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often end up with an exercise test for his own reassurance but, since this is not totally specific or sensitive may be superseded by cardiac CT in the future.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.