Bladder calculus
c ) Chronic prostatitis
d ) Urinary tract infection
e ) Urethritis
f ) Benign prostatic hypertrophy
g ) Urethral stricture

INSTRUCTION: Choose the single most likely option above for each of the scenarios below. Each option can be used once, more than once or not at all.


1 . A 58 year old patient, who has previously been catheterized and has undergone a T.U.R.P, complains of diminishing urine flow over a period of months. Rectal examination reveals no prostatic enlargement.

The Correct answer is g.
2 . A 65 year old patient presents with terminal dribbling, poor flow and hesitancy. Rectal examination reveals a smooth and symmetrical swelling. The surface is flattened and it is difficult to get the examining finger forward round each side.

The Correct answer is f.
3 . A 32 year old diabetic man presents with chronic, perineal pain of varying severity and frequency. It is exacerbated by sitting on a hard chair. He also describes low back pain extending down his left leg with bouts of fever and dysuria. Rectal examination reveals an enlarged, firm, and irregular prostate.

The Correct answer is c.

Prostate cancer is rare below the age of 50. Benign prostatic hypertrophy is a common condition in older men; it is unusual before 50 years of age and is most common between 60 and 70

8. A 67 year old woman, who is well known to you, has been diagnosed with Alzheimer’s disease and is in a care home. You are asked to see her because she has become aggressive and violent towards carers and other residents. Carers have followed NICE guidance on the management of aggression with no success. You manage to examine her and can find no obvious cause for her deterioration. You decide that she will need admission for further assessment in order to exclude other remediable causes for her agitation, and that it is justifiable to sedate her at this point. Which the single most appropriate drug for this purpose?

a ) IM haloperidol
b ) Oral diazepam
c ) Oral chlorpromazine
d ) IM lorazepam
e ) Oral lorazepam

Answr: E

Agitation and aggression should be managed by non-pharmacological methods where possible. The use of drugs is often unnecessary, and they can increase the risk of cerebrovascular events. If the risks have been considered and are justified, oral drugs are preferable to parenteral routes. Oral lorazepam, haloperidol or olanzapine in the lowest effective dose are the preferred drugs. Careful patient monitoring after sedation is mandatory.


10. A 23 year old man, who is a reformed intravenous drug misuser, was screened by the practice for blood borne viruses. He was found to be suffering from chronic Hepatitis C. He is accepted on to a treatment programme and is given pegylated Interferon and Ribavirin. He presents to you complaining of feeling extremely tired and not wanting to do anything. His appetite is poor and his bowel is looser than usual. He has lost weight. As a precaution you check his bloods. Which one of the following is the most likely diagnosis?

a ) Crohn’s disease
b ) Depression
c ) Gastric carcinoma
d ) Psychotic illness
e ) Renal failure

Answer: B

This combination of drugs has a very wide range of adverse side effects including effects on the liver, heart, kidney, gastrointestinal and haemopoietic systems. However, depression and flu-like symptoms are much more common.

Monday 26 January 2009

AKT Questins

1. As part of their annual review for hypertension, your patients have urea and electrolytes measured. Significant numbers are now coming back with evidence of chronic renal impairment. Which of the following statements about this condition are true? Select three statements only.

A. Most laboratories now provide a measurement of the patient’s true glomerular filtration rate (GFR) which is a definitive guide to renal function
B.Patients with eGFR > 60 ml/min per 1.73 m2 do not have renal impairment
C.An eGFR < 15 is the cut-off for stage 5 chronic renalimpairment, at which point patients should be considered for dialysis
D. A blood pressure treatment goal of < 125/75 is indicatedfor patients with proteinuria
E. A high-protein diet is required in patients with proteinuria to replace urinary losses
F. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with only one kidney
G. Patients with moderate-to-severe chronic renal impairment should follow a diet restricted in potassium

Answer: C,D,G

The result measured by laboratories is an estimated GFR (or eGFR), which assumes standard body surface area and race. Patients who have, for instance, had an amputation may receive erroneous results. An eGFR between 60 and 89 correlates with mild renal impairment. Stage 5 chronic kidney disease is defined as eGFR < 15. Low protein diet has been shown to reduce death rate in chronic renal disease. Patients with only one kidney are prone to renal impairment and should all be considered for ACE inhibitors.

more free AKT questions

1. Which of the following statements about screening for colorectal cancer are true? Select three options only.

A. The presence of a latent phase with precancerous lesions makes colorectal cancer ideal for screening
B. Colonoscopy is the only screening method proven to reduce mortality
C. Of patients with colorectal cancer 90% have symptoms of rectal bleeding
D. Proposed national screening for colorectal cancer will target those aged 50-74 years
E. Flexible sigmoidoscopy in women of average risk picks up only 35% of cancers
F. Of patients with iron-deficient anaemia in general practice 11% were found to have gastrointestinal cancer

Answer: A,E, F

fecal occult blood testing isthe only screening method proven to cut death rates. the proposed screenig programme will start in 2010 an scren the age group 60-69 years. the CONCeRN study showed low sensitivity for colonoscopy in women of average risk. rectal bleeding occurs in less than 50% of colorectal cancer.

2. A patient with dyspepsia has recently had an upper gastrointestinal endoscopy. His histology comes back positive for Helicobacter pylori. Which of the following statements about the management of this situation are true? Select two answers only.

A. Serological testing is highly sensitive and specific
B. Resistance to metronidazole is common in inner city areas
C. Eradication therapy involves a combination of amoxicillin and a proton pump inhibitor
D. Serological testing can be repeated after 4 weeks to confirm eradication
E. Prescriptions for Heliclear (amoxicillin, clarithromycin and lansoprazole) treatment packs are charged three prescription charges

Answer: B, E

Breath esting, CLO testing and stol antigen tsts are senstive and senstive. eradication therapy involves high dose amoxicillin, clarithromycin and lansoprazol. serological testing tkes 6-12 months to retur to normal.

3. A 73-year-old mentions at a routine blood pressure check-up that he has to get up four or five times a night to go to the toilet. This is disturbing his wife to the point that he has moved into the spare room. Examination reveals a smooth enlarged prostate and you send blood for PSA (prostate-specific antigen) testing and a urine specimen for culture. This comes back clear and his PSA level is 3.6. Which of the following statements about his management is true?

A. He should be referred for a prostate biopsy
B. Transurethral resection of the prostate is the treatment of choice in this patient C. Finasteride will provide rapid relief from his symptoms with no risk of postural hypotension
D. Saw palmetto has been shown to have a placebo effect only
E. a-Blockers are the first-line treatment in this patient group

Answer: E

Surgery should be reserved for patients with bladder outflow obstruction or in those in whom medical therapy fails. Finasteride is effective but takes some weeks to work. Its mode of action is to shrink the prostate. Saw palmetto has been shown to be an effective treatment for prostatism.

4. A 56-year-old man presents with unprovoked, painless, macroscopic haematuria. Dipstick testing confirms the presence of blood but no leucocytes or nitrites. Which of the following may be a cause of these symptoms?

A. Renal colic
B. Beetroot consumption
C. Urinary tract infection
D. Bladder tumour
E. Renal trauma
F. all of the above.

Answe: D

Painless macroscopic haematuria should be considered to be the result of renal tract cancer until proven otherwise. A UTI would be associated with dysuria and leucocytes and nitrites. Beetroot may discolour the urine but would not affect dipstick results. Trauma and colic are associated with pain, although haematuria may be a sign of a coagulopathy.

Friday 9 January 2009

AKT Questions

1. The following are notifiable diseases in England and Wales

a. acute encephalitis T
b. dysentery T
c. pulmonary tuberculosis T
d. chicken pox F
e. Kawasaki disease F

Bacterial: anthrax, diphtheria, leptosporosis, pertussis, plague, Brucellosis, tetanus, typhus, cholera, dysentery, food poisoning, paratyphoid fever, typhoid, leprosy, tuberculosis, meningitis, meningococcal infection, ophthalmia neonatorum, erysipelas, scarlet fever.
Viral: acute encephalitis, AIDS, hepatitis B, measles, mumps,rubella, poliomyelitis, rabies, varicella (encephalitis- chickenpox isn't) , yellow fever.
Protozoal: malaria.
Chicken pox is notifiable in Scotland.

2. Theme:Causes of deafness

A Acoustic neuroma
B Alport's syndrome
C Barotrauma
D Drug induced
E Hypothyroidism
F Meningitis
G Otitis media
H Paget's disease
I Pendred's syndrome
J Radiotherapy
K Stroke

Select the most likely cause of deafness in the following cases:

-A 75-year-old male presents as he has increasing problems with deafness. He suffers from Parkinson's disease and takes l-dopa therapy.On examination, he has a pill rolling tremor and reduced mobility. There is also enlargement of the skull.

Answer: H
Although this man has Parkinson's disease, the description of a large skull suggests Paget's disease as the cause of deafness as l-dopa does not cause deafness. Paget's causes enlargement of the bone in the inner ear which can be responsible for the conductive deafness

- A 20-year-old female presents with increasing deafness. She only takes the oral contraceptive pill. On examination, there is nil of note but urinalysis reveals blood ++ and protein++.

Answer: B
Alport's syndrome is an inherited condition associated with sensorineural deafness and renal dysfunction.

- A 54-year-old female presents with a two month history of increasing deafness in the left ear. She has a history of hypertension for which she takes lisinopril and amlodipine. On examination she has decreased hearing in the left ear both through air and bone and there is loss of the corneal reflex on the left side.

Answer: A
The sensorineural deafness suggests involvement of the VIII cranial nerve and the loss of corneal reflex indicates involvement of the V cranial nerve. This would occur in the posterior fossa of the brain and hence the likely lesion is an acoustic neuroma.

3. You have been informed by the local hospital that a 4-year-old patient from your practice has been admitted with definite meningococcal sepsis. There have not been any previous cases. You need to organise appropriate prophylaxis. Which of the following is the single most appropriate group to treat?

a. All family members
b. All family members and friends who have played with the child in the last 48 hours
c. All family members and children at the same nursery
d. All household members
e. All household members and children at the same nursery

Answer: D


The following groups would be classed as close contacts and require prophylaxis:

people in the same household
people who have slept in the house during the 7 days prior to the onset of the illness
people who have spent several hours a day in the house inthe last 7 days
â€کKissing contacts’, ie boy/girlfriend
students sharing the same room or flat as the case
anyone who gave mouth-to-mouth resuscitation to the index case
Those attending the same childminder as the index case in the last 7 days.


Groups not requiring prophylaxis:
school, nursery or playgroup contacts
students on the same course or in the same hall of residence who are not in the above categories.


4. THEME: VOMITING

A Cow’s milk protein intolerance

B Gastroenteritis

C Gastro-oesophageal reflux

D Hiatus hernia

E Hirschprung’s disease

F Lactose intolerance

G Overfeeding

H Posseting

I Pyloric stenosis

J Reduced gastric motility


For each of the following clinical situations, choose the single most likely diagnosis from the list of options given above. Each option can be used once, more than once or not at all.


A 1-week-old baby is brought by his mother. He was born at home. Mum is concerned that he is vomiting and not feeding well. On questioning, his mother tells you that she cannot remember her child opening his bowels. On examination, the child appears grey, his abdomen is distended and firm. He vomits forcefully when you palpate his abdomen.


E Correct answer
Classically presents in the neonatal period with failure to pass meconium within 24 hours and features of obstruction. It is caused by aganglionosis of the distal bowel. If only a small segment of large bowel is affected children can present several years later with chronic constipation. diagnosis is made by rectal biopsy.


A 6-week-old baby is brought to see you with increasing vomiting. His mother reports that he feeds very well and is always hungry. Initially he vomited small amounts after some feeds. Over the last week, he has had large vomits after every feed. On examination, the baby is alert and hungry but appears to have lost weight.


I Correct answer
Caused by hypertrophy of the pyloric sphincter. Classically presents at 6 weeks with a preceding history of worsening vomiting as the pylorus becomes increasingly hypertrophied with use. Babies usually feed very well and are very hungry. Weight loss can be dramatic. Management includes stopping feeds, correction of electrolyte imbalance and surgical correction. The prognosis is very good.


A 6-week-old baby has a history of vomiting. His mother reports that from the age of 1 week her child has vomited after almost every feed. He is distressed when he vomits and if he is laid flat after a feed. He is thriving and examination is unremarkable.


C Correct answer
Common in infancy, due to relatively poor muscle tone. Symptoms improve with age. This is due to stronger muscle tone, introduction of dietary solids and a more upright posture for the baby. in severe cases there can be failure to thrive and feeding aversion because of the distress associated with feeds. there are several management options:
Keeping the child upright (no proved benefit)
Propping up the head of the bed (no proved benefit)
Thickening agents (proved benefit)
Antacids, eg Gaviscon (no proved benefit)
Ranitidine (proved benefit)
Omeprazole and domperidone, often used but not licensed.


A 6-week-old baby has a history of vomiting. His mother reports that he vomits after feeds, two or three times a day. He is described as a hungry baby. He takes 300 ml every 3 hours during the day, having seven feeds in 24 hours. His weight is above the 99th centile. Examination is otherwise unremarkable.


G Correct answer
Full-term babies normally require 150 ml/kg/day of milk. Particularly hungry babies might need more than this to settle them but volumes over 200 ml/kg/day are not recommended. Overfeeding is common and often results in vomiting.


An 8-month-old baby has a history of vomiting. She attends nursery 3 days per week. She has a 2-day history of vomiting after some feeds and the vomiting is worsening today. She is opening her bowels regularly and had one loose stool this morning. Examination is unremarkable, although she cries throughout.


B Correct answer
Mild, self-limiting episodes of gastroenteritis are common in this age group. Infants who attend nursery have twice the number of viral infections as those that do not.


5. THEME: JAUNDICE

A ABO incompatibility

B Biliary atresia

C Breast milk jaundice

D Galactosaemia

E Gilbert syndrome

F Hepatitis

G Hypothyroidism

H Physiological jaundice

I Rhesus incompatibility

J Sepsis


For each of the following clinical situations choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not all.


· A 20-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well and the baby’s mother has no concerns. On further questioning, she tells you that the baby’s urine is dark in colour and that the stools are the same colour as the baby’s nappy. Examination reveals no abnormality.


B Correct answer
This is a congenital abnormality, presenting as prolonged conjugated jaundice. A history of dark urine and pale stools might also be given. This requires urgent corrective surgery. A significant number of children operated on after 6 weeks of age develop chronic hepatic failure and some require liver transplantation.


· A 10-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well. The jaundice was first noted on day 2 of life. The baby’s mother is concerned that her baby has a red rash in the nappy area and some small spots on the face. Examination reveals no other abnormalities.


C Correct answer
Babies who are breastfed are more likely to become jaundiced because they are taking less milk volume in the first 48 hours. The jaundice also takes longer to resolve than in formula-fed babies. This is not harmful and there is no need to stop breastfeeding.


·A 4-day-old baby is brought to your surgery by his father. He is concerned that the baby has not been feeding well for the past 24 hours. On examination, the baby is jaundiced and floppy and the heart rate is 160/minute. The father cannot give you any further history.


J Correct answer
Infection can present with jaundice in the neonatal period. Onset of jaundice in the first 24 hours of life warrants investigation for sepsis. After this time there are usually other symptoms and signs indicating infection, as in this case. In prolonged jaundice (visible after 14 days), an untreated infective cause (eg urinary tract infection) should be ruled out.


· A 6-day-old baby is brought to your surgery by her mother. She is the third baby in the family and the mother is concerned about her baby’s feeding. She describes her baby as sleepy and floppy and taking a long time to finish bottles. The mother says that the baby has been jaundiced since day 3 of life. On examination, the baby is jaundiced and floppy with a large fontanelle.


G Correct answer
Hypothyroidism can present in the neonatal period as jaundice, poor tone and poor feeding. examination is usually otherwise normal, although a large fontanelle and umbilical hernia may be features. Urgent investigation and treatment is necessary as mental retardation develops early and is irreversible. Screening for hypothyroidism is now part of the national neonatal screening programme, but the result would not be available at this stage. If there is clinical suspicion of hypothyroidism it is important to check the baby’s full thyroid function profile as the screening test only measures thyroid-stimulating hormone levels.


· You see a 6-day-old baby who is jaundiced. The baby was noted to be jaundiced on day 2 of life. Bilirubin levels were checked in the hospital and the baby did not require any treatment. Although he took a few days to start feeding, he is now breastfeeding well. The mother feels he is slightly less jaundiced than yesterday. Other than jaundice you can find no other abnormalities on examination.


H Correct answer
In full-term babies, physiological jaundice is usually visible from day 2 or day 3, peaks at day 5, and has resolved by day 14. Treatment consists of ensuring adequate milk intake and ruling out any other causes (ie infection, rhesus or aBo incompatibility). If the bilirubin level is rising rapidly, phototherapy might be necessary but can usually be avoided if feeding issues are addressed early. Physiological jaundice in preterm infants starts sooner and usually lasts longer, up to 21 days.


6. THEME: WHEEZE
A Anaphylaxis

B Asthma

C Bronchiolitis

D Chronic lung disease

E Croup

F Cystic fibrosis

G Foreign body inhalation

H Primary ciliary dyskinesia

I Recurrent aspiration

J Virus-induced wheeze


For each of the following clinical situations, choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not at all.


· A 2-year-old child is brought to see you with sudden onset of wheeze and shortness of breath. The symptoms started when the child was at nursery this morning. She has been otherwise well. There is no significant past medical or family history. On examination, she is distressed, with mild subcostal recession; there is an audible wheeze. On auscultation, you can hear wheeze on the right side of the chest, with good air entry throughout.


G Correct answer
A sudden onset of respiratory distress in a child of 18 months to 3 years should raise the suspicion of an inhaled foreign body. If there is a suggestive history and/or unilateral clinical signs it is an important diagnosis to rule out. Urgent paediatric assessment is required.


·A 20-month-old boy is brought to see you with respiratory distress. He has been unwell for 2 days with a runny nose, cough and reduced feeding. He is normally fit and well. On examination, the child is coryzal and has a temp of 38.1 °C. His respiratory rate is 32/minute, with mild subcostal recession. Wheeze can be heard throughout the chest with good air entry. He has a blanching maculopapular rash on his trunk


J Correct answer
Many children aged under 3 years wheeze with viral infections. no treatment is usually necessary. a trial of salbutamol via inhaler and spacer can be given to children aged over 1 year if respiratory distress is severe or if there is a strong family history of atopy.


·A white 22-month-old boy is brought to see you by his mother. They have recently moved to the area. His mother tells you that he often needs antibiotics for his chest and that this is why she has brought him in now. On examination, the child is small and thin (weight and height are on 0.4th centile) with visible Harrison’s sulci. He has mild subcostal recession. Wheeze can be heard throughout the chest.


F Correct answer
Recurrent lower respiratory tract infections and poor weight gain warrant further investigation. The most likely diagnosis in the white population is cystic fibrosis. Other pathologies such as immunodeficiencies, congenital lung abnormalities and rarer causes of bronchiectasis such as primary ciliary dyskinesia should be considered if cystic fibrosis tesing is negative.


·You are asked to visit a 3-year-old girl at home. She is not known to you but from her notes you see that she has diagnoses of cerebral palsy, kyphoscoliosis and severe gastro-oesophageal reflux. She is fed via a gastrostomy tube. She has symptoms of a moist cough and fever. On examination, she has a respiratory rate of 28/minute and wheeze and crepitations throughout the chest.


I Correct answer
Children with chronic neurological conditions often have gastrooesophageal reflux and are at high risk of recurrent aspiration. Fundoplication and gastrostomy feeds can help. Infections need to be treated early and aggressively because this is the main cause of mortality in this group of patients.


· A 6-week-old baby is brought to see you with breathing difficulties. She was born at 33 weeks’ gestation and was discharged home 2 weeks ago. She has a 24-hour history of fast, noisy breathing and reduced feeding and the mother thinks that she might have stopped breathing just now in the waiting room. On examination, there is subcostal recession and wheeze is heard bilaterally.


C Correct answer
Bronchiolitis is a viral illness affecting infants aged under 1 year. It is predominantly caused by respiratory syncitial virus (rsv). Clinical features include respiratory distress, wheeze, coryzal symptoms, lowgrade temperature and reduced feeding. Treatment is supportive. Those under the age of 2 months, ex-premature babies and those with existing pathology (eg cardiac disease) are at particular risk and can develop apnoeas. Paluvizumab, a monoclonal antibody against rsv, is now available, though it is very expensive. It is currently offered to premature babies with significant lung disease and to some children with cardiac problems

Thursday 8 January 2009

AKT Questions

1. A 33- year-old woman presents with a 6-month history of a progressively painful area in the upper outer quadrant of her right breast. She has been on oral contraception intermittently for nearly 15 years. Clinically, there is as area of moderate nodularity in the right breast but no discrete lesion is palpable. Select the single most likely diagnosis from the list below?

A. benign breast change
B. breast carcinoma
C. fibroadenoma.
D. haematoma
E. mondor's disease.

Answer: A

Painful nodularity of the breast (unilateral or bilateral) is characteristic of benign breast change (sometimes referred to as "abnormalities of normal development and involution" or ANDI, "fibroadenosis" or "fibrocystic changes"). It affects 1/3 of all women and often causes anxiety in premenopausal women. The symptoms can be cyclical and evening primrose oil provides symptomatic relief.

2. Which of the following statements about Crohn's disease is true?

A. active disease should be treated initially with mesalazine
B. antimycobacterial therapies are an effective treatment if used early
C. anti-TNF-α therapy is associated with remission rates of 80%.
d. Crohn's disease only affects the colon
E. patients should be referred early for surgery.

Answer: B

Mesalazine is no better than placebo in the management of active disease. Its main use is in prevention of relapse after surgery. Infliximab is an effective anti-TNF-α therapy in up to 80% of cases, but only 24% are steroid free. Surgery should be reserved for patients who do not respond to steroids, Methotrexate or Infliximab. Antibiotics should only be used for septic complications and perianal disease. Crohn' disease can affect any part of the GI tract from the mouth to the anus.

AKT Questions

1. A 15 year old boy is brought in by his father. The father describes witnessing his son collapsing and becoming briefly unconscious during a game of football two days earlier. Which one of the following would be the most appropriate management in the surgery?

a ) FBC
b ) 12 lead ECG
c ) Reassurance
d ) Spirometry
e ) Urinalysis

Answer: B

Sudden death in the young during exertion can commonly be due to Long QT syndrome and may present with syncope and or palpitation prior to sudden death at a later date. It is increasingly recognised that non-competitive physical activity or even emotional upsets can be associated with arrhythmias and sudden death. A history such as this should, therefore, always prompt further cardiac investigation.

2. A 45 year old man (lifelong UK resident) presents with a three month history of cough, sweats, tiredness and weight loss. Despite these symptoms, he is managing all activities of daily living. He has recently moved into a flat with his new partner and her seven year old son having previously been homeless and living in hostels. He has no significant past medical or drug history. He had a chest X-ray carried out which suggested a diagnosis of active pulmonary TB. Risk assessment suggests that this is unlikely to be a multiple drug resistant strain. In infection control, which one of the following is the most appropriate statement?

a ) Wear a face mask when seeing him during the early weeks of treatment
b ) Screen close contacts only if they become symptomatic
c ) Admit him for commencement of treatment in isolation
d ) His BCG vaccinated partner should be screened
e ) The asymptomatic son should receive BCG vaccination immediately

Answer: D

Generally a face mask is unnecessary unless the patient has multiple drug resistant TB (MDR TB) in which case it is advisable until the patient is no longer infectious. All close contacts should be assessed and screened for asymptomatic disease. Once disease has been excluded BCG vaccination can be considered. Unless the patient is clinically unwell, hospital admission for tests or treatment should be avoided. Previous BCG vaccination cannot be assumed to give immunity for a close contact, particularly so if they could be HIV positive. All patients should have a risk assessment carried out for HIV and MDR Tuberculosis.

3. OPTIONS:

a ) Abdominal ultrasound
b ) Ankle brachial pressure index
c ) Exercise tolerance ECG
d ) Echocardiography
e ) 12 lead resting ECG
f ) 24 hour ambulatory blood pressure monitoring
g ) 24 hour ambulatory ECG monitoring

INSTRUCTION: From the above list, select the investigations most likely to confirm the clinical diagnosis for each of the following patients. Each option can be used once, more than once or not at all.

A . A 45 year-old woman presents with a three month history of feelings of thumping in the chest, associated with breathlessness. She is a non-smoker and drinks 30 units of alcohol weekly. Examination reveals a regular pulse, and a BP of 150/90.

The Correct answer is g.
B . A 50 year-old man has experienced a tight sensation in his chest for three weeks when walking uphill on the golf course, and after meals. He smokes 10 cigarettes daily. Examination is normal.

The Correct answer is c.
C. A 70 year-old man presents with two weeks’ vague lumbar backache. His past history is unremarkable apart from controlled hypertension, and he stopped smoking 20 years ago. His father died suddenly in his 60s, of an unknown cause. Examination reveals no abnormality except obesity.

The Correct answer is a.

Resting ECGs should be performed in patients with palpitations or chest pain, but a normal ECG does not exclude coronary artery disease. It also rarely picks up episodic arrhythmias. Abdominal aortic aneurysm should be considered as a cause of vague abdominal or back pain in the elderly.

4. A young woman, for whom you have been prescribing daily supervised Methadone 40mgs, tells you she is approximately 10 weeks pregnant. She relates that, about 20 minutes after taking her Methadone, she vomits it up. She then feels sweaty and agitated for the rest of the day. She asks if she could be given more Methadone to take later in the day. What is the single most appropriate action?

a ) Reduce her daily dose of Methadone
b ) Prescribe additional Methadone for a few weeks
c ) Report her to Social Services
d ) Arrange additional drug counselling
e ) Stop her Methadone

Answer: B

The main objective is to maintain drug taking stability during pregnancy as this is associated with a better outcome.

5. You examine a five year old child who has had a cough and runny nose for 48 hours. He has a temperature of 38oC. There are no significant focal signs. He is very active around your room, showing no signs of being unwell or distressed. With regard to his temperature, which one of the following is the best intervention?

a ) Tepid sponging
b ) Paracetamol
c ) No treatment
d ) Paracetamol with Ibuprofen
e ) Ibuprofen

Answer: C

Antipyretic therapy should not be used routinely with the sole aim of reducing body temperature in children with a fever who are otherwise well and not distressed. Discussion with the parent is clearly an important part of the management plan

6. A 25 year old woman with a diagnosis of chronic fatigue syndrome asks your opinion on various interventions which she has read about on the internet. Based on a systematic review of randomised controlled trials, which one of the following interventions has been shown to improve measures of fatigue and physical functioning?

a ) Antidepressants
b ) Hypnotherapy
c ) Galantamine
d ) Graded exercise
e ) Immunotherapy

Answer: D

7. OPTIONS:

a ) Bacterial vaginitis
b ) Breakthrough bleeding
c ) Cervical carcinoma
d ) Dysfunctional uterine bleeding
e ) Ectopic pregnancy
f ) Pelvic inflammatory disease
g ) Threatened abortion

INSTRUCTION: For each patient with vaginal bleeding or discharge, select the most likely single diagnosis. Each option can be used once, more than once or not at all.

A . A 26 year old woman attends complaining of recent onset of painful vaginal bleeding. Her period is two weeks late although she puts this down to a recent illness. On vaginal examination, she has some cervical excitation and on abdominal examination there is guarding and rebound tenderness in the left iliac fossa.

The Correct answer is e.
B. A 20 year old non-pregnant woman presents with a fever of 38C, bilateral lower abdominal pain and increased vaginal discharge. Abdominal examination reveals generalised tenderness with no rebound. Vaginal examination reveals cervical excitation with adnexal tenderness.

The Correct answer is f.
C . A 40 year old woman, with a previous regular period pattern, presents with a three month history of painless inter menstrual and post coital bleeding. She is a current smoker and has a past history of HPV. A pregnancy test is negative.

The Correct answer is c.

Always think of ectopic pregnancy in a sexually active woman with abdominal pain and bleeding. There is usually amenorrhoea but an ectopic may be present before a period is missed. Tubal colic causes abdominal pain which may precede vaginal bleeding. Blood loss may be dark (prune juice) or fresh. Symptoms may range from mild to severe (shock if rupture occurs). Early diagnosis is vital, immediate referral for assessment is required. Early diagnosis and treatment of pelvic infection is essential to minimise immediate and future complications (e.g. sepsis, pain, menorrhagia, dysmenorrhoea, infertility and ectopic pregnancy). Risk factors for cervical carcinoma include smoking and the Human Papilloma Virus. Overt carcinoma is rarely detected on a smear. Non menstrual bleeding (intermenstrual, postcoital) is the classic symptom and should always be investigated.

8. A 41 year old overweight type 2 diabetic with three children presents for review of contraception. She has a history of dysmenorrhoea and menorrhagia with iron deficiency anaemia. She is troubled by migraine with aura. Her mother suffered a fractured neck of femur and died from breast carcinoma. She does not wish sterilisation. Which one of the following methods would you recommend?

a ) Combined oral contraceptive (COC)
b ) Depomedroxyprogesterone acetate (DMPA)
c ) Intrauterine device (IUD)
d ) Intrauterine system (IUS)
e ) Norethisterone enantate

Answer: D

Migraine contraindicates the use of COC. The IUD can exacerbate menorrhagia. DMPA is associated with a small loss in bone mineral density, which is largely recovered after discontinuation, and it is recommended that it should be used with care in the over 40s. There is no evidence that an IUS causes weight gain, whereas DMPA use can be associated with a weight gain of up to 2-3kg in one year.

Wednesday 7 January 2009

AKT Questions

1. Which of the following statements about encompresis is true?

A. it cannot be diagnosed before the age of four.
B. it involves the voluntary passage of faeces.
C. it I particularly a common problem in lower socioeconomic groups.
D. it is best managed with a coercive approach to potty training.
E. it is more common in females.


Answer: A

Encompresis is the involuntary passage of fully formed faeces and is not a diagnosis that can be made before the age of four. It is an uncommon disorder but much more common in boys. Coercive potty training is likely to worsen the condition. Organic disorders such as Hirschprung's disease must be excluded before psychiatric management is considered. The treatment of choice includes behavioural management, such as the use of a start chart, along with parental counselling or family therapy to help modify hostile attitudes.

2. A 34-year-old man presents to his GP with a 6-month Hx of back pain with no recent Hx of trauma. There are no red flag symptoms. He works long hours as an IT technician. You see from the notes that he has presented in the past with intermittent episodes of back stiffness and occasional neck ache. He is otherwise fit and well, though he was treated with a steroid injection for plantar fascitis last year. On examination, he has no neurological signs but does have reduced range of movement in his cervical spine, particularly for extension. Which one of the following options is the most likely diagnosis?

A. ankylosing spondylitis
B. mechanical back pain
C. osteoarthritis
D. rheumatoid arthritis
E. wedge fracture


Answer: A

AS has prevalence of approximately 1 in 2200 and affects men twice as frequently as women. It tends to present n young men with morning back pain and stiffness. As progressive spinal fusion occurs there can be reduced spinal movement, with kyphosis and sacroiliac joint pain. It is associated with plantar fascitis, lung fibrosis, inflammatory bowel disease and amyloidosis. X-ray of the spine might show a "bamboo spine" with vertebral fusion. The diagnosis is associated with HLA-B27 positivity.

3. Which one of the following food items has the highest glycaemic index?

A. cucumber
B. oranges.
C. peanuts
D. potatoes
E. tomatoes


Answer: D

The GI index and nutrition are popular in the exam as this is important with regard to diabetes and also dieting. Foods with low GI give a smaller rise in blood glucose and are said to result in better glycaemic control in diabetes. Potatoes have a high GI, whereas cucumber has the lowest.

4. Which one of the following is true of psoriasis?

A. topical steroids should be the mainstay of treatment.
B. oral steroids cause pustular psoriasis
C. psoriatic arthropathy never occurs in the absence of a typical rash.
d. Methotrexate is only used to treat the arthropathy.
E. can be cured outright.


Answer: B

Topical steroids are used to treat psoriasis, but second line and for short periods. Oral steroids can produce dramatic pustular psoriasis. Psoriatic arthropathy can occur without skin changes but usually there are nail changes. Methotrexate is used to treat psoriasis without arthropathy and at this point in time the disease is not curable.

5. A 19-year old man has had perineal pain for the past 3 days and has developed fever. He also describes dysuria. On rectal examination he is found to have a tender boggy prostate gland. Which one of the following actions is the most appropriate next step?

A. an HIV test should be organised as soon as possible.
B. a urine sample should be obtained for culture.
C. antibiotics should be started only after any culture results are received.
D. rectal tissue should be swabbed and sent to the laboratory.
E. the prostate should be massaged to obtain Prostatic fluid for culture.

Answer: B

This patient has symptoms consistent with acute prostatitis. Fever, arthralgia, low abdominal pain and a urethral discharge are all common symptom. Diagnosis is made by urine culture. Prostatic massage should be avoided as it can allow the infection to disseminate and will be painful to the patient.

6. A 55-year-old patient has longstanding treated hypertension. He has had his eGFR measured on annual basis. Last year his eGFR was estimated at 54 ml/min/1.73m2. This year he has an unexplained fall in eGFR to 41 ml/min/1.73m2. He feels otherwise well. Which one of the following actions is the most appropriate?

A. arrange renal US and only refer to renal team if US is abnormal.
B. repeat eGFR in 6 months.
C. repeat eGFR in one year.
D. routine OP referral to the renal team.
E. urgent OP referral to the renal team


Answer: D

Patients who have an unexplained fall in eGFR might warrant routine referral to the renal team. An unexplained annual fall in eGFR of >15% is considered significant by the renal association. NICE guidelines also suggest referral for patients with a fall in eGFR. Those with at least a 5-ml/min unexplained fall in eGFR over one year (or less) should be referred. A renal US is also indicated in these patients.

7. A child has just registered with your practice because his family has moved to the area. He has recently been diagnosed with hereditary spherocytosis. Which one of the following statements about this condition is true?

A. it is X-linked recessive condition.
B. it is associated with aplastic crises
C. it is usually diagnosed incidentally in adulthood on routine blood testing
D. patients should be treated with vit. B12 supplementation.
E. there is usually no clinical signs.


Answer: B

Hereditary spherocytosis is an autosomal recessive condition that affects 1 in 5000 live births. It usually presents in childhood as jaundice or with aplastic crises, usually triggered by parvovirus infections. Most children receive folic acid supplementation. Splenomegaly is common. It is rarely diagnosed in adulthood.