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.